[Repair of intrathoracic visceral damage using video-assisted thoracoscopic surgery for blunt chest trauma and rib fixation at the site of mini-thoracotomy]

Is intrathoracic rib plate fixation advantageous over extrathoracic plating? A biomechanical cadaveric study

BACKGROUND

The high morbidity following surgical interventions on the chest wall because of large incisions often prevents surgeons from operative rib fracture treatment. Minimally invasive approaches to the intrathoracic side of the rib could allow for smaller incisions with lower morbidity while maintaining stability of fixation. The aim of this study was to explore the biomechanical competence of intrathoracic versus extrathoracic plating in a human cadaveric rib fracture model and investigate the effect of plating using two versus three screws per fracture fragment.

METHODS

Twenty pairs of fresh-frozen human cadaveric ribs from elderly female donors aged 82.4 ± 7.8 years were used. First, the stiffness of each native rib was calculated via nondestructive (2 N-5 N) biomechanical testing under two loading conditions: ramped two-point bending and combined ramped tensile bending with torsional loading. Second, the ribs were fractured under three-point bending with their intrathoracic side put under tensile stress. Third, specimens were assigned to four groups (n = 10) for either intrathoracic or extrathoracic plating with two or three screws per fragment. Following instrumentation, all ribs were dynamically tested over 400,000 cycles under combined sinusoidal tensile bending with torsional loading (2 N-5 N at 3 Hz). Finally, all specimens were destructively tested under ramped two-point bending.

RESULTS

Following instrumentation and cyclic testing, significantly higher construct stiffness was observed for intrathoracic vs. extrathoracic plating under anatomical loading conditions (p ≤ 0.03). No significant differences were detected for implant subsidence after plating with two or three screws per fragment (p ≥ 0.20).

CONCLUSION

This study demonstrates significantly higher construct stiffness following intrathoracic over extrathoracic plating, thus indicating superior plate support of the former. In the clinical context, using only two instead of three screws per fragment not only could maintain stability of fixation but also decrease surgery time and costs, and allow for smaller incisions with lower morbidity.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level V.

Outcomes after operative management of symptomatic rib nonunion

OBJECTIVE

To report the outcomes of rib reconstruction after painful nonunion.

DESIGN

Retrospective case series.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

[Chest trauma: who, how and what?]

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

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

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

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

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