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Oppizzi G, Xu D, Patel T, Diaz JJ, Zhang LQ. Open reduction internal fixation of rib fractures: a biomechanical comparison between the RibLoc U Plus ® system and anterior plate in rib implants. Eur J Trauma Emerg Surg 2023; 49:383-391. [PMID: 36018371 PMCID: PMC10148598 DOI: 10.1007/s00068-022-02075-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/08/2022] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Giovanni Oppizzi
- Department of Bioengineering, University of Maryland, 3102 A. James Clark Hall, College Park, MD, 20742, USA.,Department of Physical Therapy and Rehabilitation Science, School of Medicine, University of Maryland, 100 Penn Street, Baltimore, MD, 21201, USA
| | - Dali Xu
- Department of Physical Therapy and Rehabilitation Science, School of Medicine, University of Maryland, 100 Penn Street, Baltimore, MD, 21201, USA
| | - Tirth Patel
- Chicago College of Osteopathic Medicine, Midwestern University, 555 31st Street, Downers Grove, IL, 60515, USA
| | - Jose J Diaz
- Department of Surgery, School of Medicine, University of Maryland, 22 S Greene Street, Baltimore, MD, 21201, USA.,Department of Orthopedics, School of Medicine, University of Maryland, 110 S. Paca Street, Baltimore, MD, 21201, USA
| | - Li-Qun Zhang
- Department of Bioengineering, University of Maryland, 3102 A. James Clark Hall, College Park, MD, 20742, USA. .,Department of Physical Therapy and Rehabilitation Science, School of Medicine, University of Maryland, 100 Penn Street, Baltimore, MD, 21201, USA. .,Department of Epidemiology and Public Health, School of Medicine, University of Maryland, 660 W. Redwood Street, Baltimore, MD, 21201, USA. .,Department of Orthopedics, School of Medicine, University of Maryland, 110 S. Paca Street, Baltimore, MD, 21201, USA.
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Improved Fixation Stability of a Dedicated Rib Fixation System in Flail Chest: A Retrospective Study. Medicina (B Aires) 2022; 58:medicina58030345. [PMID: 35334521 PMCID: PMC8955880 DOI: 10.3390/medicina58030345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives: Flail chest typically results from major trauma to the thoracic cage and is accompanied by multiple rib fractures. It has been well documented that surgical fixation of rib fractures can decrease both morbidity and mortality rates. This study aimed to evaluate the effectiveness of a dedicated APS Rib Fixation System, which features a pre-contoured design based on anatomical rib data of the Asian population. Materials and Methods: We reviewed 43 consecutive patients, who underwent surgical stabilization for flail chest with the traditional Mini bone plate (n = 20), APS plate (n = 13), or Mini + APS (n = 10). Demographic and injury variables were documented. We used X-ray radiography to determine plate fractures and screw dislocations after surgical fixation. Results: No statistical differences were noted in the demographic or injury variables. APS plates demonstrated fewer cases of plate fractures and screw dislocations than Mini plates (OR = 0.091, p = 0.008). Conclusions: The pre-contoured design of the APS plate demonstrated a superior rib implant failure rate as compared to the traditional Mini bone plate. Our study indicates that the APS plate may serve as an effective surgical tool for the treatment of flail chest.
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Huang G, Li P, Li G, Yang J. Biomechanical study of embracing and non-embracing rib plates. J Appl Biomater Funct Mater 2022; 20:22808000221099132. [PMID: 35588289 DOI: 10.1177/22808000221099132] [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: 11/17/2022] Open
Abstract
The study was carried out to explore the biomechanical properties of embracing and non-embracing rib plates. Forty-eight adult cadaver rib specimens were divided randomly into six groups: three fixation model groups were made using embracing plates (two pairs of equals on both sides of the broken end), and the other three groups were fixed with a pre-shaped anatomical plate (three locking screws on each side of the end were equally spaced). The biomechanical properties of these models were analyzed using non-destructive three-point bending tests, non-destructive torsion experiments, and destructive axial compression tests. In this study, the gap of fracture ends was widened in embracing plate group in the non-destructive three-point bending experiment. No change in the fracture ends was detected in the pre-shaped anatomical plate group. The bending stress of the pre-shaped anatomical plate group was significantly enhanced at the 2-12 mm displacement points (p < 0.05). Moreover, there was no significant difference in torque noticed between the two groups in the torsion experiment (p = 0.082). In the destructive axial compression experiment, the load index of the two groups were higher than the normal physiological load, suggesting that both materials could provide sufficient strength for rib fractures. The pre-shaped anatomical plate displayed more reliable attachment in terms of stability, bending, and load. Our results indicated that the embracing plate has the advantage of fretting at the fracture end.
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Affiliation(s)
- Gang Huang
- Thoracic Surgery Department, The 3rd Hospital of Hebei Medical University, Shijiazhuang, China
| | - Pu Li
- Thoracic Surgery Department, The 3rd Hospital of Hebei Medical University, Shijiazhuang, China
| | - Gaoyang Li
- Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Jinliang Yang
- Thoracic Surgery Department, The 3rd Hospital of Hebei Medical University, Shijiazhuang, China
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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: 2] [Impact Index Per Article: 0.7] [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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Jian X, Lei W, Yuyang P, Yongdong X. A new instrument for surgical stabilization of multiple rib fractures. J Int Med Res 2019; 48:300060519877076. [PMID: 31566050 PMCID: PMC7607199 DOI: 10.1177/0300060519877076] [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] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Xiong Jian
- Department of Thoracic Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, Shanghai, China
| | - Wu Lei
- Department of Thoracic Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, Shanghai, China
| | - Pi Yuyang
- Department of Thoracic Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, Shanghai, China
| | - Xu Yongdong
- Department of Thoracic Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, Shanghai, China
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6
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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: 147] [Impact Index Per Article: 21.0] [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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8
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Sarani B, Schulte L, Diaz JJ. Pitfalls associated with open reduction and internal fixation of fractured ribs. Injury 2015; 46:2335-40. [PMID: 26521992 DOI: 10.1016/j.injury.2015.10.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 10/05/2015] [Accepted: 10/13/2015] [Indexed: 02/02/2023]
Abstract
Rib fracture is exceedingly common and remains a leading cause of death in patients with chest injury. Probability of death increases by 19% with each broken rib, and the probability of death increases further with age. Treatment is centered on pain control and early mobilization to provide adequate pulmonary hygiene. Multimodality interventions, such as incentive spirometry, postural changes, and coughing, are pivotal in minimizing the risk of pneumonia and death. Recently, many studies have found mortality benefit to operation fixation (ORIF) of ribs in select patients. However, this procedure remains underutilized partly due to lack of familiarity with its technique and pitfalls by trauma surgeons, in particular. Whereas there are publications on operative technique, there are no studies describing pitfalls associated with this procedure. The purpose of this paper is to describe pitfalls on the technical aspects of ORIF of the ribs based on the medical literature where possible and based on our experience in instances where peer reviewed evidence is lacking. The paper is not meant to serve as a protocol for managing rib fractures.
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Affiliation(s)
- Babak Sarani
- Center for Trauma and Critical Care, Department of Surgery, George Washington University.
| | - Leah Schulte
- Department of Orthopedic Surgery, George Washington University
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Snapping scapular syndrome secondary to rib intramedullary fixation device. Int J Surg Case Rep 2015; 17:158-60. [PMID: 26629853 PMCID: PMC4701874 DOI: 10.1016/j.ijscr.2015.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/12/2015] [Accepted: 11/12/2015] [Indexed: 11/22/2022] Open
Abstract
Intramedullary rib fixation has become popular. Snapping scapula syndrome is a cause of persistent pain around the scapulothoracic joint. We present a case of snapping scapula secondary to migration of a intramedullary rib splint into the scapulothoracic joint.
Background Scapulo-thoracic joint disorders, including bursitis and crepitus, are commonly misdiagnosed problems and can be a source of persistent pain and dysfunction Presentation of the case This article describes an unusual case of a snapping scapula syndrome secondary to a migration through the lateral cortex of a rib splint intramedullary fixation device into the scapulothoracic joint. Discussion Recently, the operative fixation of multiple ribs fractures with intramedullary fixation devices has become popular. Despite the good outcomes with new rib splint designs, concern remains about the potential complications related to potential loss of fracture reduction with migration of the wire resulting in pain or additional injury to the surrounding tissues. Conclusion Surgeons should pay attention to any protrusion of intramedullary rib implants, especially in the evaluation of routine X-rays following surgical treatment. We should be aware of the possibility of this rare cause of snapping scapula syndrome to avoid delayed diagnosis and consider removing the implant will resolve the pain.
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10
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The surgical stabilization of multiple rib fractures using titanium elastic nail in blunt chest trauma with acute respiratory failure. Surg Endosc 2015; 30:388-95. [PMID: 25875089 PMCID: PMC4710669 DOI: 10.1007/s00464-015-4207-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 03/23/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Blunt chest injuries are usually combined with multiple rib fractures and severe lung contusions. This can occasionally induce acute respiratory failure and prolong ventilations. In order to reduce the periods of ventilator dependency, we propose a less invasive method of fixing multiple rib fractures. METHODS Since October 2009, we have developed a new method to fix fractured ribs caused by blunt trauma. Rib fixations were performed using 2.0- or 2.5-mm intramedullary titanium elastic nails (TEN), with the help of video-assisted thoracoscopic surgery (VATS) and minimal thoracic incisions. All the patients' demographics and postoperative data were collected. RESULTS From January 2010 to December 2012, a total of 65 patients presenting with multiple rib fractures resulting in acute respiratory failure were included in the study. Twelve patients received the new surgical fixation. Rib fixations were performed at an average of 4 days after trauma. Patients were successfully weaned off ventilators after an average of 3 days. The average length of stay in the hospital and the intensive care unit (ICU) was shorter for the patients with fixation than for nonsurgical patients. All twelve patients returned to normal daily activities and work. CONCLUSIONS In the reconstruction of an injured chest wall, the VATS with TENs fixation in multiple rib fractures is feasible. This method is also effective in decreasing the length of the surgical wound. Because the structure of the chest cage is protected, the period of mechanical ventilation is shortened and the length of stay in the hospital and the ICU can be reduced.
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Huang KN, Xu ZF, Sun JX, Ding XY, Wu B, Li W, Qin X, Tang H. Stabilization of multiple rib fractures in a canine model. J Surg Res 2014; 192:621-7. [PMID: 25255725 DOI: 10.1016/j.jss.2014.07.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/27/2014] [Accepted: 07/23/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Operative stabilization is frequently used in the clinical treatment of multiple rib fractures (MRF); however, no ideal material exists for use in this fixation. This study investigates a newly developed biodegradable plate system for the stabilization of MRF. METHODS Silk fiber-reinforced polycaprolactone (SF/PCL) plates were developed for rib fracture stabilization and studied using a canine flail chest model. Adult mongrel dogs were divided into three groups: one group received the SF/PCL plates, one group received standard clinical steel plates, and the final group did not undergo operative fracture stabilization (n = 6 for each group). Radiographic, mechanical, and histologic examination was performed to evaluate the effectiveness of the biodegradable material for the stabilization of the rib fractures. RESULTS No nonunion and no infections were found when using SF-PCL plates. The fracture sites collapsed in the untreated control group, leading to obvious chest wall deformity not encountered in the two groups that underwent operative stabilization. CONCLUSIONS Our experimental study shows that the SF/PCL plate has the biocompatibility and mechanical strength suitable for fixation of MRF and is potentially ideal for the treatment of these injuries.
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Affiliation(s)
- Ke-Nan Huang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Zhi-Fei Xu
- Department of Thoracic and Cardiovascular Surgery, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Ju-Xian Sun
- Department of Thoracic and Cardiovascular Surgery, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Xin-Yu Ding
- Department of Thoracic and Cardiovascular Surgery, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Bin Wu
- Department of Thoracic and Cardiovascular Surgery, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Wei Li
- Materials Science and Engineering Lab, Shanghai Jiaotong University, Shanghai, China
| | - Xiong Qin
- Department of Thoracic and Cardiovascular Surgery, Shanghai First People's Hospital, Shanghai Jiaotong University, Shanghai, China.
| | - Hua Tang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai, China.
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Lee SA, Hwang JJ, Chee HK, Kim YH, Lee WS. Flail chest stabilization with Nuss operation in presence of multiple myeloma. J Thorac Dis 2014; 6:E43-7. [PMID: 24822124 DOI: 10.3978/j.issn.2072-1439.2014.02.10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 02/19/2014] [Indexed: 12/31/2022]
Abstract
Nowadays the Nuss operation has been widely adopted as a minimally invasive procedure and standard surgical choice in pectus excavatum. However, much debate and concern have been raised regarding its applicability in adults with pectus excavatum flail chest and other thoratic wall deformities, as compared with younger patients, in terms of complications after surgery. To stabilize the segment of paradoxical chest wall movement we performed the Nuss operation on a patient with multiple myeloma who sustained blunt thoracic trauma. The patient presented with paradoxical movement of the thoracic wall and sternum instability due to multiple myeloma, which led to severe dyspnea, hypoxemia, hypercapnea, and bedridden state. His condition progressed to acute respiratory distress syndrome and did not respond to conservative treatment. We performed the Nuss operation on the patient, and his clinical symptoms were relieved after surgery. The patient regained the ability to walk unassisted and was discharged from the hospital without any specific events.
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Affiliation(s)
- Song Am Lee
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
| | - Jae Joon Hwang
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
| | - Hyun Keun Chee
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
| | - Yo Han Kim
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
| | - Woo Surng Lee
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
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Abstract
Blunt chest wall trauma accounts for a large proportion of all trauma presentations to the Emergency Departments in the United Kingdom and has a high reported incidence of morbidity and mortality. The difficulty in the assessment and management of this patient group arises from the possibility that the patient may develop potentially life-threatening complications up to approximately 72 h post-injury, even in patients who have sustained what is initially considered a minor injury. Limited consensus currently exists in the literature regarding optimal assessment or management strategies for this patient group. The aim of this review is to provide an overview of current research investigating the optimal assessment and management strategies for the blunt chest wall trauma patient.
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Affiliation(s)
- Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea, UK
- College of Medicine, Swansea University, Swansea, UK
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Bottlang M, Long WB, Phelan D, Fielder D, Madey SM. Surgical stabilization of flail chest injuries with MatrixRIB implants: a prospective observational study. Injury 2013; 44:232-8. [PMID: 22910817 DOI: 10.1016/j.injury.2012.08.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 07/31/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Surgical stabilization of flail chest injury with generic osteosynthesis implants remains challenging. A novel implant system comprising anatomic rib plates and intramedullary splints may improve surgical stabilization of flail chest injuries. This observational study evaluated our early clinical experience with this novel implant system to document if it can simplify the surgical procedure while providing reliable stabilization. METHODS Twenty consecutive patients that underwent stabilization of flail chest injury with anatomic plates and intramedullary splints were prospectively enrolled at two Level I trauma centres. Data collection included patient demographics, injury characterization, surgical procedure details and post-operative recovery. Follow-up was performed at three and six months to assess pulmonary function, durability of implants and fixation and patient health. RESULTS Patients had an Injury Severity Score of 28±10, a chest Abbreviated Injury Score of 4.2±0.4 and 8.5±2.9 fractured ribs. Surgical stabilization was achieved on average with five plates and one splint. Intra-operative contouring was required in 14% of plates. Post-operative duration of ventilation was 6.4±8.6 days. Total hospitalization was 15±10 days. At three months, patients had regained 84% of their expected forced vital capacity (%FVC). At six months, 7 of 15 patients that completed follow-up had returned to work. There was no mortality. Among the 91 rib plates, 15 splints and 605 screws in this study there was no hardware failure and no loss of initial fixation. There was one incidence of wound infection. Implants were removed in one patient after fractures had healed. CONCLUSIONS Anatomic plates eliminated the need for extensive intraoperative plate contouring. Intramedullary rib splints provided a less-invasive fixation alternative for single, non-comminuted fractures. These early clinical results indicate that the novel implant system provides reliable fixation and accommodates the wide range of fractures encountered in flail chest injury.
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Affiliation(s)
- Michael Bottlang
- Legacy Research Institute, 1225 NE 2nd Ave, Portland, OR 97232, United States.
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Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2013; 73:S351-61. [PMID: 23114493 DOI: 10.1097/ta.0b013e31827019fd] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite the prevalence and recognized association of pulmonary contusion and flail chest (PC-FC) as a combined, complex injury pattern with interrelated pathophysiology, the mortality and morbidity of this entity have not improved during the last three decades. The purpose of this updated EAST practice management guideline was to present evidence-based recommendations for the treatment of PC-FC. METHODS A query was conducted of MEDLINE, Embase, PubMed and Cochrane databases for the period from January 1966 through June 30, 2011. All evidence was reviewed and graded by two members of the guideline committee. Guideline formulation was performed by committee consensus. RESULTS Of the 215 articles identified in the search, 129 were deemed appropriate for review, grading, and inclusion in the guideline. This practice management guideline has a total of six Level 2 and eight Level 3 recommendations. CONCLUSION Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion. Obligatory mechanical ventilation in the absence of respiratory failure should be avoided. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status. Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure or continuous positive airway pressure should be provided. High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.Steroids should not be used in the therapy of pulmonary contusion. Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.
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Marasco SF, Liovic P, Šutalo ID. Structural integrity of intramedullary rib fixation using a single bioresorbable screw. J Trauma Acute Care Surg 2012; 73:668-73. [PMID: 23007016 DOI: 10.1097/ta.0b013e3182569f75] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Operative management of flail chest injury is receiving increasing interest. However, we have noticed in our own practice the difficulty in achieving reliable results with posterior rib fracture fixation. In this article, we analyze and model the physiologic forces acting on posterior rib fractures and assess the suitability of an intramedullary screw fixation technique in this site. METHODS Computerized finite element analysis (FEA) was used to model a typical sixth rib and analyze the physiologic forces that act on the rib in vivo. A fracture in the posterior aspect of the rib was incorporated into the model, and an intramedullary screw fixation concept was assessed, using both a bioabsorbable polymer screw and a stainless steel screw.The records of 120 consecutive patients with flail chest were reviewed, and 26 patients were identified as having multiple posterior rib fractures with displacement. These patients formed a clinical correlation group by which to assess the FEA model. RESULTS FEA modeling of the posterior rib fracture showed likely posterior displacement in response to physiologic forces. Review of the 26 patients with flail chest and displaced posterior fractures confirmed the direction of displacement. Modeling of an intramedullary screw fixation showed significant stresses in the bone/screw contact areas (stainless steel solution) and the prosthesis itself (bioabsorbable polymer solution) CONCLUSION This FEA model demonstrates that physiologic forces cause posterior displacement at posterior rib fracture sites. Fixation solutions to counteract these forces need to overcome significant stresses at both the bone/prosthesis contact regions and within the prosthetic material itself. LEVEL OF EVIDENCE Epidemiologic/therapeutic study, level V.
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Affiliation(s)
- Silvana F Marasco
- CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Perth, Western Australia, Australia.
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A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture. Int J Surg 2011; 9:478-81. [PMID: 21763475 DOI: 10.1016/j.ijsu.2011.06.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Revised: 05/24/2011] [Accepted: 06/01/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the intensity of pain and duration of return to normal activity in patients with rib fractures treated with surgical stabilization with plating versus conventional treatment modalities. PATIENTS AND METHODS This study was conducted over a 12 month period. Patients with rib fractures were assessed by numerical pain scale. Patients having pain scale less than 5 were excluded from study. Patients having pain scale of 5 or more than 5 were treated with conventional treatment for next 10 days. On 11th day patients were again assessed by numerical pain scale and patients having score less than 5 were excluded from study. Patients having pain scale of 5, 6, and 7 were treated with conventional treatment and patients having pain scale of 8, 9, and 10 were selected for operative management. Operative and control group were compared on basis of intensity of pain and duration of return to normal activity. Follow up was done on 5, 15, and 30 post operative day. RESULTS There was less pain in operative group as compared to control group. Mean rib fracture pain in operative group was 9.15, 2.31, 1.12 as compared to 6.25, 5.96, 4.50 in control group on 5, 15 and 30 post operative days. Also there was early return to normal activity in operative group. CONCLUSION Surgical stabilization of rib fracture, an underutilized intervention is better than conventional conservative management in terms of both, decrease in intensity of pain and early return to normal activity.
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Bottlang M, Walleser S, Noll M, Honold S, Madey SM, Fitzpatrick D, Long WB. Biomechanical rationale and evaluation of an implant system for rib fracture fixation. Eur J Trauma Emerg Surg 2010; 36:417-26. [PMID: 21841953 PMCID: PMC3150823 DOI: 10.1007/s00068-010-0047-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Accepted: 08/23/2010] [Indexed: 11/29/2022]
Abstract
Background Biomechanical research directed at developing customized implant solutions for rib fracture fixation is essential to reduce the complexity and to increase the reliability of rib osteosynthesis. Without a simple and reliable implant solution, surgical stabilization of rib fractures will remain underutilized despite proven benefits for select indications. This article summarizes the research, development, and testing of a specialized and comprehensive implant solution for rib fracture fixation. Methods An implant system for rib fracture fixation was developed in three phases: first, research on rib biomechanics was conducted to better define the form and function of ribs. Second, research results were implemented to derive an implant system comprising anatomical plates and intramedullary rib splints. Third, the functionality of anatomic plates and rib splints was evaluated in a series of biomechanical tests. Results Geometric analysis of the rib surface yielded a set of anatomical rib plates that traced the rib surface over a distance of 13–15 cm without the need for plate contouring. Structurally, the flexible design of anatomic plates did not increase the native stiffness of ribs while restoring 77% of the native rib strength. Intramedullary rib splints with a rectangular cross-section provided 48% stronger fracture fixation than traditional intramedullary fixation with Kirschner wires. Conclusion The anatomic plate set can simplify rib fracture fixation by minimizing the need for plate contouring. Intramedullary fixation with rib splints provides a less-invasive fixation alternative for posterior rib fracture, where access for plating is limited. The combination of anatomic plates and intramedullary splints provides a comprehensive system to manage the wide range of fractures encountered in flail chest injuries.
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Affiliation(s)
- M. Bottlang
- Biomechanics Laboratory, Legacy Clinical Research and Technology Center, 1225 NE 2nd Avenue, Portland, OR 97215 USA
| | - S. Walleser
- Biomechanics Laboratory, Legacy Clinical Research and Technology Center, 1225 NE 2nd Avenue, Portland, OR 97215 USA
| | - M. Noll
- Biomechanics Laboratory, Legacy Clinical Research and Technology Center, 1225 NE 2nd Avenue, Portland, OR 97215 USA
| | - S. Honold
- Biomechanics Laboratory, Legacy Clinical Research and Technology Center, 1225 NE 2nd Avenue, Portland, OR 97215 USA
| | - S. M. Madey
- Biomechanics Laboratory, Legacy Clinical Research and Technology Center, 1225 NE 2nd Avenue, Portland, OR 97215 USA
| | - D. Fitzpatrick
- Slocum Center for Orthopedics and Sports Medicine, Eugene, OR USA
| | - W. B. Long
- Biomechanics Laboratory, Legacy Clinical Research and Technology Center, 1225 NE 2nd Avenue, Portland, OR 97215 USA
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Fitzpatrick DC, Denard PJ, Phelan D, Long WB, Madey SM, Bottlang M. Operative stabilization of flail chest injuries: review of literature and fixation options. Eur J Trauma Emerg Surg 2010; 36:427-33. [PMID: 21841954 PMCID: PMC3150812 DOI: 10.1007/s00068-010-0027-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Accepted: 04/26/2010] [Indexed: 11/29/2022]
Abstract
Background Flail chest injuries cause significant morbidity, especially in multiply injured patients. Standard treatment is typically focused on the underlying lung injury and involves pain control and positive pressure ventilation. Several studies suggest improved short- and long-term outcomes following operative stabilization of the flail segments. Despite these studies, flail chest fixation remains a largely underutilized procedure. Methods This article reviews the relevant literature concerning flail chest fixation and describes the different implants and techniques available for fixation. Additionally, an illustrative case example is provided for description of the surgical approach. Results Two prospective randomized studies, five comparative studies, and a number of case series documented benefits of operative treatment of flail chest injuries, including a decreased in ventilation duration, ICU stay, rates of pneumonia, mortality, residual chest wall deformity, and total cost of care. Historically, rib fractures have been stabilized with external plates or intramedullary implants. The use of contemporary, anatomically contoured rib plates reduced the need for intraoperative plate bending. Intramedullary rib splints allowed less-invasive fixation of posterior fractures where access for plating was limited. Conclusion Operative treatment can provide substantial benefits to patients with flail chest injuries and respiratory compromise requiring mechanical ventilation. The use of anatomically contoured rib plates and intramedullary splints greatly simplifies the procedure of flail chest fixation.
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Affiliation(s)
| | - P. J. Denard
- Department of Orthopedics, Oregon Health and Science University, Portland, OR USA
| | - D. Phelan
- Biomechanics Laboratory, Legacy Clinical Research and Technology Center, 1225 NE 2nd Avenue, Portland, OR 97215 USA
| | - W. B. Long
- Biomechanics Laboratory, Legacy Clinical Research and Technology Center, 1225 NE 2nd Avenue, Portland, OR 97215 USA
| | - S. M. Madey
- Biomechanics Laboratory, Legacy Clinical Research and Technology Center, 1225 NE 2nd Avenue, Portland, OR 97215 USA
| | - M. Bottlang
- Biomechanics Laboratory, Legacy Clinical Research and Technology Center, 1225 NE 2nd Avenue, Portland, OR 97215 USA
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