Rib Fixation.

Alan Sweenie.

• History.

• Evidence.

• Barriers to obtaining more evidence.

• How it is done.

• Our experience.

• Referral process.

History.

• Soranus:- Greek physician from Ephesus.- Described resection of depressed rib #s for

pleuritic pain.

• Pare:- French surgeon in 16th C.- Closed reduction for displaced rib #s.- If that failed, advocated open resection of

offending fragments.

History.

• WW2 Surgeons - resection of fragments that were driven into the pleural cavity or lung parenchyma.

• Preventilator era - flail chest an ominous diagnosis. Unilateral flail – positioning; bilateral or sternal – external fixation/traction.

• Success of IPPV brought investigation of internal fixation to a halt.

Flail Chest.

• Anatomically – 4 or more consecutive ribs involved.

• Clinically – Identify paradoxical movement with respiration.

• Sternal flail – dissociated from hemi-thoraces.

Tanaka et al.

• Published in J of Trauma, 2002.

• Age over 14, requiring IPPV for flail of >5 ribs.

• Excluded if severe TBI, spinal injuries, comorbid problems of heart, chest or kidney disease.

• Used Judet struts to fix ribs, within 14d of injury.

Tanaka et al.

• Operative (18) v conservative (19).

• LOV: 10.8 (3.8) v 18.3 (7.4); p<0.05

• LOS: 16.5 (7.4) v 26.8 (13.2); p<0.05

• %FVC 6/12: 95 v 78; p<0.05

• %FVC 12/12: 96 v 80; p<0.05

• %FT employment at 6/12: 61 v 5; p<0.05

Voggenreiter et al.• J of A C Surgeons, 1998.

• Non randomised comparative study.

• 1 – surg without contusion (10). LOV 6.5d*

• 2 – surg with contusion (10). LOV 30.8d

• 3 – cons without cont (18). LOV 26.7d

• 4 – cons with cont (4). LOV 29.3d

• *P<0.02 when compared to groups 2 and 3.

Voggenreiter et al.

Group Pneumonia rate Mortality rate

1 1/10 0

2 4/10 3/10

(2 from haemorrhage)

3 5/18 7/18

4 2/4 1/4

Granetzny et al.

• Published 2005.

• Randomised 40 pts. Significantly less LOV support, ICU stay and rates of pneumonia in surgical group as compared with non operative.

• Visual deformity less and FVC significantly higher at 2 months.

NICE - October 2010.

• Ltd in quality; consistently shows efficacy however.

• Aim to allow earlier weaning, reduce acute complications, avoid chronic pain issues.

• No major safety concerns in context of severe trauma with impaired pulmonary function.

• Not with underlying contusions or severe TBI.

NICE - Safety.

• 30% mortality rate in those with pulmonary contusions – 2 from massive bleeding, 1 from sepsis.

• Persistent pain reported in 6/57 (6/12 FU) and 5/21 (3/12 FU) in published case series.

Other Potential Indications.

• Chest wall deformity.

• Pain and disability reduction.

• Non union.

• Thoracotomy for other indication.

Barriers to Furthering Evidence.

• Low numbers – requiring multicentre studies and having surgeons experienced enough.

• Specific indications not defined – although flail already investigated.

• Expense.

• Differing techniques.

Kit.

Preparation.

• Remove chest drain at least day before operation, if possible.

• 3D CT helpful to define rib fractures, extent of displacement and plan surgical approach.

Newcastle Experience.

• 37pts with multiple rib fractures or flail chest since 1.8.07. Mean LOS 7.5d

• 3 deaths – all in 80s.

• Fixation started 4 months ago.

• 4 acutes, 1 non union, 1 sternal flail (without complication so far).

Referral process.

• Sion Bernard, John Williams, Paul Fearon.

• We envisage patients coming to VW ICU at least the day before planned surgery.

• Sale AND return.

In Summary.

• Reviewed evidence, including NICE guidance.

• Potential indications and exclusions.

• Seen pretty pictures.

• Referral process.

Questions?