Stabilization of flail chest injuries: minimized approach techniques to treat the core of instability

[Treatment strategy for severe implosion injuries of the lateral chest wall]

In the majority of cases implosion injuries to the thoracic wall are caused by blunt, massive force acting on the thorax. Basically, different regions and directions of the acting energy have to be taken into account. In common usage, the term implosion injury has become established, especially for the sequelae of lateral energy impact. Particular attention should be paid to the stability of the shoulder girdle, the underlying hemithorax and its intrathoracic organs.

Retrospective comparison of operative technique for chest wall injuries

BACKGROUND

Surgical management of chest wall injuries is a common procedure. However, operative techniques are diverse, and no universal guidelines exist. There is a lack of studies comparing the outcome with different operative techniques for chest wall surgery. The aim of this study was to compare hospital outcomes between patients operated for chest wall injuries with a conventional method with large incisions and often a thoracotomy or a minimally invasive, muscle sparing method.

PATIENTS AND METHODS

A retrospective study was carried out including patients ≥18 years operated for chest wall injuries 2010-2020. Patients were divided into two groups based on the surgery performed: conventional surgery (C-group) and minimally invasive surgery (M-group). Data on demographics, trauma, surgery, and outcomes were extracted from patient records. Primary outcome was length of stay on mechanical ventilator (MV-LOS). Secondary outcomes were length of stay in intensive care (ICU-LOS) and in hospital (H-LOS), and complications such as re-operation, incidence of empyema, tracheostomy, pneumonia, and mortality.

RESULTS

Of 311 included patients, 220 were in the C-group and 91 in the M-group. The groups were similar in demographics and injury pattern. MV-LOS was 0 (0-65) in the C-group vs 0 (0-34) in the M-group (p < 0.001). ICU-LOS and H-LOS were significantly shorter in the M-group as compared to the C-group (p < 0.001), however with a large overlap. Tracheostomy was performed in 22.3% of patients in the C-group vs 5.4% in the M-group (p < 0.001). Pneumonia was diagnosed in 32.3% of patients in the C-group vs 16.1% in the M-group (p = 0.004). In-hospital mortality was lower in the M-group compared to the C-group but there was no difference in mortality within 30 days or a year.

CONCLUSIONS

Our study indicates that a minimally invasive technique was favorable regarding clinical outcomes for patients operated for chest wall injuries.

Iatrogenic rib fractures and the associated risks of mortality

PURPOSE

Rib fractures, though typically associated with blunt trauma, can also result from complications of medical or surgical care, including cardiopulmonary resuscitation. The purpose of this study is to describe the demographics and outcomes of iatrogenic rib fractures.

METHODS

Patients with rib fractures were identified in the 2016 National Inpatient Sample. Mechanism of injury was defined as blunt traumatic rib fracture (BTRF) or iatrogenic rib fracture (IRF). IRF was identified as fractures from the following mechanisms: complications of care, drowning, suffocation, and poisoning. Differences between BTRF and IRF were compared using rank-sum test, Chi-square test, and multivariable regression.

RESULTS

34,644 patients were identified: 33,464 BTRF and 1180 IRF. IRF patients were older and had higher rates of many comorbid medical disorders. IRF patients were more likely to have flail chest (6.1% versus 3.1%, p < 0.001). IRF patients were more likely to have in-hospital death (20.7% versus 4.2%, p < 0.001) and longer length of hospitalization (11.8 versus 6.9 days, p < 0.001). IRF patients had higher rates of tracheostomy (30.2% versus 9.1%, p < 0.001). In a multivariable logistic regression of all rib fractures, IRF was independently associated with death (OR 3.13, p < 0.001). A propensity matched analysis of IRF and BTRF groups corroborated these findings.

CONCLUSION

IRF injuries are sustained in a subset of extremely ill patients. Relative to BTRF, IRF is associated with greater mortality and other adverse outcomes. This population is understudied. The etiology of worse outcomes in IRF compared to BTRF is unclear. Further study of this population could address this disparity.

Optimizing surgical stabilization of rib fractures using intraoperative ultrasound localization

BACKGROUND

Surgical stabilization of rib fractures (SSRF) significantly improve the outcomes of patients with rib fractures. Ultrasound is a specific modality for localizing rib fractures. We hypothesized that use of perioperative ultrasound localization of fracture sites optimizes surgical approach and clinical outcomes.

METHODS

We performed a retrospective cohort study of adult patients undergoing SSRF and compared those with and without adjunctive perioperative ultrasound fracture localization. Our primary outcome was improved surgical efficiency as measured by incision length and total operative time. Secondary clinical outcomes included numeric pain score on follow-up visit and daily morphine milligram equivalent prescribed within 30 days from discharge.

RESULTS

We performed 49 surgical rib fixations between 2015 and 2020; of which, 13 (26.5%) additionally underwent ultrasound localization (26.5%). There were no significant differences between groups in age, sex, number of ribs repaired, or days till surgery. More patients in the ultrasound group had nonflail chest wall injury (76.9% vs. 27.8%, p = 0.003). Use of perioperative ultrasound was associated with shorter incision length (median, 9 vs. 15.5 cm; p = 0.0001), shorter operative time (median, 120 vs. 174 minutes; p = 0.003), less daily morphine milligram equivalent (25 vs. 68 mg, p = 0.009), and reduced numeric pain score on follow up (median, 4 vs. 7, p = 0.05).

CONCLUSION

Use of perioperative ultrasound localization of rib fractures to optimize surgical approach for SSRF was associated with reduced incision length, operative time, and opioid requirements on patient discharge. We recommend considering routine perioperative localization to improve surgical approach and efficiency during SSRF.

LEVEL OF EVIDENCE

Therapeutic, level IV.

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.

Minimally invasive surgery rib fracture fixation based on location and anatomical landmarks

BACKGROUND

Rib fracture is closely related to thoracic injury with high morbidity and mortality. This study aimed to investigate the clinical effect of Zhang ZhiFei (ZZF) zoning method on the selection of incision and approach in minimally invasive surgery for rib fracture.

METHODS

A total of 110 patients with rib fractures from July 2017 to July 2019 were enrolled in the study. Preoperative computed tomography and three-dimensional reconstruction of ribs was performed. Then, the rib fractures to be surgically fixed were divided into costal cartilage zone, chest zone, lateral costal zone, high posterior costal zone, low posterior costal subscapular zone, and low posterior costal paraspinal zone, which was called ZZF zoning method. Rib fractures in each zone had unique minimally invasive incision approach, and the open reduction and internal fixation of rib fracture was performed under minimally invasive surgery of corresponding small incision.

RESULTS

The average incision length and number of incisions of the 110 patients were 6.2 cm and 1.3, respectively. The average number of internal fixation was 5.3 and the average operation time was 82 min. The postoperative fracture end was well aligned. After 3 months of follow-up, no internal fixation was displaced or detached.

CONCLUSION

Based on the anatomical characteristics of different zones of the chest wall, ZZF zoning method provides a new idea and reference for the selection of incision and approach in minimally invasive internal fixation for rib fracture.

[Injuries of the posterior and lateral chest wall-importance of an additional clavicular fracture]

BACKGROUND

Flail chest wall injuries (FCI) are common in younger patients due to high-speed trauma and in older patients due to low-energy trauma or falls from a low height. They show a high incidence of concomitant injuries and are therefore associated with high morbidity and mortality. If there is also an ipsilateral clavicular fracture (CF), the outcome is significantly poorer. The skeleton of the shoulder and chest loses stability and can lead to a loss of function of the shoulder and a pronounced deformation of the chest wall.

OBJECTIVE

This article shows the origin and clinical importance of FCI. What importance does a concomitant ipsilateral CF have and how can these costoclavicular injuries (CCI) be managed conservatively and operatively?

MATERIAL AND METHODS

After primary emergency care of the patients with appropriate diagnostics, in the presence of CCI operative stabilization was carried out by means of locked plate osteosynthesis of the clavicle and the affected ribs via minimally invasive approaches with the patient under general anesthesia. Patients were followed up postoperatively. Various minimally invasive posterolateral approaches to the chest wall were previously performed in a corpse study and then put into practice.

RESULTS AND CONCLUSION

This study presents therapeutic options for the reconstruction of the chest wall based on the established literature and clinical examples. An ipsilateral CF combined with fractures of the 2nd-4th ribs can be treated through an innovative clavipectoral approach. For the other fractures, standard approaches to the anterolateral and posterolateral chest wall are performed, which are associated with a good outcome in clinical practice. An operative stabilization should be performed at the latest when FCI or CCI together with a dislocating fracture and a marked deformation of the thoracic wall are present. Remaining misalignments are associated with a simultaneous loss of function of the chest wall and shoulder.

Functional Outcomes After Muscle-Sparing Fixation of Flail Chest Injuries

OBJECTIVES

To present outcomes in a multicenter review of a large number of flail chest patients.

DESIGN

Retrospective case series.

SETTING

One urban Level I and 1 urban Level II trauma center.

PATIENTS/PARTICIPANTS

Fifty-two adult patients who underwent treatment of their flail chest injury with locking plate and screw constructs through muscle-sparing approaches, followed for a minimum of 1 year postoperatively.

RESULTS

All patients went on to successful union, with complication rates in line with recent published norms. Periscapular strength returned to greater than 90% of the noninjured side by 3 months postoperatively and to within a mean of 95% of the noninjured side by 6 months postoperatively. Glenohumeral range of motion similarly improved over this same interval.

CONCLUSIONS

Use of anatomically designed modern locking plate and screw fixation constructs with muscle-sparing approaches results in efficient return to function and restoration of shoulder function and strength as compared with the noninjured shoulder.

LEVEL OF EVIDENCE

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

Three common exposures of the chest wall for rib fixation: anatomical considerations

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.

Efficacy of nickel-titanium memory alloy in the treatment of multiple rib fracture combined with sternal fracture

Clinical efficacy and complications of nickel-titanium memory alloy in the treatment of multiple rib fractures combined with sternal fractures was investigated. A retrospective analysis of 123 patients with multiple rib fractures combined with sternal fractures admitted to First People's Hospital of Fuzhou from January 2013 to December 2015 was performed, including study group (treated with internal fixation by the nickel-titanium memory alloy, n=68) and control group (treated with internal fixation by partial pressure bandage, n=55). Μean arterial pressure (MAP), heart rate (HR), and visual analogue pain score (VAS) of the two groups before and after treatment were compared and analyzed. No significant difference in MAP, HR and VAS scores between groups was detected before treatment (P>0.05). After treatment, MAP score of study group was significantly higher, and HR and VAS scores were significantly lower (P<0.05). Μethod of internal fixation by the nickel-titanium memory alloy, with better efficacy than the traditional method of internal fixation by partial pressure bandage and less postoperative complications in the treatment of flail chest caused by multiple rib fractures combined with sternal fractures, is worthy of clinical application and promotion.

[Single-port VATS-assisted internal fixation of serial rib fractures]

This article describes the operative stabilization of a flail chest due to traumatic serial rib fractures with extensive chest wall deformation and respiratory insufficiency. Initial conservative treatment including systemic and regional pain management and non-invasive positive pressure ventilation did not improve the pain or ventilation. Therefore, a single-port video-assisted thoracoscopic surgery (VATS) assisted internal fixation of the ribs was performed. The thoracoscopy enabled easy repositioning of the ribs and additionally an estimation of intrathoracic injuries.