Original article| Volume 44, ISSUE 7, P1333-1336, July 2009

Does overgrowth of costal cartilage cause pectus excavatum? A study on the lengths of ribs and costal cartilages in asymmetric patients



      The cause of pectus excavatum has been hypothesized to be overgrowth of the costal cartilage. According to this theory, the length of costal cartilages must be longer in the side of deep depression in asymmetric patients. To challenge this hypothesis, we measured the lengths of ribs and costal cartilages and investigated lateral differences.

      Subjects and methods

      Twenty-four adolescent and adult patients with asymmetric pectus excavatum (14-30 years of age) with no history of surgery were investigated in this study. The fifth and sixth ribs and costal cartilages were individually traced to measure their full lengths on 3-dimensional computed tomographic (CT) images. As an index of asymmetry, sternal rotation angle was measured in the chest CT images. Patients with a 21° or greater angle of sternal twist were designated as an asymmetric group and those with an angle of smaller than 20° as a symmetric group. Lateral differences in the fifth and sixth costal and costal cartilage lengths were compared between the groups.


      On comparison of the costal and costal cartilage lengths in the asymmetric group, the right fifth ribs and costal cartilages were significantly shorter than the left (P = .02 and .03, respectively), and right sixth ribs were also significantly shorter than the left (P = .004), but right sixth costal cartilages were not (P = .31). In the symmetric group, the lengths of the left and right fifth ribs and costal cartilages were showing no significant difference (P = .20 and P = .80, respectively), and those of the sixth ribs and costal cartilage were also showing no significant difference (P = .97 and P = .64, respectively).


      The ribs and costal cartilages on the right side with severer depression were significantly shorter or not different than those on the contralateral side. Based on these findings, the theory of costal cartilage overgrowth is contradictory.
      The etiology of asymmetric chest deformity should be reevaluated.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Pediatric Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Sweet R.H.
        Pectus excavatum.
        Ann Surg. 1944; 119: 922-934
        • Haller Jr, J.A.
        • Kramer S.S.
        • Lieteman S.A.
        Use of CT scans in selection of patients for pectus excavatum.
        J Pediatr Surg. 1987; 22: 904-908
      1. Bauhinus, Joh Observatoinum Medicarim. Francfurti, Liver II, Observ 1600 264:507.

      2. Ebstein, E. Zur Geschicte der familiaren Trichterbrust. Deutsche med. Wchnschr 1921;47:1070.

        • Brown A.L.
        Pectus excavatum.
        J Thorac Surg. 1939; 9: 164
        • Grieg J.D.
        • Azmy A.F.
        Thoracic cage deformity: a late complication following repair of an agenesis of diaphragm.
        J Pediatr Surg. 1990; 25: 1234
        • Rupperecht H.
        • et al.
        Pathogenesis of the chest wall deformities—electron microscope studies and analysis of trace elements in the cartilage of the ribs.
        Z Kinderchir. 1987; 42: 228
        • Kasai Y.
        • Takegami K.
        • Uchida A.
        Length of the ribs in patients with idiopathic scoliosis.
        Arch Orthop Trauma Surg. 2002; 122: 161-162
        • Normelli H.
        • Sevastik J.
        • Akrivos J.
        The length and ash weight of the ribs of normal and scoliotic persons.
        Spine. 1995; 10: 590-592