To Plate or Not to Plate

8/11/2019 To Plate or Not to Plate

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Robert Southard, MDAssistant Professor of SurgeryBaylor College of Medicine


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I have received speaking and consultation fees from Synthes and BioMet


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30 yo man in MVC

Multiple rib fractures


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30 yo man in MVC


Treated initially with epidural anesthesia


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30 yo man in MVC


Treated initially with epidural anesthesia

Pain limited ability to cough/use IS

Despite functioning epidural

Offered ORIF


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100,000 patients admitted/year

Present in 10% of trauma admissions

Marker of significant blunt chest trauma

Associated with underlying injuries

Pulmonary contusion

Solid organ injury


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Recognized as an injury pattern afterinvention of automobile

Up to 80% mortality


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Fracture of 3 or more contiguous ribs in 2 ormore places


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Paradoxical movement of segment of chestwall
http://ps.cnis.ca/wiki/images/5/57/Chapter_65_Image_10_Web_Size.jpg


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Pulmonary Toilet

Pain control

Positive pressure ventilation


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Pulmonary Toilet

Pain control

Positive pressure ventilation

Anatomic correction unnecessary


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1990


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2001


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2014


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High mortality prompted attempts at therapy

Internal Pneumatic Support

Tried and True

Anatomic Fixation Technology Searching for an Indication


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High mortality prompted attempts at therapy

Internal Pneumatic Support Avery E, et al. Severe crushing injuries of the chest; a new method

of treatment with continuous hyperventilation by means ofintermittent positive endotracheal insufflation. Q Bull Northwest

Univ Med Sch. 1955;29(4):3013

Anatomic Fixation Jones T, Richardson E. Traction on the sternum in the treatment of

multiple fractured ribs. Surg Gynec Obstet. 1926;42:283.


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Jones 1926 Traction applied with bulletforceps


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Jaslow 1946 Clothes hangerpercutaneously fixed to

sternum


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Heroy 1951 Traction with clamp applied tosternum


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Schrire 1963 Cape Town Limpet

Plunger applied externally

Traction on metal cross-bar


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Constantinescu 1965 Easily placed T-hooksecured in chest

External fixation


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Advantages

Restores chest volume

Improves respiratory mechanics

Disadvantages

Danger of placement

Infection

Mechanical failure


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Suturing Fractures

Suture

K wires

Reported as part of other descriptionsLikely high rate of failure, though not reported


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Intramedullary fixation

Klassen 1949 Medullary pegs

Crutcher and Nolen 1956 Pins Paris 1975 IM struts


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Plates

Labitzke 1980

Titanium


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Restoration of chest volume beneficial

Success of external fixation and ORIF


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Early fixation systems

Case reports showed they could be effective

Mechanical failures may not have been reported

Difficulties with fixation of ribs


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Difficulties with fixation of ribs

Thin walled

Bicortical screws necessary Neurovascular bundle

Plates wrapping around inferior border

Fear of devascularization

Possibility of nerve impingement

Constant motion of ribs

Failure using stiff plates


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Plates

Casali 2005

Judet plates Sanchez plates


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Acute Innovations

Inion OTPS


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STRATOS

Synthes MatrixRIB

BioMet


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Is this a technology looking for an indication?

Historically risk-benefit ratio favored internalpneumatic stabilization


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Tanaka, et al Trauma 2002

37 Patients

Randomized on Day 5 Repaired Ribs 4-10

Pneumatic Stabilization Control

Surgical Stabilization of Internal Pneumatic Stabilization? A Prospective Randomized Study of Management

of Severe Flail Chest Patients. H. Tanaka et al. J Trauma. 2002 Apr; 52(4):727-32


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Granetzny et al ICVTS 2005

40 Patients

Fixation at 24 to 36 hours after injury Used Kirschner wires

Strapping and packing control

Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. A Granetzny et al.

Interact Cardiovasc Thorac Surg. 2005 Dec;4(6):583-7


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Granetzny et al ICVTS 2005


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Marasco et al JACS 2013

46 Patients

Vent dependent with flail chest Fixation at day 4 to 5 (mean)

Used Inion system biodegradable plates/screws

Only fixed 1 fracture in flail segment

Nonoperative management control

Protocolized extubation criteria in both arms

Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. SF Marasco et al. J

Am Coll Surg. 2013 May;216(5):924-32


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Marasco et al JACS 2013Outcomes Operative

group (n = 23)Nonoperative group(n = 23)

p Value

Duration of IMVpostrandomization,

h, mean SD

151.8 83.1 181.0 130.2 0.37

Total ICU stay, h,median (IQR)

324 (238380) 448 (323647) 0.03

Failed extubation,n (%)

3 (13) 1 (4) 0.61

Readmission toICU, n (%) 2/23 (9) 2/23 (9) 0.99

Pneumonia, n (%) 11/23 (48) 17/23 (74) 0.07

Duration ofhospital stay, d,median (IQR)

20 (1828) 25 (1838) 0.24

In hospital

mortality, n

0 1 0.87


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p Value


h, mean SD

151.8 83.1 181.0 130.2 0.37


324 (238380) 448 (323647) 0.03


3 (13) 1 (4) 0.61


Pneumonia, n (%) 11/23 (48) 17/23 (74) 0.07


20 (1828) 25 (1838) 0.24

In hospital

mortality, n

0 1 0.87


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p Value


h, mean SD

151.8 83.1 181.0 130.2 0.37


324 (238380) 448 (323647) 0.03


3 (13) 1 (4) 0.61


Pneumonia, n (%) 11/23 (48) 17/23 (74) 0.07


20 (1828) 25 (1838) 0.24

In hospital

mortality, n

0 1 0.87


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Marasco et al JACS 2013

Cost Analysis

Non-operative 5.17 more ICU days x $4,109/day

$21,243

Operative costs (OR time + Implants)

$6,800

Net savings

$14,443


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Leinicke et al Annals of Surgery 2013

Meta-analysis

Identified 9 comparative trials

Operative Management of Rib Fractures in the Setting of Flail Chest: A Systematic Review and Meta-

Analysis. JA Leinicke et al. Ann Surg. 2013 Mar 18 (Epub)


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Not technology looking for an indication

Evolution of technology over time

Historically risk-benefit ratio favored internalpneumatic stabilization

Recent advances may have shifted this balance


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Non-union

Severely displaced fractures

Failure of non-operative therapy


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Prospective study of 24 patients

3 months or more after injury

Resection of pseudoarthrosis, with plating ifdefect


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203 patients with rib fracture

7% had flail segments

Chronic pain in 22%

Decreased functional status in 53%

No identifiable injury characteristics predictive ofchronic pain

The contribution of rib fractures to chronic pain and disability. Gordy S, Fabricant L, Ham B, Mullins R,

Mayberry J. Am J Surg. 2014 May;207(5):659-62


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Nine case reports/series

Low complication rate

Many patients lost to follow up Patients reported decreased pain postoperatively


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Little data

Delaying repair increases difficulty of case

Further trials needed to identify who is likelyto fail non-operative therapy and benefit

from ORIF


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Flail chest

Yes

Severely displaced fractures

Not routinely, unless.


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Failure of non-operative therapy

Yes, but when????

Non-union

Maybe

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To Plate or Not to Plate