Patients receiving the Nuss procedure for pectus excavatum are often advised to restrict their activity for months after surgery to avoid pectus bar displacement (PBD). But new research shows those restrictions may be unnecessary.
The 10-center study involved more than 500 patients – 405 with activity restrictions and 127 without – and found the PBD rate was the same for both groups. Children’s HealthSM was one of the 10 sites.
“Following this study, our center stopped recommending activity restrictions. Methods for securing bars and managing pain have advanced so much that the old activity protocols don’t apply,” says Samir Pandya, M.D., Pediatric Surgeon at Children’s Health and Professor at UT Southwestern.
Restrictions vary but are often onerous
Experts have long disagreed about the need for activity restrictions following Nuss. As a result, some centers around the country recommend restrictions, while others don’t.
Common restrictions for pediatric patients include:
Sleeping in a supine position for 4-8 weeks
Staying home from school for 2-3 weeks
Limiting activity and twisting motions for several weeks
Avoiding competitive sports for 3 months or, in some cases, until after the pectus bars are removed.
Having worked at centers with different approaches across his career, Dr. Pandya questioned whether that caution was necessary.
“The physics didn’t make sense to me. I couldn’t see how someone could flip a bar by running or twisting their torso,” Dr. Pandya says.
Centers changed their ways to participate in the study
Rates of PBD have gone down in recent decades as methods of securing and connecting bars have improved. Today, the risk of PBD likely derives more from how the surgery is performed than from how the patient moves afterward.
Dr. Pandya and his colleagues at the nine other centers tested this theory by placing no activity restrictions on patients they treated during an 18-month span. They compared outcomes from this cohort to historical data.
Prior to the study, Children’s Health was one of the centers that did recommend restrictions. But Dr. Pandya found that getting his colleagues to change their practice wasn’t difficult.
“Our team has been early adopters of other innovations to pectus repair, including cryoablation to reduce pain. We agreed that foregoing activity restrictions was worth a look,” says Lauren Ann Gillory, M.D., Pediatric Surgeon at Children’s Health and Assistant Professor at UT Southwestern.
Lifting restrictions had no impact on PBD rate
The rate of PBD across all patients in the study was 1.6%, consistent with national averages.
The rate for each patient group was comparable: 1.7% for patients with activity restrictions, 0.8% for those without.
Rates of infection, reoperation and other complications were also aligned between the groups.
The no-restrictions cohort had more complex procedures on average, including sternal elevation and/or two pectus bars.
“For us, this data is definitive. We no longer recommend restrictions at Children’s Health,” Dr. Pandya says.
Instead, he lets patients be the stewards of their own health. If exercise and other vigorous activities are important to them, they can give it a try.
That was certainly the case for one of Dr. Pandya’s patients, a college athlete who was looking to be recruited for a professional career and didn’t want to disrupt his conditioning.
“He spent one night in the hospital and was back in the gym the next day,” Dr. Pandya says.
Why Children’s Health: Leading the way in pectus care and innovation
Dr. Pandya and Dr. Gillory see patients and lead research through the Center for Pectus and Chest Wall Anomalies at Children’s Health. The concentration of expertise and record of strong patient outcomes at the center make it a regional leader in pectus care and innovation.
Children’s Health was among the first pediatric centers to adopt cryoablation of the chest-wall nerves and document how it reduces length of stay and opioid reliance.
It is also an early adopter of interlocking bar technology to stabilize multiple bars and minimize rotation. The interlocking bars slide together and have multiple slots for bolting in place, offering greater flexibility and stability than previous bar designs.
“Pectus repair used to be a major chest surgery. Now kids are home the next day and free to go back to school and sports without missing a beat. We’re proud to help make that possible,” Dr. Pandya says.
Learn more about innovative pectus care at Children’s Health.
