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   Table of Contents - Current issue
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January-December 2019
Volume 4 | Issue 1
Page Nos. 1-69

Online since Monday, December 30, 2019

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EDITORIALS  

Necessity is the mother of invention: Rib fixation with pediatric ankle plates and screws after successful thoracoabdominal damage control surgery Highly accessed article p. 1
Moheb A Rashid
DOI:10.4103/jctt.jctt_20_19  
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Chest wall injury society editorial p. 3
Thomas W White, SarahAnn S Whitbeck
DOI:10.4103/jctt.jctt_21_19  
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ORIGINAL ARTICLES Top

Current trends in the management of flail chest and the perceived role of the surgeon p. 4
J Brock Walker, Sean M Mitchell, Pierce Johnson, Joshua W Hustedt, Niloofar Dehghan, Michael D Mckee, Clifford B Jones
DOI:10.4103/jctt.jctt_2_19  
Background: Flail chest injuries typically occur in poly-traumatized patients and are often associated with prolonged hospital stays and high rates of morbidity and mortality. Despite multiple studies showing significantly improved outcomes with surgical fixation, the surgical community has been slow to adopt rib fixation as a part of practice and, as a result, many of these patients never undergo surgical fixation. Purpose: The purpose of this study is to determine the percentage of flail chest injuries that are being treated with surgical fixation in the United States. In addition, a survey of orthopedic trauma surgeons was conducted to assess their perception of the role of orthopedics in the treatment of patients with flail chest injuries. Methods: Patients diagnosed with a flail chest injury were identified using the National Inpatient Sample (NIS) database between 2001 and 2012 and divided into two groups based on whether or not surgical fixation of the chest wall was performed. In addition, we distributed a survey questionnaire to orthopedic trauma surgeons focusing on each individual's experience with rib fracture fixation both in training and practice. Results: A total of 45,202 patients with a flail chest injury were identified using the NIS database between 2001 and 2012. Of these, 2.1% underwent surgical fixation of the chest wall with an increase in rate of fixation from 0.8% to 3.3% over the study period. According to our survey, only 20% of orthopedic trauma surgeons performed any rib fracture fixation cases in training, and only 24% perform rib fracture fixation cases in their practice. Of those who do not perform rib fracture fixation, 72% would consider doing so if they received additional training on the topic. Of all participants surveyed, 60% believed that rib fracture fixation should be a part of the orthopedic residency curriculum and 89% believed that it should be a part of the orthopedic trauma fellowship curriculum. Conclusions: Very few flail chest injuries are being treated with surgical fixation despite the emerging literature showing improved outcomes when compared to nonoperative management. Our survey shows that there is significant interest in incorporating rib fracture fixation into surgeons' training curriculum, as well as providing specialized workshops for practicing surgeons. We hope this work encourages the surgical community to embrace rib fracture fixation as a part of our specialty so that patients with flail chest injuries receive optimal care.
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Surgical rib fixation: Does increase case volume lead to improved outcomes? p. 10
Bhavik M Patel, Gary S L. Hung, Martin E Wullschleger
DOI:10.4103/jctt.jctt_4_19  
Background: Surgical rib fixation in displaced rib fracture has been associated with positive patient outcomes in the literature. There is no data in the literature detailing the volume related outcomes in centres that offer surgical rib fixation in these patients. Methods: A retrospective review was conducted on surgical rib fixation cases performed from 2014 to 2018, with the early phase (EP) consisting of cases performed in the 2014-2017 period and the recent phase (RP) consisting of cases performed in 2018 to date. Variables for comparison included, indication for intervention, pain outcomes, and length of stay (LOS). Results: The five-year period yielded 37 cases. In the EP, 17 cases were performed, compared to 20 cases in the RP. The chest AIS scores were >3 for all cases with an average ISS of 21 in the EP compared to 19 in the RP. All patients underwent surgical rib fixation within 96 hours of admission. Pain was the predominant indication for intervention in the EP (65%, n = 11) compared to the RP where deformity and respiratory support (55%, n = 11) were the chief indicators. Subjective pain improvement was in favour of RP by 2.5 days. The average LOS was 546 hours days in the EP group, and 391 hours in the RP group. More anatomically difficult posterior and bilateral rib fixation cases were carried out in the RP group. Follow-up rate between the EP and RP were 75% vs 85% respectively with no hardware or pulmonary complications. Conclusion: Preliminary data analysis from the authors' institution suggests surgical rib fixation can be conducted with minimal complication. Increased case volume might improve outcomes related to subjective pain scores, length of stay, and complexity of surgical technique.
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What is the minimum fixation required to repair flail chest? p. 14
Kate Wallwork, Jenny Mitchell, Najib Rahman, Elizabeth Belcher
DOI:10.4103/jctt.jctt_5_19  
Context: Flail chest is associated with significant mortality risk. Chest wall repair is associated with improved outcomes; however, the optimal fixation technique is unknown. Aims: We undertook a review to assess the optimal fixation technique required in order to successfully repair flail chest. Subjects and Methods: This is a retrospective review of consecutive patients with multiple rib fractures undergoing surgical fixation. The predictive value of ratio of fractures fixed in relation to flail segment and ratio of ribs fixed in relation to flail segment was assessed by the primary outcome measure of requirement for reoperation. Results: Thirty-one patients presenting with symptomatic rib fractures were referred to a single surgeon for primary management or a second opinion following previous fixation, between August 2011 and October 2018, and underwent repair. Twenty-two patients were male (71%), and the median age was 66 years (range: 18–81). Twenty-seven patients (87%) were diagnosed with flail segment. Twenty-four patients had a “Fracture Fixation to Flail” ratio (Fx: Fl) ≥1, and none required further rib fixation, whereas three patients had Fx: Fl<1, two of whom (67%) required further rib fixation (P = 0.0085). Twenty patients had Rx: Fl≥1, and none required further rib fixation, whereas seven patients had Rx: Fl<1, in whom five (71%) required no further intervention and two (29%) required further rib fixation (P = 0.0598). Minimum fixation number (MFN) was calculated. MFN was achieved in 22 of 27 patients. Two of the four patients with MFN did not achieve the required refixation (P = 0.0171). Conclusions: Fx:Flmost accurately predicts the risk of underfixation and subsequent requirement for further intervention in patients undergoing operative repair of flail chest.
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Internal thoracic rib plating: A minimally invasive system for the management of displaced rib fractures p. 20
Douglas H Anderson, Daniel A Goldman, Troy A Moritz, Anatoliy A Korzhuk
DOI:10.4103/jctt.jctt_14_19  
Rib fractures are common following blunt chest trauma and are associated with increased morbidity and mortality. Surgical stabilization and rib fixation (SSRF), or rib plating, is an increasingly utilized treatment for displaced rib fractures. SSRF is most commonly performed with an external plate construct, often requiring extensive dissection and soft-tissue mobilization. This article discusses a novel minimally invasive system for SSRF using video assisted thoracoscopic surgery (VATS).
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Rib Fractures in Geriatric Patients: An Observational Study of Surgical Management p. 23
Joy Dowden Hughes, Michelle J Berning, Alexander S Hunt, Brian D Kim, Mariela Rivera, David S Morris, Henry J Schiller, Martin D Zielinski
DOI:10.4103/jctt.jctt_9_19  
Background: Due to increased frailty and comorbidities, surgeons may be reluctant to perform surgical stabilization of rib fractures (SSRF) in geriatric (≥65yr) and super-geriatric (≥80yr) patients. We hypothesized that elderly patients would have delayed time to operation and more complications. We aimed to determine whether advanced age was a factor in deciding to proceed with SSRF and presented a risk for mortality. Methods: Single-institution review of rib fracture (RF) patients from 8/2009-2/2017. Univariate analysis was performed for groups age ≤64yr, 65-79yr, and ≥80yr, and SSRF vs non-SSRF. Baseline injury characteristics were compared for all age groups. Results: We identified 3098 non-SSRF patients (≤64yr, n=1770; 65-79yr, n=706; ≥80yr, n= 622) and 277 SSRF (≤64yr, n=162pt; 65-79yr, n=73pt; ≥80yr, n=42pt). For SSRF, there were no differences in sex or race, time from admission to operation, number of RF, or SSRF indications between any age group. Mortality was greater for non-SSRF patients overall [155/3098 (5%) vs 4/277 (1.4%), P < 0.01], for non-SSRF patients less than 65 years old [63/1770 (3.6%) vs 0/159, P < 0.01], and between 65-79 years old [35/706 (5%) vs 0/76, P = 0.03] but similar between non-SSRF and SSRF patients in the 80 and older cohort [57/622 (9.2%) vs 4/42(9.2%), P = 0.9]. In analysis of injury characteristics, for SSRF≥80yr greater mortality was associated with GCS <14 vs GCS≥14 (1/3 vs 0/39, P < 0.01), and more RF [median 20RF in pts with mortality (IQR:5-13) vs 10RF in patients without mortality (IQR:10-29), P = 0.02). Conclusions: Age was not associated with longer time to OR nor with difference in injury pattern or severity as indication for SSRF. Although mortality increases for RF after 80yr, among appropriately selected super-geriatric patients SSRF is a safe and effective treatment. Level of Evidence: IV Study type: Therapeutic.
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A multi-institution case series of intercostal nerve cryoablation for pain control when used in conjunction with surgical stabilization of rib fractures p. 28
Frank Z Zhao, John D Vossler, Adam J Kaye
DOI:10.4103/jctt.jctt_12_19  
Background: Intercostal cryoneurolysis (IC) causes axonotmesis resulting in numbness distal to the nerve lesion with eventual nerve regeneration. Reported outcomes in thoracic surgery range from the majority of patients recovering normal sensation within a few weeks to some incidences of chronic neuropathic pain. We hypothesize its use can decrease pain for rib fracture patients. Methods: Multi-institution retrospective review of 13 patients who underwent surgical stabilization of rib fractures (SSRFs) with video-assisted thoracoscopy-guided IC. Demographics included mechanism of injury, number of ribs fractured and plated, and number of intercostal nerves ablated. Outcomes include pre- and post-operative pain scores, completeness of nerve function return, and dysesthesias experienced during healing. Pre- and post-operative pain scores were compared by paired t-test. Statistical significance was attributed to P < 0.05. Results: The median age was 58 (35–77) and all injuries were caused by blunt mechanism. Median number of ribs fractured was 7 (4–11). Mean time to operation was 2.1 ± 1.2 days. Median number of ribs plated was 4 (range 3–6), and the median number of intercostal nerves ablated was 6 (3–7). Eleven patients with complete pain scores were found to have mean preoperative pain of 6.9 ± 2.3 and mean postoperative pain of 4.9 ± 2.9 (P = 0.026). The mean length of stay was 8.1 ± 2.9 days after admission and 5.9 ± 2.7 days after surgery. At an average follow-up of 21.3 ± 6.2 weeks, all patients had regained some sensation. Sensation regained ranged from 10% at 16.1 weeks to 100% as early as 15.9 weeks. One patient (7.6%) developed transient severe, lifestyle limiting, hyperesthesia present at 3 months and resolved at 6 months. 8 of 13 (61.5%) patients developed transient mild-to-moderate, nonlifestyle limiting, dysesthesias. These symptoms resolved by 6 months. Conclusion: In our patients with severe rib fractures, cryoneurolysis with SSRF resulted in significantly decreased postoperative pain and approximately 70% of patients reporting some transient dysesthesias in the recovery process. While these results are encouraging, larger, prospective studies are needed to fully characterize the indications for IC.
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Complications from Pulmonary Contusions after Rib Plating: A Case Series and Lessons Learned p. 35
Mariana Tumminello, Alison Smith, Patrick McGrew, Anna E Meade, Chrissy Guidry, Clifton Mcginness, Juan Duchesne, Patrick Greiffenstein
DOI:10.4103/jctt.jctt_17_19  
Background: Surgical stabilization of rib fractures (SSRF) is increasing in popularity with low reported complication rates. Pulmonary contusion (PC) has been cited as a relative contraindication to SSRF in cases of patients with respiratory failure due to chest wall injury. However, the reported experience and clinical data regarding PC on this topic remain limited. The objective of this study was to describe the experience treating patients with moderate-to-severe PCs utilizing SSRF and identify risk factors for pulmonary complications postoperative acute respiratory distress syndrome (ARDS). Methods: The trauma registry of a Level 1 trauma center was reviewed from 2015 to 2019, and patients who underwent SSRF were assessed. Computed tomography was examined, and PC score was calculated in patients with a documented PC by a researcher and verified by a board-certified radiologist using the PC score as described by Chen et al. Demographic, clinical, and outcome data were analyzed and reported. Results: Ninety-two patients were included in the initial analysis as having undergone SSRF in the study period. The patients were 72.8% male and averaged 5.5 ± 4.4 days from admission to SSRF. Nine patients with severe chest trauma and PCs underwent SSRF. Of these patients, four had severe bilateral PCs and five had severe unilateral PC, totaling >20% of total lung capacity. Three patients had ipsilateral moderate-to-severe PCs with traumatic pneumatoceles. They underwent SSRF within 48 h of admission per standard practice. They were all placed in the lateral decubitus position with the affected side up. Their intraoperative courses were complicated by bloody secretions present in the endotracheal tubes. Only one patient had lung isolation using dual-lumen endotracheal intubation and had an uneventful perioperative course. Postoperatively, the other two patients developed severe ARDS that required mechanical ventilation for several days, significantly complicating their recovery. Discussion: This case series highlights the relative risk of SSRF in patients with significant PC. Early SSRF in patients with PC ≥3 was associated with ARDS when patients did not undergo intraoperative lung isolation. In two patients with severe PC, the contusions themselves did not produce respiratory failure on admission; however, intraoperative positioning resulted in the aspiration of bloody secretions from the contused lung into the unaffected lung, causing severe postoperative ARDS. Suggested measures to prevent future events may include isolating the contused lung intraoperatively or delaying SSRF until contusion has resolved, if feasible.
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REVIEW ARTICLE Top

Surgical stabilization of rib fractures p. 41
Adam M Shiroff, Jane Keating, Jose Ribas Milanez de Campos, Thomas W White
DOI:10.4103/jctt.jctt_19_19  
Multiple rib fractures from trauma are common and nonoperative management, including pain control and aggressive pulmonary care, are the mainstay of treatment. However, patients with hindered pulmonary function despite maximal medical therapy, either from acute pain or chest wall instability (flail chest) should be considered for surgical rib stabilization. Additionally, patients with persistent pain or with rib fractures that do not heal (nonunion) should also be considered for surgery. Indications, contraindications, surgical considerations, complications, and future directions of surgical stabilization of rib fractures are reviewed here.
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SURGICAL TECHNIQUES AND VIDEOS Top

SSRF subscapular approach p. 48
Thomas W White
DOI:10.4103/jctt.jctt_18_19  
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CASE REPORTS Top

To fix or not to fix: Delayed repair of anterior flail in the frail and multiply injured p. 49
Brian T Dusseau, Brent J Goslin, William B DeVoe
DOI:10.4103/jctt.jctt_7_19  
A 72-year-old male with a history of atrial fibrillation, remote stroke, hypertension, and chronic obstructive pulmonary disease presented following a high-speed motor vehicle collision. Injuries included bilateral segmental rib fractures with radiographic anterior flail and a right acetabular fracture. Secondary to thoracic trauma, mechanical ventilation was required and the patient underwent surgical stabilization of left-sided fractures utilizing by 75, 75, 115, and 50 mm plates for ribs 3, 4, 5, and 6, respectively, early in his hospital course followed by fixation of the right hemipelvis. A trial of extubation was unsuccessful. During reintubation, he developed marked abdominal distension and large volume pneumoperitoneum with signs of compartment syndrome. Emergent decompressive laparotomy revealed a perforated posterior prepyloric gastric ulcer that was repaired. Intensive care unit course was complicated by 72 h of multisystem organ failure; however, he recovered and was again nearing the point of ventilator liberation. Right-sided rib stabilization, albeit it delayed, was performed with fixation of 3, 4, 5, and 6 accomplished with long-segment plates bridging to costal cartilage in order to achieve stability. Dense inflammation and callous formation were encountered prolonging operative time. Tracheostomy was performed 3 days postoperatively, despite minimal ventilator requirements, given ongoing secretions and development of pseudomonal pneumonia. The patient was weaned to tracheostomy collar with in-line speaking valve within 2 weeks. This case highlights surgical rib stabilization in a frail, multiply injured patient through which ventilator wean was expedited and rehabilitation potential was optimized.
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Vertical plate for flail chest repair p. 52
Marcel Tafen, Alexa Giammarino, Ceyda Bertram, Roman Petrov
DOI:10.4103/jctt.jctt_10_19  
Operative treatment of rib fractures in the context of flail chest and respiratory failure is a well-established approach. In-line rib osteosynthesis with plates is the standard treatment sufficient to eliminate flail, achieve sufficient stability, and create chest rigidity to improve the respiratory cycle and maintain reduction. However, bridging large skeletal defects with missing portion of ribs is very challenging, particularly in the absence of suitable anchoring rib fragments. We describe an unusual use of vertical plate rib osteosynthesis in a patient with traumatic flail chest, exacerbated by a prior thoracoplasty and severe osteoporosis.
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Complex reconstruction following traumatic forequarter amputation p. 55
Tara M Barry, Thomas J Herron, Steven M Lorch, David J Ciesla
DOI:10.4103/jctt.jctt_15_19  
Interscapulothoracic amputation is a radical and morbid procedure used for the management of upper extremity trauma and more commonly for resection of solid tumors. Traumatic forequarter amputation poses a unique challenge for achieving adequate tissue coverage depending on the condition of the muscle and soft tissue of the ipsilateral extremity. We present a case of a 38-year-old construction worker who suffered an almost complete forequarter amputation of his right upper extremity secondary to blunt force trauma from a crane pulley that fell from 60 ft. This is a unique mechanism of injury, as most traumatic forequarter amputations occur as a result of traction injury. Details of the case report including the unique challenges, techniques for tissue salvage, fillet flaps, and chest wall reconstruction are presented.
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Rescue re-do inline osteosynthesis with wire cerclage for failed rib plating of multilevel rib nonunion p. 59
Tatiana Kazakova, Marcel Tafen, Warner Wang, Roman Petrov
DOI:10.4103/jctt.jctt_13_19  
Rib nonunion is a rare occurrence that requires surgical management and has a high rate of failure that may necessitate repeated intervention. We present the case of successful rescue redo repair of previously failed plating of chronic nonunion for multilevel posterior rib fractures, reinforced by wire cerclage of the osteosynthesis plate. Our objective is to illustrate the feasibility of repeated interventions, and the technique to resolve this challenging problem.
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Traumatic lung herniation after ATV rollover p. 63
Roxanne Kyriakakis, Geoffrey Lam, Carrie Valdez
DOI:10.4103/jctt.jctt_3_19  
Traumatic pulmonary hernia is a rare entity that often presents immediately after the trauma but may appear years after the incident. We report a case of a 53-year-old female with polytrauma including a traumatic pulmonary hernia following an all-terrain vehicle (ATV) rollover. Left pulmonary hernia reduction, rib plating, and pectoralis flap were performed. After the surgery, the patient's pain and respiratory status drastically improved, and the patient was able to leave the hospital without any supplemental oxygen requirements. Pulmonary hernia is a rare etiology seen in blunt traumas involving the chest. These often can be associated with rib fractures, pulmonary contusions, and clavicular fractures. There are multiple techniques for surgical repair including using autologous tissues, synthetic materials, and even minimally invasive techniques. Although pulmonary hernia is rare, every trauma and thoracic surgeon should be aware of the etiology of this condition and the options available for surgical repair.
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Colonic injury during delayed surgical stabilization of rib fractures for flail chest: A case report and literature review p. 66
Heather M Grant, Andrew R Doben
DOI:10.4103/jctt.jctt_6_19  
Surgical stabilization of rib fractures (SSRFs) is becoming increasingly common, particularly in the setting of flail chest. In adult patients with flail chest, SSRF has been shown to reduce mortality, the incidence of pneumonia, and the need for tracheostomy, in addition to shortening the duration of mechanical ventilation, hospital length of stay (LOS), and intensive care unit LOS. Despite rising popularity, SSRF is not without risks. We present the case of a 22-year-old man who sustained an iatrogenic colonic injury during delayed SSRF for severe nonunion and chest wall motion abnormalities after a motorcycle collision. In multisystem injured trauma patients, it is important to remain cognizant of possible anatomic alterations that could affect surgical management. We present a very uncommon, yet devastating complication related to anatomic alterations from the initial injury.
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IMAGES IN CARDIOTHORACIC TRAUMA Top

Immediate repair of flail chest p. 69
Thomas W White
DOI:10.4103/jctt.jctt_22_19  
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