Asymmetric Pectus Excavatum Is Associated with Overgrowth of Ribs Rather Than Cartilage

Abstract

Background To evaluate whether the overgrowth of costal cartilage exists in patients with pectus excavatum, we compared the length of the costal cartilage and ribs between patients with asymmetric pectus excavatum and controls without chest wall deformity using three-dimensional computed tomography.

Materials and Methods Nineteen adult patients with asymmetric pectus excavatum and 19 age and sex matched controls without chest wall deformity were enrolled. We measured the full lengths of the fourth to sixth ribs and costal cartilage using three-dimensional volume-rendered computed tomography images and curved multiplanar reformatting techniques. The lengths of ribs and costal cartilage, their summations, and the costal index ([length of cartilage/length of rib] × 100 [%]) were compared on the asymmetrically depressed side of patients (Group A), the opposite side of the same patients (Group B), and controls (Group C) at the fourth to sixth levels.

Results The lengths of the ribs of groups A and B were significantly longer (p < 0.001) than those of group C (299.4 ± 14.9 mm vs. 302.9 ± 15.3 mm vs. 288.9 ± 12.2 at the fourth level, 312.3 ± 14.1 mm vs. 318.4 ± 14.6 mm vs. 303.2 ± 12.7 mm at the fifth level, and 322.2 ± 17.2 mm vs. 325.2 ± 17.5 mm vs. 309.4 ± 12.3 mm at the sixth level). The costal cartilage lengths did not differ (p > 0.05) among the three groups (53.1 ± 7.3 mm vs. 54.6 ± 8.6 mm vs. 52.9 ± 5.2 at the fourth level, 71.9 ± 9.6 mm vs. 72.3 ± 9.9 mm vs. 69.2 ± 7.1 mm at the fifth level, and 100.1 ± 15.2 mm vs. 104.2 ± 15.8 mm vs. 99.1 ± 9.1 mm at sixth level). The summations of the rib and costal cartilage lengths were longer in groups A and B than in group C. The costal indices were not different among the three groups at the fourth, fifth, and sixth rib levels.

Conclusion In patients who had asymmetric pectus excavatum with a ≥ 21-degree angle of sternal rotations, the ribs but not the costal cartilage were longer than those of controls. These findings suggest that cartilage overgrowth is not the main factor responsible for asymmetric pectus excavatum, and it could instead be related to abnormal rib growth.

Keywords

pectus excavatum - costal cartilage - rib - three-dimensional computed tomography

• References

• 1 Dean C, Etienne D, Hindson D, Matusz P, Tubbs RS, Loukas M. Pectus excavatum (funnel chest): a historical and current prospective. Surg Radiol Anat 2012; 34 (7) 573-579
• 2 Goretsky MJ, Kelly Jr RE, Croitoru D, Nuss D. Chest wall anomalies: pectus excavatum and pectus carinatum. Adolesc Med Clin 2004; 15 (3) 455-471
• 3 Creswick HA, Stacey MW, Kelly Jr RE , et al. Family study of the inheritance of pectus excavatum. J Pediatr Surg 2006; 41 (10) 1699-1703
• 4 Willital GH, Maragakis M, Schaarschmidt K, Kerremans I. [Indications for the treatment of funnel chest]. Dtsch Krankenpflegez 1991; 44 (6) 418-423
• 5 Brochhausen C, Turial S, Müller FK , et al. Pectus excavatum: history, hypotheses and treatment options. Interact Cardiovasc Thorac Surg 2012; 14 (6) 801-806
• 6 Nakaoka T, Uemura S, Yano T, Nakagawa Y, Tanimoto T, Suehiro S. Does overgrowth of costal cartilage cause pectus excavatum? A study on the lengths of ribs and costal cartilages in asymmetric patients. J Pediatr Surg 2009; 44 (7) 1333-1336
• 7 Nakaoka T, Uemura S, Yoshida T, Tanimoto T, Miyake H. Overgrowth of costal cartilage is not the etiology of pectus excavatum. J Pediatr Surg 2010; 45 (10) 2015-2018
• 8 Egan JC, DuBois JJ, Morphy M, Samples TL, Lindell B. Compressive orthotics in the treatment of asymmetric pectus carinatum: a preliminary report with an objective radiographic marker. J Pediatr Surg 2000; 35 (8) 1183-1186
• 9 Daunt SW, Cohen JH, Miller SF. Age-related normal ranges for the Haller index in children. Pediatr Radiol 2004; 34 (4) 326-330
• 10 Haller Jr JA, Kramer SS, Lietman SA. Use of CT scans in selection of patients for pectus excavatum surgery: a preliminary report. J Pediatr Surg 1987; 22 (10) 904-906
• 11 Park CH, Kim TH, Haam SJ, Lee S. Does overgrowth of costal cartilage cause pectus carinatum? A three-dimensional computed tomography evaluation of rib length and costal cartilage length in patients with asymmetric pectus carinatum. Interact Cardiovasc Thorac Surg 2013; 17 (5) 757-763
• 12 Sandoz B, Badina A, Laporte S, Lambot K, Mitton D, Skalli W. Quantitative geometric analysis of rib, costal cartilage and sternum from childhood to teenagehood. Med Biol Eng Comput 2013; 51 (9) 971-979
• 13 Fokin AA, Steuerwald NM, Ahrens WA, Allen KE. Anatomical, histologic, and genetic characteristics of congenital chest wall deformities. Semin Thorac Cardiovasc Surg 2009; 21 (1) 44-57
• 14 Fonkalsrud EW. Current management of pectus excavatum. World J Surg 2003; 27 (5) 502-508
• 15 Desmarais TJ, Keller MS. Pectus carinatum. Curr Opin Pediatr 2013; 25 (3) 375-381
• 16 Robicsek F, Watts LT. Pectus carinatum. Thorac Surg Clin 2010; 20 (4) 563-574
• 17 Park CH, Kim TH, Haam SJ, Jeon I, Lee S. The etiology of pectus carinatum involves overgrowth of costal cartilage and undergrowth of ribs. J Pediatr Surg 2014; 49 (8) 1252-1258
• 18 Cartoski MJ, Nuss D, Goretsky MJ , et al. Classification of the dysmorphology of pectus excavatum. J Pediatr Surg 2006; 41 (9) 1573-1581
• 19 Geisbe H, Buddecke E, Flach A, Müller G, Stein U. [88. Biochemical, morphological and physical as well as animal experimental studies on the pathogenesis of funnel chest]. Langenbecks Arch Chir 1967; 319: 536-541