Kalinin Samara Regional Clinical Hospital, 

Samara, Russia

 

Despite of significant success in many fields of surgery science in the beginning of XXI century, the number of sections exists, which require development of optimal programs for diagnostics and treatment. For acute thoracic surgery such problem is floating fractures of rib cage [3, 12]. The obviousness and the significance of the issues are defined by many public, organizational and medical tactic questions which are solve with both complex measures and single specific activities. Particularly, the presence of the problem at the intersection of traumatology and orthopedics conditioned both variety of approaches and definite inconsistency in curative measures [15]. Traditionally, general and thoracic surgeons investigated issues of internal organ injuries, whereas traumatology and orthopedics oriented to skeletal injuries. Such feature of surgical specialization resulted in the fact that traumatologists have limited skills for chest surgery, and thoracic surgeons are not familiar with the modern approaches to fracture fixation [21]. Possibly, this cause is associated with the fact that conditions and outcomes of treatment for severe thoracic injury demonstrate necessity for multidisciplinary approach to such patients, particularly, synergistic effect of activities of thoracic surgeons and traumatologists-orthopedists. The convergence point for these disciplines is using the classical orthopedics and traumatology techniques for multiple and floating rib fractures which are reviewed in this article.

The first published technique for successful surgical intervention for stabilizing the chest with floating rib fractures is associated with T. Jones et al. who described (1924) transcutaneous rib traction with bullet forceps for a child with 8 unilateral fractured ribs who was treated successfully [30].

Thereafter the authors proposed many techniques for stabilization by means of surgical fixation or similar interventions. The main idea of the technology was associated with the fact that traction could result in pulmonary tissue                  stretching through creation of higher lung vital capacity and decreasing resistance, risk of atelectasis, pneumonia and pulmonary insufficiency. Furthermore, chest stabilization had to decrease pain syndrome and result in more comfort for patients [15].

The confirmation was made in the publications by W.W. Heroy et al. who described three different types of floating fractures with specific treating techniques for each type. Stabilization for typical frontal costal valve was achieved with clamp fixing the sternum and following traction. The technique of placement of screws (made of titan and chrome) into the sternum was used followed by traction upon condition of Fowler’s position. Such position persisted about 24 hours. After that screws were removed, and the next step was realized: surgical forceps were introduced into two screw holes. Forceps were used for traction with weight of 10 pounds during 17 days [27].

The theoretic description of another interesting technique was made by I. Jaslow (1946). Patients with floating fractures of the sternum and ribs receive stabilization with introduction of a metal threaded hook (cloth hanger) into the sternum. Sternal drilling is performed through a small skin incision under local anesthesia; after that, hook introduction into this small hole was performed. For prevention of penetrating the posterior cortical plate the author calculated that 5 hook turns about the axis was enough and safe. Suspension was performed after creation of connection between the hook and the weight. A patient is proposed to stay in such position for 8 days [29]. Unfortunately, the author did not realize his idea, but, possibly, he described the first variant of Schanz screw [15].

In 1963 T. Schire described a device for indraught (Cape Town Limpet). It acts like force cup. This device was applied to a floating segment. Vacuum is created with a metal axis tube. Then traction from transverse metal plate is performed [44].

Hereafter, many traction and suspension techniques were proposed. So, M. Williams (1948) proposed towel clamps and bullet forceps. C. Gardner (1946) offered conduction of metal wire around a rib. W.W. Heroy (1951) offered twisting into the sternum [15].

Another exclusive construction was offered by a Hungarian surgeon O. Constantinescu (1965). The author created the hook with 90° angle. One part of the hook could be curved in view of T-shape in the tissues. Traction was performed by means of installation of hook with a metal plate under patient’s skin [18].

The domestic experience was described by V.V. Klyuchevsky in his work “Skeletal Traction”. Here the author describes correction of chest wall paradoxical displacement by means of continuous damped skeletal traction from the chest and ribs in locations of the greatest valve impaction according to the techniques by N.K. Mityukhin and E.G. Gryaznukhin [4].

 Moreover, E.A. Vagner demonstrates that the uniform technique for treating the costal valve was not offered, and chest traction was not perfect [1]. Most research works included single clinical observations, but without comparative analysis. Only in 1996 A. Gyhra et al. offered the results of the experimental study of two different techniques of external stabilization for floating rib fractures. The first group received application of adhesive plaster and pouches with sand, the second group ‒ transcutaneous traction with towel clamps. The statistically significant improvements were observed in the animals receiving traction: respiratory volume, respiratory volume, pulmonary minute volume and gas composition blood [26].

However some present works indicate continuing use of these techniques for treating patients with multiple and floating rib fractures. A.E. Balci et al. (2004) presented the result of their clinical study. They examined three groups of patients with floating fractures of the ribs. The authors promulgated the fixation technique with silk ligatures and traction from skin sutures. The results improved significantly compared to the groups with focus on different ventilation modes [13].

N.G. Ushakov compared the treatment outcomes in two groups of the patients with multiple and floating fractures of the ribs. The main group received skeletal traction from ribs and the sternum using bullet forceps and towel clamps in combination with internal pneumatic stabilization. The control patients received prolonged artificial lung ventilation. The author noted decreasing duration of artificial lung ventilation from 15 days to 6 days, decreasing mortality from 34.7 % to 20.9 % in the patients with skeletal traction.

It is evident that skeletal traction technique is still used by surgeons. However it is appropriate to use this technique only for temporary stabilization in case of absent conditions for other techniques.

Surgical techniques for floating rib fractures developed along with transcutaneous traction techniques. The implementation of these techniques initiated the era for metal constructs (pins, rods, nails, wire sutures, plates) for fixation of injured ribs. Invasive surgical techniques oriented to stabilizing the floating fractures or direct fixation of fracture regions.

A.A. Vishnevsky et al. in their work “Chest Surgery” described most common techniques for external surgical stabilization of floating ribs. The sense of the technique by A.F. Gredzhev and A.P. Paniotov (1977) is special trocar, which is introduced into pleural cavity through the center of a floating part. A trocar has the folding four-bar linkage in the forward end. This trocar opens during turning the internal rod. Trocar shoulders bear against the internal surface of injured ribs; the device is tightened, and, using nuts, the ribs are attached closely to an arc-shaped plastic panel. The obligatory condition is fixing the ends of the arc-shaped panel, which is above flotation region, to uninjured rib parts or the sternum [2]. The technique by N.K. Goloborodko (1967) was simple and available. It is associated with fractured rib fixation to thermoplastic or wire splint. A thermoplastic plate should overlap fracture lines by 5-7 cm in front and back. For modeling the splint according to chest shape it is put into hot water. After achieving appropriate shape it is put into cold water for consolidation with saving the curve. Floating segments are fixed to the splint through holes (using ligatures). The fixation terms were 2-3 weeks. The negative aspects of the technique are impossibility for administration in bilateral multi-plane rib fractures, sternal injuries and risk of infection along ligatures [2].

Extrafocal osteosynthesis according to Yu.B. Shapota uses non-injured or stabilized segments of the chest and the shoulder girdle. Over and below a floating part the pair of crossing pins is used through uninjured ribs (the sternum, the clavicle). Pins penetrate both cortical layers. Similarly, two pairs of pins are conducted through uninjured ribs. Pins are fixed with a threaded nail along the anterior chest wall [9].

In 2001 M. Glavas et al. described a technique, with a floating segment, which is covered and fixed with a manually produced prosthesis (Palacos cement). During application the prosthesis extends from proximal to distal uninjured ribs and crosses a floating segment tangentially. The ribs are fixed to the prosthesis with sutures or wires. The authors reported the results of 56 patients with good results of treatment. However they did not report detailed information [22]. Similar technology was described by Actis Dato et al., who offered to use the self-retaining and easily removable prosthesis (Sea Gull Wing Prosthesis) [10]. In our country the similar method was the technique by V.I. Maslov and M.A. Takhtamysh. The technique is based on ligature fixation of floating rib valves to thoracic splint [7].                     

In 2009 Ya.G. Kolkin et al. described a technique for panel fixation of the rib cage after multiple and floating fractures. The technique is related to using an external panel, which supports “shoulders” (in pleural cavity) for fixing rib fragments. The authors showed the high efficiency of the technique and achieving the mortality rate of 4.7 % [5].

One of the effective techniques for external stabilization of chest wall frame is extrafocal extrapleural osteosynthesis with external fixation device on the basis of clinching elements or rib hooks. Rib hooks are fixed to floating and uninjured rib parts, sutured to bearing bar and fixed with nuts and holders. In case of simultaneous injuries to the ribs and the sternum, sternal osteosynthesis is performed at first. The bearing bar is fixed to a stabilizing sternal bar. Therefore, one can correct rib cage instability, deformation and restore pleural cavity volume. The device is removed in 3-4 weeks after fracture consolidation [2].

Therefore, the available results about external fixation techniques for multiple and floating rib fractures have proven efficiency and can be reviewed as the methods for temporary or final stabilization.

Surgical (internal) fixation of fractured ribs was an attractive idea for surgeons. One of the first publications were the works by D. Elkin (1943) and K. Hagen (1945) who described fixation for depressed fractures of the ribs using metal wire or sutures during open surgery [15]. The similar technique from A.P. Kuzmichev et al. supposed fixing the rib fractures with tantalian clips which are tightened with SGR-20 and SRKCh-22 devices [6].

V. Dor, a French surgeon, was the first man who published description of the technique for stabilizing fractured ribs during thoracotomy using K-wire [19]. Beltrami et al. and Guernelli et al. independently described the technique for stabilizing fractures with two long K-wires, which were introduced into costal valve region during thoracotomy and after it. Afterwards the authors compared the technique and cross-shaped introduction of spits. Pins were removed in 30 days. The good outcomes were achieved [14, 25].

Yu.B. Shapot et al. offered the modification of fixation for multiple multi-plane fractures of the ribs: K-wire is curved according to rib shape, applied around it and fixed to a rib using tantalian clips with SGR-20 modified device. Pins are removed in 8-10 months. Such fixation technique prevents deformation of bone and muscle structures of the chest wall and restores functions of external breathing and circulation [9].

During the last 50 years the authors published multiple studies about fixation with K-wires, predominantly with good outcomes. А. Granetzny et al. performed a prospective study and compared the outcomes of treatment in 20 patients who received surgical fixation with intramedullary K-wires, and 20 patients who received non-surgical treatment with adhesive plaster. The significant differences were found in duration of artificial lung ventilation, ICU stay, the rate of residual chest deformations, pneumonia and wound infections in the surgical and no-surgical groups correspondingly [24]. The similar results were received in the retrospective study by Z. Ahmed et al. in 1995 [11].

Among the disadvantages of fixation with K-wires one should note some rotational instability in fractures, potential loss of fracture stabilization as result of spinal migration, pain syndrome and additional injuries to adjacent tissues [11, 20]. For preventing these undesirable consequences A. Ivanic (2009) described a technique on the basis of K-wire; wire is fixed in 8-shape for higher stability [28]. Low invasive modified fixation for floating fractures with K-wire was described by K.G. Zhestkov et al. They performed conduction and fixation of wire through small incisions in soft tissues under thoracoscopy control. The authors noted high safety and efficiency of the technique [3].

In 1991 R.S. Landreneau et al.  presented the technique for fixing the floating segments using metal rods from the orthopedic toolbox for external fixation (Lunque). Rods are introduced into the ribs during thoracotomy and are fixed using an external connecting device which is located subcutaneously. The technique by R.S. Landreneau is actually an analogue of Nuss operation, which was primarily offered for treating the funnel chest [32]. W. Glinz and P. Carbognani  et al. (independently from each other) described a technique using metal plates for chest wall stabilization in treatment for floating fractures [17, 23].

The top of perfection of internal surgical fixation techniques is osteosynthesis for injured ribs. External osteosynthesis implies full restoration of an injured rib, when intramedullary implants are used as so called “splints” supporting a floating segment in the anatomic position and preventing paradoxal movements without rigid fixation.

For conduction of intramedullary osteosynthesis R.R. Crutcher et al. (1956) offered bone nails, K.P. Klassen (1949) ‒ sharp nails [21]. In 1976 the direct administration of Rehbein intramedullary plates was described. The plates were designed for providing higher rotation stability of a fractured rib [45]. One end of the plate is located outside the intramedullary channel and is fixed to the rib by means of sutures for limitation of possible migration. Much later the precontoured rib splint for intramedullary fixation of rib fractures was developed. It has the square cross section, is precontoured as natural rib curve and is fixed to the rib using a locking screw for preventing the possible migration and providing the angle stability. The biomechanical analysis of the implant showed significant advantages compared to the simple fixation with K-wire: rib construction is 48 % stronger and it allows preventing the cutting out and migration, especially in cases of fractured posterior sections, when application of bone plates has limitations [16].

The development of this direction suggested improvement in design of the plates. W. Sillar was the first man who reported about administration of the plates for chest stabilization. He used a metal plate for fixation of injured sternum in combination with intramedullary introduction of K-wires into rib floating segment in 6 patients [46]. F. Paris et al. described several different stabilizing techniques with the plates of their own design. The plates were 40 cm long and were used for stretching the floating segments. They were applied along, between or across the ribs with use of sutures, and usually were removed after fracture healing. The comparative analysis showed the best results in the patients with this surgical stabilization. The authors also described the minimally invasive plate osteosynthesis: plates were conducted above injured ribs from two small incisions [40].

The mechanisms for fixing plates to the rib were improved. Some plates were fixed to the rib with screws. However in some cases a plate could separate from the rib because of plate rigidity and relative softness of rib tissues [15]. As result, R. Labitzke, a German surgeon, created a plate with rib locking mechanism for simplification of plate fixation and decreasing risk of an injury to intercostal vascular nerve structures which are vulnerable during fixation with locking stitch (Labitzke plate). He was the first who used titan plates. The plate design was quite original: understanding the necessity for plate curvature in two planes defined presence of locking brackets with asymmetrical connections allowing curvature in plate plane. The first experience with 18 patients showed rapid restoration of spontaneous breathing, pain correction and decreasing rates of complications. However high flexibility of the plate impeded rigid fixation of a floating segment [31].

The repetitive interest in relation to rib fixation with plates appeared in the last decades of 20^th century. The favourable reports about standard plates like Drettelrohr were presented by H.L. Lindenmaier [34]. V. Vecsei et al. implemented a low profile plate for wire fixation. This plate did not require further removal. However the cross-type transverse section of the plate did not allow correcting along the contour and the plate length (about 8 cm) could not cover whole floating segment [48]. Judet plates have boundary compressing sections and the flat central section of 5.3 cm for fixing the single fractures [15]. It allows capturing relatively soft costal bone by means of flat hooks instead of screw fixation, resulting in decrease in risk of plate disconnection and injuries to subjacent structures with drilling. High effective fixation with Judet plates was showed in the prospective randomized study by H. Tanaka et al. [47]. Voggenreiter et al. substantiated efficiency of such plates for patients with rib injuries and lung contusion [50].

R. Nirula et al. (2006) used Adkins plates and wire sutures for fixing the floating segments and compared this technique with internal pneumatic stabilization. Primary estimation of results of ICU and hospital stay did not find any statistical significant differences between the groups. However amount of ALV days (from surgery to extubation) was significantly lower in the surgery group (2.9 days) compared to the conservative group (9.4 days) [38].

Basing on necessity for rigid fixation of a floating segment, J. Sanches-Lloret offered the rib plates, 13-19 cm, with locking boundary sections covering all sides of a floating segment with single implant. Middle circular section matched according the rib contour, but the limitation was the low profile of the plates [43].

D. Lardinois et al. performed fixation with 3.5 mm stainless reconstruction plates. The authors noted the possibility for early extubation, decreasing amount of ALV period and return to professional activities in 100 % of operated patients. The consequent removal of plates was performed for 11 % of the patients, and it was associated with postsurgical pain associated with plates [33].

J.C. Mayberry et al. (2003) published their first experience with resorbable plates for rib fractures. They found the good functional outcomes and presented this technique as method of choice for fractures of the ribs [37]. The positive impressions from resorbable plates were observed by S. Marasco et al. in 2009. The authors used fixation for 13 patients with floating fractures of the ribs. Restoration without complications was achieved in all cases [35].

Minimal invasive fixation for single rib fractures was described by J.R. Sales et al. They published the study of the new design of the plates (about 5 cm) using both principles (screwdriving and capturing). The result of the study was development of U-shaped plate RibLoc (Acute Innovations). The plate name means the performance principle: U-shape provides sliding and placement onto the rib. Subsequent fixation was achieved by means of angle stabilizing screws [42].

For achieving the appropriate contour J.R. Oyarzun et al. recommend primarily to use a template (after rib reposition), followed by curving the plate with pliers or other instruments according to the template [39]. Such difficulty requires team approach: a thoracic or general surgeon provides surgical exploration and draws the orthopedic team for plate fixation [41].

In 2007 J. Vodicka described 10 year experience covering 40 patients with rib fractures who received surgical fixation with Medin plates. These plates had similar characteristics with Judet plates, because the ribs are supported with hooks. A surgeon can add several additional screws for better fixation. The difference was that the plates were fixed on the rib surface, not circumferentially [49].

In 2008 the new system called Stratos (Strasbourg thoracic osteosynthesis system) appeared in France. It was destined for only rib fractures and chest deformations. The fixation mechanism is comparable with Judet plates. The system is equipped with arcs which are connected to plates for covering or suspending the chest segments [15].

The newest fixation system is presented by Synthes company ‒ Matrix rib fixation system. This system of anatomic costal plates and splints is exclusively designed for rib fixation with locking screws. The plates are made of titan, and their design completely satisfies biodynamical characteristics of the ribs that excludes necessity for templates and plate premodelling. It decreases surgery complexity and reduces operation time, especially during stabilization for floating fractures and costal window. The anatomic costal plates, specially designed for stabilizing the floating fractures, confirm use of long plates, which are simultaneously strong and low-profile, and provide fixation for a floating segment [16].

Despite appearance of special costal plates, the standard tubular (1/3) and 3.5 mm reconstructive plates are most common implants for fixation of fractured ribs because of the widespread availability. The standard plates have appropriate contour and provide sufficient stability for fixing a floating segment. However these plates are sufficiently rigid for pressure concentration and provoking a disruption and displacement of a screw from osteoporosis rib [15]. Moreover, R. Labitzke found that the plates require curvature that makes their administration more difficult and labor consuming compared to flexible locking plates [31].

Therefore, despite of sufficient amount of different techniques for multiple and floating fractures of the ribs, the scale of administration is quite small, and the publications about long term outcomes for each fixation technique are limited. In 2009 Mayberry et al. interviewed 405 cardiothoracic surgeons, traumatologists and orthopedists about their opinions concerning chest fixation. They found that most specialists considered appropriateness of chest fixation in some cases, but few people had experience with this procedure. Also they found that most surgeons knew nothing about literature concerning the chest. Moreover, it was evident that the surgeons, who usually operate the chest, did not have knowledge about technologies and instruments for fixation [36].

 

CONCLUSION

During many years of advancement in thoracic surgery and traumatology multiple technologies were used for achievement of chest and rib stabilization in multiple and floating fractures. Nevertheless, considering the multiple offered ways for solving the problem, the final fixation method is absent. The modern invasive techniques are quite effective, but their promotion will be achieved with co-operation of thoracic surgeons and traumatologists-orthopedists, as well as concentration of experience in specialized departments in big centers for polytrauma treatment. The analysis of different techniques for surgical stabilization showed that one could await the best results from the special materials, which are specifically designed for rib fixation.