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Rib Fixation.

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 16 th C.

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Rib Fixation.

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  1. Rib Fixation. Alan Sweenie.

  2. History. • Evidence. • Barriers to obtaining more evidence. • How it is done. • Our experience. • Referral process.

  3. 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.

  4. History. • WW2 Surgeons - resection of fragments that were driven into the pleural cavity or lung parenchyma. • Preventilator era - flail chest anominous diagnosis. Unilateral flail – positioning; bilateral or sternal – external fixation/traction. • Success of IPPV brought investigation of internal fixation to a halt.

  5. Flail Chest. • Anatomically – 4 or more consecutive ribs involved. • Clinically – Identify paradoxical movement with respiration. • Sternal flail – dissociated from hemi-thoraces.

  6. 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.

  7. 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

  8. 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.

  9. Voggenreiter et al.

  10. 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.

  11. 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.

  12. 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.

  13. Other Potential Indications. • Chest wall deformity. • Pain and disability reduction. • Non union. • Thoracotomy for other indication.

  14. 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.

  15. Kit.

  16. 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.

  17. 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).

  18. 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.

  19. In Summary. • Reviewed evidence, including NICE guidance. • Potential indications and exclusions. • Seen pretty pictures. • Referral process.

  20. Questions?

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