A 17-year-old young man presents with the following chest wall condition, What is the most appropriate management to treat this condition?

 

 

 

 

[size=20px]a Pectus compression brace

 

b Reverse Nuss procedure

 

c Nuss Procedure

 

d Open repair with sternal plating

 

e Sandwich technique[/size]

C

C

D

D

C

C

c

C

C

C

Correct answer

d Open repair with sternal plating

 

Pectus arcuatum is a rare congenital chest wall condition featuring severe protrusion of the upper sternum at the sternomanubrial angle and bilateral deformity of the 2nd to 4th rib cartilages. Other names for pectus arcuatum include Currarino-Silverman syndrome, chondro-manubrial deformity, or type 2 pectus carinatum. Pectus arcuatum is often misdiagnosed and treated as a pectus excavatum deformity or a mixed pectus excavatum and carinatum deformity. Chest CT scan will show no sternal depression while confirming the severe sternomanubrial angulation (see below).

 

 

The treatment for this condition requires an open or modified-Ravitch operation and must include bilateral resection of the 2nd to 4th costal cartilages with preservation of the perichondrium. The remaining costal cartilages must be detached from the sternum in order to free the sternum for adequate remodeling. Due to the steep angulation, one or two V-shaped sternal osteotomies are required. Sternal plating aides in maintaining adequate reduction and healing of the sternum. Sternal plating also stabilizes the sternum in the immediate postoperative period. Parallel plates off the midline are recommended in case the patient requires a future sternotomy (see below).

 

 

Routine pectus bracing is unsuccessful due to the location and early ossification of this defect. A Nuss repair is not indicated, as this is not a pectus excavatum defect. Other techniques utilized overseas such as the reverse Nuss (for treatment of pectus carinatum) or sandwich technique (for treatment of mixed pectus excavatum and carinatum defects) are not indicated given the location and defect type.