Pectus - Surgical Approaches for Failed Repair

About 30% of Don's practice is revision pectus surgery, not all his own cases.

Reported recurrence rates vary widely; some sites report almost no recurrence, others fairly high rates. The true incidence is unknown because many patients don't report back to centers.

In Don's original adult open Ravitch series with Fonkalsrud at UCLA, the reported recurrence rate was about 5%, but over the last 10 years at least 20 patients from that series contacted him wanting revision because they recurred.

Nuss revision cases recur for different reasons than open Ravitch cases: Nuss failures are more related to technical issues (bar positioning, bar rotation, early removal), whereas open cases involve healing issues, malunion, and regression.

Once Nuss bars rotate, their ability to put pressure and elevate the chest wall is lost, and they usually cause pain.

The most common Nuss failure Don sees in adults is lateral stripping: the bar looks perfect on frontal X-ray but has stripped posteriorly on lateral view, losing forward elevation and sometimes causing cardiac obstruction or compression of lower lobes, diaphragm, and liver.

In the adult population, the chest is often so stiff and rigid that the intercostal spaces cannot support the pressure of the bar, so they rip out, spread wider, and drop the bar in. Pressure also makes it easier for bars to rotate.

Don uses forced sternal elevation (Rultract), reinforces intercostal spaces on heavier adults (initially only on spaces that stripped during bar placement, now preemptively if there is any chance of lateral stripping), fixes bars medially, uses multiple bars, and performs releasing osteotomies if elevation is inadequate.

The Rultract is a retractor used to hold the chest up during internal mammary harvest for heart bypass; Don attaches a bone clamp to the sternum and lifts, creating an open space for dissection and reducing force during bar rotation.

Don initially used the Rultract only on complicated cases but now uses it on almost all cases for safety and ease.

Don reinforces intercostal spaces with FiberWire (a woven PTFE suture) in a figure-of-eight around the ribs and bar to prevent the ribs from separating and allowing the bar to drop in and strip further.

About 30% of Don's patients now receive three bars to balance the defect. A single bar in the center is not enough for heavier, stiffer chests and causes tremendous pain; balancing the defect reduces pain and risk of movement and stripping.

Don uses FiberWire (not stabilizers) to catch at least three ribs. On lower bars, he makes a small incision over the sternum, drills a hole, and passes suture to loop around the sternum and bar in the center to ensure bars do not rotate.

In a 28-year-old revision case with severe pain, residual defect (Haller 4.6), and rotated 17-inch bar with lateral stabilizer, Don removed the long bar, used the Rultract, reinforced intercostal spaces, and placed two 14-inch bars, achieving good correction.

In a 20-year-old with two bars that failed to elevate and developed a left-sided carinatum, Don removed the two 15-inch bars, used the Rultract, and placed two 12.5-inch bars. The carinatum was compressible on exam and was tied down to the bar with sutures, correcting the defect.

A 49-year-old woman had three prior OR visits (two Nuss attempts and a reoperation for bleeding), severe pain, residual Haller 4.9, and cardiac compression from an intrathoracic, laterally migrated bar. Don spent about 4 hours lysing adhesions (pericardium stuck, history of pericarditis and effusion), then used the Rultract to lift the chest and placed two bars with intercostal reinforcement. She did well postoperatively.

The hosts report that since visiting Mayo and attending the Phoenix course, they use the Rultract on almost all cases, finding it makes dissection easier, safer, and provides better visualization.

Don's bar-length criterion: 2–3 cm overlap around the lateral chest curve, catching one of the side ribs but not wrapping all the way to the back. This is harder to judge in women (breast tissue) or heavier patients.

In Don's series of over 300 adults (more than 200 over age 30), almost all patients under 30 could be lifted with the Rultract and Lorenz dissector (only a couple could not). In the over-30 group, 88.7% could be lifted, but 11–12% would not lift and required osteotomies.

If a chest does not lift with forced elevation, bars alone will not make it lift—they are not strong enough. Patients with bars that did not lift initially will not lift eventually by keeping the bars in longer.

Don performs a mini-osteotomy when the chest will not lift: makes cuts to free the cartilages from the sternum at the site that won't lift, then shortens the cartilages (like a cartilage-sparing Ravitch) to allow them to come back down. Sometimes a second releasing cut is needed.

Don often places a small plate across the osteotomy site if it is trying to lift up.

In a bodybuilder with a very severe, completely rigid chest, Don attached two clamps in separate areas and tried to lift, but snapped the sternum in half. He then performed a small midline incision, finished the sternal osteotomy, released a couple of side cartilages, and achieved a nice repair.

In an older gentleman with a severe round defect, the chest lifted except for one lower left rib cartilage that was stuck. Don made a small incision over that cartilage, sliced it, and the chest came up. Sometimes only one or two sites are fixing the chest, so a big conversion is not always necessary.

Don calls his approach a 'hybrid repair': once the chest is lifted (with or without osteotomies), he places bars just like a regular Nuss patient.

Don initially did not plate osteotomy sites (used suture like in old Ravitch), but found they would knob up and not look cosmetically nice. Now he places a small plate to stabilize them, and they heal very nicely.

In older patients with calcified cartilage, the classic cartilage-sparing perichondrial dissection is often not feasible because everything is stuck and messy. Don starts with a slicing osteotomy to free the cartilage from the sternum, then when the sternum is up, the cartilage is often redundant and must be shortened by taking a segment out.

If osteotomies are needed, they must be done open (not thoracoscopically). Don uses an osteotome to open the cartilage, but sometimes the tissue is bone and he must use a mini sternal saw.

After an osteotomy, the rib must be stabilized with a stitch or plate; otherwise it will not stay down and will elevate and stick up because the chest alignment has changed.

Don tried doing carinatum repairs minimally invasively from the inside but did not get good cosmetic results. Now, with a small incision, he can do a lot and achieve very nice results.

Redo open pectus cases fall into three categories: those that didn't get support and just fell in (can be re-Nussed, lift nicely); those that are fixed and require osteotomies; and big disasters with holes in the chest and malunion.

Patients with any evidence of hernia, malunion, or thoracic dystrophy are automatically open cases. All others are attempted with the Rultract like primaries; if they lift, bars are placed; if not, Don converts to a small incision with osteotomies.

Don preps all redo open cases with groins exposed in case of life-threatening bleeding, allowing cannulation for bypass through the groin.

Don plates all redo open cases anteriorly in addition to placing posterior bars. He learned early on that patients who had only bars and no anterior plating recurred again when the bars were removed.

A 45-year-old man had a Ravitch two years prior; his Haller is now 8.3, two points higher than before surgery. Don found one abnormally fused spot, cut it, placed a plate, and used three bars. The patient elevated quite nicely with no other malunion.

Malunion or pseudarthrosis is identified on CT by ribs not attached to the midline. Physical exam is more reliable than CT for assessing malunion. Worst-case scenario is a floating sternum.

Patients with malunion have a lot of pain and inability to Valsalva. The Haller index can be almost normal, so they are often told by multiple physicians that they are fine despite having symptoms.

Reconstruction of malunion cases requires stabilization, often with bone graft or methylmethacrylate filler to fill spaces, mesh, and definitely plating.

A 28-year-old had a Ravitch at age 15 and chronic chest pain since. On exam, severe malunion with the whole chest wall moving; paradoxical movement on coughing. Haller index only 3.4. Intraoperatively, sternum completely separate from both sides of chest wall. Don placed two posterior bars, cleaned edges to viable tissue, plated across, and used biologic mesh in the middle because the pec muscles had atrophied and lateralized, leaving a segment that wouldn't cover the plates. Covering everything is important in skinny patients.

A 62-year-old runner had a prior Ravitch with excision, two pectus bars in place, and a big hole in the front of his chest. He could see his heart falling out when running. Don laparoscopically mobilized omentum, pulled it through the diaphragm, used methylmethacrylate to recreate the lower chest wall, secured it with plating, and covered with omentum. At 1.5 years postop, no recurrence, no symptoms, back to running marathons.

A 47-year-old woman (referred by Doctor Garcia) had a Ravitch with Bioridge plating about a year prior, severe chronic pain, Haller 4.0. CT showed inflammatory fibrous mass. Intraoperatively, partially disintegrated material behind the sternum, between cartilages, free edge with malunion, nothing healed. Don debrided to viable tissue, placed posterior bars, used cadaveric bone graft paste with biologic mesh to fill spaces, and stabilized lower detached costal cartilages with titanium plating. Bars not yet removed; chronic pain is a big problem and stabilization does not always fix it.

A 50-year-old trumpet player had a Ravitch with revision three years prior, has been on disability with chronic narcotic dependence, cannot play trumpet or breathe well. Seen by 10 physicians who told him he was fine. Inspiratory Haller 2.2, but expiratory Haller 5.0 with collapse of the whole left side and a huge hole. Intraoperatively, lung herniating through chest wall, recurrence and collapse of right side with no support into the pericardium. Don used methylmethacrylate, posterior bars, and anterior plating. Patient did very well, back to playing trumpet and normal life. Bars removed at 2 years; anterior plates left in; no recurrence.

When deciding how many revisions are too many, it depends on what has been done. If bars were placed and then removed and the patient collapsed, there are other issues to address. If a patient has had bars, plating, and multiple procedures and is still collapsing—especially with a connective tissue disorder or a chest that won't heal—you start getting into infections, more osteonecrosis, and other issues, and it becomes hard to know when to stop.

Don and Doctor Sawyer have a joint patient who has been operated on 8 times (many by Don). It's hard because you get into a cycle with these patients, chasing one problem area after another. Many are litigious, which can become a big issue.

Doctor Garcia emphasizes that the best operation is the first operation. Despite the Nuss procedure appearing simple, there is a significant learning curve, and it is not a 'see one, do one' operation. This has not received the necessary attention.