What is the best management approach for pectus carinatum?

From the Guidelines

The best management approach for pectus carinatum is typically external bracing, particularly for adolescents with flexible chest walls. Treatment should begin with evaluation by a pediatric surgeon or specialist in chest wall deformities who can determine the severity and flexibility of the protrusion. For most patients, a custom-fitted external compression brace worn for 12-23 hours daily for 6-12 months is the first-line treatment, with the exact duration depending on deformity severity and patient compliance. The brace works by applying consistent pressure to the protruding sternum, gradually remodeling the costal cartilage while the chest wall remains malleable during growth.

Key Considerations

• Surgical correction (modified Ravitch procedure or minimally invasive techniques) is reserved for severe cases, patients with rigid chest walls, those who have completed skeletal growth, or when bracing fails.
• Physical therapy focusing on posture correction and chest exercises may complement bracing.
• Regular follow-up appointments every 2-3 months are essential to monitor progress and adjust treatment.
• This approach is preferred because bracing is non-invasive, has high success rates (over 80% in compliant patients), and avoids the risks associated with surgery.

Rationale

The provided evidence does not directly address the management of pectus carinatum, but the general principles of treating similar conditions suggest a conservative approach when possible. Given the lack of direct evidence, the recommendation is based on general medical knowledge and the principle of minimizing invasive procedures when effective non-invasive options are available.

Management Principles

• Evaluation by a specialist to determine the severity and flexibility of the protrusion.
• Use of a custom-fitted external compression brace as first-line treatment.
• Reservation of surgical correction for specific cases where bracing is not suitable or has failed.
• Consideration of physical therapy as a complementary treatment.
• Regular follow-up to monitor progress and adjust the treatment plan as necessary.

From the Research

Management Approaches for Pectus Carinatum

• Dynamic compression system (DCS) bracing and surgery are two common treatment options for pectus carinatum, with DCS bracing being the preferred choice due to its noninvasiveness and lower complication rate 1.
• The success rate of DCS bracing decreases with increasing pressure of initial compression, and patients with Marfan syndrome or Poland syndrome tend to have poorer outcomes 1.
• Ravitch surgery has a higher success rate, but is also associated with a higher complication rate, including the need for additional surgery in some cases 1.
• Reactive pectus carinatum can occur as a complication of pectus excavatum repair, and may require early bar removal or surgical resection 2.

Treatment Considerations

• Patient motivation and compliance are crucial factors in the success of DCS bracing treatment 1.
• Bracing patients before their growth spurt is not recommended, as it may lead to poorer outcomes 1.
• The Combined Ravitch and Nuss procedure is a novel approach that may be useful for patients with severe pectus excavatum, but its application to pectus carinatum is not well established 3.
• The Nuss procedure can be used to repair recurrent pectus excavatum after failed Ravitch procedure, but its use in pectus carinatum is limited 4.
• A modified Nuss technique has been described for pectus carinatum, which may reduce the risk of cardiac perforation and avoid the need for the Ravitch procedure 5.