Patient-specific outcome simulation after surgical correction of Pectus Excavatum: a preliminary study

Although minimally invasive Nuss procedure is frequently performed to correct Pectus Excavatum, the successful aesthetical outcome is not always ensured. Using the computed tomography (CT) data of six patients, high-quality surfaces of the anterior chest wall were generated, alongside with a personalized corrective-bar. Through finite element method (FEM), replicating the surgical procedure, a simulation of the anterior chest wall correction was conducted. The assessment of this methodology was verified by comparing the metrics from the real meshes (3D scanned before and after surgery) and simulated meshes (obtained before and after FEM). Results show a mean difference of 2.85 +/- 5.77 mm on the point of maximum correction between simulated and real outcomes. No statistical differences were found (p = 0.281). High aesthetical similarity was observed concerning simulated and real outcomes. The proposed methodology presents a patient-specific simulation that may be used to plan, predict and improve the surgical outcome of the Nuss procedure. Further studies should continue to improve the presented methodology.This work has been funded by FEDER funds, through the Competitiveness Factors Operational Programme (COMPETE), and by National funds, through the Foundation for Science and Technology (FCT), under the scope of the projects POCI-01-0145-FEDER-007038; NORTE-01-0145-FEDER-000013; and NORTE-01-0145-FEDER-024300, supported by the Northern Portugal Regional Operational Programme (NORTE 2020), under the Portugal 2020 Partnership Agreement, through the European Regional Development Fund (FEDER). Joao Gomes-Fonseca was funded by FCT under the Ph.D. grant PD/BDE/113597/2015

Presence and Localization of Pro-and Mature Forms of Biglycan and Decorin in Human Costal Cartilage Derived from Chest Wall Deformities

Costal cartilage is a type of hyaline cartilage that forms rod-like structures that connect the ribs to the sternum. The most common chest wall deformities, pectus excavatum and pectus carinatum involved efective costal cartilage resulting in sternal displacement. Costal cartilage is not widely studied leaving little insight into possible factors involved in the pathogenesis of these pectus deformities. This study focused on the presence and distribution of two important regulators of collagen fibrillogenesis and organization, biglycan and decorin. Immunohistochemical analysis of transverse cross sections of normal and deformed costal cartilage revealed that biglycan and decorin mainly localized in the territorial matrix except for prodecorin which was only found within chondrocytes. Western blot analysis of whole protein extracts demonstrated the presence of both pro and mature forms of biglycan and mature decorin in patients and controls. In normal costal cartilage of different ages, the mature form of decorin was absent in a fetal sample whereas mature biglycan was weakly expressed, suggestive that mature biglycan may play a role in early costal cartilage development. Further studies are needed to determine the functional differences between the pro- and mature forms of biglycan and decorin both in age and disease

Finite element analysis of pectus carinatum surgical correction via a minimally invasive approach

Pectus carinatum (PC) is a chest deformity caused by a disproportionate growth of the costal cartilages compared to the bony thoracic skeleton, pulling the sternum towards, which leads to its protrusion. There has been a growing interest on using the 'reversed Nuss' technique as a minimally invasive procedure for PC surgical correction. A corrective bar is introduced between the skin and the thoracic cage and positioned on top of the sternum highest protrusion area for continuous pressure. Then, it is fixed to the ribs and kept implanted for about 2-3 years. The purpose of this work was to (a) assess the stresses distribution on the thoracic cage that arise from the procedure, and (b) investigate the impact of different positioning of the corrective bar along the sternum. The higher stresses were generated on the 4th, 5th and 6th ribs backend, supporting the hypothesis of pectus deformities correction-induced scoliosis. The different bar positioning originated different stresses on the ribs' backend. The bar position that led to lower stresses generated on the ribs backend was the one that also led to the smallest sternum displacement. However, this may be preferred, as the risk of induced scoliosis is lowered.This work was financially supported by the Potuguese Foundation for Science and Techrnology (FCT) under the R&D project PTDC/SAU-BEB/103368/2008 and the fellowship SFRH/BPD/46851/2008

Development and Validation Methodology of the Nuss Procedure Surgical Planner

Pectus excavatum (PE) is a congenital chest wall deformity which is characterized, in most cases, by a deep depression of the sternum. A minimally invasive technique for the repair of PE (MIRPE), often referred to as the Nuss procedure, has been proven to be more advantageous than many other PE treatment techniques. The Nuss procedure consists of placement of a metal bar(s) underneath the sternum, thereby forcibly changing the geometry of the ribcage. Because of the prevalence of PE and the popularity of the Nuss procedure, the demand to perform this surgery is greater than ever. Therefore, a Nuss procedure surgical planner would be an invaluable planning tool ensuring an optimal physiological and aesthetic outcome. In this dissertation, the development and validation of the Nuss procedure planner is investigated. First, a generic model of the ribcage is developed to overcome the issue of missing cartilage when PE ribcages are segmented and facilitate the flexibility of the model to accommodate a range of deformity. Then, the CT data collected from actual patients with PE is used to create a set of patient specific finite element models. Based on finite element analyses performed over those models, a set force-displacement data set is created. This data is used to train an artificial neural network to generalize the data set. In order to evaluate the planning process, a methodology which uses an average shape of the chest for comparison with results of the Nuss procedure planner is developed. This method is based on a sample of normal chests obtained from the ODU male population using laser surface scanning and overcomes challenging issues such as hole-filling, scan registration and consistency. Additionally, this planning simulator is optimized so that it can be used for training purposes. Haptic feedback and inertial tracking is implemented, and the force-displacement model is approximated using a neural network approach and evaluated for real-time performance. The results show that it is possible to utilize this approximation of the force-displacement model for the Nuss procedure simulator. The detailed ribcage model achieves real-time performance

Automatic pre-bended customized prosthesis for pectus excavatum minimal invasive surgery correction

Pectus excavatum is the most common deformity of the thorax. A minimally invasive surgical correction is commonly carried out to remodel the anterior chest wall, by employing an intrathoracic convex prosthesis in substernal position. The process of prosthesis modeling and bending still remains an area of improvement. The authors developed a new system, i3DExcavatum, which can automatically model and bend the bar preoperatively based on a thoracic CT-scan. This paper presents a comparison between automatic and manual bending. The i3DExcavatum was used to personalize prosthesis for 41 patients who underwent pectus excavatum surgical correction between 2007 and 2012. Regarding the anatomic variations, the soft tissue thicknesses external to the ribs show that symmetric or asymmetric patients have always asymmetric variations by comparing both patients’ sides. It highlighted that the prosthesis bar should be modeled according to each patient ribs position and dimension. The average differences between the skin and costal line curvature lengths were 84±4 mm and 96±11mm, for male and female patients, respectively. On the other hand, the i3DExcavatum ensured a smooth curvature of the surgical prosthesis and was capable to predict and simulate a virtual shape and size of the bar for asymmetric or symmetric patients. In conclusion, the i3DExcavatum allows preoperative personalization according to the thoracic morphology of each patient. It reduces surgery time and minimizes the margin error induced by the manual bended bar shape that only uses a template that copies the chest wall curvature

Biochemical and Histological Differences Between Costal and Articular Cartilages

Biologically, costal cartilage is an understudied tissue type and much is yet to be learned regarding underlying mechanisms related to form and function, and how these relate to disease states, specifically chest wall deformity. Chest wall deformities have a component of inheritance, implying underlying genetic causes; however the complexity of inheritance suggests multiple genetic components. At our Centre investigations were performed on gene expression of key select genes from costal cartilage removed at surgery of patients with chest wall deformity to show high expression of decorin, a key player in collagen fiber formation and growth. Also, the degree of tissue differentiation was investigated that was different to that of articular cartilage as measured by gene ratio. Ultrastructural aspects of costal cartilage were determined by scanning and atomic force microscopy to show the presence of ‘nanostraws’ and preliminary data of nanostraw strength by measuring Young’s modulus of individual nanostraws. Protein deposition of collagen type II, decorin, and biglycan suggest orchestration of fiber formation in the interterritorial matrix. Although no specific biological markers related to chest wall deformity have currently been identified, work from our Centre has identified potential areas of interest

Quantitative geometric analysis of rib, costal cartilage and sternum from childhood to teenagehood

Better understanding of the effects of growth on children’s bones and cartilage is necessary for clinical and biomechanical purposes. The aim of this study is to define the 3D geometry of children’s rib cages: including sternum, ribs and costal cartilage. Three-dimensional reconstructions of 960 ribs, 518 costal cartilages and 113 sternebrae were performed on thoracic CT-scans of 48 children, aged four months to 15 years. The geometry of the sternum was detailed and nine parameters were used to describe the ribs and rib cages. A "costal index" was defined as the ratio between cartilage length and whole rib length to evaluate the cartilage ratio for each rib level. For all children, the costal index decreased from rib level one to three and increased from level three to seven. For all levels, the cartilage accounted for 45 to 60% of the rib length, and was longer for the first years of life. The mean costal index decreased by 21% for subjects over three years old compared to those under three (p<10-4). The volume of the sternebrae was found to be highly age dependent. Such data could be useful to define the standard geometry of the paediatric thorax and help to detect clinical abnormalities.Grant from the ANR (SECUR_ENFANT 06_0385) and supported by the GDR 2610 “Biomécanique des chocs” (CNRS/INRETS/GIE PSA Renault

Biomechanical validation of novel Nuss procedure simulations for patients with various morphological types of pectus excavatum

A novel Nuss procedure simulation was developed for patients with pectus excavatum considering the displacement of a metal bar and a chest wall model, including the intercostal muscles. However, this simulation was developed for a typical symmetrical patient among the various morphological types of pectus excavatum. Accordingly, this study aimed to validate and confirm the novel simulation for patients with eccentric and imbalanced types, which are severe types of pectus excavatum, considering factors such as depression depth and eccentricity among others. Three-dimensional models of chest walls and metal bars were created for three different types of patients. The rotation-equilibrium displacement and chest wall with intercostal muscles were set according to the methods and conditions of the novel Nuss procedure simulation. The anterior sternal translation and the Haller index derived from the simulation results were compared and verified using medical data from actual postoperative patients. Additionally, maximum equivalent stresses and strains were derived to confirm the suitability of the novel Nuss procedure for each patient type. The severe types had similar precision to the typical type when compared to the actual postoperative patient. Relatively high maximum equivalent stresses and strains were observed on the metal bars and sternum in the severe type, thereby predicting and confirming the biomechanical characteristics of these types. In conclusion, a novel Nuss procedure simulation for severe types was numerically validated. This underscores the importance of biomechanical evaluation through a novel Nuss procedure simulation when planning actual surgeries for severe types of cases

Understanding the Mechanical Behavior of Costal Cartilage at Their Curved Exterior Surface Via a Tactile Sensor with a Built-In Probe for Distributed-Deflection Detection

This dissertation is aimed to determine the mechanical properties at the exterior surface of costal cartilages (CC) and examine how they vary with the cartilage length and the anatomical sites of CC in the ribcage via conformal indentation testing which is built upon a tactile sensor for distributed-deflection detection. The sensor entails a rectangular Polydimethylsiloxane (PDMS) microstructure sensing-plate integrated with a 5 ×1 transducer array with 0.75mm spatial resolution underneath and a built-in probe of 0.5mm×5mm×3mm above. By pressing the sensor against the exterior surface of a CC tissue with a pre-defined indentation pattern, the sensor conforms to the curved tissue surface via the built-in probe first, and then the mechanical properties of the tissue translate to the spatially distributed deflection in the sensor and register as resistance changes by the transducer array. As a load-bearing and non-stop deforming tissue from respiration, the mechanical properties of CC are critical for maintaining their structural health and delivering their function. CC have been used as a viable source of graft tissue for many autologous therapies and as a cell source for engineered articular cartilage (AC) due to its abundance and surgical accessibility. However, the mechanical properties of CC are not well understood yet. Chest wall deformities, such as Pectus Carinatum (PC), are known to arise from the disorder of CC, but their pathogenesis remains unknown and their surgical outcomes are unpredictable. The mechanical properties of the CC exterior surface influence diffusion of oxygen and nutrients and thus are intrinsic to maintaining their structural characteristics. However, very limited knowledge exists on the mechanical properties of peripheral CC due to their highly irregular geometries. In this dissertation, a novel testing method, conformal indentation, was used to measure the mechanical properties at the CC curved exterior surface, where the structural integrity of CC is retained. Conformal indentation was conducted at the anterior/posterior surfaces of whole porcine 5th -12th CC segments and the anterior/posterior surfaces and the superior/inferior borders of five human PC CC segments from the 7th ~10th ribs along the cartilage length to record their time-dependent response to a multi-step indentation-relaxation testing protocol. The instant indentation modulus and normalized relaxation of the CC segments were derived from the recorded data to quantify their elasticity and viscosity, respectively. The instant indentation modulus at the porcine CC and PC CC exterior surface are in the range of 130kPa ~500kPa and 98kPa~1173kPa, respectively, which are well below their counterpart at the CC transverse cross-sections. The normalized relaxation at the CC exterior surface is relatively high with low applied stress but becomes constant with high applied stress. The constant normalized relaxation at the porcine and PC CC exterior surfaces are in the range of 25%~40% and 5%~25%, respectively. The human CC have higher elasticity and lower viscosity than the porcine CC. Overall, the measured mechanical properties of CC vary with their anatomical sites and thus indicate the adaptation of CC to their local biomechanical environment in the ribcage