Surgical Correction Of Pectus Excavatum Research Articles

МИНИИНВАЗИВНАЯ ТОРАКОПЛАСТИКА У ПАЦИЕНТОВ С ВОРОНКООБРАЗНОЙ ДЕФОРМАЦИЕЙ ГРУДНОЙ КЛЕТКИ

The article is devoted to a description of our own observations and treatment of patients with pectus excavatum. It is noted that approaches to surgical treatment of patients with pectus excavatum require increased efficiency and safety, which makes this issue relevant. Attention is focused on videothoracoscopic technologies in the form of inserting a plate under the sternum under the control of a videothoracoscopy. It has been established that the operation using the Nuss technique is the optimal method of surgical correction of pectus excavatum. The main advantage of surgery using the Nuss method is a good cosmetic effect and a stable long-term correction result. The use of thoracoscopic navigation reduces the risk of intraoperative complications, minimizes blood loss, reduces the invasiveness of the intervention, and reduces the duration of the operation and the patient’s time in the hospital.

Клінічні результати використання протоколу прискореного відновлення дітей після корекції лійкоподібної деформації грудної клітки

The funnel-shaped deformity of the chest is the most common defect of the chest, which can cause cosmetic problems, but also a decrease in tolerance to physical activity, cause fatigue, shortness of breath and chest pain. The application of the enhanced recovery protocol and rehabilitation interventions after Nuss procedure are poorly described in the literature. Purpose - to evaluate the clinical results of using a modified protocol of enhanced recovery after surgical correction of pectus excavatum in children. Materials and methods. The results of the treatment of 79 patients with a funnel-shaped chest deformity aged (14.2±1.6) who underwent surgical correction of the deformity according to Nuss method were analyzed. Two groups of patients were analyzed, according to the protocol of postoperative management: the Group I (n=20) - patients of traditional postoperative management, the Group II (n=59) - according to the the enhanced protocol of recovery. In the Group II, psychological and physical training was additionally included in the preoperative plan. Results. The groups were the same in terms of age, Haller index, and time of surgery (p>0.05). The length of stay in the hospital was significantly (p<0.001) shorter in patients of the Group II. The use of the epidural analgesia method in patients of the Group II made it possible to significantly reduce both the dose and the duration of taking opioid analgesics to 1 day, in contrast to the Group I (up to 3 days). The lack of pleural drainage enabled the patient to become more active after a day - to get up, walk, and take some procedures. Conclusions. The protocol of the enhanced postoperative recovery, which includes a program of rehabilitation treatment, early removal of the urinary catheter and early verticalization of the patient, improves the quality of recovery of patients after reconstruction of funnel-shaped deformity of the chest and reduces the length of stay of patients in hospital treatment after surgery. The research was carried out in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the Local Ethics Committee of the participating institution. Informed consent of the patients was obtained for the research. No conflict of interests was declared by the authors.

Outcomes of the Nuss procedure in children with pectus excavatum: 14 years of experience.

We aimed to assess the effectiveness of the Nuss procedure for pectus excavatum (PE) and explore the impacts of sex and age on outcomes. We retrospectively reviewed 594 consecutive children ≤18 years of age who underwent the thoracoscopy-assisted Nuss technique between January 2006 and July 2019. The severity of pectus deformity was calculated according to the Haller index (HI). The classification of PE and clinical data including complications was analyzed. Of the 594 patients, 456 (76.8%) were boys and 138 (23.2%) were girls. The mean age at surgery was 10.0 ± 5.0 years. The most common types of PE were 1A and 2A2 according to Park classification. Intraoperative and postoperative complication rates were 2/594 (0.3%) and 74/594 (12.5%), respectively. The most common complication was bar displacement. The bar was removed in 414 patients 3.5 ± 0.8 years later. The mean preoperative HI, postoperative HI with bar, and HI after bar removal were 4.2 ± 1.7, 2.4 ± 0.3, and 2.7 ± 0.5, respectively. Compared to the preoperative HI, both the postoperative HI with bar and HI after bar removal were significantly lower ( p < 0.001). For preschool-age children, the preoperative HI was significantly higher ( p = 0.027) and the change in HI significantly improved compared to school-age children ( p = 0.004). Boys and adolescents needed significantly more bars and stabilizers. Surgical correction of PE using the Nuss procedure is a safe procedure and improves the HI in children of different ages, even in those younger than 6 years of age.

Intercostal spinal nerve cryoablation for analgesia following pectus excavatum repair

Pectus excavatum is a common chest wall deformity, most often treated during adolescence, that presents a significant postoperative pain control challenge for pediatric surgeons following surgical correction. The purpose of this article is to review the technique and outcomes of intercostal spinal nerve cryoablation for postoperative analgesia following surgical correction of pectus excavatum. Contemporary and historic literature were reviewed. Findings are summarized to provide a concise synopsis of the benefits of intercostal spinal nerve cryoablation relative to alternative analgesic modalities, as well as advocate for more widespread inclusion of this technique into multimodal pain regimens.

Intercostal Nerve Cryoablation Reduces Opioid Use and Length of Stay Without Increasing Adverse Events: A Retrospective Cohort Study of 5442 Patients Undergoing Surgical Correction of Pectus Excavatum.

To examine differences in opioid use, length of stay, and adverse events after minimally invasive correction of pectus excavatum (MIRPE) with and without intercostal nerve cryoablation. Small studies show that intraoperative intercostal nerve cryoablation provides effective analgesia with no large-scale evaluations of this technique. The pediatric health information system database was used to perform a retrospective cohort study comparing patients undergoing MIRPE at children's hospitals before and after the initiation of cryoablation. The association of cryoablation use with inpatient opioid use was determined using quantile regression with robust standard errors. Difference in risk-adjusted length of stay between the cohorts was estimated using negative binomial regression. Odds of adverse events between the two cohorts were compared using logistic regression with a generalized estimating equation. A total of 5442 patients underwent MIRPE at 44 children's hospitals between 2016 and 2022 with 1592 patients treated after cryoablation was introduced at their hospital. Cryoablation use was associated with a median decrease of 80.8 (95% CI: 68.6-93.0) total oral morphine equivalents as well as a decrease in estimated median length of stay from 3.5 [3.2-3.9] days to 2.5 [2.2-2.9] days ( P value: 0.016). Cryoablation use was not significantly associated with an increase in any studied adverse events. Introduction of cryoablation for perioperative analgesia was associated with decreased inpatient opioid use and length of stay in a large sample with no change in adverse events. This novel modality for perioperative analgesia offers a promising alternative to traditional pain management in thoracic surgery.

Measurement and Thermodynamic Modeling of Energy Flux During Intercostal Nerve Cryoablation

IntroductionIntercostal nerve cryoablation is an increasingly adopted technique to decrease postoperative pain in patients undergoing surgical correction of pectus excavatum (SCOPE). Concerns regarding cryo-induced systemic hypothermia have been raised in pediatric patients; however, assessment of a cooled cryoprobe on body temperature has not been performed. We aimed to determine the energy flux from a maximally cooled cryoprobe and model the possible effects on a whole-body system. MethodsTo directly measure energy flux, a maximally cooled cryoSPHERE probe (AtriCure, Inc, Mason, OH) was isolated in a well-mixed water bath at 37°C. Real-time temperatures were recorded. Three models were created to estimate intraoperative flux. Perioperative temperatures of 50 patients who received cryoablation during SCOPE were compared to 50 patients who did not receive cryoablation. ResultsDirect calorimetry measured average energy flux of the maximally cooled cryoprobe to be 28 J/s. Thermodynamic modeling demonstrated the following: 1) The highest possible cryoprobe flux is less than estimated basal metabolic rate (BMR) of the average teenager undergoing SCOPE and 2) Flux in a best model of human tissue energy transfer using available literature is far less than the effects of BMR and insensible losses. Clinically, there were no significant differences in the minimum intraoperative, end procedure or first postoperative body temperatures for patients who received cryoablation and those who did not. ConclusionsCryoprobe flux is significantly fewer joules per second than BMR. Furthermore, in a clinical series there were no empiric differences in body temperature due to cryoablation employment, contradicting concerns regarding hypothermia secondary to cryoablation.

Change in cardiorespiratory parameters following surgical correction of pectus excavatum: protocol for the historical-prospective HeartSoar cohort

IntroductionHow cardiorespiratory function changes following the surgical correction of pectus excavatum (PE) often gives mixed results, with meta-analyses demonstrating no benefit in terms of pulmonary function but improvement in cardiac...

ID: 204376 Pectus Excavatum Intercostal Neuralgia Relief With Peripheral Nerve Stimulation

Pectus excavatum, the posterior displacement of the sternum and adjoining ribs into the thoracic cavity, is the most common anterior chest wall deformation (1). Its incidence has been estimated to occur in 1 in 40 to 1 in 400 births (1). Moderate to severe cases of pectus excavatum are often associated with chronic sternal and chest wall pain, dyspnea, restrictive lung disease, and cardiovascular compression (2). In recent years, intercostal nerve cryoablation during surgical correction of pectus excavatum via the Nuss procedure has been associated with a shorter hospital length of stay, decreased opioid usage, and longer duration of chest numbness particularly in adults (3). Intercostal neuralgia is commonly treated with oral medications and single shot injections; however, pain relief can be unsatisfactory or short-lived in refractory cases. Despite the development of neuromodulation in treatment of various pain syndromes, there are only scant case reports on using spinal cord stimulation and no study on using peripheral nerve stimulation to treat intercostal neuralgia from pectus excavatum. In this case report, we describe a 69-year-old woman with a history of chronic chest wall pain secondary to pectus excavatum who found pain relief with peripheral nerve stimulation at the T4 nerve root bilaterally after minimal pain relief with physical therapy, multiple neuropathic agents, and chronic opioids.

Surgical treatment of children with asymmetric pectus excavatum: Literature review

BACKGROUND: The surgical treatment of children with pectus excavatum is regarded as an urgent problem still demanding solution despite the multitudes of surgical correction methods available nowadays. The currently available well-known techniques cannot be considered perfect because they are not proper enough for solving all the tasks, not to mention the problem of asymmetric forms of pectus excavatum treatment.&#x0D; AIM: To analyze publications containing information on the methods of surgical treatment used for children with pectus excavatum.&#x0D; MATERIALS AND METHODS: The study presents the results of literature review on the methods of surgical correction of pectus excavatum. Information was retrieved in PubMed, Google Scholar, and eLibrary scientific databases using keywords. Consequently, 63 foreign and domestic scientific sources over the period from 1609 to 2022 were identified. Among them, 29 publications refer to the latest decade.&#x0D; RESULTS: Given the variety of methods used for chest deformity correction, thoracoplasty by D. Nuss has become the gold standard for the treatment of pectus excavatum. However, according to the search results, it is impossible to name one universal method of surgical intervention that could solve all the urgent problems at present. Modern surgery methods used for pectus excavatum correction can be considered only as modifications of treatment methods having been used before.&#x0D; CONCLUSIONS: The shortcomings of modern thoracoplasty determine the necessity to keep searching for new techniques and improve those available at present. Besides, the standard suitable for both surgeons and patients should be elaborated.

First experience of using a vacuum bell in the treatment of pectus excavatum in children

BACKGROUND: To date, N.F. Filatov Childrens Hospital has great experience in the surgical correction of pectus excavatum in children. For 22 years, 1000 minimally invasive repair procedures of pectus excavatum were performed in the thoracic surgery department. Despite the satisfactory and excellent outcomes of the surgical correction of pectus excavatum, the search for alternative nonsurgical methods of treating this pathology continues. In world practice, a vacuum bell is used as a conservative treatment. However, its effectiveness and indications are still in question.&#x0D; AIM: To evaluate the first experience of using a vacuum bell in the treatment of pectus excavatum in children.&#x0D; MATERIALS AND METHODS: A vacuum bell is a device consisting of sight glass, silicone ring, and manual pump, lifting chest wall deformities through a vacuum. The device is selected individually depending on the growth and shape of the ventral surface of the chest. According to instructions, the vacuum bell should be used a minimum of 1 h per day. All patients underwent a standardized assessment of the results of treatment every 36 months: measuring the depth of deformation, visual treatment control, analysis of photo documentation, and questionnaires.&#x0D; RESULTS: In the N.F. Filatov Childrens Hospital from 2015 to 2021, treatment results of 35 children using vacuum bell for 636 months were analyzed. Patients were divided into two groups depending on the percentage of deformation correction. The first group included 23 (65.7%) patients, and the percentage of correction was 50%. The second group included 12 (34.3%) patients, and the percentage of correction was 50%. In these groups, the main differences in the age of treatment initiation, regularity of use, and time of daily use have influenced the results. In the first and second groups, the average ages were 8.7 2.69 and 13.7 3.56 years, and the average daily use times were 5.7 2.04 and 3.6 1.61 h/day, respectively.&#x0D; CONCLUSIONS: Vacuum bell therapy is an effective and safe method for correcting pectus excavatum in children, and in some cases, it can be an alternative to surgical treatments.

Effectiveness of one minute per level intercostal nerve cryoablation for postoperative analgesia after surgical correction of pectus excavatum

PurposeIntraoperative intercostal nerve cryoablation has emerged as a promising modality for postoperative analgesia following Surgical Correction of Pectus Excavatum (SCOPE). Most centers use two-minute cryoablation per level, although data from histologic and adult studies suggest the effectiveness of one-minute freezes. We aimed to describe our center's experience with one minute per level cryoablation. MethodsA retrospective single institution review of patients undergoing SCOPE was performed to compare patients pre- and post-intercostal nerve cryoablation implementation. Cryoablation was performed as one minute for each of the thoracic intercostal nerves T3-T7. Multivariable regression analyses were conducted to compare the outcomes and cost between pre- and post-implementation groups. ResultsDuring the study period, 198 patients underwent SCOPE with one Nuss bar, receiving either intraoperative intercostal nerve cryoablation (Cryo, n = 100) or preoperative thoracic paravertebral catheters (NoCryo, n = 98). Surgical time was on average 9 min longer for the Cryo group (p<0.01). Median length of stay for the Cryo group was 3 days shorter compared to the NoCryo group (p<0.01). The Cryo group had a 19-fold and 5.6-fold reduction in average inpatient and total postoperative opioid usage, respectively (p<0.01). Total hospital costs were significantly lower in the Cryo group (p<0.01). Overall complication rate was not statistically significant different between the two groups. ConclusionsIntraoperative one minute per level cryoablation is a potent approach to postoperative analgesia for SCOPE patients that led to a shorter hospital length of stay, lower hospital costs, and decreased opioid use compared to conventional analgesia at our institution. Pediatric surgeons performing correction of chest wall deformities should consider offering this technique.

Intraoperative Methadone Reduces Postoperative Opioid Requirements in Nuss Procedure for Pectus Excavatum.

Surgical correction of pectus excavatum by Nuss procedure, commonly referred to as minimally invasive repair of pectus excavatum (MIRPE), often results in significant postoperative pain. This study investigated whether adding intraoperative methadone would reduce the postoperative opioid requirement during admission for patients undergoing MIRPE. A retrospective cohort chart review was conducted for 40 MIRPE patients between 2018 and 2020. Patients were stratified into 2 groups: those who received multimodal anesthesia (MM, n = 20) and those who received multimodal anesthesia with the addition of intraoperative methadone (MM + M, n = 20). Data collected included total opioid consumption during hospital stay (morphine milligram equivalents [MMEs]), hospital length of stay (LOS), pain scores, time to ambulation, and time to tolerating solid food. Addition of intraoperative methadone for patients undergoing MIRPE significantly reduced postoperative opioid requirements (MME/kg) during admission (P = .007). On average, patients in the MM group received 1.61 ± .55MME/kg while patients in the MM + M group received 1.16 ± .44MME/kg. Hospital opioid (non-methadone) total was also significantly reduced between the MM (1.87 ± .54) and MM + M group (1.37 ± .46), P = .003. There was no significant difference in hospital opioid total MME/kg administered between the groups. There were no significant differences observed in hospital LOS, pain scores, time to ambulation, or time to toleration of solid food. Incorporating intraoperative methadone for patients undergoing MIRPE reduced postoperative opioid requirements and hospital opioid (non-methadone) totals without a significant change in pain scores. Patients undergoing the Nuss procedure may benefit from the administration of intraoperative methadone.

Incidence and severity of surgical complications after pectus excavatum bar removal.

Pectus bar removal is the final step of minimally invasive repair of pectus excavatum. Complication rates related to bar removal have been reported in 2-15% of patients and severe, near-fatal and fatal complications have been reported. No systematic assessment of complication severity or risk factors associated with bar removal has been reported in large study populations. The aim of this paper is to investigate the safety of the bar removal procedure with regard to complication rates and severities as well as assessment of risk factors. Between 2003 and 2019, 1574 patients underwent the bar removal procedure. Medical records were assessed retrospectively and complications registered. Complications were categorized in infections, bleedings and other complications. The severity of the surgical complications was systematically classified using the validated Clavien-Dindo classification. Furthermore, risk factors associated with complications were assessed. The overall complication rate was 4.1% (Clavien-Dindo classification I-IV), mainly consisting of bleedings (1.3%) and infections (1.5%). Five cases of severe bleedings were registered (0.3%, Clavien-Dindo classification IV). Risk factors associated with complications during bar removal were greater age and removal of more than one bar. The bar removal procedure is a safe and effective procedure. Both age and number of bars inserted should be considered prior to surgical correction of pectus excavatum as these factors predict complications related to bar removal.

Pectus excavatum in osteogenesis imperfecta type I treated with Nuss procedure after pamidronate therapy

Osteogenesis imperfecta is a genetic disorder caused by mutations in genes affecting type I collagen that is mostly found in bone, skin and tendons. In addition to bone fragility and increased risk of fractures, patients with osteogenesis imperfecta can have chest wall deformities including pectus excavatum and pectus carinatum. Cardiorespiratory problems caused by these deformities is the major cause of morbidity and mortality in these patients. Outcomes of surgical correction of pectus excavatum in patients with osteogenesis imperfecta have not been described in the literature. It is important to establish definitive treatment options for these patients to improve their respiratory capacity and reduce mortality. In this case series we present the case of two pre-pubertal pediatric patients with osteogenesis imperfecta type I who underwent surgical correction of pectus excavatum with the Nuss procedure after pamidronate therapy. Both patients had successful correction of the chest wall deformity with significant improvement in their quality of life. • Osteogenesis imperfecta is a rare genetic disorder that causes bone fragility. • Pectus excavatum can be associated with this disease, however the number of cases is limited. • Bisphosphonate therapy can be given prior to undergoing Nuss procedure in patients with osteogenesis imperfecta type I.

Surgical correction of pectus excavatum in an adult with the use of thoracoscopic intercostal nerve cryoablation

Despite the improvement of the surgical approach for the correction of pectus pectus deformity, the reduction of the invasiveness of the intervention and the use of modern technologies, the optimal technology for the prevention and treatment of postoperative pain has not yet been determined. We have presented an alternative approach to regional analgesia for surgical treatment of pectus excavatum.

Deep venous thrombosis and abortion: an unusual clinical manifestation of severe form of pectus excavatum

Pectus excavatum is a chest wall malformation with a strong psychological and aesthetic impact. Rarely, pectus excavatum patients can show respiratory or cardiac symptoms occurring mainly during physical exertion. We report a case of a 34-year-old pregnant woman with a severe degree of pectus excavatum who developed serious cardiovascular disease resulting in spontaneous twin abortion at the twenty-first week of gestation. Cardiovascular disease was resolved after open surgical correction of pectus excavatum. This case shows how a tardive diagnosis and a delayed surgical approach for pectus excavatum can lead to severe consequences.

Transesophageal echocardiography during pectus excavatum correction in children: What happens to the heart?

ObjectivesCardiac compression in pectus excavatum remains difficult to evaluate. We describe the findings with intraoperative transesophageal echocardiography during pectus excavatum correction in pediatric patients. MethodsWe studied right heart changes during surgical correction of pectus excavatum by transesophageal echocardiograph. Four-D echo was associated to assess morphology of the tricuspid annulus. ResultsTwenty patients were included, mean age 13.5 (+/− 2.9). Mean preoperative Haller Index was 6.3 (+/− 2.63) and mean Correction Index 47.63% (+/− 12.4%). Preoperative transthoracic echocardiography at rest showed mild right heart compression in 6. Correction was gained by Nuss technique in 19, and Taulinoplasty in one. Initial transesophageal echocardiography showed compression of the right heart and deformation of the tricuspid annulus in all. During the sternal elevation, diameters of right atrium, ventricle and tricuspid annulus significantly improved: mean augmentation of right ventricle was 5.78 mm (+/− 3.56 p < 0.05), right atrium 6.64 mm (+/− 5.55 p < 0.05) and tricuspid annulus 6.02 mm (+/− 3.29 p < 0.05). The morphology of the tricuspid annulus in 4D normalized. ConclusionsPreoperative transthoracic echocardiography at rest underestimates right chamber compression in pediatric patients with pectus excavatum. Surgical correction improves diameters of the right ventricle, right atrium and tricuspid annulus and normalizes the morphology of the tricuspid annulus (4D). Level of evidenceLevel III.

Aesthetic outcomes after surgical repair of pectus excavatum in females: Differences between patients and professional evaluators.

BackgroundPectus excavatum is less common in females than in males, and it often aggravates a coexistent breast asymmetry. We conducted a study comparing female patients’ versus medical professionals’ evaluation of pectus excavatum repair to assess differences in aesthetic outcome ratings. Moreover, we evaluated the influence of surgical correction on patients’ self-perception.MethodsOf 30 female patients who were initially screened, 18 patients (mean age, 20 years) who underwent bar removal after surgical correction of pectus excavatum deformity participated in the survey (60%). They completed a questionnaire rating their appearance before and after surgery and responded to a psychological questionnaire about the changes that they had experienced. The mean interval between pectus bar removal and evaluation was 28 months. Standardized preoperative and postoperative patient photographs were evaluated using the same questionnaire by a panel of medical professionals and students (n=24) and the results were compared.ResultsPatients rated their preoperative deformity as more severe than the other evaluators, revealing the significant impact of the deformity on patients’ self-perception. Postoperatively, patient and professional evaluations were much better than before and were very similar. The psychological evaluation showed a clear improvement in well-being. The ratings of the medical professionals were not influenced by their degree of medical education.ConclusionsSurgical correction of pectus excavatum in female patients positively influences body perception and psychological well-being. It should therefore not be considered as a merely aesthetic correction, but as an important procedure to restore a patient’s self-perception.

Correlation of Preoperative State Anxiety and Pain Six Weeks After Surgical Correction of Pectus Excavatum.

BackgroundPain is a major concern in the early postoperative phase after correction of pectus excavatum. Most studies only focus on pain management in the first days after surgery and describe methods to alleviate the pain immediately postoperatively. The severity of postoperative pain may be influenced by anxiety. So far, few studies have looked into the relationship between anxiety and postoperative pain after pectus excavatum correction.ObjectivesThis study aimed to investigate the correlation between preoperative anxiety and late postoperative pain scores.MethodsThis was a prospective cohort study. Anxiety was assessed with the State and Trait Anxiety Inventory questionnaire. Visual analogue scale (VAS) for pain scores assessed the pain at rest and activity. Anxiety was measured before surgery and pain scores six weeks after surgery. A hierarchical linear regression analysis was performed to investigate the correlation between baseline anxiety and pain measurements six weeks after surgery.ResultsIn this study, 136 patients were included. State anxiety was not associated with postoperative pain (mean of pain on activity and in rest), only with pain on activity after six weeks. Age and sex were not effect modifiers in any of the models. Relevant confounding factors, although not significant, consisted of trait, sex, minor complications, epidural duration, major complications, and the number of stabilizer plates. The explained variance of state anxiety on VAS for pain scores was minimum after 6 weeks.ConclusionsPreoperative anxiety does not appear to influence postoperative pain after PE correction.

Surgical correction of recurrent pectus excavatum of an adult patient, case report, and review of literature.

The aim of this paper is to review the literature on recurrent pectus excavatum (PE) and present our surgical approach to a complex case of recurrent PE in an adult patient at a Mexican Hospital. We present the case of an adult patient with severe and symptomatic PE, with history of a failed Nuss procedure 1 year previous our intervention, which consisted of a combination of both classic techniques, by performing an osteochondrectomy of affected cartilages and placing a titanium bar substernal and stabilizing coastal arches with secondary osteosynthesis system (Stratos ™ system, medXpert, Germany). Adequate correction of thoracic silhouette and both cardiac and respiratory disorders in the 1-year follow-up was achieved as indicated by the improvement of the patient's Haller index. Successful surgical correction of pectus excavatum is achieved when the thoracic silhouette is restored, thus improving cardiopulmonary symptoms. As there are many different techniques available, the more minimally invasive ones are reserved for mild cases, but the treatment of complex cases as in our patient requires a combination of multiple techniques and reconstruction materials in order to achieve adequate correction of the thoracic deformity and reduce recurrence rate.