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Trinidad S, McKenna E, Jenkins T, Bates C, Garcia VF, Brown RL. Outcomes From a Nurse Practitioner Led Dynamic Compression System Bracing Program for Pectus Carinatum. J Pediatr Surg 2024; 59:950-955. [PMID: 37973419 DOI: 10.1016/j.jpedsurg.2023.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/16/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Dynamic compression system (DCS) is often effective at treating pectus carinatum (PC). However, some patients will fail therapy. This study reports outcomes from a nurse-practitioner led bracing program, and evaluates what factors are predictive of successful therapy. METHODS We performed a retrospective cohort study involving all patients treated with DCS bracing at our institution between February 2018 and February 2022. Patients with at least three visits were included. The primary outcome was achieving neutral chest. Factors considered potentially predictive included patient age, sex, initial pressure of correction (PIC), and the change in pressure of correction between the first two visits (deltaPC1). A Cox proportional hazards model was used for analysis, and Kaplan-Meier analyses estimated the median time to correction. RESULTS 283 patients were evaluated. The median age was 14 (IQR 12-15), the majority were male (90.1 %) and white (92.6 %). The median PIC and deltaPC1was 4.13 PSI (IQR 3.17-5.3), and 1.34 PSI (IQR 0.54-2.25), respectively. 117 patients achieved correction. The median estimated time to correction was 7.5 months (95 % CI 5.9-10.1). In the final Cox model, greater deltaPC1 was associated with increased risk of correction (HR: 2.46; 95 % CI 2.03-2.98), and increased PIC was associated with decreased risk of correction up to one year of therapy (0-3 months HR 0.62, 95 % CI 0.50-0.78; 3-12 months HR 0.62; 95 % CI 0.45-0.85). CONCLUSIONS DCS bracing administered by advanced care providers in collaboration with surgeons can effectively treat PC. The deltaPC1 and PIC are the factors most predictive of successful therapy. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Stephen Trinidad
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Emily McKenna
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Todd Jenkins
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christina Bates
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Victor F Garcia
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rebeccah L Brown
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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2
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Kwong JZ, Gulack BC. Non-surgical approaches to the management of chest wall deformities. Semin Pediatr Surg 2024; 33:151388. [PMID: 38219537 DOI: 10.1016/j.sempedsurg.2024.151388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Chest wall deformities in children encompass a broad spectrum of disorders but pectus excavatum and carinatum are by far the most common. Treatment varies substantially by center, and depends on patient symptoms, severity of disease, and surgeon preference. Historically, surgical approaches were the mainstay of treatment for these disease processes but new advances in non-surgical approaches have demonstrated reasonable results in select patients. These non-surgical approaches include vacuum bell therapy, autologous fat grafting and hyaluronic acid injections for pectus excavatum, and orthotic brace therapy for pectus carinatum. There is debate with regards to optimal patient selection for these non-surgical approaches, as well as other barriers including reimbursement issues. This paper will review the current non-surgical approaches to chest wall deformities available, including optimal patient selection, treatment protocols, indications, contraindications, and outcomes.
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Affiliation(s)
- Jacky Z Kwong
- General Surgery Resident, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Brian Ch Gulack
- General Surgery Resident, Department of Surgery, Rush University Medical Center, Chicago, IL, USA.
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van Braak H, de Beer SA, Zwaveling S, Oomen MWN, de Jong JR. Ravitch Surgery or Dynamic Compression Bracing for Pectus Carinatum: A Retrospective Cohort Study. Ann Thorac Surg 2024; 117:144-150. [PMID: 36395878 DOI: 10.1016/j.athoracsur.2022.10.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pectus carinatum is a pediatric condition that can be treated by dynamic compression system (DCS) bracing or surgery. Several publications on DCS bracing or surgery are available; however, they do not compare both treatments. METHODS Over a 10-year period, 738 patients with pectus carinatum were treated at the Amsterdam Pectus Center (Amsterdam, The Netherlands). This study describes this 10-year experience and the results of both treatments. RESULTS Of the 631 patients who underwent DCS bracing treatment, 553 finished treatment, and 78 patients are still under treatment. A total of 73.8% (n = 408) of these patients finished treatment successfully, 13.6% (n = 75) experienced treatment failure, and 12.7% (n = 70) were lost to follow-up. The success rate decreased with an increasing pressure of initial compression (84.2%-67.3%). Marfan syndrome and Poland syndrome were associated with unfavorable results. Ravitch surgery was performed in 105 patients, with a success rate of 92.4%. Complications occurred in 32.4% of patients, and 6.7% of patients had complications for which surgery was needed. No relationship was found between osteotomy or sternal fixation and outcomes or complications. The Abramson procedure was performed in 2 patients. CONCLUSIONS DCS bracing should be the treatment of choice in patients with pectus carinatum because of its noninvasiveness, good results, and lower complication rate compared with surgery. Besides pressure of initial correction, motivation is an important factor influencing outcomes, and compliance remains a major challenge in treating pectus carinatum using DCS bracing. Bracing patients before their growth spurt should be discouraged. Patients with a higher pressure of initial compression (>8.0-8.5 psi) and Marfan syndrome or Poland syndrome have poorer outcomes. In those patients, surgery may be considered.
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Affiliation(s)
- Hendrik van Braak
- Department of Pediatric Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Sjoerd A de Beer
- Department of Pediatric Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Sander Zwaveling
- Department of Pediatric Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Matthijs W N Oomen
- Department of Pediatric Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Justin R de Jong
- Department of Pediatric Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Hayward R, Saxena AK. Pectus carinatum bracing in female patients. J Plast Reconstr Aesthet Surg 2023; 86:214-215. [PMID: 37769483 DOI: 10.1016/j.bjps.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Romilly Hayward
- Department of Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, London, United Kingdom
| | - Amulya K Saxena
- Department of Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, London, United Kingdom.
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5
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Sargent B, Varela K, Eggett D, McKenna E, Bates C, Brown R, Garcia V, Howell L. Modeling of the chest wall response to prolonged bracing in pectus carinatum. PLoS One 2023; 18:e0288941. [PMID: 37578962 PMCID: PMC10424870 DOI: 10.1371/journal.pone.0288941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/06/2023] [Indexed: 08/16/2023] Open
Abstract
Pectus carinatum is a chest wall deformity that is often treated through the wearing of an external brace. The treatment of the deformity could benefit from a greater understanding of chest wall characteristics under prolonged loading. These characteristics are difficult to model directly but empirical studies can be used to create statistical models. 185 patients from 2018-2020 received bracing treatment. Data on the severity of the deformity, treatment pressures, and time of wear were recorded at the first fitting and all subsequent follow-up visits. This data was analyzed using a statistical mixed effects model to identify significant measures and trends in treatment. These models were designed to help quantify changes in chest wall characteristics through prolonged bracing. Two statistical models were created. The first model predicts the change in the amount of pressure to correct the deformity after bracing for a given time and pressure. The second model predicts the change in pressure response by the body on the brace after bracing for a given time and pressure. These models show a high significance in the amount of pressure and time to the changes in the chest wall response. Initial deformity severity is also significant in changes to the deformity. The statistical models predict general trends in pectus carinatum brace treatment and can assist in creating treatment plans, motivating patient compliance, and can inform the design of future treatment systems.
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Affiliation(s)
- Brandon Sargent
- Department of Mechanical Engineering, Gonzaga University, Spokane, Washington, United States of America
| | - Katie Varela
- Department of Mechanical Engineering, Brigham Young University, Provo, Utah, United States of America
| | - Dennis Eggett
- Department of Statistics, Brigham Young University, Provo, Utah, United States of America
| | - Emily McKenna
- Chest Wall Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Christina Bates
- Chest Wall Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Rebeccah Brown
- Chest Wall Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Victor Garcia
- Chest Wall Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Larry Howell
- Department of Mechanical Engineering, Brigham Young University, Provo, Utah, United States of America
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Musters GD, Oomen MWN, Zwaveling S, de Jong JR, de Beer SA. [Dynamic compression brace for pectus carinatum: 5 years on]. Ned Tijdschr Geneeskd 2019; 163:D3557. [PMID: 30638003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Pectus carinatum is a congenital chest-wall deformity with a prevalence of 0.3-0.7%. This chest-wall deformity can lead to functional, cosmetic and psychosocial problems. For many years, the only available treatment was an invasive surgical procedure. A less-invasive treatment, namely external compression of the sternum with a brace, showed disappointing results due to discomfort, a high percentage of skin complications and low compliance. The introduction of the dynamic compression brace has meant that the pressure of sternal compression can be measured and adjusted, which has improved comfort and compliance and resulted in an increased success rate of 92% and a decrease in the percentage of skin complications to just 8%. Despite the fact that wearing a compression brace for a longer period of time is not an easy undertaking for an adolescent, the use of the dynamic compression brace results in a high success rate, and is a safe and an efficient treatment.
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Affiliation(s)
| | | | | | | | - Sjoerd A de Beer
- Amsterdam UMC, locatie AMC-UvA, afd. Kinderchirurgie
- Contact: S.A. de Beer
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Rosière NI, Gutiérrez R, Madrid C, Mendoza M, Martínez A, Bellia-Munzón G. [Result of 12 years of non-surgical treatment of pectus carinatum]. Cir Pediatr 2018; 31:115-120. [PMID: 30260102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To report our experience in the treatment of pectus carinatum by using the dynamic compression system. MATERIAL AND METHODS Retrospective study during the period from January 2005 to September 2017. Patients with typical condrogladiolar pectus carinatum and correction pressure (PC) ≤ 14 PSI (pound square inch) were included. Exclusion criteria: patients with previous thoracic surgery, mixed malformations and chondromanubrial pectus carinatum. For the treatment, the Dynamic Thoracic Compressor System (FMF) with pressure meter in PSI was used. The PC, the treatment pressure (PT), the correction time (TC) and the maintenance time (TM), recurrences and complications were analyzed. A qualitative scale was measured in three grades: where A is excellent or very good, B is regular and C is bad. RESULTS We treated 104 patients under 18 years of age. The PT was 2.26. The average of the TC was 8.8 months. The TM was on average 8 months. 36.5% of the patients finished the treatment, 36.5% still continue in treatment and 26.9% of the patients lost the follow-up due to desertion. The qualitative assessment was positive in 95.5% of our patients, and unfavourable in 4.5%. CONCLUSION The non-surgical treatment of pectus carinatum is efficient, non-invasive and of low morbidity. Regarding the high dropout rate, we must analyze the variables to be modified to reduce it. This treatment should be considered as the first option to correct pectus carinatum in patients with flexible thorax.
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Affiliation(s)
- N I Rosière
- Servicio de Cirugía Torácica. Hospital General de Niños "Dr. Pedro de Elizalde". Ciudad Autónoma de Buenos Aires, Argentina
| | - R Gutiérrez
- Servicio de Cirugía Torácica. Hospital General de Niños "Dr. Pedro de Elizalde". Ciudad Autónoma de Buenos Aires, Argentina
| | - C Madrid
- Servicio de Cirugía Torácica. Hospital General de Niños "Dr. Pedro de Elizalde". Ciudad Autónoma de Buenos Aires, Argentina
| | - M Mendoza
- Servicio de Cirugía Torácica. Hospital General de Niños "Dr. Pedro de Elizalde". Ciudad Autónoma de Buenos Aires, Argentina
| | - A Martínez
- Servicio de Cirugía Torácica. Hospital General de Niños "Dr. Pedro de Elizalde". Ciudad Autónoma de Buenos Aires, Argentina
| | - G Bellia-Munzón
- Servicio de Cirugía Torácica. Hospital General de Niños "Dr. Pedro de Elizalde". Ciudad Autónoma de Buenos Aires, Argentina
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Redondo Sedano JV, Delgado Muñoz MD, Martí Carrera ME, Gómez Fraile A. [Surgery in times of crisis: conservative treatment of pectus carinatum by static corset]. Cir Pediatr 2017; 30:83-88. [PMID: 28857530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Dynamic compression system is the elective treatment for chondrogladiolar pectus carinatum. Nevertheless, its high cost poses a problem for its prescription in places where it is not subsidized. This article analyzes the experience of the Paediatric Plastic Surgery Service at a third grade hospital in the treatment of this deformity with a static compression system. MATERIALS AND METHODS The study presents a descriptive, retrospective analysis of 30 patients with pectus carinatum treated with a static compression system. Furthermore, we describe the protocol of treatment used at our unit, and we analyse the satisfaction with bracing therapy, and its relation to therapeutic compliance. RESULTS The study includes 28 boys and 2 girls. 93% of the patients presented a chondrogladiolar pectus carinatum. At the moment of finishing the study, 11 patients have completed the treatment, 14 still bracing, and 5 were lost in the follow-up. Satisfaction questionnaires were answered by 19 patients. CONCLUSION Bracing therapy with static compression system is the treatment of choice for chondrogladiolar pectus carinatum in our unit, because of its effectiveness and lower price. Quality of life questionnaires show better marks in patients that are in the second phase of treatment.
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Affiliation(s)
- J V Redondo Sedano
- Servicio de Cirugía Pediátrica. Sección Cirugía Plástica Infantil. Hospital Universitario 12 de Octubre. Madrid
| | - M D Delgado Muñoz
- Servicio de Cirugía Pediátrica. Sección Cirugía Plástica Infantil. Hospital Universitario 12 de Octubre. Madrid
| | - M E Martí Carrera
- Servicio de Cirugía Pediátrica. Sección Cirugía Plástica Infantil. Hospital Universitario 12 de Octubre. Madrid
| | - A Gómez Fraile
- Servicio de Cirugía Pediátrica. Sección Cirugía Plástica Infantil. Hospital Universitario 12 de Octubre. Madrid
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Thaker S, Anderson M, Fezio J, Rader C, Misra MV. Pectus Carinatum: Factors That Contribute to Success and Failure of Nonoperative Treatment. Conn Med 2017; 81:203-208. [PMID: 29714404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Pectus carinatum is a congenital chest wall deformity characterized by protrusion ofthe sternum and ribs. External bracing has been the gold standard treatment for this condition for the past 20 years. PURPOSE The primary purpose of the study was to identify factors that contribute to treatment success of bracing for patients with pectus carinatum. The secondary aim was to identify the optimal age to recommend bracing for pectus carinatum. METHODS 176 patients who were evaluated for a brace for pectus carinatum were contacted to participate in an online survey about their experience. A retrospective chart review was conducted on patients who participated in the survey. RESULTS Subjects rated themselves as more confident afterbracing(P=.002). Patients who hadfamily sup- port, and no documented complaints (P = .024) and (P = .009) respectively, were more likely to say they had made the right choice to wear the brace. CONCLUSIONS This study demonstrated that family support and fewer complaints are predictors of success for the brace.
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Lascombes P, Ruchonnet-Métrailler I, Beghetti M, Bottani A, Wilde J. [Pectus excavatumn and carinatum in children and adolescents : what to say, what to do ?]. Rev Med Suisse 2017; 13:414-420. [PMID: 28714634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In children presenting with a pectus excavatum (PE) or pectus carinatum (PC) an underlying syndrome including Marfan's syndrome needs to be excluded. In adolescents, severe chest wall deformities may cause cardiac or respiratory problems but most commonly they have a psychological impact. The conservative treatment is a Vacuum Bell for PE, and a Dynamic Compression System for PC ; they play an increasing role in young patients. These devices need to be worn multiple hours per day for several months for an optimal result. Surgery is usually reserved for adolescents. The Nuss procedure for PE, also known as minimal invasive repair of PE offers excellent results. Sterno-chondro-plasty with stabilisation of the sternum with struts clipped to the ribs offers the same good results for PC. In our opinion, a multidisciplinary approach is preferable.
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Affiliation(s)
- Pierre Lascombes
- Service d'orthopédie pédiatrique, HUG, 1211 Genève 14
- Centre universitaire romand de chirurgie pédiatrique, HUG, 1211 Genève 14
- Département de l'enfant et de l'adolescents, HUG, 1211 Genève 14
| | - Isabelle Ruchonnet-Métrailler
- Unité de pneumologie pédiatrique, service des spécialités, HUG, 1211 Genève 14
- Département de l'enfant et de l'adolescents, HUG, 1211 Genève 14
| | - Maurice Beghetti
- Centre universitaire romand de cardiologie et chirurgie cardiaque pédiatrique, HUG, 1211 Genève 14
- Département de l'enfant et de l'adolescents, HUG, 1211 Genève 14
| | | | - James Wilde
- Service de chirurgie pédiatrique, HUG, 1211 Genève 14
- Centre universitaire romand de chirurgie pédiatrique, HUG, 1211 Genève 14
- Département de l'enfant et de l'adolescents, HUG, 1211 Genève 14
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Wong KE, Gorton GE, Tashjian DB, Tirabassi MV, Moriarty KP. Evaluation of the treatment of pectus carinatum with compressive orthotic bracing using three dimensional body scans. J Pediatr Surg 2014; 49:924-7. [PMID: 24888836 DOI: 10.1016/j.jpedsurg.2014.01.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/27/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this study is to measure the effectiveness of compressive orthotic brace therapy for the treatment of pectus carinatum using an adjusted Haller Index (HI) measurement calculated from 3D body scan (BS) images. METHODS Pediatric patients with pectus carinatum were treated with either compressive orthotic bracing or observation. An adjusted BS Haller index (HI) was calculated from serial 3D BS images obtained on all patients. Medical records were evaluated to determine treatment with bracing and brace compliance more than 12hours daily. Compliant patient measurements were compared to non-compliant and non-brace groups. RESULTS Forty patients underwent compressive orthotic bracing, while ten were observed. Twenty-three patients were compliant with bracing, and seventeen patients were non-compliant. Compliant patients exhibited an 8.2% increase, non-compliant patients had a 1.5% increase, and non-brace patients exhibited a 2.5% increase in BS HI. The change in BS HI of compliant patients was significantly different compared to non-brace patients (p=0.004) and non-compliant patients (p<0.001). CONCLUSIONS Three dimensional BS is an effective, radiation free, and objective means to evaluate patients treated with compressive orthotic bracing.
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Affiliation(s)
- Kaitlyn E Wong
- Baystate Children's Hospital, Springfield, MA; Shriners Hospitals for Children, Springfield, MA.
| | | | - David B Tashjian
- Baystate Children's Hospital, Springfield, MA; Shriners Hospitals for Children, Springfield, MA
| | - Michael V Tirabassi
- Baystate Children's Hospital, Springfield, MA; Shriners Hospitals for Children, Springfield, MA
| | - Kevin P Moriarty
- Baystate Children's Hospital, Springfield, MA; Shriners Hospitals for Children, Springfield, MA
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