title: Chest Wall Constriction after the Nuss Procedure Identified from Chest Radiograph and Multislice Computed Tomography Shortly after Removal of the Bar.
abstract: BACKGROUND
  This study radiographically examined the changes in the chest walls of patients with pectus excavatum (PE) after Nuss bar removal, to define the deformation caused by the bar and stabilizer. In the first part of the study, we compared the changes in chest radiographs of patients with PE to a preoperation PE control group. In the second part, we used multislice computed tomography (CT) scans to provide three-dimensional reconstructions with which to evaluate the changes to the thoracic wall.
  
  
  METHODS
  Part 1 From June 2006 to August 2011, 1,125 patients with PE who had posteroanterior chest radiographs taken before undergoing the Nuss procedure at four hospitals were enrolled as a preoperative control group. At the same time, 203 patients who had the bar removed were enrolled as the study group. The maximum dimensions of the outer boundary of the first to ninth rib pairs (R1-R9, rib pair width), chest height, and chest width were measured. Part 2 Thirty-one consecutive patients with PE (20 males and 11 females) who underwent Nuss bar removal were evaluated 7 to 30 days after operation. During this period, a further 34 patients with PE who had undergone CT imaging before bar insertion were evaluated and compared with the postoperative group.
  
  
  RESULTS
  Part 1 The width of the lower ribs (R4-R9) after bar removal was significantly less than in the age-matched controls. The ribs adjacent to the bar (R5-R7) showed the greatest restriction. The width of the upper ribs (R1-R3) 2 to 3 years after bar placement did not differ significantly from the controls. Patients who were operated on after 10 years of age had less of a restrictive effect. Three years of bar placement resulted in more restriction than a 2-year period, particularly in patients younger than 10 years old. Part 2: A significant constriction of the chest wall was observed in 13 patients after removal of the Nuss bar. Constriction at ribs 5 to 8 was found to be present adjacent to the site of bar insertion. However, constriction of the chest wall was found in only 3 of the 34 patients in the preoperative group. The severity of constriction (as graded by the spline model) also increased in the postoperative group.
  
  
  CONCLUSIONS
  The growth of the chest wall was restricted after placement of the Nuss bar for PE correction. Long-term follow-up of chest wall growth is needed to clarify whether such constriction resolves with time.
authors.affiliation: Department of Pediatric Surgery, Chang-Gung University, Taoyuan, Taiwan.
authors.forename: Pei-Yeh
authors.initials: PY
authors.lastname: Chang
authors.affiliation: Department of Pediatric Surgery, Capital Medical University, Beijing, China.
authors.forename: Qi
authors.initials: Q
authors.lastname: Zeng
authors.affiliation: Department of Pediatrics, Chang-Gung University, Taoyuan, Taiwan.
authors.forename: Kin-Sun
authors.initials: KS
authors.lastname: Wong
authors.affiliation: Department of Radiology, Chang Gung University, Taoyuan, Taiwan.
authors.forename: Chao-Jan
authors.initials: CJ
authors.lastname: Wang
authors.affiliation: Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan.
authors.forename: Chee-Jen
authors.initials: CJ
authors.lastname: Chang
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D020878:Device Removal; D005260:Female; D005660:Funnel Chest / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D021621:Imaging, Three-Dimensional; D008297:Male; D061330:Multidetector Computed Tomography; D019637:Orthopedic Procedures / Q000295:instrumentation*; D011237:Predictive Value of Tests; D011857:Radiographic Image Interpretation, Computer-Assisted; D012189:Retrospective Studies; D013624:Taiwan; D035441:Thoracic Wall / Q000002:abnormalities / Q000000981:diagnostic imaging / Q000254:growth & development / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult