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Rib Fixation.
Alan Sweenie.
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• History.
• Evidence.
• Barriers to obtaining more evidence.
• How it is done.
• Our experience.
• Referral process.
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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.
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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.
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Flail Chest.
• Anatomically – 4 or more consecutive ribs involved.
• Clinically – Identify paradoxical movement with respiration.
• Sternal flail – dissociated from hemi-thoraces.
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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.
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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
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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.
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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
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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.
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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.
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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.
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Other Potential Indications.
• Chest wall deformity.
• Pain and disability reduction.
• Non union.
• Thoracotomy for other indication.
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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.
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Kit.
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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.
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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).
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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.
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In Summary.
• Reviewed evidence, including NICE guidance.
• Potential indications and exclusions.
• Seen pretty pictures.
• Referral process.
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Questions?