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 Table of Contents  
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 59-62

Rescue re-do inline osteosynthesis with wire cerclage for failed rib plating of multilevel rib nonunion

1 Department of Family Medicine, Jefferson Health, Temple University Hospital, Philadelphia, PA, USA
2 Department of Surgery, Albany Medical College, Albany, NY, USA
3 Department of Surgery, Marietta Memorial Hospital, Marietta, Ohio, USA
4 Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA

Date of Web Publication30-Dec-2019

Correspondence Address:
Roman Petrov
Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jctt.jctt_13_19

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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.

Keywords: Hardware failure, redo rib repair, rib cerclage, rib fractures, rib nonunion, rib osteosynthesis, rib plating

How to cite this article:
Kazakova T, Tafen M, Wang W, Petrov R. Rescue re-do inline osteosynthesis with wire cerclage for failed rib plating of multilevel rib nonunion. J Cardiothorac Trauma 2019;4:59-62

How to cite this URL:
Kazakova T, Tafen M, Wang W, Petrov R. Rescue re-do inline osteosynthesis with wire cerclage for failed rib plating of multilevel rib nonunion. J Cardiothorac Trauma [serial online] 2019 [cited 2021 Oct 18];4:59-62. Available from: https://www.jctt.org/text.asp?2019/4/1/59/274201

  Introduction Top

Rib fractures occur in about 10% of trauma admission.[1] Mainstay management is supportive care and pain control. With this approach, most rib fractures will heal; however, a small subset will not heal.[2] Surgical stabilization with inline osteosynthesis for nonunion of rib fractures is a valuable option for the restoration of function and addressing the associated chronic pain syndrome. However, posterior rib fractures at the angle of rib are a specifically challenging problem due to difficult exposure, contour angulation, and shortened proximal rib segment anchoring for the adequate plate purchase, limited by the transverse process. We present a 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.

  Case Report Top

S. N. is a 64-year-old male, physically active, construction worker, with excellent performance status who presented with severe chronic pain, after sustaining multiple left rib fractures due to blunt trauma 16 months prior. The patient was referred to by pain management specialist after failing medical and interventional therapy.

Workup revealed healed multiple left rib fractures with chronic nonunion with “elephant leg” deformity at the angle of the rib of the left 6th through 10th ribs [Figure 1]. The patient underwent resection of the nonunions and inline osteosynthesis of ribs 6 through 10. We used locking RibFix Blu system (Zimmer Biomet, Warsaw, IN) plates with bicortical screw fixation. Care was taken to place three screws on each side of the fracture without immediate complications [Figure 2]. With early postoperatively, the patient continued to complain of recurrent pain. Repeat evaluation revealed the failure of the hardware with pull out of the screws from ribs fragment and collapse of the chest wall [Figure 3] and [Figure 4]. Decision was made to proceed with rescue repair 8 weeks after the original procedure. This time, longer plates were selected, anchoring with at least five screws on each side of the fracture and reinforcing this construct with #7 metal wire cerclage of ribs 6 through 9 [Figure 5] and [Figure 6]. The tenth rib plate appeared competent and was left intact. After an uneventful recovery, the patient reported a significant improvement of pain. Several months later, the patient reported the recurrence of pain in the projection of the lower plate. Physical examination demonstrated piano key sign and imaging confirmed similar mode of hardware failure with pullout of screws from proximal stump of the rib. Six months after second intervention the patient was reexplored for the third time where failed hardware with complete union of the tenth rib fracture was found. This plate was explanted with complete resolution of pain. The patient remains asymptomatic at 2 years follow-up.
Figure 1: Computed tomography demonstrating multiple healed posterior rib fractures of ribs 2 through 12 with chronic rib fracture nonunion of ribs 6 through 10

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Figure 2: Intraoperative image of the original in-line osteosynthesis of ribs 6–10. Patient is in prone position with left paraspinal incision with head toward left of the picture

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Figure 3: Immediate postoperative and first clinic follow-up chest X-ray demonstrating progressive hardware failure with displacement of the plates

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Figure 4: Computed tomography demonstrating hardware failure with pull out of the screws from rib stump and chest wall collapse

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Figure 5: Intraoperative image of rescue in line rib osteosynthesis with wire cerclage of ribs 6-through 9

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Figure 6: Postoperative imaging of the rescue repair after lower plate explanation 6 months after rescue repair. Hardware remains competent

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  Discussion Top

Traumatic rib fractures are common in blunt trauma and frequently are managed conservatively. An emerging body of literature demonstrates the benefits of surgical repair of acute rib fractures.[3] Surgical stabilization of ribs has been shown to shorten length of stay reduce rates of respiratory failure, pneumonia, intensive care unit stay, and mortality.[4],[5],[6],[7],[8],[9] Only 1% of patients with rib fractures undergo surgical stabilization, with a vast majority being treated non-operatively.[10] Rib fracture patients often do not return to work, develop chronic pain, dyspnea and in a small portion of patients nonunion develops.[11],[12],[13] Nonunion of ribs mainly manifests with chronic pain, and traditional pain management modalities are rarely effective.[14] Limited data suggest positive outcomes with surgical repair of rib nonunion.[15],[16]

However, surgical management of the nonunion represents significant challenges. Bone contour distortion frequently demands resection of the site of nonunion for realignment. Sufficient immobilization of the fracture is subsequently required to facilitate an altered healing process.[14],[15],[17]

Notably, posterior rib fractures, especially the angle of the rib, are particularly challenging due to a short proximal rib fragment and contour angulation.[18] The short posterior segment and the proximity to the transverse vertebral process restrict the proximal landing zone and purchase of the osteosynthesis plate.[19] The acute angulation renders it specifically difficult contouring the plate for satisfactory alignment. In addition, the long anterior segment of the rib serves as a lever, exerting excessive torque on the area of fracture, leading to displacement, and hardware failure. Potentially, “U” plates like the RibLock U + system (Acute Innovations, Hillsboro, OR) can be advantageous due to the circumferential fixation. However, in the case of angle of rib fracture it is difficult to align “U”-plate with the rib. Our technical solution with wire cerclage in addition to longer segment with at least five screws proved sufficient.

One concern exists about the galvanic pair of the titanium plate and stainless-steel wire. However, in the experimental settings, this combination did not produce adverse outcomes.[20] We have not observed any adverse events of addition of the wire cerclage to the repair during the 2 years of follow-up. Alternatively, Sternal ZIPFIX® System (Synthes, West Chester, PA, USA) could be used for the same purpose. We feel that this was the deciding factor to the successful resolution of this difficult problem.

To the best of our knowledge, this is the first case of rescue osteosynthesis of posterior rib nonunion repair with the use of wire cerclage in the literature. This case demonstrates the feasibility of repeated repair for the management of chronic posttraumatic pain caused by rib fracture nonunion and the technical solution for this anatomically difficult problem.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to b'e reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma 1994;37:975-9.  Back to cited text no. 1
Billè A, Okiror L, Campbell A, Simons J, Routledge T. Evaluation of long-term results and quality of life in patients who underwent rib fixation with titanium devices after trauma. Gen Thorac Cardiovasc Surg 2013;61:345-9.  Back to cited text no. 2
Richardson JD, Franklin GA, Heffley S, Seligson D. Operative fixation of chest wall fractures: An underused procedure? Am Surg 2007;73:591-6.  Back to cited text no. 3
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;52:727-32.  Back to cited text no. 4
Lodhia JV, Konstantinidis K, Papagiannopoulos K. Surgical management of multiple rib fractures/flail chest. J Thorac Dis 2019;11:1668-75.  Back to cited text no. 5
Cheema FA, Chao E, Buchsbaum J, Giarra K, Parsikia A, Stone ME, et al. State of rib fracture care: A NTDB review of analgesic management and surgical stabilization. Am Surg 2019;85:474-8.  Back to cited text no. 6
Shibahashi K, Sugiyama K, Okura Y, Hamabe Y. Effect of surgical rib fixation for rib fracture on mortality: A multicenter, propensity score matching analysis. J Trauma Acute Care Surg 2019;87:599-605.  Back to cited text no. 7
Liu T, Liu P, Chen J, Xie J, Yang F, Liao Y, et al. Arandomized controlled trial of surgical rib fixation in polytrauma patients with flail chest. J Surg Res 2019;242:223-30.  Back to cited text no. 8
Bartscherer A, Miller C, Johnson M, Stolarski A, Vitto M, Kazakova T, et al. Closed chest compressions after rib plating. J Thorac Dis 2019;11:S1096-9.  Back to cited text no. 9
Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: A review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg 2014;76:462-8.  Back to cited text no. 10
Gordy S, Fabricant L, Ham B, Mullins R, Mayberry J. The contribution of rib fractures to chronic pain and disability. Am J Surg 2014;207:659-62.  Back to cited text no. 11
Landercasper J, Cogbill TH, Lindesmith LA. Long-term disability after flail chest injury. J Trauma 1984;24:410-4.  Back to cited text no. 12
Majercik S, Cannon Q, Granger SR, VanBoerum DH, White TW. Long-term patient outcomes after surgical stabilization of rib fractures. Am J Surg 2014;208:88-92.  Back to cited text no. 13
Hernandez MC, Reisenauer JS, Aho JM, Zeb M, Thiels CA, Cross WW 3rd, et al. Bone autograft coupled with locking plates repairs symptomatic rib fracture nonunions. Am Surg 2018;84:844-50.  Back to cited text no. 14
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. 15
Kaplan DJ, Begly J, Tejwani N. Multiple rib nonunion: Open reduction and internal fixation and iliac crest bone graft aspirate. J Orthop Trauma 2017;31 Suppl 3:S34-5.  Back to cited text no. 16
Sarani B, Allen R, Pieracci FM, Doben AR, Eriksson E, Bauman ZM, et al. Characteristics of hardware failure in patients undergoing surgical stabilization of rib fractures: A chest wall injury society multicenter study. J Trauma Acute Care Surg 2019;87:1277-81. doi: 10.1097/TA.0000000000002373.  Back to cited text no. 17
Haines KL, Zens T, Warner-Hillard C, DeSouza E, Jung HS, Agarwal S, et al. Rib fracture location should be evaluated when predicting morbidity and mortality in trauma patients. Am Surg 2018;84:1462-5.  Back to cited text no. 18
Bartscherer A, Stolarski AE, Miller CP, Johnson M, Giammarino A, Bonville D, et al. Costotransverse screws in repair of paraspinal rib fractures-a novel approach for rib fractures threatening the aorta. J Thorac Dis 2019;11:S1090-5.  Back to cited text no. 19
Høl PJ, Mølster A, Gjerdet NR. Should the galvanic combination of titanium and stainless steel surgical implants be avoided? Injury 2008;39:161-9.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

This article has been cited by
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