<unk>  requires no corrective procedures in mild cases. Treatment of severe cases can involve either invasive or non-invasive techniques or a combination of both. Before an operation proceeds several tests are usually performed. These include, but are not limited to, a CT scan, pulmonary function tests, and cardiology exams (such as auscultation and ECGs). After a CT scan is taken, the Haller index is measured. The patient's Haller is calculated by obtaining the ratio of the transverse diameter (the horizontal distance of the inside of the ribcage) and the anteroposterior diameter (the shortest distance between the vertebrae and sternum). A Haller Index of greater than 3.25 is generally considered severe, while normal chest has an index of 2.5. The cardiopulmonary tests are used to determine the lung capacity and to check for heart murmurs. Conservative treatment The chest wall is elastic, gradually stiffening with age. Non-surgical treatments have been developed that aim at gradually alleviating the<unk>  condition, making use of the elasticity of the chest wall, including the costal cartilages, in particular in young cases. Exercise Physical exercise has an important role in conservative<unk>  treatment though is not seen as a means to resolve the condition on its own. It is used in order to halt or slow the progression of mild or moderate<unk>  conditions and as supplementary treatment to improve a poor posture, to prevent secondary complications, and to prevent relapse after treatment. Exercises are aimed at improving posture, strengthening back and chest muscles, and enhancing exercise capacity, ideally also increasing chest expansion.<unk>  exercises include deep breathing and breath holding exercises, as well as strength training for the back and chest muscles. Additionally, aerobic exercises to improve cardiopulmonary function are employed. Vacuum bell Vacuum bell for<unk>  treatment, with hand pump (left) and measuring rod (right) An alternative to surgery, the vacuum bell, was described in 2006; the procedure is also referred to as treatment by cup suction. It consists of a bowl shaped device which fits over the caved-in area; the air is then removed by the use of a hand pump. The vacuum created by this lifts the sternum upwards, lessening the severity of the deformity. It has been proposed as an alternative to surgery in less severe cases. Once the defect visually disappears, two additional years of use of the vacuum bell is required to make what may be a permanent correction. The treatment, in combination with physiotherapy exercises, has been judged by some as "a promising useful alternative" to surgery provided the thorax is flexible; the duration of treatment that is required has been found to be "directly linked to age, severity and the frequency of use". Long-term results are still lacking. A single-center study reported in the Journal of Pediatric Surgery found that use of vacuum bell therapy resulted in an excellent correction in twenty percent of patients, but "is not a substitute for the Nuss procedure which can achieve an excellent result in 90% of patients". Variables predictive of an excellent outcome include age ≤ 11 years, chest wall depth ≤ 1.5 cm, chest wall flexibility, and vacuum bell use over 12 consecutive months. In an article by Interactive Cardiovascular and Thoracic Surgery, the results found that vacuum bell treatment is safe for correcting the deformity non-surgically. The treatment has been shown to have higher success rates in patients who present earlier, have a mild and/or symmetrical deformity, a flexible chest wall and lack of costal flaring. The vacuum bell can also be used in preparation to surgery. Orthoses Brazilian orthopedist Sydney Haje developed a non-surgical protocol for treating<unk>  carinatum as well as<unk> . The method involves wearing a compressive orthosis and adhering to an exercise protocol. Mild cases have also reportedly been treated with corset-like orthopedic support vests and exercise. Thoracic surgery Incentive spirometers deepen lung ventilation after surgery to avoid atelectasis There has been controversy as to the best surgical approach for correction of<unk> . It is important for the surgeon to select the appropriate operative approach based on each individual's characteristics. Surgical correction has been shown to repair any functional symptoms that may occur in the condition, such as respiratory problems or heart murmurs, provided that permanent damage has not already arisen from an extremely severe case. Surgical correction of the<unk>  has been shown to significantly improve cardiovascular function; there is inconclusive evidence so far as to whether it might also improve pulmonary function. One of the most popular techniques for repair of<unk>  today is the minimally invasive operation, also known as MIRPE or Nuss technique. Magnetic mini-mover procedure The magnetic mini-mover procedure (3MP) is a minimally invasive procedure used to correct<unk>  by using two magnets to realign the sternum with the rest of the chest and ribcage. One magnet is inserted 1 cm into the patient's body on the lower end of the sternum, the other is placed externally onto a custom fitted brace. These two magnets generate around 0.04 tesla (T) in order to slowly move the sternum outwards over a number of years. The maximum magnetic field that can be applied to the body safely is around 4 T, making this technique safe from a magnetic viewpoint. The 3MP technique's main advantages are that it is more cost-effective than major surgical approaches such as the Nuss procedure and it is considerably less painful postoperatively. Its effectiveness is limited to younger children in early- to mid-puberty because older individuals have less compliant (flexible) chest walls. One potential adverse interaction with other medical devices is possible inactivation of artificial pacemakers if present. Ravitch technique The Ravitch technique is an invasive surgery that was introduced in 1949 and developed in the 1950s. It involves creating an incision along the chest through which the cartilage is removed and the sternum detached. A small bar is inserted underneath the sternum to hold it up in the desired position. The bar is left implanted until the cartilage grows back, typically about six months. The bar is subsequently removed in a simple outpatient procedure; this technique is thus a two-stage procedure. The Ravitch technique is not widely practiced because it is so invasive. It is more often used in older individuals, where the sternum has calcified when the deformity is asymmetrical, or when the less invasive Nuss procedure has proven unsuccessful. Nuss procedure X-ray of a 15-year-old male after undergoing the Nuss procedure In 1987, Donald Nuss, based at Children's Hospital of The King's Daughters in Norfolk, Virginia, performed the first minimally invasive repair of<unk>  (MIRPE) and presented it much later at a conference in 1997. His procedure, widely known as the Nuss procedure, involves slipping in one or more concave steel bars into the chest, underneath the sternum. The bar is flipped to a convex position so as to push outward on the sternum, correcting the deformity. The bar usually stays in the body for about two years, although many surgeons are now moving toward leaving them in for up to five years. When the bones have solidified into place, the bar is removed through outpatient surgery. Although initially designed to be performed in younger children (less than 10 years of age) whose sternum and cartilage is more flexible, there are successful series of Nuss treatment in patients well into their teens and twenties. The Nuss procedure is a two-stage procedure. Robicsek technique In 1965, Francis Robicsek, based at Charlotte Memorial Hospital, now named Carolinas Medical Center in Charlotte, North Carolina, developed the Robicsek procedure. Each time the procedure is performed, it is individually tailored based on the extent and location of the deformity in the patient. The operation begins with an incision, no more than 4–6 centimeters, to the sternum. The pectoralis major muscles are then detached from the sternum. Using the upper limit of the sternal depression as a guide, the deformed cartilages are removed one by one, using sharp and blunt dissection. The lower tip of the sternum is then grabbed with a towel-clip and, using blunt dissection, is freed of tissue connections with the pericardium and the pleura. The sternum is then forcefully bent forward into a corrected position. To keep the sternum elevated, a piece of mesh is placed under the mobilized sternum and sutured under moderate tension bilaterally to the stumps of the ribs. The pectoralis muscles are united in front of the sternum and the wound is closed. The Robicsek procedure is a single-stage procedure (one surgery only). The purported advantage of this technique is that it is less invasive than the Ravitch technique, but critics have suggested that the relapse rate may be high due to cartilage and bone displaying memory phenomenon. Taulinoplasty In 2016, Carlos Bardají, a Barcelona-based pediatric surgeon, together with Lluís Cassou, a biomedical engineer, published a paper describing an extra-thoracic surgical procedure for the correction of<unk>  called taulinoplasty. A specially designed implant and traction hardware were developed specifically for the
Pectus excavatum
Pectus carinatum
Pes cavus
Pediculosis pubis
Morsicatio buccarum
Protrusio acetabuli
Subungual hematoma
Pediculosis corporis