Causes analysis, prevention and management of bar displacement after Nuss procedure

doi:10.3877/cma.j.issn.1673-5250.2024.02.014

Objective

To explore the causes of bar displacement after minimally invasive orthopaedic Nuss procedure for pectus excavatum, and to summarise the preventive and treatment measures.

Methods

A total of 17 patients admitted to Sichuan Provincial People′s Hospital from June 2010 to February 2022 with bar displacement after Nuss procedure were selected into this study. Their clinical case data were retrospectively analysed to summarize the causes of bar displacement and its treatment measures. This study was approved by the Medical Ethics Committee of Sichuan Provincial People′s Hospital (Approval No. 2023-46). Informed consents were obtained from all patients or their guardians.

Results

① The patients in this study were 15 males and 2 females, aged (12.8±4.7) years old (5.5-25.3 years old), with Haller index of 3.6±0.3 (3.3-4.3). ② Of the 17 patients in this study: 14 cases had the bar flipping, 1 case had the bar flipping combined with lateral sliding, and 2 cases had the dorsal shift of the bar (ages 25.3 and 18.3 years old, respectively); there were 13 cases of asymmetric pectus excavatum and 4 cases of symmetric type; and there were 12 patients whose age was >12 years old. ③ All 17 patients were reoperated to adjust the bar, and the bars were consolidate with stabilizer and medical stainless steel wire. Among them, 2 cases were found to have bar flipping >3 months after Nuss procedure, and the fixed plate was placed by replacing the rib gap after selecting a new incision to take out the plate; the remaining 15 cases were found to have bar displacement within 0-3 months after Nuss procedure, and the bar was relocated by replacing the rib gap through the original incision (4 cases) or reset the bar through the original incision with the original rib gap (11 cases) and re-fixed. ④ Of the 17 patients in the study, 6 cases had inappropriate bar placement, 8 cases had confirmed or suspected history of strenuous activity or trauma after the Nuss procedure, 13 cases had asymmetrical pectus excavatum, 2 cases had severe sternal recess, and 12 cases were >12 years old.

Conclusions

Appropriate age at the time of Nuss procedure in pectus excavatum patients, appropriate bar type and placement, and avoidance of premature strenuous activity or trauma after surgery are the main measures to reduce bar displacement after Nuss procedure. Once the postoperative bar displacement is found, it should be corrected and handled in a timely manner depending on the specific situation.

Key words: Funnel chest, Nuss, Postoperative complications, Bar displacement, Etiology, Pain management

图1　1例钢板上下倾斜移位患儿(男性，18.5岁)胸部X射线摄片图(可见钢板安置位置在第5～6肋间隙，位置过高，未在胸壁最凹陷处)　图2　1例钢板上下倾斜移位患儿(男性，8.3岁)胸部X射线摄片图　图3　1例钢板上下倾斜移位合并左右横向移位患儿(男性，14.0岁)胸部X射线摄片图

表1 本组17例Nuss手术后不同类型钢板移位患者胸廓对称性、性别、年龄比较[例数(%)]

钢板移位类型	例数	胸廓对称性		性别		年龄
钢板移位类型	例数	非对称型	对称型	男	女	<12岁	>12岁
上下倾斜	14	10(71.4)	4(28.6)	12(85.7)	2(14.3)	5(35.7)	9(64.3)
上下倾斜合并横向移位	1	1(100.0)	0(0)	1(100.0)	0(0)	0(0)	1(100.0)
向后陷入	2	2(100.0)	0(0)	2(100.0)	0(0)	0(0)	2(100.0)
合计	17	13(76.5)	4(23.5)	15(88.2)	2(11.8)	5(29.4)	12(70.6)

表1 本组17例Nuss手术后不同类型钢板移位患者胸廓对称性、性别、年龄比较[例数(%)]

钢板移位类型	例数	胸廓对称性		性别		年龄
钢板移位类型	例数	非对称型	对称型	男	女	<12岁	>12岁
上下倾斜	14	10(71.4)	4(28.6)	12(85.7)	2(14.3)	5(35.7)	9(64.3)
上下倾斜合并横向移位	1	1(100.0)	0(0)	1(100.0)	0(0)	0(0)	1(100.0)
向后陷入	2	2(100.0)	0(0)	2(100.0)	0(0)	0(0)	2(100.0)
合计	17	13(76.5)	4(23.5)	15(88.2)	2(11.8)	5(29.4)	12(70.6)

表2 本组17例Nuss手术后不同类型钢板移位患者安置钢板位置、钢板固定方式及手术切口选择比较

钢板移位类型	例数	安置钢板位置	钢板固定方式	切口选择(例)
钢板移位类型	例数	安置钢板位置	钢板固定方式	原切口	新开切口
上下倾斜移位	14	原肋间隙或更换肋间隙	钢丝	12	2
上下倾斜合并横向移位	1	原肋间隙	钢丝	1	0
向后陷入移位	2	原肋间隙	钢丝	2	0

表2 本组17例Nuss手术后不同类型钢板移位患者安置钢板位置、钢板固定方式及手术切口选择比较

钢板移位类型	例数	安置钢板位置	钢板固定方式	切口选择(例)
钢板移位类型	例数	安置钢板位置	钢板固定方式	原切口	新开切口
上下倾斜移位	14	原肋间隙或更换肋间隙	钢丝	12	2
上下倾斜合并横向移位	1	原肋间隙	钢丝	1	0
向后陷入移位	2	原肋间隙	钢丝	2	0

表3 本组17例Nuss手术后不同类型钢板移位患者钢板移位原因比较(例)

钢板移位类型	例数	钢板安置位置不合适	剧烈活动或外伤史	胸廓不对称	胸骨凹陷严重	年龄>12岁
上下倾斜移位	14	6	8	10	0	9
上下倾斜合并横向移位	1	0	0	1	0	1
向后陷入移位	2	0	0	2	2	2

表3 本组17例Nuss手术后不同类型钢板移位患者钢板移位原因比较(例)

钢板移位类型	例数	钢板安置位置不合适	剧烈活动或外伤史	胸廓不对称	胸骨凹陷严重	年龄>12岁
上下倾斜移位	14	6	8	10	0	9
上下倾斜合并横向移位	1	0	0	1	0	1
向后陷入移位	2	0	0	2	2	2

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