title: Minimally invasive repair of pectus excavatum using the Nuss technique in children and adolescents: indications, outcomes, and limitations.
abstract: BACKGROUND
  Pectus excavatum (PE) is a common congenital deformity. The Nuss technique for minimally invasive repair of PE involves thoracoscopy-assisted insertion of a bar or plate behind the deformity to displace the sternum anteriorly. Our objective here was to clarify the indications and limitations of the Nuss technique based on a review of 70 patients.
  
  
  METHODS
  A retrospective review of children managed at two centres identified 70 patients who had completed their growth and had their plate removed. Mean age was 13.8 years (range, 6-19 years). The reason for surgery was cosmetic disfigurement in 66 (95%) patients. The original Nuss technique was used in 63 patients, whereas 7 patients required an additional sub-xiphoid approach. Time to implant removal ranged from 8 months to 3 years.
  
  
  RESULTS
  The cosmetic outcome was considered satisfactory by the patients in 64 (91%) cases and by the surgeon in 60 (85.7%) cases. Major complications requiring further surgery occurred in 6 (8.5%) patients and consisted of haemothorax (n=2), chest wall sepsis (n=2, including 1 after implant removal), allergy (n=1), and implant displacement (n=1). Early or delayed minor complications occurred in 46 (65%) patients and resolved either spontaneously or after non-surgical therapy.
  
  
  CONCLUSIONS
  The minimal scarring and reliably good outcomes support the widespread use of the Nuss technique in children and adolescents. Our complication rates (minor, 65%; and major, 8.5%) are consistent with previous publications. In our opinion, contra-indications to thoracoscopic PE correction consist of a history of cardio-thoracic surgery and the finding by computed tomography of a sternum-to-spine distance of less than 5 cm or of sternum rotation greater than 35°. In these situations, we recommend a sub- and retro-xiphoid approach to guide implant insertion or a classic sterno-chondroplasty procedure.
  
  
  METHODS
  Level IV, retrospective descriptive cohort study.
authors.affiliation: Service de chirurgie orthopédique pédiatrique, hôpital d'Enfants de la Timone, AP-HM, Aix-Marseille université, rue Saint-Pierre, 13385 Marseille cedex 5, France. Electronic address: redakabbaj@hotmail.com.
authors.forename: R
authors.initials: R
authors.lastname: Kabbaj
authors.affiliation: Service de chirurgie orthopédique pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, université Lyon 1, 59, boulevard Pinel, 69677 Bron cedex, France.
authors.forename: M
authors.initials: M
authors.lastname: Burnier
authors.affiliation: Service de chirurgie orthopédique pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, université Lyon 1, 59, boulevard Pinel, 69677 Bron cedex, France.
authors.forename: R
authors.initials: R
authors.lastname: Kohler
authors.affiliation: Service de chirurgie orthopédique pédiatrique, hôpital d'Enfants de la Timone, AP-HM, Aix-Marseille université, rue Saint-Pierre, 13385 Marseille cedex 5, France.
authors.forename: N
authors.initials: N
authors.lastname: Loucheur
authors.affiliation: Service de chirurgie thoracique pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, université Lyon 1, 59, boulevard Pinel, 69677 Bron cedex, France.
authors.forename: R
authors.initials: R
authors.lastname: Dubois
authors.affiliation: Service de chirurgie orthopédique pédiatrique, hôpital d'Enfants de la Timone, AP-HM, Aix-Marseille université, rue Saint-Pierre, 13385 Marseille cedex 5, France.
authors.forename: J-L
authors.initials: JL
authors.lastname: Jouve
mesh_terms: D000293:Adolescent; D002648:Child; D015331:Cohort Studies; D020878:Device Removal; D004954:Esthetics; D005260:Female; D005660:Funnel Chest / Q000601:surgery*; D006801:Humans; D008297:Male; D011183:Postoperative Complications; D019736:Prostheses and Implants; D012189:Retrospective Studies; D013249:Sternum / Q000601:surgery*; D013906:Thoracoscopy; D055815:Young Adult
keywords: Child; Funnel chest; Minimally invasive Nuss procedure; Pectus excavatum