In a keel chest (technical term: pectus carinatum), the sternum protrudes conspicuously outwards, which is caused by excessive growth of the cartilage connections between the sternum and the ribs. As a result, the front chest wall takes on the shape of a keel. The exact cause of this is still unclear. This chest deformity occurs in 1:3000-4000 newborns and is therefore approx. 10 times rarer than a funnel chest. Boys are affected much more frequently in percentage terms and a familial clustering has been observed. The findings often increase during puberty. There are various forms of keel chest, the height and length of the "keel" varies from patient to patient and it can be symmetrical or asymmetrical.

Restrictions due to a keel chest

As a rule, keel chest patients have no limitations to their physical performance. A relevant factor in keel chest patients is usually a pronounced emotional burden due to dissatisfaction with the appearance of the anterior chest. As a result, many sufferers are restricted in their social life, they avoid going to the swimming pool or are teased by classmates. As with a funnel chest, this can result in a significant reduction in quality of life. There are now numerous studies on this aspect in which this has been scientifically proven. In addition, scoliosis can also cause back pain.

In most cases, a keel chest is a harmless clinical finding that does not require treatment. In rare cases, extreme forms may cause skin irritation through contact with clothing. However, if the affected person suffers from the appearance of their chest, especially emotionally, the keel chest can be corrected. There are various methods for this, which are briefly explained below.

1) Compression therapy using a brace: The least invasive therapy method is compression treatment with a special orthosis [2 - 5]. In adolescence, the bones of the rib cage are still flexible and can be brought into the desired position by applying pressure. The compression orthosis (also known as a brace) is individually fitted for each patient and regularly exerts light pressure on the highest point of the keel chest. This gradually "presses down" the keel chest. In addition, the usually "round" chest of keel chest patients is pressed flatter, which causes a physiological widening at the sides. The clear advantage of this treatment method is that the only risks are skin irritation and slight pain when wearing the compression orthosis.

Ideal age for correction: The ideal time for correction of the keel chest is during puberty. This is because the bones of the rib cage are still flexible during this phase and can be brought into the desired position by applying pressure. The older the patient is, the stiffer the rib cage usually is. As a keel chest does not usually cause any physical complaints and compression therapy requires reliable cooperation from the patient, we do not believe that earlier treatment is advisable. A keel chest often only develops during puberty. And in this phase of life, social life is often restricted due to dissatisfaction with the appearance of the chest. Many patients avoid going to the swimming pool or are teased by classmates. Correction can usually counteract this development and patients feel comfortable in their bodies again [1; 6].

Necessary examinations before therapy: No special examinations are usually required before therapy begins. During an appointment in our consultation, the flexibility of the chest is tested manually by carefully pressing the ball of the hand on the keel chest. X-ray or even CT examinations are not usually necessary. In our Clinical Department, however, we have the option of scanning and imaging the surface of the rib cage using a 3D scanner without radiation. It is also important to ensure that the patient strongly desires the therapy. This is because a good result can only be achieved if the patient is sufficiently willing to actively participate in the therapy, as the compression orthosis is applied by the patient themselves.

Course of therapy: We work very closely with the orthopaedic technicians at John & Bamberg GmbH & Co KG (there is no business relationship between the medical supply store and the MHH). With a prescription, the measurements for the individual trunk orthoses are taken there on site and then the orthosis is made. This can take several weeks. A further appointment is made at John und Bamberg GmbH & Co KG for fitting. The compression orthosis is then worn daily for as long as possible (optimally 23 hours) and should only be removed for sports and showering. The brace can be worn directly on the skin or over a T-shirt; overall, the orthosis can often be easily concealed under clothing. The pressure is adjusted each time the brace is put on. If possible, the pressure should be set so that a slight reddening of the skin/imprint is visible after removal. The longer the brace is worn with sufficient pressure, the faster you will see a flattening of the keel chest. The first results are usually visible after just a few weeks. If the orthosis is worn consistently, a beautiful result can be achieved after approx. 6 - 9 months. The result depends on the stiffness of the rib cage at the start of treatment as well as the patient's cooperation. Once the desired result has been achieved, the duration of the daily compression treatment is gradually reduced.

Advantages of the compression method: The clear advantages of this method are that it is a conservative method and the deformity can be corrected without surgery. There is therefore no risk of surgery-related complications.

Possible complications and risks: The only complications that can occur with this correction method are redness or irritation of the skin and slight pain when wearing the orthosis.

Risk of recurrence after completion of brace therapy: As soon as the shape of the rib cage has stabilized, a recurrence is rather unlikely. However, should a recurrence occur during further growth, the orthosis can be reapplied and the (often less pronounced) keel chest can be corrected again.

2) Minimally invasive keel breast correction according to Abramson: The minimally invasive repair of pectus carinatum (MIRPC) is a modified method of minimally invasive funnel chest correction (also known as "reverse nut surgery") and was first published by Horacio Abramson in 2009 [7 - 9]. The principle consists of a specially adapted metal stirrup that is placed above the sternum, fixed laterally to stabilizers and presses the sternum down, which immediately corrects the keel chest. This stirrup remains in place for approx. 2 years with normal progression and must then be surgically removed in a further procedure under anesthesia.

Since compression therapy using a brace can be used successfully in pediatric surgery and the complications associated with surgery can be avoided, brace therapy is the primary treatment option for us. Only in the absence of success would we perform a surgical keel-breast correction. As we do not consider the minimally invasive method to be a good alternative for rigid and poorly repositionable sternums, we do not offer this type of correction due to the possible complications.

3) Open correction method according to Ravitch: If the sternum is too rigid, i.e. too stiff, or if the corrective shape of the ribcage does not appear to be sufficiently good under compression of the sternum, open surgery of the keel chest can be performed. This also applies to highly asymmetrical forms or mixed forms with a funnel chest. This correction method is performed in accordance with the operation to correct a funnel chest, which was developed by Dr. Mark Ravitch in 1949 [10]. The deformed rib cartilage is removed via an incision in the anterior chest area, the sternum is cut if necessary and brought into the desired shape. This correction method also involves the subsequent insertion of metal implants for stabilization, which must be removed again after approx. 6 months via a minor procedure [11].

As compression therapy can be used successfully in pediatric surgery and the complications associated with surgery can be avoided, this is the primary treatment option for us. Only in the absence of success or in special cases do we also offer surgical correction of the keel chest.

Link: www.chestwall.org