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Study finds locked plate fixation preferred option for flail chest
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Patients with a flail chest scored higher on every single variable when treated surgically with locked plate fixation as opposed to nonoperative care, according to a pilot study of 22 patients.
Flail chest was defined as four or more ribs fractured at more than two sites.
“We were surprised how much better patients did with operative treatment,” said lead study author Peter L. Althausen, MD. “In fact, if we did not treat these patients with this technique, we would probably consider care to be substandard.”
The current standard of care is continuous epidural anesthesia, pain medicine and respiratory support (intubation).
“Patients often experience pulmonary contusions,” Althausen said. “However, without having a stable chest wall, improvement can take a long time, so we’ve been placing metal plates to restore chest stability. This has been incredibly helpful. Patients are on a ventilator for much less time and there are much fewer complications. Patients also do not need to be intubated again.” Moreover, fewer narcotics are prescribed and people can return to work sooner.
In the past, when patients breathed the chest wall would move, causing screws and plates to loosen and float around and trigger complications. “But with locked plates, the screw locks into the plate so it cannot move,” Althausen told Orthopedics Today. “This is the first study on rib fractures where there have been no hardware complications.”
Operative advantages
Findings were presented at the 2010 Annual Meeting of the Orthopaedic Trauma Association, in which the 22 study patients were compared with 28 nonoperatively managed patients. For every parameter, the operative cohort fared better, including a shorter ICU length of stay by almost 2 days; decreased ventilator requirements by nearly 5 days; a shorter hospital stay 11.9 vs. 19.0 days; one-third fewer tracheostomies; fewer cases of pneumonia; and significantly overall lower cost.
Rib fixation takes under an hour and the learning curve is “extremely easy,” Althausen said. The study also demonstrated that the sooner the surgical intervention, the better the outcomes. “In some cases, surgery has been performed within the first few hours of the patient being in the hospital, so the patient never ends up in ICU for intubation,” he said.
Team approach
“Our major philosophy, which is why we have not had major complications, is that this surgery involves entering the chest,” Althausen said. “Therefore, we always perform it in conjunction with one of our general surgery trauma colleagues. We do not believe this is a procedure that should be attempted by an orthopedic surgeon alone.”
A team approach is important, so that the chest specialist can address the lung and potential heart injuries. However, due to reimbursement issues, many general surgeons are now doing rib plating by themselves, without orthopedic assistant “But these surgeons have no training in bone healing and in the placement of fixation, so there are complications,” Althausen said.
Althausen said there are a number of different rib fractures that are not clearly defined as a flail chest, “so the indications for locked plate fixation are expanding. – by Bob Kronemyer
Reference:
- Althausen PL, Coll D, O’Mara T, et al. Surgical stabilization of flail chest with locked plate fixation. Presented at the 2010 Annual Meeting of the Orthopaedic Trauma Association. Oct. 13-16, 2010. Baltimore.
- Peter L. Althausen, MD, can be reached at Reno Orthopaedic Clinic, 555 N. Arlington Ave., Reno, NV 89503; 775-786-3040; e-mail: palthausen@sbcglobal.net.
- Disclosure: Althausen has no relevant financial disclosures.
