Open Pectus Repair Utilizing Absorbable Sternal Bars
Daniel L Miller1, Manu S Sanchetti2
1WellStar Health System, Marietta, GA;2Emory Healthcare, Atlanta, GA
OBJECTIVES: Open pectus repair is the preferred method of choice for correction of pectus defects in adults. In the majority of patients metal bars or struts are used to solidify the repair and prevent early sternal depression. Long term results have been satisfactory; unfortunately the patient has to undergo a second procedure for bar removal, thus increasing the risk for recurrence. Recently, an absorbable bar (polylactic acid - PLA) was developed for rib fracture repair. The advantage of the absorbable bar is that it remains structurally intact for 18 to 24 months and does not require removal. To determine if absorbable bars are an acceptable alternative for posterior sternal stabilization, we introduced it into our practice and this series represents our results.
METHODS: We respectively reviewed the medical records of all patients (> 18 years of age) who underwent open repair of pectus defects at our institutions between January 2009 and December 2017. The standard open repair is a modified Ravitch anatomical repair consisting of subperichondrially removal of bilateral costal cartilages (3 through 7), anterior wedge osteotomy of sternum, mobilization of bilateral pectoralis and rectus muscle flaps, and posterior sternal support PLA bars of various combinations depending on the severity of the pectus defect.
RESULTS: Seventy-five patients underwent open repair. Median age was 31 years old (range, 18 - 72 years); 45 (60%) were men. Eighteen patients (24%) had an open repair previously at a median of 15 years (range, 2 - 24 years). Median pectus index was 4.7 (range 3.5 -11.1); 52 patients (69%) had an asymmetric defect. All 75 patients underwent posterior sternal support with PLA absorbable bars; 35 had a single doublet, 33 had a single triplet, and 7 had two doublets anchored to the ribs bilaterally. Median hospital stay was 4 days (3 - 9 days). Postoperative complications occurred in 9 patients (12%); six had a seroma and three a pneumothorax. Late complications occurred in five patients (7%), three a wound infection and two a foreign body reaction (FBR). Median follow-up was 50 months (range, 1 - 90 months). None of the patients required reoperation for a pectus recurrence, but three patients (4%) developed an incision hernia of the rectus muscles, which required repair. Two patients had bars removed for FBR. Patient satisfaction with their repair was excellent in 93% and good in 7%. One patient (2%) experienced a mild recurrence of their pectus abnormality at last follow-up (36 months) secondary to weight gain.
CONCLUSIONS: Pectus repair with placement of PLA absorbable bars for posterior sternal support provides a safe alternative to a metal bar. This series represent the first reported experience using PLA absorbable bars for posterior sternal support for open pectus repair in adults. Utilization of absorbable PLA bars should be used for all open pectus repairs to prevent early recurrence and to eliminate requirement of a second procedure for bar removal.
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