NEPA Vital Signs - Winter 2019 Spring 2020 - 23

WINTER 2019-2020

only consider patients with flail chest (two or
more consecutive rib fractures in two or more
places). However, current evidenced-based
literature has expanded the consideration of
SSRF to a greater number of patients who
would potentially benefit from undergoing
this procedure. Today, SSRF should be
considered in patients with multiple, severe
(unicortical or bicortical) displaced fractures
with or without a flail segment, in patients
who fail early, optimal non-operative management regardless of radiographic fracture
pattern, patients who are young, active and
working, in patients who are unable to be
liberated from mechanical ventilation, for
patients who have another surgical indication
for thoracic surgery to be repaired on the
way out during closure and for patients with
chronic pain, deformity or potential injury to
adjacent organs, tissues or other structures
which severely effects their quality of life or
limits them to perform their occupations.
If a patient is deemed a candidate for
SSRF, operative planning and timing of
surgery is essential for the best outcomes.
In general, SSRF is technically easier within
72 hours of injury, and published operative
guidelines have advocated repair within
this time window. Once inflammation and
callus formation have initiated, it can be
more difficult to reduce fractures to normal
alignment. Often fractures will displace
further with time; this phenomenon also
may make anatomic reduction more difficult and could possibly lead to more pain,
pulmonary complications and functional
mobility deficits if left untreated.
Selection of ribs for repair involves
consideration of rib number, location of
the fracture on the rib as it relates to surrounding structures (e.g., costal cartilage
anteriorly and transverse process posteriorly), and characterization of the fracture itself
(i.e. degree of displacement, angulation,
and bone loss). Ribs one and two contribute minimally to respiratory mechanics
and exposure can be both challenging and
unduly morbid. Ribs 11 and 12 (known as
the "floating" ribs) likewise are not critical
to respiration and repair likely does not
alter pain levels or respiratory functionality
substantially. Exceptions include markedly
displaced lower ribs that might result in lung

3D model used to prefabricate custom plates for rib fractures and sternal fracture (author in picture utilizing
the Zimmer-Biomet RibFix Blu™ SSRF platform)

or other organ impalement, lung hernia, or
marked chest wall deformity. Theoretically,
repairing all ribs that can be readily accessed
through the index incision will provide
optimal stability, pain reduction, and healing
and currently recommendation to repair all
fractures within the exposure surgical field
is what is practiced at this center.
Utilization of advanced CT imaging helps
the operating trauma surgeon obtain a better
understanding of the underlying pathoanatomic condition. Standard CT imaging is
obtained of the thorax and then is sent for
further post-processing at our advanced 3D
imaging and printing lab. From here, the
surgeon must decide if the patient would
clinically benefit from SSRF. If so, a custom
3D print model is fabricated of the patient's
injuries. Prints can take anywhere from six
to 60 hours depending on the complexity
and size of the model as well as the printer
and its capabilities. Limitations to print
build volume may require parts to be split
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VITAL SIGNS

into separate prints in order to achieve fullscale models. Post-print processing to cure
the models and remove unwanted support
material is also labor intensive and can
take anywhere from one to several hours.
This model then is utilized by the surgeon
to pre-fabricate custom rib plates and
pre-select screws based on that individual
patient's imaging. After the custom plates are
completed, they are numbered with respect
to the injured rib, placed in a specialized
container and sent to the operating room for
standardized sterilization and preparation
for implantation.
Post-operatively, patients usually are
admitted to the ICU for the first 24 hours.
Here aggressive pulmonary toilet, pain control and early mobilization are considered
the keystones to optimal recovery. Chest
tubes that were placed to ensure drainage
of the pleural cavity are often removed
within the first 24-48 hours. Patients are
often transferred to the progressive care

NEPA Vital Signs - Winter 2019 Spring 2020

Table of Contents for the Digital Edition of NEPA Vital Signs - Winter 2019 Spring 2020