Brace Treatment of Chest Wall Deformity, Scoliosis and Chest Wall

06/24/2016
Brace Treatment of Chest Wall Deformity,
Scoliosis and Chest Wall Programs
Davi P. Haje, MD, PhD
Moacir Silva Neto, MD
Sydney A. Haje, MD (in memorian)
Centro Clínico ORTHOPECTUS
Hospital de Base do DF – SES – GDF
Brasília, DF, Brazil
Literature about treatment of pectus
excavatum and carinatum with braces
• 1977 to 2014: Haje et al published 24 papers about braces treatment of
carinatum and excavatum
• 1993: Mielke e Winter (n=1)
• 1999: Beirão (n=30)
• 2000: Egan e cols (n=5)
Treated 36 pectus
carinatum
•2006 – 2014: others 20 papers about braces treatment of pectus carinatum
(braces became first treatment option in a lot of centers for carinatum)
• Only Haje published papers / book chapters about braces treatment of:
• Pectus excavatum
• Superior carinatum or Currarino type
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06/24/2016
HAJES PAPERS ABOUT ETIOLOGY
OF PECTUS
1) Describe the presence of growth plates between the sternal segments
and costocondral junction.
2) Provoked pectus deformities in animals by the lesion of these growth
plates.
Group with
lesion of
growth
plates
Control
group
Haje SA et al(1998) Disorders in the sternum growth and pectus deformities: an experimental model and clinical
correlation. Acta Ortop Bras 6: 67-75
Haje: described the possibility of iatrogenic pectus after
sternotomy for repair of cardiac problems.
Haje SA (1995)
Iatrogenic
pectus carinatum:
a case report.
Int Orthop
19/6:370-373.
1994
9yo
FIRST LITERATURE PAPER ABOUT IATROGENIC PECTUS
2002
17yo
After Haje’s treatment
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06/24/2016
Haje: Pectus deformities are caused by growth disturbances
of heredity origin
They usually GET WORSE without treatment in the adolescence!
12 yo
5 yo
2006
2014
10 yo
14 yo
Haje: Pectus deformities are caused by growth disturbances
of heredity origin, but etiology probably is multifactorial
In some cases:
- abnormal respiratory
patterns?
- pectus patients have earlier,
severe, and more frequent asthma (Cserháti et al, 1984)
- Hajes 5791 patients  15% of
asthma = NORMAL POPULATION
- abnormal muscular balance in
the trunk?
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06/24/2016
NON SURGICAL TREAMENT
PRINCIPLES
WRONG TREAMENT PRINCIPLES: Never prescribe
just gym
exercises without braces for CARINATUM patients
12-1-11
GHDMF
dn 25-9-93
Spontaneous breathing
Doing Valsava maneuver
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06/24/2016
MOAJR DN 11-7-97
Never prescribe just gym exercises without braces for pectus
Octuber 2014
17 years old
June 2015
Did only gym exercises.
Got muscles but kept the
pectus
Got better after doing
exercises using braces
Treatment of Pectus Carinatum and Excavatum by Haje’s Method
–
Treatment Principles – based on
orthopaedic principles
O
R
T
H
O
S
P
A
E
D
I
A
Nicolas Andry
France, 1741
Bone remodeling
Julius Wolff Germany, 1892
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06/24/2016
Treatment of Pectus Carinatum and Excavatum by Haje’s Method
–
Treatment Principles
Before treating pectus with braces and
exercises you need to understand that
bone can remodel or reoriented
Bone remodeling
Julius Wolff
Germany, 1892
...and this kind of treatment was used before 1977 in orthopaedic.
In 1979: Haje first description
of pectus treatment with
braces(RBO, v. 14, p. 167)
1977
DCC I – dinamic chest
compressor
1988
1988: began treatment of pectus
excavatum with DCC II (JPO, v. 12, p. 795)
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06/24/2016
Dynamic Remodeling (DR) method:
braces + exercises (Haje, SA et al, 2006): CARINATUM
External pressure of
Dynamic Chest Compressor (DCC)
braces on protruded areas
Exercises that increase the
pressure in the protuded areas that have
the brace on: carinatum can correct faster
Haje SA, Haje DP (2006) Overcorrection during treatment of pectus deformities with DCC orthoses: experience in 17 cases. International
Orthopaedics (SICOT), 2006, vol. 30/4: 262-267.
Haje, S, Haje DP. Tórax e Cintura Escapular (2009). In Hebert, S.K.; Xavier, R.; Pardini Jr. A. G.; Barros Filho T.E.P. Ortopedia e Traumatologia:
Princípios e Prática. 3ª ed. Porto Alegre: Artmed Editora, p. 147-162.
Dynamic Remodeling (DR) method:
braces + exercises HOW CAN CORRECT EXCAVATUM?
Exercises that increase
the
intrathoracic pressure
along with the use of
DCC
pressure on
depressed areas
Video 1
Video 2
External pressure of
DCC braces on
protruded areas: flared
ribs and sometimes
above nipple
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06/24/2016
Dynamic Remodeling (DR) method:
braces + exercises HOW CAN CORRECT EXCAVATUM?
MOAJR DN 11-7-97
CORRECTING THE INFERIOR RIBS HELPS TO CORRECT THE
DEPRESSED AREA: RIBS EXCESS IN CORRECTED POSITION MAY GIVE
MORE SUPPORT TO THE UPPER CHEST (?)
KJT
Dynamic Remodeling (DR) method:
braces + exercises:? HOW CAN CORRECT EXCAVATUM?
CORRECTING THE INFERIOR RIBS HELPS TO CORRECT THE DEPRESSED AREA:
MAY HELP RESPIRATORY MUSCLES TO WORK BETTER(?) AND MAY INCREASE
INTRATHORACIC PRESSURE (?)
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06/24/2016
Treatment of Pectus Carinatum and Excavatum by
braces and exercises (HAJE’S
METHOD)
• For that we have a PROTOCOL FOR treating each type of pectus and for:
developed a
specific
software and
forms
•
•
•
•
•
Assessing the patient for the first time
Making the measures of the brace
Adjusting the brace for the first time and in follow-up
Exercises protocol
Protocol of assessing patient in returning visits and
weaning phase
Form for first
consultation
Forms for
braces
Forms for
follow-up
Forms for
patient
ETC...
HAJE AND HAJE CLASSIFICATION FOR
PECTUS
Inferior
PCI
Lateral
PCL
Superior
PCS
Pectus
Carinatum
Localized PEL
Wide
PEW
Pectus
Excavatum
Haje SA, Haje DP (2009) Tórax e Cintura Escapular. In Hebert S.
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06/24/2016
Proposing a modification in Hajes classification (2013):
Pectus
Excavatum
Localized PEL
BIG CENTRAL
DEPRESSION
+ LITTLE
FLARED RIBS
(type 1)
DEPRESSION +
FLARED RIBS
OF SAME
PROPORTION
(type 2)
LITTLE
DEPRESSION +
BIG FLARED
RIBS
(type 3)
Proposing a modification in Hajes classification (2014):
Pectus
Carinatum
Superior
PCS
Very high
above NIPPLE
LINE
(CURRARINO
TYPE – type 1)
JUST ABOVE
NIPPLE LINE
(type 2)
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06/24/2016
Proposing a modification in Hajes classification (2015):
Pectus
Excavatum
Wide
PEW
Wide
DEPRESSION
(type 1)
Wide
DEPRESSION In
lower chest
(type 2)
Assimetric
wide
DEPRESSIOn
(type 3)
HAJE : DISCRIBED THAT PECTUS HAS DIFFERENT
FLEXIBILITY LEVELS AND THAT CAN IMPLICATES
IN TREATMENT PROGNOSIS (1992, JPO)
Video 3
-
Rigid (F0)
Mild flexibility (F1)
Moderate flexibility (F2)
Very flexible (F3)
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06/24/2016
Treatment of Pectus Carinatum and Excavatum by a
TREATMENT Method
(HAJE’S METHOD)
• YOU NEED A PROTOCOL OR STANDARZED APROACH OF:
• Assessing the patient for the first time
• When proposing treatment: one of the most important point is the
psychological one  easy to treat motivated patients
• Show photos of other patients treated and simplify
treatment
• Most of adolescents are worried it they have to wear the
brace at school – “show that the the brace is no big deal
and temporary”
Tell the kids that
they can adorn
the brace
PSMF
July 2015
December 2015
Psychological aspects
Some patients do not
like to tell others why
they are using the
brace...
The patients may tell
others that they are
treating their spine....
Better to use over the shirt
Using the brace inside the shirt
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06/24/2016
• Also explain that :
MEDICAL PROTOCOL FOR
PECTUS ORTHOTIC
TREATMENT
1. Compliance is essential for a successful treatment
2. Use the DCC(s) 23 hours a day
If use less than 18-15 hours a day: no or little correction
If use 12 hours : avoiding getting worse
Do exercises everyday
3. To avoid recurrence: gradual weaning/release from
the braces, in one, two or more years*.
LMB
EXAMPLE OF
RECURRENCE
May 2012
11 years
September 2012
11 years
April 2014
13 years
May 2015
14 years
TO NOT HAVE RECURRENCE: AFTER
GETTING BETTER NEEDS TO USE THE
BRACE FOR SLEEPING AND FOR GYM
EXERCISES UNTIL SKELETAL MATURITY
BOYS – 16 – 17 YEARS OLD
GILRS – 14 - 15 YEARS OLD
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06/24/2016
EXAMPLE OF
RECURRENCE
OVERCORRECTION
14 y
GREAT CORRECTION
14 y + 8 m
STOPED TREATMENT AND JUST DID GYM
EXERCICES
STARTED
TREATMENT AGAIN
16 y + 7 m
Partial correction
Stopped treatment
Started treatment
12 y
13 y
14 y + 8 m
STARTED
TREATMENT AGAIN
EXAMPLES OF
RECURRENCE –
STOPPED TREATMENT
BEFORE MEDICAL
ADVICE
15 y
14
06/24/2016
Braces developed by Hajes
Dynamic Chest Compressor (DCC) and
AdjustableDCC(ADCC)
DCC 1 (1977)
DCC 2 (1988)
ADCC 1 and 2
(2013)
•Manage pressure with lateral screws  can put pressure slowly: 1
turn in the screw make the anterior pad compress 1 mm
• No need to measure pressure with external applied devices.
ADCC (adjustable) 1 and 2 - project (2013)
I needed a brace that would be less
dependent of a prosthetic
I have a lot of patients from others
cities and countries.
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06/24/2016
The same PAD PATTERNS IN THE DCC AND ADCC:
DCC 2 X
ADCC 2
same types of
anterior and
posterior pads
DCC 1 X
ADCC 1
Same type of
posterior pads.
Anterior pads of
different patterns
X
DCC
ADCC
(making it larger: patient growing and chest enlargement
because of treatment)
Ideal
distance
to the
patient
tight
Need to send the brace to
the prosthetic workshop or
atelier
Telescoptic bars allow
doctor to do it in his office
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06/24/2016
May change pads position during treatment
3 months
For the best
results you
must see all
the details...
DCC
X
ADCC
(changing the position of anterior pad)
Bone protuberance can change position during treatment
because of pectus improvement or growing of the patient
To change position:
new holes and rivets
in prosthetic
workshop
Possible to change position in
doctors office
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06/24/2016
DCC
X
ADCC
(pressure: controled by screw and lateral bar size)
Can increase or decrease pressure
Changing lateral bar: must
be done in prosthetic
workshop
Can chage lateral bars in doctors
office
DCC
X
ADCC
(measurements: detailed prescription of pads size, level and shape)
Cast mold
Caliper rule and flexible rule:
faster and cleaner
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06/24/2016
Making measures for manufacturing the
DCC – plaster caster mold with
detailed prescription for pads level,
size and shape
Video 4
Video 5
FORM
Video 6
For customized
DCC brace(s),
Making measures for manufacturing
the
ADCC – rules / caliper rule or
3D SCAN
NO NEED FOR CAST
MOLDS
Send the form by email
to the prosthetic
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06/24/2016
X
DCC
ADCC
(manufacturing and assembling the brace)
Manufacturing and assembling in
prosthetic workshop
Possible to be
assembled in the
doctor’s office
Cost
Preestablished sizes of the
anterior and posterior bars. Can
assemble the brace in the office.
Costs more? Depends if you can
reuse bars and how much
prosthetic charges for making
adjustments in the DCC.
DCC
ADCC
no
yes
Low cost
Low cost, but higher
than DCC
ADJUSTABLE DCC I AND II
• ADCC: possibility to assemble
Video 7
the brace as you may have the
anterior and posterior bars premanufactured
• may take measures of brace and
start treatment in the same day.
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06/24/2016
TREATMENT RESULTS: DCC X ADCC
• ADCC: initial research:
• 17 patients used ADCC: mean follow-up of 14,4 months
• DCC and ADCC same treatment results
• ADCC: no need of a prosthetic to change or repair brace
in the initial use and during treatment
• ADCC: mean of 2 brace adjustments per patient - the
same of the DCC (but needs a prosthetic)
• after initial testing became the gold standart brace in
our center.
TGC DN 08-05-03
RESULTS FOR
ADCC
1 ENLARGEMENT
PEW – PECTUS
EXCAVATUM WIDE
11
months
January 2014
10 y + 8 m
December 2014
10 y + 8 m
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06/24/2016
TSG DN – 9-12-03
15-12-14
25-6-14
NO
ADJUSTMENTS
RESULTS FOR
ADCC
Mild pectus not in
the growth spurt:
less adjustments
PEW – PECTUS
EXCAVATUM WIDE
6
months
Dez 2015
12 y + 0 m
July 2014
11 y + 6 m
EGD
ADCC
RESULTS
PCI – PECTUS
CARINATUM
INFERIOR
1 lateral bar
changed
needed
11
months
January 2014
14 y
December 2014
15 y
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06/24/2016
BEFORE
AFTER
2
enlargements
needed:
Pectus
improvement+
growing chest
FOR EVERY PECTUS THERE IS A POSSIBLE
BRACE + EXERCICES TREATMENT
TREATMENT OF PCInferior
TREATMENT OF PCLateral
TREATMENT OF PCSuperior
TREATMENT OF PEWide
TREATMENT OF PELocalized
CHILDREN /
ADOLESCENTS
ADULTS
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06/24/2016
TREATMENT OF PCI – INFERIOR TYPE
PCI – usually flexible deformity;
• Treatment in puberty: most of the cases
• Start treatment earlier: in childhood, when is a
severe deformity
TREATMENT OF PCI – INFERIOR TYPE
Start treatment EARLIER in SEVERE CASES
2 YEARS
OLD
AFTER 3 YEARS AND 3 MONTHS
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06/24/2016
Result after
10 months
Treat all the
deformity
components
Use DCC I and II for treating carinatum
Jun 06
Dez 04
YVDS
E
X
A
M
P
L
E
Out 05
11+8
Dez 04
13+2
Jun 06
DCC I
DCC II
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06/24/2016
Use DCC I and II for treating carinatum
Feb 16
Oct 15
16 y
4 months
HGSL
Oct 15
DCC I
DCC II
July 2012
July 2013
15 years
After 1 year treatment using only
for sleeping time and exercicies
until skeletal maturity
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06/24/2016
DB Jul 2005
Jan 2006
Apr 2015
Jul 2009
Jan 2007
August 2015
..... 10
years followup
TREATMENT OF PCI – INFERIOR TYPE
10-11-15
1-9-14
females
HCAP
Less divergent breasts after
PCI improvement
before
after
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06/24/2016
TREATMENT OF PCI – INFERIOR TYPE
DR Method: patients’ compliance in different phases of life
IT IS POSSIBLE TO TREAT ADULTS
PRE
27 ye + 6 m
POST
27+10
POST
28+10
From
USA
TREATMENT OF PCL – LATERAL TYPE
PCL – usually flexible deformity, but a less
then PCI;
• Treatment in puberty: most of the cases
• Start treatment earlier: in childhood, when is a a
severe deformity or when is a .....
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06/24/2016
TREATMENT OF PCL – LATERAL TYPE
VFM
dn 13-11-01
Oct 2013
Aug 2011
9 years
..... is a girl start treatemnt earlier because you can not put
pressure over the breast
TREATMENT OF PCL – LATERAL TYPE
VFM
dn 13-11-01
CT IMPROVEMENT
PARTIAL CORRECTION OF HER BONE
DEFORMITY, BUT SHE HAD ASSIMETRIC
BREASTS ALSO
before
3-8-11
after
8-10-13
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06/24/2016
VFM
dn 13-11-01
TREATMENT OF PCL – LATERAL TYPE
naf
..... But if the breast are already develeped you also may do
the treatment for the lateral type
PCL – POSSIBLE TO TREAT ADULTS
AUGUST-2012
AUGUST-2013
23
YEARS
23
years
Treat mild pectus
From USA
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06/24/2016
TREATMENT
CURRARINO
TREATMENTOF
OFPCS
PCSOR
– Superior
type
PCS – rigid deformity;
• Start treatment earlier: in childhood, as soon as
you make the diagnosis.
• The treatment is almost preventive.
• The x-ray and CT can help for an earlier
diagnosis.
UNDERSTANDING WHY THE TREATMENT OF CURRARINO
OR SUPERIOR TYPE IS ALMOST PREVENTIVE
X-RAY: STERNUM CAN BE SHORTER THAN REFERENCE VALUES
Normal
Haje SA, Harcke HT, Bowen JR, Pediatric Radiology, 1999
6 months
13 years
Premature closure or
assimetric growth of
sternum growth plates
can lead to deformitie.
Normal BM / BXM = 2.16
(SD ±0.24)
BM and BXM index
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06/24/2016
TREATMENT OF PCS – Superior type
Irregular
manubrio-sternal
junction
Only two sternal
body segments
April 2001 – 3 ye + 8 mon
Fusion of the
manubrio-sternal
junction.
Look at the shape
of the sternum.
The anterior
angulation of the
sternum got
worse
Aug 2003 – 6 ye
Treatment indicated
TREATMENT OF PCS / CURRARINO
Db. 26-7-97
DEFORMITY
Treatment was
considered preventive
and was indicated.
Family was advised of
the risk of these mild
deformity of getting
worse and RIGID.
Aug 2003 – 6 ye
Quit treatment after 3
months
Came back after 10
years with a worse
deformity and
psychological
problems.
April 2013 – 15 ye + 10 mo
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06/24/2016
PCS – what is the best conservative approach?
Early brace treatment (6 – 10 years of age) is also
curative.
May 2010 – 6 ye + 4 mo
Started treatment 23 h/day
preventive, not only
December 2015 – 11 ye + 11 mo
Using braces 18 hours/day
PCS – what is the best treatment?
Even it seens too late and it is a rigid type, try first the brace
treatment. You steel can have good results...
March 2010 – 12 ye + 5 mo
Sept 2012 – 14 ye + 11 mo
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06/24/2016
JB
PCS – POSSIBLE TO TREAT ADULTS
Jan 2007
24
years
Dec 2008
From Sweden
RF
PCS – POSSIBLE TO TREAT ADULTS
32
years
Dec 2013
March 2014
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06/24/2016
TREATMENT OF PEW – WIDE
EXCAVATUM
PEW :
• Treatment as soon as you make the diagnosis
• Better results in pacients using the brace 23
hours a day + exercices everyday
• Variable flexibility
y
Pectus excavatum- tendency to start treatment
earlier
Db 28-12-02
5 years
DCC and exercicies
8 years
Using only for sleeping time and
exercicies
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06/24/2016
Pectus excavatum- better to use full time until
skeletal maturity or full correction
MVPM
February 2015
November 2015
KEEP USING 23 HOURS A DAY
RMF dn 23-9-99
Pectus excavatum- Improvement showed by CT.
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06/24/2016
Pectus excavatum- weaning phase should be
slower than carinatum
Nov 2011
May 2014
12 years
August 2015
14 y + 8 m
15 y + 11 m
KEEP USING 23 HOURS A DAY
STARTED THE WEANING
Pectus excavatum- treatment total time may be
shorter in the end of adolescence
Sep 2010
15 y + 6 m
Jan 2013
17 y + 10 m
28 months follow-up:
released from braces
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06/24/2016
PEW – POSSIBLE TO TREAT ADULTS
Bone can remodel !!!
Can have sucess for
the flared ribs in
some patients
Patient who
received
surgery
before the
Dynamic
Remodeling
(DR)
method
Sweden,
3 years
after
DR
method
20 years
TREATMENT OF PEL – LOCALIZED
EXCAVATUM
PEL :
• Treatment as soon as you make the diagnosis
• Better results in pacients using the brace 23
hours a day + exercices everyday
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06/24/2016
DR Method: good results to pectus carinatum and pectus EXCAVATUM
TREATMENT OF PEL – LOCALIZED
EXCAVATUM
Feb 2008
May 2009
10 years
1 year
Aug 2013
15 y + 5 m
5 years
follow-up
July 2012
April 2014
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06/24/2016
y
Pectus excavatum- when the problem is more the
flared ribs than the depression?
Db 28-12-02
Best results than the ones with bigger depressions.
Aug 2012
June 2013
15 y +
5m
13 y + 10 m
JPRC
PEL – partial result can avoid surgery
22-7-15
Patient willing to do
surgery
23-2-16
Patient do not want
surgery anymore
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06/24/2016
PEL – POSSIBLE TO TREAT ADULTS
Bone can remodel in some patients
Can have partial or total sucess in some patients
49 years
Sep 2000
Jan 2000
PEL – POSSIBLE TO TREAT ADULTS
March 2013
27-3-13
20 years
Nov 2013
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06/24/2016
PEL – partial initial result in adult
Can lead to better results in plastic surgery or Nuss.
21 years
JVSS
COMPLICATIONS
Jan 2015
Jan 2016
12
months
- Skin problems –
never need to stop treatment
- Bone edema: one case
(adult)
-
Overcorrection
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06/24/2016
Haje SA, Haje DP. Overcorrection during treatment
of pectus deformities with DCC orthoses. Int Orthop, 2006.
Jan/05
e
x
c
a
v
a
t
u
m
1997
May/05
Oct05
e
x
c
a
v
a
t
u
m
c
a
r
i
n
a
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Nov 2011
1998
n
o
r
m
a
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n
o
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m
a
l
2002
July 2013
13 y + 9 m
FLARED RIBS OVERCORRECTED
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06/24/2016
Nov 2011
Jan 2014
FLARED RIBS in CORRECT
POSITION
RESULTS – Haje’s method
Haje, Haje and Silva – 1977 - 2016
5791 - pectus patients
3338 - treated
2493 – RELIABLE DATA and treated with follow up > 12
months
Walmsley – 2011 – 2014
120 - pectus patients
82 – treated
12 – RELIABLE DATA and treated with follow up > 12 months
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06/24/2016
RESULTS
IMPROVEMENT:
3 – EXCELLENT OR GOOD (70-100%)
2 – MODERATE (40-70%)
1 – LITTLE (<40%)
0- NO IMPROVEMENT
ANALYSE PATIENT SATISFACTION AT THE END OF
TREATMENT.
PERSPECTIVE: 3D SCAN ANALYSIS PRÉ AND
PÓS TREATMENT
RESULTS IN PATIENTS UNDER 19 YEARS OLD
– minimum follow-up of 1 year (1977-2016)
Improvement PCI PCL PCS PEL
PEW
IM 3 e 2 77% 62% 42% 45%
39%
IM 1
13% 19% 42% 39%
42%
IM 0
10% 19% 16% 16%
19%
RESULTS IN moderate (F2) to very flexible (F3)
pectus in patients with compliance
Improvement PCI PCL PCS PEL
PEW
IM 3 e 2 92% 75% -% 60%
70%
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06/24/2016
Association of Braces and Exercises
to Vacuum Bell for the Treatment of
Pectus Excavatum
HAJE, DP (2016): VACUUM BELL + BRACES +
EXERCISES  57% of pectus excavatum
patients had good or excellent results (R2‐R3)
being most cases rigid
(F0)
to mild flexible
(F1) excavatum.
See our poster
presentation for
more details
AVC
PEL – Haje’s method + vacuum bell
dn 30-6-09
For patients with pectus excavatum that after few months
of treatment shows that the depression component of
the deformity have only partial results, we are
associating in some cases the
11
MONTHS
only
Vacuum Bell
+20
MONTHS
+
46
06/24/2016
PEL – Haje’s method + vacuum bell
AVC dn 30-6-09
31 MONTHS
PEL – Haje’s method + vacuum bell
AVC dn 30-6-09
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06/24/2016
Concomitant orthotic treatment of
Scoliosis, Hyperkyphosis and Chest Malformations
Davi P. Haje, MD, PhD
Moacir Silva Neto, MD
Sydney A. Haje, MD (in memorian)
Centro Clínico ORTHOPECTUS
Hospital de Base do DF – SES – GDF
Brasília, DF, Brasil
Thoracic deformities
48
06/24/2016
Posterior (SPINE) and anterior (STERNUM) chest wall are
anatomically connected (by the RIBS and COSTAL
CARTILAGES)!
Pectus deformities
and Scolioses
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06/24/2016
Pectus deformities and Scolioses
Waters et al 21% of 596 patients with pectus that were operated
presented scoliosis and needed orthosis or surgery.
Waters P et al (1989) Scoliosis in children with pectus excavatum
and pectus carinatum. J Pediatr Orthop 9(5):551-56
Frick 4% to 5% of patients with pectus have scoliosis to warrant
consultation and assessment by a spinal deformity specialist.
Frick SL (2000) Scoliosis in children with anterior chest wall deformities.
Chest Surg Clin N Am. May;10(2):427-36
Pectus deformities and Scolioses
Haje SA and Haje DP (2009):
• Exacerbation of thoracic kyphosis was present in 14% of pectus cases.
• Scoliosis of 5° to 19° was detected 42% of pectus cases
Haje AS and Haje DP. (2009) ORTHOPEDIC APPROACH TO PECTUS DEFORMITIES: 32 YEARS OF
STUDIES, Rev Bras Ortop. Jan; 44(3): 191–198.
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Haje SA, Haje DP, Silva Neto M, Cassia GS, Batista RC, Oliveira GRA, Mundim TL (2010)
Pectus deformities: tomographic analysis and clinical correlation. Skeletal Radiology,
Vol. 39/8: 773-782.
WOS dn 4-11-95
20-7-11
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WOS dob 4-11-95
20-7-11
What is the main problem of this patient?
Pectus Carinatum
Inferior
Signs of SCOLIOSIS
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06/24/2016
No SCOLIOSIS
Signs of SCOLIOSIS
CT: Latero-lateral assimetry of sternum
body shape
Haje SA, Haje DP, Silva Neto M, Cassia GS, Batista RC, Oliveira GRA, Mundim TL (2010) Pectus deformities: tomographic
analysis and clinical correlation. Skeletal Radiology, Vol. 39/8: 773-782
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SCOLIOSES – RADIOLOGICAL STUDY
Cobb
angle
A study of vertebral rotationNo asymmetry
Pedicles
method
Pedicle in the
first segment
Pedicle in the
second segment
Nash & Moe JBJS 1969
Metha angle
When to treat mild pectus + mild or
moderate scoliosis (<20º) with the
help of pectus braces?
• I treat all cases
Scoliosis risk of progression:
Age
<19°
20-29º
30-39º
>40°
10-12
25%
60%
90%
100%
13-15
10%
40%
70%
90%
16
0%
10%
30%
70%
Nachemson AL, Lonstein JE, Weinstein SL.
Report of the prevalence and natural history committee
of the Scoliosis Research Society. Denver: Scoliosis Research Society, 1982.
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ORTHOTIC TREATMENT:
Dynamic Remodelling (DR) method
Haje SH & Haje DP, International Orthopaedics, 2006
Dynamic Chest Compressor orthoses + exercises
DR method: clinical benefits also on postural kyphosis and scoliosis signs
BEFORE
AFTER
BEFORE
AFTER
PCI
Patient treated with Dynamic Chest Compressor and exercises only
Patients with pectus deformity and mild scoliosis: treatment by DR
method only
DCC
orthosis
16º
May 08
Oct 08
11º
May 08
9°
Oct 08
5°
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Adolescent with pectus and
18º scoliosis
Dec 2008
AOA
7/7/09
March 2010
14/1/10
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Braces + exercises for pectus and spine/postural problems
KCM, 9 years
YMS, 15 years
Could this 9 years
old girl with mild
lateral
pectus
carinatum
and
very mild signs of
scoliosis become
this 15 year old
girl with SEVERE
scoliosis
and
assimetric trunk?
It is possible...
So let’s treat her
when she is 9....
Braces + exercises for pectus and spine/postural problems
kcm
August 14
9 years
March 15
7 months
Improved mild
pectus
carinatum
lateral + mild
hyperkyphosis
and signs of
scoliosis
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ABMF
Braces + exercises for pectus, scoliosis and hyperkyphosis
August 13
9 years
BEFORE
November 14
10 years
AFTER
+
EXERCISES
When you have pectus +
hyperkyphosis and scoliosis
BEFORE
PECTUS IMPROVEMENT
AFTER
KYPHOSIS IMPROVEMENT
treat before growth
spurt
BEFORE
AFTER
SCOLIOSIS IMPROVEMENT
When to treat scoliosis with the help
of scoliosis braces?
• more than 20º of Cobb angle in the X-ray in
growing subjects
• but depending on the scoliosis curve is possible to
treat some skeletally mature patients (controversial
theme)
• Possible braces
• Milwaukee
• Boston
• Charleston
• Chaneau
• Brasília
Boston Brace
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Brasília Bending Brace (BBB)
with
BBB
BBB: Plaster cast mold with corrective tilt made by the doctor
back view
back view
Haje SA et al (2008) Órtese inclinada de usocontínuo e exercícios para tratamento da
escoliose idiopática: uma nova proposta. Day and night bending brace and exercises
for treatment of idiopathic scoliosis: a new proposal. Brasilia Med; 45(1):10-20
CONCOMITANT TREATMENT
Four hours a day: DCC orthoses + one hour of DR method exercises,
plus side bending and stretching exercises.
Rest of the time: BBB
Brasília
Bending
Brace
DCC
4h/day
+
exercises
19h/day
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Lateral bending effect on the spine
Aug 03
Dec 03
DCC mark
25°
7°
“When the spine is bent to one side, an
automatic rotation of the vertebrae occurs to
the same side.”
Prat AG, Burniol JR. Biomecánica de la columna vertebral. In:
Viladot A, ed. Lecciones básicas de biomecánica del aparato
locomotor. Barcelona: Masson, 2004:112.
CONCOMITANT ORTHOTIC TREATMENT OF PECTUS DEFORMITIES AND MODERATE SCOLIOSIS
Pre
Evolution
Post
Pre
40 months
52º
Post
27
º
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CONCOMITANT ORTHOTIC TREATMENT OF PECTUS DEFORMITIES AND MODERATE SCOLIOSIS
RESULT AFTER 60 MONTHS
pre
T6
post
T6
T10
T10
52º
34º
L1
L1
CONCOMITANT ORTHOTIC TREATMENT OF PECTUS DEFORMITIES AND MODERATE SCOLIOSIS
RESULT AFTER 60 MONTHS
Age 13+11
pre
Age 18+11
post
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Another case: 20 years, PCI, 42º scoliosis + pectus carinatum inferior
Before
After
42º
Treatment
in a
skeletally
mature
patient
22º
Scoliosis + Pectus CONCLUSION
Haje SA, Haje DP, Martins GEV, Ferrer MG (2011), The spine lateral bending and the dynamic chest
compression principles for concomitant orthotic treatment of scoliosis and pectus deformities,
Coluna/Columna, 10(4): 293-9
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Pectus deformities
and Hyperkyphosis
ETIOLOGY of hyperkyphosis?
• Aseptic necrosis of the ring vertebral apophyses.
• Excess axial spine load due to heavy weight lifting.
• Hereditary predisposition.
• Sedentary lifestyle and muscles disbalance
shortened pectoral
muscles / anterior
protusion of
shoulders
Shy patients –
not motivated
for exercises
Weak
paravertebral
muscles
Flared ribs or
pectus
Weak
abdominal
muscles
shortened
hamstring
muscles
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Adolescent + hyperkyphosis
Some pectus
patients develop
hyperkyphosis during
adolescence
because they want
to hide the protusion
or depression that is
behind their shirt
CHILDREN + HYPERKYPHOSIS
Children are not ashamed of their pectus
condition as adolescents.
Probably the kyphosis is because of weaker
muscles or hereditary
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When to treat hyperkyphosis
with the help of braces?
• not responding to kinesiotherapy
• clinically relevant
• > 45º of Cobb angle in the X-ray
• better in flexible cases
• can have or not signs of
Scheuermann's kyphosis (at least 3
adjacent vertebrae demonstrating
wedging of >5 degrees)
When to treat hyperkyphosis
with the help of braces?
• not responding to kinesiotherapy
• clinically relevant
• > 45º of Cobb angle in the X-ray
• better in flexible cases
• can have or not signs of
Scheuermann's kyphosis (at least 3
adjacent vertebrae demonstrating
wedging of >5 degrees)
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How to treat hyperkyphosis and
pectus together with brace?
- to treat kyphosis: in literature
most of doctors use the:
1)Milwaukee brace (apex > T9)
- low compliance
- do not correct shoulders
- do not correct pectus
or flared ribs
OR
2) TLSO (apex < T9)
- do not correct shoulders
- do not correct pectus or flared
Milwaukee brace
ribs
ALTG
Brasília Kyphosis Brace
-
First brace described that can correct pectus + kyphosis
developed in 2013 by Haje, DP
can correct shoulders position, pectus and flarring ribs
compliance looks better than Milwaukee
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06/24/2016
My braces possibilities to
associate to specific exercises
Hyperkyphosis alone that failed
other treatments
Hyperkyphosis + pectus
Pectus brace (DCC or ADCC)
Brasília Kyphosis Brace
making pressures in the
flared ribs
Pectus brace (DCC or ADCC)
connected with shoulders
straps
Brasília Kyphosis Brace
(the point of pressure
will depends on the
pectus type)
My braces possibilities to
associate to specific exercises
Hyperkyphosis alone that failed
other treatments
Hyperkyphosis + pectus
Pectus brace (DCC or ADCC)
Brasília Kyphosis Brace
making pressures in the
flared ribs
Pectus brace (DCC or ADCC)
connected with shoulders
straps
Brasília Kyphosis Brace
(the point of pressure
will depends on the
pectus type)
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13-8-15
Hyperkyphosis alone that failed other
treatments
Brasília Kyphosis Brace making pressures in the flared ribs
ALTG
29-4-14
19-4-16
13y + 10 m
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06/24/2016
My braces possibilities to
associate to specific exercises
Hyperkyphosis alone that failed
other treatments
Hyperkyphosis + pectus
Pectus brace (DCC or ADCC)
Brasília Kyphosis Brace
making pressures in the
flared ribs
Pectus brace (DCC or ADCC)
connected with shoulders
straps
Brasília Kyphosis Brace
(the point of pressure
will depends on the
pectus type)
3-11-98
Take
these photos in the first appointment and ask
FBS
the patient what photo he likes more
May 2013
15 y + 6 m
13 y + 6 m
Tell the patient
that he needs to
strengthen and
stretches his
muscles and that
the brace will help
him to stay in the
right position
One of the reasons that he stay in hyperkyphosis
is because he is ashmed of his chest
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3-11-98
FBS
When the chest starts getting better it helps to correct the
hyperkyphosis because the patient is less ashmed
May 2013
13 y + 6 m
3-11-98
FBS
May 2015
15 y + 6 m
May 2013
– natural
posture
13 y + 6 m
May 2015
15 y + 6 m
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06/24/2016
May 2013 - in the
beginnig when asked
to stay in the correct
position
May 2015
– natural
posture
15 y + 6 m
13 y + 6 m
Braces + exercises for pectus and hyperkyphosis
December 12
November 15
18 years
VERF
15 years
DN 12-10-97
Natural
Improved
kyphosis
and
pectus
Natural
He keeps
doing
treatment
because
every year
he is
better
Trying to
correct posture
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06/24/2016
My braces possibilities to
associate to specific exercises
Hyperkyphosis alone that failed
other treatments
Hyperkyphosis + pectus
Pectus brace (DCC or ADCC)
Brasília Kyphosis Brace
making pressures in the
flared ribs
Pectus brace (DCC or ADCC)
connected with shoulders
straps
Brasília Kyphosis Brace
(the point of pressure
will depend on the
pectus type)
Treating hyperkyphosis + pectus together
Pectus brace (ADCC) connected with
shoulders straps
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06/24/2016
My braces possibilities to
associate to specific exercises
Hyperkyphosis alone that failed
other treatments
Hyperkyphosis + pectus
Pectus brace (DCC or ADCC)
Brasília Kyphosis Brace
making pressures in the
flared ribs
Pectus brace (DCC or ADCC)
connected with shoulders
straps
Brasília Kyphosis Brace
(the point of pressure
will depends on the
pectus type)
Treating hyperkyphosis + pectus together with Brasilia’s
Kyphosis Brace
Brasília Kyphosis Brace
- initial experience in 7 cases: good preliminary
results
- All cases improved clinically
- Mean X-ray kyphosis angle 58,4
(pré)
52º
(pós)
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06/24/2016
Treating hyperkyphosis + pectus together with Brasilia’s
Kyphosis Brace
Pain because of a
osteomyelitis
No pain
This lecture is
dedicated to Sydney
Abrão Haje, my
father, pioneer of
the non-surgical
treatment of pectus
deformities.
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06/24/2016
THANK
YOU
75