What is the treatment for pectus carinatum?

Treatment of Pectus Carinatum

For skeletally immature patients with flexible pectus carinatum, initiate dynamic compression bracing worn 23 hours daily until correction is achieved, then transition to 8-hour nocturnal maintenance bracing until skeletal maturity; reserve surgery for brace failure, noncompliance, or rigid deformities. 1, 2

Initial Assessment and Patient Selection

Evaluate Chest Wall Flexibility

• Test compressibility of the protrusion by manual pressure—flexible deformities respond to bracing while rigid deformities require surgery 3, 4
• Flexible pectus carinatum is the primary indication for conservative bracing treatment 4

Screen for Associated Genetic Syndromes

• Perform complete cardiac evaluation when Marfan syndrome, Noonan syndrome, or other connective tissue disorders are suspected 5, 6
• In Marfan syndrome, pectus carinatum scores 2 points in the systemic features scoring system (versus 1 point for pectus excavatum) 7
• Noonan syndrome patients may have concurrent cardiac lesions like pulmonary stenosis requiring evaluation 5, 6
• Assess for mitral valve prolapse, particularly in connective tissue syndromes 5

First-Line Treatment: Dynamic Compression Bracing

Bracing Protocol

• Correction Phase: Wear lightweight, patient-controlled chest brace for 23 hours daily until the convex deformity is corrected 1
• Maintenance Phase: Reduce to 8 hours daily (nocturnal bracing) until axial skeletal maturation ceases 1
• Average correction phase duration is 4.3 months 1

Monitoring Response to Treatment

• Pressure of Correction (POC) is the key predictor of success—successful patients show a 50% decrease in POC beginning one month after starting treatment 2
• If POC does not fall after initial treatment period, consider this a predictor of brace failure and transition to surgical planning 2
• Monitor external pectus carinatum protrusion measurements and subjective appearance 1

Expected Outcomes with Bracing

• Success rate of 40% in compliant patients who complete treatment 2
• Significant objective improvement in protrusion (pre-treatment 22±6 mm vs post-treatment 6.0±6.2 mm) 1
• Recurrence occurs in approximately 5% of cases, typically 5.4 months after treatment completion 2
• Rare overcorrection to pectus excavatum (0.4% of cases) 2

Common Pitfalls

• Patient compliance is paramount—dropout rates reach 32% in some series 2
• Noncompliance accounts for 12.5% of treatment failures 1
• Diligent follow-up is essential for treatment success 1

Surgical Intervention

Indications for Surgery

• Brace failure (lack of POC reduction after initial treatment period) 2
• Patient noncompliance with bracing protocol 2
• Rigid, non-compressible deformities 3, 4
• Patient preference or special circumstances (15% of patients in one series) 2
• Mixed deformities with excavatum on one side and carinatum on the other 2

Surgical Options

Open Repair (Ravitch Technique)

• Most reliable option with no recurrence reported in recent series 2
• Complication rate of 2% (primarily infection) 2
• Traditional gold standard for pectus carinatum correction 8

Minimally Invasive Repair (Abramson Procedure)

• Involves presternal bar placement with bilateral fixation to posterolateral costal arches 3
• Bar remains implanted approximately 1 year until chest wall remodeling achieved 3
• Significant complication profile: 48% revision rate, 26% early bar removal rate, 13% infection rate, and 13% recurrence rate 2
• Given high complication rates with currently available implants in the U.S., open repair remains preferable for most surgical candidates 2

Nuss Procedure

• Reserved for patients who develop excavatum overcorrection following bracing or have mixed deformities 2

Special Surgical Considerations

• Patients with kyphoscoliosis and pectus carinatum may have cardiac migration to the left hemithorax, limiting surgical working angles 5, 6
• Osteogenesis imperfecta patients may have more severe restrictive respiratory patterns requiring careful preoperative assessment 6

Treatment Algorithm Summary

1. Assess flexibility of chest wall deformity
2. Screen for genetic syndromes with complete cardiac evaluation if suspected
3. Initiate bracing for flexible deformities in skeletally immature patients (23 hours daily)
4. Monitor POC at 1 month—if no 50% reduction, consider surgical consultation
5. Continue bracing if POC decreases appropriately until correction achieved
6. Transition to maintenance phase (8 hours nocturnally) until skeletal maturity
7. Proceed to open surgical repair for brace failures, rigid deformities, or noncompliance