CHKD Surgical Group | Journal | Vol. 3, 2014 1

Arthroscopic surgery corrects hip impingement in adolescents by Allison Crepeau, MD

Summary: New techniques in hip arthroscopy offer resolution in adolescent patients with fem-oroacetabular impingements (FAI) in the hip resulting from sports and dance injuries.

Hip pain and joint damage are often associated with an older population; however, an increas-ing number of younger patients are being diagnosed with labral tears of the hip and/or femoroacetabular impingement (FAI), hip conditions associated with both acute and over-use injuries caused by sports and dance activities. Children’s Hospi-tal of The King’s Daughters can now successfully treat adolescents diagnosed with labral tears and FAI using minimally invasive arthroscopic surgery.

FAI is a spectrum of bony abnormalities around the hip that can lead to damage to the labrum and cartilage over time. Ultimately, this may lead to early hip arthritis. FAI is not an uncommon condition for adolescents, espe-cially those in their mid-to-late teenage years who have a history of sports participation. Wear and tear on the hip joint from even mild bony abnormalities can cause erosion of the cartilage and tearing of the labrum. Frequently misdiagnosed as a groin pull, tendonitis or

muscle strain, FAI is often diagnosed after conservative treatments for these more com-mon conditions fail. While the underlying cause of FAI is not completely understood, we know that genetics and involvement in certain sports and activities may play a role.

The average patient profile tends to be an active adolescent athlete with un-resolved hip or groin pain. Sports activities associated with FAI in-clude field and ice hockey, soccer, lacrosse, martial arts, tennis, golf, rowing and dance. Dancers usually have less bony-type FAI, but more labrum damage based on unusual positioning of the hip joint during dance activities. Female patients present symptoms at a younger age

due to an earlier onset of puberty. There are three main FAI designations:

pincer, cam and combined. Pincer-type pres-ents when there is over-coverage on the acetabular side of the hip (socket is too deep), causing the labrum to be compressed when the hip is flexed. Cam-type FAI occurs when there is a bony prominence on the femoral neck that impinges during flexion, damaging the labrum and grinding cartilage inside the acetabulum. In many cases, both FAI types are present in a combined condition.

Symptoms of FAI include groin pain, hip pain or aching after sitting or walking, locking

V o l . 3 , 2 0 1 4

CHKD Surgical Group Journal is a publication of Children’s Hospital of The King’s Daughters Health System

Medical Editors: Joseph F. Dilustro, MD, FACSRobert E. Kelly Jr., MD, FACS, FAAPJyoti Upadhyay, MD, FAAPDouglas Mitchell, MD, FAAP

Executive EditorJohn Hamilton Vice President, Physician Practice Management

Managing EditorRidgely IngersollDirector of Marketing

EditorSharon CindrichMarketing & PR Manager

Graphic DesignerDawn Midgette

continued on page 2

3Surgery corrects ear deformities

4CHKD Surgical Services Directory

6Phased approach for treatment of pectus carinatum

8CHKD welcomes new surgeons

JournalCHKD Surgical Group

Allison Crepeau, MD

2 CHKD Surgical Group | Journal | Vol. 3, 2014

or clicking of the hip joint and low back pain. Pain levels may be sharp or ag-gravated when the hip is turned, twisted or bent, but can also present as a dull ache.

Patient evaluation for arthroscopy includes comprehensive analysis of prior treatments, X-rays, a physical ex-amination and physical therapy if not previously attempted. If tests are incon-clusive and conservative treatments do not resolve symptoms, an MRI arthro-gram is ordered. Abnormalities revealed on the MRI will merit diagnostic injec-tions, administered to confirm damage inside the hip joint and positively iden-tify candidates for arthroscopy.

Non-operative treatment is general-ly the first course of action. A decreased level of activity and hip-strengthening exercises may be recommended, along with physical therapy or stretching. Anti-inflammatory medications may provide limited relief. When symptoms do not resolve or increase in intensity, arthroscopic surgery can potentially correct the problem.

Surgery candidates should be to-wards the end of growth to be eligible for arthroscopy. Arthroscopy is performed under general anesthesia. During the procedure, an arthroscope is used along with a variety of tools to repair or anchor

damaged labrums or articular cartilage. Corrections are made to bony abnormal-ities through osteoplasty by shaving the femoral head or trimming the rim of the acetabulum. The procedure can take as little as two hours to complete. and corrections generally resolve symptoms and likely mitigate future damage.

Before arthroscopy was available, open surgical hip dislocation surgery re-quired a 7-10 inch incision and a longer recovery process. Minimally-invasive arthroscopic surgery reduces recovery time, decreases the length of the hospital stay, cuts surgery costs and minimizes the risk of infection and complications. Arthroscopic procedures are performed as outpatient surgeries or accompanied by a one-night stay at CHKD in Norfolk. Patients can typically return to full sports activities at 3-4 months after surgery.

Long-term outcomes are generally better when FAI is treated through early intervention, rather than when there is already irreparable damage to the ar-ticular cartilage. While long term data are not available for this new procedure, the hope is that by intervening and re-storing normal anatomy, we can stop a process that seems to lead to early ar-thritis. The techniques and instruments for hip arthroscopy are continuing to advance every day. At CHKD, our thor-

Symptoms of FAI mimic a variety of other common sport-related injuries making diagnosis a challenge. Consider FAI if a patient presents with the following:

▪ History of groin and hip pain without resolution using conservative therapies

▪ A positive FABER test

▪ A positive impingement test

▪ X-rays that reveal bony abnormalities on the femoral head or acetabular rim

▪ MRI arthrogram that details fraying or tears of the carti-lage or labrum

When to consider FAI

CHKD surgeon featured at international eventDr. Jyoti Upadhyay of CHKD Surgical Group’s urol-

ogy practice was a featured speaker at the 33rd annual Congress of The Societe Internationale d’Urologie in Van-couver in September.

Dr. Upadhyay’s presentation was titled, “Neurogenic bladder in adolescence and childhood: weighing the risks of surgical intervention against the goal of achieving social continence.” In it, she highlighted non-surgical approach-es such as anticholinergic medications, clean intermittent catheterization and botulinum-toxin, which have prevented the need for surgery in some patients.

Dr. Upadhyay also addressed the cognitive and physi-cal limitations that can hinder the quest for independence of this population and recommended that individual treat-ment regimens reflect the input of multidisciplinary teams.

Candidates for surgical intervention benefit from the availability of many novel approaches to reconstruction. Dr. Upadhyay shared her experience with slings, bladder neck procedures and augmentation cystoplasty utilizing the small bowel, large bowel and even the urinary drainage system of a non-functioning renal unit.

To reach Dr. Upadhyay, please call 668-7878.

ough evaluation of each patient allows us to treat adolescent patients with FAI using minimally-invasive, arthroscopic techniques to resolve pain and damage, allowing patients to return to their ac-tivities.

Dr. Crepeau is board-eligible in sports medicine and pediatric orthopedic surgery at CHKD. You may reach her at (757) 668-6550.

CHKD Surgical Group | Journal | Vol. 3, 2014 3

Implant offers alternative approach to correct ear deformitiesby George Hoerr, MD

Summary: A synthetic implant offers an alternative to rib cartilage for ear recon-struction.

Congenital ear deformities, also known as microtia, are a common birth defect. Occurring in approximately 1 in 6,000 children, microtia is identified when the auricle of one or both ears is not fully formed. Children’s Hospital of The King’s Daughters now offers an advanced pediatric ear re-construction surgery to repair the defect that combines a bio-compatible synthetic implant and the patient’s own tissue to create a replacement outer ear.

Microtia is divided into four classifications. Patients with a smaller ver-sion of a typical ear may be diagnosed with grade 1 microtia. Grade 2 microtia occurs when many of the typical features of the outer ear are missing and the ear canal is very narrow or closed (canal stenosis). The most common form of microtia is grade 3, also known as aural atresia, occurring when a small vertical appendage of car-tilage and skin is present in place of an external ear and there is no external ear canal (aural atresia). The most severe type of microtia is known as anotia – the com-plete absence of the outer ear.

In most cases of microtia, the defect is unilateral, and the inner workings of the affected ear are present, so children have hearing abilities with impairment relative to the ear canal opening. Patients evaluated with a grade 1 level of microtia may opt out of corrective surgery. When microtia of a grade 2 or up is present, sur-gical correction is warranted.

Children diagnosed with microtia are given a full physical evaluation and as-

sessed by the CHKD’s multi-disciplinary craniofacial team for anomalies and syn-dromes that may be associated with the microtia. Microtia is often considered a cosmetic problem; however, social issues associated with the defect can become significant as a child develops, so correc-tion is generally recommended.

Reconstructing the outer ear is a challenge due to the unique, complex

architecture of the auricle. For more than 40 years, standard surgical correction for microtia involved using rib cartilage to sculpt a framework for the ear and positioning this under the skin around the ear canal. A series of follow-up surgeries allows the surgeon to lift and position the cartilage, build the outer ear and construct an ear

lobe. This standard repair is generally done after age 6, when a child has enough rib cartilage to remove for reconstruction of the ear framework.

More recently, a surgical technique was developed using the Medpor porous polyethylene form and the patient’s liv-ing tissue to reconstruct the outer ear. In preparation for the procedure, surgeons trim the synthetic form to match the pa-tient’s opposite auricle. Since the ear of a child at age 3 is approximately 80 to 85 percent of the child’s adult-sized ear, the form is designed to be 15 to 20 percent larger than the opposite ear. While the ears will initially be slightly different in size, the child’s unaffected ear will grow to match the ear created from the synthet-ic implant by the age of 10.

During the procedure, an incision is made behind the ear and a flap of tem-peroparietal fascial tissue is pulled down to cover the synthetic form. A second skin graft is generally taken from the up-per leg area above the groin to cover the

living tissue. I trained with Dr. John Reinisch, the

pioneer of this technique, in Los Angeles in 1994, and I have found this approach to have numerous advantages for young patients. It is definitely a less invasive procedure, eliminating the need to resect rib cartilage. The synthetic form is infec-tion resistant and provides a standard size and shape for the auricle, reducing variables involved in sculpting a match-ing outer ear from the rib cartilage and eliminating resorption of the graft over time. It provides an ear which looks natu-ral and can be functional when combined with reconstruction of the canal. Without the use of rib cartilage, children as young as 3 years old can have surgery, allowing patients with atresia to receive ear canal reconstruction at an early age and reduc-ing challenges that can be associated with hearing impairments.

The method can be completed in one to two outpatient surgeries involving in-cisions to the scalp and graphed skin, reducing pain, recovery time, and risk of complications and scarring. Children can resume activities in six to eight weeks post-surgery. In addition to microtic pa-tients, the technique can also be used to reconstruct an outer ear damaged or de-tached due to traumatic injuries, such as dog bites and motor vehicle accidents.

Dr. Hoerr is a board-certified pediatric plas-tic surgeon at CHKD. You may reach him at (757) 668-7713.

George Hoerr, MD

The ear can be reconstructed using a synthetic implant and the patient’s own tissue.

before after

4 CHKD Surgical Group | Journal | Vol. 3, 2014

Cardiac SurgeryLocated at CHKDSurgeries offered at CHKD in NorfolkConsults .........................................(757) 668-8850Fax ................................................(757) 668-9344

Benjamin Peeler, MD, FACSMD Degree: Vanderbilt UniversityResidency: General Surgery, Vanderbilt University Affiliated Hospitals Fellowship: Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center; Vascular Surgery, University of Virginia Health Sciences Center; Pediatric Cardiothoracic Surgery, Emory UniversityCertification: American Board of Thoracic Surgery, Congenital Cardiac SurgerySpecial Interests: Complex neonatal repair; treat-ment of single ventricle defects; simple and com-plex atrioventricular canal, aortic valve repair and replacementE-mail Address: benjamin.peeler@chkd.org

Felix Tsai, MDMD Degree: Northwestern UniversityResidency: General Surgery, Morristown Memorial Hospital; Cardiothoracic Surgery, George Washington University Fellowship: Pediatric Cardiothoracic Surgery, Medical University of South CarolinaCertification: American Board of Thoracic SurgerySpecial Interests: Neonatal heart surgery; mechanical circulatory support; quality improve-ment; enhanced patient safetyE-mail Address: felix.tsai@chkd.org

NeurosurgeryLocated at CHKDSurgeries offered at CHKD in NorfolkAppointments & consults ..............(757) 668-7990Fax ................................................(757) 668-7995

John Birknes, MDMD Degree: Jefferson Medical College, PhiladelphiaResidency: Neurological Surgery, Thomas Jefferson University Hospital, PhiladelphiaFellowship: Pediatric Neuro-surgery, Children’s Hospital of Philadelphia; Pediatric Spinal Deformity and Scoliosis, Shriners Hospital for Children of PhiladelphiaCertification: American Board of Neurological Surgery

Special Interests: Brain tumors; spinal deformity and scoliosis; Chiari malformation; hydrocepha-lus; epilepsy; spina bifida/cerebral palsy; neuro-endoscopyE-mail Address: john.birknes@chkd.org

Joseph F. Dilustro, MD, FACSMD Degree: Eastern Virginia Medical SchoolResidency: Neurological Surgery, Eastern Virginia Medical School Graduate School of MedicineFellowship: Microvascular and Cerebrovascular Surgery, London Health Sciences Center, University of Western OntarioCertification: American Board of Neurological SurgerySpecial Interests: Craniofacial surgery; brain tumors; spina bifida/cerebral palsy; hydrocepha-lus; cerebrovascular disorders in children; Chiari malformationE-mail Address: joseph.dilustro@chkd.org

Orthopedics & Sports MedicineLocated in Norfolk, Chesapeake, Virginia Beach and Newport NewsSurgeries offered at CHKD Surgery Centers in Norfolk, Newport News and Virginia BeachAppointments & consults ..............(757) 668-6550Same-day appointments ...............(757) 668-6545Fax ................................................(757) 668-6544

J. Marc Cardelia, MDMD Degree: Thomas Jefferson University Medical College, PhiladelphiaResidency: Surgery, UMDNJ–Robert Wood Johnson Medical School, New Brunswick, NJFellowship: Pediatric Orthopedics, Rady Children’s Hospital, San DiegoCertification: American Board of Orthopedic SurgerySpecial Interests: Sports injuries; spinal defor-mity; trauma in childrenE-mail Address: marc.cardelia@chkd.org

Allison Crepeau, MDMD Degree: Georgetown University School of Medicine Residency: Orthopedics, SUNY at Stony Brook Fellowship: Pediatric Orthopedic Surgery, Arnold Palmer Hospital for Children; Pediatric and Adult Sports Medicine, Boston Children’s HospitalSpecial Interests: Sports medicine; dance medi-cine; hip arthroscopy for treatment of labral tears and impingementE-mail Address: allison.crepeau@chkd.org

Cara Novick, MDMD Degree: New York University School of Medicine Residency: Orthopedics, New York University Medical Center/Hospital for Joint DiseasesFellowship: Pediatric Orthopedic Surgery, Shriner’s Hospital for ChildrenSpecial Interests: Office-based pediatric orthope-dics, fracture management, sports medicineCertification: American Board of Orthopedic SurgeryE-mail Address: cara.novick@chkd.org

H. Sheldon St. Clair, MD MD Degree: Medical College of Virginia Residency: Orthopedics, Tufts-New England Medical Center Hospital, BostonFellowship: Pediatric Orthopedics, Boston Floating Hospital for ChildrenCertification: American Board of Orthopedic SurgerySpecial Interests: Scoliosis and spinal deformi-ties; cerebral palsy; neuromuscular diseases; limb lengthening and deformity correction; congenital deformities; sports injuriesE-mail Address: harvey.stclair@chkd.org

Carl R. St. Remy, MDMD Degree: Columbia University College of Physicians and Surgeons, New YorkResidency: Orthopedics, New York Orthopaedic Hospital, Columbia University-Presbyterian Hospital, New YorkFellowship: Pediatric Orthopedics, Texas Scottish Rite Hospital for Children, DallasCertification: American Board of Orthopedic SurgerySpecial Interests: Scoliosis and spinal deformities; neuromuscular disorders; limb reconstruction; congenital deformities; sports injuries; traumaE-mail Address: carl.stremy@chkd.org

Allison Tenfelde, MDMD Degree: Michigan State University College of Human MedicineResidency: Orthopedics, Michigan State UniversityFellowship: Pediatric Orthopedics, University of Michigan – Mott Children’s Hospital; Orthopedic Sports Medicine, Detroit Medical CenterCertification: American Board of Orthopedic SurgerySpecial Interests: Pediatric and adolescent sports injuries; arthroscopic surgery of the shoulder, knee and elbowE-mail Address: allison.tenfelde@chkd.org

CHKD Surgical GroupFor physician-to-physician consults and access: Call CHKD Doctors Direct, (757) 668-9999 or 1-800-207-2022

For a complete list of pediatric specialists and surgeons, visit chkd.org/referraldirectory

CHKD Surgical Group | Journal | Vol. 3, 2014 5

Pediatric SurgeryLocated at CHKD, Virginia Beach, Chesapeake and Newport NewsSurgeries offered at CHKD Surgery Centers in Norfolk, Newport News and Virginia BeachAppointments & consults ..............(757) 668-7703Fax ................................................(757) 668-8860

Frazier W. Frantz, MD, FACSMD Degree: Duke University School of MedicineResidency: General Surgery, Medical College of VirginiaFellowship: Pediatric Surgery, Children’s Hospital Medical Center, CincinnatiCertification: American Board of Surgery, Pediatric Surgery Special Interests: Surgical treatment of colorectal diseases in children; congenital chest wall defor-mities; vascular anomaliesE-mail Address: frazier.frantz@chkd.org

Michael J. Goretsky, MD, FACS, FAAPMD Degree: State University of New York, Stony BrookResidency: General Surgery, University of Cincinnati; Pediatric Surgery, Children’s Hospital of Michigan, DetroitFellowship: Surgical Research, Shriners Burn Institute, Cincinnati; ECMO, Children’s Hospital of CincinnatiCertification: American Board of Surgery, Pediatric SurgerySpecial Interests: Minimally invasive surgery; Hirschsprung’s disease; non-cardiac thoracic sur-gery; Nuss Procedure for pectus excavatum repair and other chest deformitiesE-mail Address: michael.goretsky@chkd.org

Robert E. Kelly Jr., MD, FACS, FAAPMD Degree: Johns Hopkins UniversityResidency: Surgery, Vanderbilt University, NashvilleFellowship: ECMO and Surgical Research, UCLA School of Medicine, Los Angeles; Pediatric Surgery, Children’s Hospital of BuffaloCertification: American Board of Surgery, Pediatric SurgerySpecial Interests: Esophageal and pulmonary problems; neck masses; Hirschsprung’s disease; Nuss Procedure for pectus excavatum repair and other chest deformities; pectus carinatumE-mail Address: robert.kelly@chkd.org

M. Ann Kuhn, MD, FACS, FAAPMD Degree: Marshall University, John C. Edwards School of Medicine Residency: General Surgery, Ohio State University

Fellowship: Pediatric Surgery, University of Oklahoma Health Sciences Center Certification: American Board of Surgery, Pediatric SurgerySpecial Interests: Minimally invasive laparoscopic surgery; Nuss Procedure for pectus excavatum repair and other chest deformities; colorectal dis-ease; thoracic surgery; surgical oncologyE-mail Address: ann.kuhn@chkd.org

Michele Lombardo, MDMD Degree: Boston University School of MedicineResidency: General Surgery, Brown University and Rhode Island HospitalFellowship: Pediatric Surgery, Brown University and Hasbro Children’sCertification: American Board of SurgeryE-mail Address: michele.lombardo@chkd.org

Robert J. Obermeyer, MD, FACS, FAAPMD Degree: University of Cincinnati College of Medicine Residency: General Surgery, Western Reserve Care Forum HealthFellowship: Pediatric Surgery, University of Arkansas Children’s Hospital; Minimally Invasive Surgery, Baylor College of Medicine Certification: American Board of Surgery, Pediatric SurgerySpecial Interests: Minimally invasive laparoscopic surgery; pediatric thoracic surgery; pediatric sur-gical oncology; Nuss Procedure for pectus excava-tum repair and other chest wall deformitiesE-mail Address: robert.obermeyer@chkd.org

Plastic SurgeryLocated at CHKD, Chesapeake, Virginia Beach and Newport NewsSurgeries offered at CHKD Surgery Centers in Norfolk, Newport News and Virginia BeachAppointments & consults ..............(757) 668-7713Fax ................................................(757) 668-7711

George Hoerr, MDMD Degree: University of Missouri, ColumbiaResidency: General Surgery, EVMS/Sentara Norfolk General/CHKD; Plastic Surgery, University of California – IrvineFellowship: Pediatric Plastic Surgery, USC/Children’s Hospital of Los AngelesCertification: American Board of Plastic SurgerySpecial Interests: Craniofacial surgery; congenital ear reconstruction; cleft lip and cleft palate; birth-marks and hemangiomas; congenital hand surgeryE-mail Address: george.hoerr@chkd.org

UrologyLocated at CHKD, Chesapeake, Virginia Beach, Newport News and WilliamsburgSurgeries offered at CHKD Surgery Centers in Norfolk, Newport News and Virginia BeachAppointments & consults ..............(757) 668-7878Fax ................................................(757) 668-7883

Charles E. Horton Jr., MD, FAAP, FACS MD Degree: Eastern Virginia Medical SchoolResidency: General Surgery, Dartmouth University; Urology, Harvard UniversityFellowship: Pediatric Urology, Johns Hopkins UniversityCertification: American Board of Urology Special Interests: Urogenital reconstruction; hypo-spadias; laparoscopyE-mail Address: charles.horton@chkd.org

Jyoti Upadhyay, MD, FAAPMD Degree: Wayne State University, MichiganResidency: General Surgery, Wayne State University; Urology, Wayne State UniversityFellowship: Pediatric Urology, Hospital for Sick Children, TorontoCertification: American Board of Urology Special Interests: Complex genitourinary recon-struction, including augmentation cystoplasty and catheterizable urinary stomas for neurogenic bowel and bladder disease; reconstructive surgery for ambiguous genitalia, congenital adrenal hyper-plasia and intersex states; microscopic varicoce-lectomy; minimally invasive laparoscopic kidney procedures; ureteroscopy; holmium laser use for pediatric kidney and ureteral stones; certified to perform daVinci robotic-assisted pyeloplasties for utereral anomaliesE-mail Address: jyoti.upadhyay@chkd.org

Louis Wojcik, MDMD Degree: Vanderbilt University School of MedicineResidency: Brown UniversityFellowship: Children’s Hospital San DiegoCertification: American Board of UrologySpecial Interests: Hydronephrosis; hypospadias; undescended testis; vesicoureteral refluxE-mail Address: louis.wojcik@chkd.org

6 CHKD Surgical Group | Journal | Vol. 3, 2014

Data supports phased approach for treatment of pectus carinatum by Robert Kelly, MD

Summary: Pectus carinatum, also known as pigeon breast, is a deformity of the chest wall characterized by protrusion of the sternum and rib cartilage. Staged treatment beginning with a dynamic compression bracing system allows the majority of adolescent patients to be managed without surgery. Patients who are not candidates for bracing, as well as those who do not achieve optimal results from bracing, can be corrected surgically using the Abramson Procedure, a variety of implants or a traditional open repair.

As the clinical home of the mini-mally invasive Nuss Procedure used to correct pectus excavatum, Children’s Hospital of The King’s Daughters has been an international treatment and re-search center for chest wall deformities for more than 20 years. Since CHKD Surgeon-in-Chief Emeritus Donald Nuss first developed his revolutionary procedure, more than 1,700 patients have undergone the surgical correction of chest wall deformities at our hospital.

The wide adoption of the Nuss Pro-cedure has given our pediatric surgery

team the opportunity to gather and pub-lish clinically significant outcomes, to determine best practices, and to conduct and facilitate multi-center re-search into the causes and effects of chest wall defor-mities. The Center for Chest Wall Repair at CHKD now of-fers many different treatment options, including non-sur-gical and surgical options, to address malformations of the chest wall. The goal of patient evaluations in our center is to find the least least invasive option that will be effective for each patient’s specific physiology.

Pectus Carinatum Pectus carinatum can cause chest

pain, shortness of breath and difficulty exercising. Patients may also experi-ence psychological distress and negative body image. The deformity affects males more than females and often becomes more pronounced during puberty.

Surgeons have long recommended compressive orthotic bracing as a first line of treatment for pectus carinatum, but patient compliance can be a chal-

lenge. Advanced bracing technology recently developed by Martinez-Ferro, et al. introduces a dynamic compression

system (DCS) that applies op-timal pressure for results and compliance. This system’s custom-made aluminum brace and cushioned compression plate are adjusted as treat-ment progresses, effectively remodeling the chest wall in most patients. Over four years of use, we have treated more than 200 patients with the dy-namic compression bracing system, with very encouraging

results, reported here.For patients who are not good can-

didates for bracing and those who do not achieve satisfactory results, surgery remains a viable option. In 2008, my col-leagues and I performed the first reverse Nuss Procedure for pectus carinatum, also known as the Abramson Procedure, in the US at CHKD. This minimally-invasive surgery is advantageous for younger patients with flexible chests. The Abramson procedure uses the pat-ented Nuss bar to press the sternum and ribs down into the correct position

Robert Kelly, MD

Dynamic Compression System The Abramson Procedure

CHKD Surgical Group | Journal | Vol. 3, 2014 7

in much the same way that orthodontic braces correct an overbite.

For patients with more complex chest wall deformities, we may use one of a va-riety of implants, such as the Strasbourg Stratos system of titanium implants, to shape and stabilize the chest wall. A fi-nal option is the traditional open repair operation, which is very successful for skeletally mature patients with pectus carinatum.

Treatment OutcomesFor an article published in the Jour-

nal of Pediatric Surgery in 2013 (Vol. 48, 315-320)*, we reviewed records from the Chest Wall Anomaly Clinical Database of 137 patients treated for pectus carinatum at CHKD between October 2008 and December 2011. Cor-rections included dynamic compression bracing, minimally invasive surgery and open repair.

For each patient identified as a can-didate for correction, we calculated the compression pressure required to flatten the sternum with a brace. This pressure of correction (POC) was measured in pounds per square inch (PSI). Patients with low to moderate correction pressure (POC<7.5) were recommended for the dynamic compression bracing system. Patients with high correction pressures (POC>7.5 PSI), severe asymmetry, his-tory of previous bracing failure, or those deemed unlikely to be compliant were offered surgical treatment with the mini-mally invasive Abramson Procedure or an open repair. A total of 13 patients underwent the Abramson Procedure. One of these corrections failed, but was remedied with an open repair yielding excellent results. A total of five patients received an open repair with good re-sults.

A total of 122 patients with a median age of 14 (10 to 28) were amenable to bracing. These patients were measured and fitted for the dynamic compres-sion brace. Patients were encouraged to wear the device as much as possible including during sleep but not during athletic activities or showering. A mini-mum daily bracing duration of eight to 12 hours was recommended. Physical

Device offers non-surgical option to some pectus excavatum patients

While bracing is not generally an option for pectus excavatum, a defor-mity where the chest wall is sunken or caved in toward the spine, CHKD is currently utilizing the Vacuum Bell, a mini-mally-invasive device developed by German engineer Eckart Klobe to address mild cases of PE for patients who want or need to avoid surgery. We have also used the Vacuum Bell intraoperatively to el-evate the sternum prior to inserting the Nuss bar.

The Vacuum Bell comes in three sizes: 16 cm, 19cm and 26 cm. There is also a special model designed specifically for adolescent girls and women to accommodate breast tissue. The device uses a suction cup to cre-ate a vacuum seal on the chest wall and pull the sternum forward. The patient adjusts the pressure with a

hand pump and wears the device for several hours each day and allows patients to receive treatments with-out interfering with school, sports or

daily activities. With regular use, patients have reported an im-proved appearance to the sternum after two to three years of treatment. To date, the Vacuum Bell has been implemented on approximately 40 patients with en-

couraging outcomes, similar to those reported by Swiss surgeon Frank-Mar-tin Haecker in the European Journal of Cardiothoracic Surgery in 2006 and in the Turkish Toraks Cerrahisi Bulteni in 2011. Further research and time elapsed post-treatment will be needed to evaluate long-term effec-tiveness. Dr. Robert Obermeyer leads the Vacuum Bell treatment initiative and can be contacted at 668-7703.

therapists instructed patients regarding daily strength and flexibility exercises to optimize results.

Patients were seen in the clinic every one to three months to make adjustments to the brace and reinforce compliance. After the chest wall was reshaped and the sternum was flattened by the brace, patients wore the brace for progressively fewer hours as a retainer for five months to maintain the shape of the chest wall.

In an analysis of the 122 bracing patient outcomes, 67 were progress-ing under active treatment at the time of review, 37 exhibited flattening of the sternum after an average of six months without the need for surgery. Five pa-tients were lost to follow up and 13 patients failed treatment. Three of the patients who failed bracing treatment were then corrected surgically.

Complications were limited to tran-sient skin breakdown in nine patients.

This was treated with temporary loos-ening of the brace to lower the POT or discontinuation until the skin healed. Patient-reported daily bracing durations recorded as a measure of treatment com-pliance revealed that the average daily bracing duration in patients who expe-rienced sternal flattening was 16 hours.

At CHKD, surgeons are trained to evaluate patients for the least invasive and most effective treatment options.

*Amy S. Coheea, James R. Linb, Frazier W. Frantzc, Robert E. Kelly Jr.c

aChildren’s Hospital of The King’s Daughters, Norfolk, VA

bEastern Virginia Medical School, Norfolk, VA

cEastern Virginia Medical School, Children’s Hospital of The King’s Daughters, Norfolk, VA

Dr. Kelly is a board-certified pediatric surgeon at CHKD. You may reach him at (757) 668-7703.

8 CHKD Surgical Group | Journal | Vol. 3, 2014

601 Children’s LaneNorfolk, VA 23507

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CHKD

CHKD Surgical Group welcomes two new surgeonsDr. Benjamin PeelerChief of Pediatric Cardiothoracic SurgeryDr. Benjamin Peeler has joined CHKD

as chief of pediatric cardiothoracic sur-

gery. A nationally-recognized expert,

Dr. Peeler trained at Vanderbilt, UVA and Emory Univer-

sity. He has published more than 30 manuscripts and six

book chapters and performs thoracic and cardiovascular

surgery and vascular surgery. He completed a fellowship

in pediatric cardiothoracic surgery at Emory University.

Dr. Peeler performs the full spectrum of pediatric car-

diothoracic procedures including treatment of complex

single ventricle defects and other congenital anomalies.

Dr. Allison TenfeldeOrthopedics and Sports MedicineDr. Allison M. Tenfelde, a fellowship-

trained orthopedic sports medicine

surgeon, has joined the orthopedic sur-

gery practice of CHKD’s Surgical Group.

Dr. Tenfelde attended medical school at the Michigan State

University College of Human Medicine and completed two

fellowships – one in pediatric orthopedic surgery at Univer-

sity of Michigan C.S. Mott Children’s Hospital and another

in orthopedic sports medicine at Detroit Medical Center.

Prior to medical school, she spent seven years as a certified

athletic trainer at a variety of institutions including Michi-

gan Capital Medical Center, University of Utah, Concentra

Occupational Health Center and St. John Health System.