Pectus carinatum, an anterior protrusion of the sternum or chest wall, is much less frequent than pectus excavatum; 16.7% of all chest wall deformities in the Boston Children’s Hospital experience. The anterior protrusion occurs in a spectrum of configurations often divided into four categories ] The most frequent form, termed chondrogladiolar by Brodkin, consists of anterior protrusion of the body of the sternum with protrusion of the lower costal cartilages. It is described as appearing as if a giant hand had pinched the chest from the front, forcing the sternum and medial portion of the costal cartilages forward and the lateral costal cartilages and ribs inward. Asymmetric deformities with anterior displacement of the costal cartilages on one side and normal cartilages on the contralateral side are less common . Mixed lesions have a carinate deformity on one side and a depression or excavatum deformity on the contralateral side, often with sternal rotation. Some authors classify these as a variant of the excavatum deformities. The least frequent deformity is the chondromanubrial or “pouter pigeon” deformity with protrusion of the upper chest involving the manubrium and second and third costal cartilages and relative depression of the body of the sternum.
The etiology is unknown. The deformity becomes more prominent with the growth spurt of puberty.
The classic repair is a modified Ravitch which involves resection of the costal cartilages and fracture of the sternum. A recent innovation is the Abramson repair which is a modified Nuss operation. This is a minimally invasive operation which is much more cosmetically acceptable.
Pectus excavatum occurs in approximately 1 in 400 live births. The defect becomes progressively worse with growth and in the teenage years can become disabling. Although considered cosmetic, and it is most certainly cosmetic, there are also well documented physiological changes such as decreased effort tolerance and cardiac arrhythmias. The young patients become used to the disability and are not really aware of any physiologic abnormalities until after the defect is repaired. For a good discription click here.
The standard repair is the open or Ravitch operation which was first described in 1950 and has become the standard. This procedure involves resecting multiple cartilages on each side of the sternum and splitting the sternum longitudinally to place it in the new position. A new procedure was described by Nuss 16 years ago and is a minimally invasive procedure which involves placing a steel bar behind the sternum pushing the sternum into the new position. This is a much more cosmetic procedure involving small lateral incisions. Especially in young girls this is a more preferable operation. The results from many centers are excellent and compared very favorably with the older Ravitch procedure.
There are two main approaches to repair of the defect. Click here for more information.
The Nuss operation is a minimally invasive procedure which was discribed by a Cape Town graduate Dr Nuss 16 years ago. It is a much quicker operation which gives considerably good results. Paper from Iceland click here. The operation is well discribed in this article(click here). For a good article click here. And here
The Nuss procedure is now being performed in South Africa. For more information contact a Thoracic Surgeon.
