An Unexpected Complication of Titanium Rib Clips

Management of non-union of rib fractures secondary to trauma: A scoping review

OBJECTIVE

Rib fracture non-union is an uncommon complication of traumatic rib fractures. Our objective was to perform a scoping review of the literature for the management of rib fracture non-union. This included analysis of the variations in surgical technique, complications experienced, and reported outcomes.

METHODS

We conducted a scoping review and searched databases (MEDLINE, CINAHL, and Embase). We performed abstract and full-text screening, and abstracted data related to pre-operative assessment, surgical technique, complications, and reported outcome measures.

RESULTS

We included 29 articles of which 19 were case reports and 10 were case series. The data quality was generally heterogeneous. The studies included 229 patients and the commonest symptoms of rib fracture non-union included chest pain, clicking, dyspnea and deformities. The patients underwent surgical management of rib fracture non-union (excluding first rib fractures) using various techniques. The majority used surgical stabilization of rib fracture with or without a graft. The reported outcomes were inconsistent between studies, but showed high rates of union (>94 %), reduction in reported VAS scores, and improved return to work when included. Implant failure occurred in 10 % of the 229 total patients reported in our studies, the re-operation rate was 13 %, and the overall complication rate was 27 %.

CONCLUSION

Surgical management of rib fracture non-union often involving locking plates and screws with or without a graft has been shown in several case reports and series as an effective treatment with acceptable implant failure and complication rates. Surgical management is therefore a viable option for symptomatic patients. Further research is required to determine optimal management strategies that further reduce surgical complications for these patients.

Spontaneous fracture of a titanium mesh cranioplasty implant in a child: A case report

BACKGROUND

Titanium mesh cranioplasty is often performed after decompressive craniectomy. Spontaneous fracture of the titanium prosthesis is an extremely rare postoperative complication. Here, we report a 10-year-old boy who presented with a spontaneous fracture of titanium mesh without antecedent head trauma.

CASE SUMMARY

A 10-year-old boy presented with a 1-wk history of a tender bulge over the left temporo-parieto-occipital scalp. He had undergone a temporo-parieto-occipital titanium mesh cranioplasty 26 mo previously. He denied antecedent head trauma. Computerized tomography disclosed a perpendicular fissure in the titanium mesh, suggesting a diagnosis of spontaneous titanium mesh fracture. He underwent a second temporo-parieto-occipital cranioplasty and made an uneventful recovery. Three-dimensional modeling and finite element analyses were used to explore potential risk factors of titanium mesh fracture.

CONCLUSION

We report a case of spontaneous fracture of a titanium mesh cranioplasty implant. The current case and literature review indicate that titanium mesh implants should be well-anchored to the base of bony defects to prevent fatigue-induced fractures.

Chest wall stabilization and rib fixation using a nitinol screwless system in selected patients after blunt trauma: long-term results in a single-centre experience

 

OBJECTIVES

First experiences with rib fixation using nitinol, in terms of reliability and morbidity, influence on pain control and quality of life (QOL), in a large series of selected patients after blunt chest trauma.

METHODS

Data of all patients who had undergone rib fixation by the use of nitinol were retrospectively analysed in terms of indications, morbidity and in-hospital mortality. Pain status and health-related QOL were assessed preoperatively, when possible, at discharge and at 1, 3, 6 and 12 months post-surgery using visual analogous scale and short form 12 questionnaires.

RESULTS

From September 2017 to April 2019, 70 patients underwent rib fixation using the nitinol device, of which 47 (67%) had dislocated, painful fractures, 6 (8.5%) had flail chest injuries, 6 (8.5%) were emergencies with haemodynamical instability and 11 (16%) had pseudoarthrosis. Morbidity was 21% without wound infection; in-hospital mortality was 3%. Fracture of the material occurred in 6% of the patients during the first year, but removal of the material was not required. Analysis of the pain score showed a statistically significant decrease in pain for both the whole collective and the group with a series of dislocated and painful fractured ribs (P < 0.001, Tukey contrast on the linear mixed-effects models). Assessment of health-related QOL revealed a significant improvement in the physical score for the mid- and long-term analysis.

CONCLUSIONS

Our results suggest that rib fixation using the nitinol device is reliable, associated with an acceptable morbidity, while significantly decreasing pain and improving health-related QOL.

Systematic Review and Meta-Analysis of Hardware Failure in Surgical Stabilization of Rib Fractures: Who, What, When, Where, and Why?

BACKGROUND

Surgical stabilization of rib fractures (SSRF) is increasingly used to reduce pulmonary complications and death among patients with rib fractures. However, the five Ws of hardware failure -who, what, when, where, and why- remains unclear. We aimed to synthesize available evidence on the five Ws and outline future research agenda for mitigating hardware failure.

METHODS

Experimental and observational studies published between 2009 and 2020 evaluating adults undergoing SSRF for traumatic rib fractures underwent evidence synthesis. We performed random effects meta-analysis of cohort/consecutive case studies. We calculated pooled prevalence of SSRF hardware failures using Freeman-Tukey double arcsine transformation and assessed study heterogeneity using DerSimonian-Laird estimation. We performed meta-regression with rib fracture acuity (acute or chronic) and hardware type (metal plate or not metal plate) as moderators.

RESULTS

Twenty-nine studies underwent qualitative synthesis and 24 studies (2404 SSRF patients) underwent quantitative synthesis. Pooled prevalence of hardware failure was 4(3-7)%. Meta-regression showed fracture acuity was a significant moderator (P = 0.002) of hardware failure but hardware type was not (P = 0.23). Approximately 60% of patients underwent hardware removal after hardware failure. Mechanical failures were the most common type of hardware failure, followed by hardware infections, pain/discomfort, and non-union. Timing of hardware failure after surgery was highly variable, but 87% of failures occurred after initial hospitalization. Mechanical failures was attributed to technical shortcomings (i.e. short plate length) or excessive force on the thoracic cavity.

CONCLUSIONS

SSRF hardware failure is an uncommon complication. Not all hardware failures are consequential, but insufficient individual patient data precluded characterizing where and why hardware failures occur. Minimizing SSRF hardware failure requires concerted research agenda to expand on the paucity of existing evidence.

An unexpected fracture of a titanium rib plate in a patient with traumatic brain injury

Surgical stabilization of rib fractures has been accepted and successfully performed for the management of patients with multiple rib fractures. Several types of devices, such as titanium bar, plate, and screws, are used for rib stabilization. Titanium devices provide a strong support for rib fixation and chest wall reconstruction and are rarely associated with complications. Herein, we report an unusual case of mechanical failure associated with a broken titanium plate. A 47-year-old man was treated with surgical stabilization of rib fractures using titanium plates after blunt trauma leading to epidural hematoma and massive hemothorax. After decompressive craniectomy, bleeding control, and rib fixation for chest trauma, he developed hyperactive delirium, which was not well controlled. On the 17 day of operation, a chest radiograph showed a broken rib plate. Surgeons who perform surgical rib stabilization should be aware that titanium plates are vulnerable to breakage under some conditions, such as hyperactive delirium.

Rib fractures in trauma patients: does operative fixation improve outcome?

PURPOSE OF REVIEW

Renewed interest in surgical fixation of rib fractures has emerged. However, conservative treatment is still preferred at most surgical departments. We wanted to evaluate whether operative treatment of rib fractures may benefit severely injured patients.

RECENT FINDINGS

Several studies report a reduction in mechanical ventilation time, ICU length of stay (LOS), hospital LOS, pneumonia, need for tracheostomy, pain and costs in operatively treated patients with multiple rib fractures compared with patients treated nonoperatively. Although patient selection and timing of the operation seem crucial for successful outcome, no consensus exists. Mortality reduction has only been shown in a few studies. Most studies are retrospective cohort and case-control studies. Only four randomized control trials exist.

SUMMARY

Conservative treatment, consisting of respiratory assistance and pain control, is still the treatment of choice in the vast majority of patients with multiple rib fractures. In selected patients, operative fixation of fractured ribs within 72 h postinjury may lead to better outcome. More randomized control trials are needed to further determine who benefits from surgical fixation of rib fractures.