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Kavaklı K, Işık H, Şengül İnan M, Sapmaz E, Yeniköy M, Ünsal U, Kılınç D, Çaylak H. Should wide chest wall resections and reconstruction intimidate thoracic surgeons? TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2024; 32:195-201. [PMID: 38933314 PMCID: PMC11197412 DOI: 10.5606/tgkdc.dergisi.2024.25804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/11/2024] [Indexed: 06/28/2024]
Abstract
Background This study aimed to compare patients in whom wide chest wall resection and reconstruction or primary closure was performed. Methods A total of 63 patients who underwent chest wall resection and reconstruction between January 2018 and December 2022 were included in the retrospective study. The patients were divided into two groups: the first group, which included 31 patients (14 males, 17 females; mean age: 44.6±16.4 years; range, 16 to 71 years) who were closed primarily, and the second group, constituting 32 patients (25 males, 7 females; mean age: 54.6±17.2 years; range, 9 to 80 years) who underwent reconstruction with plates and meshes. Results There was no significant difference between the two groups in terms of smoking and diabetes. Primary chest wall or metastatic tumor was determined in 33 patients; benign tumor and trauma were determined in 30 patients. The difference between the two groups in mean defect diameter (p=0.009), mean number of plates used (p<0.001), and mean hospital stay (p<0.001) was statistically significant. However, there was no significant difference in terms of complications (p=0.426). Conclusion Wide chest wall resection and reconstruction is a safe and feasible surgical procedure when compared with primary closure.
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Affiliation(s)
- Kuthan Kavaklı
- Department of Thoracic Surgery, Gülhane Training and Research Hospital, Ankara, Türkiye
| | - Hakan Işık
- Department of Thoracic Surgery, Gülhane Training and Research Hospital, Ankara, Türkiye
| | - Merve Şengül İnan
- Department of Thoracic Surgery, Gülhane Training and Research Hospital, Ankara, Türkiye
| | - Ersin Sapmaz
- Department of Thoracic Surgery, Gülhane Training and Research Hospital, Ankara, Türkiye
| | - Musab Yeniköy
- Department of Thoracic Surgery, Gülhane Training and Research Hospital, Ankara, Türkiye
| | - Ufuk Ünsal
- Department of Thoracic Surgery, Gülhane Training and Research Hospital, Ankara, Türkiye
| | - Denizhan Kılınç
- Department of Thoracic Surgery, Gülhane Training and Research Hospital, Ankara, Türkiye
| | - Hasan Çaylak
- Department of Thoracic Surgery, Gülhane Training and Research Hospital, Ankara, Türkiye
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Li Z, Zhu W, Zhang B, Zhang Y, Li H, Lv B, Zhen Q, Liu L, Liu L, Wu Y, Li S. A novel minimally invasive fixation method for flail chest management in a Canine model: an animal research. J Cardiothorac Surg 2023; 18:359. [PMID: 38098070 PMCID: PMC10722814 DOI: 10.1186/s13019-023-02445-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 11/04/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Multiple rib fractures can lead to flail chest with up to 35% mortality rate due to severe pulmonary complications. Current treatments of flail chest remain controversial. Studies have shown that surgical treatments can improve outcomes and reduce mortality, comparing to non-operative treatments. Current surgical fixation methods focus on stabilization of ribs on the outward facing side, and they require division of intercostal muscles. Damages to surrounding nerves and vessels may lead to chronic pain. This study tests a novel interior fixation method that minimizes neurovascular injuries. METHODS Twelve healthy canines were divided in two surgical operation groups for exterior and interior fixation using titanium metal plates. Osteotomy with oblique fractures was prepared under general anesthesia. Exterior fixation was performed in open surgery. Interior fixation was minimally invasive using custom made tools including a flexible shaft extension screwdriver, solid plate stand, guiding wire loop and metal plates with threaded holes. RESULTS Respiratory and cardiovascular functions (RR, PO2, PCO2, SpO2, and HR) together with body temperature were measured before anesthesia and within 48 h after surgery. The difference in measurements was not statistically significant between the two groups before surgery with P values greater than 0.05. However, the interior group canines had better RR and PO2 values starting from the 24th hour, and better PCO2, SpO2, and HR values starting from the 48th hour. It took longer operation time to complete the minimally invasive interior fixation surgery (P value less than 0.001), but the total blood loss was less than the exterior fixation group (P value less than 0.001). Results also showed that interior group canines suffered less pain, and they had quicker recovery in gastrointestinal and physical mobility. CONCLUSIONS The investigative interior fixation method was safe and effective in rib stabilization on a canine rib fracture model, comparing to the exterior fixation method. The interior fixation was minimally invasive, with less damages to tissues and nerves surrounding the ribs, leading to better postoperative outcomes.
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Affiliation(s)
- Zhe Li
- Department of Thoracic Surgery, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang City, Hebei, 050000, China
- Department of Thoracic Surgery, Shijiazhuang People's Hospital, No. 365 Jianhua South Street, Shijiazhuang City, Hebei, 050031, China
| | - Weiwei Zhu
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Bing Zhang
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Yaxiao Zhang
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Huixian Li
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Baolei Lv
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Qiang Zhen
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Lin Liu
- Hebei General Hospital, No.348 Heping West Road, Shijiazhuang City, Hebei, 050051, China
| | - Lijun Liu
- Department of Thoracic Surgery, Hebei General Hospital, No.348 Heping West Road, Shijiazhuang City, Hebei, 050051, China
| | - Yanxin Wu
- Hebei General Hospital, No.348 Heping West Road, Shijiazhuang City, Hebei, 050051, China
| | - Shujun Li
- Department of Thoracic Surgery, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang City, Hebei, 050000, China.
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Retrospective comparison of operative technique for chest wall injuries. Injury 2023:S0020-1383(23)00248-6. [PMID: 36925375 DOI: 10.1016/j.injury.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Surgical management of chest wall injuries is a common procedure. However, operative techniques are diverse, and no universal guidelines exist. There is a lack of studies comparing the outcome with different operative techniques for chest wall surgery. The aim of this study was to compare hospital outcomes between patients operated for chest wall injuries with a conventional method with large incisions and often a thoracotomy or a minimally invasive, muscle sparing method. PATIENTS AND METHODS A retrospective study was carried out including patients ≥18 years operated for chest wall injuries 2010-2020. Patients were divided into two groups based on the surgery performed: conventional surgery (C-group) and minimally invasive surgery (M-group). Data on demographics, trauma, surgery, and outcomes were extracted from patient records. Primary outcome was length of stay on mechanical ventilator (MV-LOS). Secondary outcomes were length of stay in intensive care (ICU-LOS) and in hospital (H-LOS), and complications such as re-operation, incidence of empyema, tracheostomy, pneumonia, and mortality. RESULTS Of 311 included patients, 220 were in the C-group and 91 in the M-group. The groups were similar in demographics and injury pattern. MV-LOS was 0 (0-65) in the C-group vs 0 (0-34) in the M-group (p < 0.001). ICU-LOS and H-LOS were significantly shorter in the M-group as compared to the C-group (p < 0.001), however with a large overlap. Tracheostomy was performed in 22.3% of patients in the C-group vs 5.4% in the M-group (p < 0.001). Pneumonia was diagnosed in 32.3% of patients in the C-group vs 16.1% in the M-group (p = 0.004). In-hospital mortality was lower in the M-group compared to the C-group but there was no difference in mortality within 30 days or a year. CONCLUSIONS Our study indicates that a minimally invasive technique was favorable regarding clinical outcomes for patients operated for chest wall injuries.
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Biomechanical characteristics of rib fracture fixation systems. Clin Biomech (Bristol, Avon) 2023; 102:105870. [PMID: 36623327 DOI: 10.1016/j.clinbiomech.2023.105870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/20/2022] [Accepted: 01/02/2023] [Indexed: 01/05/2023]
Abstract
BACKGROUND The primary aim of this study was to determine and compare the biomechanical properties of a fractured or intact rib after implant fixation on an embalmed thorax. METHODS Five systems were fixated on the bilateral fractured or intact (randomly allocated) 6th to 10th rib of five post-mortem embalmed human specimens. Each rib underwent a four-point bending test to determine the bending structural stiffness (Newton per m2), load to failure (Newton), failure mode, and the relative difference in bending structural stiffness and load to failure as compared to a non-fixated intact rib. FINDINGS As compared to a non-fixated intact rib, the relative difference in stiffness of a fixated intact rib ranged from -0.14 (standard deviation [SD], 0.10) to 0.53 (SD 0.35) and for a fixated fractured rib from -0.88 (SD 0.08) to 0.17 (SD 0.50). The most common failure mode was a new fracture at the most anterior drill hole for the plate and screw systems and a new fracture within the anterior portion of the implant for the clamping systems. INTERPRETATION The current fixation systems differ in their design, mode of action, and biomechanical properties. Differences in biomechanical properties such as stiffness and load to failure especially apply to fractured ribs. Insight in the differences between the systems might guide more specific implant selection and increase the surgeon's awareness for localizing hardware complaints or failure.
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Comparison of surgical stabilization of rib fractures vs epidural analgesia on in-hospital outcomes. Injury 2023; 54:32-38. [PMID: 35914987 DOI: 10.1016/j.injury.2022.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/06/2022] [Accepted: 07/23/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgical stabilization of rib fractures (SSRF) improves functional outcomes compared to controls, partly due to reduction in pain. We investigated the impact of early SSRF on pulmonary complications, mortality, and length of stay compared to non-operative analgesia with epidural analgesia (EA). METHODS Retrospective cohort study of the Trauma Quality Improvement Program (TQIP) 2017 dataset for adults with rib fractures, excluding those with traumatic brain injury or death within twenty-four hours. Early SSRF and EA occurred within 72 h, and we excluded those who received both or neither intervention. Our primary outcome was a composite of pulmonary complications including acute respiratory distress syndrome (ARDS) or ventilator-associated pneumonia (VAP). Additional outcomes included unplanned endotracheal intubation, in-hospital mortality, and hospital and intensive care unit (ICU) length of stay (LOS) for those surviving to discharge. Multiple logistic and linear regressions were controlled for variables including age, sex, flail chest (FC), injury severity, additional procedures, and medical comorbidities. RESULTS We included 1,024 and 1,109 patients undergoing early SSRF and EA, respectively. SSRF patients were more severely injured with higher rates of FC (42.8 vs 13.3%, p<0.001), Injury Severity Score (ISS) > 16 (56.9 vs 36.1%, p<0.001), and Abbreviated Injury Scale (AIS) Thorax > 3 (33.3 vs 12.2%, p<0.001). Overall, 49 (2.3%) of patients developed ARDS or VAP, 111 (5.2%) required unplanned intubation, and 58 (2.7%) expired prior to discharge. On multivariable analysis, SSRF was not associated with the primary composite outcome (OR: 1.65, 95%CI: 0.85-3.21). Early SSRF significantly predicted decreased risk of unplanned intubation (OR:0.59, 95%CI: 0.38-0.92) compared with early EA alone, however, was not a significant predictor of in-hospital mortality (OR: 1.27, 95%CI: 0.68-2.39). SSRF was associated with significantly longer hospital (Exp(β): 1.06, 95%CI: 1.00-1.12, p = 0.047) and ICU LOS (Exp(β): 1.17, 95%CI: 1.08-1.27, p<0.001). CONCLUSIONS Aside from unplanned intubation, we observed no statistically significant difference in the adjusted odds of in-hospital pulmonary morbidity or mortality for patients undergoing early SSRF compared with early EA. Chest wall injury patients may benefit from referral to trauma centers where both interventions are available and appropriate surgical candidates may receive timely intervention.
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Wong THY, Siu ICH, Lo KKN, Tsang EYH, Wan IYP, Lau RWH, Chiu TW, Ng CSH. Ten-Year Experience of Chest Wall Reconstruction: Retrospective Review of a Titanium Plate MatrixRIB™ System. Front Surg 2022; 9:947193. [PMID: 35865033 PMCID: PMC9294311 DOI: 10.3389/fsurg.2022.947193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Chest wall tumor resection can result in a large defect that can pose a challenge in reconstruction in restoring chest wall contour, maintaining respiratory mechanics, and improving cosmesis. Titanium plates were first introduced for treating a traumatic flail chest, which yielded promising results in restoring chest wall stability. Subsequently, the applications of titanium plates in chest wall reconstruction surgery were demonstrated in case reports and series. Our center has adopted this technique for a decade, and patients are actively followed up after operation. Here, we retrospectively analyze our 10-year experience of using titanium plates and other reconstruction approaches for chest wall reconstruction, in terms of clinical outcomes, complications, and reasons for reoperation to determine long-term safety and efficacy. Thirty-eight patients who underwent chest wall resection and reconstruction surgery were identified. Of these, 11 had titanium plate insertion, 11 had patch repair or flap reconstruction, and the remaining 16 had primary closure of defects. Chest wall reconstruction using titanium plate(s) and patch repair (with or without flap reconstruction) was associated with larger chest wall defects and more sternal resections than primary closure. Subgroup analysis also showed that reconstruction by the titanium plate technique was associated with larger chest wall defects than patch repair or flap reconstruction [286.80 cm2 vs. 140.91 cm2 (p = 0.083)]. There was no 30-day hospital mortality. Post-operative arrhythmia was more commonly seen following chest wall reconstruction compared with primary closure (p = 0.041). Furthermore, more wound infections were detected following the use of titanium plate reconstruction compared with the patch repair (with or without flap reconstruction) approach (p = 0.027). In conclusion, the titanium plate system is a safe, effective, and robust approach for chest wall reconstruction surgery, especially in tackling larger defect sizes.
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Affiliation(s)
- Teddy H. Y. Wong
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Ivan C. H. Siu
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Kareem K. N. Lo
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Ethan Y. H. Tsang
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Innes Y. P. Wan
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Rainbow W. H. Lau
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - T. W. Chiu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Calvin S. H. Ng
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
- Correspondence: Calvin S. H. Ng
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Kheirbek T, Martin TJ, Cao J, Tillman AC, Spivak HA, Heffernan DS, Lueckel SN. Comparison of Infectious Complications after Surgical Fixation versus Epidural Analgesia for Acute Rib Fractures. Surg Infect (Larchmt) 2022; 23:532-537. [PMID: 35766917 DOI: 10.1089/sur.2022.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Surgical stabilization of rib fractures (SSRF) is associated with decreased mortality and respiratory complications. Patients who are not offered SSRF are often treated with epidural analgesia (EA) to reduce pain and improve pulmonary mechanics. We sought to compare infectious complications in patients undergoing either SSRF or EA. We hypothesized that infectious complications are equivalent between the two treatment groups. Patients and Methods: We performed a retrospective cohort study of adult trauma patients with acute rib fractures within the Trauma Quality Improvement Program (TQIP) 2017 dataset and used International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to identify patients who underwent SSRF or EA. We excluded patients who received both treatments in the same admission. Our primary outcome was the development of sepsis. Secondary outcomes were specific infections including ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), and central line-associated blood stream infections (CLABSI). Multiple logistic regression analyses were used to adjust for age, injury severity score (ISS), chest Abbreviated Injury Scale (AIS), flail chest, traumatic brain injury (TBI), and comorbidities. Results: We identified 2,252 and 1,299 patients who underwent SSRF and EA, respectively. Patients with SSRF were younger with higher ISS and longer length of stay (LOS). There was no difference in mortality, however, SSRF had higher rate of sepsis (1.6% vs. 0.5%; p = 0.001), VAP (5.1% vs. 0.9%; p < 0.001), CAUTI (1.7% vs. 0.5%; p = 0.001), and CLABSI (0.2% vs. 0%; p = 0.05). On multiple regression, SSRF was associated with higher odds of sepsis (odds ratio [OR], 2.63; 95% confidence interval [CI], 1.04-6.63), CAUTI (OR, 2.96; 95% CI, 1.11-7.88), and VAP (OR, 3.24; 95% CI, 1.73-6.06). Among those who developed sepsis, there was no significant difference in mortality or LOS between groups. Conclusions: Despite no difference in mortality, SSRF was associated with increased risk of septic complications in patients with rib fractures compared to epidural analgesia. Identifying, and addressing, risk factors of sepsis in this patient population is a critical performance improvement process to optimize outcomes without increased adverse events.
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Affiliation(s)
- Tareq Kheirbek
- Brown University, Alpert Medical School, Department of Surgery, Providence, Rhode Island, USA
| | - Thomas J Martin
- Brown University, Alpert Medical School, Department of Surgery, Providence, Rhode Island, USA
| | - Jessica Cao
- Brown University, Alpert Medical School, Department of Surgery, Providence, Rhode Island, USA
| | - Anastasia C Tillman
- Brown University, Alpert Medical School, Department of Surgery, Providence, Rhode Island, USA
| | - Holden A Spivak
- Brown University, Alpert Medical School, Department of Surgery, Providence, Rhode Island, USA
| | - Daithi S Heffernan
- Brown University, Alpert Medical School, Department of Surgery, Providence, Rhode Island, USA
| | - Stephanie N Lueckel
- Brown University, Alpert Medical School, Department of Surgery, Providence, Rhode Island, USA
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RAMIREZ O, TORRES-SANMIGUEL CR, CECCARELLI M, URRIOLAGOITIA-CALDERÓN GM. NUMERICAL AND EXPERIMENTAL VALIDATION OF A RIB IMPLANT USING AN ARTIFICIAL RIB. J MECH MED BIOL 2022. [DOI: 10.1142/s0219519422500361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This paper presents a numerical and experimental evaluation of a new osteosynthesis rib implant. The reported cases are studied using the Finite Element Method (FEM) to compute the implant’s surface strain. The implant was placed to a human morphological rib manufactured in polylactic acid (PLA) by 3D printing. Experimental studies are carried out with a strain gage stuck on the implant’s surface and tested by using a testing machine called Testing Machine for Artificial Rib Impact (TEMARI). The machine was used to emulate the compression force that performs in the chest during deep breathing on humans. The results from numerical analysis and the experimental test show a variation of 4.9% in the compression displacement of the rib, 6.1% in the strain of the left surface of the rib, 1.6% for the strain of the right surface of the rib, and finally 3.1% for the strain in the middle surface of the implant.
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Affiliation(s)
- O. RAMIREZ
- Instituto Politécnico Nacional, Escuela Superior de Ingeniería Mecánica y Eléctrica Unidad Zacatenco, Sección de Estudios de Posgrado e Investigación, Departamento de Mecánica, 07738 CDMX, México
| | - C. R. TORRES-SANMIGUEL
- Instituto Politécnico Nacional, Escuela Superior de Ingeniería Mecánica y Eléctrica Unidad Zacatenco, Sección de Estudios de Posgrado e Investigación, Departamento de Mecánica, 07738 CDMX, México
| | - M. CECCARELLI
- Università di Rome Tor Vergata, Dipartimento di Ingegneria Industriale, LARM2, Laboratory of Robotics and Mechatronics, Via del Politecnico 1, 00133 Roma, Italy
| | - G. M. URRIOLAGOITIA-CALDERÓN
- Instituto Politécnico Nacional, Escuela Superior de Ingeniería Mecánica y Eléctrica Unidad Zacatenco, Sección de Estudios de Posgrado e Investigación, Departamento de Mecánica, 07738 CDMX, México
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Kong LW, Huang GB, Yi YF, Du DY. The Chinese consensus for surgical treatment of traumatic rib fractures 2021 (C-STTRF 2021). Chin J Traumatol 2021; 24:311-319. [PMID: 34503907 PMCID: PMC8606596 DOI: 10.1016/j.cjtee.2021.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/18/2021] [Accepted: 07/26/2021] [Indexed: 02/04/2023] Open
Abstract
Rib fracture is the most common injury in chest trauma. Most of patients with rib fractures were treated conservatively, but up to 50% of patients, especially those with combined injury such as flail chest, presented chronic pain or chest wall deformities, and more than 30% had long-term disabilities, unable to retain a full-time job. In the past two decades, surgery for rib fractures has achieving good outcomes. However, in clinic, there are still some problems including inconsistency in surgical indications and quality control in medical services. Before the year of 2018, there were 3 guidelines on the management of regional traumatic rib fractures were published at home and abroad, focusing on the guidance of the overall treatment decisions and plans; another clinical guideline about the surgical treatment of rib fractures lacks recent related progress in surgical treatment of rib fractures. The Chinese Society of Traumatology, Chinese Medical Association, and the Chinese College of Trauma Surgeons, Chinese Medical Doctor Association organized experts from cardiothoracic surgery, trauma surgery, acute care surgery, orthopedics and other disciplines to participate together, following the principle of evidence-based medicine and in line with the scientific nature and practicality, formulated the Chinese consensus for surgical treatment of traumatic rib fractures (STTRF 2021). This expert consensus put forward some clear, applicable, and graded recommendations from seven aspects: preoperative imaging evaluation, surgical indications, timing of surgery, surgical methods, rib fracture sites for surgical fixation, internal fixation method and material selection, treatment of combined injuries in rib fractures, in order to provide guidance and reference for surgical treatment of traumatic rib fractures.
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Affiliation(s)
- Ling-Wen Kong
- Department of Cardiothoracic Surgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400014, China
| | - Guang-Bin Huang
- Department of Trauma Surgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400014, China
| | - Yun-Feng Yi
- Department of Cardiothoracic Surgery, Xiamen University Affiliated Southeast Hospital, Zhangzhou, 363000, Fujian Province, China,Corresponding author. Xiamen University Affiliated Southeast Hospital, Zhangzhou, 363000, Fujian Province, China.
| | - Ding-Yuan Du
- Department of Cardiothoracic Surgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400014, China,Department of Trauma Surgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400014, China,Corresponding author. Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400014, China.
| | - Consensus expert groupBaiXiang-JundChengLi-MingeCuiShu-SenfDuDing-YuangDuGong-LianghDengJiniDaiJi-GangjDangXing-BohFuXiao-BingkFuYonglGeBingmGaoJin-MougHouLi-JunnHuPei-YangoHouZhi-YongpJiangBao-GuoqJiangJian-XinrJiaYan-FeisJingJue-HuatKongLing-WengLiChun-MinguLvDe-ChengvLiuGuo-DongwLiangGui-YouxLianHong-KaiyLiKai-NanzLiLeiaaLiuLiang-MingrLinYi-DanabLiZhan-FeidLiuZhong-MinacShaoBiaoadShenYanaeTaoNingafTangPei-FukTanQun-YourHuangGuang-BingHuPinggWangChengagWuChunahWangDa-LiaiWangGangajWangHai-DongakWuJing-LanalWuQing-ChenamWangRu-WenrWangTian-BingsWuXuajWangZheng-GuorXuFenganXiaoRen-JuaoXiaoYing-BinapYuAn-YongaiYuBinajYangJunaqYangXiao-FengaeYiYun-FengarZhuDong-BoasZengJunatZhouJi-HongrZhangLian-YangauZhaoXing-JigZhongYong-FuavTongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyTongji Hospital, Tongji University School of MedicineChina-Japan Union Hospital of Jilin UniversityChongqing Emergency Medical Center, Chongqing University Central HospitalShanxi Province People's HospitalAffiliated Hospital of Guizhou Medical UniversityXinqiao Hospital, Army Military Medical UniversityGeneral Hospital of People's Liberation ArmyThe Second Hospital,University of South ChinaThe Fourth People's Hospital of GuiyangChangzheng Hospital, Second Military Medical UniversityTiantai People's Hospital of Zhejiang ProvinceThe Third Hospital of Hebei Medical UniversityPeking University People's Hospital, National Center for Trauma MedicineArmy Medical Center of People's Liberation ArmyThe Second Affiliated Hospital of Inner Mongolia Medical UniversityThe Second Hospital of Anhui Medical UniversityJilin Central HospitalFirst Affiliated Hospital of Dalian Medical UniversityEditorial Department of Chinese Journal of TraumaGuizhou Medical UniversityZhengzhou Central Hospital Affiliated to Zhengzhou UniversityAffiliated Hospital of Chengdu UniversityEditorial Department of Chinese Journal of Traumatology(English Edition)West China Hospital of Sichuan UniversityShanghai Oriental Hospital of Tongji UniversityThe First People's Hospital of KunmingThe First Affiliated Hospital, School of Medicine, Zhejiang UniversitySuining Central Hospital, Sichuan ProvinceThe First Affiliated Hospital of Hainan Medical UniversityChildren's Hospital of Chongqing Medical UniversityAffiliated Hospital of Zunyi Medical UniversitySouthern Hospital of Southern Medical UniversitySouthwest Hospital of Army Medical UniversityUnion Shenzhen Hospital, Huazhong University of Science and TechnologyThe First Affiliated Hospital of Chongqing Medical UniversityThe First Affiliated Hospital of Soochow UniversityPeople's Hospital of Xingyi City, Guizhou ProvinceXinqiao Hospital of Army Medical UniversityChongqing Emergency Medical Center, Central Hospital of Chongqing UniversityXiamen University Affiliated Southeast HospitalThe Affiliated Hospital of Nantong UniversitySichuan Provincial People's HospitalDaping Hospital, Army Military Medical UniversityChongqing University Three Gorges Hospital)
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Martin TJ, Cao J, Benoit E, Kheirbek T. Optimizing surgical stabilization of rib fractures using intraoperative ultrasound localization. J Trauma Acute Care Surg 2021; 91:369-374. [PMID: 33938512 DOI: 10.1097/ta.0000000000003262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) significantly improve the outcomes of patients with rib fractures. Ultrasound is a specific modality for localizing rib fractures. We hypothesized that use of perioperative ultrasound localization of fracture sites optimizes surgical approach and clinical outcomes. METHODS We performed a retrospective cohort study of adult patients undergoing SSRF and compared those with and without adjunctive perioperative ultrasound fracture localization. Our primary outcome was improved surgical efficiency as measured by incision length and total operative time. Secondary clinical outcomes included numeric pain score on follow-up visit and daily morphine milligram equivalent prescribed within 30 days from discharge. RESULTS We performed 49 surgical rib fixations between 2015 and 2020; of which, 13 (26.5%) additionally underwent ultrasound localization (26.5%). There were no significant differences between groups in age, sex, number of ribs repaired, or days till surgery. More patients in the ultrasound group had nonflail chest wall injury (76.9% vs. 27.8%, p = 0.003). Use of perioperative ultrasound was associated with shorter incision length (median, 9 vs. 15.5 cm; p = 0.0001), shorter operative time (median, 120 vs. 174 minutes; p = 0.003), less daily morphine milligram equivalent (25 vs. 68 mg, p = 0.009), and reduced numeric pain score on follow up (median, 4 vs. 7, p = 0.05). CONCLUSION Use of perioperative ultrasound localization of rib fractures to optimize surgical approach for SSRF was associated with reduced incision length, operative time, and opioid requirements on patient discharge. We recommend considering routine perioperative localization to improve surgical approach and efficiency during SSRF. LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- Thomas J Martin
- From the Department of Surgery, Alpert Medical School, Brown University, Providence, Rhode Island
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Choi J, Kaghazchi A, Sun B, Woodward A, Forrester JD. Systematic Review and Meta-Analysis of Hardware Failure in Surgical Stabilization of Rib Fractures: Who, What, When, Where, and Why? J Surg Res 2021; 268:190-198. [PMID: 34333416 DOI: 10.1016/j.jss.2021.06.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/10/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Jeff Choi
- Department of Surgery, Division of General Surgery, Stanford University, Stanford, California; Department of Epidemiology and Population Health, Stanford University, Stanford, California; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, California.
| | - Aydin Kaghazchi
- Department of Epidemiology and Population Health, Stanford University, Stanford, California; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, California
| | - Beatrice Sun
- Department of Surgery, Division of General Surgery, Stanford University, Stanford, California; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, California
| | - Amanda Woodward
- School of Medicine, Stanford University, Stanford, California
| | - Joseph D Forrester
- Department of Surgery, Division of General Surgery, Stanford University, Stanford, California; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, California
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Stefani A, Tormen F, Scamporlino A, Natali P, Cavallesco G, Morandi U. Surgical stabilization of severe flail chest with Judet and Sanchez-Lloret plates. A case report. Int J Surg Case Rep 2021; 81:105805. [PMID: 33774448 PMCID: PMC8039542 DOI: 10.1016/j.ijscr.2021.105805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/18/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Flail chest is now usually treated by conservative methods and surgical fixation remains indicated in selected cases. Different techniques can be used for fixation. The aim of this paper is to present a case in which Judet and Sanchez-Loret plates were employed and to discuss the usefulness of this traditional technique. PRESENTATION OF CASE A 79-year-old woman was admitted for left thoracic trauma with severe antero-lateral flail chest. She was affected by COPD with chronic respiratory failure, ischemic heart disease, autoimmune thrombocytopenia treated on chronic steroid therapy and severe osteoporosis. CT-scan detected multiple rib fractures, left hemothorax and lung contusions. An initial conservative treatment of flail chest involved compressive bandage and then internal pneumatic stabilization in ICU, but it failed. The patient underwent successful surgical treatment of the flail chest by fixation of the anterior fractures from the second to the eight rib. Judet and Sanchez-Lloret plates were used. A bilateral pneumonia developed during the rehabilitation period and the patient died two months after operation. DISCUSSION Judet and Sanchez-Lloret plates represent a traditional technique for fixation of flail chest. This technique is less and less used and progressively replaced by newer materials, especially titanium plates with screws or intramedullary struts. Our patient had multiple comorbidities and a very fragile bones that advised against use of screws or intramedullary struts. CONCLUSION Judet and Sanchez-Lloret plates can be still considered a useful tool for the fixation of flail chest in cases of thin and fragile bones.
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Affiliation(s)
- Alessandro Stefani
- Division of Thoracic Surgery, University of Modena and Reggio Emilia, Modena, Italy.
| | - Francesco Tormen
- Division of Thoracic Surgery, University of Modena and Reggio Emilia, Modena, Italy.
| | - Adriana Scamporlino
- Division of Thoracic Surgery, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.
| | - Pamela Natali
- Division of Thoracic Surgery, University of Modena and Reggio Emilia, Modena, Italy.
| | | | - Uliano Morandi
- Division of Thoracic Surgery, University of Modena and Reggio Emilia, Modena, Italy.
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Peek J, Beks RB, Hietbrink F, Heng M, De Jong MB, Beeres FJ, Leenen LP, Groenwold RH, Houwert RM. Complications and outcome after rib fracture fixation: A systematic review. J Trauma Acute Care Surg 2020; 89:411-418. [DOI: 10.1097/ta.0000000000002716] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Butano V, Zebley JA, Sarani B. Current Status of Rib Plating: Hardware Failure When and How? CURRENT SURGERY REPORTS 2020. [DOI: 10.1007/s40137-020-00257-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Zhang JP, Sun L, Li WQ, Wang YY, Li XZ, Liu Y. Surgical treatment ofpatients with severe non-flail chest rib fractures. World J Clin Cases 2019; 7:3718-3727. [PMID: 31799296 PMCID: PMC6887616 DOI: 10.12998/wjcc.v7.i22.3718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/08/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Many patients have inadequate long-term analgesia, respiratory distress, and hypoxemia due to a long-standing substantial smoking history or the presence of primary pulmonary diseases; analgesic treatment is not valid in these patients. Even if the imaging findings of rib fractures are relatively mild, rib fractures may cause severe position limitation, respiratory distress, and hypoxemia.
AIM To investigate the curative effect of surgical treatment for patients with severe non-flail chest rib fractures.
METHODS A total of 78 patients from our hospital with severe noncontinuous thoracic rib fractures from September 2016 to September 2018 were enrolled in our study. Thirty-nine patients underwent surgical treatment, and 39 underwent conservative treatment. The surgical treatment group received surgery performed with titanium plates, and the screws were inserted with open reduction and internal fixation. The conservative treatment group received analgesia and symptomatic treatment. The pain scores at 72 h, 1 wk, 2 wk, 4 wk, 6 wk, 3 mo, and 6 mo were compared, and the SF-36 quality of life scores were compared atthe 3rd and 6th months.
RESULTS Pain relief in the surgical group was significantly better than that in the conservative group at each time point (72 h, 1 wk, 2 wk, 4 wk, 6 wk, 3 mo, and 6 mo after surgery, P < 0.001). ( The SF-36 scores were significantly higher in the surgical group than in the conservative group at 1 mo and 6 mo (P < 0.05).
CONCLUSION Patients with severe non-flail chest rib fractures have a better quality of life following surgical treatment than following conservative treatment, and surgical treatment is also useful for relieving pain. We should pay more attention to the physiological functions and clinical manifestations of patients with severe rib fractures. In patients with non-flail chest rib fractures, surgical treatment is feasible and effective.
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Affiliation(s)
- Jian-Peng Zhang
- Department of Thoracic Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
| | - Lin Sun
- Department of Thoracic Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
| | - Wei-Qiang Li
- Department of Thoracic Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
| | - Yan-Yu Wang
- Department of Thoracic Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
| | - Xin-Zhen Li
- Department of Thoracic Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
| | - Yang Liu
- Department of Thoracic Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
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Peek J, Beks RB, Kremo V, van Veelen N, Leiser A, Houwert RM, Link BC, Knobe M, Babst RH, Beeres FJP. The evaluation of pulmonary function after rib fixation for multiple rib fractures and flail chest: a retrospective study and systematic review of the current evidence. Eur J Trauma Emerg Surg 2019; 47:1105-1114. [PMID: 31768585 DOI: 10.1007/s00068-019-01274-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 11/15/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The primary aim of this retrospective cohort study was to evaluate the pulmonary function after rib fixation for patients with multiple rib fractures and flail chest. Secondary, a systematic review was performed to give an overview of the current literature and to allow comparison with our results. METHODS All adult (≥ 18 years) patients who underwent rib fixation for multiple rib fractures or flail chest between 2010 and 2018 and who received a control pulmonary function test during the postoperative follow-up at our level-1 trauma center were retrospectively reviewed. Secondary, the PubMed, EMBASE and Cochrane databases were searched to identify studies reporting on the pulmonary function after rib fixation. The primary outcome parameters were the forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, maximum vital capacity (VCmax), total lung capacity (TLC), residual volume (RV), and RV/TC ratio. RESULTS Of the 103 patients who underwent rib fixation, a total of 61 (59%) patients underwent a pulmonary function test in our hospital and were ultimately included. In the majority of patients all pulmonary function parameters fell within the normal range of the reference values. Obstructive impairment was predominantly seen in patients with pre-existing chronic obstructive pulmonary disease (COPD). Patients with multiple rib fractures had better recovery compared to those with a flail chest. The systematic review included a total of 15 studies and showed comparable results. CONCLUSION The present study demonstrates that rib fixation for multiple rib fractures or flail chest results in adequate recovery of the pulmonary function within 3 months after surgery. In addition, based on the current literature, further gradual improvement to maximum pulmonary values appears to occur during the first 12 months after rib fixation.
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Affiliation(s)
- Jesse Peek
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland. .,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Reinier Bart Beks
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Valerie Kremo
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Nicole van Veelen
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Alfred Leiser
- Department of Thoracic and Cardiovascular Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | | | - Björn-Christian Link
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Matthias Knobe
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Reto Hansjörg Babst
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
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Craxford S, Deacon C, Myint Y, Ollivere B. Assessing outcome measures used after rib fracture: A COSMIN systematic review. Injury 2019; 50:1816-1825. [PMID: 31353094 DOI: 10.1016/j.injury.2019.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/01/2019] [Accepted: 07/03/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE The incidence of invasive treatment of rib fracture has increased significantly over the last decade however the evidence of improved patient outcomes to support this is lacking. A systematic review was performed to identify patient reported outcome measures (PROMs) used in the assessment of outcomes following chest wall injury. The quality of evidence for the psychometric properties of the identified PROMs was graded using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. METHODS Rib fracture studies measuring patient reported outcomes were identified using PubMed/Medline, EMBASE, AMED and PsycINFO. Methodological quality of measurement properties was evaluated with the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist. RESULTS A total of 64 studies were identified including 19 different PROM instruments. Domains included in the reported PROMs included pain, breathlessness, general health quality of life, physical function and physiological health. No rib fracture specific PROM was identified. The most frequently reported instrument was the SF-36 reporting overall quality of life (HRQoL) although there was very low quality evidence for its content validity. There was low quality evidence to support good content validity for the Medical Research Council (MRC) dyspnoea scale, Brief Pain Index (BPI) and McGill Pain Questionnaire (MPQ). No PROM had undergone validation in a rib fracture population. The overall quality of the PROM development studies was poor. While we were unable to identify a clear "gold standard", based on the limited current evidence, we recommend that the EQ-5D-5L is used in combination with the MRC and BPI or MPQ for future rib fracture studies. CONCLUSION The lack of validated outcome measures for rib fracture patients is a significant limitation of the current literature. Further studies are needed to provide validated outcome measures to ensure accuracy of the reported results and conclusions. As interventions for rib fractures have become more common in both research and clinical practice this has become an urgent priority.
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Affiliation(s)
| | - Christopher Deacon
- Department of Trauma and Orthopaedics, Queens Medical Centre, Nottingham, UK
| | - Yulanda Myint
- Department of Trauma and Orthopaedics, Queens Medical Centre, Nottingham, UK
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[Injuries of the posterior and lateral chest wall-importance of an additional clavicular fracture]. Unfallchirurg 2019; 121:615-623. [PMID: 30043074 DOI: 10.1007/s00113-018-0528-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Flail chest wall injuries (FCI) are common in younger patients due to high-speed trauma and in older patients due to low-energy trauma or falls from a low height. They show a high incidence of concomitant injuries and are therefore associated with high morbidity and mortality. If there is also an ipsilateral clavicular fracture (CF), the outcome is significantly poorer. The skeleton of the shoulder and chest loses stability and can lead to a loss of function of the shoulder and a pronounced deformation of the chest wall. OBJECTIVE This article shows the origin and clinical importance of FCI. What importance does a concomitant ipsilateral CF have and how can these costoclavicular injuries (CCI) be managed conservatively and operatively? MATERIAL AND METHODS After primary emergency care of the patients with appropriate diagnostics, in the presence of CCI operative stabilization was carried out by means of locked plate osteosynthesis of the clavicle and the affected ribs via minimally invasive approaches with the patient under general anesthesia. Patients were followed up postoperatively. Various minimally invasive posterolateral approaches to the chest wall were previously performed in a corpse study and then put into practice. RESULTS AND CONCLUSION This study presents therapeutic options for the reconstruction of the chest wall based on the established literature and clinical examples. An ipsilateral CF combined with fractures of the 2nd-4th ribs can be treated through an innovative clavipectoral approach. For the other fractures, standard approaches to the anterolateral and posterolateral chest wall are performed, which are associated with a good outcome in clinical practice. An operative stabilization should be performed at the latest when FCI or CCI together with a dislocating fracture and a marked deformation of the thoracic wall are present. Remaining misalignments are associated with a simultaneous loss of function of the chest wall and shoulder.
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Bartscherer A, Miller C, Johnson M, Stolarski A, Vitto M, Kazakova T, Lee C, Tafen M. Closed chest compressions after rib plating. J Thorac Dis 2019; 11:S1096-S1099. [PMID: 31205767 DOI: 10.21037/jtd.2018.09.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Claire Miller
- Department of Surgery, Albany Medical College, Albany, NY, USA
| | - Matthew Johnson
- Department of Surgery, Albany Medical College, Albany, NY, USA
| | | | - Marco Vitto
- Department of Radiology, Albany Medical College, Albany, NY, USA
| | - Tatiana Kazakova
- Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Christina Lee
- Department of Surgery, Albany Medical College, Albany, NY, USA
| | - Marcel Tafen
- Department of Surgery, Albany Medical College, Albany, NY, USA
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Akil A, Ziegeler S, Reichelt J, Semik M, Müller MC, Fischer S. Rib osteosynthesis is a safe and effective treatment and leads to a significant reduction of trauma associated pain. Eur J Trauma Emerg Surg 2019; 45:623-630. [DOI: 10.1007/s00068-018-01062-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/20/2018] [Indexed: 08/26/2023]
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Lin HL, Tarng YW, Wu TH, Huang FD, Huang WY, Chou YP. The advantages of adding rib fixations during VATS for retained hemothorax in serious blunt chest trauma - A prospective cohort study. Int J Surg 2019; 65:13-18. [PMID: 30878761 DOI: 10.1016/j.ijsu.2019.02.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/05/2019] [Accepted: 02/19/2019] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Hsing-Lin Lin
- Department of Critical Care Medicine, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan
| | - Yih-Wen Tarng
- Division of Trauma and Fracture, Department of Orthopedics, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan
| | - Tung-Ho Wu
- Department of Critical Care Medicine, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan; Division of Thoracic Surgery, Department of Surgery, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan
| | - Fong-Dee Huang
- Division of Trauma, Department of Emergency, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan
| | - Wen-Yen Huang
- School of Accounting and Finance, Beijing Institute of Technology, Zhuhai, China
| | - Yi-Pin Chou
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan; Division of Trauma, Department of Emergency, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan; Department of Cosmetic Science, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan.
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Surgical Stabilization Improves 30-day Mortality in Patients With Traumatic Flail Chest: A Comparative Case Series at a Major Trauma Center. J Orthop Trauma 2019; 33:15-22. [PMID: 30418334 DOI: 10.1097/bot.0000000000001344] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the outcomes including early mortality after surgical rib fixation using a locking plate system as part of a newly introduced chest trauma pathway. DESIGN Prospective cohort study with retrospective case-controlled matching with a minimum of 1-year follow-up. SETTING Regional Level 1 trauma center. PATIENTS/PARTICIPANTS Consecutive patients undergoing surgical rib fixation were prospectively recruited over a 3-year period (56 patients) and matched to similar patients managed nonoperatively (89 patients) using our local trauma registry. Matching was based on injury severity scores and patient demographics. INTERVENTION Surgical rib fixation with locking plates. MAIN OUTCOME MEASUREMENTS The primary outcome measure was 30-day mortality with secondary outcomes of hospital length of stay, intensive care unit length of stay, and patient-reported outcome measures including quality of life (EuroQol-EQ-5D-5L). Official causes of death were obtained from the coroner including postmortem results. RESULTS There was a significant reduction in 30-day mortality in the fixed patients with 1.8% (1/56) compared to 12.4% (11/89) of the nonfixed patients (P = 0.03). This difference remained significant after further exclusion of other nonsurvivable injuries (P = 0.046). Although hospital length of stay was significantly longer in the fixed group, there was no difference on multivariable analysis. Other secondary outcomes were comparable between the groups with no significant differences in any patient-reported measures. CONCLUSIONS Mortality was significantly lower in patients who underwent rib stabilization. Quality of life and other patient-reported measures were similar, demonstrating no evidence of detrimental longer-term effects of rib stabilization. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Ong K, Ong CS, Chua YC, Fazuludeen AA, Ahmed ADB. The painless combination of anatomically contoured titanium plates and porcine dermal collagen patch for chest wall reconstruction. J Thorac Dis 2018; 10:2890-2897. [PMID: 29997954 DOI: 10.21037/jtd.2018.04.116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background A plethora of new biomaterials and dedicated rib fixator implant systems have been introduced into the field of chest wall reconstruction. The aim of our study is to evaluate the surgical outcomes of a novel combination of the anatomically contoured titanium rib implant and porcine dermal collagen patch for chest wall reconstruction. Methods We performed a retrospective review of eight consecutive patients who underwent chest wall resection and reconstruction between January 2014 to August 2015 in a single institution. MatrixRib Fixation System and Permacol Surgical Implant were utilized to achieve chest wall reconstruction. Results The indication for reconstruction was malignant infiltration in 50% of patients. Three other subjects (37.5%) had chest wall resections to achieve adequate and safe surgical exposure. One patient had a right lung apical mycetoma with chest wall invasion. All patients underwent lung resections with the removal of 2 to 6 (median 3) ribs. Reconstruction was performed using the MatrixRib system, with a median of 2.5 (range, 2-4) ribs fixed in each patient. There was no post-operative mortality. One patient had a superficial wound infection which resolved with one week of oral antibiotics. Upon discharge, the pain scores were near zero with minimal analgesic requirements. None of the patients required repeat surgery or removal of their implants. Conclusions Our early experience indicates that the combination of the MatrixRib system and Permacol patch for chest wall reconstruction is safe and feasible with promising results in terms of anatomical restoration of the chest wall mechanics, infection and pain.
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Affiliation(s)
- Kingsfield Ong
- Division of Thoracic Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Chin Siang Ong
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Yang Chong Chua
- Division of Surgical Oncology, National Cancer Centre, Singapore
| | - Ali Akbar Fazuludeen
- Division of Thoracic Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore
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25
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A novel method of using bioabsorbable materials for the surgical repair of flail chest. J Trauma Acute Care Surg 2018; 81:984-987. [PMID: 27602896 DOI: 10.1097/ta.0000000000001240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Grubmüller M, Kerschbaum M, Diepold E, Angerpointner K, Nerlich M, Ernstberger A. Severe thoracic trauma - still an independent predictor for death in multiple injured patients? Scand J Trauma Resusc Emerg Med 2018; 26:6. [PMID: 29310701 PMCID: PMC5759165 DOI: 10.1186/s13049-017-0469-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 12/22/2017] [Indexed: 01/26/2023] Open
Abstract
Background Over the past, the severe thoracic trauma has had decisive influence on the outcome of multiple injured patients. Today, new therapies (e.g. extracorporeal membrane oxygenation (ECMO), protective ventilation methods and new forms of patient positioning) are available and applied regularly. What impact on the patient’s outcome does the thoracic trauma have today? Methods Prospective data collection of multiple injured patients in a level-I trauma center was performed between 2008 and 2014. Patients with an ISS ≥16 were included and divided into 2 groups: Severe thoracic trauma (STT: AISThorax ≥ 3) and mild thoracic trauma (MTT: AISThorax < 3). In addition to preclinical and trauma room care, detailed information about clinical course and outcome were assessed. Results In total, 529 patients (STT: n = 317; MTT: n = 212) met the in- and exclusion criteria. The mean Injury Severity Score (ISS) was significantly higher in patients of the STT group (STT: 33.5 vs. MTT: 24.7; p < 0.001), while the RISC II Score showed no significant differences (STT: 20.0 vs. MTT: 17.1; p = 0.241). Preclinical data revealed a higher intubation rate, more chest tube insertions and a higher use of catecholamines in the STT group (p < 0.05). Clinically, we found significant differences in the duration of invasive ventilation (STT: 7.3d vs. MTT: 5.4d; p = 0.001) and ICU stay (STT: 12.3d vs. MTT: 9.4d; p < 0.001). While the complication rate was higher for the STT group (sepsis (STT: 11.4% vs. MTT: 5.7%; p = 0.017); lung failure (STT: 23.7% vs. MTT: 12.3%; p = 0,001)), neither the non-adjusted lethality rate (STT: 13.2% vs. MTT: 13.7%; p = 0.493) nor the Standardized Mortality Ratio (SMR) showed significant differences (STT: 0.66 vs. MTT: 0.80; p = 0.397). The multivariate regressive analysis confirmed that severe thoracic trauma is not an independent risk factor for lethality in our patient cohort. Conclusion Despite a higher injury severity, the extended need of emergency measures and a higher rate of complications in injured patients with severe blunt thoracic trauma, no influence on lethality can be proved. The reduction of the complication rate should be a goal for the next decades.
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Affiliation(s)
- Michael Grubmüller
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Eva Diepold
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Katharina Angerpointner
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Michael Nerlich
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Antonio Ernstberger
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany.
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Comparative studies of different types of osteosynthesis on the human corpse preparation in bilateral antero-lateral flail chest. Injury 2017; 48:2709-2716. [PMID: 29037517 DOI: 10.1016/j.injury.2017.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 10/07/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Bilateral flail chest injuries are challenging in treatment and comparatively often require an operative stabilization of the anterior chest wall to re-establish normal physiological conditions of the chest wall in shape and statics. Various procedures have been described which are technically sophisticated for the surgeon. Consequently there is an increasing interest in potentials of operative care and their effectiveness on the anterolateral chest wall. MATERIALS AND METHODS 12 Human cadavers were prepared and the natural Sternum Position (NP) was marked. A digital probe was fixed to the sternum at the height of the 4th intercostal space in order to measure and compare the stability of the thorax. Readings were taken of the sternal displacement at 1-5cm sagittal distance from NP in starting conditions and from every combination of materials. Serial osteotomies were performed on 2 locations on ribs 2-8 to induce bilateral flail chest. Afterwards the stabilization was achieved with different implants: RESULTS: The osteotomies lead to a subsidence of the sternum occurred to almost 75 mm from NP which corresponds to a maximal unstable situation. The unstable chest wall showed substantially more stabilization through the use of locking plates. Our materialcombinations showed a stability of up to 60% of normal. The more ribs were treated osteosynthetically, the higher the stability of the chest wall. DISCUSSION AND CONCLUSIONS Locking plate fixation offers anatomically realignment of the ribs whereas metal strut support only lifts up the chest wall, but could not provide realignment of the dislocated ribs.
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Reduced invasive and muscle-sparing operative approaches to the posterolateral chest wall provide an excellent accessibility for the operative stabilization! Eur J Trauma Emerg Surg 2017; 44:471-481. [DOI: 10.1007/s00068-017-0877-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022]
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Kocher GJ, Sharafi S, Azenha LF, Schmid RA. Chest wall stabilization in ventilator-dependent traumatic flail chest patients: who benefits? Eur J Cardiothorac Surg 2017; 51:696-701. [PMID: 28007867 DOI: 10.1093/ejcts/ezw365] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/16/2016] [Indexed: 12/18/2022] Open
Abstract
Objectives Traumatic flail chest is a potentially life threatening injury, often associated with prolonged invasive mechanical ventilation and intensive care unit stay. This study evaluates the usefulness and cost-effectiveness of surgical rib stabilization in patients with flail chest resulting in ventilator dependent respiratory insufficiency. Methods A retrospective study on a consecutive series of patients with flail chest with the need for mechanical ventilation was performed. Effectiveness of rib fixation was evaluated in terms of predictors for prolonged ventilation, cost-effectiveness and outcome. Results A total of 61 patients underwent flail chest stabilization using a locked titanium plate fixation system between July 2010 and December 2015 at our institution. 62% ( n = 38) of patients could be weaned from the ventilator within the first 72 h after surgery. Multiple linear regression analysis revealed that closed head injury, bilateral flail chest, number of stabilized ribs and severity of lung contusion were the main independent predictors for prolonged mechanical ventilation (Odds ratio (OR) 6.88; 3.25; 1.52 and 1.42) and tracheostomy (OR 9.17; 2.2; 1.76 and 0.84 ), respectively. Furthermore cost analysis showed that already a two day reduction in ICU stay could outweigh the cost of surgical rib fixation. Conclusions Operative rib fixation has the potential to reduce ventilator days and ICU stay and subsequently hospital costs in selected patients with severe traumatic flail chest requiring mechanical ventilation. Especially associated closed head injury can adversely affect mechanical ventilation time. Furthermore the subgroups of patients sustaining a fall from a height and those with flail chest after cardiopulmonary re-animation seem to profit only marginally from surgical rib fixation.
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Affiliation(s)
- Gregor J Kocher
- Division of General Thoracic Surgery, University Hospital Bern/Inselspital, Bern, Switzerland
| | - Siamak Sharafi
- Center for Communicable Diseases Control, Ministry of Health and Medical Education, Tehran, Iran
| | | | - Ralph A Schmid
- Division of General Thoracic Surgery, University Hospital Bern/Inselspital, Bern, Switzerland
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Bemelman M, de Kruijf MW, van Baal M, Leenen L. Rib Fractures: To Fix or Not to Fix? An Evidence-Based Algorithm. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 50:229-234. [PMID: 28795026 PMCID: PMC5548197 DOI: 10.5090/kjtcs.2017.50.4.229] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/21/2017] [Accepted: 07/22/2017] [Indexed: 12/19/2022]
Abstract
Rib fractures are a common injury resulting from blunt chest trauma. The most important complications associated with rib fractures include death, pneumonia, and the need for mechanical ventilation. The development of new osteosynthesis materials has stimulated increased interest in the surgical treatment of rib fractures. Surgical stabilisation, however, is not needed for every patient with rib fractures or for every patient with flail chest. This paper presents an easy-to-use evidence-based algorithm, developed by the authors, for the treatment of patients with flail chest and isolated rib fractures.
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Affiliation(s)
| | | | | | - Luke Leenen
- Department of Surgery, University Medical Centre Utrecht
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31
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Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury 2017; 48:307-321. [PMID: 27912931 DOI: 10.1016/j.injury.2016.11.026] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 11/05/2016] [Accepted: 11/21/2016] [Indexed: 02/02/2023]
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32
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Forward DP, Ollivere BJ, Ng JWG, Coughlin TA, Rollins KE. Current concepts in rib fracture fixation. ACTA ACUST UNITED AC 2016. [DOI: 10.1302/2048-0105.55.360464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Rib fracture fixation by orthopaedic and cardiothoracic surgeons has become increasingly popular for the treatment of chest injuries in trauma. The literature, though mainly limited to Level II and III evidence, shows favourable results for operative fixation. In this paper we review the literature and discuss the indications for rib fracture fixation, surgical approaches, choice of implants and the future direction for management. With the advent of NICE guidance and new British Orthopaedic Association Standards for Trauma (BOAST) guidelines in production, the management of rib fractures is going to become more and more commonplace.
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Nickerson TP, Thiels CA, Kim BD, Zielinski MD, Jenkins DH, Schiller HJ. Outcomes of Complete Versus Partial Surgical Stabilization of Flail Chest. World J Surg 2016; 40:236-41. [PMID: 26374224 DOI: 10.1007/s00268-015-3169-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rib fractures are common after chest wall trauma. For patients with flail chest, surgical stabilization is a promising technique for reducing morbidity. Anatomical difficulties often lead to an inability to completely repair the flail chest; thus, the result is partial flail chest stabilization (PFS). We hypothesized that patients with PFS have outcomes similar to those undergoing complete flail chest stabilization (CFS). METHODS A prospectively collected database of all patients who underwent rib fracture stabilization procedures from August 2009 until February 2013 was reviewed. Abstracted data included procedural and complication data, extent of stabilization, and pulmonary function test results. RESULTS Of 43 patients who underwent operative stabilization of flail chest, 23 (53%) had CFS and 20 (47%) underwent PFS. Anterior location of the fracture was the most common reason for PFS (45%). Age, sex, operative time, pneumonia, intensive care unit and hospital length of stay, and narcotic use were the same in both groups. Total lung capacity was significantly improved in the CFS group at 3 months. No chest wall deformity was appreciated on follow-up, and no patients underwent additional stabilization procedures following PFS. CONCLUSION Despite advances in surgical technique, not all fractures are amenable to repair. There was no difference in chest wall deformity, narcotic use, or clinically significant impairment in pulmonary function tests among patients who underwent PFS compared with CFS. Our data suggest that PFS is an acceptable strategy and that extending or creating additional incisions for CFS is unnecessary.
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Affiliation(s)
- Terry P Nickerson
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Cornelius A Thiels
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Brian D Kim
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Martin D Zielinski
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Donald H Jenkins
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Henry J Schiller
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Benyan AS, Korymasov EA, Pushkin SY. [Ribs osteosynthesis in patients with isolated and combined chest trauma]. Khirurgiia (Mosk) 2016:26-33. [PMID: 27239911 DOI: 10.17116/hirurgia2016426-33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Rapid methods of costal fractures fixation using special costal plates are becoming more common. AIM To evaluate the efficacy of ribs osteosynthesis in patients with isolated and combined chest trauma. MATERIAL AND METHODS It is presented an experience of surgical treatment of patients with costal fractures in case of isolated (30) and combined (29) chest injury. System for ribs osteosynthesis was used predominantly in surgical tactics. RESULTS Immediate surgical results were analyzed. Most patients had increase of blood gas parameters, oxygenation in the postoperative period. In case of isolated chest injury mean duration of mechanical ventilation was 1.3±1.1, incidence of complications - 3.3%, mortality rate - 0%. In group of combined injuries those indexes were 4.6±3.05, 13.8% and 13.8% respectively. CONCLUSION The method of ribs osteosynthesis in patients with isolated and combined chest trauma showed high efficiency.
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Affiliation(s)
- A S Benyan
- Samara State Medical University, Ministry of Health of the Russian Federation, Samara; V.D.Seredavin Samara Regional Clinical Hospital, Samara
| | - E A Korymasov
- Samara State Medical University, Ministry of Health of the Russian Federation, Samara; V.D.Seredavin Samara Regional Clinical Hospital, Samara
| | - S Yu Pushkin
- Samara State Medical University, Ministry of Health of the Russian Federation, Samara; V.D.Seredavin Samara Regional Clinical Hospital, Samara
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De Palma A, Sollitto F, Loizzi D, Di Gennaro F, Scarascia D, Carlucci A, Giudice G, Armenio A, Ludovico R, Loizzi M. Chest wall stabilization and reconstruction: short and long-term results 5 years after the introduction of a new titanium plates system. J Thorac Dis 2016; 8:490-8. [PMID: 27076945 DOI: 10.21037/jtd.2016.02.64] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND We report short and long-term results with the dedicated Synthes(®) titanium plates system, introduced 5 years ago, for chest wall stabilization and reconstruction. METHODS We retrospectively analyzed (January 2010 to December 2014) 27 consecutive patients (22 males, 5 females; range 16-83 years, median age 60 years), treated with this system: primary [3] and secondary [8] chest wall tumor; flail chest [5]; multiple ribs fractures [5]; sternal dehiscence-diastasis [3]; sternal fracture [1]; sternoclavicular joint dislocation [1]; Poland syndrome [1]. Short-term results were evaluated as: operating time, post-operative morbidity, mortality, hospital stay; long-term results as: survival, plates-related morbidity, spirometric values, chest pain [measured with Verbal Rating Scale (VRS) and SF12 standard V1 questionnaire]. RESULTS Each patient received from 1 to 10 (median 2) titanium plates/splints; median operating time was 150 min (range: 115-430 min). Post-operative course: 15 patients (55.6%) uneventful, 10 (37%) minor complications, 2 (7.4%) major complications; no post-operative mortality. Median post-operative hospital stay was 13 days (range: 5-129 days). At a median follow-up of 20 months (range: 1-59 months), 21 patients (78%) were alive, 6 (22%) died. Three patients presented long-term plates-related morbidity: plates rupture [2], pin plate dislodgment [1]; two required a second surgical look. One-year from surgery median spirometric values were: FVC 3.31 L (90%), FEV1 2.46 L (78%), DLCO 20.9 mL/mmHg/min (76%). On 21 alive patients, 7 (33.3%) reported no pain (VRS score 0), 10 (47.6%) mild (score 2), 4 (19.1%) moderate (score 4), no-one severe (score >4); 15 (71.5%) reported none or mild, 6 (28.5%) moderate pain influencing quality of life. CONCLUSIONS An optimal chest wall stabilization and reconstruction was achieved with the Synthes(®) titanium plates system, with minimal morbidity, no post-operative mortality, acceptable operating time and post-operative hospital stay. Long-term restoration of a normal respiratory function was achieved, with minimal plates-related morbidity and chest pain.
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Affiliation(s)
- Angela De Palma
- 1 Section of Thoracic Surgery, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy ; 2 Section of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy ; 3 Section of Plastic Surgery and Burn Center, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Francesco Sollitto
- 1 Section of Thoracic Surgery, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy ; 2 Section of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy ; 3 Section of Plastic Surgery and Burn Center, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Domenico Loizzi
- 1 Section of Thoracic Surgery, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy ; 2 Section of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy ; 3 Section of Plastic Surgery and Burn Center, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Francesco Di Gennaro
- 1 Section of Thoracic Surgery, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy ; 2 Section of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy ; 3 Section of Plastic Surgery and Burn Center, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Daniele Scarascia
- 1 Section of Thoracic Surgery, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy ; 2 Section of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy ; 3 Section of Plastic Surgery and Burn Center, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Annalisa Carlucci
- 1 Section of Thoracic Surgery, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy ; 2 Section of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy ; 3 Section of Plastic Surgery and Burn Center, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Giuseppe Giudice
- 1 Section of Thoracic Surgery, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy ; 2 Section of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy ; 3 Section of Plastic Surgery and Burn Center, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Andrea Armenio
- 1 Section of Thoracic Surgery, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy ; 2 Section of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy ; 3 Section of Plastic Surgery and Burn Center, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Rossana Ludovico
- 1 Section of Thoracic Surgery, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy ; 2 Section of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy ; 3 Section of Plastic Surgery and Burn Center, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Michele Loizzi
- 1 Section of Thoracic Surgery, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy ; 2 Section of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy ; 3 Section of Plastic Surgery and Burn Center, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
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Schulz-Drost S, Grupp S, Pachowsky M, Oppel P, Krinner S, Mauerer A, Hennig FF, Langenbach A. Stabilization of flail chest injuries: minimized approach techniques to treat the core of instability. Eur J Trauma Emerg Surg 2016; 43:169-178. [PMID: 27084543 DOI: 10.1007/s00068-016-0664-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 03/11/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Stabilizing techniques of flail chest injuries usually need wide approaches to the chest wall. Three main regions need to be considered when stabilizing the rib cage: median-anterior with dissection of pectoral muscle; lateral-axillary with dissection of musculi (mm) serratus, externus abdominis; posterior inter spinoscapular with division of mm rhomboidei, trapezius and latissimus dorsi. Severe morbidity due to these invasive approaches needs to be considered. This study discusses possibilities for minimized approaches to the shown regions. METHOD Fifteen patients were stabilized by locked plate osteosynthesis (MatrixRib®) between May 2012 and April 2014 and prospectively followed up. Flail chest injuries were managed through limited incisions to the anterior, the lateral, and the posterior parts of the chest wall or their combinations. Each approach was 4-10 cm using Alexis® retractor. RESULTS One minimized approach offered sufficient access at least to four ribs posterior and laterally, four pairs of ribs anterior in all cases. There was no need to divide latissimus dorsi muscle. Trapezius und rhomboid muscles were only limited divided, whereas a subcutaneous dissection of serratus and abdominis muscles was necessary. A follow-up showed sufficient consolidation. COMPLICATIONS pneumothorax (2) and seroma (2). CONCLUSION Minimized approaches allow sufficient stabilization of severe dislocated rib fractures without extensive dissection or division of the important muscles. Keeping the arm and, thus, the scapula mobile is very important for providing the largest reachable surface of the rib cage through each approach.
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Affiliation(s)
- S Schulz-Drost
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany. .,Department of Pediatric Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.
| | - S Grupp
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - M Pachowsky
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - P Oppel
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - S Krinner
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - A Mauerer
- Department of Orthopedic and Trauma Surgery, St. Theresien Krankenhaus, Mommsenstr. 24, Nuremberg, Germany
| | - F F Hennig
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - A Langenbach
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
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DeFreest L, Tafen M, Bhakta A, Ata A, Martone S, Glotzer O, Krautsak K, Rosati C, Stain SC, Bonville D. Open reduction and internal fixation of rib fractures in polytrauma patients with flail chest. Am J Surg 2015; 211:761-7. [PMID: 26899958 DOI: 10.1016/j.amjsurg.2015.11.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/02/2015] [Accepted: 11/06/2015] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Lori DeFreest
- Division of Trauma and Critical Care, Department of Surgery, Albany Medical Center Hospital, 42 New Scotland Avenue, 194 Albany, NY, 12208-3479, USA.
| | - Marcel Tafen
- Division of Trauma and Critical Care, Department of Surgery, Albany Medical Center Hospital, 42 New Scotland Avenue, 194 Albany, NY, 12208-3479, USA
| | - Avinash Bhakta
- Division of Trauma and Critical Care, Department of Surgery, Albany Medical Center Hospital, 42 New Scotland Avenue, 194 Albany, NY, 12208-3479, USA
| | - Ashar Ata
- Division of Trauma and Critical Care, Department of Surgery, Albany Medical Center Hospital, 42 New Scotland Avenue, 194 Albany, NY, 12208-3479, USA
| | - Stephen Martone
- Division of Trauma and Critical Care, Department of Surgery, Albany Medical Center Hospital, 42 New Scotland Avenue, 194 Albany, NY, 12208-3479, USA
| | - Owen Glotzer
- Division of Trauma and Critical Care, Department of Surgery, Albany Medical Center Hospital, 42 New Scotland Avenue, 194 Albany, NY, 12208-3479, USA
| | - Kevin Krautsak
- Division of Trauma and Critical Care, Department of Surgery, Albany Medical Center Hospital, 42 New Scotland Avenue, 194 Albany, NY, 12208-3479, USA
| | - Carl Rosati
- Division of Trauma and Critical Care, Department of Surgery, Albany Medical Center Hospital, 42 New Scotland Avenue, 194 Albany, NY, 12208-3479, USA
| | - Steven C Stain
- Division of Trauma and Critical Care, Department of Surgery, Albany Medical Center Hospital, 42 New Scotland Avenue, 194 Albany, NY, 12208-3479, USA
| | - Daniel Bonville
- Division of Trauma and Critical Care, Department of Surgery, Albany Medical Center Hospital, 42 New Scotland Avenue, 194 Albany, NY, 12208-3479, USA
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Slobogean GP, Kim H, Russell JP, Stockton DJ, Hsieh AH, O’Toole RV. Rib Fracture Fixation Restores Inspiratory Volume and Peak Flow in a Full Thorax Human Cadaveric Breathing Model. ARCHIVES OF TRAUMA RESEARCH 2015; 4:e28018. [PMID: 26848471 PMCID: PMC4733518 DOI: 10.5812/atr.28018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 06/10/2015] [Accepted: 09/10/2015] [Indexed: 11/16/2022]
Abstract
Background: Multiple rib fractures cause significant pain and potential for chest wall instability. Despite an emerging trend of surgical management of flail chest injuries, there are no studies examining the effect of rib fracture fixation on respiratory function. Objectives: Using a novel full thorax human cadaveric breathing model, we sought to explore the effect of flail chest injury and subsequent rib fracture fixation on respiratory outcomes. Patients and Methods: We used five fresh human cadavers to generate negative breathing models in the left thorax to mimic physiologic respiration. Inspiratory volumes and peak flows were measured using a flow meter for all three chest wall states: intact chest, left-sided flail chest (segmental fractures of ribs 3 - 7), and post-fracture open reduction and internal fixation (ORIF) of the chest wall with a pre-contoured rib specific plate fixation system. Results: A wide variation in the mean inspiratory volumes and peak flows were measured between specimens; however, the effect of a flail chest wall and the subsequent internal fixation of the unstable rib fractures was consistent across all samples. Compared to the intact chest wall, the inspiratory volume decreased by 40 ± 19% in the flail chest model (P = 0.04). Open reduction and internal fixation of the flail chest returned the inspiratory volume to 130 ± 71% of the intact chest volumes (P = 0.68). A similar 35 ± 19% decrease in peak flows was seen in the flail chest (P = 0.007) and this returned to 125 ± 71% of the intact chest following ORIF (P = 0.62). Conclusions: Negative pressure inspiration is significantly impaired by an unstable chest wall. Restoring mechanical stability of the fractured ribs improves respiratory outcomes similar to baseline values.
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Affiliation(s)
- Gerard P. Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
- Corresponding author: Gerard P. Slobogean, Department of Orthopaedics, University of Maryland School of Medicine, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA. Tel: +1-4103286280, Fax: +1-4103282893, E-mail:
| | - Hyunchul Kim
- Fischell Department of Bioengineering, Orthopaedic Mechanobiology Laboratory, University of Maryland, College Park, Maryland, USA
| | - Joseph P. Russell
- Fischell Department of Bioengineering, Orthopaedic Mechanobiology Laboratory, University of Maryland, College Park, Maryland, USA
| | - David J. Stockton
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Adam H. Hsieh
- Fischell Department of Bioengineering, Orthopaedic Mechanobiology Laboratory, University of Maryland, College Park, Maryland, USA
| | - Robert V. O’Toole
- Department of Orthopaedics, University of Maryland School of Medicine, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
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Zhang X, Guo Z, Zhao C, Xu C, Wang Z. Management of patients with flail chest by surgical fixation using claw-type titanium plate. J Cardiothorac Surg 2015; 10:145. [PMID: 26530190 PMCID: PMC4632363 DOI: 10.1186/s13019-015-0363-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/28/2015] [Indexed: 11/29/2022] Open
Abstract
Background The goal of the study was to compare surgical rib fixation using claw-type titanium plate with conservative treatment in the management of patients with flail chest. Methods The study retrospectively studied 23 patients suffering from flail chest injury, who admitted to our hospital from October, 2010 to February, 2014. The patients received surgical fixation by using claw-type titanium plate (surgical fixation group). A age and sex-matched cohort of 29 patients received conservative treatment and defined as conservative treatment group. Outcome variables included number of cases undergoing mechanical ventilation, ventilation time, time of hospital stay, incidence of respiratory complications, incidence of thoracic deformity and postoperative forced expiratory volume in the first second (FEV1). Results Compared with conservative treatment group, surgical fixation group had fewer cases undergoing mechanical ventilation, shorter ventilation time, shorter hospital stay, lower incidence of respiratory complications and thoracic deformity and improved pulmonary function. Patients undergoing surgery earlier had shorter time of mechanical ventilation. Conclusions Surgical rib fixation with claw-type titanium plate is a reliable and efficient method in the management of patients with flail chest.
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Affiliation(s)
- Xufeng Zhang
- The Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, NO.164 Lan Xi Road, Shanghai, 200062, China.
| | - Zhiqiang Guo
- The Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, NO.164 Lan Xi Road, Shanghai, 200062, China.
| | - Chuncheng Zhao
- The Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, NO.164 Lan Xi Road, Shanghai, 200062, China.
| | - Chenyuan Xu
- The Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, NO.164 Lan Xi Road, Shanghai, 200062, China.
| | - Zheng Wang
- The Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, NO.164 Lan Xi Road, Shanghai, 200062, China.
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The oblique fracture of the manubrium sterni caused by a seatbelt--a rare injury? Treatment options based on the experiences gained in a level I trauma centre. INTERNATIONAL ORTHOPAEDICS 2015; 40:791-8. [PMID: 25957589 DOI: 10.1007/s00264-015-2801-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Sternal fractures are rare with 3-8 % out of the total number of trauma cases mostly caused by direct impact to the anterior chest wall. Most cases described are due to motor vehicle crash either caused by direct impact to the steering wheel or by the seat belt. Fractures mainly occur to the sternal body. Only rarely are cases of manubrium fractures described in literature, for example, in relationship with a direct impact to the shoulder which caused an oblique fracture near to the sternoclavicular joint. Three patients with profoundly dislocated oblique manubrium fracture were admitted to our Level I Trauma Center in 2012 and 2013. Those patients suffered from instability of the upper sternum and the shoulder girdle. MATERIAL AND METHODS Between January 2012 and October 2013, a total of 538 trauma patients were admitted to the emergency room and received whole body CT-scan. They were analysed retrospectively for sternal fractures. In cases of instability and dislocation, fracture stabilisation was performed by anterior plating through a medial approach using low profile titanium plates (MatrixRib®). RESULTS Seventy-nine (14.7 %) patients showed sternal fracture, out of which 13 (2.4 %) patients showed a fracture of manubrium, ten caused by seatbelt. In three cases stabilization was performed. Follow up showed sufficient consolidation without complications. DISCUSSION A total of 16.5 % of sternal fractures were localized at the manubrium, mostly caused by seat belt. Fractures without significant dislocation seemed to be stable and healed well under conservative treatment. Dislocation in this region leads to unstable shoulder girdle. Anterior plating provides sufficient stabilisation and allowed consolidation.
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Abstract
Despite significant advances in critical care management, flail chest remains a clinically significant finding, with a mortality rate of up to 33%. Nonsurgical management is associated with prolonged ventilator support, pneumonia, respiratory difficulties, and lengthy stays in the intensive care unit, as well as chronic pain from nonunion and malunion of the bony thorax. Treatment with aggressive pulmonary toilet, ventilator support, and different modalities of pain control remains the benchmark of care. However, several recent randomized controlled studies of surgical intervention of flail chest have demonstrated an improvement in the number of ventilator days, intensive care unit and hospital stays, incidence of pneumonia, and respiratory function and hospital costs, as well as faster return to work. The success of these surgical constructs compared with those of historical attempts at open fixation is largely the result of modern plating technology and improvement in surgical approaches. Clinical evidence continues to grow regarding proper indications and techniques for surgical stabilization of flail chest.
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Dean NC, Van Boerum DH, Liou TG. Rib plating of acute and sub-acute non-union rib fractures in an adult with cystic fibrosis: a case report. BMC Res Notes 2014; 7:681. [PMID: 25270323 PMCID: PMC4197343 DOI: 10.1186/1756-0500-7-681] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 09/26/2014] [Indexed: 11/21/2022] Open
Abstract
Background Rib fractures associated with osteoporosis have been reported to occur ten times more frequently in adults with cystic fibrosis. Fractures cause chest pain, and interfere with cough and sputum clearance leading to worsened lung function and acute exacerbations which are the two main contributors to early mortality in cystic fibrosis. Usual treatment involves analgesics and time for healing; however considerable pain and disability result due to constant re-injury from chronic repetitive cough. Recently, surgical plating of rib fractures has become commonplace in treating acute, traumatic chest injuries. We describe here successful surgical plating in a White cystic fibrosis patient with multiple, non-traumatic rib fractures. Case presentation A-37-year old White male with cystic fibrosis was readmitted to Intermountain Medical Center for a pulmonary exacerbation. He had developed localized rib pain while coughing 2 months earlier, with worsening just prior to hospital admission in conjunction with a “pop” in the same location while bending over. A chest computerized tomography scan at admission demonstrated an acute 5th rib fracture and chronic non-united 6th and 7th right rib fractures. An epidural catheter was placed both for analgesia and to make secretion clearance possible in preparation for the surgery performed 2 days later. Under general anesthesia, he had open reduction and internal fixation of the right 5th, 6th and 7th rib fractures with a Synthes Matrix rib set. After several days of increased oxygen requirements, fever, fluid retention, and borderline vital signs, he stabilized. Numerical pain rating scores from his ribs were lower post-operatively and he was able to tolerate chest physical therapy and vigorous coughing. Conclusions In our case report, rib plating with bone grafting improved rib pain and allowed healing of the fractures and recovery, although the immediate post-op period required close attention and care. We believe repair may be of benefit in selected cystic fibrosis patients, such as our patient who had suffered multiple rib fractures that were healing poorly.
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Affiliation(s)
- Nathan C Dean
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, Utah 84107, USA.
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Lee SA, Hwang JJ, Chee HK, Kim YH, Lee WS. Flail chest stabilization with Nuss operation in presence of multiple myeloma. J Thorac Dis 2014; 6:E43-7. [PMID: 24822124 DOI: 10.3978/j.issn.2072-1439.2014.02.10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 02/19/2014] [Indexed: 12/31/2022]
Abstract
Nowadays the Nuss operation has been widely adopted as a minimally invasive procedure and standard surgical choice in pectus excavatum. However, much debate and concern have been raised regarding its applicability in adults with pectus excavatum flail chest and other thoratic wall deformities, as compared with younger patients, in terms of complications after surgery. To stabilize the segment of paradoxical chest wall movement we performed the Nuss operation on a patient with multiple myeloma who sustained blunt thoracic trauma. The patient presented with paradoxical movement of the thoracic wall and sternum instability due to multiple myeloma, which led to severe dyspnea, hypoxemia, hypercapnea, and bedridden state. His condition progressed to acute respiratory distress syndrome and did not respond to conservative treatment. We performed the Nuss operation on the patient, and his clinical symptoms were relieved after surgery. The patient regained the ability to walk unassisted and was discharged from the hospital without any specific events.
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Affiliation(s)
- Song Am Lee
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
| | - Jae Joon Hwang
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
| | - Hyun Keun Chee
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
| | - Yo Han Kim
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
| | - Woo Surng Lee
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
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Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg 2014; 76:462-8. [PMID: 24458051 DOI: 10.1097/ta.0000000000000086] [Citation(s) in RCA: 206] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Flail chest injuries are associated with severe pulmonary restriction, a requirement for intubation and mechanical ventilation, and high rates of morbidity and mortality. Our goals were to investigate the prevalence, current treatment practices, and outcomes of flail chest injuries in polytrauma patients. METHODS The National Trauma Data Bank was used for a retrospective analysis of the injury patterns, management, and clinical outcomes associated with flail chest injuries. Patients with a flail chest injury admitted from 2007 to 2009 were included in the analysis. Outcomes included the number of days on mechanical ventilation, days in the intensive care unit (ICU), days in the hospital, and rates of pneumonia, sepsis, tracheostomy, chest tube placement, and death. RESULTS Flail chest injury was identified in 3,467 patients; the mean age was 52.5 years, and 77% of the patients were male. Significant head injury was present in 15%, while 54% had lung contusions. Treatment practices included epidural catheters in 8% and surgical fixation of the chest wall in 0.7% of the patients. Mechanical ventilation was required in 59%, for a mean of 12.1 days. ICU admission was required in 82%, for a mean of 11.7 days. Chest tubes were used in 44%, and 21% required a tracheostomy. Complications included pneumonia in 21%, adult respiratory distress syndrome in 14%, sepsis in 7%, and death in 16%. Patients with concurrent severe head injury had higher rates of ventilatory support and ICU stay and had worse outcomes in every category compared with those without a head injury. CONCLUSION Patients who have sustained a flail chest have significant morbidity and mortality. More than 99% of these patients were treated nonoperatively, and only a small proportion (8%) received aggressive pain management with epidural catheters. Given the high rates of morbidity and mortality in patients with a flail chest injury, alternate methods of treatment including more consistent use of epidural catheters for pain or surgical fixation need to be investigated with large randomized controlled trials. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level IV.
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Krüger M, Zinne N, Zhang R, Schneider JP, Heckmann A, Haverich A, Petersen C. Multidirectional Thoracic Wall Stabilization: A New Device on the Scene. Ann Thorac Surg 2013; 96:1846-9. [DOI: 10.1016/j.athoracsur.2013.06.088] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/17/2013] [Accepted: 06/20/2013] [Indexed: 11/16/2022]
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Abstract
Blunt chest wall trauma accounts for a large proportion of all trauma presentations to the Emergency Departments in the United Kingdom and has a high reported incidence of morbidity and mortality. The difficulty in the assessment and management of this patient group arises from the possibility that the patient may develop potentially life-threatening complications up to approximately 72 h post-injury, even in patients who have sustained what is initially considered a minor injury. Limited consensus currently exists in the literature regarding optimal assessment or management strategies for this patient group. The aim of this review is to provide an overview of current research investigating the optimal assessment and management strategies for the blunt chest wall trauma patient.
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Affiliation(s)
- Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea, UK
- College of Medicine, Swansea University, Swansea, UK
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Muhm M, Härter J, Weiss C, Winkler H. Severe trauma of the chest wall: surgical rib stabilisation versus non-operative treatment. Eur J Trauma Emerg Surg 2013; 39:257-65. [DOI: 10.1007/s00068-013-0262-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 01/30/2013] [Indexed: 11/25/2022]
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