Patient demographics and injury characteristics

Average age (years) of patients was 68.5±16 (range 34–98) with 66% being male (table 1). Mechanisms of injuries were: fall (n=17), all-terrain vehicle (ATV) accident (n=2), motorcycle crash (n=1), and assault (n=1) with an average ISS of 14±6, and an average chest abbreviated injury score score of 3.14±0.35. Patients presented with a median of 5 fractured ribs, with an average of 1 rib that was bicortically displaced, and 19% presented with clicking on inspiration. Fifty-two per cent of patients presented with subcutaneous emphysema, 57% of patients had PTX, and 67% of patients had HTX (table 1).

Surgical indications

Surgery was offered to patients with Pieracci/Dobin (P/D) indications. P/D indications include (1) radiographic or clinical flail chest, (2) three or more bicortically displaced fractures, (3) >30% volume loss of a hemithorax, and (4) failure of optimal medical management. Failure of optimal medical management included 4–6 hours or longer with two or more of the following: (1) numeric pain score >5, (2) incentive spirometry <50% predicted, (3) poor cough, and (4) respiratory rate >20.9 SSRF was also performed if rib fractures penetrating parietal pleura was noted during VATS performed for HTX evacuation, continued air leak, further displacement of rib fractures, and failure to wean from respiratory support. Surgical decision was often made within the first 24 hours of hospitalization, but the timing of surgery was dependent on operating room and surgeon availability with a goal of fixation within 48–72 hours of admission.

Sixteen patients (76%) met P/D indications for surgery while five patients did not and presented with the following indications for SSRF: retained HTX with unstable rib fractures, continued air leak, and further displacement of rib fractures (table 2).

Operative technique standardization

Review of operative reports demonstrated that standardization of technique occurred during these 21 operative cases, resulting in a consistent surgical approach. The patient was placed in a lateral decubitus position. Following initiation of single lung ventilation, the first thoracoscopic port site was created, most often at the fifth intercostal space at the anterior axillary line, and CO₂ insufflation commenced to assist in complete lung collapse. Fracture sites were identified through a combination of palpation of areas of instability and visualization of pleura injury.

Based on fracture location, a second thoracic port site (2–3 cm) was placed under direct visualization, inferior to the level of the rib fractures at the midaxillary line, most often at the eighth or ninth intercostal space. This small incision allowed for insertion of the RibFix Advantage plate. Finally, a skin incision was made over the involved ribs and small skin flaps created to reveal the underlying musculature. Port and incision placement is demonstrated in figure 1. In our experience, it was difficult to precisely locate the exact fracture site by palpation and observation alone unless the parietal pleura was disrupted.

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Figure 1

Port and incision placement. (A) First port site at ~fifth intercostal space, anterior axillary line. (B) Second port site at eighth or ninth intercostal space, midaxillary line. (C) Skin incision over fractured ribs to be addressed.

Once the fracture sites were confirmed, the overlying muscle was spread to permit 1 cm of access to the rib on either side of the fracture. Under thoracoscopic visualization, holes were drilled through the bone at these two sites in a freehand fashion (without the set’s clamp-drill guide). An 8 Fr red rubber catheter, with the ends cut at a 45-degree angle, were passed through each hole and out the chest through the caudal thoracic incision. Guidewires attached to the RibFix Advantage plate were then passed into the catheters and out through the drilled holes. The plate was introduced into the chest using the caudal thoracic incision under thoracoscopic visualization, taking attention not to cross wires or snag on anatomical structures.

Reduction of the fracture occurred as the plate was pulled into place. Pulling the wires apart slightly allowed the rib fracture site to distract and reduce as the plate was brought against the rib. The plate was secured with a washer and cap-screw on each of the two posts. After verifying secure fixation and rib stability, the posts are trimmed flush with the postcutter (diagonal cutting pliers). These steps are repeated for each fracture site. The minimal number of ribs to achieve chest wall stabilization were plated. The thoracic cavity was irrigated, an apical chest tube placed through the caudal thoracic incision, and the lung re-inflated under thoracoscopic visualization.

Patient outcomes

Timing of surgery was dependent on operating room and surgeon availability. Mean time from presentation to surgery was 3 days (range 0–7). The mean number of ribs fixated per patient was 2.2 (range 1–5) with a mean operative time of 221.7 min (range 98–397) (table 3).

Patient outcomes were a mean HLOS of 11±3.7 days (range 6–24), mean postoperative LOS of 8 days (range 4–21), and mean ICU LOS of 6.6±2.9 days (range 4–16). Discharge disposition included 43% (n=9) to home, 33% (n=7) to skilled nursing facility, 15% (n=3) to rehab, and 5% (n=1) left against medical advice. One patient died after electing for comfort measures due to underlying metastatic lung cancer.

Five patients in our series were super elderly (aged ≥85 years) who had a mean age of 90.8±4.7 years (range 86–98). This group presented with an average of four rib fractures (table 4). Eighty per cent of this population met P/D indication for surgery. An average of 2.4 ribs were plated (range 2–4). The procedure was well tolerated with an HLOS of 9.4±2 days (range 6–12), and all five patients were discharged to a rehab facility with no in-hospital mortalities.