Enhanced Recovery After Surgery 2.0: Optimizing Pain Management in Nuss Procedure: Cryoablation and Nerve Block Strategies for Reduced Opioid Use.

INTRODUCTION: Our study assesses the association between cryoablation, with and without nerve block supplementation, post-Nuss procedure pain, and opioid use in pectus excavatum (PE) patients. METHODS: We conducted a retrospective cohort study at a single center for PE patients who underwent the Nuss procedure from 2017 to 2022. Outcomes included postoperative opioid use (measured in oral morphine milligram equivalent per kilogram [OME/kg]), average pain score (scale 0-10), and length of stay (LOS). RESULTS: One hundred sixty-four patients (146 males and 18 females) were included, with 79 (48.2%) receiving neither cryoablation nor nerve block, 60 (36.6%) receiving intraoperative cryoablation alone, and 25 (15.2%) receiving both cryoablation and nerve block. The median age was 16 y. Nerve block recipients consumed fewer opioids during hospitalization than cryoablation alone and nonintervention groups (1.5 versus 2.3 versus 5.8 OME/kg, respectively, P < 0.0001). Average pain scores over the total LOS were lower in nerve block recipients (3.5 versus 3.8 versus 4.2, P = 0.03), particularly on postoperative day 0 (P = 0.002). Nerve block recipients had a shorter LOS than cryoablation alone and nonintervention groups (43.4 versus 54.7 versus 66.2 h, P < 0.0001). On multivariate analysis, cryoablation alone resulted in significantly less opioid use compared to no intervention (3.32 OME/kg reduction, 95% confidence interval -4.16 to -2.47, P < 0.0001). Addition of nerve block further reduced opioid use by 1.10 OME/kg (95% confidence interval -2.07 to -0.14, P = 0.04). CONCLUSIONS: Cryoablation with nerve block supplementation is associated with reduced pain, opioid use, and LOS post-Nuss for PE repair compared to cases without cryoablation or with cryoablation only. Cryoablation with regional nerve blocks should be considered for Nuss repair under the enhanced recovery after surgery pathway.

Thoracic and vertebral deformities in lung transplantation: perioperative complications and long-term prognoses.

BACKGROUND: Lung transplantation (LTx) is a crucial therapeutic strategy for patients suffering from end-stage respiratory diseases, necessitating precise donor-recipient size matching to ensure optimal graft function. While standard allocation protocols rely on predicted lung capacity based on factors such as sex, age, and height, a subset of patients with respiratory diseases presents an additional challenge - thoracic or vertebral deformities. These deformities can complicate accurate volume predictions and may impact the success of lung transplantation. METHODS: In this retrospective cohort study of patients who underwent LTx at Tohoku University Hospital between January 2007 and April 2022, with follow-up until October 2022, the primary objective was to assess the influence of thoracic and vertebral deformities on perioperative complications, emphasizing interventions, such as volume reduction surgery. The secondary objective aimed to identify any noticeable impact on long-term prognoses in recipients with these deformities. RESULTS: Of 129 LTx recipients analyzed, 17.8% exhibited thoracic deformities, characterized by pectus excavatum, while 16.3% had vertebral deformities. Perioperative complications, requiring delayed chest closure, tracheostomy, and volume reduction surgery, were more prevalent in the deformity group. Thoracic deformities were notably associated with the need for volume reduction surgery. However, long-term prognoses did not differ significantly between patients with deformities and those without. Vertebral deformities did not appear to significantly impact perioperative or long-term outcomes. CONCLUSIONS: This study highlights the prevalence of thoracic deformities in LTx recipients, correlating with increased perioperative complications, particularly the potential need for volume reduction surgery. Importantly, these deformities do not exert a significant impact on long-term prognoses. Additionally, patients with vertebral deformities, such as scoliosis and kyphosis, appear to be manageable in the context of LTx.

The pectus care guidelines: best practice consensus guidelines from the joint specialist societies SCTS/MF/CWIG/BOA/BAPS for the treatment of patients with pectus abnormalities.

Pectus defects are a group of congenital conditions found in approximately 1 in 250 people, where the sternum is depressed back towards the spine (excavatum), protrudes forwards (carinatum) or more rarely is a mixture of both (arcuatum or mixed defects). For the majority of patients, it is well tolerated, but some patients are affected psychologically, physiologically or both. The deformity becomes apparent at a young age due to the growth of the ribs and the cartilage that links them to the sternum. The majority of defects are mild and are well tolerated, i.e. they do not affect activity and do not cause psychological harm. However, some young people develop lower self-esteem and depression, causing them to withdraw from activities (such as swimming, dancing) and from interactions that might 'expose' them (such as sleepovers, dating, going to the beach and wearing fashionable clothes). This psychological harm occurs at a crucial time during their physical and social development. A small number of patients have more extreme depression of their sternum that impedes their physiological reserve, which can occur when engaging in strenuous exercise (such as running) but can also limit moderate activity such as walking and climbing stairs. The effects can be so extreme that symptoms occur at rest or cause life-threatening compression of the major blood vessels and organs. The group of patients with physiological impairment usually also suffer from low self-esteem and depression. This paper summarizes the current evidence for the different treatment strategies for this condition, including supportive care, psychological support and non-surgical techniques including bracing and vacuum bell therapy. We also consider surgical techniques including the Ravitch procedure, the Nuss procedure (minimally invasive repair of pectus excavatum), pectus implants and other rare procedures such as Pectus Up. For the majority of patients, supportive care is sufficient, but for a minority, a combination of the other techniques may be considered. This paper also outlines best practice guidance for the delivery of such therapies, including standardized assessment, consent to treatment, audit, quality assurance and long-term support. All the interventions have risks and benefits that the patient, parents and clinicians need to carefully consider and discuss when deciding on the most appropriate course. We hope this evidence review of 'Best Practice for Pectus' will make a significant contribution to those considerations and help all involved, from patients to national policy makers, to deliver the best possible care.

The role of 3D printing in chest wall reconstruction.

Technology is advancing fast, and chest wall surgery finds particular benefit in the broader availability of three-dimensional (3D) reconstruction and printing. An increasing number of reports are being published on the use of these resources in virtual 3D reconstructions of chest walls in computed tomography (CT) scans, virtual surgeries, 3D printing of real-size models for surgical planning, practice, and education, and of note, the manufacture of customized 3D printed implants, changing the fundamental conception from a surgery that fits all, to a surgery for each patient. In this review, we explore the evidence published on simple chest wall reconstruction, including the use of 3D technology to assist in the improvement of the repair of the most frequent chest wall deformities: pectus excavatum and carinatum. Current studies are oriented to the automatization and customization of transthoracic implants, as well as education on real-size models. Next, we investigate the implementation of 3D printing in the repair of complex chest wall reconstruction, comprised of infrequent chest wall deformities such as pectus arcuatum and Poland syndrome. These malformations are very heterogeneous resulting in a high degree of improvisation during the surgical repair. In this setting, 3D technology plays a role in the standardization of a process that contemplates customization, concepts that may seem contradictory. Finally, 3D printing with biocompatible materials is rapidly becoming the first choice for the reconstruction of wide chest wall oncological resections. In this work, we review the first and most important current publications on the subject.

The sandwich technique used for correction of pectus carinatum combined with Harrison sulcus.

We aimed to investigate the feasibility of the sandwich technique to treat pectus carinatum combined with Harrison sulcus. We retrospectively analysed the clinical data of 38 paediatric patients with pectus carinatum combined with Harrison sulcus treated from June 2015 to October 2022. All the patients underwent surgery using the sandwich technique. The surgical conditions and postoperative outcomes of the patients and the satisfaction score of family members were analysed. Overall, the patients had a mean duration of surgery of 179.05 ± 36.01 min, intraoperative blood loss of 10.03 ± 2.77 mL, postoperative hospital stay of 6.89 ± 0.73 days, and postoperative satisfaction score of 89.4 ± 4.6. The incidence of surgical complications was 7.89%. The internal fixation stents were removed in 22 patients, and there was no recurrence during a follow-up 371.4 ± 6.3 days post-stent removal. These results were satisfactory. The use of the sandwich technique to treat this condition does not reduce the volume of the thorax after the procedure and results in an aesthetically pleasing incision, less complications, and fast postoperative recovery. Thus, it is a safe and effective method that is worthy of being promoted for clinical application.

Bilateral Lung Injury with Delayed Pneumothorax following Preoperative Cryoanalgesia for Pectus Excavatum Repair in a 13-year-old Boy.

A 13-year-old male patient with marfanoid features and pectus excavatum with Haller index 4 and correction index of 38% underwent the Nuss procedure with cryoanalgesia 9 days prior, which transpired uneventfully. Preoperative spirometry was normal, and echocardiogram showed light aortic valve dilation. A month later, during a routine outpatient checkup, he referred middle abdominal pain, denying respiratory symptoms nor thoracic pain. He presented bilateral apical and right basal hypophonesis. Chest X-ray revealed bilateral pneumothorax and right pleural effusion. Consequently, the patient was admitted to the emergency room, and a chest computed tomography was ordered, reporting right apical blebs. Bilateral thoracoscopy was performed, and apexes were checked for pulmonary blebs to rule out primary pneumothorax. In the right chest, a wedge resection of a distorted area on the apex and pleuroabrasion were done. Four air leaking eschars were found when performing lung expansion under water as leaking test, corresponding to cryoanalgesia intercostal eschars, and subsequently closed by primary suture. In the left chest, there were no blebs. However, another four pleural lesions with intact pleura in the left lower lobe were also found. Postoperative course was uneventful and chest drains were removed 48 hours after surgery. He remains asymptomatic 21 months after discharge. Cryoanalgesia in pectus excavatum is spreading due to the improvement in postoperative pain control. However, some complications may occur.

Pectus excavatum: the effect of tricuspid valve compression on cardiac function.

BACKGROUND: Pectus excavatum (PE) is a common congenital chest wall deformity with various associated health concerns, including psychosocial impacts, academic challenges, and potential cardiopulmonary effects. OBJECTIVE: This study aimed to investigate the cardiac consequences of right atrioventricular groove compression in PE using cardiac magnetic resonance imaging. MATERIALS AND METHODS: A retrospective analysis was conducted on 661 patients with PE referred for evaluation. Patients were categorized into three groups based on the degree of right atrioventricular groove compression (no compression (NC), partial compression (PC), and complete compression(CC)). Chest wall indices were measured: pectus index (PI), depression index (DI), correction index (CI), and sternal torsion. RESULTS: The study revealed significant differences in chest wall indices between the groups: PE, NC=4.15 ± 0.94, PC=4.93 ± 1.24, and CC=7.2 ± 4.01 (P<0.0001). Left ventricle ejection fraction (LVEF) showed no significant differences: LVEF, NC=58.72% ± 3.94, PC=58.49% ± 4.02, and CC=57.95% ± 3.92 (P=0.0984). Right ventricular ejection fraction (RVEF) demonstrated significant differences: RVEF, NC=55.2% ± 5.3, PC=53.8% ± 4.4, and CC=53.1% ± 4.8 (P≥0.0001). Notably, the tricuspid valve (TV) measurement on the four-chamber view decreased in patients with greater compression: NC=29.52 ± 4.6; PC=28.26 ± 4.8; and CC=24.74 ± 5.73 (P<0.0001). CONCLUSION: This study provides valuable insights into the cardiac consequences of right atrioventricular groove compression in PE and lends further evidence of mild cardiac changes due to PE.

Spinal posture, mobility, and position sense in adolescents with chest wall deformities: a comparison of pectus excavatum, pectus carinatum and healthy peers.

PURPOSE: The study aimed to compare spinal posture, mobility, and position sense in adolescents with pectus excavatum (PE), pectus carinatum (PC), and healthy control (HC). METHODS: 22 with PE, 22 with PC, and 21 HC were included in the study. The spinal posture (thoracic kyphosis, lumbar lordosis, pelvic tilt, thoracic, lumbar, pelvic lateral tilt angles) and mobility (thoracic, lumbar, hip/sacral, and overall, in the sagittal and frontal plane) with the spinal mouse, and spinal position sense (repositing errors) with the inclinometer were assessed. RESULTS: The thoracic kyphosis angle of PE and PC was higher than in HC (p < 0.001; p = 0.001). Hip/sacral mobility in the sagittal plane was lower in the PE and PC than control, respectively (p < 0.001; p < 0.001). Overall sagittal spinal mobility (p:0.007) and hip/sacral mobility in the frontal plane (p:0.002) were lower in the PC than in HC. Overall frontal spinal mobility was lower in the PE and PC than in HC (p:0.002; p:0.014). The PE and PC repositing errors were higher (p < 0.001; p:0.014). CONCLUSION: The study found that adolescents with PE and PC had decreased spinal mobility, spinal alignment disorders, and a decline in spinal position sense. It is important not to overlook the spine during physical examinations of adolescents with chest wall deformities. In clinical practice, we suggest that adolescents with chest deformities should undergo a spine evaluation and be referred for physical therapy to manage spinal disorders.

Quality of life, psychological states, and personality traits in patients with pectus excavatum.

Objective: The quality of life (QOL) and psychological states of patients with pectus excavatum (PE) have yet to be well understood. This study aimed to evaluate the health-related QOL (HRQOL), psychological states, and personality traits of patients with PE, alongside the associations of these factors with the severity of PE. Methods: A cross-sectional evaluation was prospectively performed in patients scheduled to undergo PE repair surgery between July 2019 and April 2021. The primary outcome was the patients' HRQOL, and the secondary outcomes were depression, social anxiety, self-efficacy, and personality traits. Results: In total, 129 patients were subjected to analyses. Patients' HRQOL had a lower role component summary score (mean ± standard deviation: 41.8 ± 12.8, P < .001) than the general population controls. Patients' HRQOL had a significantly better physical component summary (54.0 ± 10.4, P < .001) and mental component summary (53.3 ± 8.8, P < .001) than that of the general population. Fourteen patients' (10.9%) and 56 patients' (43.4%) scores indicated the presence of depression and social anxiety disorder, respectively. Patients' self-efficacy (46.1 ± 11.4, P, .001) and level of extraversion (46.5 ± 11.8, P < .001) were lower than those of the general population. No significant correlation was found between the severity of PE and these scores. Conclusions: Our study revealed that patients with PE had decreased social-role QOL, depressive tendencies, increased social anxiety, lower self-efficacy, and introversion. No correlation between the severity of PE and the patients' psychological outcomes leads us to conclude that surgical implications of PE should not be decided solely by a physical index.

The Association of a Single Nucleotide Variant in COL5A1 to Early Onset Keratoconus and Pectus Excavatum-Convergence of Extracellular Matrix Pathologies.

Keratoconus is a bilateral ocular condition characterized by irregularities and the thinning of the cornea. Decreased central corneal thickness is a hallmark of the condition, and numerous genes have played a role in altering corneal thickness and the subsequent development of keratoconus. Variants in the structural and regulatory genes of the extracellular matrix have been highly associated with keratoconus, as well as with pectus excavatum, a chest wall deformity commonly seen in connective tissue disorders. This report describes a patient with a c.1720-11T>A intronic variant in the collagen-encoding gene, COL5A1, who was diagnosed with early-onset keratoconus and demonstrated a significant pectus excavatum. This report associates a COL5A1 variant with these seemingly unrelated phenotypic associations, further advancing the literature on the topic.

Effect of Preoperative Clear Liquid Consumption on Postoperative Recovery in Pediatric Patients Undergoing Minimally Invasive Repair of Pectus Excavatum: A Prospective Randomized Controlled Study.

Background/Objectives: Preoperative fasting guidelines traditionally aim to reduce pulmonary aspiration risk. However, concerns over the adverse effects of prolonged fasting have led to exploring alternatives. This study aimed to investigate the impact of preoperative clear liquid intake on postoperative outcomes in children undergoing minimally invasive repair of pectus excavatum (MIRPE). Methods: A prospective randomized controlled study was conducted on children aged 3-6 years scheduled for elective MIRPE. Patients were randomized into either a routine overnight fasting group (NPO) or a clear liquid group. The incidence and severity of emergence delirium (ED) were assessed using Pediatric Anesthesia Emergence Delirium (PAED) and Watcha scales at recovery room. Postoperative pain scores and opioid requirements were evaluated at intervals of 1-6 h, 6-12 h, and 12-24 h after surgery. Results: Fasting time was 178.6 ± 149.5 min and 608.9 ± 148.4 min in the clear liquid group compared and NPO group, respectively. The incidence of ED, measured by PAED and Watcha scales, was lower in the clear liquid group (PAED score ≥ 12: 55.6% vs. 85.2%, p = 0.037; Watcha score ≥ 3: 51.9% vs. 85.2%, p = 0.019). The highest PAED score recorded in the recovery room was significantly lower in the clear liquid group (11.4 ± 2.8 vs. 14.6 ± 2.8, p < 0.001). Clear liquid group showed significantly lower pain scores at 1-6, 6-12, and 12-24 h postoperatively. Additionally, clear liquid group had lower opioid requirement at 1-6 and 6-12 h postoperatively. Conclusions: Preoperative clear liquid consumption was associated with a lower incidence of ED in pediatric patients undergoing MIRPE.

'Short Bars Crossed' to Remodel the Entire Chest Wall in Children and Adolescents with Pectus Excavatum.

BACKGROUND: The cross-bar technique of minimally invasive pectus excavatum (PE) correction remains underreported, which is especially true of pediatric patients. We therefore reviewed the experience of a Turkish and an Austrian center. An additional novelty characterizing both pediatric cohorts was the use of short bars. METHODS: In a retrospective study, pediatric PE corrections involving 'short bars crossed' were analyzed for complications and intra-/postoperative outcomes. Cases with two or three bars were included, given that a horizontal third bar was placed whenever considered useful for upper-chest elevation. All bars were fitted with a single stabilizer near the surgical entry point. In the Austrian center, intercostal nerve cryoablation was used for pain management. Descriptive statistics are presented. RESULTS: Seventy-eight patients ≤18 years old were evaluable at the Turkish (n = 56) and Austrian (n = 22) centers. Total median values were 16.2 (IQR: 15.1-17.4) years for age and 4.60 (IQR: 3.50-6.11) for Haller index. Ten mild or moderate complications (12.8%) were observed, including just one revision requirement due to bar migration (1.28%). Intercostal nerve cryoablation (n = 13) was associated with longer surgical procedures at 150 (IQR: 137-171) versus 80 (IQR: 60-100) minutes but with shorter hospital stays, given an IQR of 3-4 days versus 4-5 days. CONCLUSION: 'Short bars crossed'-with a single stabilizer in a ventral position close to the surgical entry point-ensure a wide distribution of forces, protect against bar migration, are safe and effective, and offer stability at an age characterized by growth and physical activity. LEVEL OF EVIDENCE: IV.

Pectus Bar Dislocation: Comparison Between Three Different Stabilization Techniques Adopted in a Single Centre.

BACKGROUND: Bar dislocation has always been considered a fearsome complication of Minimally Invasive Repair of Pectus Excavatum (MIRPE), therefore multiple techniques and types of stabilization have been introduced. The aim of the study is to compare different stabilization techniques in a cohort of patients operated by the same first operator. METHODS: MIRPE was adopted at our institution in 2005. Data on MIRPE patients from January 2013 to December 2022 were collected prospectively and reviewed. Patients with a follow-up of at least 12 months were included. Throughout the years different ways of stabilization were used. Patients were divided in 3 groups according to the stabilization strategy adopted- Group A: no stabilizer; Group B: single bar fixation; Group C: bridge fixation. Dislocation was diagnosed if a bar rotated more than 30° or displaced laterally for more than 1.5 cm. We compared bar dislocation percentage of each group. RESULTS: We positioned 733 bars in 468 patients. Group A included 113 bars (15.4%), Group B 415 bars (56.6%), Group C 205 bars (28%). No patients were lost at follow-up. Total dislocation rate was 4.1% (30 bars). Dislocation was observed in 10 bars of group A (8.8%), 20 bars of group B (4.8 %), 0 bars of group C (0%). Differences between groups were statistically significant. CONCLUSIONS: The use of stabilizers reduced dislocation percentage. In particular, bridge fixation technique reduced to zero bar dislocation and is now our preferred technique of stabilization. LEVEL OF EVIDENCE: III.

Use of Osteopathic Manipulative Treatment for the Management of Pectus Excavatum: A Single Case Study.

Pectus excavatum (PE) is a congenital defect that presents with an anterior depression of the chest wall, which can impact cardiopulmonary function. A 25-year-old hypermobile male presented with a history of PE and chronic dyspnea on exertion, chronic cough, and intermittent chest wall pain. This study explores osteopathic manipulative treatment (OMT) as a possible alternative to improve symptoms associated with PE. Osteopathic structural exam (OSE), volumetric measurements of the thoracic cavity, vitals, and pulmonary function tests were evaluated at baseline and after OMT. The patient was treated with 14 weeks of weekly OMT for his exertional dyspnea, cough, and chest wall pain. Somatic dysfunctions were addressed through OMT, which all improved by the end of the 14-week treatment. Notably, the excursion at the sternal angle increased by threefold after complete treatment. The patient reported subjective improvement in all symptoms, with durable improvement in chest wall pain at 10 months after cessation of treatment. The application of OMT can help alleviate symptoms of pectus excavatum and aid in the management of patients who have not received surgical interventions.

Case Report: Double Pectus Up in severe pectus excavatum, the new frontier of modified taulinoplasty.

Introduction: Pectus excavatum, also known as "sunken chest" or "funnel chest," is a congenital condition where the sternum caves inward, creating a noticeable depression in the chest. This deformity can range from mild to severe cases, and can affect appearance and lung and heart function. Treatment options vary depending on the severity of the condition and associated symptoms. A case study was conducted on three patients suffering from severe forms of pectus excavatum using modified taulinoplasty with two Pectus Up bars. Case description: The patients were males, with an age of 15 years. Preoperatively, they underwent spirometry, an echocardiogram, and allergy tests. The procedure involved inserting two Pectus Up bars into the chest wall at the major sternal defect, allowing the implant to remain completely invisible. The procedure involved placing the sternal plate at the deepest point and anchored to the sternum with five self-tapping screws. The chest plate was then fixed to the bar using two screws. Discussion: The use of Pectus Up was first reported in 2016 and has been a subject of scientific discussion and research. The double Pectus Up technique offers improved correction, increased stability, and reduced complications. However, it also presents challenges such as increased technical complexity and potential for prolonged operative times. Patient outcomes showed promising results in terms of short-term correction and long-term stability. The use of a double bar technique in the modified Taulinoplasty procedure is a key area of ongoing clinical research and innovation in pectus excavatum repair. Further studies will be needed, including more institutions that use this technique to validate our initial experience.

Evaluating the web as a source of information for patients with chest wall deformities: insights into engagement and disparities.

BACKGROUND: Recent data highlight the internet's pivotal role as the primary information source for patients. In this study, we emulate a patient's/caregiver's quest for online information concerning chest deformities and assess the quality of available information. METHODS: We conducted an internet search using combination of the terms "pectus excavatum," "pectus excavatum surgery," "funnel chest," "pectus excavatum repair" and identified the first 100 relevant websites from the three most popular search engines: Google, Yahoo, and Bing. These websites were evaluated using the modified Ensuring Quality Information for Patients (EQIP) instrument. RESULTS: Of the 300 websites generated, 140 (46.7%) were included in our evaluation after elimination of duplicates, non-English websites, and those targeting medical professionals. The EQIP scores in the final sample ranged from 8 to 32/36, with a median score of 22. Most of the evaluated websites (32.8%) originated from hospitals, yet none met all 36 EQIP criteria. DISCUSSION: None of the evaluated websites pertaining to pectus excavatum achieved a flawless "content quality" score. The diverse array of websites potentially complicates patients' efforts to navigate toward high-quality resources. Barriers in accessing high-quality online patient information may contribute to disparities in referral, patient engagement, treatment satisfaction, and overall quality of life. LEVEL OF EVIDENCE: IV.

Correlation of anterior chest wall anomalies and spinal deformities: a comprehensive descriptive study.

PURPOSE: To investigate the association and evaluate the characteristics between different types of anterior chest wall and spinal deformities. METHODS: A total of 548 patients with anterior chest wall deformities were included in this study. Clinical and radiological examinations were performed to determine spinal deformities. The type and severity of the spinal deformities were evaluated and their relationships with chest wall deformity subtypes were statistically analyzed. RESULTS: Spinal deformities were identified in 93 (16.97%) patients. The patients were subdivided into 71 (76.3%) male and 22 (23.7%) female patients. A spinal deformity was detected in 57 (13%) of 418 pectus excavatum (PE) patients, in 23 (19%) of 117 pectus carinatum (PC) patients, and in all patients with mixed pectus deformity (PE + PC), syndromic deformity and rib anomalies. In the PE group, scoliosis, and kyphosis were observed at 57.9 and 31.6%, respectively. In the PC group, these rates were 43.5 and 47.8%, respectively. Idiopathic scoliosis was observed in 42 (77.7%) and constituted the most common scoliosis subgroup. The main thoracic curvature was the most common curve pattern, which was observed in 15 (35.7%) patients with idiopathic scoliosis. CONCLUSIONS: Idiopathic scoliosis with main thoracic curvature is the most common deformity in patients with anterior chest wall deformity. Spinal deformities are more common in male patients with chest deformities. Kyphosis is found in a significant number of PE and PC patients. Patients with mixed PE and PC, rib anomalies, and syndromic disease are more likely to have spinal deformities.

Pectus Disorders: Excavatum, Carinatum and Arcuatum.

This article reviews pectus excavatum, carinatum, and arcuatum. Topics covered include etiology, epidemiology, associated syndromes, physiologic impact, workup, indications for treatment, surgical and nonsurgical therapy, results, complications, and emerging therapies. Pectus excavatum is an inward deformation of the sternum and/or anterior chest wall. Pectus carinatum is ether an outward protrusion or tilt of the sternum with potential psychological impact, but no demonstrated physiologic impact. Nonoperative compression bracing is successful in carinatum patients with chest wall flexibility who are compliant with a bracing program. Pectus arcuatum is an abnormally short, fully fused sternum with a high anterior protrusion.