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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 20-22

Internal thoracic rib plating: A minimally invasive system for the management of displaced rib fractures


Department of Surgery, UPMC Pinnacle, Harrisburg, Pennsylvania, USA

Date of Web Publication30-Dec-2019

Correspondence Address:
Douglas H Anderson
Department of Surgery, UPMC Pinnacle, Harrisburg, Pennsylvania
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jctt.jctt_14_19

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  Abstract 


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).

Keywords: Internal rib plating, minimally invasive rib plating, rib fracture, surgical stabilization and rib fixation


How to cite this article:
Anderson DH, Goldman DA, Moritz TA, Korzhuk AA. Internal thoracic rib plating: A minimally invasive system for the management of displaced rib fractures. J Cardiothorac Trauma 2019;4:20-2

How to cite this URL:
Anderson DH, Goldman DA, Moritz TA, Korzhuk AA. Internal thoracic rib plating: A minimally invasive system for the management of displaced rib fractures. J Cardiothorac Trauma [serial online] 2019 [cited 2020 Oct 19];4:20-2. Available from: https://www.jctt.org/text.asp?2019/4/1/20/274202




  Introduction Top


Rib fractures are the most common injury following blunt chest trauma, accounting for over half of all nonpenetrating injuries. Approximately 10% of all patients admitted after blunt chest trauma have 1 or more rib fractures.[1] Rib fractures are associated with increased morbidity and mortality as well as chronic pain and disability.[2] The operative management of rib fractures is surgical stabilization and rib fixation (SSRF). It is well established that patients with a flail chest injury pattern benefit from rib fixation with decreased mortality, intensive care unit length of stay, pneumonia, and need for tracheostomy.[1],[3] The majority of patients with rib fractures do not have a flail chest. Given the complications associated with rib fractures, there has been an increase in the utilization of SSRF for nonflail rib fractures, with a measurable decrease in both morbidity and mortality.[4],[5] Currently, rib fixation is commonly performed utilizing an open-plating technique, using a large incision to provide exposure, followed by fracture reduction and externally placed plates. Here, we describe a novel intrathoracic rib plating technique using video-associated thoracoscopic surgery (VATS).


  Description of Technique Top


General anesthesia is induced and the patient is intubated with a double-lumen endotracheal tube. The patient is placed in a standard right or left lateral decubitus position depending on fracture location and single-lung ventilation is initiated. A 12 mm trocar is placed anteriorly in the ninth rib space for the thoracoscope. Another utility incision may be made for the placement of additional instruments based on the specific situation or fracture location. Once the fracture site is visualized, a 1.5 cm incision is made over the fracture site and dissection is carried down to the level of the rib. The fracture is reduced using rib clamps, pulling the internally displaced segment outward into a more anatomical position. Osteotomies are made on either side of the fracture using a drill sleeve guide to ensure central placement within the displaced rib [Figure 1]. Plastic guide tubes are then threaded through the osteotomies into the thorax and pulled through the initial 12 mm trocar site [Figure 2]. Two guidewires on a plate with preloaded posts are threaded through the plastic tubes [Figure 3]. The plate is then introduced into the thoracic cavity, and the wires are pulled up through the plastic tubes which are then removed. With continuous upward traction on the wires, the plate is then approximated to the internal rib surface reducing the fracture outward [Figure 4]. Locking screws are brought down along the wires externally through the incisions and are secured onto the preloaded posts. The posts are cut at the level of the locking screws, ensuring an appropriate length without the need for the measurement [Figure 5]. These steps are repeated for each fracture requiring fixation. A chest tube is placed and the lung is re-expanded. Incisions are then closed.
Figure 1: Drill guide in place allowing for precise mid-rib placement[6]

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Figure 2: Plastic guide tubes placed through osteotomies

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Figure 3: Plate with screw posts and wires[6]

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Figure 4: Internal thoracic rib plates fixed in place

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Figure 5: (a and b) Screw caps overlocking posts ensure correct length[6]

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  Discussion Top


Rib fixation is performed for an increasing range of indications beyond flail chest, including severely displaced fractures, multiple fractures, significant pain refractory to multimodal pain management, fractures with associated injuries requiring surgery, and nonunion or malunion.[4],[5],[7],[8] Current rib fixation techniques involve the placement of plates on the external aspect of the rib, which require a dissection area large enough for the plate to fit. Merchant and Onugha demonstrated the successful use of a minimally invasive extrathoracic approach with rib plating.[9] Although utilizing smaller incisions, this technique still involved significant subcutaneous tissue dissection to allow for the apposition of the plate onto the rib as well an extrathoracic rib plating construct. Internal plate fixation through just one or two VATS trocars and a 1.5 cm incision for the rib clamp/drill guide complex allows for less muscle and soft-tissue mobilization. In addition, the 1.5-cm incision can be used to access fractures on immediately adjacent ribs, both superiorly and inferiorly. The benefits of this approach include a decreased area of dissection, improved cosmesis, and simultaneous evaluation of the thorax, allowing the surgeon to address associated intrathoracic injuries such as sites of hemorrhage or complete drainage of a retained hemothorax.

The rib acts as an arch along the chest wall, under an inherent inward force exerted by negative intrathoracic pressure. The additive effect of the inward displacement due to a fracture results in a significant collapsing force on the ribs. In addition to the reduction and fixation of the rib to its original anatomic orientation, it is proposed that an internal plate construct provides greater support against this inward collapsing force. Another anticipated benefit is a reduction of surgical site infections as the incisions are smaller and the hardware is placed internally. This system also ensures an appropriate screw length with every use, as it is cut flush with the locking screw cap once the plate has been secured in place. This bypasses the additional time normally required to measure cortical depth and select an appropriate screw length, a process needed in most other plating systems. This minimally invasive technique is also theorized to be associated with decreased postoperative pain, opioid requirements, and length of hospital stay; however, this has yet to be formally demonstrated.

This proposed internal rib plating technique does have some potential drawbacks. The learning curve is not currently known and with every new technique could potentially lead to increased operative times while surgeons become more familiar with the steps. The incidence of complications such as surgical site infection, plate fracture, or failure has yet to be determined as compared to the current external plating systems. Future comparative studies will be needed to evaluate this technique, as it is utilized more frequently.

Internal thoracic rib plating with VATS provides a direct evaluation of the thoracic cavity after injury along with a potentially more supportive plate construct. This technique provides a new minimally invasive option for thoracic and trauma surgeons to achieve effective surgical rib fixation.

Acknowledgments

All investigators have freedom of investigation from competing interests and had complete control of the procedure, methods used, outcome parameters and results, analysis of data, and production of this report. The rib plating system used is from the SIG Medical Corp., 238 E. Chocolate Ave., Suite 2, Hershey PA 17033. All costs were submitted to the patient's insurance for reimbursement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, et al. Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern association for the surgery of trauma. J Trauma Acute Care Surg 2017;82:618-26.  Back to cited text no. 1
    
2.
Witt CE, Bulger EM. Comprehensive approach to the management of the patient with multiple rib fractures: A review and introduction of a bundled rib fracture management protocol. Trauma Surg Acute Care Open 2017;2:e000064.  Back to cited text no. 2
    
3.
Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Surgical fixation vs. nonoperative management of flail chest: A meta-analysis. J Am Coll Surg 2013;216:302-110.  Back to cited text no. 3
    
4.
Pieracci FM, Agarwal S, Doben A, Shiroff A, Lottenberg L, Whitbeck SA, et al. Indications for surgical stabilization of rib fractures in patients without flail chest: Surveyed opinions of members of the chest wall injury society. Int Orthop 2018;42:401-8.  Back to cited text no. 4
    
5.
Fitzgerald MT, Ashley DW, Abukhdeir H, Christie DB 3rd. Chest wall stabilization leads to shortened chest tube stay time in rib fracture patients after traumatic chest wall injury. Am Surg 2018;84:680-3.  Back to cited text no. 5
    
6.
Advantage Rib Surgical Technique Guide. Hershey, PA: SIG Medical. Available from: http://www.sigmedical.net. [Last accessed on 2019 Jan 08].  Back to cited text no. 6
    
7.
Gauger EM, Hill BW, Lafferty PM, Cole PA. Outcomes after operative management of symptomatic rib nonunion. J Orthop Trauma 2015;29:283-9.  Back to cited text no. 7
    
8.
Fitzgerald MT, Ashley DW, Abukhdeir H, Christie DB 3rd. Rib fracture fixation in the 65 years and older population: A paradigm shift in management strategy at a level I trauma center. J Trauma Acute Care Surg 2017;82:524-7.  Back to cited text no. 8
    
9.
Merchant NN, Onugha O. Novel extra-thoracic VATS minimally invasive technique for management of multiple rib fractures. J Vis Surg 2018;4:103.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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