The surgical stabilization of multiple rib fractures using titanium elastic nail in blunt chest trauma with acute respiratory failure

Clinical effect of the internal fixation for rib fracture with single utility port complete video-assisted thoracoscopic surgery

BACKGROUNDS

The internal fixation for rib fracture with single-operation-port (two ports) complete video-assisted thoracoscopic surgery (VATS) is a promising surgical approach for treating multiple rib fractures. The study aimed to investigate the minimally invasive surgical procedure's clinical effect in treating multiple rib fractures.

METHODS

Seventy-three patients with multiple rib fractures were divided into two groups according to surgical procedure. In the study group, 42 patients were operated on with the internal fixation of rib fracture with single-operation-port complete VATS. In the control group, this study performed the open operative internal fixation for rib fracture with traditional thoracotomy on 31 patients. The surgical-related indexes were retrospectively analyzed. These included the operative time, the intraoperative blood loss, the drainage amount of the chest tube, the placement time of the chest tube, the postoperative hospital stay, the incidence of postoperative complications, the imaging efficacy of rib fixation of rib fractures, and visual analog scale of pain scoring (VAS scoring).

RESULTS

There was no difference in the operative time between the study and control groups (P = 0.806). The intraoperative blood loss, the chest tube drainage amount, the chest tube placement time, the postoperative hospital stay, and the incidence of postoperative complications in the study group were lower than those in the control group (P < 0.05). There was no significant difference in the imaging efficacy of rib fixation of rib fractures between the two groups (P = 0.806). VAS scores in the study group on the seventh postoperative day were significantly reduced compared with the control group (P = 0.026).

CONCLUSION

The internal fixation for rib fractures with single-operation-port complete VATS is a feasible, safe, simple, and minimally invasive surgical procedure to treat multiple rib fractures, which is worthy of clinical application.

Surgical stabilization of multiple rib fractures in an Asian population: a systematic review and meta-analysis

Background

There is no consensus on the effectiveness of surgical stabilization in multiple rib fractures in Asia, especially among patients with a non-flail rib fracture pattern. We aim to synthesize the evidence on the effectiveness of surgical stabilization of rib fractures (SSRF) in an Asian population with multiple non-flail rib fractures.

Methods

The MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews were searched in this systematic literature review and meta-analysis to identify studies conducted in Asia that included patients with multiple non-flail rib fractures in at least one of their treatment groups. The intervention of interest was SSRF, and the comparator was a nonoperative treatment. The duration of mechanical ventilation (DMV) was the primary outcome. Posttreatment pain score, pneumonia, atelectasis, intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), need for tracheostomy, respiratory function, functional outcomes, quality of life (QoL), and mortality were identified as the secondary outcomes. A random effects model (REM) was used to pool data for outcomes reported in two or more studies.

Results

A total of 12 studies (n=2,440 patients) were included. There was a significantly shorter DMV {mean difference (MD): -5.23 [95% confidence interval (CI): -9.64 to -0.81], P=0.02}, lower 4-week post-treatment pain score [standard mean difference (SMD): -2.24 (95% CI: -3.18 to -1.31), P<0.00001], lower risk for pneumonia [risk ratio (RR): 0.46 (95% CI: 0.23 to 0.95), P=0.04], lower risk for atelectasis [RR: 0.44, (95% CI: 0.29 to 0.65), P<0.0001], shorter ICU LOS [MD: -4.00 (95% CI: -6.33 to -1.66), P=0.0008], and shorter HLOS [MD: -6.54 (95% CI: -9.28 to -3.79), P<0.00001] in favor of SSRF. Effect estimates for the need for tracheostomy [RR: 0.67 (95% CI: 0.42 to 1.08), P=0.10] and mortality [RR: 0.94 (95% CI: 0.37 to 2.41), P=0.90] were nonsignificant.

Conclusions

In the Asian population with mainly non-flail rib fracture patterns, SSRF was associated with shorter DMV, ICU LOS, and HLOS as well as lower risks for atelectasis and pneumonia, and pain scores after 4 weeks. The risk of mortality was comparable between treatment groups.

Stabilization of the floating sternocostal segment of the chest with multiple bilateral fractures of the ribs and the manubrium of the sternum

Among patients with floating rib fractures without pneumo- and hemopneumothorax or after their elimination, the most severe disorders of ventilation and circulation occur in patients with multiple bilateral rib fractures and a fracture of the sternum manubrium with the formation of a floating sternocostal segment of the chest. At the same time, the suction aero- and hemodynamic function of the chest is disturbed, there is pressure on the heart and large vessels. As a result, the efficiency of external respiration progressively decreases, the respiratory muscles are exhausted, which requires an urgent transfer to artificial ventilation of the lungs. The article presents a clinical case of successful treatment of such a chest injury using the author’s technique (Patent No. 2621871 of the Russian Federation). The extrathoracic silicone reinforced splint has two horizontal branches that go around the mammary glands. The splint is attached to the floating sternocostal segment with ligatures passed behind the sternum and laterally – to stable sections of the ribs along the posterior axillary line on both sides. The tire reliably holds the sternocostal segment from paradoxical movements. The tire is removed after 3  weeks. By this time, fibrous calluses are formed in places of fractures of bones and cartilage, and the swelling of the chest wall subsides. Superficial bedsores in the places of fixation of the splint are epithelialized under the scab within 7–8 days. The patient was examined a year later, her condition was satisfactory, she had no complaints, there was no chest deformity. The technique is less traumatic, it is indicated for patients with polytrauma and in other cases. 

Operative versus nonoperative treatment of multiple simple rib fractures: A systematic review and meta-analysis

PURPOSE

Surgical rib stabilization in flail chest is proven to be beneficial over nonoperative treatment in terms of rate of pneumonia, Intensive Care (IC) length of stay (ICLOS) and mechanical ventilation days. The aim of this systematic review and meta-analysis was to evaluate the effect of operative versus nonoperative treatment on the occurrence of pneumonia and other relevant clinical outcomes in patients with multiple simple rib fractures.

METHODS

A search was performed in Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar. The primary outcome was the occurrence of pneumonia. Secondary outcomes were duration of mechanical ventillation, ICLOS, hospital length of stay (HLOS), mortality, and wound infections. Publication bias was assessed using funnel plots for the outcome measures and random-effect models were used when heterogeneity of data on outcome measures was significant (I²≥40%).

RESULTS

The search resulted in 592 unique records, of which 14 studies on 13 cohorts were included. The 14 studies comprised five prospective and nine retrospective cohort studies with a cumulative total of 4565 patients. Meta-analysis showed a significant decrease of the occurrence of pneumonia (n=2659 patients; risk ratio, RR=0.66; 95% confidential interval [CI] 0.49 to 0.90; p=0.008), mortality (n=4456 patients; RR=0.32; 95% CI 0.19 to 0.54; p<0.001), and HLOS (n=648 patients; mean difference, MD=-5.78 days; 95% CI -10.40 to -1.15; p=0.01) in favor of operative treatment. No effect of operative treatment was found for the duration of mechanical ventilation (n=113 patients; MD=-6.01 days; 95% CI =-19.61 to 7.59; p=0.39), or ICLOS (n=524 patients; MD=-2.93 days; 95% CI -8.65 to 2.80; p=0.32). The postoperative wound infection rate ranged from 0 to 9.4%.

CONCLUSION

Surgical treatment of multiple simple rib fractures may result in a significant reduction of pneumonia, mortality, and hospital length of stay. A reducing effect of treatment on the duration of mechanical ventilation and IC length of stay, was not demonstrated. However, due to nonstandard or absent definitions of outcome measures as well as heterogenous patient groups and the observational design of studies, results must be interpreted with caution and high-quality studies are needed.

Facilitating ventilator weaning through rib fixation combined with video-assisted thoracoscopic surgery in severe blunt chest injury with acute respiratory failure

Background

Severe blunt chest injury sometimes induces acute respiratory failure (ARF), requiring ventilator use. We aimed to evaluate the effect of performing rib fixation with the addition of video-assisted thoracoscopic surgery (VATS) on patients with ARF caused by blunt thoracic injury with ventilator dependence.

Methods

This observational study prospectively enrolled patients with multiple bicortical rib fractures with hemothorax caused by severe blunt chest trauma. All patients received positive pressure mechanical ventilation within 24 h after trauma because of ARF. Some patients who received rib fixation with VATS were enrolled as group 1, and the others who received only VATS were designated as group 2. The length of ventilator use was the primary clinical outcome. Rates of pneumonia and length of hospital stay constituted secondary outcomes.

Results

A total of 61 patients were included in this study. The basic demographic characteristics between the two groups exhibited no statistical differences. All patients received operations within 6 days after trauma. The length of ventilator use was shorter in group 1 (3.19 ± 3.37 days vs. 8.05 ± 8.23, P = 0.002). The rate of pneumonia was higher in group 2 (38.1% vs. 75.0%, P = 0.005). The length of hospital stay was much shorter in group 1 (17.76 ± 8.38 days vs. 24.13 ± 9.80, P = 0.011).

Conclusion

Rib fixation combined with VATS could shorten the length of ventilator use and reduce the pneumonia rate in patients with severe chest blunt injury with ARF. Therefore, this operation could shorten the overall length of hospital stay.

Current status and research progress of minimally invasive surgery for flail chest

Chest trauma accounts for ~13.5% of all traumas, and direct death from chest trauma accounts for 20–25% of all traumatic deaths. Chest trauma is the second cause of death from trauma. Frequent rib fractures, especially in patients with flail chest, often cause severe pain, chest wall softening, abnormal breathing and severe lung contusion and laceration, usually requiring thoracic surgery. In recent years, the open reduction and internal fixation treatment of rib fractures with flail chest has achieved satisfactory results, and some surgical indications have reached consensus. A number of scholars and medical centers have demonstrated the practicality and cost-effectiveness of rib fixation in flail chest, including the small incidence of pulmonary complications, the short ICU mechanical ventilation time, and the reduction of digestive tract inhibition. Open reduction and internal fixation of rib fractures involves multiple ribs. Conventional rib fractures require a large incision to achieve satisfactory exposure. Chest wall muscles, blood vessels and nerves (long thoracic and thoracodorsal nerves) are injured, resulting in a high infection rate of the incision and postoperative dysfunctions, such as limited upper limb, shoulder and back function, and long time numbness on the affected side of the chest. Therefore, the damage of muscles and nerves caused by conventional surgical methods limits the development of such surgical technique. Although the video-assisted thoracoscopic technique has become a necessary technical means for the treatment of thoracic trauma and has been applied to thoracic exploration and hemostasis, there is no report on the application of open reduction and internal fixation for rib fracture. The difficulty lies in the tightly combined bony thorax and the soft tissue of the chest wall. Therefore, experts have explored a variety of minimally invasive surgical methods for the flail chest. The current status and research progress of minimally invasive surgery for thoracic surgery are reviewed.

A new instrument for surgical stabilization of multiple rib fractures

Objective

Rib fixation is an effective treatment for patients with multiple rib fractures. We retrospectively evaluated the application of a four-claw titanium plate in patients with rib fractures.

Methods

Fifty-four patients treated for multiple rib fractures in our hospital from 2012 to 2016 were divided into a surgery group (n = 27) and conservative treatment group (n = 27). The patients’ age, sex, cause of fracture, Injury Severity Score, chest Abbreviated Injury Scale score, number of ventilator days, and length of hospitalization were recorded.

Results

The mean duration of mechanical ventilation was 4.5 ± 0.7 and 7.9 ± 1.7 days in the surgery and control group, respectively, with a significant difference. The length of intensive care unit stay was also significantly different between the groups (5.9 ± 0.6 vs. 10.6 ± 1.9 days, respectively). The length of hospital stay and recovery time to regular life in the surgery and control group were 11.5 ± 1.9 and 3.9 ± 4.0 days and 38.2 ± 8.3 and 60.8 ± 12.1 days, respectively, both with significant differences.

Conclusion

A four-claw titanium plate is valuable for patients with multiple rib fractures, allowing easy fixation of broken ribs beneath the scapula, even the second rib.

Thoracoscope and thoracotomy in the treatment of thoracic trauma

Objective:

To compare clinical effects of thoracoscopic surgery and thoracotomy in the treatment of thoracic trauma.

Methods:

Two hundred and fourteen patients with thoracic trauma were randomly divided into a control group and an observation group, 107 in each group. The control group was treated with conventional thoracotomy, while the observation group was treated with thoracoscopic surgery. The operation-related indications, hospitalization, postoperative complications and inflammatory factor level were observed and compared between the two groups. The study was conducted from April 2016 to February 2018.

Results:

The duration of operation of the observation group was shorter than that of the control group, the amount of bleeding during operation of the observation group was less than that of the control group, and the postoperative visual analogue score (VAS) of the observation group was lower than that of the control group; the difference were statistically significant (P<0.05). The hospitalization time, time of off-bed activity and time of resuming daily life of the observation group were shorter than those of the control group, and the amount of drainage fluid of the observation group within 24 hours after operation was less than that of the control group; the differences had statistical significance (P<0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P>0.05). The levels of C-reactive protein (CRP), tumor necrosis factor (TNF)-a and interleukin (IL)-6 in both groups after surgery were higher than those before surgery, but the indicators in the observation group were lower than those in the control group (P<0.05).

Conclusion:

Thoracoscopic surgery can reduce pains of patients, speed up recovery, and reduce incidence of surgical infection in the treatment of thoracic trauma. It is a safe and effective treatment method, which is worth clinical application.

Rib soft fixation produces better analgesic effects and is associated with cytokine changes within the spinal cord in a rat rib fracture model

Traumatic rib fracture can cause severe pain and is usually associated with the depression of respiratory drive followed by severe respiratory complications. It is critical for patients with rib fracture to receive adequate analgesia. However, strong opioids and other analgesics often produces side effects and may even cause respiratory suppression. Meanwhile, rib fixation now has become a popular method for treating rib fracture patients. However, the actual molecular mechanism leading to its effectiveness as an analgesia has not been fully investigated, and the best analgesic method for its use in rib fracture patients has not yet been determined. We developed a new animal model for rib fracture and evaluated changes in pain severity after rib fixation. Our data indicated significantly better analgesic behavior if a soft string rib fixation is performed, which is associated with cytokine (interleukine-6 and interleukine-10) decreases in the spinal cord and co-localization with glia cells. Our results provided a treatment suggestion for rib fracture patients and the possible molecular mechanism for the analgesic effects. Further molecular mechanisms and the best therapeutic methods are still needed for this severe painful condition.

Comparison of the Effectiveness of Surgical Versus Nonsurgical Treatment for Multiple Rib Fractures Accompanied with Pulmonary Contusion

Objective: To compare the effectiveness of surgical versus nonsurgical treatment for multiple rib fractures accompanied with pulmonary contusion.

Methods: The clinical records of consecutive 167 patients with multiple rib fractures accompanied with pulmonary contusion, who were treated from June 2014 to June 2017, were retrospectively analyzed. Of them, 75 and 92 underwent surgery (surgery group) and non-surgical treatment (non-surgery group), respectively. Patient pain score, complications, length of hospital stay, cost of hospitalization, and post-treatment 3-month follow-up results were compared.

Results: The mean number of days and moderate pain in the surgery group was significantly lower than that of the non-surgery group (p <0.01). The incidence of post-treatment complications was significantly lower in the surgery group than in the non-surgery group. The length of hospital stay of the surgery group was also significantly shorter than that of the non-surgery group (p <0.01). The cost of hospitalization was significantly higher in the surgery group than in the non-surgery group (p <0.01). The chest computed tomography (CT) scan which was performed 3 months after the treatment revealed that the surgery group had a better recovery than the non-surgery group. Physical recovery of the surgery group was also significantly better than that of the non-surgery group.

Conclusion: Surgery to treat multiple rib fractures (≥ 4 fractures) accompanied with pulmonary contusion is safe and effective.

Recent advances in rib fracture fixation

As a means of treating rib fractures, surgical stabilization of rib fractures (SSRF) has been carried out sporadically for nearly 100 years. However, with the recent advent of new materials and technologies suitable for SSRF, the developmental rate and data concerning SSRF have increased greatly. The main manifestations of these advancements include the improvement of the preoperative localization method by combining CT scanning with three-dimensional reconstruction technology and ultrasound application to accurately locate fractures. The bone fracture plate is specifically used for rib fixation, and the intramedullary fixation devices and special SSRF tools make SSRF relatively simple. The application of 3D printing technology can accurately reproduce the anatomical shape of the fracture site under in vitro conditions before operation and combine with the internal fixation of chest wall, especially the thoracoscopy-assisted internal fixation of the chest wall, to achieve the minimally invasive internal fixation of the rib fracture. Absorbable internal fixation materials and thoracoscopic SSRF are considered the primary future research directions.

The advantages of adding rib fixations during VATS for retained hemothorax in serious blunt chest trauma - A prospective cohort study

BACKGROUND

Serious blunt chest trauma usually induces hemothorax, pneumothorax, and rib fracture. Early video-assisted thoracoscopic surgery (VATS) to evacuate retained hemothorax is one commonly used treatment. In this study, a new strategy was implemented to combine VATS with fractured rib fixation simultaneously.

METHODS

This prospective observational study was performed from January 2013 to April 2018. All patients were aged 18 years or older and had blunt chest trauma with displaced fractures in more than three ribs. No patients had acute respiratory failure within 24 h after trauma. Patients with retained hemothorax who received VATS constituted the study cohort. Subsequently, patients who received rib fixation during VATS procedures were compared with those who did not. Clinical outcomes such as dose of analgesics, and length of hospital stay were recorded.

RESULTS

During the study period, 128 patients were enrolled. Available demographic characteristics of the 2 groups were compared, and no statistical differences were observed. The rates of shorter temporary ventilator dependence after operations were lower in the rib fixation group (0% vs. 24.7%, P = 0.017). Persistent air leakage more than 5 days after operations were also lower in the rib fixation group (0% vs. 10.4%, P = 0.001). The length of stay in overall hospital stay were longer for patients who received VATS without rib fixation (9.29 ± 2.51 days vs. 12.39 ± 4.65, P = 0.001). Furthermore, the rib fixation group were administered much lower doses of opiates during their hospital stays (52.45 ± 15.67 mg vs. 77.24 ± 50.42 mg, P = 0.001).

CONCLUSION

Adding rib fixation during VATS in the management of retained hemothorax can contribute to shorten whole treatment courses. Rib fixation can also reduce pain, thus reducing dependence on analgesics.

The beneficial application of preoperative 3D printing for surgical stabilization of rib fractures

Objectives

The beneficial application of three-dimensional (3D) printing for surgical stabilization of rib fractures (SSRF) has never been proposed in the literature before. The aim of this study was to verify patients’ surgical outcomes when utilizing preoperative three-dimensional printing for SSRF.

Methods

We retrospectively reviewed the records of all consecutive patients who were treated at our hospital for SSRF from July 2015 to December 2017. The patients were divided into two groups according to whether or not 3D printing was utilized.

Results

Forty-eight patients who underwent SSRF at our hospital were enrolled. Of them, three patients underwent bilateral surgeries. The patients with application of preoperative 3D printing for SSRF had statistically significant associations with shorter operation time per fixed plate (p < 0.001), and a smaller incision length (p < 0.001).

Conclusions

We present an useful technique involving 3D printing for promoting SSRF significantly with shorter operation time and an appropriate incision length.

Surgical plate fixation of multiple rib fractures: a case report

Background

The healthcare system in developing countries is limited; particularly, medical specialties such as emergency and trauma medicine are underdeveloped. Consequently, trauma injuries sustained in traffic accidents result in chronic morbidity more often than similar cases in developed countries. Multiple rib fractures induce significant patient morbidity. Current international guidelines recommend a multidisciplinary, surgery-based treatment approach to achieve optimal clinical benefit.

Case presentation

We admitted a 41-year-old Albanian man to our emergency department following a pedestrian-vehicle accident 5 days earlier. He presented with severe upper thoracic pain, chest deformity, dyspnea, tachycardia, subcutaneous emphysema, and hematoma. Chest radiography pointed to hypoventilated lung fields and a minor pleural effusion. Computed tomographic scans indicated displaced fractures of right lateral ribs 5 –11, hyperdensity regions from bone fragments, and pulmonary contusion. The treatment consisted of surgical fixation of ribs 7–10 using titanium reconstruction plates and cortical locking screws. The patient’s clinical condition rapidly improved postoperatively. Follow-up at 6 weeks confirmed a full return to preoperative daily activities and a high quality of life.

Conclusions

In this case report, we present a novel and promising development in the field of trauma medicine in the Republic of Macedonia. Trauma injuries can be treated via advanced multidisciplinary medical care according to international standards, allowing optimal health recovery.

Open reduction and internal fixation of rib fractures in polytrauma patients with flail chest

BACKGROUND

Open reduction and internal fixation (ORIF) of fractured ribs for flail chest is safe and effective but who is most likely to benefit is unknown. Our purpose is to compare ORIF with nonoperative management (NOM) in polytrauma patients.

METHODS

Albany Medical Center Hospital Trauma Registry was queried for adult patients with flail chest admitted over 7 years.

RESULTS

Eighty-six patients with radiographic flail chest were identified who met inclusion criteria. The 41 ORIF and 45 NOM patients had similar demographics and injury severity. Hospital length of stay and intensive care unit length of stay were significantly longer in the ORIF group than that of the NOM group. There was a trend toward longer time on the ventilator in the ORIF group.

CONCLUSIONS

In this retrospective study, patients treated by ORIF had longer hospitalization and ventilator duration. Future studies should be designed to optimally identify patients who are most likely to benefit from ORIF.