brace treatment of chest wall deformity, scoliosis and ... · brace treatment of chest wall...

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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


JUST ABOVE NIPPLE LINE

Very high above NIPPLE

LINE(CURRARINO

TYPE – type 1)

(type 2)

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Pectus

Excavatum

Wide PEW


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


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


..... 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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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


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


RESULT AFTER 60 MONTHS

T10T10

Age 13+11 pre post


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




pectus type)






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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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pectus type)






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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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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pectus type)






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

brace treatment of chest wall deformity, scoliosis and ... · brace treatment of chest wall...

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