Journal of Indian Association of Pediatric Surgeons
Journal of Indian Association of Pediatric Surgeons
                                                   Official journal of the Indian Association of Pediatric Surgeons                           
Year : 2019  |  Volume : 24  |  Issue : 4  |  Page : 252--256

Surgical correction of pectus excavatum using a rib graft strut following excision of costal cartilages

Veereshwar Bhatnagar1, Nitin Sharma1, Anjan Dhua1, Manisha Jana2,  
1 Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Prof. Veereshwar Bhatnagar
Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi


Background: A number of techniques are described for correction of pectus excavatum (PE). This article describes the experience with an innovative procedure which combines features from the Ravitch and Nuss procedures without using prosthetic material. Methods: This cross-sectional study included 12 cases of PE from January 2000 to March 2017 managed by excision of deformed costal cartilages and support to the thoracic cage using an autologous free rib graft as a strut. Indication for surgery was Haller's Index above 3.2 with or without respiratory distress. Noncontrast computed tomography scans were done at 6 months after surgery to document the position of the strut and to see the final correction and new Haller's Index, respectively. Results: The male-to-female ratio was 2:1. Preoperative Haller's Index in all cases was >3.2 (range 3.25–14). The average age at surgery was 5 years and 8 months (range: 7 months–15 years). Mean duration of hospital stay was 11 days (range 5–16 days).The 11th rib was used commonly although in two cases, the 10th rib was used as the 11th rib was considered relatively short. Pericardial effusion requiring strut removal was seen in one case; in another case, removal of the rib was needed because of nonhealing of a delayed dehisced surgical wound. Others had an uneventful postoperative period. The mean postoperative Haller's Index was 2.75 (range 2.0–7). Conclusion: This modified procedure using an autologous rib strut is technically feasible and reproducible even with limited facilities and gives excellent results.

How to cite this article:
Bhatnagar V, Sharma N, Dhua A, Jana M. Surgical correction of pectus excavatum using a rib graft strut following excision of costal cartilages.J Indian Assoc Pediatr Surg 2019;24:252-256

How to cite this URL:
Bhatnagar V, Sharma N, Dhua A, Jana M. Surgical correction of pectus excavatum using a rib graft strut following excision of costal cartilages. J Indian Assoc Pediatr Surg [serial online] 2019 [cited 2021 Apr 20 ];24:252-256
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Pectus excavatum (PE) is the most common malformation of the anterior chest wall. This deformity is cosmetically and physiologically disturbing and in the majority of the cases is associated with psychological effects. Surgical management of PE can broadly be classified into three categories, namely, (i) extensive resection procedures, (ii) minimally invasive procedures, and (iii) correction using struts. In this report, we are describing the experience with an innovative procedure which involves limited resection of the involved costal cartilages, sternal elevation and support using autologous rib strut.


This cross-sectional study was conducted in the Department of Pediatric Surgery of a tertiary care public hospital. All the consecutive PE patients (n = 12) managed between January 2000 and March 2017 under a single pediatric surgery consultant formed the basis of the present analysis (excluding two female patients who did not give consent for an additional incision on the chest wall). Preoperative investigations included a noncontrast computed tomography (NCCT) scan of the thorax to calculate the preoperative Haller's Index, and a plain X-ray chest to select the rib to be harvested for use as a strut. A pulmonary function test and echocardiography were done in all cases to document any aberration. Those cases who presented with a cosmetically severe deformity (irrespective of the age of presentation) and a Haller'sIndex above 3.2 (moderate and severe PE) with or without respiratory distress were included. Those who refused consent for participation were excluded. The steps of the surgical procedure are depicted in [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e.{Figure 1}

Harvesting the rib to be used as a strut: The rib to be used as a strut was decided after going through the preoperative X-ray chest. The 11th rib was preferred because of its curvature. In case the 11th rib was too short, then the 10th rib was harvested. In a lateral position, an oblique incision was made just over the rib to be harvested along its longitudinal axis [Figure 1]a. The periosteum was elevated and rib harvested along the whole length; the harvested rib was then preserved in normal saline to be used as a strut. The periosteum was then closed using 3-0 polyglactin sutures followed by standard layer-wise wound closure.

Excision of the deformed costal cartilages and correction of the deformity

In a supine position, a midline incision was made to reach the sternum. At the site of maximum involvement of the costal cartilages, a subperichondrial excision of the costal cartilages was done on both sides through multiple horizontal muscle cutting incisions [Figure 1]b and [Figure 1]c. These incisions were then closed using 3-0 polyglactin sutures. Thus, following excision of the costal cartilages, the sternum could be elevated [Figure 1]c. In older children, an osteotomy of the inner plate of the sternum just below the manubrium was done using a wire saw.

Placement of the rib strut – After correcting the deformity, an extrapleural space was created under the lower part of the sternum, and the harvested rib was placed in this space as a strut to support the elevated sternum. The strut was fixed on either side with adjacent ribs using 3-0 polyglactin interrupted sutures to maintain its position [Figure 1]d. In the last 2 cases, the rib strut was placed anterior to the sternum and just under the skin, and the sternum was tied to the strut to maintain its elevated position [Figure 1]e. We have used polyglactin sutures, but appropriate nonabsorbable suture can also be used.

The skin incision was closed over a suction drain using subcuticular sutures.

The drain was removed after 48–72 h when the effluent was minimal. Analgesics were judicially used in the postoperative period. Patients were discharged once fully ambulatory. An X-ray chest was done in the 1st-week postoperatively to document the position of the strut, followed by an NCCT at 6 months to see the final correction and the change in the Haller's Index [Figure 2]. Patients were then followed up every 6 months for at least 2 years to look for any recurrence.{Figure 2}


The average age at surgery was 5 years and 8 months (range 7 months–15 years). Both the cases, mean duration of hospital stay for the procedure was 11 days (range 5–16 days). Mean follow-up was 4 years (range 6 months–13 years). The 11th rib was used as the strut in 10 cases; in two cases, 10th rib was used due to a short length of the 11th rib. All the patients required usual doses of paracetamol for the management of pain in the postoperative period.

One patient presented with dull pain in the chest after 1 month of surgery. The rib strut was found to be impinging upon the heart and causing pericardial effusion, it had to be removed. After this case, the rib strut has been placed anterior to the sternum. In another patient, there was a delayed wound infection. The wound dehisced exposing the anteriorly placed rib strut requiring removal after 8 weeks from the operation. A mild recurrence of the deformity occurred in these two cases only. The other patients did not have any early or late complications. In all patients, the rib strut was resorbed by 6 months after surgery, and the harvested rib had regrown. There was no secondary deformity.

The preoperative Haller's Index was more than 3.2 (range 3.25–14) with significant cosmetic deformity in all patients. The mean postoperative Haller's Index was 2.75 (range 2.0–7). The longest follow-up was 13 years after surgery. The change in Haller's Index is shown in [Figure 3].{Figure 3}

All the cases had an acceptable cosmetic and radiological correction in the postoperative period [Figure 4].{Figure 4}


PE and pectus carinatum are the most common chest wall deformities. PE is characterized by the posterior depression of the sternum and costal cartilages. The first and second ribs and the manubrium are usually in their normal positions, but the lower costal cartilages and the body of the sternum are depressed. PE may occur in 1 in 300–400 live births, and it occurs more frequently in boys than in girls. The male-to-female ratio is reported as 4:1.[1] Chin proposed a classification of PE deformities. Type I was defined as a localized symmetrical depression with steep walls and angulation of the costal cartilages medial to the mammary line. Type II was described as a symmetrical but diffuse depression with sloping walls and angulation on, or lateral, to the mammary line. Type III was an asymmetrical deformity, diffuse or localized, with the rotation of the sternum, usually to the left, resulting in a depression on one side and protrusion on the other side.[2] PE is characterized by a significant psychological disturbance due to the severity of the cosmetic deformity. It has been reported that cases of PE are associated with some degree of cardiorespiratory complaints; often this complaint brings the patients to a surgeon. In our experience, it was the cosmetic deformity which brought the patients to our clinic. There were no associated cardiorespiratory complaints.

A number of scoring systems have been proposed for grading the severity of PE. There have been various objective and subjective parameters used in grading the severity of the defect. Davis and Weinstein expressed the severity as a numerical expression of observer's subjective impression of severity; a scale of 1–10 was proposed, with one being barely noticeable and ten being the most severe.[3] Due to difficult reproducibility, this score did not become popular. Several authors including Welch,[4] Backer et al.,[5] Hümmer and Willital,[6] Haller et al.,[7] and Derveaux et al.[8] have created indices to quantify the deformity and to enable the comparison between the preoperative and postoperative periods more objectively. The common point that can be observed in these indices is that all of them are obtained with measurements that relate the proximity of the sternum to the thoracic vertebral column and not with the unevenness of the sternal region about the costal cartilage in the direction of the column. A modified index, known as the Hollow Index, was proposed by Actis Dato et al.; this index was the ratio between the amount of water contained in the chest depression and the body surface area. An index of >50 ml/m2 was said to indicate the presence of PE.[9] Since Haller's Index is the most commonly and widely used index, we used it in grading the severity of our cases. Haller's Index is the ratio between the maximum transverse diameter and the narrowest anteroposterior length of the chest. In the original study by Haller et al., there were 33 patients with PE and 19 normal individuals, the cutoff point observed was 3.25. Patients having index above 3.25 were classified as moderate or severe PE and were considered for surgery.[7] Daunt et al., in a study on 557 patients (where the Haller's Index was measured tomographically), showed that children under 2 years had a lower Haller's Index than older ones and that women have a higher Haller's Index than men from 0 to 6 and 12–18 years. They thus showed statistical differences regarding age and gender.[10]

Surgical management of PE can broadly be classified into three categories, namely, extensive resection procedures, minimally invasive procedures, and correction using struts. Until recently, most surgeons performed a small number of corrective operations for PE and carinatum each year; the commonly used techniques were open surgical techniques based on the early reports by Ravitch,[11] Welch,[4] and Haller et al.[12] The reported results have been inconsistent, which has often caused reluctance among referring physicians, as well as patients, especially regarding the correction of these deformities. One of the significant causes of reluctance was the extensive resection involved in these procedures and technically demanding steps. Besides this, the chances of avascular necrosis of sternum, particularly if the posterior table is divided to elevate the sternum and extensive resection is also present. With the advent of the new concept of minimally invasive PE repair reported by Nuss et al.,[13] an increase in the number of procedures performed rose suddenly due to its simplicity. Nuss procedure is a two-stage, minimally invasive approach that avoids resection of the costal cartilage. The first stage involves small bilateral incisions through which a convex metal plate is placed behind the sternum and then rotated 180 degrees to move the sternum ventrally. The second phase consists of removal of the bar, which is recommended at 2–4 years after the first phase. The most significant drawback with Nuss procedure is the requirement of an expensive Nuss bar; two-stage approach and the need of infrastructural support for the placement and removal of the bar. Fonkalsrud[14] proposed limited resection of the deformed costal cartilage instead of extensive resections, as in the Ravitch procedure to avoid Nuss bar, but this approach lacked long-term follow-up. It has also been realized that the unsupported sternum after resection of the costal cartilage may lead to the recurrence of the deformity.

Struts have been proposed since long as a support to the deformed sternum. It started with Adkins and Blades[15] who suggested the use of metallic struts in the support. Limited resection with a supporting strut is a better option because it combines the benefits of both the widely accepted techniques (resection and support). Certainly, there are limited reports on the use of struts, and most of them lack reproducibility and long-term results. Most of the structures used as struts in the past were Kirschner's wires, sewing of sternum with steel sutures, metal (stainless steel) struts, resin strut, seagull wing prosthesis, Steinman pins, Rehbein splint, a vascularized rib strut, Marlex mesh, bioabsorbable polydioxanone weave, and bioabsorbable poly-L-lactide plaque.[2],[16],[17],[18],[19],[20],[21],[22] The shortcoming of most of these techniques was the cost of the strut and the requirement of a second surgery for the removal. Besides, absorbable alternatives are very costly and not readily available. In this study, we combined the resection and support technique. Limited resection of the diseased costal cartilages was done at the site of maximum deformity. The depressed sternum was then elevated usually without osteotomy and supported posteriorly or anteriorly using an autologous subperiosteally harvested rib strut. The advantage of using such a rib strut are:

The strut required to support the elevated sternum does not cost anything and is dependableThis rib strut gets reabsorbed by 6 months, thus avoiding the need for a second operationBy 6 months, the wound has already healed, and acceptable cosmetic result is achieved before the strut gets reabsorbedRib at the donor site also regrows, and any secondary deformity is avoidedOsteotomy is avoided during elevation and thus fewer chances of secondary deformityMinimal pain and complications


Thus, using an autologous rib as strut and limited resection, we can achieve equally good cosmetic results. This technique is technically less demanding and is easily reproducible at any center even with limited facilities.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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