Fixation Of Rib Fractures Research Articles

Unexpected Diaphragmatic Hernia Among Patients Undergoing Video-Assisted Thoracic Surgery for Internal Fixation of Rib Fractures.

Traumatic blunt diaphragm injuries are a diagnostic challenge in trauma. They may be missed due to the increasing trend of non-operative management of patients. The purpose of this study was to review the rate of occult blunt diaphragm injuries in patients who underwent video assisted thoracic surgery (VATS) for rib fixation. This retrospective study included patients that received VATS as part of our institutional protocol for rib fracture management. This includes utilizing incentive spirometry, multimodal analgesia, and early consideration for VATS. Data was abstracted from the electronic medical record and included demographics, operative findings, and outcomes. Thirty patients received VATS per our rib fracture protocol. No patients had any identified diaphragm injury on pre-operative imaging. A concomitant diaphragm injury was identified in 20% (6/30) of the study population. All patients were alive at 30 days. For all patients, total hospital length of stay was 14.5 days, ICU length of stay was 8.9 days, and average ventilator days was 4.2 days. When comparing patients with and without concomitant diaphragm injuries, hospital length of stay was 16.8 days vs. 14.5 (P = 0.59), ICU length of stay was 11.8 days vs. 8.2 (P = 0.54), and ventilator days was 4.5 days vs. 4.2 (P = 0.93). This study revealed that 20% of patients undergoing VATS for rib fracture fixation had a concomitant diaphragm injury. This higher-than-expected prevalence suggests that groups of patients sustaining blunt trauma may have occult diaphragmatic injuries that are otherwise unidentified. This raises the need for improved diagnostic modalities to identify these injuries.

Cartilage Plating in Flail Chest Fixation

Introduction: Operative stabilization of flail chest has been shown to have several benefits over nonoperative management. Often, flail chest injuries will involve the anterior ribs and their associated costal cartilage. In certain cases, operative fixation with open reduction and internal fixation (ORIF) of anterior rib fractures involving the costal cartilage may be warranted. Currently, there is scant literature regarding the surgical approach and clinical outcomes of ORIF involving the costal cartilage. The purpose of this study is to describe the surgical approach and first reported clinical series for patients undergoing anterior rib ORIF involving the costal cartilage.Patients and Methods: After Institutional Review Board approval was obtained, a retrospective case series was performed at a single urban level 1 trauma center including patients 18 years of age or older who underwent ORIF of anterior rib fractures involving the costal cartilage. All surgical approaches were performed with muscle-sparing techniques. Patients were followed during their hospitalization period and postoperatively as routinely scheduled. Data collection including patient demographics, injury characteristics, operative variables, and postoperative outcomes were collected and analyzed.Results: Thirty patients, with a mean age of 54.4 years, were included in this study. All patients had a flail chest injury and were treated with ORIF on average 4.1 days following injury. There were no intraoperative complications reported. Total hospital length of stay averaged 22.8 days with an intensive care unit stay averaging 6.1 days; total ventilator time averaged 5.2 days. Six patients were diagnosed with postoperative pneumonia and no postoperative superficial infections, deep infections, or seromas were noted. Eight patients required tracheostomy postoperatively. Only 1 patient had evidence of radiographic malunion, and a separate patient had evidence of screw loosening; no patients required or requested implant removal. Union rate was 100% and one-year mortality was 0%.Conclusion: Open reduction and internal fixation of anterior rib fractures involving the costal cartilage is a safe procedure with low complication rates and favorable postoperative outcomes including hospital length of stay, intensive care unit length of stay, postoperative pneumonia, need for tracheostomy, and mechanical ventilation time.

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

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. 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. 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. 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.

Complete Video-assisted Thoracoscopic Surgery for Rib Fractures: Series of 35 Cases

BackgroundVideo-assisted thoracoscopic surgery (VATS) for internal fixation of rib fractures is a promising approach for treating rib fractures and flail chest. Currently the standard practice is to make 1 or several incisions on the chest wall, which will inevitably aggravate the original trauma. MethodsWe retrospectively analyzed the data of patients with rib fractures who were treated with memory alloy for internal fixation by complete VATS using a thoracoscopic transthoracic memory alloy rib coaptation board and an implantation tool through the clip applier method or the puncture, traction, and suspension method at our hospital from October 2016 to June 2019. ResultsOf 35 patients, 12 had traumatic flail chest injury and 23 had simple multiple rib fractures. Of the 23 patients with multiple rib fractures, 9 had fracture ends in the scapular or paravertebral region and 14 in the anterior or lateral chest walls. All surgeries were performed with complete VATS, which showed quick recovery and good thoracic appearance and function, with no complications for all patients. Follow-up for 6 to 24 months revealed no detachment of the internal fixation device. ConclusionsInternal memory alloy fixation with complete VATS for the treatment of rib fractures is a simple and minimally invasive method that enables fixing fractured ribs internally while treating thoracic trauma with a thoracoscope.

Safety and effectiveness of surgical fixation versus non-surgical methods for the treatment of flail chest in adult populations: a systematic review and meta-analysis

PurposeThe objective of this systematic review is to compare the safety and efficacy of surgical fixation of rib fractures against non-surgical interventions for the treatment of flail chest in the adult population.MethodsA search was performed on the 22nd of July 2020 to identify articles comparing surgical fixation versus clinical management for flail chest in adults, with a description of the outcome parameters (resource utility, mortality, adverse effects of the intervention and adverse progression in pulmonary status). Relevant randomised controlled trials were selected, their risk of bias assessed, and the data then extracted and analysed.Results157 patients were included from four studies in the analyses, with 79 and 78 patients in the surgical and non-surgical groups, respectively. The pooled effects of all outcomes tended towards favouring surgical intervention. Surgical intervention was associated with lower rates of pneumonia (I2 = 46%, Tau2 = 0.16, p = 0.16), significantly lower rates of tracheostomy (I2 = 76%, Tau2 = 0.67, p = 0.02), and a significantly lower duration of mechanical ventilation (I2 = 88%, Tau2 = 33.7, p < 0.01) in comparison to the non-surgical management methods.ConclusionOur results suggest that surgical intervention reduces the need for tracheostomy, reduces the time spent in the intensive care unit following a traumatic flail chest injury and could reduce the risk of acquiring pneumonia after such an event. There is a need for further well-designed studies with sufficient sample sizes to confirm the results of this study and also detect other possible effects of surgical intervention in the treatment of traumatic flail chest in adults.

Clinical outcomes of critically ill multiple trauma patients with rib fractures. Aprospective study with retrospective control.

Rib fracture fixation is becoming more popular and widely accepted among trauma surgeons worldwide as the recommended treatment method for flail chest injury. Recent data demonstrate improved results when compared with non-operative treatment. Improved outcomes were reported regarding ICU stay, need for tracheostomy, length of hospital stay, ventilator-associated pneumonia (VAP), and even death. The objective of this study was to ascertain whether clinical respiratory para-meters are improved after rib fracture fixation procedure. This is aprospective study using aretrospective cohort for control, which took place at the Soroka University Medical Centre, Israel. Inclusion criteria included all patients over 18 years of age with flail chest injury or multiple ribs fractures, who were admitted to the General Intensive Care Unit (GICU). Between October 2015 and December 2018, we identified 24 patients who had their rib fractures operatively fixed and compared them to 61 patients with flail chest and multiple rib fractures, who were admitted to our GICU between the years 2010 and 2015 and were treated non-opera-tively. In all the surgical cases operations were performed within 72 hours of arrival in accordance with our treatment algorithm. All fractures were fixed using specialised anatomic locking plates/nails. Demographic data were collected, and respiratory parameters before and after the surgery were recorded and analysed. We compared patients who had had their rib fractures fixed with acohort group of patients who had been treated non-operatively in the past. No demographic differences were found between the 2 groups, nor were there any differences in their clinical trauma scoring, mechanical ventilation days, length of ICU stay, VAP, and death rates. The respiratory parameters (paO2/FiO2 ratio and chest wall compliance) were significantly higher during the 3 ensuing days after surgery and continued to improve in Group 1 (rib fixation group), in comparison to group 2 (non-operative) patients (P = 0.007 and P < 0.0001, respectively). The peak inspiratory pressure and PEEP para-meters were significantly lower in group 1 in comparison to group 2 during the 3 days, in favour of the operated group, with significant improvement noted over the 3 days post-surgery (P = 0.007 and P = 0.02, respectively). We suggest that surgical treatment of flail chest and multiple rib fractures has clinical benefit and improves respiratory parameters even in the presence of multiple trauma injuries.

Application of fracture body surface localization film combined with CT volume rendering in the minimally invasive rib fractures internal fixation.

To investigate the application value of the technique of fracture body surface localization film combined with CT volume rendering in the selection of minimally invasive incision for internal fixation of rib fractures. Clinical data of 55 cases of patients who underwent internal fixation for rib fracture in our hospital from June 2019 to April 2020 were selected. The differences in the accuracy of preset incision, incision length, operation time, intraoperative blood loss, postoperative wound drainage, and postoperative pain score between the group with fracture body surface localization film combined with CT volume rendering (n=32) and the group with traditional localization method (n=23). Compared with traditional localization method, fracture body surface localization film combined with CT volume rendering could improve the accuracy of surgical incision, reduce the operation time, incision length, intraoperative blood loss, postoperative wound drainage, and postoperative pain score (p<0.05). The application of fracture body surface localization film combined with CT volume rendering has obvious effects on the accurate selection of incision of rib fracture internal fixation, and it is an effective method that is worthy of promotion.

Effectiveness of surgical fixation for rib fractures in relation to its timing: a retrospective Japanese nationwide study.

PurposeThe effectiveness of surgical rib fixation is currently controversial, partly because of differences in timing. We used a Japanese nationwide database to investigate the effectiveness of surgical rib fixation in relation to its timing.MethodsWe used the Japanese Diagnosis Procedure Combination database to identify patients with rib fractures who underwent mechanical ventilation from 1 July 2010 to 31 March 2018. We performed overlap weight analysis to compare in-hospital outcomes between patients who had and had not undergone surgical rib fixation within 3, 6 or 10 days after admission. The primary outcomes were duration of mechanical ventilation and post-rib fixation length of hospital stay. The secondary outcomes were tracheostomy, post-admission pneumonia and all-cause 28-day in-hospital mortality.ResultsWe identified 8922 eligible patients. Surgical rib fixation within 3 days after admission was associated with shorter duration of mechanical ventilation (percent difference, − 42.9%; 95% confidence interval, − 57.4 to − 23.3) and shorter hospital stay (percent difference, − 19.6%; 95% confidence interval, − 31.8 to − 5.2). There were no significant differences between the groups in tracheostomy (risk difference, − 0.04; 95% confidence interval, − 0.15 to 0.07), post-admission pneumonia (risk difference, − 0.04; 95% confidence interval, − 0.13 to 0.05) or all-cause 28-day in-hospital mortality (risk difference, − 0.02; 95% confidence interval, − 0.07 to 0.03). However, there were no significant differences in any in-hospital outcomes between those who had and had not undergone rib fixation within 6 or 10 days after admission.ConclusionEarly surgical rib fixation was associated with better in-hospital outcomes, whereas later surgical rib fixation was not.Electronic supplementary materialThe online version of this article (10.1007/s00068-020-01548-1) contains supplementary material, which is available to authorized users.

Dysrhythmia in traumatic RIB Fixation

IntroductionThe fixation of traumatic rib fractures with metallic plates has multiple benefits, especially in flail segments. These include reducing the number of ventilated and ICU days, the need for a tracheostomy, reduced incidence of pneumonia, and overall improvement in pain [1]. While the benefits have been defined, there have been a paucity of data in the reported medical risks of the procedure. At our institution, an anecdotally observed complication following the procedure included cardiac arrhythmia.MethodsA retrospective review of all patients sustaining acutely traumatic rib fractures undergoing operative fixation over a five-year period from March of 2015 to March of 2020 were included. A total of fifteen patients met criteria. All patients were confirmed to be in normal sinus rhythm preoperatively. Postoperatively, all patients were sent to the surgical ICU and continuously monitored for arrhythmia via telemetry. All arrhythmias identified were confirmed via twelve-lead electrocardiograms (EKG).ResultsNo patients had a history of arrhythmia preoperatively. Of the 15 patients, 11 (73%) [95% CI: 45-92%] were confirmed to have any arrhythmia postoperatively [Table 1]. Excluding sinus tachycardia, which may be attributable to a number of other perioperative factors, 8 (53%) patients [95% CI: 26-78%] were found to have experienced another arrhythmia as described above [Table 1].DiscussionThese results show that rib fixation carries a significant risk for perioperative cardiac dysrhythmia. Historical controls show the incidence of arrhythmia in non-cardiac, thoracic surgery to be between 17-30%, with atrial fibrillation accounting for the majority [2,3,4,5]. The total incidence of any arrhythmia after rib plating was 73%, which is significantly higher than the upper boundary (30%) of historical norms (p=0.0003) [Table 2]. Excluding sinus tachycardia, the incidence drops to 53% for rib plating, which still remains elevated above historical controls (p=0.05) [Table 2]. Multiple studies in cardiac surgery have proven preoperative antiarrhythmics effective in providing arrhythmia prophylaxis. Further investigation should be performed in arrhythmia prophylaxis in rib fixation. The fixation of traumatic rib fractures with metallic plates has multiple benefits, especially in flail segments. These include reducing the number of ventilated and ICU days, the need for a tracheostomy, reduced incidence of pneumonia, and overall improvement in pain [1]. While the benefits have been defined, there have been a paucity of data in the reported medical risks of the procedure. At our institution, an anecdotally observed complication following the procedure included cardiac arrhythmia. A retrospective review of all patients sustaining acutely traumatic rib fractures undergoing operative fixation over a five-year period from March of 2015 to March of 2020 were included. A total of fifteen patients met criteria. All patients were confirmed to be in normal sinus rhythm preoperatively. Postoperatively, all patients were sent to the surgical ICU and continuously monitored for arrhythmia via telemetry. All arrhythmias identified were confirmed via twelve-lead electrocardiograms (EKG). No patients had a history of arrhythmia preoperatively. Of the 15 patients, 11 (73%) [95% CI: 45-92%] were confirmed to have any arrhythmia postoperatively [Table 1]. Excluding sinus tachycardia, which may be attributable to a number of other perioperative factors, 8 (53%) patients [95% CI: 26-78%] were found to have experienced another arrhythmia as described above [Table 1]. These results show that rib fixation carries a significant risk for perioperative cardiac dysrhythmia. Historical controls show the incidence of arrhythmia in non-cardiac, thoracic surgery to be between 17-30%, with atrial fibrillation accounting for the majority [2,3,4,5]. The total incidence of any arrhythmia after rib plating was 73%, which is significantly higher than the upper boundary (30%) of historical norms (p=0.0003) [Table 2]. Excluding sinus tachycardia, the incidence drops to 53% for rib plating, which still remains elevated above historical controls (p=0.05) [Table 2]. Multiple studies in cardiac surgery have proven preoperative antiarrhythmics effective in providing arrhythmia prophylaxis. Further investigation should be performed in arrhythmia prophylaxis in rib fixation.

Characterization and influence of ipsilateral scapula fractures among patients who undergo surgical stabilization of sub-scapular rib fractures.

Current decision algorithms involving surgical stabilization of rib fractures (SSRF) do not consider either specific fracture locations or other chest wall bony injuries. Our objective was to characterize the impact of scapula fractures on morbidity among patients who underwent fixation of sub-scapular rib fractures. We hypothesized that an ipsilateral scapula fracture was associated with poor acute and long-term outcomes. Retrospective review of two institutions' prospectively maintained SSRF databases (October 2010 to January 2019). Patients who underwent repair of ≥ 1 sub-scapular rib fracture were included. Patients were grouped by the presence of an ipsilateral scapula fracture. Outcomes were acute SSRF complications, long-term rib implant removal, and quality of life via phone survey. A total of 144 patients were analyzed; 53 (36.8%) had an ipsilateral scapula fracture. Patients with a scapula fracture had a higher injury severity score (p = 0.02), degree of pulmonary contusion (p < 0.01), and RibScore (p < 0.01). The overall incidence of both acute re-operation (n = 4, 2.8%) and long-term implant removal (n = 5, 3.8%) following SSRF was low and did not vary by the presence of a scapula fracture. Only twenty-one patients completed phone questionnaires a median of 38months after SSRF; both shoulder and rib outcomes were excellent and did not vary by the presence of a scapula fracture. Ipsilateral scapula fractures are common in patients who undergo surgical stabilization of sub-scapular rib fractures. Despite higher injury severity, patients with an ipsilateral scapula fracture did not incur worse outcomes.

Long-term quality of life and functional outcome after rib fracture fixation.

The primary aim of this study was to assess the long-term quality of life and functional outcome after rib fracture fixation for patients with multiple rib fractures or flail chest. Secondarily, this study sought to identify risk factors associated with the quality of life. A retrospective cohort study with a follow-up by questionnaire was performed at a level-1 trauma center in Switzerland. All adult patients with three or more rib fractures treated with rib fixation between 2010 and 2018 were eligible for inclusion. All outcomes were independently assessed for patients with multiple rib fractures and patients with a flail chest. The outcome measures were quality of life, level of dyspnea, return to work, implant irritation, and implant removal after a minimum of 12months of follow-up. Quality of life was assessed using the EuroQol five-dimensional five-level questionnaire (EQ-5D-5L) and level of dyspnea was determined with the modified Medical Research Council dyspnea (mMRC) scale. The survey was completed by 74 out of 102 patients (73%) at a median follow-up of 26months (IQR 15-37). The median EQ-5D utility index score was 0.91 (0.89-1.0), which was equivalent to the reference population (0.902, p = 0.523). The vast majority of patients experienced 'no problems' or 'slight problems' in any of the EQ-5D-5L dimensions. The complication rate associated with rib fracture fixation was low, implant-related irritation was the most common long-term sequela and occurred in 31% of patients. In multivariable regression analyses, total length of stay on the intensive care unit (ICU-LOS) was independently associated with a worse quality of life. Patients who underwent rib fracture fixation for multiple rib fractures or flail chest after severe chest trauma experienced a good quality of life at least 1 year after surgery. A longer ICU-LOS was independently associated with impaired quality of life. In addition, there were no significant differences in the long-term quality of life and functional outcome between patients with multiple rib fractures and a flail chest. Implant-related irritation was the most important long-term sequela and occurred in one-third of patients.

Complications and outcome after rib fracture fixation: A systematic review.

In recent years, there has been a growing interest in operative treatment for multiple rib fractures and flail chest. However, to date, there is no comprehensive study that extensively focused on the incidence of complications associated with rib fracture fixation. Furthermore, there is insufficient knowledge about the short- and long-term outcomes after rib fracture fixation. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The MEDLINE, EMBASE, and Cochrane databases were searched to identify studies reporting on complications and/or outcome of surgical treatment after rib fractures. Complications were subdivided into (1) surgery- and implant-related complications, (2) bone-healing complications, (3) pulmonary complications, and (4) mortality. Forty-eight studies were included, with information about 1,952 patients who received rib fracture fixation because of flail chest or multiple rib fractures. The overall risk of surgery- and implant-related complications was 10.3%, with wound infection in 2.2% and fracture-related infection in 1.3% of patients. Symptomatic nonunion was a relatively uncommon complication after rib fixation (1.3%). Pulmonary complications were found in 30.9% of patients, and the overall mortality was 2.9%, of which one third appeared to be the result of the thoracic injuries and none directly related to the surgical procedure. The most frequently used questionnaire to assess patient quality of life was the EuroQol-5D (EQ-5D) (n = 4). Four studies reporting on the EQ-5D had a weighted mean EQ-5D index of 0.80 indicating good quality of life after rib fracture fixation. Surgical fixation can be considered as a safe procedure with a considerably low complication risk and satisfactory long-term outcomes, with surgery- and implant-related complications in approximately 10% of the patients. However, the clinically most relevant complications such as infections occur infrequently, and the number of complications requiring immediate (surgical) treatment is low. Systematic Review, level III.

Late Operative Rib Fixation is Inferior to Nonoperative Management.

Operative rib fixation (ORF) of traumatic rib fractures has been shown to decrease hospital length of stay (LOS), ventilator days, and mortality. ORF performed within 1 day of admission has been shown to have favorable outcomes compared to later ORF. This report examines the ORF experience over 10 years at a level I trauma center. ORF patients from January 2007-January 2018 were matched to nonoperative controls in a 1:2 ratio based on age, injury severity score (ISS), chest Abbreviated Injury Score (AIS), and head AIS. Patient demographic, injury, and outcome data were collected from the trauma registry and medical records. Hospital day of ORF was identified for each ORF patient. Hospital LOS, ICU LOS, ventilator days, and mortality were compared against matched nonoperative controls. Ninety-five ORF patients were matched to 190 nonoperative patients. ORF patients had a higher number of rib fractures (9.6 vs 6.4, P < .001). ORF patients with short time to operation (0-2 days) had a shorter average hospital stay than those with delayed operations (11.8 vs 12.6 vs 13.4 vs 19.6 days, P = .003). ORF patients with operations performed 3-4 days and >6 days after admission also had statistically significant longer ICU LOS and ventilator days. Patient mortality was higher when ORF was performed after 6 days. Early ORF may improve pulmonary function, patient outcomes, and decrease LOS. Shifting practice toward early fixation may help further solidify the benefits of this procedure in the treatment of blunt chest trauma.

Rib Fracture Fixation, a new Era in Treatment of Chest Trauma in Albania

Rib fractures are a consequence of the forces of various arthritis that the chest wall and the thoracic cage itself undergo, and are most often due to closed injuries (eg, motor vehicle collision, falls from height, and Hits with strong objects ..), but penetrating injuries (eg, wounds with sharp tools, gunshot injuries ...) can also result in rib fractures. Non-operative treatment is based on pain control and pulmonary support, which mainly aim to avoid the need for intubation, which is associated with increased levels of pulmonary disorders until death.&#x0D; For patients who continue to have acute pain or instability of the chest wall (eg, flail chest), each of which impedes pulmonary function despite maximal medical therapy, or those with non-consolidating rib fractures and causing pain in the persistence and impairment of pulmonary function, surgicaly stabilization of fractured ribs, also known as osteosynthesis, are now well-known procedures that improve the quality of treatment of the traumatized patient.&#x0D; The thoracic wall injury association has been established to better study all aspects related to the consequences, diagnosis and treatment of thoracic wall injuries [1].&#x0D; Indications for osteosynthesis, patient preparation, operative technique for stabilizing fractured ribs and the results are quite significant.

Feasibility of laryngeal mask anesthesia combined with nerve block in adult patients undergoing internal fixation of rib fractures: a prospective observational study

BackgroundThe laryngeal mask airway (LMA) is occasionally used in internal fixation of rib fractures. We evaluated the feasibility of general anesthesia with an LMA associated to a thoracic paravertebral block (TPB) and/or an erector spinae plane block (ESPB) for internal fixation of rib fractures.MethodsTwenty patients undergoing unilateral rib fracture fixation surgery were enrolled. Each patient received general anesthesia with an LMA combined with TPB and/or ESPB, which provided a successful blocking effect. All patients received postoperative continuous analgesia (PCA) with 500 mg of tramadol and 16 mg of lornoxicam, and intravenous injection of 50 mg of flurbiprofen twice a day. Our primary outcomes including the partial pressure of arterial oxygen (PaO2) and arterial carbon dioxide (PaCO2) were measured preoperatively and on the first day after surgery. Secondary outcomes including the vital signs, ventilation parameters, postoperative numerical rating scale (NRS) pain scores, the incidence of postoperative nausea and vomiting (PONV), perioperative reflux and aspiration, and nerve block-related complications were also evaluated.ResultsThirteen men and seven women (age 35–70 years) were enrolled. Six (30%) had a flail chest, nine (45%) had hemothorax and/or pneumothorax, and two (10%) had pulmonary contusions. The postoperative PaO2 was higher than the preoperative value (91.2 ± 16.0 vs. 83.7 ± 15.9 mmHg, p = 0.004). The preoperative and postoperative PaCO2 were 42.1 ± 3.7 and 43.2 ± 3.7 mmHg (p = 0.165), respectively. Vital signs and spontaneous breathing were stable during the surgery. The end-tidal carbon dioxide concentrations (EtCO2) remained within an acceptable range (≤ 63 mmHg in all cases). NRS at T1, T2, and T3 were 3(2,4), 1(1,3), and 0(0,1), respectively. None had PONV, regurgitation, aspiration, and nerve block-related complications.ConclusionsThe technique of laryngeal mask anesthesia combined with a nerve block was feasible for internal fixation of rib fractures.Trial registrationCurrent Controlled Trials ChiCTR1900023763. Registrated on June 11, 2019.

Application of rib surface positioning ruler combined with volumetric CT measurement technique in endoscopic minimally invasive thoracic wall fixation surgery

Application value of rib surface positioning ruler combined with volumetric CT measurement in selection of the incision for minimally invasive internal fixation of rib fracture was investigated. A total of 80 patients who received internal fixation of rib fractures in Tianjin Hospital Affiliated to Tianjin University (Tianjin, China) from May 2018 to April 2019 were selected. Patients were treated with the rib surface positioning ruler combined with volumetric CT measurement method (n=42) or traditional positioning method (n=38). The following parameters were compared between the two groups: Preset incision accuracy, operation incision length, operation time, intraoperative bleeding volume, postoperative wound drainage volume and postoperative pain score. Compared with the traditional positioning method, rib surface positioning ruler combined with volumetric CT measurement method can improve preset incision accuracy, reduce operation time, incision length, intraoperative bleeding volume, postoperative wound drainage volume, and postoperative pain score, with statistically significant differences (P<0.05). In conclusion, the application of rib surface positioning ruler combined with volumetric CT measurement technique has obvious effect on the selection of incision for internal fixation of rib fracture, and is an effective method worth promoting.

Primary thoracoabdominal hernias.

Primary thoracoabdominal hernias involve the triad of an intercostal hernia, abdominal wall hernia, and diaphragmatic hernia. We report a case series of this rare entity and describe the evolution and outcomes. We completed a retrospective analysis of thoracoabdominal hernia repairs performed January 2010-April 2019 at Prisma Health-Upstate and Carolinas Medical Center. This includes all patients with spontaneous defects, excluding incisional hernias or those resulting from external trauma. Of 16 patients with thoracoabdominal hernias, 15 patients developed hernias after forceful coughing and one patient developed a hernia after strenuous physical activity. Seven patients required at least one additional intervention; two for recurrence; two for recurrence of original intercostal repairs done elsewhere; two for wound complications; and one had a missed abdominal wall component. Primary thoracoabdominal hernias require a high index of suspicion. Durable repair involves complex reconstruction of the thoracoabdominal wall including the diaphragm, intercostal space, rib fracture fixation, and mesh reinforcement of the abdominal wall with permanent fixation constructs.

Surgical fixation of rib fractures: how I do it

Chest wall trauma is common worldwide. The majority of cases are a result of blunt mechanisms. Among these injuries, rib fractures are considered the most frequent type of clinically significant blunt thoracic trauma sequelae and are associated with considerable morbidity and mortality. Despite a large number of cases annually, there are no internationally recognized guidelines for rib fracture treatment yet. This controversy in treatment options can be attributed to the lack of high-level convincing clinical research that confirms the benefits of surgical treatment over conservative treatment measures. Over the last 100 years, rib fixation has been carried out infrequently using non-specific materials due to lack of specific rib fixation systems. However, a substantial advancement in materials (e.g., low profile titanium plates) and technologies (e.g., angle-stable locking screws) was achieved in the last decade. Despite these developments, so far no clinical study has proven the superiority of one system over another. In this article, we would like to share our experience in this field including indications for surgical rib fixation and how we perform such procedures.

Posterior chest wall reconstruction: A novel approach

Traditional access for open reduction internal fixation (ORIF) of posterior rib fractures occurs through either a posterior lateral thoracotomy or posterior paramedian approach. We report the case of severe blunt chest wall injury reconstruction using the novel implementation of an Opening Wedge Thoracostomy (OWT) approach. This approach is conventionally indicated for expansion thoracostomy in the surgical management of scoliosis. The OWT approach facilitates chest wall reconstruction vis-a-vis reflection of the trapezius and latissimus dorsi muscles providing excellent exposure of the posterior thoracic cage facilitating surgical reduction and fixation. Satisfactory stability of the posterior chest is not achievable using previously described approaches. OWT approach exposure for posterior thoracic reconstruction absents the surveyed literature.

Surgical fixation of rib fractures decreases intensive care length of stay in flail chest patients.

BackgroundNonoperative treatment is currently the standard therapy for rib fractures. However, there is a trend towards surgical fixation from conservative management over the last decade. While surgical fixation of rib fractures has shown promising results, its impact on the clinical results remains unclear based on the current literature. As such, the present study aims to compare the short-term outcomes of multiple rib fracture patients treated by surgical fixation with traditional conservative management.MethodsData for patients with multiple (three or more) rib fractures admitted to our department between January 2012 and January 2019 were retrospectively collected and analyzed. Propensity score matched patients were compared between those treated with surgical rib fixation and those of nonoperatively treated. Primary outcomes were hospital length of stay for multiple rib fracture patients, and intensive care unit (ICU) length of stay for flail chest patients. Secondary outcomes included in hospital mortality, ICU usage rate, duration of ventilator support, ventilator usage rate, and pneumonia.ResultsThe study included 1,201 patients with mean age of 50.1±12.7 years, of whom 954 (79.4%) were male. The average number of rib fractures was 6.3±2.4, with a mean injury severity score of 20.5±7.3. Among them, 563 (46.9%) patients had surgical rib fixation and 638 (53.1%) patients received nonoperative treatment. There were 191 patients with a flail chest, 133 (69.6%) had operative rib fixation and 58 (30.4%) were nonoperatively treated. After propensity score match, the hospital length of stay was not significantly differed between surgery and conservative management in multiple rib fracture patients (10.7±3.4 vs. 10.2±3.8 days, P=0.067), nor were the secondary outcomes, in terms of in hospital mortality (0.9% vs. 1.1%, P=0.704), ICU usage rate (12.3% vs. 12.9%, P=0.820), duration of ventilator support (100.1±13.9 vs. 99.8±20.7 hours, P=0.822), ventilator usage rate (12.0% vs. 12.9%, P=0.732), and pneumonia (24.3% vs. 24.9%, P=0.861). For patients with a flail chest, shorter ICU length of stay was found to be associated with surgical rib fixation comparing with nonoperative treatment (5.5±1.9 vs. 6.7±2.1 days, P=0.011). No secondary outcomes such as in hospital mortality (4.4% vs. 4.4%, P=1.000), ICU usage rate (20.0% vs. 22.2%, P=0.796), duration of ventilator support (113.1±20.4 vs. 131.2±19.5 hours, P=0.535), ventilator usage rate (20.0% vs. 20.0%, P=1.000), pneumonia (28.9% vs. 31.1%, P=0.818) were significant different between the operative and nonoperative groups.ConclusionsSurgical rib fixation results in a shorter ICU length of stay in patients with a flail chest, and a comparable outcome for patients with multiple rib fractures when compared with nonoperative treatment.