1 / 35

Rib Fixation.

Rib Fixation. Alan Sweenie. History. Evidence. Barriers to obtaining more evidence. How it is done. Our experience. Referral process. History . Soranus: - Greek physician from Ephesus. - Described resection of depressed rib #s for pleuritic pain. Pare: - French surgeon in 16 th C.

isaura
Télécharger la présentation

Rib Fixation.

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Rib Fixation. Alan Sweenie.

  2. History. • Evidence. • Barriers to obtaining more evidence. • How it is done. • Our experience. • Referral process.

  3. History. • Soranus: - Greek physician from Ephesus. - Described resection of depressed rib #s for pleuritic pain. • Pare: - French surgeon in 16th C. - Closed reduction for displaced rib #s. - If that failed, advocated open resection of offending fragments.

  4. History. • WW2 Surgeons - resection of fragments that were driven into the pleural cavity or lung parenchyma. • Preventilator era - flail chest anominous diagnosis. Unilateral flail – positioning; bilateral or sternal – external fixation/traction. • Success of IPPV brought investigation of internal fixation to a halt.

  5. Flail Chest. • Anatomically – 4 or more consecutive ribs involved. • Clinically – Identify paradoxical movement with respiration. • Sternal flail – dissociated from hemi-thoraces.

  6. Tanaka et al. • Published in J of Trauma, 2002. • Age over 14, requiring IPPV for flail of >5 ribs. • Excluded if severe TBI, spinal injuries, comorbid problems of heart, chest or kidney disease. • Used Judet struts to fix ribs, within 14d of injury.

  7. Tanaka et al. • Operative (18) v conservative (19). • LOV: 10.8 (3.8) v 18.3 (7.4); p<0.05 • LOS: 16.5 (7.4) v 26.8 (13.2); p<0.05 • %FVC 6/12: 95 v 78; p<0.05 • %FVC 12/12: 96 v 80; p<0.05 • %FT employment at 6/12: 61 v 5; p<0.05

  8. Voggenreiter et al. • J of A C Surgeons, 1998. • Non randomised comparative study. • 1 – surg without contusion (10). LOV 6.5d* • 2 – surg with contusion (10). LOV 30.8d • 3 – cons without cont (18). LOV 26.7d • 4 – cons with cont (4). LOV 29.3d • *P<0.02 when compared to groups 2 and 3.

  9. Voggenreiter et al.

  10. Granetzny et al. • Published 2005. • Randomised 40 pts. Significantly less LOV support, ICU stay and rates of pneumonia in surgical group as compared with non operative. • Visual deformity less and FVC significantly higher at 2 months.

  11. NICE - October 2010. • Ltd in quality; consistently shows efficacy however. • Aim to allow earlier weaning, reduce acute complications, avoid chronic pain issues. • No major safety concerns in context of severe trauma with impaired pulmonary function. • Not with underlying contusions or severe TBI.

  12. NICE - Safety. • 30% mortality rate in those with pulmonary contusions – 2 from massive bleeding, 1 from sepsis. • Persistent pain reported in 6/57 (6/12 FU) and 5/21 (3/12 FU) in published case series.

  13. Other Potential Indications. • Chest wall deformity. • Pain and disability reduction. • Non union. • Thoracotomy for other indication.

  14. Barriers to Furthering Evidence. • Low numbers – requiring multicentre studies and having surgeons experienced enough. • Specific indications not defined – although flail already investigated. • Expense. • Differing techniques.

  15. Kit.

  16. Preparation. • Remove chest drain at least day before operation, if possible. • 3D CT helpful to define rib fractures, extent of displacement and plan surgical approach.

  17. Newcastle Experience. • 37pts with multiple rib fractures or flail chest since 1.8.07. Mean LOS 7.5d • 3 deaths – all in 80s. • Fixation started 4 months ago. • 4 acutes, 1 non union, 1 sternal flail (without complication so far).

  18. Referral process. • Sion Bernard, John Williams, Paul Fearon. • We envisage patients coming to VW ICU at least the day before planned surgery. • Sale AND return.

  19. In Summary. • Reviewed evidence, including NICE guidance. • Potential indications and exclusions. • Seen pretty pictures. • Referral process.

  20. Questions?

More Related