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CLINICAL SCIENCE
The search for stability: bar displacement in three series of pectus excavatum patients treated with the Nuss technique
Miguel Lia TeddeI,
Corresponding author
tedde@usp.br

Tel.: 55 11 2661-5708
, José Ribas Milanez de CamposI,II, João-Carlos Das-Neves-PereiraIII, Fernando Conrado AbrãoI, Fábio Biscegli JateneI
I Department of Thoracic Surgery, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo/SP, Brazil.
II Hospital Israelita Albert Einstein, São Paulo/SP, Brazil.
III Hôpital Européen Georges Pompidou - Chirurgie Thoracique/ Paris/FR.
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pectus excavatum</span> &#40;PE&#41; is the most common pediatric congenital anomaly of the chest wall and is observed mostly in male patients&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;2</a> The systemic effects of the deformity range from otherwise asymptomatic presentation to exercise intolerance that necessitates surgical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a> The surgical treatment options include chondrosternal resection&#44; sternal osteotomy and elevation&#44; sternal turnover&#44; and other modifications introduced since the late 1950s&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">A minimally invasive operation using a <span class="elsevierStyleItalic">pectus</span> bar with interesting results was described by Nuss et al&#46;<a class="elsevierStyleCrossRef" href="#bib4">4</a> This procedure improves the anatomic&#44; aesthetic&#44; and functional results without an unaesthetic anterior chest wall incision&#46; However&#44; early and late complications of the Nuss method have been reported in the literature&#44; including pneumothorax&#44; pleural effusion&#44; pain&#44; pericardial effusion&#44; cardiac perforation&#44; wound infection&#44; and bar displacement&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a></p><p id="para30" class="elsevierStylePara elsevierViewall">Bar displacement is a serious complication that can occur anytime&#44; but occurs most frequently in the 30 days following the minimally invasive repair of PE&#46;<a class="elsevierStyleCrossRef" href="#bib4">4</a> Following the initial acceptance and widespread use of the Nuss procedure&#44; the rate of bar displacement was high&#46; However&#44; since the initial development of the technique&#44; several modifications have been proposed in an effort to make the technique both safer and more effective&#46; These modifications include the introduction and development of new positioning&#44; fixation techniques&#44; and stabilizers to replace pericostal sutures or other methods used to prevent bar displacement &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a></p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p id="para40" class="elsevierStylePara elsevierViewall">The objective of this paper is to present our experience and compare bar displacement rates before and after the introduction of new methods&#44; including using a shorter bar&#44; a new model and a more medial positioning of the stabilizers throughout the execution of the Nuss procedure&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">PATIENTS AND METHODS</span><p id="para50" class="elsevierStylePara elsevierViewall">After Ethics Committee approval&#44; we retrospectively reviewed the patient data of 122 patients &#40;109 males and 13 females&#41; with a mean age of 17&#177;3 &#40;range 5 to 37&#41; years that had undergone <span class="elsevierStyleItalic">pectus excavatum</span> repair utilizing the Nuss procedure between May 2003 and June 2010&#46; All data related to the hospital stay and follow-up results from 1 to 83 months post-operation were reviewed&#46; During the study period&#44; we used the basic Nuss technique with two technical modifications&#46; For this purposes of this study&#44; the patients who were treated with the modified techniques were divided into two additional series&#44; for an overall total of three patient series&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">In the first series&#44; which included the first 24 patients&#44; we fixed the bar and stabilizers in a manner similar to the original Nuss procedure&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a></p><p id="para70" class="elsevierStylePara elsevierViewall">In the second series&#44; which included patients 25&#8211;71&#44; we added the technical modification proposed by Hebra et al&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a> in an effort to reduce the bar displacement rate&#46; This modification&#44; referred to as &#8220;third point fixation&#44;&#8221; involves placing a suture around the bar and the underlying ribs&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">Finally&#44; our third series&#44; which is a group of 51 patients &#40;post-2008&#41;&#44; underwent the Nuss procedure with additional technical modifications&#44; including a smaller bar size and the use of a newly designed stabilizer model&#46; This new model&#44; with central grooves on the posterior surface&#44; allows improved sliding of the stabilizer over the bar&#44; regardless of its curvature&#46; This ensures a more medial positioning of the stabilizer &#40;<a class="elsevierStyleCrossRef" href="#fig2">Figure 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a></p><elsevierMultimedia ident="fig2"></elsevierMultimedia><p id="para90" class="elsevierStylePara elsevierViewall">Three patients were referred to us 7&#44; 8&#44; and 11 years post unsuccessful treatment with a modified Ravitch technique&#46; Two of these patients were included in the second series&#44; and one patient was included in the third&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">Chest X-rays were taken postoperatively in all patients to both document the results and enable comparison of the position of the bar throughout the follow-up period&#46; As no movement of the bar is expected&#44; any position different from the initial location visualized in the X-rays was classified as bar displacement&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">Postoperative pain management was achieved using epidural catheters and non-steroidal anti-inflammatory drugs&#46; The follow-up protocol included outpatient visits at three weeks&#44; three months&#44; six months and annually for three years&#46; Light physical activity was allowed three weeks after surgery&#44; all kinds of sports except contact sports were allowed after three months&#44; and all activity was allowed after six months&#46; The bar was removed after the three-year follow-up period&#46;</p><p id="para120" class="elsevierStylePara elsevierViewall">Complications were classified as &#8220;major&#8221; if an organ injury occurred or if a secondary intervention became necessary or as &#8220;minor&#8221; if there was any need for clinical treatment and&#47;or if evacuation of fluid or air from the thorax by drainage became necessary&#46;</p><p id="para130" class="elsevierStylePara elsevierViewall">The data is presented as the frequency and percentage&#46; To compare the incidence of complications in each of the series we used the Likelihood Ratio test&#46; A <span class="elsevierStyleItalic">p-</span>value less than 0&#46;05 was considered significant&#46; All statistical analyses were performed using SPSS Version 13 software &#40;SPSS&#44; Chicago&#44; IL&#44; USA&#41;&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">RESULTS</span><p id="para140" class="elsevierStylePara elsevierViewall">There were no deaths in any of the series&#46; The observed complications are listed in <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="para150" class="elsevierStylePara elsevierViewall">Minor complications occurred in six &#40;4&#46;9&#37;&#41; patients&#46; There was pneumothorax with spontaneous resolution in two &#40;1&#46;6&#37;&#41; patients&#44; with one in the first series and one in the second series&#46; In addition&#44; two &#40;1&#46;6&#37;&#41; cases in the first series suffered suture site infection&#46; There were two &#40;1&#46;6&#37;&#41; cases of bar displacement that did not require surgery to remove the bar&#46;</p><p id="para160" class="elsevierStylePara elsevierViewall">Major complications were observed in eight &#40;6&#46;5&#37;&#41; patients&#46; Skin erosion&#47;seroma occurred in one &#40;0&#46;8&#37;&#41; patient in the first series&#46; In the second-series patients&#44; we observed pleural effusion requiring drainage in one &#40;0&#46;8&#37;&#41; patient&#44; a reaction to the bar &#40;ABA foreign body reaction&#41; in one &#40;0&#46;8&#37;&#41; patient&#44; pneumonia and septic shock in one &#40;0&#46;8&#37;&#41; patient and cardiac perforation in one &#40;0&#46;8&#37;&#41; patient&#46; Bar displacement that required bar removal occurred in three &#40;2&#46;5&#37;&#41; patients&#44; two who were in the first series and one who was in the second series&#46;</p><p id="para170" class="elsevierStylePara elsevierViewall">When the incidence of minor complications was compared among the three series&#44; the only complication that presented a significant difference was suture infection &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#46;036&#41;&#46;</p><p id="para180" class="elsevierStylePara elsevierViewall">The incidence of bar displacement was the only major complication that was significantly different among the three series &#40;<a class="elsevierStyleCrossRef" href="#fig3">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig3"></elsevierMultimedia><p id="para190" class="elsevierStylePara elsevierViewall">We were able to remove the bar after the three-year follow-up period in 37 &#40;30&#46;3&#37;&#41; of the 122 patients&#46; In two &#40;1&#46;6&#37;&#41; patients the bar was removed within 2&#46;5 years of placement&#46; In one case&#44; the removal was performed because of a persistent wound infection following a thoracic trauma with skin erosion&#46; The other early removal was performed at the patient&#39;s request&#44; as it was his desire to join the Navy&#46; In all of these patients&#44; the contour of the chest wall obtained after surgical correction was maintained&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">DISCUSSION</span><p id="para200" class="elsevierStylePara elsevierViewall">The rate of bar displacement following the original Nuss procedure was 15&#37;&#59; however&#44; the introduction of stabilizers reduced this rate to 5&#37;&#46; According to some authors&#44; the rate can be lowered even further with the addition of pericostal sutures placed around the bar&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;7&#44;8</a></p><p id="para210" class="elsevierStylePara elsevierViewall">Hebra et al&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a> were the first to advocate the placement of a suture around the bar and the underlying ribs&#44; which they called &#8220;third point fixation&#46;&#8221; In our second series of patients &#40;patients 25&#8211;71&#41;&#44; we used this technique&#46; The main complaints reported by our patients in the first postoperative month were thoracic pain and discomfort close to the fixation points&#44; perhaps due to compression of the intercostal bundle&#46; With this technical modification to our procedure&#44; the incidence of bar displacement dropped from four &#40;16&#46;6&#37;&#41; in the first series of patients to one &#40;2&#46;1&#37;&#41; in the second series&#46;</p><p id="para220" class="elsevierStylePara elsevierViewall">Park et al&#46;<a class="elsevierStyleCrossRef" href="#bib7">7</a> described a variety of mechanisms governing bar displacement that we also observed in our cases&#44; such as flipping&#44; lateral sliding&#44; and a backward shift&#46; Flipping is most common at the hinge-point&#44; with the bar sliding laterally towards the more depressed side and&#47;or shifting backward&#44; and is often accompanied by a breakdown in the intercostal muscles&#46; While they advocated a fifth wire stitched on the right side at the hinge-point or several pericostal wires to attain the desired firmness&#44;<a class="elsevierStyleCrossRef" href="#bib8">8</a> the rupture of the wire sutures used to secure the stabilizer and&#47;or bar on the underlying rib is a common complication reported in 27&#46;8&#37; of the cases&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> Furthermore&#44; the broken wire can hamper removal of the bar by requiring the surgeon to find and extract minute wire pieces&#46; As a result&#44; residual wire fragments remain embedded under the ribs of some patients&#46; Therefore&#44; dispensing with wire stitching is a welcome development in the Nuss technique&#46;</p><p id="para230" class="elsevierStylePara elsevierViewall">Recently&#44; the use of two bars has been reported<a class="elsevierStyleCrossRef" href="#bib4">4</a> to increase stability and enhance the aesthetic results&#46; Vergunta et al&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> advocates routinely placing two bars&#44; with a stabilizing plate for each&#44; on opposite sides of the chest&#46; They justify this by noting that &#8220;a single bar can be inherently unstable because the deepest point of the sternum is balanced on only the center of one bar&#46; Two bars placed above and below the midpoint of the deformity provides for increased stability&#8221;&#46; However&#44; there are no data comparing the morbidity associated with one or two or more bars&#46;</p><p id="para240" class="elsevierStylePara elsevierViewall">Instead of using two bars to avoid displacement&#44; we chose to use one stabilizer at each side of the bar&#44; distributing the forces to at least two ribs&#46; The two stabilizers provide a stable basis for the correction we observed in all patients in our third series &#40;<a class="elsevierStyleCrossRef" href="#fig4">Figure 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig4"></elsevierMultimedia><p id="para250" class="elsevierStylePara elsevierViewall">In our third series of patients&#44; we followed the recommendations of Pilegaard et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib9">9</a> who&#44; in 2008&#44; concluded that their procedure may have reduced the incidence of bar displacement in 383 patients&#46; These authors modified the original Nuss technique by using a shorter <span class="elsevierStyleItalic">pectus</span> bar and placing the stabilizer on the left side of the bar as close as possible to the entry of the thoracic cavity&#46;</p><p id="para260" class="elsevierStylePara elsevierViewall">Several factors work against the lateral position of the stabilizer&#46; According to Watanabe et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib10">10</a> due to its size&#44; the use of a stabilizer in a lateral position increases the incidence of wound complications&#44; such as seroma and dermatitis due to pressure damage&#46; In one patient in our first series&#44; the stabilizer had to be removed to control seroma&#44; dermatitis&#44; and skin erosion due to pressure damage&#46; When the stabilizer was placed more medially&#44; it was at least partially covered with the <span class="elsevierStyleItalic">pectoralis major</span> muscle&#46;</p><p id="para270" class="elsevierStylePara elsevierViewall">To summarize&#44; we would like to emphasize some concepts already published and that we have been following&#58;<a class="elsevierStyleCrossRef" href="#bib11">10</a><ul class="elsevierStyleList" id="celist10"><li class="elsevierStyleListItem" id="celistitem10"><span class="elsevierStyleLabel">1&#41;</span><p id="para280" class="elsevierStylePara elsevierViewall">small bars are probably more stable than large bars&#59;</p></li><li class="elsevierStyleListItem" id="celistitem20"><span class="elsevierStyleLabel">2&#41;</span><p id="para290" class="elsevierStylePara elsevierViewall">the placement of the bar should be at the deepest point of the excavatum deformity &#40;<a class="elsevierStyleCrossRef" href="#fig5">Figure 5</a>&#41;&#59;</p><elsevierMultimedia ident="fig5"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="celistitem30"><span class="elsevierStyleLabel">3&#41;</span><p id="para300" class="elsevierStylePara elsevierViewall">older&#44; asymmetric&#44; or severe deformities may require placement of an additional bar or may require another method of correction&#59;</p></li><li class="elsevierStyleListItem" id="celistitem40"><span class="elsevierStyleLabel">4&#41;</span><p id="para310" class="elsevierStylePara elsevierViewall">bar should be secured with two stabilizers positioned medially&#44; as close as possible to the hinge-point&#46;</p></li></ul></p><p id="para320" class="elsevierStylePara elsevierViewall">In conclusion&#44; the use of these measures can prevent bar instability as demonstrated in our comparison of the incidence of bar displacement in our three series of patients &#40;<span class="elsevierStyleItalic">p</span>&#60;0&#46;05&#41;&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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        0 => array:2 [
          "identificador" => "xpalclavsec1582223"
          "titulo" => "KEYWORDS"
        ]
        1 => array:2 [
          "identificador" => "cesec10"
          "titulo" => "INTRODUCTION"
        ]
        2 => array:2 [
          "identificador" => "cesec20"
          "titulo" => "PATIENTS AND METHODS"
        ]
        3 => array:2 [
          "identificador" => "cesec30"
          "titulo" => "RESULTS"
        ]
        4 => array:2 [
          "identificador" => "cesec40"
          "titulo" => "DISCUSSION"
        ]
        5 => array:2 [
          "identificador" => "xack639235"
          "titulo" => "ACKNOWLEDGMENTS"
        ]
        6 => array:1 [
          "titulo" => "REFERENCES"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-06-05"
    "fechaAceptado" => "2011-06-30"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "KEYWORDS"
          "identificador" => "xpalclavsec1582223"
          "palabras" => array:5 [
            0 => "<span class="elsevierStyleItalic">Pectus excavatum</span>"
            1 => "Nuss technique"
            2 => "<span class="elsevierStyleItalic">Pectus</span> bar"
            3 => "Bar displacement"
            4 => "Bar instability"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:2 [
        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">OBJECTIVES&#58;</span><p id="spara70" class="elsevierStyleSimplePara elsevierViewall">To compare bar displacement and complication rates in three retrospective series of patients operated on by the same surgical team&#46;</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">METHOD&#58;</span><p id="spara80" class="elsevierStyleSimplePara elsevierViewall">A retrospective medical chart analysis of the three patient series was performed&#46; In the first series&#44; the original&#44; unmodified Nuss technique was performed&#46; In the second&#44; we used the &#8220;third point fixation&#8221; technique&#44; and in the last series&#44; the correction was performed with modifications to the stabilizer and stabilizer position&#46;</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">RESULTS&#58;</span><p id="spara90" class="elsevierStyleSimplePara elsevierViewall">There were no deaths in any of the series&#46; Minor complications occurred in six &#40;4&#46;9&#37;&#41; patients&#58; pneumothorax with spontaneous resolution &#40;2&#41;&#44; suture site infection &#40;2&#41;&#44; and bar displacement without the reoperation need &#40;2&#41;&#46; Major complications were observed in eight &#40;6&#46;5&#37;&#41; patients&#58; pleural effusion requiring drainage &#40;1&#41;&#44; foreign body reaction to the bar &#40;1&#41;&#44; pneumonia and shock septic &#40;1&#41;&#44; cardiac perforation &#40;1&#41;&#44; skin erosion&#47;seroma &#40;1&#41;&#44; and displacement that necessitated a second operation to remove the bar within the 30 days of implantation &#40;3&#41;&#46; All major complications occurred in the first and second series&#46;</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSION&#58;</span><p id="spara100" class="elsevierStyleSimplePara elsevierViewall">The elimination of fixation wires&#44; the use of shorter bars and redesigned stabilizers placed in a more medial position results in a better outcome for <span class="elsevierStyleItalic">pectus excavatum</span> patients treated with the Nuss technique&#46; With bar displacement and instability no longer significant postoperative risks&#44; the Nuss technique should be considered among the available options for the surgical correction of <span class="elsevierStyleItalic">pectus excavatum</span> in pediatric patients&#46;</p></span>"
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            "titulo" => "METHOD&#58;"
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          2 => array:2 [
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            "titulo" => "RESULTS&#58;"
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            "identificador" => "ceabs40"
            "titulo" => "CONCLUSION&#58;"
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      0 => array:1 [
        "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">No potential conflict of interest was reported&#46;</p>"
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        "etiqueta" => "Figure 1"
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">A and B&#58; Examples of bar displacement&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">New positioning of the stabilizer&#46;</p>"
        ]
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        "identificador" => "fig3"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">The incidence of bar displacement in the three series&#46;</p>"
        ]
      ]
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        "identificador" => "fig4"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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            "imagen" => "gr4.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">A and B&#58; Examples of the new technique&#46;</p>"
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        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spara50" class="elsevierStyleSimplePara elsevierViewall">A&#41; One stabilizer&#44; with two different&#44; non-parallel planes between the bar and internal surface of the sternum&#46; B&#41; Two stabilizers&#44; with two different&#44; parallel planes&#46;</p>"
        ]
      ]
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="top" scope="col">Complication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">First series &#40;<span class="elsevierStyleItalic">n</span> &#61; 24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Second series &#40;<span class="elsevierStyleItalic">n</span> &#61; 47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Third series &#40;<span class="elsevierStyleItalic">n</span> &#61; 51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Pneumothorax&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">1 &#40;4&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">1 &#40;2&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Suture infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">2 &#40;8&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Pleural effusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">1 &#40;2&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Reaction to the bar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">1 &#40;2&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Skin erosion&#47;seroma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">1 &#40;4&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">1 &#40;2&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Cardiac perforation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">1 &#40;2&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top" style="border-bottom: 2px solid black">Bar displacement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">4 &#40;16&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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ISSN: 18075932
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos