Absorbable plates for rib fracture repair: preliminary experience

Suture fixation of traumatic rib fracture flail segment with Klebsiella osteomyelitis

We report the case of a 71-year-old male who initially presented with urosepsis and was found to have a rib fracture of his right 6th rib with a flail segment and an associated abscess. Given the concern for infection, surgical rib fixation with titanium plating was not pursued during the washout of his abscess and instead, he successfully underwent rib fracture stabilization with bilateral suture transfixation. He was continued on a prolonged course of antibiotics for Klebsiella pneumonia osteomyelitis and was discharged uneventfully with optimal pain control and adequate respiratory effort.

Functionally graded 3D printed plates for rib fracture fixation

BACKGROUND

Design freedom offered by additive manufacturing allows for the implementation of functional gradients - where mechanical stiffness is decreased along the length of the implant. It is unclear if such changes will influence failure mechanisms in the context of rib fracture repair. We hypothesized that our novel functionally graded rib implants would be less stiff than controls and decrease occurrence of secondary fracture at implant ends.

METHODS

Five novel additively manufactured rib implants were tested along with a clinically used Control implant. Fracture reconstructions were modeled with custom synthetic rib bones with a transverse B1 fracture. Ribs were compressed in a cyclic two-point bend test for 360,000 cycles followed by a ramp to failure test. Differences in cyclic stiffness, 3D interfragmentary motions, ramp-to-failure stiffness, maximum load, and work to failure were determined.

FINDINGS

The Control group had lower construct stiffness (0.76 ± 0.28 N/mm), compared to all novel implant designs (means: 1.35-1.61 N/mm, p < 0.05) and rotated significantly more about the bending axis (2.7° ± 1.3°) than the additively manufactured groups (means between 1.2° - 1.6°, p < 0.05). All constructs failed via bone fracture at the most posterior screw hole. Experimental implants were stiffer than Controls, and there were few significant differences between functional gradient groups.

INTERPRETATION

Additively manufactured, functionally graded designs have the potential to change the form and function of trauma implants. Here, the impact of functional gradients was limited because implants had small cross-sectional areas.

A novel minimally invasive fixation method for flail chest management in a Canine model: an animal research

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.

Prospective Randomized Trial of Metal vs Resorbable Plates in Surgical Stabilization of Rib Fractures

INTRODUCTION

Surgical stabilization of rib fractures has gained popularity as both metal and resorbable plates have been approved for fracture repair. Is there a difference between metal and resorbable plate rib fixation regarding rib fracture alignment, control of pain, and quality-of-life scores (Rand SF-36 survey)?

METHODS

Eligible patients (pts) included ≥18 years with one or more of the following: flail chest, one or more bi-cortical displaced fractures (3 -10), non-displaced fractures with failure of medical management. Pts were randomized to either metal or resorbable plate fixation. Primary outcome was fracture alignment. Secondary outcomes were pain scores, opioid use and QOL scores.

RESULTS

30 pts were randomized (15 metal/15 resorbable). Total ribs plated 167 (88 metal/79 resorbable). Pts with rib displacement at day of discharge (DOD) metal 0/14 (1 pt died, not from plating) vs resorbable 9/15 or 60% (p = .001). Ribs displaced at DOD metal 0/88 vs resorbable 22/79 or 28% (p < .001), 48% in posterior location. Pts with increased rib displacement 3-6-months: metal 0/11 vs resorbable 3/9 or 33% (p = .043). Ribs with increased displacement 3-6-months metal 0/67 vs resorbable 6/49 or 12.2% (p < .004). Pain scores & narcotic use at post-op day 1, 2, 3, DOD, 2 wks, 3 and 6 months showed no statistically significant difference between groups. QOL scores were also similar at 3 and 6 months. Trauma recidivism in outpatient period resulted in fracture of resorbable plates in 2 pts requiring a second surgery.

CONCLUSION

Metal plates provided better initial alignment with no displacement over time. Clinical outcomes were similar regarding pain, narcotic use & QOL scores. Routine use of resorbable plates for posterior rib fractures is not warranted. Lateral repairs were technically most feasible for using resorbable plates but still resulted in significant displacement. Resorbable plates may not maintain rib alignment when exposed to subsequent injury.

LEVEL OF EVIDENCE

Level II, therapeutic.

Prosthetic-free ribs stabilization technique in critical complex chest wall traumas: first results and experiences

Background

Surgical stabilization in complex chest wall traumas, especially in case of posterior ribs arch destruction and flail chest, still remains a challenge for thoracic and trauma surgeons. Throughout the years different techniques and materials developed to address the complex anatomy of the ribs and reach an adequate fixation. Our aim is to present a prosthetic-free ribs stabilization technique which is easily reproducible and can achieve an efficient mechanical stabilization of the chest wall.

Methods

This surgical technique can be summarized in three steps: muscle sparing thoracotomy following modified “Shaw-Paulson’s” technique (complete section of the latissimus dorsi muscle along the transverse processes of vertebral spine to rich the serratus muscles plane), prosthetic-free ribs fixation with single stiches (Maxon™ 1) and muscles repositioning.

Results

Between January 2018 and June 2020, we retrospectively evaluated ten consecutive patients (six male and four female) which underwent a chest wall stabilization because of a posterior ribs destruction and flail chest. No chest wall deformities were observed during follow-up with CT-scan after 4, 30 and 90 days and no patient underwent additional early or late stabilization procedures.

Conclusions

In the case of severe thoracic trauma with chest wall destruction and flail chest, modified “Shaw-Paulson approach” and prosthetic-free fixation technique with Maxon thread should be considered as a valuable option allowing an adequate stabilization of the chest with optimal respiratory function.

Operative Stabilization of Chest Wall Trauma: Single-Center Report of Initial Management and Long-Term Outcome

BACKGROUND

Conservative treatment of even severe thoracic trauma including flail chest was traditionally the standard of care. Recently, we reported possible benefits of surgical chest wall stabilization in accordance with other groups. The aim of this study was to critically review our indications and results of internal fixation of rib fractures in the long-term course.

METHODS

We retrospectively analyzed the data of a consecutive series of patients with internal rib fracture fixation at our institution from 8/2009 until 12/2014, and we retrospectively studied the late outcome through clinical examination or personal interview.

RESULTS

From 1398 patients, 235 sustained a severe thoracic trauma (AIS ≥3). In 23 of these patients, 88 internal rib fixations were performed using the MatrixRIB^® system. The median age of these operated patients was 56 years [interquartile range (IQR) 49-63] with a median ISS of 21 [IQR 16-29]. From 18 local resident patients, follow-up was obtained after an average time period of 27.6 (12-68) months. Most of these patients were free of pain and had no limitations in their daily routine. Out of all implants, 5 splint tips perforated the ribs in the postoperative course, but all patients remained clinically asymptomatic. Plate osteosynthesis showed no loss of reduction in the postoperative course. No cases of hardware prominence, wound infection or non-union occurred.

CONCLUSIONS

In our carefully selected thoracic trauma patients, locked plate rib fixation seemed to be safe and beneficial not only in the early posttraumatic course, but also after months and years, patients remain asymptomatic and complete recovery as a rule. Trial registration number KEK BASEC Nr. 2016-01679.

Rib fixation: Who, What, When?

Rib fractures are among the most common traumatic injury found in ∼20% of all patients who suffer thoracic trauma. The majority of these are a result of a blunt mechanism and are often associated with other traumatic injuries. The most common associated injury is lung contusion. Rib fractures impart an increased morbidity and mortality with the highest mortality associated with a flail chest in the elderly population. Flail chest is defined radiographically as 3 or more consecutive ribs fractured in 2 or more places. This often translates to a clinical flail which is associated with paradoxical chest wall movement during respiratory cycles. The mainstay of treatment has been pain control and respiratory support with positive pressure ventilation. However, over the past 2 decades, there has been mounting evidence to suggest that open reduction and internal fixation of ribs benefits patients. The indications remain confined to the most severely injured patients with flail chest or chronic non-unions; however, there remains debate whether or not less severely injured patients would benefit as well. This article will review the current evidence and provide proposed indications based on available evidence and current expert opinion.

Current concepts in rib fracture fixation

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.

Lateral Thoracic Osteoplastic Rib-Sparing Technique Used for Lateral Spine Surgery: Technical Note

Of patients who have undergone lateral approaches to the thoracic spine, surgical site postoperative pain appears to be greater among those who have undergone transection and removal of a rib segment than those who have not. Therefore, techniques that conserve anatomical position and minimize tissue disruption would theoretically result in less pain and a quicker recovery. Herein, we describe a rib-sparing osteoplastic technique used when rib segments need to be displaced in order to create an unobscured corridor to the operative target. Our approach minimizes soft tissue disruption and restores the anatomical function of the rib. Based on our experience, these patients report less pain, mobilize earlier, and are discharged sooner than those who have had rib segments sacrificed as part of a lateral approach to the spine.

Fixation of a human rib by an intramedullary telescoping splint anchored by bone cement

A novel concept for rib fixation is presented that involves the use of a bioresorbable polymer intramedullary telescoping splint. Bone cement is used to anchor each end of the splint inside the medullary canal on each side of the fracture site. In this manner, rib fixation is achieved without fixation device protrusion from the rib, making the splint completely intramedullary. Finite element analysis is used to demonstrate that such a splint/cement composite can preserve rib fixation subjected to cough-intensity force loadings. Computational fluid dynamics and porcine rib experiments were used to study the anchor formation process required to complete the fixation.

Potential Benefits of Rib Fracture Fixation in Patients with Flail Chest and Multiple Non-flail Rib Fractures

The purpose of this study is to evaluate the potential benefits of rib fracture fixation in patients with flail chest and multiple non-flail rib fractures versus conventional treatment modalities. A retrospective reviewed study compared 86 cases which received surgical treatment between June 2009 and May 2013 to 76 cases which received conservative treatment between January 2006 and May 2009. The patients were divided into the flail chest (n = 38) and multiple non-flail rib fracture groups (n = 124). In the flail chest group, the mechanical ventilation time, ICU monitoring time, tracheostomies, thoracic deformity, and impaired pulmonary function and return to full-time employment were compared. In the multiple non-flail rib fracture group, fracture healing, visual analog scale (VAS) pain score, inpatient length of stay, atelectatic, pulmonary complications, and normal activity-returning time were compared. Patients in the flail chest operative fixation group had significantly shorter ICU stay, decreased ventilator requirements, fewer tracheostomies, less thoracic deformity and impaired pulmonary function, and more returned to full-time employment. Patients in the multiple non-flail rib fracture operative fixation had shorter hospital stay, less pain, earlier return to normal activity, more fracture healing, less atelectasis, and fewer pulmonary infections. This study demonstrates the potential benefits of surgical stabilization of flail chest and multiple non-flail rib fractures with plate fixation. When compared with conventional conservative management, operatively managed patients demonstrated improved clinical outcomes.

A Novel Biodegradable Polycaprolactone Fixator for Osteosynthesis Surgery of Rib Fracture: In Vitro and in Vivo Study

Osteosynthesis surgery for rib fractures is controversial and challenging. This study developed a noval poly(ε-caprolactone) (PCL)-based biodegradable “cable-tie” fixator for osteosynthesis surgery for rib fractures. A biodegradable fixator specifically for fractured ribs was designed and fabricated by a micro-injection molding machine in our laboratory. The fixator has three belts that could be passed through matching holes individually. The locking mechanism allows the belt movement to move in only one direction. To examine the in vitro biomechanical performance, ribs 3–7 from four fresh New Zealand rabbits were employed. The load to failure and stress-strain curve was compared in the three-point bending test among native ribs, titanium plate-fixed ribs, and PCL fixator-fixed ribs. In the in vivo animal study, the sixth ribs of New Zealand rabbits were osteotomized and osteosynthesis surgery was performed using the PCL fixator. Outcomes were assessed by monthly X-ray examinations, a final micro-computed tomography (CT) scan, and histological analysis. The experimental results suggested that the ribs fixed with the PCL fixator were significantly less stiff than those fixed with titanium plates (p < 0.05). All ribs fixed with the PCL fixators exhibited union. The bridging callus was confirmed by gross, radiographic micro-three-dimensional (3D) CT, and histological examinations. In addition, there was no significant inflammatory response of the osteotomized ribs or the PCL-rib interface during application. The novel PCL fixator developed in this work achieves satisfactory results in osteosynthesis surgery for rib fractures, and may provide potential applications in other orthopedic surgeries.

Outcomes after operative management of symptomatic rib nonunion

OBJECTIVE

To report the outcomes of rib reconstruction after painful nonunion.

DESIGN

Retrospective case series.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Between November 2007 and May 2013, 10 patients who presented with 16 rib nonunions and disabling pain were treated with reconstruction of their nonunited rib fractures.

INTERVENTION

Rib nonunion reconstruction predominately with iliac crest bone graft and a tension band plate with a locked precontoured plating system for ribs.

MAIN OUTCOME MEASUREMENTS

Demographic data, mechanism of injury, and number of rib nonunions were recorded. Operative procedure, length of follow-up, complications, Short Form Survey 36, and a patient questionnaire were also captured and documented.

RESULTS

Eight of the 10 patients sustained their original fractures from a fall. Outcomes were available for the 10 patients at a mean follow-up of up of 18.6 months (range, 3-46 months). All 16 ribs went on to union with a mean time from reconstruction to union of 14.7 weeks (range, 12-24 weeks). At final follow-up, the mean mental and physical component Short Form Survey 36 scores were 54.4 and 43.5, respectively. Eight of the 10 patients were able to return to work and/or previous activities without limitations. Complications included 1 wound infection that resolved after irrigation and debridement with adjunctive antibiotics. One symptomatic implant was removed.

CONCLUSIONS

Ten patients with 16 symptomatic rib nonunions were reconstructed using autologous bone graft and implant/mesh fixation manifesting in successful union with improved patient function and a low rate of complications.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical treatment of flail chest and rib fractures

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.

Stabilization of multiple rib fractures in a canine model

BACKGROUND

Operative stabilization is frequently used in the clinical treatment of multiple rib fractures (MRF); however, no ideal material exists for use in this fixation. This study investigates a newly developed biodegradable plate system for the stabilization of MRF.

METHODS

Silk fiber-reinforced polycaprolactone (SF/PCL) plates were developed for rib fracture stabilization and studied using a canine flail chest model. Adult mongrel dogs were divided into three groups: one group received the SF/PCL plates, one group received standard clinical steel plates, and the final group did not undergo operative fracture stabilization (n = 6 for each group). Radiographic, mechanical, and histologic examination was performed to evaluate the effectiveness of the biodegradable material for the stabilization of the rib fractures.

RESULTS

No nonunion and no infections were found when using SF-PCL plates. The fracture sites collapsed in the untreated control group, leading to obvious chest wall deformity not encountered in the two groups that underwent operative stabilization.

CONCLUSIONS

Our experimental study shows that the SF/PCL plate has the biocompatibility and mechanical strength suitable for fixation of MRF and is potentially ideal for the treatment of these injuries.

Article Commentary: Contemporary Management of Flail Chest

Thoracic injury is currently the second leading cause of trauma-related death and rib fractures are the most common of these injuries. Flail chest, as defined by fracture of three or more ribs in two or more places, continues to be a clinically challenging problem. The underlying pulmonary contusion with subsequent inflammatory reaction and right-to-left shunting leading to hypoxia continues to result in high mortality for these patients. Surgical stabilization of the fractured ribs remains controversial. We review the history of management for flail chest alone and when combined with pulmonary contusion. Finally, we propose an algorithm for nonoperative and surgical management.

Surgical Management of Rib Fractures: Strategies and Literature Review

Background and Aims:

Rib fractures can cause significant problems in trauma patients, often resulting in pain and difficulty with respiration. To prevent pulmonary complications and decrease the morbidity and mortality rates of patients with rib fractures, currently there is a trend to provide surgical management of patients with flail chest. However, the indications for rib fracture fixation require further specification.

Material and Methods:

Past and current strategies are described according to a review of the medical literature. A systematic review was performed including current indications for rib fracture fixation. MEDLINE (2000–2013) was searched, as well as Embase (2000–2013) and Cochrane Databases, using the keywords rib, fracture, fixation, plate, repair, and surgery.

Results:

Three retrospective studies were found that described different techniques for rib fracture fixation. The results demonstrated a reduced number of ventilation days, decreased long-term morbidity and pain, and satisfactory rehabilitation after surgical treatment. In addition to flail chest, age, Injury Severity Score, and the number of rib fractures were important predictive factors for morbidity and mortality.

Conclusion:

Surgical rib fracture fixation might be indicated in a broader range of cases than is currently performed. Prospective randomized trials are needed for further confirmation.

Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis of studies comparing operative to nonoperative therapy in adult FC patients. Outcomes were duration of mechanical ventilation (DMV), intensive care unit length of stay (ICULOS), hospital length of stay (HLOS), mortality, incidence of pneumonia, and tracheostomy.

BACKGROUND

Flail chest (FC) results in paradoxical chest wall movement, altered respiratory mechanics, and frequent respiratory failure. Despite advances in ventilatory management, FC remains associated with significant morbidity and mortality. Operative fixation of the flail segment has been advocated as an adjunct to supportive care, but no definitive clinical trial exists to delineate the role of surgery.

METHODS

A comprehensive search of 5 electronic databases was performed to identify randomized controlled trials and observational studies (cohort or case-control). Pooled effect size (ES) or relative risk (RR) was calculated using a fixed or random effects model, as appropriate.

RESULTS

Nine studies with a total of 538 patients met inclusion criteria. Compared with control treatment, operative management of FC was associated with shorter DMV [pooled ES: -4.52 days; 95% confidence interval (CI): -5.54 to -3.50], ICULOS (-3.40 days; 95% CI: -6.01 to -0.79), HLOS (-3.82 days; 95% CI: -7.12 to -0.54), and decreased mortality (pooled RR: 0.44; 95% CI: 0.28-0.69), pneumonia (0.45; 95% CI: 0.30-0.69), and tracheostomy (0.25; 95% CI: 0.13-0.47).

CONCLUSIONS

As compared with nonoperative therapy, operative fixation of FC is associated with reductions in DMV, LOS, mortality, and complications associated with prolonged MV. These findings support the need for an adequately powered clinical study to further define the role of this intervention.

Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND

Despite the prevalence and recognized association of pulmonary contusion and flail chest (PC-FC) as a combined, complex injury pattern with interrelated pathophysiology, the mortality and morbidity of this entity have not improved during the last three decades. The purpose of this updated EAST practice management guideline was to present evidence-based recommendations for the treatment of PC-FC.

METHODS

A query was conducted of MEDLINE, Embase, PubMed and Cochrane databases for the period from January 1966 through June 30, 2011. All evidence was reviewed and graded by two members of the guideline committee. Guideline formulation was performed by committee consensus.

RESULTS

Of the 215 articles identified in the search, 129 were deemed appropriate for review, grading, and inclusion in the guideline. This practice management guideline has a total of six Level 2 and eight Level 3 recommendations.

CONCLUSION

Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion. Obligatory mechanical ventilation in the absence of respiratory failure should be avoided. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status. Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure or continuous positive airway pressure should be provided. High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.Steroids should not be used in the therapy of pulmonary contusion. Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.

[Chest trauma: who, how and what?]

A chest-trauma management system, tagged as the "Pécs model" in a tertiary referral center is described with extensive references to the state of the art in thoracic trauma. Chest drainage has utmost importance in primary therapy as well as in surgical decision making (diagnosis). Thoracotomy is a general surgical competence, just as damage control is. Definitive treatment and management of sequelae, however, requires competence in thoracic surgery. Multidisciplinarity is underscored.

Predicting outcome of patients with chest wall injury

BACKGROUND

Rib fractures occur in 10% of injured patients, are associated with morbidity and mortality, and frequently necessitate intensive care unit (ICU) care. A scoring system that identifies the risk for respiratory failure early in the evaluation process may allow early intervention to improve outcomes. The aim of this study was to test the hypothesis that a scoring system based on initial clinical findings can identify patients with rib fractures at greatest risk for morbidity and mortality.

METHODS

A simple scoring system to stratify risk was developed and applied to patients through a retrospective trauma registry review. Points were assigned as follows: age < 45 years = 1 point, age 45 to 65 years = 2 points, age > 65 years = 3 points; <3 fractures = 1 point, 3 to 5 fractures = 2 points, >5 fractures = 3 points; no pulmonary contusion = 0 points, mild pulmonary contusion = 1 point, severe pulmonary contusion = 2 points, bilateral pulmonary contusion = 3 points; and bilateral rib fracture absent = 0 points, bilateral rib fracture absent present = 2 points. A review of trauma registry patients with rib fractures (June 2008 to February 2010) at a state-designated level 1 trauma center was performed. Data reviewed included age, number of fractures, bilateral injury, presence of pulmonary contusion, classification of the contusion, length of hospital stay, mechanical ventilation, ICU admission, and length of stay. The scoring system was retrospectively applied to 649 patients to determine validity.

RESULTS

A score ≤ 7 indicated lower mortality (24 of 579 [4.2%]) compared with patients with scores > 7 (10 of 70 [14.3%]) (Fisher's 2-sided P = .0018). Patients with scores ≤ 6 were less likely to be admitted to an ICU (29.7%) compared with those with scores ≥ 7 (56.7%) (P < .0001). Patients with total scores < 7 were less likely to require intubation (20.6%) compared with those with scores ≥ 7 (40.0%) (P < .0001). Patients with scores ≤ 4 had shorter lengths of stay (36.0% <5 days) compared with those who had scores > 4 (59.7%) (P < .0001).

CONCLUSIONS

A simple scoring system predicts the likelihood that patients will require mechanical ventilation and prolonged courses of care. A score of 7 or 8 predicted increased risk for mortality, admission to the ICU, and intubation. A score > 5 predicted a longer length of stay and a longer period of ventilation. This scoring system may assist in the earlier implementation of treatment strategies such epidural anesthesia, ventilation, and operative fixation of fractures.

Early surgical stabilization of flail chest with locked plate fixation

OBJECTIVES

To compare the results of surgical stabilization with locked plating to nonoperative care of flail chest injuries.

DESIGN

Retrospective case-control study.

SETTING

Level II trauma center.

PATIENTS/PARTICIPANTS

From January 2005 to January 2010, 22 patients with flail chest treated with locked plate fixation were compared with a matched cohort of 28 nonoperatively managed patients at our institution.

INTERVENTION

Open reduction internal fixation of rib fractures with 2.7-mm locking reconstruction plates.

MAIN OUTCOME MEASUREMENTS

Demographic data, such as age, sex, injury severity score, number of fractures, and lung contusion severity, were recorded. Intensive care unit data concerning length of stay (LOS), tracheostomy, and ventilator days were noted. Operative data, such as time to OR, operative time, and estimated blood loss, were recorded. Hospital data, including total hospital LOS, need for reintubation, and home oxygen requirements, were documented.

RESULTS

Average follow-up period of operatively managed patients was 17.84 ± 4.51 months, with a range of 13-22 months. No case of hardware failure, hardware prominence, wound infection, or nonunion was reported. Operatively treated patients had shorter intensive care unit stays (7.59 vs. 9.68 days, P = 0.018), decreased ventilator requirements (4.14 vs. 9.68 days, P = 0.007), shorter hospital LOS (11.9 vs. 19.0 days, P = 0.006), fewer tracheostomies (4.55% vs. 39.29%, P = 0.042), less pneumonia (4.55% vs. 25%, P = 0.047), less need for reintubation (4.55% vs. 17.86%, P = 0.34), and decreased home oxygen requirements (4.55% vs. 17.86%, P = 0.034).

CONCLUSIONS

This study demonstrates the potential benefits of surgical stabilization of flail chest with locked plate fixation. When compared with case-matched controls, operatively managed patients demonstrated improved clinical outcomes. Locked plate fixation seems to be safe as no complications associated with hardware failure, plate prominence, wound infection, or nonunion were noted.

Traumatic ribs fracture: how to treat them?

Flail chest complicates about 10% of patients with chest trauma and is associated with a mortality rate of 10-20% in older series, while a recent one reports no mortality. The majority of the cases are treated conservatively with internal pneumatic stabilization and pain control. In recent years, nevertheless, we assisted in the resurgence of chest wall fixation due to the availability of new devices. We report our experience in the use of mouldable titanium clips (STRACOS, Strasbourg Thoracic Osteosyntheses System; MedXpert, Heitersheim, Germany) to fix traumatic rib fracture. This device presents an advantage over previous strategies, as it is easy to apply and doesn’t require drilling and screwing of the ribs.

Ten-year experience with the muscle split technique, bioabsorbable plates, and postoperative bracing for correction of pectus carinatum: the Innsbruck protocol

OBJECTIVE

We reviewed further clinical experience with our approach for pectus carinatum repair: modified surgical approach of pectoralis muscle split technique, bioabsorbable plates with screws, and postoperative compressive brace.

METHODS

From April 2000 to February 2010, 55 patients underwent pectus carinatum repair at our department with modifications of conventional Ravitch repair. There were 14 female and 41 male patients, mean age of 19.3 years at the onset of treatment. Postoperative treatment involved fitting of a lightweight, patient-controlled chest brace.

RESULTS

Average follow-up was 13.7 months. Patient satisfaction was excellent for 40 patients (72.7%) and good for the remaining 15 (27.3%); aesthetic appearance was excellent for 37 patients (67.3%) and good for the remaining 18 (32.7%). Postoperative evaluation was objective measurement with a thorax caliper and clinical examination. No major perioperative complications were observed. Postoperative complications were mild recurrence of deformity (n = 3) and persistent, mild, single costal cartilage protrusion (n = 2). No patient had palpable plates or screws, and there was no material breakdown.

CONCLUSIONS

The combination of muscle split technique and absorbable osteosynthesis represents an alternative in pectus carinatum repair. The pectoralis muscle split technique allows early patient mobilization and rehabilitation. Bioabsorbable plates get completely absorbed, avoiding second operation, and chest brace provides postoperative immobilization of the anterior thoracic wall during healing and avoids development of hypertrophic scars. Our combined approach to the correction of pectus carinatum deformities yields predominantly excellent esthetic results, with low morbidity, low costs, and less invasiveness, leading to high patient satisfaction.

Operative treatment of chest wall injuries: indications, technique, and outcomes

Most injuries to the chest wall with residual deformity do not result in long-term respiratory dysfunction unless they are associated with pulmonary contusion. Indications for operative fixation include flail chest, reduction of pain and disability, a chest wall deformity or defect, symptomatic nonunion, thoracotomy for other indications, and open fractures. Operative indications for chest wall injuries are rare.

Article Commentary: Rib Fracture Fixation: Controversies and Technical Challenges

Rib fractures are a common injury affecting more than 350,000 people each year in the United States and are associated with respiratory complications, prolonged hospitalization, prolonged pain, long-term disability, and mortality. The social and economic costs that rib fractures contribute to the health care burden of the United States are therefore significant. But despite this measurable impact on patients’ quality of life, current treatment of the majority of patients in the United States with rib fracture syndromes is supportive only. Even the most severe of chest wall injuries have historically been treated non-operatively. Recently, however, several reports from American centers support an increased application of operative fixation. With this resurgent interest of American surgeons in mind, we review the clinical presentations, potential indications, controversies, and technical challenges unique to rib fracture fixation.

Operative stabilization of flail chest injuries: review of literature and fixation options

Background

Flail chest injuries cause significant morbidity, especially in multiply injured patients. Standard treatment is typically focused on the underlying lung injury and involves pain control and positive pressure ventilation. Several studies suggest improved short- and long-term outcomes following operative stabilization of the flail segments. Despite these studies, flail chest fixation remains a largely underutilized procedure.

Methods

This article reviews the relevant literature concerning flail chest fixation and describes the different implants and techniques available for fixation. Additionally, an illustrative case example is provided for description of the surgical approach.

Results

Two prospective randomized studies, five comparative studies, and a number of case series documented benefits of operative treatment of flail chest injuries, including a decreased in ventilation duration, ICU stay, rates of pneumonia, mortality, residual chest wall deformity, and total cost of care. Historically, rib fractures have been stabilized with external plates or intramedullary implants. The use of contemporary, anatomically contoured rib plates reduced the need for intraoperative plate bending. Intramedullary rib splints allowed less-invasive fixation of posterior fractures where access for plating was limited.

Conclusion

Operative treatment can provide substantial benefits to patients with flail chest injuries and respiratory compromise requiring mechanical ventilation. The use of anatomically contoured rib plates and intramedullary splints greatly simplifies the procedure of flail chest fixation.

Pilot study of operative fixation of fractured ribs in patients with flail chest

BACKGROUND

Flail chest is a serious injury in trauma with a significant mortality rate, and long-term pain and disability. Traditionally, management has consisted of internal pneumatic splinting, leading to prolonged periods of mechanical ventilation, and its attendant complications. The aim of this study was to assess the safety of operative fixation of broken ribs in flail chest using absorbable prostheses.

METHODS

Thirteen consecutive patients with severe flail chest injury were enrolled in this pilot study. Surgery was planned after viewing three-dimensional reconstructions of the computed tomography scans of the chest. The plates were applied to the external cortical surface of the rib after reducing the fracture. Segmentally fractured ribs were usually plated only once to convert the flail segment to simple fractured ribs and correct the paradoxical wall motion abnormality.

RESULTS

All patients had a good surgical result. On average, four ribs were fixed per patient. All patients were able to be weaned from mechanical ventilation and all patients were discharged from the hospital. There were no deaths. No plates had to be removed. In all patients, the flail chest was successfully stabilized and paradoxical chest wall movement was eliminated.

CONCLUSION

This pilot study of operative fixation of broken ribs in patients with flail chest, using absorbable plates and screws, has shown the technique to be safe and effective. On the basis of these results, a prospective randomized trial has commenced at The Alfred Hospital, comparing this management strategy with conservative management.

A retrospective follow-up of ankle fracture patients treated with a biodegradable plate and screws

BACKGROUND

Biodegradable fixation implants have been developed to avoid secondary hardware removal. The aim of this study was to retrospectively follow-up ankle fracture patients treated with a biodegradable plate and screws, and to evaluate the clinical outcome and occurrence of complications.

METHODS

Fifty-seven ankle fracture patients treated with biodegradable implants were invited, and a total of 50 were available to participate in this study. The follow-up included a review of each patient's medical records, evaluation of radiographs, fracture reduction classification, and functional scoring.

RESULTS

There were 36 lateral malleolar and 14 bimalleolar fractures. No perioperative complications occurred. Average follow-up time was 17 months. All fractures healed. Fracture alignment was classified as anatomical in 49 patients and good in 1 case. The mean Olerud and Molander functional ankle score at final follow-up was 86. Eight patients had postoperative complications. These included delayed wound healing in 1 case, 3 cases of deep-vein thrombosis, and 4 soft tissue reactions.

CONCLUSIONS

According to the results of this retrospective study, the biodegradable implants used yielded fracture healing and functional results comparable to those previously reported after conventional metal fixation.

Evaluation of intramedullary rib splints for less-invasive stabilisation of rib fractures

BACKGROUND

Intramedullary fixation of rib fractures with generic Kirschner wires has been practiced for over 50 years. However, this technique has not been advanced to address reported complications of wire migration and cut-out. This biomechanical study evaluated a novel rib splint designed to replicate the less-invasive fixation approach of Kirschner wires while mitigating their associated complications.

METHODS

The durability, strength, and failure mode of rib fracture fixation with intramedullary rib splints were evaluated in 27 cadaveric ribs. First, intact ribs were loaded to failure to determine their strength and to induce realistic rib fractures. Subsequently, fractures were stabilised with a novel rib splint made of titanium alloy with a rectangular cross-section that was secured with a locking screw. All fixation constructs were dynamically loaded to 360,000 cycles at five times the respiratory load magnitude to determine their durability. Finally, constructs were loaded to failure to determine their residual strength and failure modes.

RESULTS

Native ribs had a strength of 9.7+/-5.0 N m, with a range of 3.5-19.6 N m. Fracture fixation with rib splints was uneventful. All 27 splint constructs sustained dynamic loading without fixation failure, implant migration or implant cut-out. Dynamic loading caused no significant decrease in construct stiffness (p=0.85) and construct subsidence remained on average below 0.5 mm. The residual strength of splint constructs after dynamic loading was 1.1+/-0.24 N m. Constructs failed by splint bending in 44% of specimens and by developing fracture lines along the superior and inferior cortices in 56% of specimens. Regardless of the failure mode, all rib splint constructs recoiled elastically after failure and retained functional reduction and fixation. No construct exhibited implant cut-out or migration through the lateral cortex.

CONCLUSIONS

Rib splints can provide sufficient stability to support respiratory loading throughout the healing phase, but they cannot restore the full strength of native ribs. Most importantly, rib splints mitigated the complications reported for rib fracture fixation with generic Kirschner wires, namely implant cut-out and migration through the lateral cortex. Therefore, rib splints may provide an advanced alternative to the original Kirschner wire technique for less-invasive fixation of rib fractures.

Surgical management of multiple painful rib nonunions in patient with a history of severe shoulder girdle trauma: a case report and literature review

The authors report painful nonunions after multiple rib fractures in a 50-year-old man who sustained a displaced scapula fracture and multiple ipsilateral rib fractures. The rib nonunions were reconstructed after an 11-month trial of nonoperative management, which was unsuccessful. The nonunions healed and symptoms completely resolved.

Rib fracture repair: indications, technical issues, and future directions

Rib fracture repair has been performed at selected centers around the world for more than 50 years; however, the operative indications have not been established and are considered controversial. The outcome of a strictly nonoperative approach may not be optimal. Potential indications for rib fracture repair include flail chest, painful, movable rib fractures refractory to conventional pain management, chest wall deformity/defect, rib fracture nonunion, and during thoracotomy for other traumatic indication. Rib fracture repair is technically challenging secondary to the human rib's relatively thin cortex and its tendency to fracture obliquely. Nonetheless, several effective repair systems have been developed. Future directions for progress on this important surgical problem include the development of minimally invasive techniques and the conduct of multicenter, randomized trials.

Long-Term Morbidity, Vain, and Disability after Repair of Severe Chest Wall Injuries

Long-term morbidity after severe chest wall injuries is common. We report our experience with acute chest wall injury repair, focusing on long-term outcomes and comparing our patients’ health status with the general population. We performed a retrospective medical record review supplemented with a postal survey of long-term outcomes including the McGill Pain Questionnaire (MPQ) and RAND-36 Health Survey. RAND-36 outcomes were compared with reference values from the Medical Outcomes Study and from the general population. Forty-six patients underwent acute chest wall repair between September 1996 and September 2005. Indications included flail chest with failure to wean from the ventilator (18 patients), acute, intractable pain associated with severely displaced rib fractures (15 patients), acute chest wall defect/deformity (5 patients), acute pulmonary herniation (3 patients), and thoracotomy for other traumatic indications (5 patients). Three patients had a concomitant sternal fracture repair. Fifteen patients with a current mean age of 60.6 years (range 30-91) responded to our surveys a mean of 48.5 ± 22.3 months (range 19-96) postinjury. Mean long-term MPQ Pain Rating Index was 6.7 ± 2.1. RAND-36 indices indicated equivalent or better health status compared with references with the exception of role limitations due to physical problems when compared with the general population. The operative repair of severe chest wall injuries is associated with low long-term morbidity and pain, as well as health status nearly equivalent to the general population. Both the MPQ and the RAND-36 surveys were useful tools for determining chest wall pain and disability outcomes.

Biomechanical in vitro evaluation of the effect of cyclic loading on the postoperative fixation stability and degradation of a biodegradable ankle plate

The effect of cyclic loading on the postoperative fixation stability of a biodegradable ankle plate was tested biomechanically during 12 weeks of hydrolytic degradation. Fracture of the lateral malleolus was simulated, and the parameters of cyclic loading were chosen to represent the physiological conditions during the healing period. Additionally, the effect of cyclic loading on degradation was investigated by measuring the inherent viscosities. In Group I, the cyclic loading was conducted in four phases with gradual increases in estimated walking distance and speed during the healing period. In Group II, cyclic loading was conducted after 12 weeks. Group III was used as a control for inherent viscosity measurements. None of the specimens failed under cyclic loading. No significant differences were found between the loaded groups in any of the parameters measured. Additionally, no significant difference was found in inherent viscosities at 12 weeks. The initial fixation stability provided by the biodegradable ankle plate remains biomechanically unchanged over 12 weeks. Cyclic loading, applied either during or after 12 weeks of hydrolytic degradation, does not seem to have any clinically relevant effect on the fixation stability or the degradation properties.

Open pneumothorax resulting from blunt thoracic trauma: a case report

Cases of open pneumothorax have been documented as early as 326 BC. Until the last 50 years, understanding of the epidemiology and treatment of penetrating chest trauma has arisen from military surgery. A better understanding of cardiopulmonary dynamics, advances in ventilatory support, and improvement in surgical technique have drastically improved treatment and increased the survival rate of patients with penetrating thoracic trauma. Open pneumothorax is rare in blunt chest trauma, but can occur when injury results in a substantial loss of the chest wall. This case study presents an adolescent who sustained a large open pneumothorax as a result of being run over by a car. Early and appropriate surgical intervention coupled with coordinated efforts by all members of the trauma team resulted in a positive outcome for this patient.

Biomechanical testing of a novel, minimally invasive rib fracture plating system

BACKGROUND

A novel rib fracture repair plating system was developed to provide durable fixation with a shorter length than standard systems and thus facilitate minimally invasive repair. We hypothesized that U-plate fixation would be at least equivalent in durability to standard anterior fixation.

STUDY

Twenty fresh frozen ribs (10 pairs) from two human cadavers were first tested for intact stiffness (force or deformation). A gap of 5 mm was then created in the middle of each rib with a saw. Each rib was reconstructed with either the U-plate (4.6 cm length, Acute Innovations, LLC, Hillsboro, OR) with four screws or a 2.4-mm anterior locking plate (9.5 cm length, Synthes, Paoli, PA) with six screws. The U-plates were placed on one rib and the anterior plates on the contralateral rib of the paired levels. The reconstructed ribs were cycled 50,000 times with a load of +/-2N at 1 Hz in a simulation of the repetitive loading of deep breathing. The stiffness of the construct was measured throughout the test.

RESULTS

Stiffness decreased from the intact rib to the transected/plated rib for both types of fixation; however, a significant decrease in stiffness was observed only with the anterior repair (p = 0.03). After 50,000 cycles, the U-plated ribs lost 0.12 +/- 0.03 N/mm (1.9%) stiffness, whereas the anterior-plated ribs lost 0.72 +/- 0.13 N/mm (9.9%) stiffness (p = 0.001).

CONCLUSIONS

In this simulation of an unstable rib fracture with a small bony gap, U-plate fixation was more durable than standard anterior fixation. The greatly diminished size of the U-plate compared with the standard may facilitate minimally invasive rib fracture repair.

Reduction of rib fractures with a bioresorbable plating system: preliminary observations

BACKGROUND

Operative fixation of rib fractures can reduce morbidity and mortality. Currently, resorbable fixation devices are used in a variety of surgical procedures.

METHODS

A standard osteotomy was prepared in 30 New Zealand white rabbits at the 12th rib. Eighteen had surgical repair with bioresorbable plates and 12 underwent nonoperative management. Half the animals in each group were killed at 3-week postfracture and the remaining animals were killed at 6-week postfracture. Ribs were radiographed and processed histologically to assess fracture healing. Rib reduction was defined as the alignment of the rib ends in a structural condition similar to the prefractured state and quantitative radiomorphometry measured the radiopaque callus surrounding the rib injury sites. Statistical analysis was performed using Fisher's exact test and an unpaired Student's t test and significance was established at p < 0.05.

RESULTS

At both the 3- and 6-week intervals, seven of the nine rib fractures remained reduced in the operative group, whereas zero of six and three of six of the rib fractures remained reduced, respectively, in the nonoperative group. A statistically significant increase in radiopaque callus surrounding the rib injury sites was observed at 3 and 6 weeks in the fixed groups.

CONCLUSIONS

Fixation of rib fractures with a bioresorbable miniplate system was superior to nonoperative treatment at the 3-week interval, with a statistically significant increase in radiopaque callus formation at both 3 and 6 weeks. Additional studies will evaluate the biomechanical outcomes and degradation tissue response after extended in vivo intervals.