Funnel chest

The funnel chest (pectus excavalus) is a developmental defect in the form of depression of the sternum and ribs, accompanied by various functional disorders of the respiratory and cardiovascular systems.

A funnel-shaped chest was first described by G. Bauhinus in 1600. Abroad, the first operation in a patient with similar deformity was performed by A. Tietze in 1899, performing a resection of the altered lower part of the sternum.

[1], [2], [3], [4],

Causes of the funnel chest

Funnel chest, as a rule, is a congenital malformation. The detailed classification of the etiopathogenetic concepts of funnel chest deformity combines four main groups of theories,

• The first group of theories links the development of funnel-shaped deformity with the uneven growth of bone and cartilage formations of the chest, as well as the xiphoid process, due to the embryonic inferiority of the apophysial and epiphyseal growth zones. Sternum and cartilaginous divisions of the ribs are lagging behind in their development. The formation of the chest is uneven. It changes its shape, volume and size, which is manifested by a decrease in sterno-vertebral distance and flattening of the chest itself.
• The second group is represented by theories explaining the formation of funnel-shaped deformation by congenital changes of the diaphragm: shortening and lagging in the development of its sternal part, the presence of a shortened sterno-diaphragmatic ligament. The ribs have an excessive oblique or oblique direction, as a result of which the position of the chest muscles, as well as the diaphragm, especially its anterior sections at the site of attachment to the costal arches, changes.
• The third group combines theories that suggest that the funnel chest is the result of imperfect development of the sternum in the embryonic period, connective tissue dysplasia, which in turn leads to anatomical and topographic and clinical and functional changes not only from the chest itself, but also respiratory and cardiovascular systems, and is manifested metabolic disorders of the whole organism. Some authors identify reliable dysplastic signs indicating a congenital nature of the disease. These include Mongoloid incision of the eyes, arachnodactyly, high palate, hyperelasticity of the skin, dysplasia of the auricles, dystostenome, scoliosis, mitral valve prolapse, umbilical hernia, sphincter weakness. It is also noted that the presence of more than four of the listed signs in patients is an unfavorable prognostic sign.
• The fourth group includes eclectic theories explaining the formation of a funnel-shaped deformity by the incorrect position of the fetus in the uterus during malnutrition or infectious processes in the mediastinum.

There is no doubt that in some patients with a funnel chest, this deformity is a hereditary defect. X. Novak surveyed 3,000 schoolchildren and found deformity in 0.4%, and among their relatives, a funnel chest was found in 38% of those examined. The congenital nature of the disease is confirmed by combining it with other congenital malformations.

Currently, the funnel chest in most cases is associated with dyschondroplasia. In the early stages of the embryonic period (first 8 weeks), the development of cartilaginous cells of the ribs and sternum is delayed. As a result, at the time of childbirth, embryonic cartilage remains, characterized by fragility due to excessive development of soft tissue structures and a quantitative lack of cartilage cells. O.A. Malakhov and co-author (2002) consider dyshistogenesis of hyaline cartilage tissue to be a major factor in the formation and progression of chest deformity, leading to uneven development of chest elements due to the rapid growth of ribs with subsequent circulatory disorders and respiratory biomechanics.

The funnel-shaped deformation of the chest decreases the volume of the chest, which leads to hypertension in the pulmonary circulation, chronic hypoxemia, functional impairment of the internal organs of the chest cavity, changes in acid-base status and water-salt metabolism with the formation of a vicious circle. On the other hand, changes in the attachment points of the muscles involved in the breathing act cause their atrophy, loss of elasticity, tone and degenerative rebirth, which is confirmed by electromyography of the respiratory and auxiliary muscles examined at rest and during exercise tests, as well as by histological examination in time of operations. Such changes lead to a decrease in the elasticity and mobility of the chest, a decrease in its excursion, and the development of persistent paradoxical breathing. In addition, bronchial compression, displacement of the mediastinum and torsion of large vessels are noted, which disrupts the activity of the respiratory system and the pulmonary circulation.

[5], [6], [7]

Symptoms of the funnel chest

Funnel chest visible in newborns in the form of a small depression. A characteristic sign in infants is a symptom of the “paradox of inhalation”: when you inhale, and especially when crying children or crying, the depression of the sternum and ribs increases. G.I. Bairov indicates that in half of the children the deformation of the chest and paradoxical breathing disappear in the first months of life. And only in the second half, with their growth, does the sternum depression increase. During this period, the edges of the coastal arcs and the furrow formed under it begin to appear. Rising, the edges of the ribs push the rectus abdominis forward, giving the impression of its increase. These changes are mistaken for the symptoms of rickets.

An increase in the strain in the first half of the year may lead to dysfunction of the organs of the chest, susceptibility to respiratory diseases of the upper respiratory tract, chronic pneumonia.

In some children, stridal breathing is noted - difficulty whistling inhalation is accompanied by great tension of the respiratory muscles, retraction of the jugular cavity, epigastric region and intercostal space, which is caused by the increasing negative movement in the chest cavity. On an ECG at babies, as a rule, do not find changes.

Funnel chest begins to appear especially bright after 3 years of age. By this time, a gradual transition to a fixed curvature of the sternum and ribs is usually completed. Appearance and posture become typical of a funnel-shaped chest.

Thoracic kyphosis increases, rarely the back becomes flat. There may be lateral curvature of the spine. On examination, lowered shoulder girdle, protruding belly are striking. The chest is flattened, in the region of the sternum is determined funnel chest.

The depth and volume of the funnel can vary in different limits depending on the severity of the pathology and the age of the patient. The depth of the funnel is measured by the distance from the plane connecting both edges of the indentation to the top of the funnel. In addition, its value can be determined by the amount of the containing liquid. The volume of the funnel with small deformations is 10-20 cm ³, and when expressed, up to 200 cm ³ or more in adult patients.

[8], [9], [10]

Stages

N.I. Kondratin developed a classification of funnel chest deformity, in which patients are conventionally divided into groups according to the clinical course of the disease, form, type and severity of deformity.

There are three degrees of deformation of the sternum, taking into account the depth of the funnel and the degree of displacement of the heart:

• I degree - the depth of the crater up to 2 cm, there is no shift of the heart;
• II degree - depth of deformation up to 4 cm, displacement of the heart within 2-3 cm;
• Grade III - deformation depth of more than 4 cm, the heart is displaced by more than 3 cm.

The degree of deformity of the sternum determines the clinical course of the disease.

In this regard, isolated compensated, subcompensated and decompensated stages of the disease.

• In the compensated stage, only a cosmetic defect is detected, there are no functional disorders or they are minimal. As a rule, this stage of the disease corresponds to the I degree of chest deformity.
• The subcompensated stage of deformation corresponds to the II degree of deformation. At the same time, mild functional disorders of the heart and lungs are noted.
•   At the decompensated stage, III degree of funnel deformity with significant functional impairments is detected.

Distinguishing deformations in shape, they distinguish ordinary and flat-funnel-shaped, and in appearance they are symmetrical and asymmetrical (right-sided, left-sided).

• Flat-crowned chest in most cases is the result of the progression of a deep funnel chest.
• The symmetric form of deformation is characterized by the uniform development of both halves of the chest,

Some authors, complementing the classification of N.I. Kondrashin, distinguish the following forms of the sternum with a funnel-shaped deformation flat, hooked and sternum with osteophyte.

Diagnostics of the funnel chest

To assess the functions of the lungs, an elactromyographic study of the respiratory (intercostal) and auxiliary (nodative and trapezoidal) is performed.

An electromyographic study reveals structural changes in the respiratory muscles and chest in half of patients with funnel chest deformity. Such indicators are an argument in favor of dysfunction of spinal cord motoneurons.

Children with severe chest deformity are asthenic, lagging in physical development, have weak muscular system and vegetative-vascular dystonia, since a sharp decrease in lung capacity (15-30%) and a pronounced manifestation of cardiac and pulmonary insufficiency make blood exchange of blood difficult. Often, patients complain of fatigue and stabbing pain in the heart. Reduced excursion of the chest and diaphragm, dysfunction of external respiration leads to a change in the redox processes in the body. This is manifested in the violation of carbohydrate, protein and water-salt exchanges, as well as the acid-base state.

For an objective assessment of the state of the internal organs in patients with funnel chest deformity, the function of external respiration is investigated by a special technique, the vital capacity of the lungs, and the reserve volume of inhalation and exhalation.

Funnel deformity of the chest is characterized by insufficient expansion of the lungs, which reduces the "lung membrane" through which gas exchange takes place. Due to incomplete expansion of the lungs, the "anatomical dead space" increases, and alveolar ventilation decreases. To compensate for these disorders, the body increases lung perfusion, which leads to right ventricular hypertrophy. Functional disorders of the cardiovascular and respiratory systems in patients with funnel chest deformity lead to tissue hypoxia, changes in enzymatic and metabolic processes.

Vital capacity of the lungs (VC) within the normal range was noted only in 21% of patients with grade II chest deformity. A moderate deviation of the VC was in 45%, a significant decrease in 6%. In patients with III degree of deformity, normal values of VC are not observed. As a rule, funnel-shaped deformity of the chest is interconnected with the deformation of the anterior chest wall and impaired respiratory function. The tendency is unidirectional: the higher the degree of deformation, the more pronounced are impaired ventilation of the lungs.

During the electrocardiographic study, most patients showed various abnormalities (81-85). Thus, in 40% of cases blockade of the right Guissa leg, sinus arrhythmia (10%), deviation of the electrical axis of the heart to the right and left (9%) were noted, left ventricular hypertrophy (8%) and other abnormalities.

An echocardiographic examination revealed mitral valve prolapse and an abnormal arrangement of the chord in the left ventricle.

Analysis of ECG and EchoCG data allows us to conclude that with an increase in the degree of deformity, the frequency of disturbances in the activity of the cardiovascular system increases.

In addition to the clinical method of examination, use radiological - the most accurate.

According to the X-ray examination assess the degree of funnel deformity and the degree of kyphosis of the thoracic spine. And also the method helps to reveal the nature of changes in the chest organs. X-ray examination is carried out in two standard projections: anteroposterior and lateral. For better contrasting of the sternum, a wire or a strip of radiopaque material is fixed in the midline. The degree of deformation is assessed by the Gizycka index (Gizicka, 1962). It is determined on the lateral radiographs by the ratio of the smallest size of the retrosternal space (from the posterior surface of the sternum to the anterior surface of the spinal column) to the largest. The quotient obtained by dividing 0.8-1 (the norm - 1) characterizes the deformation of the 1st degree. From 0.7 to 0.5 - II degree, less than 0.5 - III degree.

The Gizycka Index, to date, remains the simplest radiological indicator to determine the degree of chest deformity and to decide the question of surgical intervention. In some patients on the lateral radiograph reveal exostose growths on the inner wall of the sternum, its thickening, which significantly reduces the retrosternal space. In these cases, there is a discrepancy between the magnitude of the deformation and functional impairment.

To assess the quantitative relationships of the respiratory capacity of various parts of the lungs, VN Stepnov and V.A. Mikhailov used the method of radiopneumography.

An X-ray examination evaluates the degree of kyphosis of the thoracic spine before and after surgical correction. 66% of patients with funnel chest deformity have cyphotic deformity of grade II, and grade 34 of kyphosis is noted in 34%.

The first report on the study of the structure of the chest and chest cavity in patients with funnel chest deformity by X-ray computed tomography appeared in 1979 (Soteropoulos G „Cigtay O., Schellinger P.). This method has great value for thoracic surgery, especially when it is necessary to visualize the organs of the chest cavity.

Ultrasound examination by the method of polypositional scanning in the longitudinal and transverse planes is widely used to assess the state of not only the internal structures of the chest cavity, but also as a method for assessing the bone and cartilage structures of the chest, both before and after surgical interventions.

One of the main preoperative examinations of patients with sunken breasts is psychological examination, since, according to different authors, from 78.4 to 100% of patients suffer from an inferiority complex. Especially with age, there are increasing rates that adversely affect the development and growth of the child; apathy, shyness and alienation in relations with peers, negativism and indifference towards parents. The combination of a pathological psychological state and physical and functional insufficiency does not allow children to lead a full-fledged social life.

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Treatment of the funnel chest

Conservative treatment of funnel chest

Physical therapy, breathing exercises, chest massage, physiotherapy, hyperbiric oxygenation, therapeutic swimming do not relieve the patient from chest deformity, but conservative measures must be carried out. In order to prevent the progression of deformity, strengthen the muscular frame and physical development of the child, prevent the development of spinal deformities, normalize posture, increase lung capacity.

[12], [13], [14]

Surgical treatment of funnel chest

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Indications for surgery

Most orthopedists involved in thoracoplasty for funnel-shaped deformity of the chest adhere to the indications for surgical baking proposed by G. A. Bairov (1982). There are functional, orthopedic and cosmetic indications for surgical intervention.

• Functional indications are due to dysfunction of the internal organs of the chest cavity.
• Orthopedic indications are caused by the need to change the broken posture and curvature of the spine.
• Cosmetic indications are associated with the presence of a physical defect that violates the aesthetics of the physique.

Applying modern methods of examination and attaching great importance to the psychological status of the patient. A.V. Vinogradov (2005) suggested indications and contraindications for the surgical treatment of children with chest deformities, including post-traumatic and congenital defects.

[19], [20], [21], [22], [23]

Absolute indications for surgery

• Funnel chest deformation of III and IV degree,
• Congenital and acquired deformities of the chest, which do not cause functional disorders in the respiratory and cardiovascular systems, but cause disturbances in the patient’s psychological status.
• Poland syndrome, accompanied by bone and cartilage defect of the chest and a decrease as a result of its frame and protective properties.
• Congenital crevices of the sternum in children of all age groups.

[24], [25]

Relative indications for surgery

• Chest deformities without defects of the bone and cartilage skeleton of the chest, causing neither functional nor psychological disorders.
• Acquired chest deformities after injuries, inflammatory diseases and surgical interventions.

Despite the simplicity and clarity of the indications for surgical treatment of the funnel chest, many orthopedic surgeons consider deformation of the II-III degree with the presence of functional disorders as the main indication for surgery.

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Contraindications for surgical treatment

• Severe concomitant pathology of the central nervous, cardiovascular and respiratory systems.
• Mental retardation moderate, severe and deep.

There are no clear recommendations on the age of patients who need thoracoplasty for funnel-shaped deformation of the breast cell. Basically, orthopedists provide data on surgical interventions in adolescents, citing this fact by the fact that young children do not reveal functional abnormalities. The funnel chest has serious functional impairments in pubertal and adolescence, since the high compensatory capabilities of the child’s body for a long time maintain the respiratory and cardiovascular functions that are close to normal. This circumstance often leads to an erroneous conclusion about the rejection of surgery in young children.

As the surgical treatment of patients with funnel chest deformity was improved, classifications by surgical treatment methods used so far have been proposed.

A convenient for practical application of operations for funnel chest deformation was proposed by V.I., Geraskin et al. 1986), dividing the methods of thoracoplasty and fixation of the sterno-rib complex into the following groups.

1. Radical surgery (thoracoplasty):

According to the method of mobilization of the sternum-ribs complex:

• subnasculator resection of deformed rib cartilage, transverse sternotomin;
• double chondrotomy, transverse sternotomy;
• lateral chondrotomy, T-shaped sternotomy
• combinations and other rare modifications.

According to the method of stabilization of the sternumfire complex;

• using external sternum traction;
• with the use of internal metal clamps;
• with the use of bone grafts;
• without the use of special fixators of the sternocore complex.

2. Operations with the rotation of the sternocore complex by 180:

• free revolution of the chest rim complex:
• a reversal of the colostrum complex with preservation of the upper vascular pedicle;
• coup of the medullary complex while maintaining connection with the abdominal muscles.

3. Palliative surgery:

There are three most common ways to mobilize the sterno-costal complex with a funnel chest.

• Subparticular resection of cartilage of the ribs, transverse sternotomy.
• Lateral chondrotomy, T-shaped sternotomy.
• Dual (parasgernadia and lateral) chondrotomy, transverse sternotomy.

[30], [31], [32], [33]

Postoperative complications of the funnel chest

The most frequent complications after thoracoplasty are hemothorax (20.2%), suppuration of the skin wound (7.8%), pneumothorax (6.2%), subcutaneous hematomas (: i, 7%), postoperative pneumonia (0.6%), pleurisy (0.9%). Along with the listed complications, without statistical clarification, mediastinitis, sepsis, osteomyelitis of the sternum, fixation migration, secondary bleeding, skin necrosis, intestinal paresis, hemopericarditis, pericarditis, myocarditis, keloid scars are isolated.

In the early postoperative period, for the timely detection of complications, hemodynamics, respiration, diuresis and the general condition of the patients are monitored. Usually, after recovering the patient's independent breathing, the patient is transferred to the intensive care unit, where symptomatic treatment of the funnel chest is carried out for 3-5 days. From the first day prescribed antibacterial treatment. Many surgeons consider the drainage of the retrosternal space with active Redon suction for 3 days to be mandatory. The chest cavity is drained with a polyethylene tube. After transferring the patient to a specialized department, a complex of therapeutic exercises and breathing exercises are prescribed in order to improve the function of the cardiorespiratory system. In the same period A.F., Krasnov and V.N. Stepnov according to a specially proposed method, apply hyperbaric oxygenation in combination with physiotherapy and electrical stimulation of the respiratory muscles.

Patients who have a funnel chest should be in the dispensary for a long time. Children after surgical interventions should be referred to health-improving treatment in a sanatorium.

[34], [35], [36], [37], [38], [39],

The effectiveness of the treatment funnel chest

The funnel chest after the operation is evaluated on the following scale: good, satisfactory and unsatisfactory.

• A good result is the absence of complaints about a cosmetic defect, the Gizyckoi (IG) index is 1.0, the complete restoration of the anatomical shape of the anterior chest wall.
• Satisfactory result - complaints of residual deformities of the anterior chest wall (slight depression or bulging of the sternum, local retraction of the ribs), IG is 0.8.
• Unsatisfactory result - complaints of a cosmetic defect, recurrence of deformity to the initial value, IG less than 0.7,

The most effective and objective assessment of various surgical interventions for funnel chest deformity is provided by Yu.I. Pozdnikin and I.A. Komolkin.

The authors for many years in the elimination of funnel chest deformity used four different surgical methods:

• thoracoplasty by GI Bairov;
• thoracoplasty by N.I. Kondrashin;
• thoracoplasty according to Paltia;
• tunnel chondrotomy (Pozdnikin Yu.I. And Komolkin IA).

Due to the significant efficacy and pathognomonicity, reconstructive combined musculoskeletal plasty of the chest should be included in the table of remote results of surgical treatment of patients with funnel chest deformity according to A.F. Krasnov and V.N. Stepnovu.

Reconstructive treatment of the funnel chest is an urgent problem of orthopedics and thoracic surgery. Foreign and domestic surgeons have proposed a significant number of fairly effective methods of surgical correction, combining the tendon-muscular plasty, bone graft, fixation of the sternocorbital complex with metal plates. Funnel chest should be treated by the method that will be optimal, taking into account the physiological state of the patient.