Pectus carinatum treatment in Canada: current practices☆
Sherif Emila,⁎, Jean-Martin Labergea, David Sigaletb, Robert Bairda
aDivision of Pediatric General Surgery, Montreal Children's Hospital, McGill University Health Centre
bDivision of Pediatric General Surgery, Alberta Children's Hospital, University of Calgary
Received 7 January 2012; accepted 26 January 2012
Background: Multiple treatment options currently exist for the correction of pectus carinatum (PC). We
performed a survey of Canadian pediatric surgeons to define current practices.
Methods: All active members of Canadian Association of Paediatric Surgeons were surveyed
online during winter 2011 through the Canadian Association of Paediatric Surgeons Web site. The
survey assessed multiple facets of PC evaluation and treatment, with particular emphasis on the
practice of bracing.
Results: Forty-five active members (85%) responded, of whom 32 (71%) currently treat PC. Fifty-three
percent of practices are low volume (b5 patients annually). In terms of preferred or most used treatment
modality, 69% of surgeons used bracing, 25% performed Ravitch repairs, 3% performed open minimal
cartilage resections, and 3% performed reverse Nuss procedures. Of 23 surgeons (72%) who used
bracing, 83% used it for most or the patients. Fifty-seven percent judged their bracing results as good or
excellent, and 74% felt that most or all patients braced were satisfied; 80% and 88% agreed or strongly
agreed that bracing was generally preferable to surgical repair and that bracing should be first line
Conclusions: Bracing is the preferred treatment for PC by most Canadian pediatric surgeons, despite lack
of prospective outcome data. This presents an opportunity for a multicenter prospective study.
© 2012 Elsevier Inc. All rights reserved.
Pectus carinatum (PC) is a chest wall deformity that
results in protrusion of all or part of the anterior chest. The
anomaly has a prevalence of 0.6% and occurs mostly in
young males . The prevalence may be underreported and,
in some chest wall anomaly practices, PC is more frequent
than pectus excavatum . Although not typically associated
with any physical disabilities, the defect can be extremely
unsightly, leading to social withdrawal and dysfunction.
Ravitch reported on the repair of the many forms of PC
over half a century ago . His classic open repair,
consisting of resection of the deformed costal cartilages
along with a single or multiple sternal osteotomies, has been
modified by Welch, Fonkalsrud, Shamberger, and others
[1,4-6]. However, its principles have not changed. In the last
decade, and particularly in the last 5 years, compressive
bracing for PC has been popularized through presentations
and reports of several case series [2,7-12]. Its proponents cite
many advantages, including noninvasiveness, cost-effective-
ness, and efficacy [2,7-12].
☆Poster Presentation at the annual meeting of the Canadian
Association of Pediatric Surgeons, Ottawa, Ontario, Canada, September
⁎Corresponding author. Division of Pediatric General Surgery,
Montreal Children's Hospital, Montreal, Quebec, Canada, H3H 1P3.
Tel.: +1 514 412 4497; fax: +1 514 412 4289.
E-mail address: Sherif.Emil@McGill.ca (S. Emil).
0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
Journal of Pediatric Surgery (2012) 47, 862–866
Chest wall deformities in Canada are almost exclusively
treated by pediatric general surgeons. We conducted a survey
of Canadian pediatric surgeons to define current practices in
PC evaluation and treatment. We wanted to particularly
evaluate the status of bracing and surgeon-reported outcomes
of this alternative approach.
A survey was designed by 3 pediatric surgeons (SE, JML,
DS) who all have extensive experience in the treatment of
chest wall deformities. The survey underwent 3 iterations
before finalization. The goal of the survey was to
“understand and evaluate the current state of PC treatment
in Canada.” To accomplish this goal, the survey posed
questions related to practice volume, practice setting,
familiarity with and use of therapeutic options for PC, and
details regarding bracing. It consisted of 34 multiple choice
questions with space for additional comments in 7. Some
questions allowed the participant to choose 1 answer only,
and some allowed for more than 1 choice. Ten to 15 minutes
were required to complete the full survey. The survey
instrument, available on the Canadian Association of
Paediatric Surgeons (CAPS) Web site (www.caps.ca), was
used. The instrument gave the surveyor the choice of
surveying all CAPS members, active members only (those
practicing in Canada), or particular members. It also allowed
for resending the survey to those who had not responded.
The survey was not validated.
The survey was sent by e-mail through the CAPS Web
site to active members in late January 2011. Participants
were specifically asked to complete the survey whether or
not they treated PC. Those who did not treat PC or who did
not use bracing were instructed to skip specific sections of
the survey. Four reminders were sent to nonresponders
approximately 7 to 10 days apart, before survey closure in
mid March 2011. Results were downloaded to a Word
document after closure of the survey. All answers were
completely anonymous because neither the survey itself nor
the CAPS survey instrument allows for linking the
participant to the response. Descriptive data generated by
the survey instrument were used for analysis.
The CAPS Web site lists 59 active members. Five
members were not in active pediatric surgery practice in
Canada at the time of the survey launch, and 1 was
incorrectly listed as an active member, leaving 53 eligible
participants. Forty-five surgeons answered the survey,
producing a response rate of 85%. Responders represented
every region in Canada and every Canadian pediatric
surgical center. Thirty-four percent were from Ontario,
22% were from Quebec, and the remainder were from
2.2. Practice characteristics
Thirty-two surgeons (71%) actively evaluated or treated
PC at the time of the survey. The most common reason for
not treating PC was the “concentration of chest wall anomaly
care in the hands of specific partners” (77%). “Lack of
expertise” and “lack of interest in chest wall anomalies” were
the next most common reasons, each cited by 39%. All but 1
surgeon, who did not treat PC, were not interested in starting
or resuming the practice. Most of all surgeons (85%)
believed that there was a learning curve in the evaluation
and treatment of PC. Responders who treated PC were quite
experienced, with 88% having more than 6 years of
experience in treating chest wall anomalies. However,
practice volumes were low, with 67% evaluating less than
10 patients per year, 53% treating less than 5 patients per
year, and 91% operating on less than 5 patients per year.
Only 2 surgeons treated PC patients in a designated chest
wall anomaly clinic. However, they reported that the clinic
included only nursing and orthotic staff, in addition to them.
Three surgeons reported collecting prospective outcome data
for PC treatment, and 9 reported collecting retrospective data
within the previous 5 years.
2.3. Treatment options
Table 1 lists the answers to several questions regarding
treatment options. Participants were allowed to choose more
than 1 answer for the first 3 questions, but only 1 for the
fourth. Familiarity was strongest with the Ravitch repair,
whereas bracing was the preferred or most frequently used
option. There was little familiarity with, or use of, minimally
techniques. Of those 23, most used it for most patients—57%
for more than 90% of patients and 26% for 61% to 90% of
more than 5 years, and 1 had used it for more than 10 years.
Most surgeons did not know if their provincial health plan
covered PC braces, except for those from Alberta and
Manitoba who reported that it was covered.
Just more than half the surgeons (52%) did not believe
that there were any contraindications to bracing. Asymmetry,
863Pectus carinatum treatment in Canada: current practices
age 16 years or older, and stiff or noncompressible chest
were chosen only once each as a contraindication. The most
common contraindication chosen (48%) was patient refusal.
In terms of bracing protocols, 74% of surgeons recom-
mended brace wear “at all times except during bathing and
sports,” whereas the rest recommend wear “as much as
tolerated” during the correction phase. There was little
agreement on bracing recommendations once correction has
taken place, with the most common recommendation (43%)
being wear “during the night only.” Patient compliance was
chosen as “almost all” by 22%, “a majority” by 52%, “a
minority” by 13%, and “few or none” by 4%. Two surgeons
could not evaluate compliance. The most common brace
used was one manufactured by the hospital's orthotics
department (57%), followed by a commercially available
brace (Braceworks, Calgary, Alberta, Canada) (35%).
In terms of outcomes, most surgeons used “surgeon
appraisal of appearance” (87%) and “subjective patient
opinion” (78%) to judge outcomes. None used pressure
measurements. Two surgeons used imaging, and 5 used the
measurement of external protrusion. Only 3 surgeons (9%)
felt that bracing should be continued past 1 year if
unsuccessful, whereas 48% chose 12 months and 30%
chose 6 months as the cutoff for failure in a compliant patient
who was not corrected. Only 57% of surgeons judged their
bracing results as “excellent” or “good.” When asked about
the frequency of patient satisfaction with bracing, 26%
answered “almost all,” 48% answered “a majority,” 13%
answered “a minority,” and 9% answered “few or none.” One
surgeon could not evaluate satisfaction. To measure
surgeons' overall impression of bracing as a treatment for
PC, the 2 questions in Table 2 were posed. A large majority
of surgeons (88%) expressed an interest in joining a
Canadian multicenter prospective study to evaluate out-
comes of bracing for PC.
Pectus carinatum has received significantly less coverage
in the medical and lay literature than pectus excavatum. The
reasons for this may include the absence of possible physical
effects, such as cardiac or lung compression, as well as the
lack of financial coverage for the repair of this “cosmetic”
deformity in private health care environments. In Canada, the
surgical repair of all chest wall anomalies is covered by all
the provincial health plans without requirement for autho-
rization or review. Patients with PC, therefore, have no
financial barrier to seeking surgical correction. In the senior
author's Quebec practice over almost 3 years, the number of
PC patients seen far exceeds the number of patients with
excavatum. This was also reported in a large Argentinean
practice . Canada also has a relatively small pediatric
surgical community, with 53 surgeons in active practice at
the time of the survey. It is therefore relatively easy to assess
the status of any particular pediatric surgical practice in the
country by surveying this small group of surgeons.
For decades, the only treatment available for chest wall
deformities was the Ravitch procedure . Although high
rates of success have been reported [1,4-6], the procedure is
quite invasive and is associated with significant postopera-
tive pain, hospital stays, and visible scarring. Modifications
have been made, most notably the minimal cartilage
resection procedures advocated by Fonkalsrud [5,6]. How-
ever, recurrence, suboptimal results, and a variety of
complications, although rare, have been reported in almost
all series of open repair [1,2,5,6,13].
In the last few years, a plethora of procedures using
minimal access techniques for PC correction have been
the “Abramson” or “reverse Nuss” procedures, are associated
with unclear indications, have shown variable results, and are
Pediatric surgeons' responses to 4 questions regarding PC treatment options
Which of the following
treatment modalities for PC
Are you familiar with?
Have you personally used in the past?
Do you currently use?
Is your current preferred or most used modality?
MIS, minimally invasive surgery.
Questions to measure surgeons' overall impression of bracing for PC
Agree Neither agree
Bracing is generally preferable to surgical repair of PC
Bracing should be offered as first-line treatment for the
majority of PC patients
864 S. Emil et al.
simply too new to judge [14-20]. Many of their technical
details are still being worked out. They cannot currently be
considered as reliable alternatives to the open procedures.
Bracing for PC was pioneered by Haje  and first
reported in the English language in 1992. His well-described
series already classified patients using rigidity of the chest
wall, a theme that was revisited more quantitatively by
Martinez-Ferro et al  in 2008. However, this modality did
not gain much traction in the pediatric surgical community
until the last decade, perhaps because it was published in the
orthopedic literature, whereas most chest wall anomalies are
treated by pediatric surgeons. The braces used by Haje were
also quite cumbersome with several pressure pads, probably
decreasing the appeal of this method. Egan et al  published
an American series of 5patients in 2000, butthe remainder of
the experience with bracing for PC has only been reported in
the last 5 years. The Canadian experience was reported by
Kravarusic  et al in 2006. All case series have been
retrospective (Table 3). Bracing protocols have varied.
Results have been promising but not consistent. All series
were not always clearly detailed.
Therefore, at present, multiple options are available for
the treatment of PC, including minimally invasive pro-
cedures and noninvasive bracing. We conducted this survey
of Canadian pediatric surgeons to evaluate the current status
of PC treatment in Canada and to specifically investigate the
use of these new alternatives to open repair. The results were
extremely instructive in many ways. Most of the responders
believe that the treatment of PC was associated with a
learning curve, and almost a third relegate this practice to
specific surgeons within their groups. Yet, the practice
volumes are quite small. Of every 3 surgeons, 2 treat less
than 5 PC patients a year, raising the question of whether
further allocation of care for this anomaly to even fewer
surgeons would be advisable. The study revealed
that there were no multidisciplinary chest wall anomaly
centers in Canada at the time of the survey. We have since
started such a center as a collaboration between our
children's hospital and the Shriners Hospital.
The answers to the questions on treatment modalities
reveal a significant shift in practice patterns. Although
surgeons are more familiar with the Ravitch repair than
any other modality, only 25% cite it as their preferred or
most used modality. Familiarity and use of the new
minimally invasive approaches are extremely low, and
only 1 surgeon cites minimal cartilage resection as the
treatment of choice. On the other hand, familiarity with
bracing approaches 90% and is currently the most
preferred modality by surgeons who treat PC. Of surgeons
who use bracing in their practice, 78% believe that bracing
is generally preferable to surgical repair, and 87% believe
that it should be offered as first-line treatment for most of
the PC patients. This is a remarkable result, given that only
57% of the same group judged their bracing results as
good or excellent, and a quarter of all surgeons who use
bracing reported poor patient satisfaction. This disconnec-
tion may be explained by the safety and noninvasiveness
of bracing and by the dislike of many pediatric surgeons
for the open repairs. We also found little agreement on
bracing protocols, as well as a variety of end points before
bracing failure is declared.
Like any survey study, ours has limitations. Although we
had a superb response rate (85%), nonresponders may have
been more likely to be surgeons who have little interest in
PC. This may have caused an underestimation of the degree
of chest wall anomaly care centralization in Canada. The
CAPS database also does not include young surgeons in
active practice who may have finished their training within
the previous 1 to 2 years and are not active CAPS members
yet. This number is likely to be extremely small, but these
surgeons may be more interested in innovative minimally
We have conducted the first national survey of surgical
practices regarding the corrections of PC. Our survey has
shown a significant enthusiasm for bracing in the Canadian
pediatric surgical community, despite lack of standardized
treatment protocols, objective assessments of results, or
prospective outcome data. This presents an excellent
opportunity for a multicenter prospective outcomes study.
Published series of bracing for PC in the English language
Publication Yearn Mean
Definition of successFurther
Matinez-Ferro et al
Stephenson et al
Lee et al
Kravursic et al
Physician rating scale
Objective CT indices
Patient rating scale
Patient rating scale
Subjective physician rating
Objective CT indices
Patient rating scale
Banever et al
Frey et al
Egan et al
Haje et al
Rx indicates treatment; F/U, follow-up; CT, computed tomography; NA, not applicable.
865 Pectus carinatum treatment in Canada: current practices
Given the interest of most of the participants in joining such a Download full-text
study, we hope to initiate one in the near future.
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