Rib Fixation Colloquium 2016: Consensus Statement Update

Fredric M. Pieracci MD, MPH, FACS

Trauma Medical Director Denver Health Medical Center Associate Professor of Surgery

University of Colorado SOM

Disclosures

• Paid faculty & consultant: – DePuy Synthes – Zimmer BioMet

Author Group

Fred Pieracci

Christian Minshall

Andrew Doben Sarah Majercik Darwin Ang Francis Ali-Osman

Silvana Marasco Mario Gasparri Bruce French

William Tisol Babak Sarani Don VanBoerum Tom White

John Edwards

Author Group

Author Group

Author Group

Methodology

• 14 topic champions reviewed literature (136 references) and rendered graded recommendations

• Delphi method of consensus – Anonymity, iteration, feedback, group response – Binary outcome: Agree vs. disagree – Consensus defined as ≥ 80% (at least 12 of 14

agree) – Two rounds of voting

Consensus Statement Topics

Topic # Recs 1 Indications for Surgery 5

2 Timing of Surgery 1

3 Regionalization of surgery 2

4 Preoperative planning 10

5 Surgical Approaches 4

6 Mode of fixation 4

7 Management of multiple fracture series 1

8 Management of bone loss 3

9 Management of muscle loss 2

10 Management of the pleural space 3

11 Loco-regional anesthesia 3

12 Postoperative care 5

13 Management of chronic non union 5

Results Degree of Consensus N % 100% (14 of 14 agree) 27 56.3%

92.9% (13 of 14 agree) 16 33.3%

85.7% (12 of 14 agree) 5 10.4%

< 80% 0 0.0%

Grade of Recommendation N % A 0 0.0%

B 7 14.6%

C 10 20.8%

D 31 64.6%

Round in which Consensus was Achieved

• First round = 43 (89.6%)

• Second round = 5 (10.4%)

Second Round Consensus

• 8.4.1. In general, repair of ribs 1, 2, 11 and 12 does not confer additional benefit in terms of either chest wall stability or pain control. In highly select circumstances, such as marked displacement, vascular impingement, or localized refractory pain, repair of these ribs may be considered (Level 5, Grade D).

• 8.4.2. Fractures within 2.5 cm of the transverse process should not be repaired (Level 5, Grade D).

• 8.4.3. Fractures within 2.5 cm of the costal cartilage may be repaired by fixation to either the cartilage or sternum (Level 5, Grade D).

Second Round Consensus

• 12.0.1. Fracture gaps > 10 mm should not be bridged (Level 2c, Grade C).

• 15.0.2. Thoracic epidural and paravertebral catheters provide equivalent loco-regional anesthesia for patients with rib fractures (Level 2, Grade B) using only a plate (Level 2c, Grade C).

• 4.0.1. SSRF should be considered in all patients with flail chest (Level 2b, Grade B).

• 8.2.2 In patients undergoing SSRF, peri-operative VTE prophylaxis with LMWH should be delayed for 24 hours following the placement of an epidural catheter. Furthermore, epidural catheter placement should occur at least 10 hours after the last dose of LMWH (Level 1c, Grade B).

• 8.3.1. Patients being considered for SSRF should undergo CT chest (Level Grade B).

Grade B Recommendations

• 15.0.2. Thoracic epidural and paravertbral catheters provide equivalent loco-regional anesthesia for patients with rib fractures (Level 2, Grade B)

• 17.0.2. Nonunion should be suspected in patients with persistent chest wall pain three to six months following injury; these patients should undergo further testing/imaging with CT chest, even if the initial CXR appears normal (Level 3A, Grade B).

• 17.0.4. Operative repair of chronic nonunions is indicated for persistent disabling pain refractory to conservative treatment methods, with thoughtful management of patient expectations. (Level 3A, Grade B).

Grade B Recommendations

• 8.2.2 In patients undergoing SSRF, peri-operative VTE prophylaxis with LMWH should be delayed for 24 hours following the placement of an epidural catheter. Furthermore, epidural catheter placement should occur at least 10 hours after the last dose of LMWH (Level 1c, Grade B).

• 8.3.2. There is insufficient evidence to recommend the routine use of 3D reconstructions of the CT Chest (2B, Grade B).

• 10.1.1. Rib fractures may be fixed using either plates or intra-medullary struts (Level 5, Grade D).

“Low” Consensus Recommendations (12/14)

• 12.0.3. Autologous graft and commercially available, non-autologous grafts are equally effective for bone grafting (Level 5, Grade C).

• 17.0.4. Operative repair of chronic nonunions is indicated for persistent disabling pain refractory to conservative treatment methods, with thoughtful management of patient expectations. (Level 3A, Grade B).

“Low” Consensus Recommendations (12/14)

• Strengths – Contemporary, graded recommendations – Multidisciplinary, experienced surgeons – Precedent for future work from this group

• Weaknesses

– Selection bias – General lack of high grade recommendations

• Future Directions – RFC Guidelines 2.0

Rib Fracture Colloquium 2016 Consensus Statement

Rib Fixation Colloquium 2016: Consensus Statement Update

Fredric M. Pieracci MD, MPH, FACS

Trauma Medical Director Denver Health Medical Center Associate Professor of Surgery

University of Colorado SOM