Recent advances in rib fracture fixation

Prognostic factors for outcomes following surgical stabilization of rib fractures: A review of the literature

Rib fractures are a common injury following blunt thoracic trauma, often resulting in high levels of morbidity and mortality. With the ageing global population, the incidence of rib fractures is expected to increase, posing a significant burden on healthcare systems worldwide. With advancements in surgical techniques and pioneering research on the topic the use of surgical stabilisation of rib fractures (SSRF) has increased significantly over the past two decades. However, the relationship between certain prognostic factors and patient outcomes following surgery is still contested and there lacks a consensus on definitive indications for the operation. This literature review presents the current research on SSRF outcomes for; patients with flail chest injuries and multiple-non flail rib fractures, optimal timing between injury and operation, and patient age. This article contributes to the ongoing dialogue surrounding chest wall trauma management and may be drawn upon to aid future research and develop clinical practice guidelines.

Should wide chest wall resections and reconstruction intimidate thoracic surgeons?

Background

This study aimed to compare patients in whom wide chest wall resection and reconstruction or primary closure was performed.

Methods

A total of 63 patients who underwent chest wall resection and reconstruction between January 2018 and December 2022 were included in the retrospective study. The patients were divided into two groups: the first group, which included 31 patients (14 males, 17 females; mean age: 44.6±16.4 years; range, 16 to 71 years) who were closed primarily, and the second group, constituting 32 patients (25 males, 7 females; mean age: 54.6±17.2 years; range, 9 to 80 years) who underwent reconstruction with plates and meshes.

Results

There was no significant difference between the two groups in terms of smoking and diabetes. Primary chest wall or metastatic tumor was determined in 33 patients; benign tumor and trauma were determined in 30 patients. The difference between the two groups in mean defect diameter (p=0.009), mean number of plates used (p<0.001), and mean hospital stay (p<0.001) was statistically significant. However, there was no significant difference in terms of complications (p=0.426).

Conclusion

Wide chest wall resection and reconstruction is a safe and feasible surgical procedure when compared with primary closure.

Comprehensive Review on Distal Femur Fractures: From Epidemiology to Treatment Strategies

Distal femur fractures present a substantial orthopedic challenge, necessitating a comprehensive exploration spanning epidemiology, anatomy, classification, diagnosis, and treatment strategies. This review thoroughly analyzes the multifaceted aspects surrounding distal femur fractures. It delves into the definition and epidemiology, shedding light on the incidence, age distribution, and associated risk factors. An exhaustive examination of the distal femur's anatomy, encompassing ligaments and tendons, establishes the groundwork for understanding fracture patterns and subsequent classification according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) system. Diagnostic considerations encompass physical examination and various imaging modalities, emphasizing the critical importance of prompt and accurate assessment. The extensive discussion on treatment options ranges from non-surgical management, including casting and traction, to surgical interventions, such as open reduction and internal fixation, intramedullary nailing, and external fixation. The implications for clinical practice underscore the necessity for tailored approaches based on fracture characteristics to optimize patient outcomes. However, this review also emphasizes areas necessitating further investigation, including exploring predictive biomarkers, advanced surgical techniques, and innovative rehabilitation protocols. Insights from long-term outcomes and quality-of-life assessments in diverse populations offer promising avenues for enhancing the comprehensive management of distal femur fractures. Continuous research in these areas can refine treatment strategies and elevate the standard of care for individuals grappling with this intricate orthopedic condition.

Impact of obesity on outcomes after surgical stabilization of multiple rib fractures: Evidence from the US nationwide inpatient sample

BACKGROUND

Obesity is a global health issue with increasing prevalence. Surgical procedures, such as surgical stabilization of rib fractures (SSRF), may be affected by obesity-related complications. The objective of the study is to investigate the effects of obesity on SSRF outcomes in multiple rib fractures.

METHODS

This retrospective study analyzed data from adults aged ≥ 20 years in the Nationwide Inpatient Sample (NIS) database diagnosed with multiple rib fractures who underwent SSRF between 2005 and 2018. It investigated the relationship between obesity and in-patient outcomes, such as discharge status, length of stay (LOS), in-hospital mortality, hospital costs, and adverse events using logistic and linear regression analyses.

RESULTS

Analysis of data from 1,754 patients (morbidly obese: 87; obese: 106; normal weight: 1,561) revealed that morbid obesity was associated with longer LOS (aBeta = 0.07, 95% CI: 0.06, 0.07), higher hospital costs (aBeta = 47.35, 95% CI: 38.55, 56.14), increased risks of adverse events (aOR = 1.63, 95% CI: 1.02, 2.61), hemorrhage/need for transfusion (aOR = 1.77, 95% CI: 1.12, 2.79) and mechanical ventilation ≥ 96 hours (aOR = 2.14, 95% CI: 1.28, 3.58) compared to normal weight patients. Among patients with flail chest, morbid obesity was significantly associated with tracheostomy (aOR = 2.13, 95% CI: 1.05, 4.32), ARDS/respiratory failure (aOR = 2.01, 95% CI: 1.09, 3.70), and mechanical ventilation ≥ 96 hours (aOR = 2.80, 95% CI: 1.47, 5.32). In contrast, morbid obesity had no significant associations with these adverse respiratory outcomes among patients without a flail chest (p > 0.05).

CONCLUSIONS

Morbid obesity is associated with adverse outcomes following SSRF for multiple rib fractures, especially for flail chest patients.

Functionally graded 3D printed plates for rib fracture fixation

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

Chest wall reconstruction, prosthesis and allografts: a narrative review

Background and Objective

What is the best material in the case of prosthesis used to replace major chest wall resection is still unknown. We reviewed most significant literature focused on the type of prosthetic materials available by highlighting their relative pros and cons.

Methods

We reviewed most significant articles, including clinical results of relevant case series (retrospective studies), published in English in the last 23 years: PubMed, Embase and Scopus databases were used in our search in the period between the 1st January 1999 and 31st December 2022.

Key Content and Findings

Overall, our literature review revealed lack of uniformity or conformity in the surgical strategies described for chest wall reconstruction with no internationally accepted standard in terms of decisions and optimal prosthetic materials and type of prostheses (soft, rigid, biological). Despite the increased interest in chest wall reconstruction, we observed a general lack of substantial prospective and multicentric studies. Likewise, there are not substantial data which may guide to the choice of optimal prosthetics in terms of characteristics and biocompatibility.

Conclusions

A variety of materials are available for reconstruction, including synthetic and biological meshes, flexible and rigid patches, and metal osteosynthesis systems. The material chosen should be optimized to each patient and damaged tissues to be restored. Prospective and multicentric studies are necessary to address current limits in this surgical field.

Use of robotic C-arm cone-beam computed tomography in surgical stabilization of rib fractures

INTRODUCTION

The effectiveness of using intraoperative robotic C-arm cone-beam computerized tomography (CT) to locate rib fractures during surgery was compared to using pre-operative CT.

METHODS

Patients diagnosed with multiple rib fracture and treated surgically in the hospital between January 2019 and September 2020 were included. The study included two groups of patients. One group had their rib fractures identified using pre-operative CT, while the other group had their fractures localized using intraoperative cone-beam CT during surgery. The operative time, blood loss, number of incisions, length of incision, duration of chest drains, visual analogue scale (VAS) score, and duration of post-operation stays were measured.

RESULTS

A total of 12 patients received intraoperative cone-beam CT, while the remaining 18 patients only received pre-operative CT. Statistical analysis showed that the group treated with cone-beam CT had lower blood loss (p = 0.012), shorter incisions (p = 0.005), and better post-operation VAS scores (p = 0.027). There were also non-significant trends towards fewer incisions, shorter operation times, and shorter duration of chest drains in the group treated with cone-beam CT.

CONCLUSIONS

Intraoperative localization of rib fracture sites with cone-beam CT is an effective method for rib fracture stabilization.

Case report: Ultrasound-guided removal of foreign matter from the chest wall

INTRODUCTION AND IMPORTANCE

Positioning nodule with a steel wire in pulmonary surgery is a common preoperative step. To date, no reports have been published on the retention of steel wires in the body post-surgery, nor have there been studies describing the ultrasound-guided removal of foreign objects from the chest wall. This report describes a case of a foreign matter was removed from the chest wall by ultrasound-guided.

CASE PRESENTATION

A 70-year-old woman underwent thoracoscope resection of a pulmonary nodule; however, a fragment of the positioning steel wire remained in the chest wall during the surgery. The anesthetist located the residual steel wire using ultrasound, and subsequently, the surgeon successfully removed it.

CLINICAL DISCUSSION

Detection of foreign matter in the body is rare and usually associated with trauma or accidental retention of materials such as absorbable gelatin sponges or sutures during surgery, which are often found using X-rays. This process is often time-consuming, and X-rays being radioactive are potentially harmful to patients and medical workers. Ultrasonic waves are safe and offer a convenient alternative for such procedures. We removed the residual steel wire through a 0.5 cm skin incision, this method neither caused trauma nor increased costs.

CONCLUSION

Ultrasonography-assisted positioning is a rapid, convenient, and safe technique, promising to enhance future surgical interventions.

Improved chest wall trauma taxonomy: an interdisciplinary CWIS and ASER collaboration

PURPOSE

Chest wall injury taxonomy and nomenclature are important components of chest wall injury classification and can be helpful in communicating between providers for treatment planning. Despite the common nature of these injuries, there remains a lack of consensus regarding injury description. The Chest Wall Injury Society (CWIS) developed a taxonomy among surgeons in the field; however, it lacked consensus and clarity in critical areas and collaboration with multidisciplinary partners. We believe an interdisciplinary collaboration between CWIS and American Society of Emergency Radiology (ASER) will improve existing chest wall injury nomenclature and help further research on this topic.

METHODS

A collaboration between CWIS and ASER gathered feedback on the consensus recommendations. The workgroup held a series of meetings reviewing each consensus statement, refining the terminology, and contributing additional clarifications from a multidisciplinary lens.

RESULTS

After identifying incomplete definitions in the CWIS survey, the workgroup expanded on and clarified the language proposed by the survey. More precise definitions related to rib and costal cartilage fracture quality and location were developed. Proposed changes include more accurate characterization of rib fracture displacement and consistent description of costal cartilage fractures.

CONCLUSIONS

The 2019 consensus survey from CWIS provides a framework to discuss chest wall injuries, but several concepts remained unclear. Creating a universally accepted taxonomy and nomenclature, utilizing the CWIS survey and this article as a scaffolding, may help providers communicate the severity of chest wall injury accurately, allow for better operative planning, and provide a common language for researchers in the future.

Comparison between non-surgical and surgical management of rib fractures in major trauma patients without brain injuries

BACKGROUND

This study aimed to evaluate the different outcomes between the non-surgical and surgical groups in patients with major trauma without brain injuries.

METHODS

This study prospectively collected data from patients with traumatic rib fractures without brain injuries from June 2017 to November 2019. The primary outcomes were the pain score at admission and discharge and the length of hospital stay. We performed multiple regression analysis to compare the outcomes and surgical risk as the severity of chest trauma between both groups.

RESULTS

Fifty-three patients were enrolled. There was no statistically significant difference in baseline characteristics between both groups. However, the surgical group had more severe chest trauma than the non-surgical group. After the analysis, the pain score improved significantly in the surgical group. The hospital stay of the surgical group was four days shorter than that of the non-surgical group, and there was severe chest trauma in the surgical group.

CONCLUSIONS

Surgical management of rib fractures can reduce pain and hospital stay in major trauma patients.

Surgical subspecialization is associated with higher rate of rib fracture stabilization: a retrospective database analysis

Background

Surgical stabilization of rib fractures (SSRF) is performed on only a small subset of patients who meet guideline-recommended indications for surgery. Although previous studies show that provider specialization was associated with SSRF procedural competency, little is known about the impact of provider specialization on SSRF performance frequency. We hypothesize that provider specialization would impact performance of SSRF.

Methods

The Premier Hospital Database was used to identify adult patients with rib fractures from 2015 and 2019. The outcome of interest was performance of SSRF, defined using International Classification of Diseases—10th Revision Procedure Coding System coding. Patients were categorized as receiving their procedures from a thoracic, general surgeon, or orthopedic surgeon. Patients with missing or other provider types were excluded. Multivariate modeling was performed to evaluate the effect of surgical specialization on outcomes of SSRF. Given a priori assumptions that trauma centers may have different practice patterns, a subgroup analysis was performed excluding patients with ‘trauma center’ admissions.

Results

Among 39 733 patients admitted with rib fractures, 2865 (7.2%) received SSRF. Trauma center admission represented a minority (1034, 36%) of SSRF procedures relative to other admission types (1831, 64%, p=0.15). In a multivariable analysis, thoracic (OR 6.94, 95% CI 5.94–8.11) and orthopedic provider (OR 2.60, 95% CI 2.16–3.14) types were significantly more likely to perform SSRF. In further analyses of trauma center admissions versus non-trauma center admissions, this pattern of SSRF performance was found at non-trauma centers.

Conclusion

The majority of SSRF procedures in the USA are being performed by general surgeons and at non-trauma centers. ‘Subspecialty’ providers in orthopedics and thoracic surgery are performing fewer total SSRF interventions, but are more likely to perform SSRF, especially at non-trauma centers. Provider specialization as a barrier to SSRF may be related to competence in the SSRF procedures and requires further study.

Type

Therapeutic/care management.

Level of evidence

IV

Clinical Outcomes of Minimally Invasive Surgical Stabilization of Rib Fractures Using Video-Assisted Thoracoscopic Surgery

Background

Multiple rib fractures are common in blunt chest trauma. Until recently, most surgical rib fixations for multiple rib fractures were performed via open thoracotomy. However, due to the invasive nature of tissue dissection and the resulting large wound, an alternative endoscopic approach has emerged that minimizes the postoperative complications caused by the manipulation of injured tissue and lung during an open thoracotomy.

Methods

Our study concentrated on patients with multiple rib fractures who underwent surgical stabilization of rib fractures (SSRF) between June 2018 and May 2020. We found 27 patients who underwent SSRF using video-assisted thoracoscopic surgery. The study design was a retrospective review of the patients' charts and surgical records.

Results

No intraoperative events or procedure-related deaths occurred. Implant-related irritation occurred in 4 patients, and 1 death resulted from concomitant trauma. The average hospital stay was 30.2±20.1 days, and ventilators were used for 12 of the 22 patients admitted to the intensive care unit. None of the patients experienced major pulmonary complications such as pneumonia or acute respiratory distress syndrome.

Conclusion

Minimally invasive rib stabilization surgery with the assistance of a thoracoscope is expected to become more widely used in patients with multiple rib fractures. This method will also assist patients in a quick recovery.

A Review on Manufacturing Processes of Biocomposites Based on Poly(α-Esters) and Bioactive Glass Fillers for Bone Regeneration

The incorporation of bioactive and biocompatible fillers improve the bone cell adhesion, proliferation and differentiation, thus facilitating new bone tissue formation upon implantation. During these last 20 years, those biocomposites have been explored for making complex geometry devices likes screws or 3D porous scaffolds for the repair of bone defects. This review provides an overview of the current development of manufacturing process with synthetic biodegradable poly(α-ester)s reinforced with bioactive fillers for bone tissue engineering applications. Firstly, the properties of poly(α-ester), bioactive fillers, as well as their composites will be defined. Then, the different works based on these biocomposites will be classified according to their manufacturing process. New processing techniques, particularly additive manufacturing processes, open up a new range of possibilities. These techniques have shown the possibility to customize bone implants for each patient and even create scaffolds with a complex structure similar to bone. At the end of this manuscript, a contextualization exercise will be performed to identify the main issues of process/resorbable biocomposites combination identified in the literature and especially for resorbable load-bearing applications.

Complete uni-port video-assisted thoracoscopic surgery for surgical stabilization of rib fractures: a case report

BACKGROUND

Rib fractures are a common injury in trauma. Potential complications include pain, pneumonia, respiratory failure, disability, and death. Surgical stabilization of rib fractures (SSRF) has become an available treatment option, and complete video-assisted thoracoscopic surgery (VATS) for SSRF is gradually accepted because of minimally invasive and pain relief. To our knowledge, complete uni-port VATS for SSRF has not yet been reported.

CASE PRESENTATION

A 53-year-old man accidentally fell off a three-meter high scaffolding while working resulting in severe chest pain and shortness of breath. He was found with left 7th through 11th rib fractures with a pulmonary contusion from computed tomography (CT). A 4 cm incision was made in the 7th intercostal space in the midaxillary line, and complete uni-port VATS for SSRF were operated. The patient's pain was significantly relieved after the operation, and the scar was tiny and unapparent.

CONCLUSIONS

Complete uni-port VATS for SSRF is a novel and modificatory method of operation with the benefit of minimal invasion, meanwhile, intrathoracic injuries could be treated at the same time. Further study is warranted.

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.

Finite element analysis of different fixation methods of screws on absorbable plate for rib fractures

Multiple rib fractures caused by trauma are common injuries and the internal fixation methods of these injuries have been paid more and more attention by surgeons. Absorbable plates and screws are the effective way to treat rib fractures, but there are no reports on which type of screw fixation method is most effective. In this study, finite element analysis was used to study the effects of five different types of screw fixation methods on anterior rib, lateral rib and posterior rib. The finite element model of the ribs was reconstructed from CT images, and the internal pressure (40 kPa) and intercostal force (30 N) on the surfaces of the ribs were simulated accordingly. An intercostal force of 30 N was applied to the upper and lower surfaces of the ribs to simulate the effect of intercostal muscle force. The pressure of 40 kPa was applied to the inner surface of the ribs, and the normal direction was applied to the inner surface of the ribs. The positive direction was considered inspiratory pressure, and the negative direction was considered expiratory pressure. The results indicate the optimal type of screw fixation on the absorbable plate for rib fractures, and provide a basis and reference for clinical application.

The Chinese consensus for surgical treatment of traumatic rib fractures 2021 (C-STTRF 2021)

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.

Evaluation of Patient Information Material in the Consent Process for Surgical Stabilization of Rib Fractures

BACKGROUND

Surgical stabilization of rib fractures is a procedure carried out in most trauma centers; however, data on evaluation of patient information material regarding this procedure are limited. The trauma service at our hospital implemented slide presentation as an adjunct tool to the consenting process for patients undergoing this procedure.

OBJECTIVE

The aim was to evaluate information material for patients undergoing surgical stabilization of rib fractures procedure and subjective outcomes from education on components of knowledge, emotion, and behavior for patients undergoing this procedure.

METHODS

A one-group posttest prospective design study was conducted over 18 months at a Level I trauma center. Supplementary visual material was provided as an adjunct to the consent process of surgical rib fixation. Evaluation from the patient's perspective was undertaken utilizing the usefulness scale for patient information material. This tool was based on a tripartite model of reading, evaluating, and responding to patient information material.

RESULTS

Over the period of 18 months, 60 patients underwent surgical stabilization of rib fractures. Fifty-two (91.7%) patients reviewed the information material, and 41 (78.8%) patients completed the feedback. The results reflect that the majority of patients perceived positive responses in emotional support (M = 8.42, SD = 6.6); behavioral motivation (M = 8.57, SD = 6.4); and education on knowledge (M = 9.09, SD = 4.6).

CONCLUSION

In this novel study, visual aids as an adjunct to the informed consent process augmented patient knowledge regarding surgical stabilization of rib fractures and received positive subjective patient feedback on knowledge about the procedure.

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

Background

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

Methods

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

Results

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

Conclusions

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

Far posterior rib plating: Preliminary results of a retrospective case series

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.

A Postoperative Displacement Measurement Method for Femoral Neck Fracture Internal Fixation Implants Based on Femoral Segmentation and Multi-Resolution Frame Registration

Femoral neck fractures have a high incidence in the geriatric population and are associated with high mortality and disability rates. With the minimally invasive nature, internal fixation is widely used as a treatment option to stabilize femoral neck fractures. The fixation effectiveness and stability of the implant is an essential guide for the surgeon. However, there is no long-term reliable evaluation method to quantify the implant’s fixation effect without affecting the patient’s behavior and synthesizing long-term treatment data. For the femur’s symmetrical structure, this study used 3D convolutional networks for biomedical image segmentation (3D-UNet) to segment the injured femur as a mask, aligned computerized tomography (CT) scans of the patient at different times after surgery and quantified the displacement in the specified direction using the generated 3D point cloud. In the experimental part, we used 10 groups containing two CT images scanned at the one-year interval after surgery. By comparing manual segmentation of femur and segmentation of femur as a mask using neural network, the mask obtained by segmentation using the 3D-UNet network with symmetric structure fully meets the requirements of image registration. The data obtained from the 3D point cloud calculation is within the error tolerance, and the calculated displacement of the implant can be visualized in 3D space.

When less is more: A minimally invasive, intrathoracic approach to surgical stabilization of rib fractures

Rib fractures are a common and serious injury in both blunt and penetrating trauma to the thorax. The morbidity and mortality associated with these fractures is often due to impaired respiratory mechanics, leading to a number of pulmonary complications and lengthy hospitalization. Surgical stabilization of rib fractures has become an increasingly popular treatment option within the trauma community, but the definitive role in management is still being established. The development of new minimally invasive techniques offers a promising future into rib fixation and its role in the treatment algorithm. Here we present a 48-year-old male who sustained four right sided rib fractures after a ground level fall and subsequently endured poor pain control and breathing mechanics requiring surgical stabilization of his rib fractures. We introduce a new minimally invasive technique for stabilization of rib fractures using an intrathoracic thoracoscopic approach. Given the patient's dramatic improvement in pain and respiratory function after surgery, we are excited about the future of this technique and all its potential.

Refractory Infection After Internal Fixation for Rib Fractures

The infection of internal fixation devices of rib fractures is rare, but it is usually severe when it occurs. Existing literature indicates that removal of infected hardware is essential for the clearance of refractory infection. We report a rare case of a patient who accepted operation for rib fractures; however, his hardware infection was not controlled after the removal of internal fixation devices, until the necrotic ribs were removed by the third operation.