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The Role of Surgical Stabilization of Rib Fractures in Polytrauma

Mayberry, John, MD, FACS

Journal of Orthopaedic Trauma: January 2019 - Volume 33 - Issue 1 - p 1–2
doi: 10.1097/BOT.0000000000001389
Editorial
Free

Sharp Memorial Hospital, San Diego, CA

The author reports no conflict of interest.

The modern resurgence of surgical stabilization of rib fractures (SSRFs) began in the early 1980s in Portland, Oregon, with William Long. Long had completed a trauma and surgical critical care fellowship at the University of Maryland Shock Trauma Center in Baltimore, followed by cardiothoracic surgery training at the University of California, San Diego, without ever seeing or hearing of SSRF. But after encountering a handful of patients with severe chest wall injury at Legacy Emanuel Medical Center in Portland, Long concluded that surgical stabilization was in select cases warranted. In 1985, Long presented his experience with SSRF in a poster display at the American College of Surgeons Clinical Congress, receiving interest but mostly disapproval.

George Haasler at the Medical College of Wisconsin reported dramatic improvement of respiratory function in a patient with multiple, severely displaced rib fractures after SSRF in 1990.1 Haasler became a strong advocate for early operative stabilization along with his colleagues, Mario Gasparri and William Tisol.2

In 1992, Donald Trunkey performed the first flail chest SSRF at Oregon Health & Science University (OHSU) in Portland after having observed SSRF earlier in San Francisco.3 Trunkey, along with Richard Mullins, the Trauma Section Chief, encouraged John Mayberry, Trauma Fellow, to investigate SSRF as a research endeavor. Their goals were to investigate the technical challenges, the indications, and the long-term outcomes of SSRF.4 The high rate of long-term disability of patients with flail chest treated nonoperatively reported by Landercasper and colleagues5 greatly influenced their research. Concurrently, Long from across the Willamette River in Portland and Mouton et al6 from Switzerland theorized that flail chest SSRF could provide not only acute benefits but also prevent long-term pain and disability.

Several seminal investigative reports quickly followed. In 1995, Ahmed and Mohyuddin7 from the United Arab Emirates repaired 26 patients with flail chest equivalents with intramedullary wires. Compared with contemporary controls, these patients required less ventilator time, less tracheostomies, less pneumonia, and had lower mortality. In 1996, Tanaka et al8 from Japan presented a prospective randomized trial of “severe flail chest patients” treated with either early SSRF or “internal pneumatic stabilization” at the American Association for the Surgery of Trauma's annual meeting with the same positive results and a dramatic return to work advantage for the stabilized patients. In 1998, Voggenreiter et al9 from Germany presented their similar series and outcomes. From their groupings of patients come the admonition that patients with pulmonary contusion may not benefit from SSRF, which Fokin et al10 currently dispute.

In the first decade of this century, SSRF was progressively accepted by the mainstream trauma surgeon community. The number of case series, cohort comparisons, and randomized trials of SSRF steadily increased, culminating in 2010 with the report from the United Kingdom National Institute for Health and Health Care Excellence that flail chest stabilization should be considered safe and within the standard of care in selected patients.11

This issue of JOT, with 4 publications related to SSRF, exemplifies the current state of affairs.10,12–14 SSRF for select flail chest injuries and other select indications has become the standard of care. Three of the articles regarding SSRF in this issue are cohort comparisons reporting trauma centers' initial positive experiences with introducing SSRF programs.10,12,13 These authors' examples of properly setting up and following the results of their SSRF programs are to be emulated. The fourth article is a novel report of the additional challenges that a polytrauma patient presents.14 Alvi and colleagues demonstrate, that in select cases, SSRF takes precedence over other serious injuries, including unstable spine injuries.

There are many questions remaining to be answered regarding the optimization of SSRF. Technical details including how many and which rib fractures to stabilize, the utility of absorbable plates, the feasibility of minimally invasive SSRF, the variety of indications that are acceptable, and the optimal timing of SSRF are still not settled.15

My congratulations to the authors of these 4 forward-looking reports.

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REFERENCES

1. Haasler G. Open fixation of flail chest after blunt trauma. Ann Thorac Surg. 1990;49:993–995.
2. Gasparri MG, Tisol WB, Haasler GB. Rib stabilization: lessons learned. Eur J Trauma Emerg Surg. 2010;36:435–440.
3. Thomas A, Blaisdell W, Schlobohm R. Operative stabilization for flail chest after blunt trauma. J Thorac Cardiovasc Surg. 1978;75:793–801.
4. Mayberry JC, Kroeker AD, Ham LB, et al. Long-term morbidity, pain, and disability after repair of severe chest wall injuries. Am Surg. 2009;75:389–394.
5. Landercasper J, Cogbill TH, Lindesmith LA. Long-term disability after flail chest injury. J Trauma. 1984;24:410–414.
6. Mouton W, Lardinois D, Furrer M, et al. Follow-up of patients with operative stabilization of a flail chest. Thorac Cardiovasc Surgeon. 1997;45:242–244.
7. Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg. 1995;110:1676–1680.
8. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization or internal pneumatic stabilization? A randomized study of management of severe flail chest patients. J Trauma. 2002;52:727–732.
9. Voggenreiter G, Neudeck F, Aufmkolk M, et al. Operative chest wall stabilization in flail chest—outcomes of patients with and without pulmonary contusion. J Am Coll Surg. 1998;187:130–138.
10. Fokin A, Wycech J, Weisz R, et al. Outcome Analysis of Surgical Stabilization of Rib Fractures in Trauma Patients. J Orthop Trauma. 2018;33:3–8.
11. Insertion of metal rib reinforcements to stabilise a flail chest wall Interventional procedures guidance [IPG361] National Institute for Health and Health Care Excellence. 2010. Available at: http://www.nice.org.uk/guidance/ipg361/evidence. Accessed October 29, 2018.
12. Gerakopoulos E, Walker L, Melling D, et al. Surgical Management of Multiple Rib Fractures Reduces the Hospital Length of Stay and the Mortality Rate in Major Trauma Patients: A Comparative Study in a UK Major Trauma Center. J Orthop Trauma. 2018;33:9–14.
13. Walters S, Craxford S, Russell R, et al. Surgical Stabilization Improves 30-day Mortality in Patients With Traumatic Flail Chest: A Comparative Case Series at a Major Trauma Center. J Orthop Trauma. 2018;33:15–22.
14. Alvi M, Kapurch J, Ivanov D, et al. Does the Coexistence of Multiple Segmental Rib Fractures in Polytrauma Patients Presenting With “Major” Vertebral Fracture Affect Care and Acute Outcomes? J Orthop Trauma. 2018;33:23–30.
15. Chest Wall Injury Society, Research Committee. Available at: https://cwisociety.org/. Accessed October 29, 2018.
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