Surgical fixation of sternal fractures: preoperative planning and a safe surgical technique using locked titanium plates and depth limited drilling

Awake sternal fixation; comparison of technical details and early results with sternal fixation methods performed via general anaesthesia

OBJECTIVES

Isolated sternal fractures are rare pathologies that rarely require surgical fixation. Although different fixation techniques are used, it is routinely performed under general anaesthesia. In our study, we aimed to share the details of the awake sternal fixation technique performed in our clinic and to compare the early results with sternal fixation methods performed under general anaesthesia.

METHODS

Between January 2009 and January 2023, 129 patients who were diagnosed with sternal fracture and who underwent investigations and follow-up in our clinic were evaluated retrospectively. Thirteen patients who underwent surgical fixation for isolated sternal fracture were included in the study. Patients were categorized according to fixation and anaesthetic technique; group 1: fixation with steel wire under general anaesthesia (n = 4), group 2: fixation with titanium plate-screw under general anaesthesia (n = 4) and group 3: fixation with awake titanium plate-screw with parasternal intercostal plane block (n = 5). Demographics, surgical indication, radiological findings, surgical incision, surgical time and hospital stay were statistically compared.

RESULTS

The mean age of the patients included in the study was 55.15 ± 15.01 years and 84.6% (n = 11) were male. The most common reason for fixation was displaced fracture (53.8%). Fixation surgery was performed due to pain in 30.8% (n = 4) and non-union in 15.4% (n = 2) of the fractures. The mean duration of surgery were 98.75 ± 16.52, 77.5 ± 35 and 41 ± 14.74 min, respectively. Duration of surgery was significantly lower in group 3 compared to the other groups (P = 0.012). The hospital stay duration for group 1 was 6 days, group 2 was 4 days and group 3 was 1 day. A notable difference was observed among all groups (P = 0.019).

CONCLUSIONS

Awake sternal fixation technique with titanium plate-screw system under superficial parasternal intercostal plane block is an easy and effective method for surgical treatment of isolated sternal fractures. This technique showed a direct positive effect on the duration of surgery and hospital stay.

A Novel Approach to Sternal Fracture Repair With the Implementation of a Compression/Distraction Device

Sternal fractures are common following blunt traumatic injury. Most sternal fractures can be managed successfully nonoperatively; however, surgical fixation should be considered in certain scenarios. Specifically, surgery may be indicated in cases of severe pain, respiratory failure or dependency on mechanical ventilation, cosmetic deformity, malunion, disunion, and compression of the heart. A variety of surgical approaches to sternal fracture fixation have been documented (steel wire, suture materials, a seven-hole aluminum plate, an eight-holed Sternolock X plate, sternum-osteosynthesis plate, t-shaped plate); however, few techniques have been discussed for the initial reduction of the sternal fracture prior to fixation. In this paper, we describe a novel surgical technique used to reduce sternal fractures and approximate the edges of the sternum using a compression/distraction device.

Postoperative transverse sternal nonunion with a chest wall defect managed by a tibial locking plate and a Gore-Tex dual mesh membrane: a case report

Background

Transverse sternal nonunion is a rare but disabling complication of chest trauma or a transverse sternotomy. Fixation methods, mainly used to manage the more common longitudinal sternal nonunion, often fail, leaving the surgical treatment of transverse nonunion to be a challenge.

Case presentation

We present a case of a highly-disabling, postoperative chest wall defect resulting from transverse sternal nonunion after a transverse thoracosternotomy (clamshell incision) and a concomitant rib resection. Following unsuccessful surgical attempts, the sternal nonunion was fixed with a tibial locking plate and bone grafted, while the post-rib resection chest defect was reconstructed with a Gore-Tex dual mesh membrane. Adequate chest stability was achieved, enabling complete healing of the sternal nonunion and the patient’s complete recovery.

Conclusion

We believe it is important to address both in the rare case of combined postoperative transverse sternal nonunion and the chest wall defect after rib resection. A good outcome was achieved in our patient by fixing the nonunion with an appropriately sized and shaped locking plate with bone grafting and covering the chest defect with a dual mesh membrane.

Sternal Fracture Fixation with a Steel Wire: The New “Timala” Technique

Purpose Traumatic sternal fractures are rare but quite disabling injuries. Timely fixation of sternal fractures reduces pain and prevents respiratory complications. However, the fixation technique should be simple, effective, and readily available in local circumstances. Methods From January 2014 to March 2020, seven patients with sternal fracture/ dislocation underwent steel wire fixation with the new “Timala” technique. In this technique, adjacent ribs are anchored with two steel wires to form an “X” in front of the fractured segment of the sternum. Patients were followed up clinically and radiologically. Results Six of the patients were men and one was a female. Five of them had injuries due to falls and two were injured in road traffic accidents. Their age ranged from 18 years to 76 years, with a median age of 41 years. All seven patients experienced immediate recovery from pain and showed evidence of fracture healing on postoperative chest X-rays and clinical examinations. Conclusions Anchoring ribs to fix the sternum with steel wire is a safe, effective, easily available, and reproducible method to fix sternal fractures or dislocations.

Surgical treatment of sternum comminuted fracture with memory alloy embracing fixator

Background

Sternal fracture can result from multiple types of severe chest trauma and carries significant risk. Surgical fixation is an effective method for sternal fracture.

Methods

The clinical data of patients with sternal fractures who presented to our hospital between August 2016 and July 2019 were collected. The 42 patients were divided into three groups, with 15 patients treated by internal fixation with NI-TI memory alloy embracing fixator, 10 patients receiving steel wire fixation, and 17 who received non-surgical treatment and who was designated as a control (conservative) group. Differences in clinical indices included the duration of surgery, blood loss, hospitalization, wound healing, hospitalization expenses, VAS scores, and patient satisfaction scores between the three groups was compared. The analysis of variance and t-test were used for quantitative variables, which were approximately normally distributed. Dichotomous data were compared used Pearson χ² or Fisher’s exact test, and a P value less than 0.05 was considered as statistically significant.

Results

All patients were cured, and there were no significant differences in general clinical features between the three groups (P>0.05). Thoracic deformity in the surgical groups was corrected anatomically and received better pain scores, while patients in the NI-TI memory alloy embracing fixator group showed advantages of bleeding and patient satisfaction (P<0.05).

Conclusions

Operative treatment for a sternal fracture is safe, effective and can quickly restore the stability of the thorax. Memory alloy embracing fixator is markedly superior to other fixator materials.

Surgical fixation by mesh plate and intraoperative safe techniques for the manubrium sterni

Plate osteosynthesis for oblique fracture of the manubrium sterni is quite rare. We present a case of a 37-year-old man with oblique fracture of the manubrium sterni caused by a traumatic injury. He was operated on using a variable-angle locking compression plate Mesh Plate 2.4/2.7 and had a good postoperative result. We also discuss intraoperative safe techniques such as use of a cement spatula for reduction support tools and depth-limited drilling to prevent excess drilling of the opposite cortex.

Sternal reconstruction using locking compression plates (LCP): our experience in Egypt, a case series

Background

Sternal fractures are rare accounting for about 3–8% of traumatic chest. There are many lines of treatments for sternal fractures which can be classified as conservative or surgical. Surgical techniques include wire fixation and sternal plating. There are no standardization of indications for each line of management.

We explore if sternal reconstruction using locking titanium plates and self-tapping screws provide the patient with the best chance of proper sternal healing avoiding chronic pain and its complications and allow the patient early mobilization and rapid restoring of his normal life at its maximum.

Methods

Our inclusion criteria are patients of both gender from 20 to 60 years of age presented with traumatic sternal fracture at any site or pathological fracture due to metastatic or primary tumors infiltrating the sternum. High Associated Injury Scale scores were excluded. Exclusion criteria also included patients younger than 20 years or older than 60 years. Primary outcome is post-operative pain score and is measured using numerical pain scale ranging from zero to 10 where zero means there is no pain at all and ten is the worst imaginable pain ever.

Results

Sternal reconstruction using titanium plates has proven to be an efficient method of stabilization with tremendous immediate relief of pain showed by the differences between pre-operative and post-operative pain scale scores in our patients (n = 5) with Median scores being 7 and 1.5 with range being from 7 to 9 and 1 to 3 respectively (p-value = .039). Operative time range between 150 min and 90 min with median of 120 min. Extubation of patients was smooth with no events with median time of extubation being 120 min. From our experience, there were no observed wound complications except at the third patient who suffered a small wound hematoma that was resolved by gentle compressing only and needed no further intervention.

Conclusion

We recommend adopting sternal reconstruction using titanium plating systems more readily encouraging even larger clinical trials on the way to a clear guidelines. Plating systems show promising results with least pain, better stability, less complications and rapid, smooth recovery.

Trial registration

NCT04092374

Osteosynthesis of sternal fractures with double locking compression plate fixation: a retrospective cohort study

PURPOSE

Sternal fractures are rare injuries and mostly treated non-operatively. In selected cases, internal fixation becomes necessary. No standard operative approach has been determined yet among experts. The aim of this study is to describe our treatment algorithm and results after operative stabilisation of sternal fractures with locking compression plates (LCP), mainly focusing on the functional outcome.

METHODS

A retrospective cohort study was conducted. We included all patients after operative stabilisation of a sternal fracture between 2008 and 2016. Endpoints were the functional outcome using the Activities of Daily Living (ADL) score, pain analysed by the numeric rating scale (NRS), breathing ability, complications and implant removal.

RESULTS

Eighteen out of 153 (12%) patients with a sternal fracture underwent operation. Three patients were lost to follow-up. Eleven out of 15 (73%) patients were treated with double straight LCP 3.5 mm implants and 4 (27%) patients with pre-countered LCP 3.5 mm implants. Mean follow-up was 57 months. The median ADL score was 1 (1-4), the median NRS was 0 (0-9), and respiratory complaints scored a median of 1 (1-4). No non-union, hardware failure or implant-related complication occurred. Post-operative complications were pneumonia (20%) and respiratory insufficiency (20%). Implants were removed in 4/15 (27%) patients; three times due to implant-related irritation, once on patient's request.

CONCLUSION

Operative stabilisation of sternal fractures with double LCP 3.5 mm provides excellent long-term functional results and seems to be an appropriate option for internal fixation. The rate of post-operative complications is low; however, 27% had a second operation for implant removal.

Minimally invasive plate osteosynthesis for the treatment of sternal fracture in the lower chest: a case report

Sternal fracture is a common complication of chest trauma but has a low incidence. Various treatments have been developed to reconstruct sternal fractures. Among these approaches, analgesia, corset fixation, and open reduction with plate internal fixation have been suggested. The use of newly developed minimally invasive plate osteosynthesis is a feasible method. In this study, we report a case involving a 54-year-old man with a sternal fracture accompanied by bilateral pleural effusion and a small amount of right-sided pneumothorax. The patient was treated with minimally invasive plate osteosynthesis. The operation was successful and the postoperative recovery was good. No pneumothorax or complications such as chest pain, paresthesia, or wound infection were observed at the 1-year follow-up visit. Additionally, the bilateral pleural effusion had been completely absorbed. The incision in the lower chest was aesthetic and minimally traumatic. This case describes a novel method for internal fixation of sternal fractures.

[Lesions of the anterior chest wall-significance of additional fractures of the spine]

BACKGROUND

Fractures of the anterior chest wall are rare among the total number of fractures. They include sternal fractures (SF) and the adjacent cartilaginous structures of the ribs. The accident mechanism can allow conclusions to be drawn about which further accompanying injuries may be present, e.g. rib and spinal fractures.

OBJECTIVE

The present work is intended to give an overview of injuries of the anterior chest wall. It includes clinical aspects as well as imaging and popular literature.

MATERIAL AND METHODS

Included are injury constellations of the anterolateral chest wall, in particular of the sternum in combination with injuries of the spinal column in the sense of a sternovertebral injury (SVI). Possible treatment strategies were reviewed and the corresponding advantages and disadvantages are presented.

RESULTS

In symptomatic fractures of the anterior chest wall, their operative stabilization should be considered in order to restore the stability of the trunk. In addition, rib fractures in direct trauma and spinal injuries in indirect trauma are often included in the treatment.

CONCLUSION

In the case of injuries of the thoracic trunk, this must always be regarded as a unit and must therefore be clarified in the context of the clinical examination and diagnostic apparatus. The possible accident mechanism can allow conclusions to be drawn about possible injury patterns, e.g. in the sense of SVIs.

Current treatment and outcomes of traumatic sternal fractures-a systematic review

Purpose

Traumatic sternal fractures are rare injuries. The most common mechanism of injury is direct blunt trauma to the anterior chest wall. Most (> 95%) sternal fractures are treated conservatively. Surgical fixation is indicated in case of fracture instability, displacement or non-union. However, limited research has been performed on treatment outcomes. This study aimed to provide an overview of the current treatment practices and outcomes of traumatic sternal fractures and dislocations.

Methods

A systematic review of literature published from 1990 to June 2017 was conducted. Original studies on traumatic sternal fractures, reporting sternal healing or sternal stability were included. Studies on non-traumatic sternal fractures or not reporting sternal healing outcomes, as well as case reports (n = 1), were excluded.

Results

Sixteen studies were included in this review, which reported treatment outcomes for 191 patients. Most included studies were case series of poor quality. All patients showed sternal healing and 98% reported pain relief. Treatment complications occurred in 2% of patients.

Conclusions

Treatment of traumatic sternal fractures and dislocations is an underexposed topic. Although all patients in this review displayed sternal healing, results should be interpreted with caution since most included studies were of poor quality.

Fractures of the manubrium sterni: treatment options and a possible classification of different types of fractures

Background

Sternum fractures are mostly located on the sternal corpus, seldom on the manubrium. Fractures of the sternal manubrium are, however, more frequently associated with severe concomitant injuries of thoracic organs, and therefore deserve special attention. In addition, in its function as a capstone in between the anterior chest wall and the shoulder girdle, it is exposed to a multiplicity of forces. Therefore the questions arise what types of fractures are observed in today's clinical practice, how to classify them and which treatment options are available. This study reports on different types of fractures which involve the manubrium sterni.

Methods

Between January 2012 and October 2014, data was collected from all severely injured patients (ISS ≥16), which received a CT scan of the thorax in our Level-I-Trauma Center and retrospectively analyzed concerning sternal fractures. Fracture type, collateral injuries, age, and information about the circumstances of the accident were noted.

Results

Of 890 evaluable patients, 154 (17.3%) had a fracture of the sternum and 23 (2.6%) of the manubrium. Fractures of the manubrium appeared in following types: A-type-transverse fracture (n=11) in 1st intercostal space by direct blunt trauma or flexion of the torso with sagittal instability; B-type-oblique fracture (n=9) by seat belt injury with rotatory instability; C-type-combined, more fragmentary fracture (n=3) by direct blunt trauma with simultaneous flexion of the torso and multi directional instability. Fractures only little dislocation were treated conservatively, and unstable fractures were surgically stabilized (n=10).

Conclusions

In summary, three main types of fractures could be found. A-type fractures were stabilized with a longitudinal plate osteosynthesis and B-type fractures with transverse positioned plates. To treat complex C-type fractures, plates with a T- or H-form could be a good solution. Level of evidence: Level III retrospective prognostic cohort study.

The modified Ravitch approach for the management of severe anterior flail chest with bilateral sternochondral dislocations: a case report

The management of flail chest continues to evolve as scientific evidence and surgical experience accumulates. Flail chest injuries that span the sternum present a rare and complicated injury pattern that can be challenging to manage both medically and surgically. Our patient is a 69-year-old involved in a high-speed motor vehicle crash with respiratory failure secondary to an anterior flail chest. Tomographic examination confirmed a sternal fracture with bilateral sternochondral dislocations and multiple rib fractures. The rib fractures created a lateral flail segment which extended towards the right side. An open Pectus exposure with a right anterolateral extension (modified Ravitch approach) and osteosynthesis plates accomplished stabilization of the chest wall, and contributed to weaning from mechanical ventilation.

Do low profile implants provide reliable stability in fixing the sternal fractures as a "fourth vertebral column" in sternovertebral injuries?

BACKGROUND

Flexion and compression forces to the trunk can cause severe instability of the vertebral column and the anterior chest wall, mostly associated with an unstable fracture of the sternum. In combination, the worst case would be a complete disruption of the trunk. Some authors consider the sternum-rib-complex to be the fourth vertebral column. This study discusses the possibilities to treat instable trunk injuries with sternal fractures concomitant to vertebral spine fractures through anterior sternal plating employing a locked plate osteosynthesis in a low profile design instead of the use of bulky implants.

METHODS

11 Patients suffering from at least one fracture of a vertebral body in combination with an unstable sternum fracture were stabilized through a locked plate osteosynthesis in low profile design at the sternum between November 2011 and October 2014. The vertebral spine injury was stabilized as well, if necessary. Patients were followed up with a look at the consolidation of the fractures and the question if any failure of the implants occurred.

RESULTS

Anterior sternal plating was uneventful in all cases. All Sternal fractures showed sufficient consolidation. No failure of implants has been seen during follow up over two years..

CONCLUSIONS

A locked plate osteosynthesis of a sternal fracture in low profile design seem to be an appropriate option for stabilization of the sternum in combined sternovertebral injuries.

Analysis of Sternal Fixation Results According to Plate Type in Sternal Fracture

BACKGROUND

Sternal fractures are relatively rare, and caused mainly by blunt anterior chest wall trauma. In most cases, sternal fractures are treated conservatively. However, if the patient exhibits problematic symptoms such as intractable chest wall pain or bony crepitus due to sternal instability, surgical correction is indicated. But no consensus exists regarding the most appropriate surgical method. We analyzed the results of surgical fixation in cases of sternal fracture in order to identify which surgical method led to the best outcomes.

METHODS

We retrospectively reviewed the medical records of patients with sternal fractures from December 2008 to December 2011, and found 19 patients who underwent open reduction and internal fixation of the sternum with a longitudinal plate (L-group) or a T-shaped plate (T-group). We investigated patients' characteristics, clinical details regarding each case of chest trauma, the presence of other associated injuries, the type of open reduction and fixation, whether a combined operation was performed, and postoperative complications.

RESULTS

Of the 19 patients, 10 patients (52.6%) were male, and their average age was 56.8 years (range, 32 to 82 years). Seven patients (36.8%) had isolated sternal fractures, while 12 (63.2%) had other associated injuries. Seven patients (36.8%) were in the L-group and 12 patients (63.2%) were in the T-group. Three patients in the L-group (42.9%) showed a loosening of the fixation. In all patients in the T-group, the fracture exhibited stable alignment.

CONCLUSION

Open reduction and internal fixation with a T-shaped plate in sternal fractures is a safer and more efficient treatment method than treatment with a longitudinal plate, especially in patients with a severely displaced sternum or anterior flail chest, than a longitudinal plate.

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

PURPOSE

Stabilizing techniques of flail chest injuries usually need wide approaches to the chest wall. Three main regions need to be considered when stabilizing the rib cage: median-anterior with dissection of pectoral muscle; lateral-axillary with dissection of musculi (mm) serratus, externus abdominis; posterior inter spinoscapular with division of mm rhomboidei, trapezius and latissimus dorsi. Severe morbidity due to these invasive approaches needs to be considered. This study discusses possibilities for minimized approaches to the shown regions.

METHOD

Fifteen patients were stabilized by locked plate osteosynthesis (MatrixRib^®) between May 2012 and April 2014 and prospectively followed up. Flail chest injuries were managed through limited incisions to the anterior, the lateral, and the posterior parts of the chest wall or their combinations. Each approach was 4-10 cm using Alexis^® retractor.

RESULTS

One minimized approach offered sufficient access at least to four ribs posterior and laterally, four pairs of ribs anterior in all cases. There was no need to divide latissimus dorsi muscle. Trapezius und rhomboid muscles were only limited divided, whereas a subcutaneous dissection of serratus and abdominis muscles was necessary. A follow-up showed sufficient consolidation.

COMPLICATIONS

pneumothorax (2) and seroma (2).

CONCLUSION

Minimized approaches allow sufficient stabilization of severe dislocated rib fractures without extensive dissection or division of the important muscles. Keeping the arm and, thus, the scapula mobile is very important for providing the largest reachable surface of the rib cage through each approach.

Spontaneous sternal fracture due to multiple myeloma requiring extensive surgical repair

Spontaneous sternal fracture is a well-known complication of multiple myeloma due to osteolytic bone lesions. The possibility of a multiple myeloma should be thoroughly investigated in patients presenting with a spontaneous sternal fracture. This work up should go beyond protein electrophoresis alone as a monoclonal paraprotein is not always present. In some cases, the myeloma plasma cell clone produces only the free light chain (κ or λ) or may even be non-secretory. The underlying plasma cell dyscrasia is treated with chemotherapy and, if needed, local radiotherapy. However, for patients with a fracture causing persistent pain and physical discomfort, internal fixation may be additionally required. We present a case of a patient who presented with a displaced pathological sternal fracture. She was treated with chemotherapy, radiotherapy and an open reduction and internal fixation with a Locking Compression Plate (LCP). This technique offers a feasible option for rigid fixation of pathological fractures.

The oblique fracture of the manubrium sterni caused by a seatbelt--a rare injury? Treatment options based on the experiences gained in a level I trauma centre

INTRODUCTION

Sternal fractures are rare with 3-8 % out of the total number of trauma cases mostly caused by direct impact to the anterior chest wall. Most cases described are due to motor vehicle crash either caused by direct impact to the steering wheel or by the seat belt. Fractures mainly occur to the sternal body. Only rarely are cases of manubrium fractures described in literature, for example, in relationship with a direct impact to the shoulder which caused an oblique fracture near to the sternoclavicular joint. Three patients with profoundly dislocated oblique manubrium fracture were admitted to our Level I Trauma Center in 2012 and 2013. Those patients suffered from instability of the upper sternum and the shoulder girdle.

MATERIAL AND METHODS

Between January 2012 and October 2013, a total of 538 trauma patients were admitted to the emergency room and received whole body CT-scan. They were analysed retrospectively for sternal fractures. In cases of instability and dislocation, fracture stabilisation was performed by anterior plating through a medial approach using low profile titanium plates (MatrixRib®).

RESULTS

Seventy-nine (14.7 %) patients showed sternal fracture, out of which 13 (2.4 %) patients showed a fracture of manubrium, ten caused by seatbelt. In three cases stabilization was performed. Follow up showed sufficient consolidation without complications.

DISCUSSION

A total of 16.5 % of sternal fractures were localized at the manubrium, mostly caused by seat belt. Fractures without significant dislocation seemed to be stable and healed well under conservative treatment. Dislocation in this region leads to unstable shoulder girdle. Anterior plating provides sufficient stabilisation and allowed consolidation.