What is the treatment for pectus carinatum?

Treatment of Pectus Carinatum

For skeletally immature patients with pectus carinatum, initiate dynamic compression bracing as first-line treatment, worn 23 hours daily until correction is achieved, then transition to 8-hour nocturnal maintenance bracing until skeletal maturity. 1, 2

Initial Assessment and Treatment Selection

Mandatory Cardiac Evaluation

• Perform complete cardiac evaluation when genetic syndromes are suspected (Marfan syndrome, Noonan syndrome, or other connective tissue disorders), as pectus carinatum may be a phenotypic manifestation requiring comprehensive cardiac workup 3, 4
• In Marfan syndrome, pectus carinatum scores 2 points in the systemic features scoring system (versus 1 point for pectus excavatum), necessitating thorough aortic assessment 5
• Noonan syndrome patients may have associated cardiac alterations such as pulmonary stenosis 3, 4

Bracing Protocol (First-Line Treatment)

Correction Phase:

• Fit a lightweight, patient-controlled dynamic chest brace 1
• Wear 23 hours per day until the convex deformity is corrected 1
• Mean correction time is 4.3 months (±2.1 months) 1
• Monitor pressure of correction (POC) monthly—successful patients demonstrate a 50% decrease in POC within the first month 2
• If POC does not fall by 50% within the first month, consider proceeding to surgery rather than continuing bracing 2

Maintenance Phase:

• After correction, reduce bracing to 8 hours per day (nocturnal) 1
• Continue until axial skeletal maturation ceases 1
• Monitor for recurrence (occurs in approximately 5% of cases, average 5.4 months after correction) 2

Expected Bracing Outcomes

• Success rate: 40% complete correction in compliant patients 2
• Dropout rate: 32% due to noncompliance 2
• Failure rate: 7% despite compliance 2
• Significant objective improvement in pectus carinatum protrusion (pre-treatment 22±6mm vs post-treatment 6.0±6.2mm) 1

Surgical Indications

Proceed directly to surgery without bracing trial in:

• Patients with rigid, non-compressible chest walls 6
• Skeletal maturity already achieved 7
• Patient preference after informed discussion 2

Proceed to surgery after failed bracing in:

• Patients who fail to show 50% reduction in POC within first month 2
• Noncompliant patients who cannot maintain bracing schedule 1, 2
• Patients with persistent deformity after adequate bracing trial 2

Surgical Options

Open Ravitch Procedure (Preferred):

• Most reliable with no recurrence reported 2
• Complication rate: 2% infection 2
• Best long-term durability 2

Minimally Invasive Abramson Procedure:

• Involves presternal bar placement with bilateral costal arch fixation 6
• Bar remains for approximately 1 year 6
• Caution: High revision rate (48%), early bar removal rate (26%), and infection rate (13%) 2
• Consider only in highly selected cases with compressible chest walls 6

Critical Pitfalls to Avoid

• Reactive pectus carinatum: Monitor all pectus excavatum repair patients for development of carinatum deformity within the first 6 postoperative months 8
• Overcorrection to pectus excavatum: Occurs in 0.4% of bracing patients—requires vigilant monitoring 2
• Premature discontinuation of maintenance bracing: Leads to 5% recurrence rate 2
• Continuing failed bracing: If POC does not decrease by 50% in first month, transition to surgical planning rather than prolonging ineffective bracing 2