Reduced invasive and muscle-sparing operative approaches to the posterolateral chest wall provide an excellent accessibility for the operative stabilization!
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Stabilizing techniques for flail chest injuries are described through wide surgical approaches to the chest wall, especially in the most affected posterior and lateral regions. Severe morbidity due to these invasive approaches needs to be considered due to dissection of the scapular guiding muscles and the risk of injuries to neurovascular bundles. This study discusses possibilities for minimized approaches to the posterior and lateral regions.
Ten fresh-frozen cadavers in lateral decubitus position were observed on both sides. Each surgical arm was kept mobile during the procedure. Approaches were performed following a standard protocol with muscle-sparing incisions starting with 5 cm in length and extending to 10 and 15 cm. The accessible surface comparing the extensions was measured. Visible ribs were counted. In a next step, MatrixRib® Plates were fixed to those ribs to prove the feasibility of rib stabilization through limited approaches.
Combinations of the posterior and lateral minimized approaches allow surgical fixation of 6–9 and 7–11 ribs through 5 and 10 cm incisions, respectively. In the case of an extreme expansion of a rib fracture series, an access extension can be made to 15 cm to be able to adequately supply the entire hemithorax using two approaches.
Extensive invasive surgical approaches to the thoracic wall can be replaced by reduced invasive and muscle-sparing access combinations. A free-moving positioning of the arm and an accurate preoperative plan for minimizing approaches are essential. Minimally invasive plate techniques are very helpful adjuncts.
KeywordsFlail chest Rib fracture Locked plate osteosynthesis Chest wall stabilization Surgical approach MIPO
Minimally invasive plate osteosynthesis
Pi = 3.14159265359
Prior presentation of this study. Parts of this study were previously presented as a poster presentation by the first author AL at the German Congress for Orthopedics and Trauma Surgery in October 2015 (DKOU 2015, Berlin, Germany) and at the 16th European Congress for Trauma and Emergency Surgery in May 2015 (ECTES, Amsterdam, The Netherlands) in an oral talk by the senior author SSD. The surgical technique had been recently shown by the senior author during a webcast of the AO Foundation with a large number of international participants (AOTrauma Webcast: “Rib Fracture Osteosynthesis—Approaches and Management in the Different Sectors of the Chest Wall”, June 7 / 8, 2017, AMTS Muttenz, Switzerland; main presenter: Stefan Schulz-Drost).
Compliance with ethical standards
Conflict of interest
The senior author has a consultant agreement with DePuySynthes and he is an advisory member of the AO TK Thoracic Surgery Expert Group (THEG). The other authors are not involved in any conflict of interest.
No funds were received in connection to this study.
- 3.NICE National Institute for Health and Clinical Excellence. Insertion of metal rib reinforcements to stabilise a flail chest wall. 2010 IPG361. http://egap.evidence.nhs.uk/IPG361.
- 4.Wiese MN, Kawel-Boehm N, Moreno de la Santa P, Al-Shahrabani F, Toffel M, Rosenthal R, Schäfer J, Tamm M, Bremerich J, Lardinois D. Functionall results after chest wall stabilization with a new screwless fixation device. Eur J Cardiothorac Surg 2015;47(5):868–75. https://doi.org/10.1093/ejcts/ezu318.CrossRefPubMedGoogle Scholar
- 5.Pieracci FM, Majercik S, Ali-Osman F, Ang D, Doben A, Edwards JG, French B, Gasparri M, Marasco S, Minshall C, Sarani B, Tisol W, VanBoerum DH, White TW. Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury 2017;48(2):307–21. https://doi.org/10.1016/j.injury.2016.11.026.CrossRefPubMedGoogle Scholar
- 10.Benninger E, Meier C. Minimally invasive lateral plate placement for metadiaphyseal fractures of the humerus and its implications for the distal deltoid insertion- it is not only about the radial nerve. A cadaveric study. Injury 2017;48(3):615–20. https://doi.org/10.1016/j.injury.2017.01.026.CrossRefPubMedGoogle Scholar
- 16.Schulz-Drost S, Krinner S, Langenbach A, Oppel P, Lefering R, Taylor D, Hennig FF, Mauerer A, TraumaRegister DGU. Concomitant sternal fracture in flail chest: an analysis of 21,741 polytrauma patients from the TraumaRegister DGU®. Thorac Cardiovasc Surg 2017. https://doi.org/10.1055/s-0037-1598194.CrossRefPubMedGoogle Scholar
- 17.Schulz-Drost S, Grupp S, Pachowsky M, Oppel P, Krinner S, Mauerer A, Hennig FF, Langenbach A. Stabilization of flail chest injuries: minimized approach techniques to treat the core of instability. Eur J Trauma Emerg Surg. 2017;43(2):169–78. https://doi.org/10.1007/s00068-016-0664-7.CrossRefPubMedGoogle Scholar