Operative Repair of Rib Fractures SIGN Conf 2013 Joel Gillard Disclosures: Design Engr with ACUTE Innovations, maker of chest wall reconstruction devices Operative Repair of Rib Fractures Rib Fx Repair Questions 1. Do patients actually benefit? 2. What are the indications? 3. What is the optimal timing – how long to wait? 4. Which fractures to fix – all or just some? 5. What technique to use? Benefits of Operative Repair ICU Days 2 – 15 Less 13 comparative studies including 3 Prospective Randomized Trials Tanaka2002 Granetzny2005 Marasco2013 Benefits of Operative Repair ICU Days 2 – 15 Less Vent Days 1 – 11 Less 13 comparative studies including 3 Prospective Randomized Trials Tanaka2002 Granetzny2005 Marasco2013 Benefits of Operative Repair ICU Days 2 – 15 Less Vent Days 1 – 11 Less Pneumonia 8% – 53% Less 13 comparative studies including 3 Prospective Randomized Trials Tanaka2002 Granetzny2005 Marasco2013 Benefits of Operative Repair ICU Days 2 – 15 Less Vent Days 1 – 11 Less Pneumonia 8% – 53% Less Mortality 5% – 24% Less 13 comparative studies including 3 Prospective Randomized Trials Tanaka2002 Granetzny2005 Marasco2013 Benefits of Operative Repair Return to Activity 27 Less Days Benefits of Operative Repair Pain Reduction Kahndelwal: 2011 (n=118) Operative Non-Op Benefits of Operative Repair Meta-analysis18 2013 11 Comparative Studies 753 Patients Indications for Operative Repair15 1.Flail Chest • Failure to wean from ventilator • Paradoxical movement visualized during weaning • No significant pulmonary contusion or brain injury 2.Reduction of Pain and Disability • Painful, moveable rib fractures • Failure of narcotics or epidural pain catheter 3.Chest Wall Deformity / Defect • Loss of thoracic volume • Severely displaced, multiple fractures that may result in permanent deformity or pulmonary hernia or are impaling the lung • Patient expected to survive other injuries 4.Symptomatic Non-Union 5.Thoracotomy for other indications Timing for Operative Repair 1 – 12 Days Patients treated earlier may have better short-term outcomes.1 Technique Guidance Preoperative Planning10 1. Chest X-rays - 3D CT recon • Locate fx • Plan incision • Assess chest wall deformity 2. Remove chest tubes from pleural space 1day in advance 3. Patients placed in the lateral decubitus position Technique Guidance Incision Approaches • Standard posterolateral thoracotomy or muscle sparing thoracotomy21 • Multiple small incisions (10-15 cm), latissimus dorsi muscle division in line with fibers, exposes three rib levels10 • Subscapular fractures may be accessed with retraction and releasing the rhomboid fascia. • Where access is limited, counter-incisions may be used for drilling and placing screws. Technique Guidance Fractures to Address • Highly displaced fractures and/or those that can be identified as causing pain15 • It may be unnecessary to plate all fractures, but enough stability to restore the normal thoracic contour.10 Hardware Recon Plates IM splints or K-wires 6mm – 14mm Judet Plates RibLoc Plates Literature Suggests Operative Repair seems to Improves Patient Outcomes Indications: Timing: Surgical Tech: Fx to fix: Flail – Pain – Deformity 1 – 12 Days Muscle Sparing Thoracotomy Most Displaced Plates & screws generally better than k-wires or suture References Publications are crossreferenced by subject in the table at right. 1. Althausen PL, Shannon S, Watts C, Thomas K, Bain MA, Coll D, et al. Early surgical stabilization of flail chest with locked plate fixation. J Orthop Trauma. 2011 Nov;25(11):641–7. 2. Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what is the benefit? J. Am. Coll. Surg. 2012 Aug;215(2):201–5. 3. Borrelly J, Aazami MH. New insights into the pathophysiology of flail segment: the implications of anterior serratus muscle in parietal failure. Eur J Cardiothorac Surg 2005; 28(5):742-749. 4. Cook, Katherine. "New System Helps Heal Broken Ribs Faster." Health News. KGW. Portland, OR, 23 Feb. 2012. Kgw.com. 23 Feb. 2012. Web. 18 June 2013. 5. Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. 2005 Dec;4(6):583–7. 6. Karev DV. Operative management of the flail chest. Wiad. Lek. 1997;50 Suppl 1 Pt 2:205–8. 7. Kerr-Valentic MA, Arthur M, Mullins RJ, Pearson TE, Mayberry JC. Rib fracture pain and disability: can we do better? J Trauma. 2003 Jun;54(6):1058–1063; discussion 1063–1064. 8. Khandelwal G, Mathur RK, Shukla S, Maheshwari A. A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture. Int J Surg. 2011;9(6):478–81. 9. Kim M, Brutus P, Christides C, et al. Re´sultats compares du traitement des volets thoraciques: stabilization penumatique interne classique, nouvelle modalite´ de la ventilation artificielle, agrafage. J Chir 1981; 118(8-9):499-503. 10. Lafferty PM, Anavian J, Will RE, Cole PA. Operative treatment of chest wall injuries: indications, technique, and outcomes. J Bone Joint Surg Am. 2011 Jan 5;93(1):97–110. 11. Lardinois D, Krueger T, Dusmet M, Ghisletta N, Gugger M, Ris HB. Pulmonary function testing after operative stabilisation of the chest wall for flail chest. Eur J Cardiothorac Surg. 2001 Sep;20(3):496– 501. 12. Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J. Am. Coll. Surg. 2013 May;216(5):924–32. 13. Mayberry JC, Kroeker AD, Ham LB, Mullins RJ, Trunkey DD. Longterm morbidity, pain, and disability after repair of severe chest wall injuries. Am Surg. 2009 May;75(5):389–94. 14. Nirula R, Allen B, Layman R, Falimirski ME, Somberg LB. Rib fracture stabilization in patients sustaining blunt chest injury. Am Surg. 2006 Apr;72(4):307–9. 15. Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications, technical issues, and future directions. World J Surg. 2009 Jan;33(1):14–22. 16. Nirula R, Mayberry JC. Rib fracture fixation: controversies and technical challenges. Am Surg. 2010 Aug;76(8):793–802. 17. Sales JR, Ellis TJ, Gillard J, Liu Q. Chen JC, Ham B, Mayberry JC. Biomechanical testing of a novel, minimally invasive rib fracture plating system. J Trauma 2008; 64:1270–1274. 18. Slobogean GP, MacPherson CA, Sun T, Pelletier M-E, Hameed SM. Surgical fixation vs nonoperative management of flail chest: a metaanalysis. J. Am. Coll. Surg. 2013 Feb;216(2):302–311.e1. 19. Solberg BD, Moon CN, Nissim AA, Wilson MT, Margulies DR. Treatment of chest wall implosion injuries without thoracotomy: technique and clinical outcomes. J Trauma. 2009 Jul;67(1):8–13; discussion 13. 20. Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002 Apr;52(4):727–732; discussion 732. 21. Taylor BC, French BG, Fowler TT. Surgical Approaches for Rib Fracture Fixation. J Ortho Trauma. In press April 2013, full text available on-line. 22. Teng J, Cheng Y, Ni D, Pan R, Cheng Y, Zhu Z, et al. Outcomes of traumatic flail chest treated by operative fixation versus conservative approach. J Shanghai Jiaotong University (Medical Science). 2009;29:1495–8. 23. Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, SchmitNeuerburg KP. Operative chest wall stabilization in flail chest-outcomes of patients with or without pulmonary contusion. J. Am. Coll. Surg. 1998 Aug;187(2):130–8.