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Van Wijck SFM, Van Diepen MR, Prins JTH, Verhofstad MHJ, Wijffels MME, Van Lieshout EMM. Radiographic rib fracture nonunion and association with fracture classification in adults with multiple rib fractures without flail segment: A multicenter prospective cohort study. Injury 2024; 55:111335. [PMID: 38290909 DOI: 10.1016/j.injury.2024.111335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 01/01/2024] [Accepted: 01/14/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Rib fracture nonunion is a probable cause of chronic pain following chest trauma, although its prevalence remains unknown. The aims of this study were to determine rib fracture nonunion prevalence following nonoperative management and to determine if presence of nonunion was associated with the number of rib fractures, or the rib fracture classification of anatomical location, type, and displacement. METHODS This multicenter prospective cohort study included trauma patients with three or more fractured ribs but without a flail segment, who participated in the nonoperative management group of the FixCon trial between January 2019 and June 2022. The number and classification of rib fractures were assessed on trauma chest CT. Chest CTs conducted six months post-trauma were evaluated for the presence of nonunion. Radiological characteristics of nonunions were compared with normally healed rib fractures using the Mann-Whitney U, χ2 test, and Fisher's exact test as appropriate. A generalized linear model adjusted for multiple observations per patient when assessing the associations between nonunion and fracture characteristics. RESULTS A total of 68 patients were included with 561 post-traumatic fractures in 429 ribs. Chest CT after six months revealed nonunions in 67 (12 %) rib fractures in 29 (43 %) patients with a median of 2 (P25-P75 1-3) nonunions per patient. Nonunion was most commonly observed in ribs seven to 10 (20-23 %, p < 0.001, adjusted p = 0.006). Nonunion occurred in 14 (5 %) undisplaced, 22 (19 %) offset, and 20 (23 %) displaced rib fractures (p < 0.001). No statistically significant association between rib fracture type and nonunion was found. CONCLUSIONS Forty-three percent of patients with multiple rib fractures had radiographic nonunion six months after trauma. Fractures in ribs seven to 10 and dislocated fractures had an increased risk of rib fracture nonunion.
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Spering C, Moerer O, White TW, Lehmann W. [Surgical reconstruction of chest wall instability : Indications, contraindications and timing of surgery]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:171-179. [PMID: 38214732 DOI: 10.1007/s00113-023-01400-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 01/13/2024]
Abstract
The impact of energy on the thorax can lead to serial rib fractures, sternal fractures, the combination of both and to injury of intrathoracic organs depending on the type, localization and intensity. Sometimes this results in chest wall instability with severe impairment of the respiratory mechanics. In the last decade the importance of surgical chest wall reconstruction in cases of chest wall instability has greatly increased. The evidence for a surgical approach has in the meantime been supported by prospective randomized multicenter studies, multiple retrospective data analyses and meta-analyses based on these studies, including a Cochrane review. The assessment of form and severity of the trauma and the degree of impairment of the respiratory mechanism are the basis for a structured decision on an extended conservative or surgical reconstructive strategy as well as the timing, type and extent of the operation. The morbidity (rate of pneumonia, duration of intensive care unit stay and mechanical ventilation) and fatality can be reduced by a timely surgery within 72 h after trauma. In this article the already established and evidence-based algorithms for surgical chest wall reconstruction are discussed in the context of the current evidence.
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Affiliation(s)
- Christopher Spering
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland.
| | - Onnen Moerer
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Thomas W White
- Department of Surgery, Intermountain Medical Center, Murray, UT, USA
| | - Wolfgang Lehmann
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland
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Forrester JD, Bauman ZM, Cole PA, Edwards JG, Knight AW, LaRoque M, Raffa T, White TW, Kartiko S. Chest Wall Injury Society recommendation for surgical stabilization of nonunited rib fractures to decrease pain, reduce opiate use, and improve patient reported outcomes in patients with rib fracture nonunion after trauma. J Trauma Acute Care Surg 2023; 95:943-950. [PMID: 37728432 DOI: 10.1097/ta.0000000000004083] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND Rib fractures are common injuries which can be associated with acute pain and chronic disability. While most rib fractures ultimately go on to achieve bony union, a subset of patients may go on to develop non-union. Management of these nonunited rib fractures can be challenging and variability in management exists. METHODS The Chest Wall Injury Society's Publication Committee convened to develop recommendations for use of surgical stabilization of nonunited rib fractures (SSNURF) to treat traumatic rib fracture nonunions. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject the recommendation. RESULTS No identified studies compared SSNURF to alternative therapy and the overall quality of the body of evidence was rated as low. Risk of bias was identified in all studies. Despite these limitations, there is lower-quality evidence suggesting that SSNURF may be beneficial for decreasing pain, reducing opiate use, and improving patient reported outcomes among patients with symptomatic rib nonunion. However, these benefits should be balanced against risk of symptomatic hardware failure and infection. CONCLUSION This guideline document summarizes the current CWIS recommendations regarding use of SSNURF for management of rib nonunion. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Joseph D Forrester
- From the Division of General Surgery, Department of Surgery (J.D.F., A.K.), Stanford University, Stanford, California; Division of Acute Care Surgery (Z.M.B.), University of Nebraska Medical Center, Omaha, Nebraska; HealthPartners Orthopaedics and Sports Medicine (P.A.C.), Bloomington, Minnesota; Department of Orthopaedic Surgery (P.A.C., M.L.), University of Minnesota, Minneapolis, Minnesota; Department of Orthopaedic Surgery (P.A.C.), Regions Hospital, Saint Paul, Minnesota; Sheffield Teaching Hospitals NHS Trust (J.G.E.), Sheffield, United Kingdom; and Center for Trauma and Critical Care (T.R., T.W.W.), Department of Surgery (T.R., S.K.), George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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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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Zhang D, Jiao C, Xi S, Wang L, Li R, Zhang Q. Evaluation of surgical outcomes in elderly patients with rib fractures: A single-centre propensity score matching study. Front Surg 2023; 10:1174365. [PMID: 37143770 PMCID: PMC10151702 DOI: 10.3389/fsurg.2023.1174365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 03/31/2023] [Indexed: 05/06/2023] Open
Abstract
Background Rib fractures are the most common injuries in chest trauma. Compared with younger patients, elderly patients with rib fracture have a higher incidence of complications and mortality. A retrospective study was conducted to investigate the effect of internal fixation compared with conservative treatment on the outcome of rib fracture in elderly patients. Material and methods We used a 1:1 propensity score matching method to perform a retrospective analysis of 703 elderly patients with rib fractures treated in the Thoracic Surgery Department of Beijing Jishuitan Hospital between 2013 and 2020. After matching, the length of hospital stay, death, symptom relief and rib fracture healing were compared between the surgery and the control group. Results The study included 121 patients receiving SSRF in the surgery group and 121 patients receiving conservative treatment in the control group. The length of hospital stay in the surgery group was significantly longer than that in the conservative group (11.39d vs. 9.48d, p = 0.000). After 9 months of follow-up, the fracture healing rate in the surgery group was significantly higher than that in the control group (96.67% vs. 88.89%, p = 0.020). The fracture healing time (p = 0.000), improvement in pain score (p = 0.000) and duration of pain medication use (p = 0.000) were also significantly better in the surgery group than in the control group. Conclusion Compared with conservative treatment, surgical treatment can prolong hospital stay to some extent. However, it has the advantages of more rapid healing and lessened pain. For rib fractures in elderly individuals, surgical treatment is a safe and effective option under strict surgical indications and is recommended.
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Affiliation(s)
- Dong Zhang
- Department of Thoracic Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Chenbo Jiao
- Health Science Center, Peking University, Beijing, China
| | - Siqi Xi
- Health Science Center, Peking University, Beijing, China
| | - Langran Wang
- Health Science Center, Peking University, Beijing, China
| | - Run Li
- Health Science Center, Peking University, Beijing, China
| | - Qiang Zhang
- Department of Thoracic Surgery, Beijing Jishuitan Hospital, Beijing, China
- Correspondence: Qiang Zhang
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Tang WR, Chang CC, Wang CJ, Yang TH, Hung KS, Wu CH, Yen YT, Tseng YL, Shan YS. Tailored Surgical Stabilization of Rib Fractures Matters More Than the Number of Fractured Ribs. J Pers Med 2022; 12:jpm12111844. [PMID: 36579572 PMCID: PMC9698685 DOI: 10.3390/jpm12111844] [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: 07/10/2022] [Revised: 09/09/2022] [Accepted: 10/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients sustaining multiple rib fractures have a significant risk of developing morbidity and mortality. More evidence is emerging that the indication of surgical stabilization of rib fractures (SSRF) should expand beyond flail chest. Nevertheless, little is known about factors associated with poor outcomes after surgical fixation. We reviewed patients with rib fractures to further explore the role of SSRF; we matched two groups by propensity score (PS). METHOD A comparison of patients with blunt thoracic trauma treated with SSRF between 2010 and 2020 was compared with those who received conservative treatment for rib fractures. Risk factors for poor outcomes were analyzed by multivariate regression analysis. RESULTS After tailored SSRF, the number of fractured ribs was not associated with longer ventilator days (p = 0.617), ICU stay (p = 0.478), hospital stay (p = 0.706), and increased nonprocedure-related pulmonary complications (NPRCs) (p = 0.226) despite having experienced much more severe trauma. In the multivariate regression models, lower GCS, delayed surgery, thoracotomy, and flail chest requiring mechanical ventilation were factors associated with prolonged ventilator days. Lower GCS, higher ISS, delayed surgery, and flail chest requiring mechanical ventilation were factors associated with longer ICU stays. Lower GCS and older age were factors associated with increased NPRCs. In the PS model, NPRCs risk was reduced by SSRF. CONCLUSIONS The risk of NPRCs was reduced once ribs were surgically fixed through an algorithmic approach, and poor consciousness and aging were independent risk factors for NPRCs.
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Affiliation(s)
- Wen-Ruei Tang
- Department of Surgery, National Cheng Kung University Hospital, Tainan 704, Taiwan
| | - Chao-Chun Chang
- Division of Trauma and Acute Care Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan 704, Taiwan
| | - Chih-Jung Wang
- Division of Trauma and Acute Care Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan 704, Taiwan
| | - Tsung-Han Yang
- Division of Trauma and Acute Care Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan 704, Taiwan
| | - Kuo-Shu Hung
- Division of Trauma and Acute Care Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan 704, Taiwan
| | - Chun-Hsien Wu
- Department of Surgery, National Cheng Kung University Hospital, Tainan 704, Taiwan
| | - Yi-Ting Yen
- Division of Trauma and Acute Care Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan 704, Taiwan
- Correspondence: ; Tel.: +886-6-235-3535 (ext. 3002)
| | - Yau-Lin Tseng
- Department of Surgery, National Cheng Kung University Hospital, Tainan 704, Taiwan
| | - Yan-Shen Shan
- Department of Surgery, National Cheng Kung University Hospital, Tainan 704, Taiwan
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Narsule CK, Mosenthal AC. Is There a Role for Rib Plating in Thoracic Trauma? Adv Surg 2022; 56:321-335. [PMID: 36096575 DOI: 10.1016/j.yasu.2022.02.009] [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: 10/14/2022]
Abstract
Rib fractures are a morbid consequence of blunt trauma and are associated with a highly variable clinical presentation ranging from nondisplaced rib fractures causing limited, manageable pain to severely displaced rib fractures with concomitant thoracic injuries leading to respiratory failure. Due to an evolution of techniques, hardware technology, and general acceptance, rib plating has increased substantially at trauma centers all throughout the United States over the past decade. This article aims to review the most recent and current reports for rib plating with respect to indications, preoperative evaluation and imaging, approaches, timing for intervention, outcomes in patients with flail chest and nonflail injuries, and the management of complications. From these data, it becomes clear that the surgical stabilization of rib fractures (SSRF) has a firm place in the management of thoracic trauma.
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Affiliation(s)
- Chaitan K Narsule
- Department of Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA.
| | - Anne C Mosenthal
- Department of Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA
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Rib fixation in non-ventilator-dependent chest wall injuries: A prospective randomized trial. J Trauma Acute Care Surg 2022; 92:1047-1053. [PMID: 35081599 DOI: 10.1097/ta.0000000000003549] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to assess pain and quality of life (QoL) outcomes in patients with multiple painful displaced fractured ribs with and without operative fixation. Rib fractures are common and can lead to significant pain and disability. There is minimal level 1 evidence for rib fixation in non-ventilator-dependent patients with chest wall injuries. We hypothesized that surgical stabilization of rib fractures would reduce pain and improve QoL during 6 months. METHODS A prospective multicenter randomized controlled trial comparing rib fixation to nonoperative management of nonventilated patients with at least three consecutive rib fractures was conducted. Inclusion criteria were rib fracture displacement and/or ongoing pain. Pain (McGill Pain Questionnaire) and QoL (Short Form 12) at 3 and 6 months postinjury were assessed. Surgeons enrolled patients in whom they felt there was clinical equipoise. Patients who were deemed to need surgical fixation or who were deemed to be too well to be randomized to rib fixation were not enrolled. RESULTS A total of 124 patients were enrolled at four sites between 2017 and 2020. Sixty-one patients were randomized to operative management and 63 to nonoperative management. No differences were seen in the primary endpoint of Pain Rating Index at 3 months or in the QoL measures. Return-to-work rates improved between 3 and 6 months, favoring the operative group. CONCLUSION In this study, no improvements in pain or QoL at 3 and 6 months in patients undergoing rib fixation for nonflail, non-ventilator-dependent rib fractures have been demonstrated. LEVEL OF EVIDENCE Therapeutic/Care Management; Level II.
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Campbell D, Arnold N, Wake E, Grieve J, Provenzano S, Wullschleger M, Patel B. Three-dimensional volume-rendered computed tomography application for follow-up fracture healing and volume measurements pre-surgical rib fixation and post-surgical rib fixation. J Trauma Acute Care Surg 2021; 91:961-965. [PMID: 34417409 DOI: 10.1097/ta.0000000000003383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical rib fixation (SRF) is being used increasingly in trauma centers for stabilization of chest wall injuries, in line with new and evolving surgical techniques. Our institution has developed a pathway for the management of chest wall injuries and SRF, which includes a follow-up low-volume, noncontrast computed tomography (CT) scan at 12 months. METHODS This study was a single-center retrospective study conducted on 25 consecutive patients who underwent SRF between February 2019 and February 2020. All CT measurements were done by a CT radiographer under the supervision of a board-certified radiologist and included the use of three-dimensional volume-rendered images. RESULTS There were no patients with SRF who experienced hardware failure at 12 months in either flail or nonflail groups. For fractured ribs treated with SRF, complete or partial union occurred in 75 of 76 ribs plated (98.7%). The median ratio for improvement in lung volumes was 1.71 for flail SRF and 1.69 for nonflail SRF in our study. CONCLUSION Three-dimensional volume-rendered CT at 12 months post-SRF showed good alignment (no hardware failure) and fracture healing of fixed ribs in both flail and nonflail groups. Lung volumes also improved pre-SRF and post-SRF for both flail and nonflail patients. More studies are needed to define how the pattern of rib fracture healing of fixed and nonfixed ribs affects lung volumes. LEVEL OF EVIDENCE Therapeutic, Level V.
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Affiliation(s)
- Don Campbell
- From the Trauma Service (D.C., E.W., M.W., B.P.), Gold Coast University Hospital; Medical Imaging Department (N.A., J.G.) and Cardiothoracic Department (S.P.), Gold Coast University Hospital; Faculty of Medicine (D.C., E.W.), Griffith University, Gold Coast; and Faculty of Medicine (B.P.), Bond University, Queensland, Australia
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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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Schuette HB, Taylor BC, Rutkowski P, Huber G, Mehta V. Cartilage Plating in Flail Chest Fixation. Injury 2021; 52:2560-2564. [PMID: 34167761 DOI: 10.1016/j.injury.2021.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/21/2021] [Accepted: 06/05/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Operative stabilization of flail chest has been shown to have several benefits over nonoperative management. Often, flail chest injuries will involve the anterior ribs and their associated costal cartilage. In certain cases, operative fixation with open reduction and internal fixation (ORIF) of anterior rib fractures involving the costal cartilage may be warranted. Currently, there is scant literature regarding the surgical approach and clinical outcomes of ORIF involving the costal cartilage. The purpose of this study is to describe the surgical approach and first reported clinical series for patients undergoing anterior rib ORIF involving the costal cartilage. PATIENTS AND METHODS After Institutional Review Board approval was obtained, a retrospective case series was performed at a single urban level 1 trauma center including patients 18 years of age or older who underwent ORIF of anterior rib fractures involving the costal cartilage. All surgical approaches were performed with muscle-sparing techniques. Patients were followed during their hospitalization period and postoperatively as routinely scheduled. Data collection including patient demographics, injury characteristics, operative variables, and postoperative outcomes were collected and analyzed. RESULTS Thirty patients, with a mean age of 54.4 years, were included in this study. All patients had a flail chest injury and were treated with ORIF on average 4.1 days following injury. There were no intraoperative complications reported. Total hospital length of stay averaged 22.8 days with an intensive care unit stay averaging 6.1 days; total ventilator time averaged 5.2 days. Six patients were diagnosed with postoperative pneumonia and no postoperative superficial infections, deep infections, or seromas were noted. Eight patients required tracheostomy postoperatively. Only 1 patient had evidence of radiographic malunion, and a separate patient had evidence of screw loosening; no patients required or requested implant removal. Union rate was 100% and one-year mortality was 0%. CONCLUSION Open reduction and internal fixation of anterior rib fractures involving the costal cartilage is a safe procedure with low complication rates and favorable postoperative outcomes including hospital length of stay, intensive care unit length of stay, postoperative pneumonia, need for tracheostomy, and mechanical ventilation time.
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Affiliation(s)
- Hayden B Schuette
- OhioHealth/Doctors Hospital, Department of Orthopedics, Columbus, OH.
| | - Benjamin C Taylor
- OhioHealth/Grant Medical Center, Department of Orthopedic Trauma, Columbus, OH
| | - Paul Rutkowski
- Mount Carmel Health System, Department of Orthopedics, Columbus, OH
| | - Grant Huber
- OhioHealth/Grant Medical Center, Department of Orthopedic Trauma, Columbus, OH
| | - Vishvam Mehta
- OhioHealth/Grant Medical Center, Department of Orthopedic Trauma, Columbus, OH
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12
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Caragounis EC, Xiao Y, Granhed H. Mechanism of injury, injury patterns and associated injuries in patients operated for chest wall trauma. Eur J Trauma Emerg Surg 2021; 47:929-938. [PMID: 30953111 PMCID: PMC8319693 DOI: 10.1007/s00068-019-01119-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 03/27/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Chest wall injuries are common in blunt trauma and associated with significant morbidity and mortality. The aim of this study was to determine the most common mechanisms of injury (MOI), injury patterns, and associated injuries in patients who undergo surgery for chest wall trauma. METHODS This was a retrospective study of trauma patients with multiple rib fractures and unstable thoracic cage injuries who were managed surgically at Sahlgrenska University Hospital during the period September 2010-September 2017. The MOI, injury severity score (ISS), new injury severity score (NISS), thoracic and associated injuries were recorded. Patients were categorized according to age (years): groups I (15‒44), II (45‒64) and III ( > 64). Unstable thoracic cage injuries were classified as sternal, anterior, lateral and posterior flail chest. RESULTS Two hundred and eleven trauma patients with a mean age (years) of 58.2 ± 15.6, mean ISS 23.6 ± 11.0, and mean NISS 34.1 ± 10.6 were included in the study. Traffic accidents were the most common MOI in Group I (62%) and falls in Group III (59%). The most common flail segments were lateral and posterior. Sternal and anterior flail segments were more common with bilateral injuries and traffic accidents, particularly frontal collisions. Injuries in at least three body regions were also more associated with traffic accidents. Diaphragmatic injury was seen in 18% of patients who underwent thoracotomy. CONCLUSIONS The MOI associated with multiple rib fractures differs according to the age of the patient and is associated with different chest wall injury patterns and extra-thoracic injuries.
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Affiliation(s)
- Eva-Corina Caragounis
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Per Dubbsgatan 15, 413 45, Gothenburg, Sweden.
| | - Yao Xiao
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Per Dubbsgatan 15, 413 45, Gothenburg, Sweden
| | - Hans Granhed
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Per Dubbsgatan 15, 413 45, Gothenburg, Sweden
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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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14
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Di Napoli M, Doben AR, DeVoe WB, Eriksson E. Reversed contour rib plate for surgical stabilization of juxtaspinal rib fractures: Description of a novel surgical technique. J Trauma Acute Care Surg 2021; 90:e163-e168. [PMID: 34016934 DOI: 10.1097/ta.0000000000003150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Marissa Di Napoli
- From the Division of General and Acute Care Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
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15
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Schuette HB, Glazier MT, Triplet JJ, Taylor BC. Far posterior rib plating: Preliminary results of a retrospective case series. Injury 2021; 52:1133-1137. [PMID: 33468313 DOI: 10.1016/j.injury.2020.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/29/2020] [Accepted: 12/06/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Far posterior, or paraspinal rib fractures, defined as fractures that are medial to the medial border of the scapula (and may involve the costovertebral articulation), are often treated nonoperatively. However, in certain cases, including severe displacement, persistent pain, nonunion, or persistent respiratory distress, stabilization with open reduction and internal fixation (ORIF) may be warranted. There is a paucity of literature regarding the surgical approach and clinical outcomes following ORIF for far posterior rib fractures and fracture-dislocations. The purpose of this paper is to describe the surgical approach and to report the first collection of clinical outcomes for patients undergoing paraspinal rib ORIF. PATIENTS AND METHODS A retrospective case series was performed at a single urban level 1 trauma center. Patients 18 years of age or older who underwent ORIF of far posterior rib fractures were included in this study. Far posterior rib fractures were defined as fractures that occurred medial to the medial border of the scapula underneath the paraspinal musculature. Data collection including patient demographics, injury characteristics, operative variables, and postoperative outcomes were collected and analyzed. RESULTS Twenty-six patients, with a mean age of 50.7 years, who underwent paraspinal rib ORIF were included in this study. The mean follow-up was 12.1 months. 80.8% of patients had a flail chest injury. On average, 3.4 ribs were instrumented posteriorly with 22.8% of patients requiring fixation spanning the costotransverse articulation. No intraoperative complications occurred. Only one patient required a repeat procedure. Total hospital length of stay averaged 17.3 days with an intensive care unit stay averaging 6.2 days. Total ventilator time averaged 4 days. 7 patients were diagnosed with postoperative pneumonia and 6 patients required tracheostomy. CONCLUSION Open reduction and internal fixation for far posterior, or paraspinal rib fractures and fracture-dislocations is a safe procedure with low complications rates and favorable postoperative outcomes including hospital length of stay, ICU length of stay, need for tracheostomy, postoperative pneumonia, and mechanical ventilation time.
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Affiliation(s)
- Hayden B Schuette
- OhioHealth/Doctors Hospital, Department of Orthopedics, Columbus, OH 43228, United States.
| | - Matthew T Glazier
- OhioHealth/Doctors Hospital, Department of Orthopedics, Columbus, OH 43228, United States
| | - Jacob J Triplet
- OhioHealth/Doctors Hospital, Department of Orthopedics, Columbus, OH 43228, United States
| | - Benjamin C Taylor
- OhioHealth Orthopedic Trauma and Reconstructive Surgeons, Grant Medical Center, Columbus, OH 43215, United States
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Zhang J, Hong Q, Mo X, Ma C. Complete Video-assisted Thoracoscopic Surgery for Rib Fractures: A Series of 35 Cases. Ann Thorac Surg 2021; 113:452-458. [PMID: 33675706 DOI: 10.1016/j.athoracsur.2021.01.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/08/2021] [Accepted: 01/25/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Video-assisted thoracoscopic surgery (VATS) for internal fixation of rib fracture is a promising approach for treating rib fractures and flail chest. Currently, the standard practice is to make one or several incisions on the chest wall, which will inevitably aggravate the original trauma. METHODS We retrospectively analyzed the data of patients with rib fractures who were treated with memory alloy for internal fixation by complete VATS using a thoracoscopic transthoracic memory alloy rib coaptation board and an implantation tool through the clip applier method or the puncture, traction and suspension method at our hospital from October 2016 to June 2019. RESULTS There were 35 patients, of whom 12 had traumatic flail chest injury, and 23 had simple multiple rib fractures. Of the 23 patients with multiple rib fractures, 9 had fracture ends in the scapular or paravertebral region, and 14 had fracture ends located in the anterior or lateral chest walls. All surgeries were performed with complete VATS, and it showed quick recovery and good thoracic appearance and function, with no complications for all patients. Follow-up for 6-24 months revealed no detachment of the internal fixation device. CONCLUSIONS Internal memory alloy fixation with complete VATS for the treatment of rib fractures is a simple and minimally invasive method, which enables fixing fractured ribs internally while treating thoracic trauma with a thoracoscope.
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Affiliation(s)
- Jijun Zhang
- Department of Cardiothoracic Surgery, Shenzhen Longgang Central Hospital, the Ninth People's Hospital of Shenzhen City, Shenzhen, China.
| | - Qiongchuan Hong
- Department of Cardiothoracic Surgery, Shenzhen Longgang Central Hospital, the Ninth People's Hospital of Shenzhen City, Shenzhen, China
| | - Xiaochao Mo
- Department of Cardiothoracic Surgery, The Fourth Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Chengfang Ma
- Department of Cardiothoracic Surgery, Shenzhen Longgang Central Hospital, the Ninth People's Hospital of Shenzhen City, Shenzhen, China
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Myers DM, McGowan SP, Taylor BC, Sharpe BD, Icke KJ, Gandhi A. A model for evaluating the biomechanics of rib fracture fixation. Clin Biomech (Bristol, Avon) 2020; 80:105191. [PMID: 33045492 DOI: 10.1016/j.clinbiomech.2020.105191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/12/2020] [Accepted: 09/28/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION High rates of morbidity and mortality following flail chest rib fractures are well publicized. Standard of care has been supportive mechanical ventilation, but serious complications have been reported. Internal rib fixation has shown improvements in pulmonary function, clinical outcomes, and decreased mortality. The goal of this study was to provide a model defining the biomechanical benefits of internal rib fixation. METHODS One human cadaver was prepared with an actuator providing anteroposterior forces to the thorax and rib motion sensors to define interfragmentary motion. Cadaveric model was validated using a prior study which defined costovertebral motion to create a protocol using similar technology and procedure. Ribs 4-6 were fixed with motion sensors anteriorly, laterally and posteriorly. Motion was recorded with ribs intact before osteotomizing each rib anteriorly and laterally. Flail chest motion was record with fractures subsequently plated and analyzed. Motion was recorded in the sagittal, coronal and transverse axes. FINDINGS Compared to the intact rib model, the flail chest model demonstrated an 11.3 times increase in sagittal plane motion, which was reduced to 2.1 times the intact model with rib plating. Coronal and sagittal plane models also saw increases of 9.7 and 5.1 times, respectively, with regards to flail chest motion. Both were reduced to 1.2 times the intact model after rib plating. INTERPRETATION This study allows quantification of altered ribcage biomechanics after flail chest injuries and suggests rib plating is useful in restoring biomechanics as well as contributing to improving pulmonary function and clinical outcomes.
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Affiliation(s)
- Devon M Myers
- Department Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA.
| | - Sean P McGowan
- Department Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA
| | - Benjamin C Taylor
- Fellowship Director, Orthopaedic Trauma and Reconstructive Surgery, Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA
| | - B Dale Sharpe
- Department Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA
| | - Kyle J Icke
- ZimmerBiomet Research Department, 1520 Tradeport Dr., Jacksonville, FL 32218, USA
| | - Anup Gandhi
- ZimmerBiomet Laboratory Department, 10225 Westmoor Dr., Westminster, CO 80021, USA
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Leasia K, Douglas I, Lawless R, Burlew CC, Platnick KB, Moore EE, Pieracci FM. Validation of current procedural terminology codes for surgical stabilization of rib fractures. Injury 2020; 51:2500-2506. [PMID: 32962828 DOI: 10.1016/j.injury.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Current procedural terminology (CPT) codes for surgical stabilization of rib fractures (SSRF) are based solely on the number of ribs fixed, tricotomized at 1-3, 4-6, and ≥ 7. Our objective was to validate CPT codes against operative time at our institution, as well as further stratify complexity by rib fracture location and surgical approach. The purpose of this study is to validate the current CPT coding schema for SSRF, and to identify potential modifiers that are associated with increased case complexity. We hypothesized that operative time is associated with CPT code, number of fractures repaired, exposure technique, and fracture location. METHODS Retrospective review of SSRF cases from October 2010 to March 2020. The primary outcome was the length of the operation (minutes). Predictor variables were CPT code, number of fractures repaired (grouped similarly to CPT codes), fractures repaired:ribs repaired ratio > 1, fracture location (sub-scapular vs. other), and positioning/exposure (supine, lateral, prone, and multiple). Kaplan-Meier time-to-event analyses were used to assess relationship with operative time. RESULTS 188 patients underwent repair of 904 fractures. Operative time was significantly associated with both number of ribs repaired and number of fractures repaired (p<0.01). Although operative time varied significantly by CPT group (p<0.01), there was no significant difference between the 4-6 rib and the ≥ 7 rib groups (p = 0.33). By contrast, each group was significantly different from the others when organized by number of fractures repaired (p = 0.04). Operative time was significantly longer when the fractures repaired:ribs repaired ratio was > 1 (p<0.01), even after stratifying by number of ribs repaired. Both multiple positions/exposures (p<0.01), and repair of ≥ 1 sub-scapular fracture (p<0.01) were significantly associated with operative time. CONCLUSION Number of fractures repaired provided a more accurate estimation of operative time as compared to number of ribs repaired. Based on these data, we recommend altering the CPT schema for SSRF to involve number of fractures repaired, with modifiers for both multiple positions/exposures and repair of sub-scapular fractures.
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Affiliation(s)
- K Leasia
- Denver Health & Hospital Authority, 777 Bannock st. MC 0206 Denver CO 80204 USA.
| | - I Douglas
- Denver Health & Hospital Authority, 777 Bannock st. MC 0206 Denver CO 80204 USA
| | - R Lawless
- Denver Health & Hospital Authority, 777 Bannock st. MC 0206 Denver CO 80204 USA
| | - C C Burlew
- Denver Health & Hospital Authority, 777 Bannock st. MC 0206 Denver CO 80204 USA
| | - K B Platnick
- Denver Health & Hospital Authority, 777 Bannock st. MC 0206 Denver CO 80204 USA
| | - E E Moore
- Denver Health & Hospital Authority, 777 Bannock st. MC 0206 Denver CO 80204 USA
| | - F M Pieracci
- Denver Health & Hospital Authority, 777 Bannock st. MC 0206 Denver CO 80204 USA
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Bauman ZM, Grams B, Yanala U, Shostrom V, Waibel B, Evans CH, Cemaj S, Schlitzkus LL. Rib fracture displacement worsens over time. Eur J Trauma Emerg Surg 2020; 47:1965-1970. [PMID: 32219487 PMCID: PMC7223740 DOI: 10.1007/s00068-020-01353-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/16/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Rib fractures (RF) occur in 10% of trauma patients; associated with significant morbidity and mortality. Despite advancing technology of surgical stabilization of rib fractures (SSRF), treatment and indications remain controversial. Lack of displacement is often cited as a reason for non-operative management. The purpose was to examine RF patterns hypothesizing RF become more displaced over time. METHODS Retrospective review of all RF patients from 2016-2017 at our institution. Patients with initial chest CT (CT1) followed by repeat CT (CT2) within 84 days were included. Basic demographics were obtained. Primary outcomes included RF displacement in millimeters (mm) between CT1 and CT2 in three planes (AP = anterior/posterior, O = overlap/gap, and SI = superior/inferior). Displacement was calculated by subtracting CT1 fracture displacement from CT2 displacement for each rib. Given anatomic and clinical characteristics, ribs were grouped (1-2, 3-6, 7-10, 11-12), averaged, and analyzed for displacement. Secondary outcome included number of missed RF on CT1. Non-parametric sign test and paired t test were used for analysis. Significance was set at p < 0.002. RESULTS 78 of 477 patients with RF on CT1 had CT2 during the study period: primarily male (76%) and age 55.8 ± 20.1 with blunt mechanism of injury (99%). Median Injury Severity Score was 21 (IQR, 13-27) with Chest Abbreviated Injury Score of 3 (IQR, 3-4). Median time between CT1 and CT2 was 6 days (IQR, 3-12). Missed RF rate for CT1 was 10.1% (p = 0.11). Average fracture displacement was significantly increased for all rib groupings except 11-12 in all planes (p < 0.002). CONCLUSION RF become more displaced over time. Pain regimens and SSRF considerations should be adjusted accordingly.
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Affiliation(s)
- Zachary Mitchel Bauman
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA.
| | - Benjamin Grams
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Ujwal Yanala
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Valerie Shostrom
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Brett Waibel
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Charity Hassie Evans
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Samuel Cemaj
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Lisa Lynn Schlitzkus
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
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Su YH, Yang SM, Ko HJ. Diagnosis and management of a trapped lung or diaphragm by fractured ribs: analysis of patients undergoing rib fracture repair. BMC Surg 2019; 19:123. [PMID: 31462238 PMCID: PMC6714410 DOI: 10.1186/s12893-019-0581-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 02/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are few reports regarding a lung or diaphragm trapped by a fractured rib. This study aimed to describe the clinical presentations, diagnosis, and management of these intrathoracic pathologies. METHODS We retrospectively reviewed the database at our institute for patients with rib fractures who underwent thoracoscope-assisted surgical stabilization of rib fracture (SSRF). We analyzed the demographic data, mechanism of trauma, presentations, operative findings, and subsequent management strategies. RESULTS A total of 38 consecutive patients who underwent SSRF were analyzed. Three patients had a trapped lung and one had a trapped diaphragm. Abnormal radiographic findings were observed in 50% of cases. The median waiting time for surgery was 25 days. Surgery was indicated for intractable dynamic pain following conservative treatment. A definitive diagnosis was made during thoracoscopic exploration. Thoracoscopic repair and resection were used for trapped lungs and thoracoscopic release for a trapped diaphragm. We subsequently performed SSRF for unhealed rib fractures. CONCLUSION As per our analysis, the incidence of a trapped lung or diaphragm was 10.5%. If a patient presents with persistent intractable dynamic pain, thoracoscopic exploration with concurrent SSRF may be a feasible and effective treatment option.
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Affiliation(s)
- Ying-Hao Su
- Department of Orthopaedics, National Taiwan University Hospital Hsin-Chu Branch, 25, Lane 442, Sec 1, Jingguo Rd, Hsinchu City, 30059, Taiwan
| | - Shun-Mao Yang
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, 25, Lane 442, Sec 1, Jingguo Rd, Hsinchu city, 30059, Taiwan
| | - Huan-Jang Ko
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, 25, Lane 442, Sec 1, Jingguo Rd, Hsinchu city, 30059, Taiwan.
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22
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Greiffenstein P, Tran MQ, Campeau L. Three common exposures of the chest wall for rib fixation: anatomical considerations. J Thorac Dis 2019; 11:S1034-S1043. [PMID: 31205760 DOI: 10.21037/jtd.2019.03.33] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although surgical fixation of rib fractures is increasingly being performed around the world, very little has been published on how to access the chest wall itself. Having performed over one hundred rib fixations in our institution in the past five years, our surgical technique has evolved as more has come to be understood about these types of injuries through examination of the literature, our own experience, and discussions with colleagues experienced in treating these patients. Retrospective chart review of our trauma registry revealed prevalent fracture patterns and we sought to describe the three simple approaches to the chest wall that we most commonly use based on these data and validated through cadaveric dissections. What follows is a description of our experience with surgical fixation and analysis of the anatomy based on functional approaches to common injury patterns. Analysis of CT scans of patients with flail chest injuries revealed the most commonly encountered in our patients requiring surgical fixation. We identified three basic incisions used to access the areas of interest in a majority of cases. Careful cadaveric dissections allowed us to provide a detailed description of what portions of the chest wall would be accessible through each with and without sparing of the chest musculature. This paper describes viable options for approaching the chest wall for most rib fracture patterns in need of surgical fixation. This is not comprehensive review, but merely presents some of the effective alternatives to a standard thoracotomy as an approach to the chest wall with the hope and expectation that future publications will expand and improve upon the techniques described here.
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Affiliation(s)
- Patrick Greiffenstein
- Department of Surgery, Louisiana State University Health Science Center, New Orleans, LA, USA
| | - Michael Q Tran
- Department of Surgery, Louisiana State University Health Science Center, New Orleans, LA, USA
| | - Lisa Campeau
- Department of Cell Biology and Anatomy, Louisiana State University Health Science Center, New Orleans, LA, USA
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Abstract
Chest wall disorders represent deformities and/or injuries that alter the rib cage geometry and result in pulmonary restriction, increased work of breathing, exercise limitations, and cosmotic concerns. These disorders are congenital or acquired and affect all ages. Disorders affecting the spine (kyphoscoliosis, ankylosing spondylitis), ribs (flail chest), and sternum (pectus excavatum) are discussed in this article, with emphasis on clinical presentations, pulmonary function abnormalities, diagnosis, and treatment.
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Affiliation(s)
- Mazen O Al-Qadi
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale-New Haven Hospital, Yale University School of Medicine, 20 York Street, New Haven, CT 06510, USA.
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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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Chipko C, Ojwang J, Gharai LR, Deng X, Mukhopadhyay N, Weiss E. Characterization of Chest Wall Toxicity During Long-term Follow Up After Thoracic Stereotactic Body Radiation Therapy. Pract Radiat Oncol 2019; 9:e338-e346. [PMID: 30731275 DOI: 10.1016/j.prro.2019.01.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/28/2018] [Accepted: 01/27/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE Chest wall (CW) pain and rib fractures are frequently diagnosed after stereotactic body radiation therapy (SBRT) for malignant lung tumors. We hypothesize that multiple risk factors, including bone mineral density (BMD), are associated with CW toxicity, and that CW pain and rib fractures often evolve into chronic clinical problems. METHODS AND MATERIALS A total of 118 lung tumors treated with SBRT in 100 patients with a minimum follow-up period of 2 years were retrospectively analyzed. The incidence, clinical course, and related demographic, clinical, and dosimetric factors of CW pain and rib fractures were analyzed. In addition, BMD was assessed, and the radiographic appearance of radiation-induced rib fractures and their healing process were characterized. RESULTS The median follow-up was 49 months (range, 24-106 months). CW pain developed in 33 of 118 treatments (28%) after, on average, 12.5 months (range, 0-50 months), and was more common in women (P = .04). The mean duration of CW pain was 25 months (range, 2-63 months), and 36% of patients never had resolution of CW pain. A total of 34 of 118 treatments (29%) resulted in rib fractures at a mean time of 22 months (range, 3-46 months); rib fractures were more common in women, African Americans, upper/middle lobe tumors, and patients with lower BMD (P < .05). The mean duration of rib fractures was 25 months (range, 5-41 months), and only 16 rib fractures (47%) healed. Shorter CW planning target volume distance resulted in a higher risk for both rib fractures and CW pain (P = .01). Sixty-seven percent of fractures developed surrounding soft tissue fibrosis, and 62% (21 of 34 fractures) heterotopic ossification. Diabetes, body mass index, and steroid use were not associated with CW pain or rib fracture. CONCLUSIONS Several factors were associated with a higher risk of SBRT-related CW toxicity. Optimal CW sparing (eg, volumetric modulated arc therapy, lower dose per fraction) should be considered in this patient group without compromising tumor control. SBRT-induced rib fractures commonly heal abnormally and result in potential chronic CW pain.
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Affiliation(s)
- Christopher Chipko
- Department of Radiation Oncology, Virginia Commonwealth University Health Systems, Richmond, Virginia.
| | - Julius Ojwang
- Department of Radiation Oncology, Virginia Commonwealth University Health Systems, Richmond, Virginia
| | - Leila Rezai Gharai
- Department of Diagnostic Radiology, Virginia Commonwealth University Health Systems, Richmond, Virginia
| | - Xiaoyan Deng
- Department of Biostatistics, Virginia Commonwealth University Health Systems, Richmond, Virginia
| | - Nitai Mukhopadhyay
- Department of Biostatistics, Virginia Commonwealth University Health Systems, Richmond, Virginia
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University Health Systems, Richmond, Virginia
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Belcher E, Wallwork K, Mitchell J, Rahman N. What is the minimum fixation required to repair flail chest? ACTA ACUST UNITED AC 2019. [DOI: 10.4103/jctt.jctt_5_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Caragounis EC, Fagevik Olsén M, Granhed H, Rossi Norrlund R. CT-lung volume estimates in trauma patients undergoing stabilizing surgery for flail chest. Injury 2019; 50:101-108. [PMID: 30482587 DOI: 10.1016/j.injury.2018.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/10/2018] [Accepted: 10/12/2018] [Indexed: 02/02/2023]
Abstract
AIM To estimate and compare lung volumes from pre- and post-operative computed tomography (CT) images and correlate findings with post-operative lung function tests in trauma patients with flail chest undergoing stabilizing surgery. PATIENTS AND METHODS Pre- and post-operative CT images of the thorax were used to estimate lung volumes in 37 patients who had undergone rib plate fixation at least 6 months before inclusion for flail chest due to blunt thoracic trauma. Computed tomography lung volumes were estimated from airway distal to each lung hilum by outlining air-filled lung tissue either manually in images of 5 mm slice thickness or automatically in images of 0.6 mm slice thickness. Demographics, pain, range of motion in the thorax, breathing movements and Forced Vital Capacity (FVC) were assessed. Total Lung Capacity (TLC) measurements were also made in a subgroup of patients (n = 17) who had not been intubated at time of the initial CT. Post-operative CT lung volumes were correlated to FVC and TLC. RESULTS Patients with a median age of 62 (19-90) years, a median Injury Severity Score (ISS) of 20 (9-54), and a median New Injury Severity Score (NISS) of 27 (17-66) were enrolled in the study. Median follow-up time was 3.9 (0.5-5.6) years. Two patients complained of pain at rest and when breathing. Pre-operative CT lung volumes were significantly different (p < 0.0001) from post-operative CT lung volumes, 3.51 l (1.50-6.05) vs. 5.59 l (2.18-7.78), respectively. At follow-up, median FVC was 3.76 l (1.48-5.84) and median TLC was 6.93 l (4.21-8.42). Post-operative CT lung volumes correlated highly with both FVC [rs = 0.75 (95% CI 0.57‒0.87, p < 0.0001)] and TLC [rs = 0.90 (95% CI 0.73‒0.96, p < 0.0001)]. The operated thoracic side showed decreased breathing movements. Range of motion in the lower thorax showed a low correlation with FVC [rs = 0.48 (95% CI 0.19‒0.70, p = 0.002)] and a high correlation with TLC [rs = 0.80 (95% CI 0.51‒0.92, p < 0.0001)]. CONCLUSIONS Post-operative CT-lung volume estimates improve compared to pre-operative values in trauma patients undergoing stabilizing surgery for flail chest, and can be used as a marker for lung function when deciding which patient with chest wall injuries can benefit from surgery.
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Affiliation(s)
- Eva-Corina Caragounis
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Blå stråket 5, 413 45, Gothenburg, Sweden.
| | - Monika Fagevik Olsén
- Department of Health and Rehabilitation/Physical Therapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 455, 405 30, Gothenburg, Sweden.
| | - Hans Granhed
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Blå stråket 5, 413 45, Gothenburg, Sweden.
| | - Rauni Rossi Norrlund
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Bruna stråket 11B, 413 45, Gothenburg, Sweden.
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García-Martínez D, Campo Martín M, González Martín A, Cambra-Moo Ó, Barash A, Bastir M. Reevaluation of ‘endocostal ossifications’ on the Kebara 2 Neanderthal ribs. J Hum Evol 2018; 122:33-37. [DOI: 10.1016/j.jhevol.2018.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 04/21/2018] [Accepted: 04/23/2018] [Indexed: 02/08/2023]
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Development of a blunt chest injury care bundle: An integrative review. Injury 2018; 49:1008-1023. [PMID: 29655592 DOI: 10.1016/j.injury.2018.03.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/28/2018] [Accepted: 03/30/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Blunt chest injuries (BCI) are associated with high rates of morbidity and mortality. There are many interventions for BCI which may be able to be combined as a care bundle for improved and more consistent outcomes. OBJECTIVE To review and integrate the BCI management interventions to inform the development of a BCI care bundle. METHODS A structured search of the literature was conducted to identify studies evaluating interventions for patients with BCI. Databases MEDLINE, CINAHL, PubMed and Scopus were searched from 1990-April 2017. A two-step data extraction process was conducted using pre-defined data fields, including research quality indicators. Each study was appraised using a quality assessment tool, scored for level of evidence, then data collated into categories. Interventions were also assessed using the APEASE criteria then integrated to develop a BCI care bundle. RESULTS Eighty-one articles were included in the final analysis. Interventions that improved BCI outcomes were grouped into three categories; respiratory intervention, analgesia and surgical intervention. Respiratory interventions included continuous positive airway pressure and high flow nasal oxygen. Analgesia interventions included regular multi-modal analgesia and paravertebral or epidural analgesia. Surgical fixation was supported for use in moderate to severe rib fractures/BCI. Interventions supported by evidence and that met APEASE criteria were combined into a BCI care bundle with four components: respiratory adjuncts, analgesia, complication prevention, and surgical fixation. CONCLUSIONS The key components of a BCI care bundle are respiratory support, analgesia, complication prevention including chest physiotherapy and surgical fixation.
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Kalverkamp S, Spillner J, Kobbe P, Hildebrand F, Lichte P. [Stabilization of the chest wall with plate osteosynthesis]. Unfallchirurg 2018; 121:413-418. [PMID: 29651512 DOI: 10.1007/s00113-018-0490-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- S Kalverkamp
- Klinik für Thorax‑, Herz- und Gefäßchirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - J Spillner
- Klinik für Thorax‑, Herz- und Gefäßchirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - P Kobbe
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - F Hildebrand
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - P Lichte
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Aachen, Deutschland
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de Campos JRM, White TW. Chest wall stabilization in trauma patients: why, when, and how? J Thorac Dis 2018; 10:S951-S962. [PMID: 29744222 DOI: 10.21037/jtd.2018.04.69] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Blunt trauma to the chest wall and rib fractures are remarkably frequent and are the basis of considerable morbidity and possible mortality. Surgical remedies for highly displaced rib fractures, especially in cases of flail chest, have been undertaken intermittently for more than 50 years. Rib-specific plating systems have started to be used in the last 10 years. These have ushered in the modern era of rib repair with chest wall stabilization (CWS) techniques that are safer, easier to perform, and more efficient. Recent consensus statements have sought to define the indications and contraindications, as well as the when, the how, and the technical details of CWS. Repair should be considered for patients who have three or more displaced rib fractures or a flail chest, whether or not mechanical ventilation is required. Additional candidates include patients who fail non-operative management irrespective of fracture pattern and those with rib fractures who need thoracic procedures for other reasons. Traditionally, unstable spine fracture and severe traumatic brain injury are definite contraindications. Pulmonary contusion's role in the decision to perform CWS remains controversial. A range of rib-specific plating systems are now commercially available.
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Affiliation(s)
| | - Thomas W White
- Trauma and Surgical Critical Care, Intermountain Medical Center, Salt Lake City, Utah, USA
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Indications for surgical stabilization of rib fractures in patients without flail chest: surveyed opinions of members of the Chest Wall Injury Society. INTERNATIONAL ORTHOPAEDICS 2017; 42:401-408. [DOI: 10.1007/s00264-017-3612-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 08/09/2017] [Indexed: 10/19/2022]
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Abstract
Chest wall trauma is common, and contributes significantly to morbidity and mortality of trauma patients. Early identification of major chest wall and concomitant intrathoracic injuries is critical. Generalized management of multiple rib fractures and flail chest consists of adequate pain control (including locoregional modalities); management of pulmonary dysfunction by invasive and noninvasive means; and, in some cases, surgical fixation. Multiple studies have shown that patients with flail chest have substantial benefit (decreased ventilator and intensive care unit days, improved pulmonary function, and improved long-term functional outcome) when they undergo surgery compared with nonoperative management.
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Affiliation(s)
- Sarah Majercik
- Division of Trauma and Surgical Critical Care, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT 84107, USA.
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, MC0206, Denver, CO 80204, USA
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Abstract
Rib fractures are a common and highly morbid finding in patients with blunt chest trauma. Over the past decade, a renewed interest in (and instrumentation for) rib fixation in this cohort has occurred. Stabilization of the chest wall in this setting, particularly when a flail segment is present, is associated with significant reductions in the rates of respiratory failure, pneumonia, ICU stay, and mortality. Thoracic surgeons should remain actively involved in this evolving area of our specialty to further optimize patient outcomes.
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Affiliation(s)
- John D Mitchell
- Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
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36
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Coughlin TA, Ng JWG, Rollins KE, Forward DP, Ollivere BJ. Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials. Bone Joint J 2017; 98-B:1119-25. [PMID: 27482027 DOI: 10.1302/0301-620x.98b8.37282] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 04/05/2016] [Indexed: 11/05/2022]
Abstract
AIMS Flail chest from a blunt injury to the thorax is associated with significant morbidity and mortality. Its management globally is predominantly non-operative; however, there are an increasing number of centres which undertake surgical stabilisation. The aim of this meta-analysis was to compare the efficacy of this approach with that of non-operative management. PATIENTS AND METHODS A systematic search of the literature was carried out to identify randomised controlled trials (RCTs) which compared the clinical outcome of patients with a traumatic flail chest treated by surgical stabilisation of any kind with that of non-operative management. RESULTS Of 1273 papers identified, three RCTs reported the results of 123 patients with a flail chest. Surgical stabilisation was associated with a two thirds reduction in the incidence of pneumonia when compared with non-operative management (risk ratio 0.36, 95% confidence interval (CI) 0.15 to 0.85, p = 0.02). The duration of mechanical ventilation (mean difference -6.30 days, 95% CI -12.16 to -0.43, p = 0.04) and length of stay in an intensive care unit (mean difference -6.46 days, 95% CI 9.73 to -3.19, p = 0.0001) were significantly shorter in the operative group, as was the overall length of stay in hospital (mean difference -11.39, 95% CI -12.39 to -10.38, p < 0.0001). CONCLUSION Surgical stabilisation for a traumatic flail chest is associated with significant clinical benefits in this meta-analysis of three relatively small RCTs. Cite this article: Bone Joint J 2016;98-B:1119-25.
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Affiliation(s)
- T A Coughlin
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
| | - J W G Ng
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
| | - K E Rollins
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
| | - D P Forward
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
| | - B J Ollivere
- University of Nottingham, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
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37
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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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Marasco S, Quayle M, Summerhayes R, Šutalo ID, Liovic P. An assessment of outcomes with intramedullary fixation of fractured ribs. J Cardiothorac Surg 2016; 11:126. [PMID: 27495253 PMCID: PMC4974717 DOI: 10.1186/s13019-016-0510-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 07/26/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgical management of fractured ribs with internal fixation is an increasingly accepted therapy. Concurrently, specific rib fixation prostheses are being developed which should improve results and minimise hardware and rib/splint construct failures. The Synthes titanium intramedullary splint lends itself to difficult to access areas such as posterior rib fractures and fractures under the scapula. We analyse a case series of patients in whom this rib fixation prosthesis has been used. METHODS Fifteen patients received 35 intramedullary splints. Follow up at 3 and 6 months was performed with three dimensional computed tomography scanning to assess for bone alignment, callus formation and healing, residual deformity, hardware failure or cut through. Computerized finite element analysis (FEA) was used to model forces acting on a posterior fracture with and without an intramedullary fixation splint in situ. RESULTS Complete healing (bony union) was noted in only 3 (9 %) of the fractures fixed with splints by 3 months. Partial healing (cartilaginous union) was noted in 28 of the 33 fractures (85 %), and non healing was noted in only 2 (6 %). In both those two patients, failure at the rib / splint interface was noted after both patients reported sneezing. No hardware failures were noted. By 6 months the fractures which had shown partial healing, had all completely healed. There were no late failures (between 3 and 6 months) of either hardware or rib/splint interfaces. FEA modelling identified sites of increased stress in the rib at the rib / splint interface and in a modelled intramedullary splint where it spans the fracture. CONCLUSIONS Further analysis of outcomes with intramedullary splints is warranted as well as further development of intramedullary rib fixation solutions.
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Affiliation(s)
- Silvana Marasco
- Cardiothoracic Surgery Department, the Alfred Hospital, 55 Commercial Rd, Prahran, 3181, Australia. .,Department of Surgery, Monash University, Melbourne, VIC, Australia.
| | - Margaret Quayle
- Cardiothoracic Surgery Department, the Alfred Hospital, 55 Commercial Rd, Prahran, 3181, Australia
| | - Robyn Summerhayes
- Cardiothoracic Surgery Department, the Alfred Hospital, 55 Commercial Rd, Prahran, 3181, Australia
| | - Ilija D Šutalo
- Faculty of Science, Monash University, Melbourne, VIC, Australia
| | - Petar Liovic
- Commonwealth Scientific and Industrial Research Organisation (CSIRO), Mathematics Informatics and Statistics, Melbourne, VIC, Australia
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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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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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Abstract
Surgical rib fixation (SRF) for severe rib fracture injuries is increasingly becoming an accepted treatment modality. There is now adequate evidence in randomised controlled trials that rib fixation in flail chest patients reduces ventilator times, intensive care stay and costs of treatment in ventilator dependent patients [1-3]. Despite this, rib fixation has not become standard of care for these patients and remains a treatment modality practised by few centres, usually those with large trauma loads who see high volumes of severe rib fracture injury patients. The purpose of this article is to outline the available prostheses, indications, operative planning and techniques of rib fixation. Surgical approaches to rib fractures in anterior, lateral and posterior positions are described as are the use of currently available cortical and medullary fixation prostheses.
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Affiliation(s)
- Silvana Marasco
- CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Australia.
| | - Pankaj Saxena
- CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Australia.
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