Revisiting Chest Repair Techniques: Two Unique Cases of Treating Recurrent Pectus Excavatum After Previous Surgery with Hardware Retained
Sometimes, the solutions we rely on can become part of the problem — especially when prior interventions complicate future repairs. But here's where it gets interesting: even after a long interval and the presence of retained surgical implants, advanced minimally invasive procedures like the modified Nuss approach can succeed where traditional methods might struggle.
Introduction
Pectus excavatum (PE), a common congenital deformity characterized by a sunken chest wall, often requires surgical correction to improve both appearance and function. The two main surgeries used are the Ravitch and Nuss procedures. While both techniques are generally effective, unfortunately, some patients face a recurrence of deformity even years after their initial treatment.
In particular, challenges emerge when previous surgeries involved long-term placement of hardware, such as stainless-steel struts, which can cause adhesions, complicate reoperations, or even contribute to ongoing symptoms. Yet, innovative surgical strategies can often overcome these hurdles.
Understanding the Surgical Background
The Ravitch procedure involves the removal of abnormal cartilage and repositioning of the sternum, often with the insertion of a support strut to sustain correction. Typically, these supports are meant for temporary use, ideally removed within a few months. However, in some cases, patients retain the hardware for much longer due to patient preference, clinical judgments, or other considerations.
Meanwhile, the Nuss procedure is less invasive and entails inserting a curved metal bar beneath the sternum to elevate the chest wall without removing cartilage or performing open surgeries. This method has gained popularity, especially for primary corrections, due to its minimal invasiveness.
Although both procedures work well, recurrence rates can be significant, spanning from 2% to as high as 37%, particularly when factors such as mechanical failure, premature hardware removal, or inadequate initial correction are involved. In such cases, especially when hardware remains implanted for many years, planning a second operation becomes complex.
Case 1: A Young Woman with a Long-Standing Hardware
A 26-year-old woman presented with worsening shortness of breath and heart palpitations. She had undergone a modified Ravitch operation about two decades earlier, with a stainless-steel support bar still in place. Recent symptoms prompted a detailed evaluation.
Imaging studies revealed a severe chest wall depression (Haller index of 11.87, indicating a very narrow thorax), compression of heart chambers, and the retained support strut, which had adhered to surrounding tissues.
Given these findings, a multidisciplinary team was assembled for surgical correction. With careful planning, including preoperative imaging and intraoperative thoracoscopic guidance, the surgeons proceeded with the modified Nuss procedure. They carefully dissected the old adherent support, then inserted a new, contoured metal bar to reposition the sternum. The retained strut was removed under direct visualization.
The operation went smoothly, and the patient experienced a rapid recovery. At follow-up, her chest wall deformity markedly improved, and cardiac function was better, with fewer symptoms.
Case 2: A Man with a Long-Standing Deformity and Hardware
A 29-year-old man experienced persistent chest depression and discomfort, which had gradually worsened over two months. He had a history of PE corrected with Ravitch surgery 15 years earlier, with a stainless-steel support still in place.
Diagnostic imaging, including a chest CT, showed significant chest wall depression (Haller index of 4.0) and the retained support strut. His lung capacity was reduced, and echocardiography indicated mitral-valve prolapse.
After discussing options, a modified Nuss approach was selected. The procedure involved making small incisions at the previous scar site, thoracoscopic dissection to safely remove the old support, and placing two new bars to lift and stabilize the chest wall. The surgery was completed successfully, and the patient’s symptoms improved considerably over the subsequent months.
Why Is This Approach Significant?
These cases highlight several important points:
- The modified Nuss procedure can be a viable option even for complex, recurrent cases following open surgery like Ravitch, and despite the presence of long-retained hardware.
- Thorough preoperative assessment and intraoperative imaging are critical to safely navigating around adhesions and retained implants.
- Gentle dissection and the use of thoracoscopy enhance visualization and reduce risks of injury.
Challenges and Future Directions
Recurrent pectus excavatum presents surgical difficulties not only because of scar tissue and adhesions but also due to hardware complications such as fracture, migration, or long-term retention. While early removal of supportive supports remains advisable, some patients understandably prefer to retain hardware for extended periods.
Recent advancements, including the use of modified bilateral thoracoscopy and subxiphoid incisions, allow surgeons to approach these complex cases with greater safety and efficacy. Still, questions remain: Is complete removal of hardware always necessary, or can some cases be successfully managed around retained supports? Are there optimal timing strategies for hardware removal to prevent recurrence?
Your Opinions Matter
These innovative approaches open up discussions about best practices: Should we prioritize early hardware removal, or can patience and advanced surgical techniques suffice? Do you believe minimally invasive methods can become standard for all recurrent cases? Share your thoughts and experiences — is this method the future of reoperative chest wall surgery, or are there situations where open approaches still reign supreme?
Final Thoughts
In sum, these two cases demonstrate that in the hands of skilled surgeons, with meticulous planning and modern techniques, even long-standing hardware-related recurrent pectus excavatum can be effectively and safely corrected using the modified Nuss procedure. As research continues, defining optimal timing and management strategies will help improve outcomes for all patients with this challenging deformity.
