What is Pectus Arcuatum (Mixed Deformity) ?

It is the rarest type of congenital thoracic all deformity. Carinatum deformity is seen on one side, while excavatum deformity may accompany on the other side. A group of these types of deformities are called as pectus arcuatum (Chondromanubrial). “Chondromanubrial” deformities are the rarest form among pectus deformities. Typically, in this form which is referred to pigeon breast, protrusion occurs on the upper costal cartilages and upper corpus of sternum (breastbone), sternum is sunken inwards. Cardiac anomalies are more often in this type. Apart from Pectus arcuatum, these group of deformities are also seen as mixed type asymmetrical and mixed type symmetrical deformities. Although less common than other pectus types, mixed deformities are the most difficult forms in terms of diagnosis and treatment. Typically, mixed deformities are a combination of both excavatum and carinatum. The incidence of mixed type pectus deformities is around 14 in thousand.

Pectus Arcuatum Sample

Pectus Arcuatum - Before Surgery - After Surgery

Causes

Cause of these form of deformities could not be exactly explained. It is characterized by hyperplasia of the costal cartilages and displacement and forward protrusion of the sternum. Very often, it occurs immediately after birth.

Signs

Except uneven appearance, it does not show any symptom. Children who are disturbed by the appearance of their thoracic cage avoid swimming or gym classes in their schools.

Diagnosis

Usually physical examination is adequate to diagnose this form of deformity. No specific test like blood test is needed, however severity of the deformity can be determined by radiological evaluation. Computed Tomography (CT) and Magnetic Resonance (MR) are the best imaging methods that can be used.

Treatment

Abramson procedure, which is very efficient in symmetrical deformities, does not provide an effective improvement in mixed deformities. Open surgery techniques are the most frequently preferred technique in these patients. However open surgery is not the only option for the treatment of mixed type pectus deformities compared to Pectus excavatum and carinatum deformities. Combination of closed surgery techniques used in the other deformities can only be performed in asymmetrical and symmetrical mixed deformities. There are two types of surgical techniques used in this area:

Sandwich surgeries in pectus deformities can be successfully performed in mixed type deformities where pectus carinatum and pectus excavatum deformities are found together. In the surgery to be performed, the dislocated chest is collapsed by first placing the carinatum bar (Abramson bar). In the second stage, one or two Nuss bars are placed on the collapsed parts of the chest wall with the Nuss surgery technique. We have successfully performed sandwich surgery on 55 patients (53 males and 2 females) with an average age of 18.9 years (the youngest is 14 and the oldest is 27).

Open surgery correction performed in pectus arcuatum and described by Dr. Onen can be summarized as a technique consisting of a combination of the technique performed by Wang for pectus carinatum using titanium plates and screws, and the Nuss procedure. At the level where the carinatum deformity is most protruded, the bone is almost “filed”. This procedure is called “wedge osteotomy by oscillator blade”. This wedge osteotomy line is fixed using a titanium plate and the pectus bar is placed at the point where the excavatum deformity is most sunk. In this procedure which lasts on average one hour, no large incision is made as in the Ravitch and similar surgical techniques and thus it provides advantages such as postoperative recovery time. Cosmetic outcomes are also satisfactory. The bar inserted is observed for up to 1 year and then removed. With its low rates of complications and high patient satisfaction levels, this method can be preferred particularly for the surgical treatment of patients with pectus arcuatum type mixed pectus deformity.