brace treatment of chest wall deformity, scoliosis and ... · brace treatment of chest wall...
TRANSCRIPT
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Brace Treatment of Chest Wall Deformity, Scoliosis and Chest Wall Programs
Davi P. Haje, MD, PhDMoacir Silva Neto, MD
Sydney A. Haje, MD (in memorian)
Hospital de Base do DF – SES – GDF
Centro Clínico ORTHOPECTUS
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 ofcarinatum and excavatum
• 1993: Mielke e Winter (n=1)• 1999: Beirão (n=30)• 2000: Egan e cols (n=5)
•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
Treated 36 pectus carinatum
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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
1) Describe the presence of growth plates between the sternal segments and costocondral junction.
HAJES PAPERS ABOUT ETIOLOGY OF PECTUS
2) Provoked pectus deformities in animals by the lesion of these growth plates.
Control group
Group with lesion of growth plates
1994
2002
9yo
17yo
FIRST LITERATURE PAPER ABOUT IATROGENIC PECTUS
After Haje’s treatment
Haje SA (1995) Iatrogenic pectus carinatum: a case report. Int Orthop19/6:370-373.
Haje: described the possibility of iatrogenic pectus after sternotomy for repair of cardiac problems.
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Haje: Pectus deformities are caused by growth disturbances of heredity origin
They usually GET WORSE without treatment in the adolescence!
5 yo 12 yo
10 yo14 yo
2006 2014
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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NON SURGICAL TREAMENT PRINCIPLES
GHDMF dn 25-9-93
12-1-11
Spontaneous breathing Doing Valsava maneuver
WRONG TREAMENT PRINCIPLES: Never prescribe just gym exercises without braces for CARINATUM patients
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MOAJR DN 11-7-97
Did only gym exercises. Got muscles but kept the
pectus
Got better after doing exercises using braces
Octuber 201417 years old
June 2015
Never prescribe just gym exercises without braces for pectus
ORTHOS
PAEDIA
Nicolas AndryFrance, 1741
Julius Wolff Germany, 1892Bone remodeling
Treatment of Pectus Carinatum and Excavatum by Haje’s Method –Treatment Principles – based on
orthopaedic principles
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Before treating pectus with braces and exercises you need to understand that
bone can remodel or reoriented
Treatment of Pectus Carinatum and Excavatum by Haje’s Method –Treatment Principles
...and this kind of treatment was used before 1977 in orthopaedic.
Julius Wolff Germany, 1892
Bone remodeling
In 1979: Haje first descriptionof pectus treatment with
braces(RBO, v. 14, p. 167)
1988: began treatment of pectusexcavatum with DCC II (JPO, v. 12, p. 795)
DCC I – dinamic chest compressor
1977
1988
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Dynamic Remodeling (DR) method: braces + exercises (Haje, SA et al, 2006): CARINATUM
External pressure ofDynamic 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.
Video 2
Dynamic Remodeling (DR) method: braces + exercises HOW CAN CORRECT EXCAVATUM?
External pressure ofDCC braces on
protruded areas: flared ribs and sometimes
above nipple
Exercises that increase the
intrathoracic pressure along with the use of DCC pressure on
depressed areas
Video 1
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MOAJR DN 11-7-97
Dynamic Remodeling (DR) method: braces + exercises HOW CAN CORRECT EXCAVATUM?
CORRECTING THE INFERIOR RIBS HELPS TO CORRECT THE DEPRESSED AREA: RIBS EXCESS IN CORRECTED POSITION MAY GIVE
MORE SUPPORT TO THE UPPER CHEST (?)
KJT
CORRECTING THE INFERIOR RIBS HELPS TO CORRECT THE DEPRESSED AREA: MAY HELP RESPIRATORY MUSCLES TO WORK BETTER(?) AND MAY INCREASE
INTRATHORACIC PRESSURE (?)
Dynamic Remodeling (DR) method: braces + exercises:? HOW CAN CORRECT EXCAVATUM?
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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: • 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
developed a specific
software and forms
Form for first consultation
Forms for follow-up
Forms for braces
Forms for patient
ETC...
Pectus
Carinatum
Inferior Lateral
Pectus
Excavatum
WideLocalized
SuperiorPCI PCL PCS
PEL PEW
HAJE AND HAJE CLASSIFICATION FOR PECTUS
Haje SA, Haje DP (2009) Tórax e Cintura Escapular. In Hebert S.
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Pectus
Excavatum
Localized PEL
Proposing a modification in Hajes classification (2013):
BIG CENTRAL DEPRESSION
+ LITTLE FLARED RIBS
DEPRESSION + FLARED RIBS
OF SAME PROPORTION
LITTLE DEPRESSION +
BIG FLARED RIBS
(type 2)
(type 3)
(type 1)
Pectus
Carinatum
Superior PCS
Proposing a modification in Hajes classification (2014):
JUST ABOVE NIPPLE LINE
Very high above NIPPLE
LINE(CURRARINO
TYPE – type 1)
(type 2)
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Pectus
Excavatum
Wide PEW
Proposing a modification in Hajes classification (2015):
WideDEPRESSION
(type 1)
WideDEPRESSION In
lower chest
Assimetricwide
DEPRESSIOn
(type 2)
(type 3)
HAJE : DISCRIBED THAT PECTUS HAS DIFFERENT FLEXIBILITY LEVELS AND THAT CAN IMPLICATES
IN TREATMENT PROGNOSIS (1992, JPO)
- Rigid (F0)- Mild flexibility (F1)- Moderate flexibility (F2)- Very flexible (F3)
Video 3
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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
Using the brace inside the shirt
PSMF
July 2015 December 2015
Some patients do notlike to tell others whythey are using thebrace...The patients may tellothers that they aretreating their spine....
Psychological aspects
Better to use over the shirt
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MEDICAL PROTOCOL FOR PECTUS ORTHOTIC
TREATMENT
1. Compliance is essential for a successful treatment
2. Use the DCC(s) 23 hours a dayIf use less than 18-15 hours a day: no or little correction
If use 12 hours : avoiding getting worseDo exercises everyday
3. To avoid recurrence: gradual weaning/release from the braces, in one, two or more years*.
• Also explain that :
LMB
May 2012 11 years
April 201413 years
May 201514 years
EXAMPLE OF RECURRENCE
September 201211 years
TO NOT HAVE RECURRENCE: AFTER GETTING BETTER NEEDS TO USE THE BRACE FOR SLEEPING AND FOR GYM
EXERCISES UNTIL SKELETAL MATURITYBOYS – 16 – 17 YEARS OLDGILRS – 14 - 15 YEARS OLD
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GREAT CORRECTION
STOPED TREATMENT AND JUST DID GYM EXERCICES
STARTED TREATMENT AGAIN
14 y 14 y + 8 m
16 y + 7 m
OVERCORRECTIONEXAMPLE OF RECURRENCE
Stopped treatment
STARTED TREATMENT AGAIN
12 y14 y + 8 m
Partial correction
13 y
EXAMPLES OF RECURRENCE –
STOPPED TREATMENT BEFORE MEDICAL
ADVICE
Started treatment
15 y
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Braces developed by HajesDynamic 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: 1turn 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 prostheticI have a lot of patients from others
cities and countries.
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DCC 2 X ADCC 2
The same PAD PATTERNS IN THE DCC AND ADCC:
same types of anterior and
posterior pads
DCC 1 X ADCC 1
Same type of posterior pads. Anterior pads of
different patterns
Need to send the brace to the prosthetic workshop or
atelier
Telescoptic bars allow doctor to do it in his office
Ideal distance
to the patient
tight
DCC X ADCC(making it larger: patient growing and chest enlargement
because of treatment)
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May change pads position during treatment
3 months
For the best results you must see all the details...
To change position: new holes and rivets
in prosthetic workshop
Possible to change position in doctors office
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
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Changing lateral bar: must be done in prosthetic
workshop
Can chage lateral bars in doctors office
DCC X ADCC(pressure: controled by screw and lateral bar size)
Can increase or decrease pressure
Cast moldCaliper rule and flexible rule:
faster and cleaner
DCC X ADCC(measurements: detailed prescription of pads size, level and shape)
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Making measures for manufacturing the DCC – plaster caster mold with
detailed prescription for pads level, size and shape
For customized DCC brace(s),
Video 6 Video 5 Video 4
FORM
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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Manufacturing and assembling in prosthetic workshop
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 X ADCC(manufacturing and assembling the brace)
ADJUSTABLE DCC I AND II• ADCC: possibility to assemble the brace as you may have the anterior and posterior bars pre-manufactured • may take measures of brace and start treatment in the same day.
DCC ADCCPossible to be
assembled in thedoctor’s office
no yes
CostLow cost
Low cost, but higherthan DCC
Video 7
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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 bracein the initial use and during treatment• ADCC: mean of 2 brace adjustments per patient - thesame of the DCC (but needs a prosthetic)• after initial testing became the gold standart brace inour center.
TGC DN 08-05-03
January 201410 y + 8 m
December 201410 y + 8 m
11 11 months
RESULTS FOR ADCC
PEW – PECTUS EXCAVATUM WIDE
1 ENLARGEMENT
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TSG DN – 9-12-0315-12-1425-6-14
July 201411 y + 6 m
Dez 201512 y + 0 m
6months
6months
RESULTS FOR ADCC
PEW – PECTUS EXCAVATUM WIDE
NO ADJUSTMENTS
Mild pectus not in the growth spurt: less adjustments
EGD
ADCC RESULTS
PCI – PECTUS CARINATUM
INFERIOR
11 11 months
January 201414 y
December 201415 y
1 lateral bar changed needed
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2 enlargements
needed:Pectus
improvement+ growing chest
BEFORE AFTER
TREATMENT OF PCInferior
FOR EVERY PECTUS THERE IS A POSSIBLE BRACE + EXERCICES TREATMENT
TREATMENT OF PCLateral
TREATMENT OF PCSuperior
TREATMENT OF PEWide
TREATMENT OF PELocalized
CHILDREN / ADOLESCENTS ADULTS
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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
2 YEARS OLD AFTER 3 YEARS AND 3 MONTHS
TREATMENT OF PCI – INFERIOR TYPEStart treatment EARLIER in SEVERE CASES
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Result after 10 months
Treat all the deformity
components
YVDSDez 04
Out 05Jun 06
Dez 04 Jun 06EXAMPLE
11+8 13+2
DCC I
Use DCC I and II for treating carinatum
DCC II
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HGSL
Oct 15 Feb 16
16 y
Use DCC I and II for treating carinatum
DCC II
Oct 15
4 months
DCC I
July 2012 July 2013
After 1 year treatment using only for sleeping time and exercicies
until skeletal maturity
15 years
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Jul 2005 Jul 2009Jan 2006 Jan 2007DB
Apr 2015 August 2015
..... 10years follow-
up
HCAP
1-9-14 10-11-15TREATMENT OF PCI – INFERIOR TYPE
Less divergent breasts after PCI improvement
females
before after
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27+10 28+10
DR Method: patients’ compliance in different phases of life
PRE POSTPOST
IT IS POSSIBLE TO TREAT ADULTS
TREATMENT OF PCI – INFERIOR TYPE
27 ye + 6 m From USA
TREATMENT OF PCL – LATERAL TYPE
PCL – usually flexible deformity, but a lessthen PCI;• Treatment in puberty: most of the cases• Start treatment earlier: in childhood, when is a asevere deformity or when is a .....
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VFM dn 13-11-01
Aug 2011 Oct 2013
TREATMENT OF PCL – LATERAL TYPE
9 years
..... is a girl start treatemnt earlier because you can not put pressure over the breast
VFM dn 13-11-01
8-10-13
TREATMENT OF PCL – LATERAL TYPECT IMPROVEMENT
PARTIAL CORRECTION OF HER BONE DEFORMITY, BUT SHE HAD ASSIMETRIC
BREASTS ALSO
3-8-11
before after
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VFM dn 13-11-01
TREATMENT OF PCL – LATERAL TYPE
..... But if the breast are already develeped you also may do the treatment for the lateral type
naf
AUGUST-2012 AUGUST-2013PCL – POSSIBLE TO TREAT ADULTS
23 YEARS
Treat mild pectus
23 years
From USA
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TREATMENT OF PCS OR CURRARINO
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.
TREATMENT OF PCS – Superior type
Haje SA, Harcke HT, Bowen JR, Pediatric Radiology, 1999
BM and BXM index
6 months 13 yearsNormal
Normal BM / BXM = 2.16(SD ±0.24)
Premature closure or assimetric growth of
sternum growth plates can lead to deformitie.
UNDERSTANDING WHY THE TREATMENT OF CURRARINO OR SUPERIOR TYPE IS ALMOST PREVENTIVE
X-RAY: STERNUM CAN BE SHORTER THAN REFERENCE VALUES
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Irregular manubrio-sternal
junction
April 2001 – 3 ye + 8 mon
Only two sternal body segments
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 – Superior type
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
Db. 26-7-97
April 2013 – 15 ye + 10 mo
Came back after 10 years with a worse
deformity and psychological
problems.
Quit treatment after 3 months
TREATMENT OF PCS / CURRARINO DEFORMITY
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PCS – what is the best conservative approach? Early brace treatment (6 – 10 years of age) is also preventive, not only
curative.
May 2010 – 6 ye + 4 mo December 2015 – 11 ye + 11 mo
Using braces 18 hours/dayStarted treatment 23 h/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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JB
Jan 2007 Dec 2008
From Sweden24
years
PCS – POSSIBLE TO TREAT ADULTS
RF
Dec 2013 March 2014
PCS – POSSIBLE TO TREAT ADULTS
32 years
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TREATMENT OF PEW – WIDE EXCAVATUM
PEW :• Treatment as soon as you make the diagnosis• Better results in pacients using the brace 23hours a day + exercices everyday• Variable flexibility
5 years
Db 28-12-02
8 years
y Pectus excavatum- tendency to start treatment earlier
Using only for sleeping time and exercicies
DCC and exercicies
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MVPM
February 2015 November 2015
KEEP USING 23 HOURS A DAY
Pectus excavatum- better to use full time until skeletal maturity or full correction
RMF dn 23-9-99
Pectus excavatum- Improvement showed by CT.
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Nov 2011
May 2014 12 years
KEEP USING 23 HOURS A DAY
14 y + 8 m
STARTED THE WEANING
15 y + 11 mAugust 2015
Pectus excavatum- weaning phase should be slower than carinatum
Sep 2010 Jan 201315 y + 6 m 17 y + 10 m
28 months follow-up: released from braces
Pectus excavatum- treatment total time may be shorter in the end of adolescence
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PEW – POSSIBLE TO TREAT ADULTS
Bone can remodel !!!Can have sucess for
the flared ribs in some patients
Sweden,3 years
afterDR
method
Patient who received surgery
before the Dynamic
Remodeling (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 23hours a day + exercices everyday
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Feb 2008 May 2009
DR Method: good results to pectus carinatum and pectus EXCAVATUM
10 years
1 year
TREATMENT OF PEL – LOCALIZED EXCAVATUM
15 y + 5 m
5 yearsfollow-up
Aug 2013
July 2012 April 2014
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Db 28-12-02
y Pectus excavatum- when the problem is more the flared ribs than the depression?
Best results than the ones with bigger depressions.
13 y + 10 m
Aug 2012 June 2013
15 y + 5 m
JPRC
22-7-15 23-2-16
PEL – partial result can avoid surgery
Patient willing to do surgery
Patient do not want surgery anymore
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PEL – POSSIBLE TO TREAT ADULTS Bone can remodel in some patients
Can have partial or total sucess in some patients
Jan 2000
Sep 200049 years
27-3-13 20 years
PEL – POSSIBLE TO TREAT ADULTS Nov 2013March 2013
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PEL – partial initial result in adultCan lead to better results in plastic surgery or Nuss.
21 years
COMPLICATIONS
- Skin problems –never need to stop treatment- Bone edema: one case
(adult)- Overcorrection
Jan 2015 Jan 2016
12 months
12 months
JVSS
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Haje SA, Haje DP. Overcorrection during treatmentof pectus deformities with DCC orthoses. Int Orthop, 2006.
Jan/05 May/05 Oct05
1997 1998 2002
carinatum
excavatum
carinatum
excavatum
normal
normal
Nov 2011 July 2013
FLARED RIBS OVERCORRECTED
13 y + 9 m
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Jan 2014
FLARED RIBS in CORRECT POSITION
Nov 2011
RESULTS – Haje’s method
Haje, Haje and Silva – 1977 - 20165791 - pectus patients
3338 - treated2493 – RELIABLE DATA and treated with follow up > 12
months
Walmsley – 2011 – 2014120 - pectus patients
82 – treated12 – RELIABLE DATA and treated with follow up > 12 months
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RESULTSIMPROVEMENT:
3 – EXCELLENT OR GOOD (70-100%)2 – MODERATE (40-70%)1 – LITTLE (<40%)0- NO IMPROVEMENT
ANALYSE PATIENT SATISFACTION AT THE END OFTREATMENT.
PERSPECTIVE: 3D SCAN ANALYSIS PRÉ AND PÓS TREATMENT
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 PATIENTS UNDER 19 YEARS OLD
– minimum follow-up of 1 year (1977-2016)
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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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 dn 30-6-09PEL – Haje’s method + vacuum bellFor 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 Vacuum Bell
11 MONTHS
+20 MONTHS
only+
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AVC dn 30-6-09
PEL – Haje’s method + vacuum bell
31 MONTHS
AVC dn 30-6-09
PEL – Haje’s method + vacuum bell
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Concomitant orthotic treatment of
Centro Clínico ORTHOPECTUS
Brasília, DF, Brasil
Scoliosis, Hyperkyphosis and Chest Malformations
Davi P. Haje, MD, PhDMoacir Silva Neto, MD
Sydney A. Haje, MD (in memorian)
Hospital de Base do DF – SES – GDF
Thoracic deformities
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Posterior (SPINE) and anterior (STERNUM) chest wall are anatomically connected (by the RIBS and COSTAL
CARTILAGES)!
Pectus deformities and Scolioses
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Pectus deformities and Scolioses
Frick 4% to 5% of patients with pectus have scoliosis to warrantconsultation 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
Waters et al 21% of 596 patients with pectus that were operatedpresented 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
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
Pectus CarinatumInferior Signs of SCOLIOSIS
What is the main problem of this patient?
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Signs of SCOLIOSIS
No SCOLIOSIS
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
CT: Latero-lateral assimetry of sternum body shape
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Nash & Moe JBJS 1969
A study of vertebral rotationNo asymmetryPedicles method
Pedicle in the first segment
Pedicle in the second segment
Cobb angle
Metha angle
SCOLIOSES – RADIOLOGICAL STUDY
When to treat mild pectus + mild or moderate scoliosis (<20º) with the
help of pectus braces?
• I treat all cases
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.
Scoliosis risk of progression:
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DR method: clinical benefits also on postural kyphosis and scoliosis signs
BEFORE BEFOREAFTER AFTER
Patient treated with Dynamic Chest Compressor and exercises only
PCI
Dynamic Chest Compressor orthoses + exercises
Dynamic Remodelling (DR) methodHaje SH & Haje DP, International Orthopaedics, 2006
ORTHOTIC TREATMENT:
9°
Oct 08May 08
5°
Oct 08May 08
16º 11º
DCCorthosis
Patients with pectus deformity and mild scoliosis: treatment by DR method only
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Dec 2008 March 2010
Adolescent with pectus and18º scoliosis
14/1/107/7/09AOA
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KCM, 9 years
Braces + exercises for pectus and spine/postural problems
YMS, 15 years
Could this 9 yearsold girl with mildlateral pectuscarinatum andvery mild signs ofscoliosis becomethis 15 year oldgirl with SEVEREscoliosis andassimetric trunk?
It is possible...
So let’s treat herwhen she is 9....
kcmMarch 15August 14
9 years
7 months
Improved mild pectus
carinatum lateral + mild
hyperkyphosis and signs of
scoliosis
Braces + exercises for pectus and spine/postural problems
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ABMFBraces + exercises for pectus, scoliosis and hyperkyphosis
August 139 yearsBEFORE
November 1410 yearsAFTER
BEFOREBEFORE AFTERAFTERPECTUS IMPROVEMENT
KYPHOSIS IMPROVEMENT SCOLIOSIS IMPROVEMENT
+ EXERCISES
When you have pectus + hyperkyphosis and scoliosis
treat before growth spurt
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)
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 exercisesfor treatment of idiopathic scoliosis: a new proposal. Brasilia Med; 45(1):10-20
with BBB
BBB: Plaster cast mold with corrective tilt made by the doctorback viewback view
DCC
BrasíliaBendingBrace
4h/day+
exercises
19h/day
CONCOMITANT TREATMENTFour hours a day: DCC orthoses + one hour of DR method exercises,
plus side bending and stretching exercises. Rest of the time: BBB
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Aug 03 Dec 03
25°7°
Lateral bending effect on the spine
“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.
DCC mark
40 monthsPre
52º
Pre PostEvolution
27º
CONCOMITANT ORTHOTIC TREATMENT OF PECTUS DEFORMITIES AND MODERATE SCOLIOSIS
Post
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52º
T6
L1
pre
34º
T6
L1
post
CONCOMITANT ORTHOTIC TREATMENT OF PECTUS DEFORMITIES AND MODERATE SCOLIOSIS
RESULT AFTER 60 MONTHS
T10T10
Age 13+11 pre post
CONCOMITANT ORTHOTIC TREATMENT OF PECTUS DEFORMITIES AND MODERATE SCOLIOSIS
RESULT AFTER 60 MONTHS
Age 18+11
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Another case: 20 years, PCI, 42º scoliosis + pectus carinatum inferior
42º 22º
Before
After
Treatment in a
skeletally mature patient
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
Weak abdominal muscles
Weak paravertebral
muscles
shortened hamstring muscles
shortened pectoral muscles / anterior
protusion of shoulders
Flared ribs or pectus
Shy patients –not motivated for exercises
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Some pectus patients develop
hyperkyphosis during adolescence
because they want to hide the protusion or depression that is
behind their shirt
Adolescent + hyperkyphosis
Children are not ashamed of their pectus condition as adolescents.
Probably the kyphosis is because of weaker muscles or hereditary
CHILDREN + HYPERKYPHOSIS
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• 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)
When to treat hyperkyphosiswith the help of braces?
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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 pectusor flared ribs
OR
2) TLSO (apex < T9)- do not correct shoulders- do not correct pectus or flared
ribs
Milwaukee brace
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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Hyperkyphosis alone that failedother treatments
My braces possibilities to associate to specific exercises
Brasília Kyphosis Brace(the point of pressure will depends on the
pectus type)
Hyperkyphosis + pectus
Pectus brace (DCC or ADCC)
Brasília Kyphosis Brace making pressures in the
flared ribsPectus brace (DCC or ADCC)
connected with shoulders straps
Hyperkyphosis alone that failedother treatments
My braces possibilities to associate to specific exercises
Brasília Kyphosis Brace(the point of pressure will depends on the
pectus type)
Hyperkyphosis + pectus
Pectus brace (DCC or ADCC)
Brasília Kyphosis Brace making pressures in the
flared ribsPectus brace (DCC or ADCC)
connected with shoulders straps
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13-8-15Hyperkyphosis alone that failed other
treatments
Brasília Kyphosis Brace making pressures in the flared ribs
ALTG29-4-14 19-4-16
13y + 10 m
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Hyperkyphosis alone that failedother treatments
My braces possibilities to associate to specific exercises
Brasília Kyphosis Brace(the point of pressure will depends on the
pectus type)
Hyperkyphosis + pectus
Pectus brace (DCC or ADCC)
Brasília Kyphosis Brace making pressures in the
flared ribsPectus brace (DCC or ADCC)
connected with shoulders straps
May 2013
3-11-98FBS
13 y + 6 m
15 y + 6 m
Take these photos in the first appointment and ask the patient what photo he likes more
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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May 2013 May 2015
3-11-98FBS
13 y + 6 m15 y + 6 m
When the chest starts getting better it helps to correct the hyperkyphosis because the patient is less ashmed
May 2013 – natural posture
May 2015
3-11-98FBS
13 y + 6 m 15 y + 6 m
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May 2015 – natural posture
13 y + 6 m 15 y + 6 m
May 2013 - in the beginnig when asked to stay in the correct
position
VERF DN 12-10-97
December 1215 years
November 1518 years
Improvedkyphosis
andpectusNatural
Trying to correct posture
Natural
Braces + exercises for pectus and hyperkyphosis
He keeps doing
treatment because
every year he is
better
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Hyperkyphosis alone that failedother treatments
My braces possibilities to associate to specific exercises
Brasília Kyphosis Brace(the point of pressure
will depend on the pectus type)
Hyperkyphosis + pectus
Pectus brace (DCC or ADCC)
Brasília Kyphosis Brace making pressures in the
flared ribsPectus brace (DCC or ADCC)
connected with shoulders straps
Treating hyperkyphosis + pectus together
Pectus brace (ADCC) connected with shoulders straps
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Hyperkyphosis alone that failedother treatments
My braces possibilities to associate to specific exercises
Brasília Kyphosis Brace(the point of pressure will depends on the
pectus type)
Hyperkyphosis + pectus
Pectus brace (DCC or ADCC)
Brasília Kyphosis Brace making pressures in the
flared ribsPectus brace (DCC or ADCC)
connected with shoulders straps
Brasília Kyphosis Brace - initial experience in 7 cases: good preliminary
results- All cases improved clinically - Mean X-ray kyphosis angle 58,4 52º
(pré) (pós)
Treating hyperkyphosis + pectus together with Brasilia’sKyphosis Brace
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Treating hyperkyphosis + pectus together with Brasilia’sKyphosis 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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THANK YOU