In the routine excavatum repair the aim is to excise a transverse, anteriorly based wedge of bone from the sternum leaving the posterior periosteum intact. I place the osteotomy between the second and third cartilages to leave the growth centres of the manubrium intact. A generous wedge is then cut using the oscillating saw. The posterior table of the sternum is fractured by bending it backwards increasing the deformity. The wedge can then be removed with forceps.

Wedge osteotomy (Quicktime movie 22secs 1.0Mb)
Wedge osteotomy
The deformity is then overcorrected and the heavy Vicryl on a skin cutting needle (Ethicon 9321) used to hold the edges of the osteotomy in place. I use two horizontal mattress sutures, officially holding periosteum but usually through the outer table of the sternum.

Osteotomy sutures (Quicktime movie 28 secs 1.8Mb)
Osteotomy Sutures
Once tied the sternum should protrude from the incision by itself with absolutely no tension on it. This removes the need for a heavy metal bar to hold it out. Sternum protrudes without support

In a carinatum defect a transverse cut is made across the sternum and the posterior table fractured. Wedges of cartilage are then placed in the cut to wedge it down to a corrected position. These are held in place with the heavy Vicryl using horizontal mattress sutures placed through periosteum and cartilage wedge. I usually suture the xiphisternum with attached rectus abdominis muscle to the anterior surface of the carinatum repair to hold down the tip of the sternum.

Mixed deformities will require combinations of osteotomies including a vertical cut wedged to counter the rotation of the sternum.

There is probably no need for fixation if the mobilisation has been performed properly and there is certainly no need for a metal bar. Virtually all the complications of this operation are produced by the metal support bars. They will eventually fracture, bend or migrate and I am personally aware of the tragic consequences when a bar migrates into the right ventricle. Infection and skin penetration are common.

Hence I do not use a metal bar. I do support the sternum with two heavy PDS absorbable sutures to prevent excessive in drawing with breathing and to provide a modicum of protection to the heart. My colleague uses a slightly stronger PDS ribbon suture for the same purpose.

Two, or in larger children three, mattress sutures are placed deep to the sternum, one at the level of the fourth and another at the sixth costal cartilage, from the tip of one cartilage across to the other. In an excavatum defect I bring the sutures out on the anterior surface of the ribs to gain as much elevation as possible. In a carinatum the reverse holds, with the sutures on the underside of the ribs.

PDS supporting suture (Quicktime movie 21 secs 1.5Mb)
PDS supporting suture

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