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in normal anatomy of the chest , the sternum and the whole anterior chest wall form the most anterior part of the body .
pectus excavatum is a condition in which the lower part of the sternum and the adjoining rib segments are sunken into the chest [ 13 ] .
the displacement of the sternum and ribs in the direction of the vertebral column reduces the anteroposterior dimension of the chest ; as a result , the vital capacity of the lungs is reduced , which contributes to the development of disorders of the circulatory and respiratory systems .
these changes are a frequent cause of recurrent bronchitis and pneumonia , dyspnea , and fatigability .
the condition may be acquired as a result of inflammatory processes and rachitis ; its congenital form ( 5% ) may be associated with impairments in the development of the diaphragm or disproportionate growth of the costal cartilages .
there is no evidence indicating that rehabilitation can slow the development of the deformation or reverse it ; the only effective method of treatment is surgery .
the aim of the study is to present the case in which pectus excavatum recurred and was treated with two methods of surgical repair ; good results of respiratory rehabilitation were achieved , which significantly contributed to the improvement of the patient 's general and respiratory fitness .
in 2000 , at the age of 7 , the patient underwent repair of the chest deformity using the ravitch method at the lower silesian center for lung diseases in wrocaw .
however , during the period of the boy 's quickened growth between the ages of 15 and 17 , the deformation began to recur , and the chest 's anatomy deteriorated systematically .
after he turned 20 , examinations showed that the lower part of his sternum , sunken inwards , was displaced dangerously close to the spine ( fig .
the patient underwent a redo procedure in order to repair the recurrent chest deformity , which had first been repaired using the ravitch method ( fig .
section through the patient 's thorax : pectus excavatum the patient prepared for the surgery the surgery was performed using a modified nuss procedure .
as the operators dissected the hard fibrous tissue , the anterior surface of the mesosternum was uncovered .
next , the medial segments of the 3 , 4 , and 5 intercostal spaces were uncovered bilaterally .
the dissection was performed under visual control using a thoracoscopic camera introduced into the intercostal spaces at the axillary line .
3 ) . skin on both sides of the chest was incised between the anterior and middle axillary lines , at the level of the 4 intercostal spaces .
bilaterally , two tunnels were formed under the muscles of the chest wall , at the level of the 3 and 5 intercostal spaces ( fig .
the sternum was raised on two thick sutures two implants were embedded under the sternum during the dissection , the right internal thoracic artery was injured .
the bleeding was stopped with sutures , and the bleeding site was monitored with a thoracoscope .
two implants were modelled ( 32 and 36 cm in length ) and placed under the sternum . concurrently
, both implants were twisted under the mesosternum . at the level of the 3 intercostal space , a lateral fissure was observed in the mesosternum .
after the implants were screwed into position , the cosmetic effect of the chest repair was very good .
a redon drain was placed on the floor of the sternal wound ; the wound was closed with a layered suture and covered with sterile dressing .
the patient was discharged from the lower silesian center for lung diseases in wrocaw in good general condition ; he was advised to report to his local surgery clinic for a postoperative control examination and suture removal .
the patient was to report back to the center after 2 - 3 years in order to plan the second stage of the procedure 
thoracic x - ray of the 21-year - old patient after ravitch and nuss procedures after the thoracic procedure , the patient received postoperative advice . during the first 3 postoperative months
the patient adhered to the postoperative recommendations ; over the next 8 weeks , he limited physical activity to the minimum and tried to make all upper extremity movements in symmetry . during the same year , on 16 october , the 21-year - old patient was admitted to the physiotherapy unit of the subcarpathian center for pulmonary diseases in rzeszw .
ultrasonographic examination of the patient 's chest revealed no postoperative complications ; however , when spirometry was performed , the results were unsatisfactory , which was in line with the information obtained from the patient during an interview .
he reported fatigability even during little exertion and significantly reduced strength . according to the results of the spirometric examination performed before the start of the rehabilitation process , his forced vital capacity ( fvc )
was limited to 48% , forced expiratory volume in 1 second ( fev1 ) was reduced to 55% , and the fev1/fvc ratio amounted to 116% .
additionally , a voldyne 5000 device was used to measure his inspiratory volume . according to the patient characteristics ( age , height , sex ) ,
the result should fall within the range of 3600 ml / min on the nomogram .
further physiotherapeutic examination demonstrated that the patient 's head jutted forward , his shoulders slouched and jutted forward , and the shoulder blades were protruding .
moreover , the anteroposterior dimension of the flattened chest was reduced , and the shoulder girdle was contractured . additionally , the stretching of the dorsal muscles ( the trapezius , rhomboid , latissimus dorsi ) contributed to the development of thoracic hyperkyphosis , a defect also known as round back .
the chest muscles were excessively tense , while the abdominal muscles demonstrated excessive flaccidity , which led to the impairment of breathing ( fig .
patient 's position assumed in order to protect the surgical site the patient was offered a personalized rehabilitation program aimed to improve the fitness of his circulatory and respiratory systems and to correct his posture .
three fundamental aspects were addressed by the therapeutic proceedings : morphological : to eliminate muscle dystonia and strengthen the muscular corset , physiological : to teach the patient to adopt the correct posture and form the habit of maintaining it , environmental : to ensure that the patient 's life conditions are conducive to eliminating the defect . 
 
morphological : to eliminate muscle dystonia and strengthen the muscular corset , physiological : to teach the patient to adopt the correct posture and form the habit of maintaining it , environmental : to ensure that the patient 's life conditions are conducive to eliminating the defect .
the occurrence of muscle contractures limited the mobility of the patient 's joints and precluded him from assuming the proper posture . the first step to eliminate
the dystonia was to stretch the muscles and restore full joint mobility . when stretching the muscles ,
the following rules were observed : during the initial stage of the stretching , the exercise consisted mostly in passive stretching , the direction of stretching movements addressed the functional structure of the muscles , when a muscle was stretched , moving one of its attachments further away , the other attachment site was stabilized . 
  during the initial stage of the stretching ,
the exercise consisted mostly in passive stretching , the direction of stretching movements addressed the functional structure of the muscles , when a muscle was stretched , moving one of its attachments further away , the other attachment site was stabilized . reducing the contractures of the thoracic muscles and the serratus anterior enabled the patient to assume the proper posture . improving
the posture began with partial / local corrections ( adjusting the position of the head , moving back the shoulder girdle , reducing thoracic kyphosis , expanding the chest ) , which were later combined to achieve holistic / global correction .
initially , the exercises were limited to positions that freed the vertebral column from axial compression ( with the patient lying down or kneeling on his hands and knees ) ; gradually , sitting and standing exercises were introduced as well .
this allowed the patient to control his posture first by adhering to a stable surface ( floor , walls ) , then by visual control using a mirror , and finally using proprioception . to strengthen the weakened muscles , exercises in the trained corrected position were employed .
the corrected position was maintained throughout the duration of the exercise , and the use of resistance ( thera - band resistance bands ) did not result in the loss of correction ( fig .
the aim of these exercises was for the patient to learn how to breathe by increasing the vital capacity of the lungs ( fig .
9 ) , to strengthen his respiratory muscles , and to increase the mobility of the chest during thoracic and diaphragmatic breathing , especially during inspiration ( raising the ribs up and forward ) .
systematic exercise and ergometer training allowed the patient to develop the habit of assuming the proper posture during exercises . in terms of morphology ,
the mobility of the shoulder joints was increased , as was the strength of the dorsal , abdominal , and other postural muscles .
kinesitherapy with thera - band resistance bands breathing exercises aimed at increasing thoracic mobility during thoracic and diaphragmatic breathing breathing and strengthening exercises in a closed system after the conclusion of the rehabilitation program , conducted at the subcarpathian center for pulmonary diseases in rzeszw and lasting 4 weeks , spirometry was repeated .
fev1 was 77% ( an increase of 22% ) , while the fev1/fvc ratio amounted to 103% ( a decrease of 13% ) .
the result , 3150 ml / min , indicated an improvement of 850 ml / min . selected spirometric values obtained before and after the rehabilitation process
surgical treatment for pectus excavatum is a complex process requiring the cooperation of a medical team .
the introduction of a new complex surgical method increased interest in the treatment , primarily due to cosmetic considerations and the visual effect after the procedure .
according to scientific reports , 81.4% of patients report for the procedure due to cosmetic reasons and low self - acceptance . despite the pain associated with the presence of the implants , persisting for up to several months
, the patients view the impact of the procedure on their quality of life as favorable , as demonstrated in a study by krasopoulos et al . .
concurrently , the literature includes reports in which treatment with the combined methods was followed by reduced spirometric parameters and negative electrocardiography changes . a study by dzielicki et al
. demonstrated the occurrence of electrocardiographic changes in 60% of cases and spirometric changes in 38% of patients . in his report , adamczyk observed reduced vc and fev1 .
pectus excavatum is characterized by a reduction in the sagittal dimension of the chest , often accompanied by a displacement of the heart to the left , resulting in the occurrence of exercise tachycardia . a study on the postoperative functioning of the lungs and the circulatory system after the surgical repair of pectus excavatum by malek et al . demonstrated a statistically significant influence of the procedure on selected circulatory parameters and no such influence on spirometric values .
the literature lacks results concerning the effects of postoperative rehabilitation in patients undergoing combined nuss and ravitch procedures .
there is no unequivocal evidence that rehabilitation has an impact on the reduction of the chest defect .
after the conclusion of the rehabilitation program , performed by a 21-year - old patient who had undergone surgery using the ravitch and nuss methods , the patient 's spirometric parameters and general fitness improved significantly . surgical treatment for pectus excavatum
this patient group is characterized by stronger will to engage in everyday physical activity . however , after the surgery , these patients are faced with safety procedures limiting their ability to engage in physical work or participate in sports .
proceeding in accordance with the postoperative guidelines leads to a reduction in their fitness . in turn , failing to adhere to the postoperative guidelines increases the risk of complications , of which the most frequent include : implant displacement , pneumothorax , and wound inflammation .
the presented method of rehabilitation should find a wider application in comprehensive treatment provided for pectus excavatum .
apart from surgical repair , it should include pre- and postoperative rehabilitation and analgesic pharmacotherapy .
the rehabilitation process should address the individual condition and fitness of the patient , obliging the physiotherapist to conduct a personalized program based on spirometric results .
rehabilitation may be helpful in the prevention of complications associated with the treatment of patients with pectus excavatum who are subjected to surgery using the ravitch and nuss methods . 
 this paper presents the case of a patient who underwent successful physical rehabilitation after 8 weeks from the surgery using the combined method . as part of the nuss procedure , 
 two plates were implanted to form a scaffolding for the patient 's chest , which had previously been corrected with the ravitch method . 
 the plates were to be removed after 24 months of treatment . 
 after the procedure , in spite of the favorable cosmetic effect of the repair , there was a significant decrease in the spirometric values and physical fitness of the patient . 
 he underwent an individual physiotherapy program , which lasted four weeks . 
 the streamlining of the respiratory system has significantly improved the spirometric values and raised the overall performance of the patient 's organism .