An assessment of outcomes with intramedullary fixation of fractured ribs

Open reduction internal fixation of rib fractures: a biomechanical comparison between the RibLoc U Plus® system and anterior plate in rib implants

OBJECTIVES

In this study, we assessed the bending strength of two surgical repairs of rib fracture using RibLoc^® U Plus system made by Acute Innovations and the anterior plate by Synthes.

METHODS

After a rib fracture was created in seven pairs of cadaveric rib specimens, one side was repaired with the anterior plate and the other side repaired with the RibLoc U Plus^® plate. Each of the rib is loaded using a custom device over 360,000 bending cycles to simulate in vivo fatiguing related to respiration. Upon completion of the cyclic loading, the specimens were compressively loaded to failure and the failure bending moment was determined.

RESULTS

The ribs repaired with the RibLoc U Plus^® system showed 79% higher failure bending moment than that of the anterior plate, with a p value of 0.033. The ribs repaired with RibLoc U Plus^® showed a trend of less stiffness reduction over the 360,000 loading cycles.

CONCLUSION

The biomechanical study showed that the RibLoc U Plus^® system is stronger in the bending moment loading of repaired ribs, possibly due to the U-shape structure supporting both the inner and outer cortices of a repaired rib.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Analysis of the therapeutic effect and prognosis in 86 cases of rib fractures and atelectasis

Background

The aim of the present study was to explore the therapeutic effect and prognosis in patients with rib fractures and atelectasis after thoracic trauma in order to provide a basis for clinical decision-making in primary hospitals.

Methods

A retrospective study was conducted on 86 patients admitted to our hospital between January 2016 and May 2020 with rib fractures and atelectasis after thoracic trauma. On the basis of the chest computed tomography scans taken at the time of discharge, the patients were divided into two groups: the reexpansion group and the non-reexpansion group. The two groups were compared with respect to the changes observed in the patients’ levels of blood oxygen saturation (SpO2) and pulmonary function, the presence of secondary pulmonary or thoracic infection, the time of chest tube drainage, the length of hospitalization, the cost of hospitalization, and the patients’ level of satisfaction with their quality of life 3 months after discharge.

Results

In the reexpansion group, there were significant differences in the levels of SpO2 and pulmonary function measured before and after pulmonary reexpansion (P < 0.05). Compared with the non-reexpansion group, the patients in the reexpansion group had a lower incidence of secondary pulmonary and thoracic infection and a higher level of satisfaction with their quality of life after discharge; these differences were statistically significant (P < 0.05). There was no statistical significance between the two groups with respect to the time of chest tube drainage or the length of hospitalization (P > 0.05). However, the cost of hospitalization was significantly higher in the reexpansion group than in the non-reexpansion group (P < 0.05).

Conclusions

The patients in the pulmonary reexpansion group had a lower incidence of complications and a better prognosis than the patients in the non-reexpansion group.

A new instrument for surgical stabilization of multiple rib fractures

Objective

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

Methods

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

Results

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

Conclusion

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

Surgical management of multiple rib fractures/flail chest

Rib fractures in the setting of trauma carries a high morbidity and mortality. Forty-three percent of patients presenting with trauma will have rib fractures. Fifty-five percent of patients, greater than 60 years of age, who die following chest trauma, have isolated rib fractures. Mortality associated with rib fractures starts to increase from the age of 45. Rib fixation is being utilised more for the management of rib fractures. Following the review of literature, we propose a pathway for the management of both simple rib fractures and flail segments. Furthermore, we review the various methods of rib fixation, discussing the advantages and disadvantages of each.

Outcome Analysis of Surgical Stabilization of Rib Fractures in Trauma Patients

OBJECTIVES

To compare outcomes in patients with rib fractures (RFX) who underwent surgical stabilization of rib fractures (SSRF) to those treated nonoperatively.

DESIGN

Retrospective cohort study.

SETTING

Two Level 1 Trauma Centers.

PATIENTS

One hundred seventy-four patients with multiple RFX divided into 2 groups: patients with surgically stabilized RFX (n = 87) were compared with nonoperatively managed patients in the matched control group (MCG) (n = 87).

INTERVENTION

SSRF.

OUTCOME MEASUREMENTS

Age, sex, injury severity score, RFX, mortality, hospital length of stay (HLOS) and intensive care unit length of stay (ICULOS), duration of mechanical ventilation (DMV), co-injuries, and time to surgery. Patients were further stratified by presence or absence of flail chest and pulmonary contusion (PC).

RESULTS

Flail chest, displaced RFX, and PC were present significantly more often in SSRF patients compared with the MCG. Mortality was lower in SSRF group. HLOS and ICULOS were longer in SSRF group compared with the corresponding MCG patients regardless of timing to surgery (P < 0.01 for all). SSRF patients with flail chest had comparable HLOS, ICULOS, and DMV to MCG patients with flail chest (P > 0.3 for all). SSRF patients without flail chest had significantly longer HLOS and ICULOS than MCG patients without flail chest (P < 0.001 for both). Presence of PC did not affect lengths of stay.

CONCLUSIONS

SSRF patients had reduced mortality compared with nonoperatively managed patients. HLOS, ICULOS, and DMV were longer in SSRF patients than in MCG. When flail chest was present, lengths of stay were comparable. PC did not seem to affect the surgical outcome.

LEVEL OF EVIDENCE

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

Development of a socket-type rib coaptation device made of poly-L-lactide fibers: feasibility study in a canine model

Background

Costal coaptation pins made of poly-L-lactide (PLA) are clinically available for fixing surgically divided ribs. However, the clinical results of such rib fixation have not been completely satisfactory. We aimed to develop a new rib coaptation socket system and explore its clinical applicability.

Methods

We surgically divided three consecutive ribs of each beagle dog, and rib coaptation sockets were implanted to stabilize each rib. Fifteen 3-dimensional (3D)-printed and 30 PLA fiber knitted sockets were implanted in five and ten dogs, respectively, to stabilize the artificially divided ribs. Mechanical analysis of the sockets and radiographical examination of costal fixation were performed to evaluate the effectiveness of the newly developed socket system for rib stabilization.

Results

All 15 ribs with 3D-printed sockets had displaced 1 month after the operation. Three ribs in one dog with implanted PLA fiber knitted sockets were displaced radiographically after 1 month, and the grade of displacement remained unchanged after 6 months. The remaining 27 ribs fixed with PLA fiber knitted sockets did not show any displacement.

Conclusions

The PLA fiber knitted rib coaptation socket system was sufficiently durable for the stabilization of divided ribs with biocompatibility. This promising finding can be applied for clinical stabilization of divided ribs.

[Chest trauma from a surgical perspective]

Patients with multiple injuries in particular frequently also suffer from chest trauma. During the initial phase the identification and treatment of life-threatening injuries is essential and tension pneumothorax is of particular importance during this phase. The Advanced Trauma Life Support (ATLS) algorithm should be followed for structured treatment. In most cases treatment by insertion of a chest tube is sufficient but for some injuries an emergency thoracotomy is unavoidable as a life-saving intervention. In the further treatment especially a flail chest and retained hemothorax are responsible for complications, such as acute lung failure and thoracic empyema. Early operative interventions in the sense of rib fracture stabilization and thoracoscopy-assisted evacuation of hematomas can help to prevent such complications.

Blunt chest trauma: is there a place for rib stabilization?

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.