Innovated Judet rib plates for treatment of chest wall instabilities (first clinical experience)

Summary

Introduction:
The method of choice in the treatment of flail chest and other unstable injuries of the chest wall is a rib osteosynthesis. Other indications for surgical stabilization of injured chest wall include deformities or defects of the chest wall, dislocated rib fractures with a lung injury, open rib fractures, open defects of the chest wall, impaired healing of rib fractures, and osteosynthesis of dislocated ribs in patients with acute thoracotomy. On the basis of extensive experiences with use of Judet plates for stabilisation of rib fractures, innovated version of the rib plates was designed, in cooperation between Traumatology Centre and Department of Surgery of the University Hospital Královské Vinohrady and 3^rd Faculty of Medicine, Charles University, and the Department of Development of the Medin a.s., Czech Republic Company. These innovated plates were subsequently used in a clinical trial for treatment of injured patients with unstable chest wall.

materials, methods: An innovated rib plate, including appropriate instruments, has been developed and constructed in the course of the last three years. The aims of innovation of the new plates included the following:

1. New technical parameters of the plates - possibility to bend the plates in all directions, construction of new fixation clips.
2. Use of locking screws for plate fixation - adequate and safe fixation in cases when the screws penetrate through both cortical layers of the rib.
3. New Instruments - tongs for holding the plate, for bending and fixation tongs.
4. Fixation of plates to the rib by bending the fixation clips - with minimal compression of intercostal vessels and nerves.

The clinical part of the project of stabilizing flail chest fractures with osteosynthesis using the innovated Judet rib plates began in 2017; the innovated plates were used in six patients.

Results:
The surgical technique using the innovated plates was performed with satisfactory outcomes in six patients with flail chest injuries. Fixation of the plates in combination with anchoring of the fixation clips and the use of cortical locking screws through both cortical parts of the rib is an adequate and safe procedure for osteosynthesis. All patients underwent revision thoracotomy due to retained haemothorax or haematoma in the pleural cavity. Pulmonary contusion was confirmed in all patients. Rib osteosynthesis was performed between the third and sixth day after injury. Postoperative mechanical ventilation lasted between 24 hours and six days. The postoperative course was without complications, with primary healing.

Conclusion:
The innovated technique of rib osteosynthesis in flail chest injuries is one of the conditions for extending this technique of stabilization of serious injuries of the chest wall. This technique of rib osteosynthesis is simple, safe, requiring a short time interval for plate fixation and providing sufficient stabilization. The first clinical experience showed safe performance of rib fixation, with a concomitant possibility to perform revision of the thoracic cavity, with a minimal risk of complications in the postoperative period.

Keywords:
Innovated Judet rib plate, osteosynthesis of rib fractures in patients with unstable chest wall, first clinical experience.

Introduction

Serious injuries of the chest wall are often the cause of life-threatening complications, such as impaired respiration in patients with unstable chest wall, furthermore pneumothorax or haemothorax when the lung is punctured with the fractured rib, and haemothorax caused by injury of an intercostal artery. Significant instability of the chest wall is a part of the clinical picture of flail chest, accompanied with the development of acute respiratory failure. Surgical stabilization of the fracture has been shown effective in the treatment of flail chest [1, 2, 3, 4] and other unstable injuries of the chest wall, and is presently performed as rib osteosynthesis. Indications for rib osteosynthesis include, apart from the already mentioned flail chest, also chest deformity, defect in the chest wall, dislocated rib fracture with injury of the lung, open rib fracture, impaired healing of rib fracture and dislocated rib fractures in acute thoracotomy due to a post-injury complication in the chest cavity. Recently, a number of techniques and materials for rib fixation have been used, including wires, anatomical splints and plates, intermarrow plates, metallic Judet plates [3, 4, 5] and bioresorbable plates [6]. Based upon previous experience with the use of Judet plates for rib osteosynthesis, the Judet-type rib plate was innovated. This plate was used in injured patients with flail chest injuries.

Patients, materials, methods

During the last three years, innovated rib plates, including appropriate instruments (Fig. 1, 2, 3) were designed and constructed within a project realized in cooperation between the Traumatology Centre and Department of Surgery, University Hospital Královské Vinohrady and 3^rd Faculty of Medicine, Charles University and Department of Development of the Medin a.s., Czech Republic Company. The performed innovations resulted in improved technical parameters of the plates:

1. Sufficient stiffness in the axis of the rib.
2. Stiff, however non-devastating fixation of the plate around the rib, with the use of fixation with locking screws.
3. Decrease in the massiveness of the plate, with sufficient stiffness.
4. Elaboration of new technique of plate fixation to the rib, using the newly designed instruments (Fig. 1, 2, 3). The instruments will enable, apart from maintaining the reduction of the fracture, also subsequent placement of the plate to the rib, with anchoring of the fixation arms to the rib using fixation tongs.

The clinical part of the project of stabilizing flail chest fractures with osteosynthesis using the innovated Judet rib plates began in 2017. The patient file consisted of six patients (Tab. 1) with flail chest injuries, as concomitant injuries in polytraumatized patients with ISS – average of 26.

All operated patients were male, in the age from 34 to 77 years. The indication of osteosynthesis was due to instability and deformity of the chest wall with flail chest or serial rib fracture. In four patients, surgical revision was required also due to retained haemothorax. In the course of preoperative diagnostics, the patients underwent 3-D multidetector computer tomography with evaluation in order to localize the performed osteosynthesis and possible injury complications located in the thoracic cavity (Fig. 4, 5).

The selected surgical procedure corresponded with the expected extent of performed rib osteosynthesis (Tab. 2, Fig. 6, 7, 8, 9), with the possibility of revision of the thoracic cavity and performance of a targeted chest drainage. During the revision of the pleural cavity, retained haemothorax was diagnosed and evacuated in four patients. Rib osteosynthesis was performed three to six days after injury (Fig. 10).

Results

In the postoperative period, the injured patients were hospitalized at the Department of Emergency Admission of the Department of Anaesthesiology and Resuscitation, University Hospital Královské Vinohrady. Mechanical ventilation continued in the patients from the first to the sixth post­operative day, with subsequent respiratory physiotherapy on spontaneous ventilation. Continuation of artificial pulmonary ventilation in the postoperative period was indicated in patients with more extensive pulmonary contusion, or with serious associated injuries (also craniocerebral). Part of the treatment regime was also antimicrobial prophylaxis. In four patients, in whom the antimicrobial treatment was administered already before surgery, the administration of antibiotics continued also after the procedure (penicillin, carbapenems). Chest drainage was removed between the second and fourth day, depending on the amount of collected fluidothorax in 24 hours. During the postoperative period, in the patient listed in Tab. 2 on the last position, with retained haemothorax on the right side, CT examination performed on the seventh day after surgery revealed bordered effusion in the interlobium (Fig. 11), which gradually diminished spontaneously. Other ope­rated patients healed without any complications. No revision surgery for removal of the plates has been scheduled yet.

Discussion

The selection of osteosynthesis of rib fractures is the basic treatment measure in selected indications [2, 4, 5, 7, 8]. The most frequent one is instability of the chest wall, namely in patients with flail chest. In comparison with conservative procedures it has been shown that surgical stabilization of rib fractures presents the best procedure, which improves the treatment results in critically ill patients, also in cases of other serious rib fractures (serial fracture, dislocated rib with injured lung).

The development in the technique of osteosynthesis is targeted, apart from selection of the fixation material, namely at the use of miniinvasive techniques, enabling sufficient stabilization and greater dislocation of the fractured ribs, without the need of extensive incision of muscles of the chest wall [1, 2, 8, 9, 10]. Advantages of the surgical treatment have been repeatedly shown, and include, among others, decreasing pain and patient discomfort, shorter period of mechanical ventilation and associated pulmonary complications, and prevention of fracture healing disorders. Apart from this, also the length of hospitalization at intensive care unit has decreased, thus lowering the costs of patient hospitalization in the hospital. The available metallic rib implants are represented with plates, clips, intramedullary splints, and wire for internal fixation. The most significant advantage of these implants is their excellent mechanical stiffness and stability. Among the disadvantages, it is possible to mention, especially in cases of internal fixation, a high rate of dislocation with the loss of fixation caused with dynamic movement of the chest during breathing. That is why fixing the plate firmly to the rib presents the most safe and most effective technique of stabilization. This includes also a use of plates with multiple fixation possibilities [3, 4, 6, 8, 10]. These facts led to the construction of the innovated Judet rib plates, providing, apart from the possibility to fix the plate to the rib with locking screws, also further anchoring possibilities with fixation arms. The safety of this type of osteosynthesis and its adequate stability following osteosynthesis has been confirmed by first experience in patients with significant instability caused with flail chest fractures. The surgical technique, which is defined preoperatively, on the basis of 3-D MDCT images of the rib fractures, is an acceptable procedure when performed by a trauma surgeon with appropriate knowledge of thoracic surgery, in order to restore not only the stability of the chest wall but also treat associated complications of the injury in the thoracic cavity (retained haemothorax, laceration of pulmonary parenchyma). This trend has been confirmed in the last decades, when the quality of plates and fixation screws improved with the use of anatomical and angularly stable plates. The experience with the use of bioresorbable plates made from poly-L-lactide and hydroxyapatite or polycaprolactone mean further development and advancements in the used material [6, 11].

Conclusion

The innovated technique of rib osteosynthesis in patients with flail chest fractures is one of the preconditions for further use of this technique of stabilization of serious injuries of the thoracic wall. This technique of rib osteosynthesis is simple, safe, with a short time interval required for plate fixation and sufficient stabilization. First clinical experience has confirmed safe performance of rib fixation, with concomitant possibility of performing a revision of the thoracic cavity and minimal risk of complications in the post-operative period.

Ass. Prof. František Vyhnánek, MD, CSc.

vyhnanek@fnkv.cz