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ORIGINAL ARTICLES
Surgical rib fixation: Does increase case volume lead to improved outcomes?
Bhavik M Patel, Gary S L. Hung, Martin E Wullschleger
January-December 2019, 4(1):10-13
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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A multi-institution case series of intercostal nerve cryoablation for pain control when used in conjunction with surgical stabilization of rib fractures
Frank Z Zhao, John D Vossler, Adam J Kaye
January-December 2019, 4(1):28-34
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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CASE REPORTS
Rescue re-do inline osteosynthesis with wire cerclage for failed rib plating of multilevel rib nonunion
Tatiana Kazakova, Marcel Tafen, Warner Wang, Roman Petrov
January-December 2019, 4(1):59-62
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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Cardiac Tamponade from Isolated Right Atrial Rupture: A Rare Presentation of Blunt Chest Trauma Without Rib Fracture
Ganesh Kumar K Ammannaya, Chaitanya Raut, Chandan Kumar Ray Mohapatra, Harsh Seth
July-December 2016, 1(1):13-15
DOI:10.4103/2542-6281.194054  
Cardiac tamponade resulting from blunt chest trauma is an emergent and life-threatening condition. Cardiac rupture from blunt chest trauma is not a common presentation, and more so in the absence of rib or sternal fracture. We present a case of blunt chest trauma, who presented with features of cardiac tamponade. Emergency sternotomy revealed a right atrial rupture near the appendage which was surgically repaired. The patient also underwent simultaneous splenectomy for Grade 4 splenic injury. The patient recovered uneventfully. Prompt recognition of the injury based on a high index of suspicion must lead to immediate surgical intervention in order for these patients to survive, even in the absence of specialized imaging investigations.
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Traumatic tension pneumopericardium: A rare complication
P Vivekananthan, Mudalipalayam N Sivakumar, Mohamed Hisham, S Lakshmikanthcharan
January-December 2017, 2(1):14-16
DOI:10.4103/jctt.jctt_12_16  
A 36- year old male was admitted with shock following a road traffic accident. The patient had a low Glasgow Coma Scale score of 8/15 for which he was ventilated and intubated. Computed tomography scan showed pneumomediastinum and pneumopericardium along with left-sided hemopneumothorax. Hemopneumothorax was addressed with an intercostal drain. There was no further blood loss. Persisting hemodynamic compromise needing inotropic support prompted a diagnosis of tamponading effect of pneumopericardium. Pericardiocentesis was performed which resulted in immediate hemodynamic stability. The patient was discharged from intensive care unit after tracheostomy and had a complete recovery. Tension pneumopericardium is an extremely rare condition which can be fatal if left untreated. Prompt suspicion, diagnosis, and treatment of the condition in a hemodynamically unstable trauma patient can be lifesaving.
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ORIGINAL ARTICLE
Cardiothoracic Contrecoup and Contralateral Injuries: Nomenclature, Mechanism, and Significance
Moheb A Rashid, Mohammad A Rashid
July-December 2016, 1(1):4-7
DOI:10.4103/2542-6281.194051  
Objective: Contrecoup injuries are well-known lesions in the neurosurgical practice, while their existence in other medical disciplines is lacking. Another term of confusion is the contralateral lesion that is ill defined when compared to the contrecoup injury. A nomenclature, mechanism, and clinical significance of such lesions in cardiothoracic trauma patients are warranted. Patients and Methods: Only one patient with thoracic contracoup injuries was found in a retrospective review of 477 patients with significant cardiothoracic trauma managed during a 10-year period, between January 1988 and December 1997, at Sahlgrenska University Hospital/Östra, Gothenburg, Sweden. The other four cases with contrecoup injuries were encountered in a prospective manner in different places both in Sweden and Norway. All the four prospective cases were witnessed and well documented during trauma occurrence and management. Results: All patients developed significant contralateral chest wall symptoms and signs requiring treatment. One patient developed huge contrecoup pneumothorax. Two patients developed contrecoup hemothoraces. One patient developed contrecoup cardiac injury. One patient developed contralateral chest wall rib fractures. Two patients developed contralateral sternal fractures; one of them was unstable and required surgical fixation. Conclusions: Nomenclatures to what are have called contrecoup and contralateral lesions in cardiothoracic practice are suggested. Discrepancy between the trauma side of the chest and the resulting lesions exactly on the contralateral part may make the diagnosis difficult to understand and could give a suspicion concerning the trauma site, and whether the patient was conscious or simply not telling the truth as in case of trauma with medicolegal aspects.
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ORIGINAL ARTICLES
What is the minimum fixation required to repair flail chest?
Kate Wallwork, Jenny Mitchell, Najib Rahman, Elizabeth Belcher
January-December 2019, 4(1):14-19
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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Rib Fractures in Geriatric Patients: An Observational Study of Surgical Management
Joy Dowden Hughes, Michelle J Berning, Alexander S Hunt, Brian D Kim, Mariela Rivera, David S Morris, Henry J Schiller, Martin D Zielinski
January-December 2019, 4(1):23-27
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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REVIEW ARTICLE
Damage Control Thoracic Surgery
James V O'Connor
July-December 2016, 1(1):8-11
DOI:10.4103/2542-6281.194052  
Damage control as a management strategy for the most severely injured and metabolically depleted patients was first utilized for penetrating abdominal trauma. The principles are early hemorrhage control, limiting enteric contamination, resuscitation in the intensive care unit and, a delayed, definitive re-operation when normal physiology is restored. Since its initial use over two decades ago, the principles of damage control have been successfully utilized in the management of vascular and orthopedic injuries, and more recently in volume resuscitation. There has been a slower adoption of damage control approach to thoracic trauma, primarily due to concerns of cardiac tamponade and impaired pulmonary physiology, both the result of packing the pleural space. This review article describes philosophy, techniques and outcomes of damage control thoracic surgery.
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Blunt thoracic aortic injury
Tara Talaie, Jonathan J Morrison, James V O’Connor
January-December 2018, 3(1):11-18
DOI:10.4103/jctt.jctt_7_18  
Blunt thoracic aortic injury (BTAI) is a significant problem in cardiothoracic trauma. It is a leading cause of prehospital death from high energy motor vehicle crashes. Injuries can be classified into one of four grades: grade I – intimal tear; grade II – intra-mural hematoma; grade III – pseudoaneurysm and grade IV – uncontained rupture. Clinical symptoms and signs are often limited, especially in minor injury grades. Left sided hemothorax and a widened mediastinum on chest radiography are concerning features suggestive of BTAI. Computed scanning is now an indispensable tool used to evaluate patients and has largely replaced aortography. The aim of management is to control hemorrhage (if present) and to reduce the risk of delayed aortic rupture. Patients with pseudoaneurysm can undergo semi-elective repair, provided blood pressure can be controlled which is critical to preventing lesion progression and rupture. Patients presenting with an uncontained rupture require emergent repair. The preferred method of intervention is no longer operative repair (with bypass for distal perfusion), but thoracic endovascular aneurysm repair (TEVAR). An endovascular approach is associated with a lower morality and lower rates of spinal cord ischemia. The aim of this review is present the history of management and the supporting evidence along with an overview of current practice from a busy US trauma center.
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