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Correction of a severe pectus carinatum by sterno-costo-
chondroplasty with double osteotomy and triple rib bridge fixation
Pectus carinatum or keel chest is a congenital chest wall deformity
with anterior protrusion of the sternum, the costal cartilages and the
ribs. We herein report the case of a severe chondrogladiolar keel
chest, corrected by sterno-costo-chondroplasty with double sternal
osteotomy and three costal titanium osteosynthesis.
A 15-year-old boy with Marfan syndrome was referred to our
institution for severe pectus carinatum (Fig. 1), resulting in a major
psychosocial impact and impaired quality of life.
Surgery involved a transverse sub-mammary incision, followed
by the mobilization of a pectoralis major flap cranially and cau-
dally (Fig. 2a). The chondro-sternal ends of the second to seventh
rib were freed with sub-perichondrial resections, and the xiphoid
process was detached from the sternum. Two transverse sternal
osteotomies were performed, creating a double green-branch frac-
ture below and above the manubriosternal angle, thus correcting
the sternal angulation (Fig. 2b,c). A 4 cm portion of the lower
end of the sternum was then resected to restore a straight bone.
The angulations of the second to the seventh ribs were corrected
with costal anterior cortical release osteotomies.
The osteotomies were stabilized with X polydioxanone sutures.
The cartilages and the xiphoid appendix were sutured to their respec-
tive edges of the sternum with vicryl sutures. The reconstruction was
stabilized with a STRATOS (Strasbourg Thorax Osteosynthesis Sys-
tem; MEDXPERT, Heitersheim, Germany) titanium device: clips
were fixed to the lateral parts of the third, fourth, and fifth ribs and tita-
nium connecting bars were curved and positioned in front of the ster-
num (Fig. 2d). The muscle flap was sutured above four suction drains.
Fig. 1. Pre-operative frontal and profile view
of the chest deformity.
© 2018 Royal Australasian College of Surgeons
The post-operative course was uneventful. Follow-up at 3 months
demonstrated an excellent cosmetic result (Fig. 3). Titanium bars
withdrawal is scheduled 18 months after surgery.
The chondrogladiolar type is the most common type of pectus
carinatum, and presents with a protrusion of the inferior part of the
sternum.1 Keel chest has mainly a psychosocial impact, as the
deformity becomes more obvious during adolescence.2
In the present case, the severity of the chest wall deformity pre-
cluded any minimally invasive or conservative approaches.3,4 Fur-
thermore, it required a double osteotomy of the sternum, while
usually, a single osteotomy is required, and more extensive chon-
drotomies, up to the second rib.5,6
Additionally, three titanium bars were fixed in order to stabi-
lize the reconstruction. While some authors recommend a bar-
free reconstruction,5,7 the severity of the deformation and the
potential re-growth of the cartilages warranted an additional sup-
port. The use of titanium rib bridge fixation is based on the
flexibility of the titanium, that allows an accurate tailoring of
the connecting bars, and enables micro-movements, thereby
reducing bending and torsional loading.8,9 The titanium bars are
usually kept in situ for 2 years. The patient is closely followed
with chest X-rays until the removal of the bars, considering their
potential risk of fracture.10 The removal of the titanium bars is
a straightforward procedure requiring a short hospitalization.
Under general anaesthesia, through the previous incision site,
the fixation device is dissected in the subcutaneous tissue and
pulled out. The connecting bars are then mobilized and
withdrawn.
ANZ J Surg (2018)
2 Images for surgeons
This case demonstrates successful management of a severe keel
chest using an updated technique of sterno-costo-chondroplasty
with double osteotomy and three costal titanium osteosynthesis.
References
1. Park CH, Kim TH, Haam SJ, Jeon I, Lee S. The etiology of pectus cari-
natum involves overgrowth of costal cartilage and undergrowth of ribs.
J. Pediatr. Surg. 2014; 49: 1252–8.
Fig. 2. (a,b) Per operative view of the chest
wall after mobilization of the pectoralis major
flap. The white arrows highlight the location
of the sternal osteotomies, the black arrows
the sub-perichondrial costal resections, and
the oblique white arrows the costal release
osteotomies, respectively. (c) Green-branch
fracture of the sternum allowing the correc-
tion of the sternal angulation, before removal
of the lower part of the sternum.
(d) Stabilization of the reconstruction with
titanium rib bridges. Picture (a) was taken
from the side and picture (b), (c) and
(d) were taken from the head of the operat-
ing table.
Fig. 3. Post-operative frontal and profile
view of the chest.
2. Knudsen MV, Grosen K, Pilegaard HK, Laustsen S. Surgical correction
of pectus carinatum improves perceived body image, mental health and
self-esteem. J. Pediatr. Surg. 2015; 50: 1472–6.
3. Cohee AS, Lin JR, Frantz FW, Kelly RE. Staged management of pectus
carinatum. J. Pediatr. Surg. 2013; 48: 315–20.
4. Yuksel M, Lacin T, Ermerak NO, Sirzai EY, Sayan B. Minimally inva-
sive repair of pectus carinatum. Ann. Thorac. Surg. 2018; 105: 915–23.
5. Robicsek F, Watts LT. Pectus carinatum. Thorac. Surg. Clin. 2010; 20:
563–74.
© 2018 Royal Australasian College of Surgeons
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6. Fonkalsrud EW, Beanes S. Surgical management of pectus carinatum: Marion Mauduit,* MD

30 years’ experience. World J. Surg. 2001; 25: 898–903. Karl Bounader,* MD
7. Bezuska L, Mussa S, Muthialu N. Chest wall reconstruction in Marfan Reda Belhaj Soumai,* MD
syndrome following aortic root replacement. Asian Cardiovasc. Thorac. Marie Aymami,* MD
Ann. 2014; 22: 872–4.
Antoine Roisné,* MD
8. Brichon P-Y, Wihlm J-M. Correction of a severe pouter pigeon breast
Jean-Marie Wihlm,† MD
by triple sternal osteotomy with a novel titanium rib bridge fixation.
Ann. Thorac. Surg. 2010; 90: e97–9.
Jean-Philippe Verhoye,* MD, PhD
9. Stefani A, Nesci J, Morandi U. STRATOS™ system for the repair of *Department of Thoracic and Cardio-Vascular Surgery, Rennes
pectus excavatum. Interact. Cardiovasc. Thorac. Surg. 2013; 17: University Hospital Center, Rennes, France and †Department of
1056–8. Thoracic Surgery, Cochin University Hospital, Paris, France
10. Sharma PK, Willems TP, Touw DJ, Woudstra W, Erasmus ME,
Ebels T. Implant failure: STRATOS system for Pectus repair. Ann. doi: 10.1111/ans.14721
Thorac. Surg. 2017; 103: 1536–43.

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