CHKD Surgical Group Journal, Volume 3, 2014

Journal CHKD Surgical Group

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Surgery corrects ear deformities

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CHKD Surgical Services Directory

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Phased approach for treatment of pectus carinatum

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CHKD welcomes new surgeons

CHKD Surgical Group Journal is a publication of Children’s Hospital of The King’s Daughters Health System Medical Editors: Joseph F. Dilustro, MD, FACS Robert E. Kelly Jr., MD, FACS, FAAP Jyoti Upadhyay, MD, FAAP Douglas Mitchell, MD, FAAP Executive Editor John Hamilton Vice President, Physician Practice Management Managing Editor Ridgely Ingersoll Director of Marketing Editor Sharon Cindrich Marketing & PR Manager Graphic Designer Dawn Midgette

Arthroscopic surgery corrects hip impingement in adolescents

by Allison Crepeau, MD

muscle strain, FAI is often diagnosed after conservative treatments for these more comSummary: New techniques in hip arthroscopy mon conditions fail. While the underlying offer resolution in adolescent patients with fem- cause of FAI is not completely understood, we oroacetabular impingements (FAI) in the hip know that genetics and involvement in certain resulting from sports and dance injuries. sports and activities may play a role.

The average patient profile tends to be an active adolescent athlete with unHip pain and joint damage resolved hip or groin pain. Sports are often associated with an older activities associated with FAI inpopulation; however, an increasclude field and ice hockey, soccer, ing number of younger patients are lacrosse, martial arts, tennis, golf, being diagnosed with labral tears rowing and dance. Dancers usually of the hip and/or femoroacetabular have less bony-type FAI, but more impingement (FAI), hip conditions labrum damage based on unusual associated with both acute and overAllison positioning of the hip joint during use injuries caused by sports and Crepeau, MD dance activities. Female patients dance activities. Children’s Hospipresent symptoms at a younger age tal of The King’s Daughters can now successfully treat adolescents diagnosed with due to an earlier onset of puberty.

There are three main FAI designations: labral tears and FAI using minimally invasive pincer, cam and combined. Pincer-type presarthroscopic surgery.

FAI is a spectrum of bony abnormalities ents when there is over-coverage on the around the hip that can lead to damage to the acetabular side of the hip (socket is too deep), labrum and cartilage over time. Ultimately, causing the labrum to be compressed when the this may lead to early hip arthritis. FAI is not hip is flexed. Cam-type FAI occurs when there an uncommon condition for adolescents, espe- is a bony prominence on the femoral neck that cially those in their mid-to-late teenage years impinges during flexion, damaging the labrum who have a history of sports participation. and grinding cartilage inside the acetabulum.

Wear and tear on the hip joint from even mild In many cases, both FAI types are present in a bony abnormalities can cause erosion of the combined condition.

Symptoms of FAI include groin pain, hip cartilage and tearing of the labrum. Frequently misdiagnosed as a groin pull, tendonitis or pain or aching after sitting or walking, locking continued on page 2 CHKD Surgical Group | Journal | Vol. 3, 2014

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or clicking of the hip joint and low back pain. Pain levels may be sharp or aggravated when the hip is turned, twisted or bent, but can also present as a dull ache.

Patient evaluation for arthroscopy includes comprehensive analysis of prior treatments, X-rays, a physical examination and physical therapy if not previously attempted. If tests are inconclusive and conservative treatments do not resolve symptoms, an MRI arthrogram is ordered. Abnormalities revealed on the MRI will merit diagnostic injections, administered to confirm damage inside the hip joint and positively identify candidates for arthroscopy.

Non-operative treatment is generally the first course of action. A decreased level of activity and hip-strengthening exercises may be recommended, along with physical therapy or stretching.

Anti-inflammatory medications may provide limited relief. When symptoms do not resolve or increase in intensity, arthroscopic surgery can potentially correct the problem.

Surgery candidates should be towards the end of growth to be eligible for arthroscopy. Arthroscopy is performed under general anesthesia. During the procedure, an arthroscope is used along with a variety of tools to repair or anchor

damaged labrums or articular cartilage.

Corrections are made to bony abnormalities through osteoplasty by shaving the femoral head or trimming the rim of the acetabulum. The procedure can take as little as two hours to complete. and corrections generally resolve symptoms and likely mitigate future damage.

Before arthroscopy was available, open surgical hip dislocation surgery required a 7-10 inch incision and a longer recovery process. Minimally-invasive arthroscopic surgery reduces recovery time, decreases the length of the hospital stay, cuts surgery costs and minimizes the risk of infection and complications.

Arthroscopic procedures are performed as outpatient surgeries or accompanied by a one-night stay at CHKD in Norfolk.

Patients can typically return to full sports activities at 3-4 months after surgery.

Long-term outcomes are generally better when FAI is treated through early intervention, rather than when there is already irreparable damage to the articular cartilage. While long term data are not available for this new procedure, the hope is that by intervening and restoring normal anatomy, we can stop a process that seems to lead to early arthritis. The techniques and instruments for hip arthroscopy are continuing to advance every day. At CHKD, our thor-

When to consider FAI Symptoms of FAI mimic a variety of other common sport-related injuries making diagnosis a challenge. Consider FAI if a patient presents with the following:

▪ History of groin and hip pain without resolution using conservative therapies

▪ A positive FABER test ▪ A positive impingement test ▪ X-rays that reveal bony

abnormalities on the femoral head or acetabular rim

▪ MRI arthrogram that details fraying or tears of the cartilage or labrum

ough evaluation of each patient allows us to treat adolescent patients with FAI using minimally-invasive, arthroscopic techniques to resolve pain and damage, allowing patients to return to their activities.

Dr. Crepeau is board-eligible in sports medicine and pediatric orthopedic surgery at CHKD. You may reach her at (757) 668-6550.

CHKD surgeon featured at international event Dr. Jyoti Upadhyay of CHKD Surgical Group’s urology practice was a featured speaker at the 33rd annual Congress of The Societe Internationale d’Urologie in Vancouver in September.

Dr. Upadhyay’s presentation was titled, “Neurogenic bladder in adolescence and childhood: weighing the risks of surgical intervention against the goal of achieving social continence.” In it, she highlighted non-surgical approaches such as anticholinergic medications, clean intermittent catheterization and botulinum-toxin, which have prevented the need for surgery in some patients.

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Dr. Upadhyay also addressed the cognitive and physical limitations that can hinder the quest for independence of this population and recommended that individual treatment regimens reflect the input of multidisciplinary teams.

Candidates for surgical intervention benefit from the availability of many novel approaches to reconstruction.

Dr. Upadhyay shared her experience with slings, bladder neck procedures and augmentation cystoplasty utilizing the small bowel, large bowel and even the urinary drainage system of a non-functioning renal unit.

To reach Dr. Upadhyay, please call 668-7878.

Implant offers alternative approach to correct ear deformities

by George Hoerr, MD

sessed by the CHKD’s multi-disciplinary craniofacial team for anomalies and synSummary: A synthetic implant offers an dromes that may be associated with the alternative to rib cartilage for ear recon- microtia. Microtia is often considered a struction. cosmetic problem; however, social issues associated with the defect can become Congenital ear deformities, also significant as a child develops, so correcknown as microtia, are a common birth tion is generally recommended. defect. Occurring in approximately 1 Reconstructing the outer ear is a in 6,000 children, microtia is identified challenge due to the unique, complex when the auricle of one or architecture of the auricle. For both ears is not fully formed. more than 40 years, standard Children’s Hospital of The surgical correction for microtia King’s Daughters now offers involved using rib cartilage to an advanced pediatric ear resculpt a framework for the ear construction surgery to repair and positioning this under the the defect that combines a bioskin around the ear canal. A compatible synthetic implant series of follow-up surgeries and the patient’s own tissue to George allows the surgeon to lift and create a replacement outer ear. Hoerr, MD position the cartilage, build the Microtia is divided into four outer ear and construct an ear classifications. Patients with a smaller ver- lobe. This standard repair is generally sion of a typical ear may be diagnosed with done after age 6, when a child has enough grade 1 microtia. Grade 2 microtia occurs rib cartilage to remove for reconstruction when many of the typical features of the of the ear framework. outer ear are missing and the ear canal is More recently, a surgical technique very narrow or closed (canal stenosis). The was developed using the Medpor porous most common form of microtia is grade polyethylene form and the patient’s liv3, also known as aural atresia, occurring ing tissue to reconstruct the outer ear. In when a small vertical appendage of car- preparation for the procedure, surgeons tilage and skin is present in place of an trim the synthetic form to match the paexternal ear and there is no external ear tient’s opposite auricle. Since the ear of a canal (aural atresia). The most severe type child at age 3 is approximately 80 to 85 of microtia is known as anotia – the com- percent of the child’s adult-sized ear, the plete absence of the outer ear. form is designed to be 15 to 20 percent In most cases of microtia, the defect larger than the opposite ear. While the is unilateral, and the inner workings of ears will initially be slightly different in the affected ear are present, so children size, the child’s unaffected ear will grow have hearing abilities with impairment to match the ear created from the synthetrelative to the ear canal opening. Patients ic implant by the age of 10. evaluated with a grade 1 level of microtia During the procedure, an incision is may opt out of corrective surgery. When made behind the ear and a flap of temmicrotia of a grade 2 or up is present, sur- peroparietal fascial tissue is pulled down gical correction is warranted. to cover the synthetic form. A second Children diagnosed with microtia are skin graft is generally taken from the upgiven a full physical evaluation and as- per leg area above the groin to cover the

living tissue.

I trained with Dr. John Reinisch, the pioneer of this technique, in Los Angeles in 1994, and I have found this approach to have numerous advantages for young patients. It is definitely a less invasive procedure, eliminating the need to resect rib cartilage. The synthetic form is infection resistant and provides a standard size and shape for the auricle, reducing variables involved in sculpting a matching outer ear from the rib cartilage and eliminating resorption of the graft over time. It provides an ear which looks natural and can be functional when combined with reconstruction of the canal. Without the use of rib cartilage, children as young as 3 years old can have surgery, allowing patients with atresia to receive ear canal reconstruction at an early age and reducing challenges that can be associated with hearing impairments.

The method can be completed in one to two outpatient surgeries involving incisions to the scalp and graphed skin, reducing pain, recovery time, and risk of complications and scarring. Children can resume activities in six to eight weeks post-surgery. In addition to microtic patients, the technique can also be used to reconstruct an outer ear damaged or detached due to traumatic injuries, such as dog bites and motor vehicle accidents.

Dr. Hoerr is a board-certified pediatric plastic surgeon at CHKD. You may reach him at (757) 668-7713. before

after

The ear can be reconstructed using a synthetic implant and the patient’s own tissue.

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CHKD Surgical Group For physician-to-physician consults and access: Call CHKD Doctors Direct, (757) 668-9999 or 1-800-207-2022 For a complete list of pediatric specialists and surgeons, visit chkd.org/referraldirectory

Cardiac Surgery Located at CHKD Surgeries offered at CHKD in Norfolk Consults..........................................(757) 668-8850 Fax.................................................(757) 668-9344

Benjamin Peeler, MD, FACS MD Degree: Vanderbilt University Residency: General Surgery, Vanderbilt University Affiliated Hospitals Fellowship: Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center; Vascular Surgery, University of Virginia Health Sciences Center; Pediatric Cardiothoracic Surgery, Emory University Certification: American Board of Thoracic Surgery, Congenital Cardiac Surgery Special Interests: Complex neonatal repair; treatment of single ventricle defects; simple and complex atrioventricular canal, aortic valve repair and replacement E-mail Address: benjamin.peeler@chkd.org

Felix Tsai, MD MD Degree: Northwestern University Residency: General Surgery, Morristown Memorial Hospital; Cardiothoracic Surgery, George Washington University Fellowship: Pediatric Cardiothoracic Surgery, Medical University of South Carolina Certification: American Board of Thoracic Surgery Special Interests: Neonatal heart surgery; mechanical circulatory support; quality improvement; enhanced patient safety E-mail Address: felix.tsai@chkd.org

Neurosurgery Located at CHKD Surgeries offered at CHKD in Norfolk Appointments & consults...............(757) 668-7990 Fax.................................................(757) 668-7995

John Birknes, MD MD Degree: Jefferson Medical College, Philadelphia Residency: Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia Fellowship: Pediatric Neurosurgery, Children’s Hospital of Philadelphia; Pediatric Spinal Deformity and Scoliosis, Shriners Hospital for Children of Philadelphia Certification: American Board of Neurological Surgery 4

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Special Interests: Brain tumors; spinal deformity and scoliosis; Chiari malformation; hydrocephalus; epilepsy; spina bifida/cerebral palsy; neuroendoscopy E-mail Address: john.birknes@chkd.org

Joseph F. Dilustro, MD, FACS MD Degree: Eastern Virginia Medical School Residency: Neurological Surgery, Eastern Virginia Medical School Graduate School of Medicine Fellowship: Microvascular and Cerebrovascular Surgery, London Health Sciences Center, University of Western Ontario Certification: American Board of Neurological Surgery Special Interests: Craniofacial surgery; brain tumors; spina bifida/cerebral palsy; hydrocephalus; cerebrovascular disorders in children; Chiari malformation E-mail Address: joseph.dilustro@chkd.org

Orthopedics & Sports Medicine Located in Norfolk, Chesapeake, Virginia Beach and Newport News Surgeries offered at CHKD Surgery Centers in Norfolk, Newport News and Virginia Beach Appointments & consults...............(757) 668-6550 Same-day appointments................(757) 668-6545 Fax.................................................(757) 668-6544

J. Marc Cardelia, MD

MD Degree: Thomas Jefferson University Medical College, Philadelphia Residency: Surgery, UMDNJ– Robert Wood Johnson Medical School, New Brunswick, NJ Fellowship: Pediatric Orthopedics, Rady Children’s Hospital, San Diego Certification: American Board of Orthopedic Surgery Special Interests: Sports injuries; spinal deformity; trauma in children E-mail Address: marc.cardelia@chkd.org

Allison Crepeau, MD MD Degree: Georgetown University School of Medicine Residency: Orthopedics, SUNY at Stony Brook Fellowship: Pediatric Orthopedic Surgery, Arnold Palmer Hospital for Children; Pediatric and Adult Sports Medicine, Boston Children’s Hospital Special Interests: Sports medicine; dance medicine; hip arthroscopy for treatment of labral tears and impingement E-mail Address: allison.crepeau@chkd.org

Cara Novick, MD MD Degree: New York University School of Medicine Residency: Orthopedics, New York University Medical Center/ Hospital for Joint Diseases Fellowship: Pediatric Orthopedic Surgery, Shriner’s Hospital for Children Special Interests: Office-based pediatric orthopedics, fracture management, sports medicine Certification: American Board of Orthopedic Surgery E-mail Address: cara.novick@chkd.org

H. Sheldon St. Clair, MD MD Degree: Medical College of Virginia Residency: Orthopedics, TuftsNew England Medical Center Hospital, Boston Fellowship: Pediatric Orthopedics, Boston Floating Hospital for Children Certification: American Board of Orthopedic Surgery Special Interests: Scoliosis and spinal deformities; cerebral palsy; neuromuscular diseases; limb lengthening and deformity correction; congenital deformities; sports injuries E-mail Address: harvey.stclair@chkd.org

Carl R. St. Remy, MD MD Degree: Columbia University College of Physicians and Surgeons, New York Residency: Orthopedics, New York Orthopaedic Hospital, Columbia University-Presbyterian Hospital, New York Fellowship: Pediatric Orthopedics, Texas Scottish Rite Hospital for Children, Dallas Certification: American Board of Orthopedic Surgery Special Interests: Scoliosis and spinal deformities; neuromuscular disorders; limb reconstruction; congenital deformities; sports injuries; trauma E-mail Address: carl.stremy@chkd.org

Allison Tenfelde, MD MD Degree: Michigan State University College of Human Medicine Residency: Orthopedics, Michigan State University Fellowship: Pediatric Orthopedics, University of Michigan – Mott Children’s Hospital; Orthopedic Sports Medicine, Detroit Medical Center Certification: American Board of Orthopedic Surgery Special Interests: Pediatric and adolescent sports injuries; arthroscopic surgery of the shoulder, knee and elbow E-mail Address: allison.tenfelde@chkd.org

Pediatric Surgery Located at CHKD, Virginia Beach, Chesapeake and Newport News Surgeries offered at CHKD Surgery Centers in Norfolk, Newport News and Virginia Beach Appointments & consults...............(757) 668-7703 Fax.................................................(757) 668-8860

Frazier W. Frantz, MD, FACS MD Degree: Duke University School of Medicine Residency: General Surgery, Medical College of Virginia Fellowship: Pediatric Surgery, Children’s Hospital Medical Center, Cincinnati Certification: American Board of Surgery, Pediatric Surgery Special Interests: Surgical treatment of colorectal diseases in children; congenital chest wall deformities; vascular anomalies E-mail Address: frazier.frantz@chkd.org

Michael J. Goretsky, MD, FACS, FAAP MD Degree: State University of New York, Stony Brook Residency: General Surgery, University of Cincinnati; Pediatric Surgery, Children’s Hospital of Michigan, Detroit Fellowship: Surgical Research, Shriners Burn Institute, Cincinnati; ECMO, Children’s Hospital of Cincinnati Certification: American Board of Surgery, Pediatric Surgery Special Interests: Minimally invasive surgery; Hirschsprung’s disease; non-cardiac thoracic surgery; Nuss Procedure for pectus excavatum repair and other chest deformities E-mail Address: michael.goretsky@chkd.org

Robert E. Kelly Jr., MD, FACS, FAAP

MD Degree: Johns Hopkins University Residency: Surgery, Vanderbilt University, Nashville Fellowship: ECMO and Surgical Research, UCLA School of Medicine, Los Angeles; Pediatric Surgery, Children’s Hospital of Buffalo Certification: American Board of Surgery, Pediatric Surgery Special Interests: Esophageal and pulmonary problems; neck masses; Hirschsprung’s disease; Nuss Procedure for pectus excavatum repair and other chest deformities; pectus carinatum E-mail Address: robert.kelly@chkd.org

M. Ann Kuhn, MD, FACS, FAAP MD Degree: Marshall University, John C. Edwards School of Medicine Residency: General Surgery, Ohio State University

Fellowship: Pediatric Surgery, University of Oklahoma Health Sciences Center Certification: American Board of Surgery, Pediatric Surgery Special Interests: Minimally invasive laparoscopic surgery; Nuss Procedure for pectus excavatum repair and other chest deformities; colorectal disease; thoracic surgery; surgical oncology E-mail Address: ann.kuhn@chkd.org

Michele Lombardo, MD

MD Degree: Boston University School of Medicine Residency: General Surgery, Brown University and Rhode Island Hospital Fellowship: Pediatric Surgery, Brown University and Hasbro Children’s Certification: American Board of Surgery E-mail Address: michele.lombardo@chkd.org

Robert J. Obermeyer, MD, FACS, FAAP MD Degree: University of Cincinnati College of Medicine Residency: General Surgery, Western Reserve Care Forum Health Fellowship: Pediatric Surgery, University of Arkansas Children’s Hospital; Minimally Invasive Surgery, Baylor College of Medicine Certification: American Board of Surgery, Pediatric Surgery Special Interests: Minimally invasive laparoscopic surgery; pediatric thoracic surgery; pediatric surgical oncology; Nuss Procedure for pectus excavatum repair and other chest wall deformities E-mail Address: robert.obermeyer@chkd.org

Plastic Surgery Located at CHKD, Chesapeake, Virginia Beach and Newport News Surgeries offered at CHKD Surgery Centers in Norfolk, Newport News and Virginia Beach Appointments & consults...............(757) 668-7713 Fax.................................................(757) 668-7711

George Hoerr, MD MD Degree: University of Missouri, Columbia Residency: General Surgery, EVMS/Sentara Norfolk General/ CHKD; Plastic Surgery, University of California – Irvine Fellowship: Pediatric Plastic Surgery, USC/ Children’s Hospital of Los Angeles Certification: American Board of Plastic Surgery Special Interests: Craniofacial surgery; congenital ear reconstruction; cleft lip and cleft palate; birthmarks and hemangiomas; congenital hand surgery E-mail Address: george.hoerr@chkd.org

Urology Located at CHKD, Chesapeake, Virginia Beach, Newport News and Williamsburg Surgeries offered at CHKD Surgery Centers in Norfolk, Newport News and Virginia Beach Appointments & consults...............(757) 668-7878 Fax.................................................(757) 668-7883

Charles E. Horton Jr., MD, FAAP, FACS

MD Degree: Eastern Virginia Medical School Residency: General Surgery, Dartmouth University; Urology, Harvard University Fellowship: Pediatric Urology, Johns Hopkins University Certification: American Board of Urology Special Interests: Urogenital reconstruction; hypospadias; laparoscopy E-mail Address: charles.horton@chkd.org

Jyoti Upadhyay, MD, FAAP MD Degree: Wayne State University, Michigan Residency: General Surgery, Wayne State University; Urology, Wayne State University Fellowship: Pediatric Urology, Hospital for Sick Children, Toronto Certification: American Board of Urology Special Interests: Complex genitourinary reconstruction, including augmentation cystoplasty and catheterizable urinary stomas for neurogenic bowel and bladder disease; reconstructive surgery for ambiguous genitalia, congenital adrenal hyperplasia and intersex states; microscopic varicocelectomy; minimally invasive laparoscopic kidney procedures; ureteroscopy; holmium laser use for pediatric kidney and ureteral stones; certified to perform daVinci robotic-assisted pyeloplasties for utereral anomalies E-mail Address: jyoti.upadhyay@chkd.org

Louis Wojcik, MD

MD Degree: Vanderbilt University School of Medicine Residency: Brown University Fellowship: Children’s Hospital San Diego Certification: American Board of Urology Special Interests: Hydronephrosis; hypospadias; undescended testis; vesicoureteral reflux E-mail Address: louis.wojcik@chkd.org

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Data supports phased approach for treatment of pectus carinatum

by Robert Kelly, MD Summary: Pectus carinatum, also known as pigeon breast, is a deformity of the chest wall characterized by protrusion of the sternum and rib cartilage. Staged treatment beginning with a dynamic compression bracing system allows the majority of adolescent patients to be managed without surgery. Patients who are not candidates for bracing, as well as those who do not achieve optimal results from bracing, can be corrected surgically using the Abramson Procedure, a variety of implants or a traditional open repair.

As the clinical home of the minimally invasive Nuss Procedure used to correct pectus excavatum, Children’s Hospital of The King’s Daughters has been an international treatment and research center for chest wall deformities for more than 20 years. Since CHKD Surgeon-in-Chief Emeritus Donald Nuss first developed his revolutionary procedure, more than 1,700 patients have undergone the surgical correction of chest wall deformities at our hospital.

The wide adoption of the Nuss Procedure has given our pediatric surgery

Dynamic Compression System

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team the opportunity to gather and publish clinically significant outcomes, to determine best practices, and to conduct and facilitate multi-center research into the causes and effects of chest wall deformities. The Center for Chest Wall Repair at CHKD now offers many different treatment options, including non-surgical and surgical options, to address malformations of the chest wall. The goal of patient Robert evaluations in our center is to Kelly, MD find the least least invasive option that will be effective for each patient’s specific physiology.

Pectus Carinatum Pectus carinatum can cause chest pain, shortness of breath and difficulty exercising. Patients may also experience psychological distress and negative body image. The deformity affects males more than females and often becomes more pronounced during puberty.

Surgeons have long recommended compressive orthotic bracing as a first line of treatment for pectus carinatum, but patient compliance can be a chal-

lenge. Advanced bracing technology recently developed by Martinez-Ferro, et al. introduces a dynamic compression system (DCS) that applies optimal pressure for results and compliance. This system’s custom-made aluminum brace and cushioned compression plate are adjusted as treatment progresses, effectively remodeling the chest wall in most patients. Over four years of use, we have treated more than 200 patients with the dynamic compression bracing system, with very encouraging results, reported here.

For patients who are not good candidates for bracing and those who do not achieve satisfactory results, surgery remains a viable option. In 2008, my colleagues and I performed the first reverse Nuss Procedure for pectus carinatum, also known as the Abramson Procedure, in the US at CHKD. This minimallyinvasive surgery is advantageous for younger patients with flexible chests.

The Abramson procedure uses the patented Nuss bar to press the sternum and ribs down into the correct position

The Abramson Procedure

in much the same way that orthodontic braces correct an overbite.

For patients with more complex chest wall deformities, we may use one of a variety of implants, such as the Strasbourg Stratos system of titanium implants, to shape and stabilize the chest wall. A final option is the traditional open repair operation, which is very successful for skeletally mature patients with pectus carinatum.

Treatment Outcomes For an article published in the Journal of Pediatric Surgery in 2013 (Vol. 48, 315-320)*, we reviewed records from the Chest Wall Anomaly Clinical Database of 137 patients treated for pectus carinatum at CHKD between October 2008 and December 2011. Corrections included dynamic compression bracing, minimally invasive surgery and open repair.

For each patient identified as a candidate for correction, we calculated the compression pressure required to flatten the sternum with a brace. This pressure of correction (POC) was measured in pounds per square inch (PSI). Patients with low to moderate correction pressure (POC<7.5) were recommended for the dynamic compression bracing system.

Patients with high correction pressures (POC>7.5 PSI), severe asymmetry, history of previous bracing failure, or those deemed unlikely to be compliant were offered surgical treatment with the minimally invasive Abramson Procedure or an open repair. A total of 13 patients underwent the Abramson Procedure.

One of these corrections failed, but was remedied with an open repair yielding excellent results. A total of five patients received an open repair with good results.

A total of 122 patients with a median age of 14 (10 to 28) were amenable to bracing. These patients were measured and fitted for the dynamic compression brace. Patients were encouraged to wear the device as much as possible including during sleep but not during athletic activities or showering. A minimum daily bracing duration of eight to 12 hours was recommended. Physical

Device offers non-surgical option to some pectus excavatum patients While bracing is not generally an option for pectus excavatum, a deformity where the chest wall is sunken or caved in toward the spine, CHKD is currently utilizing the Vacuum Bell, a minimally-invasive device developed by German engineer Eckart Klobe to address mild cases of PE for patients who want or need to avoid surgery. We have also used the Vacuum Bell intraoperatively to elevate the sternum prior to inserting the Nuss bar.

The Vacuum Bell comes in three sizes: 16 cm, 19cm and 26 cm. There is also a special model designed specifically for adolescent girls and women to accommodate breast tissue.

The device uses a suction cup to create a vacuum seal on the chest wall and pull the sternum forward. The patient adjusts the pressure with a therapists instructed patients regarding daily strength and flexibility exercises to optimize results.

Patients were seen in the clinic every one to three months to make adjustments to the brace and reinforce compliance.

After the chest wall was reshaped and the sternum was flattened by the brace, patients wore the brace for progressively fewer hours as a retainer for five months to maintain the shape of the chest wall.

In an analysis of the 122 bracing patient outcomes, 67 were progressing under active treatment at the time of review, 37 exhibited flattening of the sternum after an average of six months without the need for surgery. Five patients were lost to follow up and 13 patients failed treatment. Three of the patients who failed bracing treatment were then corrected surgically.

Complications were limited to transient skin breakdown in nine patients.

hand pump and wears the device for several hours each day and allows patients to receive treatments without interfering with school, sports or daily activities. With regular use, patients have reported an improved appearance to the sternum after two to three years of treatment. To date, the Vacuum Bell has been implemented on approximately 40 patients with encouraging outcomes, similar to those reported by Swiss surgeon Frank-Martin Haecker in the European Journal of Cardiothoracic Surgery in 2006 and in the Turkish Toraks Cerrahisi Bulteni in 2011. Further research and time elapsed post-treatment will be needed to evaluate long-term effectiveness. Dr. Robert Obermeyer leads the Vacuum Bell treatment initiative and can be contacted at 668-7703.

This was treated with temporary loosening of the brace to lower the POT or discontinuation until the skin healed.

Patient-reported daily bracing durations recorded as a measure of treatment compliance revealed that the average daily bracing duration in patients who experienced sternal flattening was 16 hours.

At CHKD, surgeons are trained to evaluate patients for the least invasive and most effective treatment options. *Amy S. Coheea, James R. Linb, Frazier W. Frantzc, Robert E. Kelly Jr.c Children’s Hospital of The King’s Daughters, Norfolk, VA a

Eastern Virginia Medical School, Norfolk, VA

b

Eastern Virginia Medical School, Children’s Hospital of The King’s Daughters, Norfolk, VA c

Dr. Kelly is a board-certified pediatric surgeon at CHKD. You may reach him at (757) 668-7703.

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NON-PROFIT ORG US POSTAGE PAID CHKD

601 Children’s Lane Norfolk, VA 23507

CHKD Surgical Group welcomes two new surgeons Dr. Benjamin Peeler Chief of Pediatric Cardiothoracic Surgery Dr. Benjamin Peeler has joined CHKD as chief of pediatric cardiothoracic surgery. A nationally-recognized expert, Dr. Peeler trained at Vanderbilt, UVA and Emory University. He has published more than 30 manuscripts and six book chapters and performs thoracic and cardiovascular surgery and vascular surgery. He completed a fellowship in pediatric cardiothoracic surgery at Emory University.

Dr. Peeler performs the full spectrum of pediatric cardiothoracic procedures including treatment of complex single ventricle defects and other congenital anomalies.

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Dr. Allison Tenfelde Orthopedics and Sports Medicine Dr. Allison M. Tenfelde, a fellowshiptrained orthopedic sports medicine surgeon, has joined the orthopedic surgery practice of CHKD’s Surgical Group.

Dr. Tenfelde attended medical school at the Michigan State University College of Human Medicine and completed two fellowships – one in pediatric orthopedic surgery at University of Michigan C.S. Mott Children’s Hospital and another in orthopedic sports medicine at Detroit Medical Center.

Prior to medical school, she spent seven years as a certified athletic trainer at a variety of institutions including Michigan Capital Medical Center, University of Utah, Concentra Occupational Health Center and St. John Health System.