Literature Summary and Reference Resource

Operative Rib Fracture Repair Improves Patient Outcomes

and Reduces Hospital Cost

Rib fractures are common, painful, and often lead to serious

complications. 8, 13, 16, 17, 19, 20 Additionally, it has been reported
that 60% of flail chest patients do not return to full-time
employment even at 5 years post injury injury.13 Significant benefits
to operative repair, however, have been suggested. Even so,
many questions regarding treatment persist today:

Do patients actually benefit from rib fracture repair?

Which patients benefit the most?

Is it cost-effective to repair rib fractures?

What is the optimal timing for repairwhen to

intervene, or how long to wait?

Which fractures should be addressed? Should all be

stabilized?

What is the optimal stabilization technique (incision

approach and device choice)?

The multitude of published comparative studies and peer

reviewed papers provide many insights to these questions.
And, while no consensus exists, the standard of care is
beginning to change. The National Institute for Health and Pre- and post-operative
Clinical Excellence in the United Kingdom, for example, now images showing
surgical reduction and
recommends operative repair for flail chest based on the
fixation of flail chest
available evidence of efficacy and safety.15

This report summarizes the current literature for operative

repair of rib fractures, articulates the potential patient and
cost benefits, and, presents basic surgical technique
guidance from literature.

Meta-analysis Results
# of paatients

# of sttudies

y 22 of 11 comparative
Results from a 2013 meta-analysis p studies,, including
g 753 patients,
p , suggest
gg
significant benefits to operative repair compared with nonoperative management of flail chest
injuries.

patients spent 4.8 fewer days in the ICU 261 4

With patients spent 7.5 fewer days on a ventilator 563 8

Operative
Repair: every 3 patients treated prevents one case of pneumonia (number needed to treat) 616 8

every 5 patients treated prevents one mortality (number needed to treat) 582 7

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SUMMARY OF LITERATURE

Benefits of Operative Repair

Results of 13 comparative studies on operative and nonoperative rib fracture repair are compiled and formatted for comparison below.
Study protocols and treatment methods vary per study and may be reviewed individually for a more comprehensive understanding of
the results.

Outcome Author: Year (n=) Operative Nonoperative

Tanaka: 2002 (37) 10.3

Nirula: 2006 (60) 2.0

Marasco: 2013 (46) 3.1 2.0 15.6

ICU Days
y fewer days
Teng 2009 (60)
Teng: 65
6.5

Althausen: 2011 (50) 2.1

Solberg: 2009 (16) 15.6

Teng: 2009 (60) 6.0

Tanaka: 2002 (37) 7.5

Nirula: 2006 (60) 4.7

Ventilator Days 1.2 11.4
Marasco: 2013 ((46)) 1.2 fewer daysy
Althausen: 2011 (50) 5.5

Solberg: 2009 (16) 11.4

Days

Marasco: 2013 (46) 26%

Tanaka: 2002 (37) 53%

Voggenreiter: 1998 (42) 8%

Pneumonia
Karev: 1997 (133) 19% 8 - 53%
fewer cases
Teng: 2009 (60) 30%

Althausen: 2011 (50) 20%

Karev: 1997 (133) 23%

Borrelly: 2005 (236) 24%

Mortality Voggenreiter: 1998 (42) 21% 5 - 24%

fewer cases
Granetzny: 2005 (40) 5%

Kim: 1981 (63) 17%

Days to return Khandelwal: 2011 (118) 27.6

27.6
to activity fewer days

Days

Bhatnagar: 2012 (N/A) $2K

$2K-$14K lower
Cost Tanaka: 2002 (37) $10K
cost
Marasco: 2013 (46) $14K

Khandelwal: 2011 (118) 9.2

Operative
p Group:
p
Pain score of 8-10 at 6.0 Patients
P ti t undergoing
d i operativeti repairi
6.3
time of inclusion reported lower pain levels after 15 days,
Pain 4.5 despite the fact that their pain at time of
Non-op Group:
Pain score of 5-7 at time
inclusion was greater than that of the
of inclusion nonoperative group.9
2.3
1.1

ACUTE Innovations
Indications for Operative Repair Timing for Operative Repair

Potential indications and inclusion criteria for repair as laid out Optimal timing for repair is not well studied and relies on
by Doctors Nirula, Diaz, Trunkey, and Mayberry.199 many patient-specific factors. While no consensus exists, it has
been suggested that patients treated earlier may have better
1. Flailchest
short-term outcomes.1, 5 The following table summarizes
Failure to wean from ventilator
Paradoxical movement visualized during weaning timing for repair reported in recent literature.
No significant brain injury
Author: Year (n=) RepairTiming (days)
2. Reductionofpainanddisability
Painful, moveable rib fractures Karev: 1997 (133) 1
Failure of narcotics or epidural pain catheter V
Voggenreiter:
it 1998 (42) 27
2-7
Minimal associated injuries (AIS < 2)
Tanaka: 2002 (37) 7
3. Chestwalldeformity/defect
Loss of thoracic volume Granetzny: 2005 (40) 1.5
Severely displaced, multiple fractures resulting in
Nirula: 2006 (60) 2.7
permanent deformity, pulmonary hernia, or are impaling
the lung Solberg: 2009 (16) 2
Patient expected to survive other injuries Althausen: 2011 (50) 2.3
4 Symptomatic
4. Symptomaticribfracturenonunion
rib fracture nonunion
Khandelwal: 2011 (118) 12
CT scan evidence of fracture nonunion
Patient reports persistent, symptomatic fracture Bhatnagar: 2012 (N/A) 5
movement Marasco: 2013 (46) 2
5. Thoracotomyforotherindications

RibLoc Rib Fracture Plating System

The ACUTE Innovations RibLoc rib fracture plate is a unique, The U-shaped design of the RibLoc plate aids in placement and
U-shaped titanium implant specifically designed to provide ensures that screws are installed through the thickest portion of the
stable, less-invasive fixation for rib fractures and non-unions. rib while avoiding the neurovascular bundle.20
The RibLoc plating system: RibLoc
Width of
Maintains stability without relying Plate dissection
on screw threads engaging into
RibLoc
bone20 Rib midline screw line
li

Avoids impingement of the neurovascular bundle20 Neurovascular

bundle
Color coded plates, screws, drills, and targeting guides
allow for quick and intuitive installation Anterior
Intercostal
Plate muscles
PerformanceofRibLocversusAnteriorPlating
Anterior plates can
track superiorly inferiorly along
superiorly-inferiorly
LossofStiffness(%)21
15% the rib surface during placement,
10% especially if improperly contoured. This can lead to suboptimal screw
thread engagement and impingement of the neurovascular bundle.
5% p = 0.001
Poor anterior plate tracking is shown in the 3D CT reconstruction
0%
below.4 Rib and plate midlines are highlighted for clarity.
RibLocPlate AnteriorPlate
Using cadaver ribs plated with a small gap, a 4.6 cm
l
long RibLoc
RibL plate
l withi h 4 screws was statistically
i i ll
superior in durability to an anterior plate of over twice
the length and 6 screws after only 50,000 breathing Anterior plate midline
cycles.21 This was evaluated based on stiffness loss, as
shown above. Additionally, the reduced length of the
RibLoc plate may facilitate a less invasive technique.20
Technique Guidance as described in literature

PreoperativePlanning
Chest X-rays, 3D CT reconstruction: locate fractures, plan
incision, assess degree of chest wall deformity11
Patients are placed in the lateral decubitus position.5,5 11 A small, muscle-sparing
incision can be used to
IncisionApproaches repair multiple fractures.
Standard posterolateral thoracotomy, muscle sparing
thoracotomy.5, 25
Multiple small incisions (10-15 cm), with latissimus dorsi
muscle division in line with fibers, expose three rib levels per FracturestoAddress
incision.11 A spinal ring retractor may help manipulate and Highly displaced fractures and/or those that can be identified
hold retraction.
retraction pain 19
as causing pain.
The periosteum should be preserved for blood supply with It may be unnecessary to plate all fractures, but enough
the plate placed over the top.11 stability to support and restore the thoracic contour is
Subscapular fractures may be accessed with retraction5 and needed.11 Others advocate plating all fractures to maximize
by releasing the rhomboid fascia. pain control and thoracic volume.5
Where access is limited, counterincisions may be used for Subscapular rib fractures are often difficult to access and,
drilling and placing screws.5, 25 given the added muscular protection, may generally be left
Manual fracture reduction can be aided from inside the chest, unaddressed.11 In addition, fracture deformity of the upper
space 5
through the pleural space. loss.11
ribs can result in less lung volume loss

Meta-analysis 14, 22 Mortality 3, 6, 7, 10, 22, 27

References Randomized Trial 6, 16, 24 Pneumonia 1, 2, 6, 7, 16, 22, 24, 26, 27
Retrospective or Case-control 1, 3, 6, 7, 9, 10, 18, 23, 26, 27 Return to Activity 8, 9, 12, 13, 17
Publications are cross-referenced Literature Review 11, 15, 19, 20 Cost 2, 16, 24, 26
by subject in the table at right.
ICU and Ventilator Days 1, 6, 12, 16, 18, 22, 23, 24, 26 Technique Guidance 5, 11, 25
1. Althausen PL, Shannon S, Watts C, Thomas K, Bain MA, Coll D, et al. Early surgical 15. NICE: National Institute for Health and Clinical Excellence. Insertion of metal rib
stabilization of flail chest with locked plate fixation. J Orthop Trauma. 2011 reinforcements to stabilise a flail chest wall. 2010 IPG361
Nov;25(11):6417. http://egap.evidence.nhs.uk/IPG361.
2. Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what is the 16. Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective
benefit? J. Am. Coll. Surg. 2012 Aug;215(2):2015. randomized controlled trial of operative rib fixation in traumatic flail chest. J. Am.
3. Borrelly J, Aazami MH. New insights into the pathophysiology of flail segment: the Coll. Surg. 2013 May;216(5):92432.
implications of anterior serratus muscle in parietal failure. Eur J Cardiothorac Surg 17. Mayberry JC, Kroeker AD, Ham LB, Mullins RJ, Trunkey DD. Long-term morbidity,
2005; 28(5):742-749. pain, and disability after repair of severe chest wall injuries. Am Surg. 2009
4. Cook, Katherine. "New System Helps Heal Broken Ribs Faster." Health News. KGW. May;75(5):38994.
Portland, OR, 23 Feb. 2012. Kgw.com. 23 Feb. 2012. Web. 18 June 2013. 18. Nirula R, Allen B, Layman R, Falimirski ME, Somberg LB. Rib fracture stabilization in
5
5. Gasparri MG,
MG Tisol WB,
WB Haasler GB.
GB Rib stabilization: lessons learned.
learned Eur J Trauma patients sustaining blunt chest injuryinjury. Am Surg
Surg. 2006 Apr;72(4):3079
Apr;72(4):307 9.
Emerg Surg 2010; 36:435-440. 19. Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications,
6. Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus technical issues, and future directions. World J Surg. 2009 Jan;33(1):1422.
conservative treatment of flail chest. Evaluation of the pulmonary status. Interact 20. Nirula R, Mayberry JC. Rib fracture fixation: controversies and technical challenges.
Cardiovasc Thorac Surg. 2005 Dec;4(6):5837. Am Surg. 2010 Aug;76(8):793802.
7. Karev DV. Operative management of the flail chest. Wiad. Lek. 1997;50 Suppl 1 Pt 21. Sales JR, Ellis TJ, Gillard J, Liu Q. Chen JC, Ham B, Mayberry JC. Biomechanical testing
2:2058. of a novel, minimally invasive rib fracture plating system. J Trauma 2008; 64:1270
8. Kerr-Valentic MA, Arthur M, Mullins RJ, Pearson TE, Mayberry JC. Rib fracture pain 1274.
and disability: can we do better? J Trauma. 2003 Jun;54(6):10581063; discussion 22. Slobogean GP, MacPherson CA, Sun T, Pelletier M-E, Hameed SM. Surgical fixation
10631064. vs nonoperative management of flail chest: a meta-analysis. J. Am. Coll. Surg. 2013
9. Khandelwal G, Mathur RK, Shukla S, Maheshwari A. A prospective single center Feb;216(2):302311.e1.
study
d to assess the h impact off surgicall stabilization
bl in patients with
h rib
b ffracture. Int J 23. Solberg
lb BD, Moon CN, Nissim AA, Wilson l MT, Margulies
l DR. Treatment off chest
h wallll
Surg. 2011;9(6):47881. implosion injuries without thoracotomy: technique and clinical outcomes. J
10. Kim M, Brutus P, Christides C, et al. Resultats compares du traitement des volets Trauma. 2009 Jul;67(1):813; discussion 13.
thoraciques: stabilization penumatique interne classique, nouvelle modalite de la 24. Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical
ventilation artificielle, agrafage. J Chir 1981; 118(8-9):499-503. stabilization of internal pneumatic stabilization? A prospective randomized study
11. Lafferty PM, Anavian J, Will RE, Cole PA. Operative treatment of chest wall injuries: of management of severe flail chest patients. J Trauma. 2002 Apr;52(4):727732;
indications, technique, and outcomes. J Bone Joint Surg Am. 2011 Jan 5;93(1):97 discussion 732.
110. 25. Taylor BC, French BG, Fowler TT. Surgical Approaches for Rib Fracture Fixation. J
12. Lardinois D, Krueger T, Dusmet M, Ghisletta N, Gugger M, Ris HB. Pulmonary Ortho Trauma. In press April 2013, full text available on-line.
function testing after operative stabilisation of the chest wall for flail chest. Eur J 26. Teng J, Cheng Y, Ni D, Pan R, Cheng Y, Zhu Z, et al. Outcomes of traumatic flail
Cardiothorac Surg. 2001 Sep;20(3):496501.
Sep;20(3):496 501. chest treated by operative fixation versus conservative approach. J Shanghai
13. Landercasper J, Gogbill TH, Lindesmith LA. Long-term disability after flail chest Jiaotong University (Medical Science). 2009;29:14958.
injury. J Trauma 1984; 24(5): 410-414/ 27. Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, Schmit-Neuerburg KP.
14. Leinicke JA, Elmore L, Freeman BD, Colditz GA. Operative management of rib Operative chest wall stabilization in flail chest--outcomes of patients with or
fractures in the setting of flail chest: a systematic review and meta-analysis. Ann without pulmonary contusion. J. Am. Coll. Surg. 1998 Aug;187(2):1308.
Surg 2013; in-press.

For additional information on the RibLoc Rib Fracture Plating System,

contact your local ACUTE Innovations sales representative, or visit: www.acuteinnovations.com