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Blunt chest trauma SSRF vs Conservative Management. Ongoing trials and best evidence . Francesco Di Chiara Consultant Thoracic Surgeon Oxford University HospitalsRib fractures are still associated with significant morbidity and mortality due to pulmonary complications Compared to multiple rib fractures, flail chest is associated with a worse outcome due to a higher incidence of respiratory compromise and concomitant injuries. A combination of adequate pain control, respiratory assistance, and physiotherapy is considered the gold standard in management of rib fractures. Over the past decades, there has been a growing interest in rib fixation for flail chest and for multiple rib fractures, however, there is no consensus regarding the indication and patient selection for rib fixation. 7/1/20XX Pitch deck title 2 “COMMON GROUND” three or more multiple simple rib fractures of which at least one is dislocated over one shaft width with unbearable pain (visual analog scale (VAS) or numeric rating scale (NRS) > 6). treated with open reduction and internal fixation. pre- and postoperative care equals treatment in the control group. nonoperative treatment, consisting of pain management, bronchodilator inhalers, oxygen support or mechanical ventilation if needed, and pulmonary physical therapy. 7/1/20XX Pitch deck title 3 In trauma surgery, there is increasing scientific evidence that inclusion of observational studies could add value to meta-analyses without decreasing quality of the results. Adding observational studies result in larger sample sizes and might enable the evaluation of small treatment effects, subgroups, and infrequent outcome measures while also providing information about the generalisability of the results. 7/1/20XX Pitch deck title 47/1/20XX Pitch deck title 57/1/20XX Pitch deck title 6 The primary outcome measure was mortality during hospitalization. Secondary outcome measures were H LOS, ICU LOS, DMV, incidence of pneumonia, need for tracheostomy, complications, revision surgery, and implant removal. 7/1/20XX Pitch deck title 7 Mortality Twenty-five studies (n=4826) reported on mortality Rib fixation resulted in a significant reduction of mortality compared to nonoperative treatment with a risk ratio (RR) of 0.41 (95% CI 0.27, 0.61, p<0.001) 7/1/20XX Pitch deck title 8 MORTALITY 7/1/20XX Pitch deck title 9 Hospital Length of stay Hospital stay length of stay Twenty-one studies (n=4770) reported on length of hospital stay. Rib fixation did not result in a significant reduction of HLOS compared to nonoperative treatment with a mean difference of −1.46 days (95% CI −4.31, 1.39, p=0.32, I 2=96%) 7/1/20XX Pitch deck title 10 ICU Length of stay ICU length of stay Twenty-six studies (n=4520) reported on length of ICU stay. Rib fixation resulted in a significant reduction of ILOS compared to nonoperative treatment with a mean difference of −2.0 (95% CI −3.61, −0.38 7/1/20XX Pitch deck title 11 DMV Duration of Mechanical Ventilation Duration of mechanical ventilation Twenty-seven studies (n = 2063) reported on duration of mechanical ventilation Rib fixation resulted in a significant reduction of days on mechanical ventilation compared to nonoperative treatment with a mean difference of −4.01 (95% CI −5.58, −2.45, p<0.001) 7/1/20XX Pitch deck title 127/1/20XX Pitch deck title 13 OBS + RCT META-ANAL YSIS rib fixation for patients with flail chest resulted in lower mortality, shorter ILOS and DMV, lower pneumonia rate, and lower need for tracheostomy Pooled results from RCTs and observational studies were similar for all studied outcome measures although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV Rib fixation significantly improves short-term outcome for patients with flail chest, although the indication and patient subgroup who would benefit most from this treatment remain unclear 7/1/20XX Pitch deck title 147 RCTs involving 538 MRFs patients (260 were treated surgically vs. 278 conservatively. Surgical treatment resulted in: shorter length of hospital stay (WMD -8.48; 95% CI -11.34 to − 5.63; P < 0.001) shorter length of ICU stay (WMD -5.72; 95% CI -7.31 to − 4.13; P < 0.001) shorter duration of mechanical ventilation (WMD -4.93; 95% CI -8.79 to − 1.07; P = 0.01) lower risk of complications including pneumonia (RR 0.40; 95% CI 0.30 to 0.53; P < 0.001) reduced incidence of chest wall deformity (RR 0.07; 95% CI 0.03 to 0.14; P < 0.001). 7/1/20XX 157/1/20XX 16 Risk of bias is inherent in trials that include non-elective poly-trauma patients due to the complex and ever evolving nature of the clinical scenarios 7/1/20XX 17 NON FLAIL Very few studies are available investigating patients with multiple rib fractures without flail chest. In a retrospective study, Qiu et al. performed separate analysis on patients with multiple rib fractures without flail segment and showed good short-term results and an earlier return to ‘normal activity’ after rib fixation 7/1/20XX Pitch deck title 18 NON-FLAIL RCT Multicenter, prospective, controlled, clinical trial (12 centers) comparing SSRF within 72 hours to medical management. Inclusion criteria were ≥ 3 ipsilateral, severely displaced rib fractures without flail chest. The primary outcome was the numeric pain score (NPS) at two week follow up. narcotic consumption, spirometry, pulmonary function tests, pleural space complications (tube thoracostomy or surgery for retained hemothorax or empyema > 24 hours from admission) both overall and respiratory disability-related quality of life (RD-QoL) 7/1/20XX 19 NON-FLAIL RCT 110 subjects were enrolled. At two week follow up, the NPS was significantly lower in the operative, as compared to the non-operative group (2.9 vs. 4.5, p,0.01) RD-QoL was significantly improved (disability score 21 vs. 25, p=0.03). Narcotic consumption also trended towards being lower in the operative, as compared to the non-operative group (0.5 vs. 1.2 narcotic equivalents, p=0.05). During the index admission, pleural space complications were significantly lower in the operative, as compared to the non-operative group (0% vs. 10.2%, p=0.02). 7/1/20XX Pitch deck title 20multicenter randomized controlled trial. Sample size 180. primary outcome measure occurrence of pneumonia within 30 days after trauma. secondary outcome measures need and duration of mechanical ventilation, thoracic pain and analgesics use, (recovery of) pulmonary function, hospital and ICU length of stay, thoracic injury-related and surgery-related complications and mortality, secondary interventions, quality of life, and cost-effectiveness comprising health care consumption and productivity loss. Follow-up visits will be standardized and daily during hospital admission, at 14 days and 1, 3, 6, and 12 month Results expected to be published mid 2022, but probably delayed by covid 7/1/20XX 21 ORIF SITES • Nottingham (CI) • Newcastle • Oxford • Liverpool • Royal London • Swansea • Birmingham • Kings College London • Bristol • Aintree • Cardiff • Plymouth • Hull • Middlesborough • … 15 in total! Queen’s Medical Centre, Nottingham (lead) ORIF:RCT John Radcliffe Hospital, Oxford James Cook University Hospital, SSRF VS CONS Middlesbrough Morriston Hospital, Swansea (restarting MANAGEMENT soon) Royal London Hospital Queen Elizabeth Hospital, Birmingham Derriford Hospital, Plymouth (paused) Aintree University Hospital, Liverpool Bristol Royal Infirmary Southmead Hospital, Bristol King’s College Hospital, London Hull Royal Infirmary Imperial College Healthcare (opening soon) Glenfield Hospital, Leicester (opening soon) 7/1/20XX Pitch deck title 23THE OPERATIVE RIB FIXATION (ORIF) STUDY • A multicentre randomised controlled trial assessing the mortality, quality of life, and cost effectiveness of • operative rib fixation plus supportive management VS • supportive management alone • for patients with multiple rib fractures requiring ventilator support. • Planned Sample Size 532. Planned Study Period 54 months (later extended due to COVID)INCLUSION CRITERIA •Patients will be suitable for inclusion in the study if they present with multiple (3 or more) rib fractures suitable for surgical repair and one or more of the following: •· Clinical flail chest •· Respiratory difficulty requiring respiratory support •· Uncontrollable pain using standard modalities •The ORiF Study aims to establish if operative rib fixation, when given in addition to supportive management, reduces mortality wall trauma. ses quality of life in patients who experience chestEXCLUSION CRITERIA •· Aged under 16 years •· Thoracic injury requiring emergent operative or interventional radiology •· Cannot be operated on within 72 hours as deemed unfit for surgery OUTCOME MEASURES • Patient reported questionnaires/patient reported outcome measures will be sent directly to the patient • Data from the registry (TARN) • From assessments during routine clinical appointments (i.e. radiological imaging). • (EQ-5D) from questionnaires sent directly to patients from the central study team in Oxfordf-life questionnaire • The all-cause mortality data will be collected directly from sites on a monthly basis and cause of death data from sites and available public data. • Patient Reported Outcome Measures (PROMs) At 90 days and again at 6 and 12 months post- randomisation • These questionnaires include: • Patient-reported questions on function • Pain Visual Analogue Scale • EQ-5D-5L · EQ-5D-3L • Health-related resource use • Complications (CRF) and access to medical careCONSIDERATIONS ON ORIF •Team effort - Preconceptions on rib fixation •1: intensivists •2: “believers” vs ”non believers” •3 Logistics: theatre space (trauma, thoracic) •4: consent on ventilated patient •Overall is a great opportunity to contribute to advance knowledge on rib fractures managementRECRUITMENT •Recruitment started at the end of 2018 with 6 centres involved gradual entry by the end of 2019, 70 patients had been enrolled •Progressive build up of momentum and encouraging recruitment rates with 92 patietns buy the end of February 2020 •In March 2020 recruitment was suspended due to COVID, reopened in some centres at the in October 2020, but in others it remained closed until June 2021 • Many more units have joined the study since 2021 Good multimodal analgesia instituted shortly after presentation to a hospital is key; assessment of the severity of pain should guide analgesia and prompt consideration of regional LA techniques. (…) Anaesthetists can expect to become increasingly involved in the management of these patients. (..). A good understanding of the pathophysiology of these important injuries is vital to improve patients’ car. 7/1/20XX Pitch deck title 30 Incentive spirometry (IS)is a clinical therapy often prescribed to reduce postoperative pulmonary complications in abdominal and thoracic surgery patients, though current literature provides little evidence definitively proving or disproving its efficacy. No studies exist on the therapeutic value of IS in patients with rib fractures. However, multiple studies have demonstrated that incentive spirometry volumes may offer diagnostic and prognostic value for assessing the respiratory function of rib fracture patients, thereby allowing clinicians to identify high-risk patients and provide aggressive, multidisciplinary treatment when appropriate. 7/1/20XX 31 Management of rib fractures is a growing problem significant implications in hospital policies requires a multidisciplinary approach Rib fixation improves short-term outcome for patients with flail chest, although the indication and patient subgroup who would benefit most from this treatment remain unclear 7/1/20XX 32GOALS FOR SURGICAL REPAIR OF RIB FRACTURE: •Preserve lung function •Reduce pain • Reduce hospital comorbidity •Improve chest mobility •Increase percentage of return to full employment •Optimize costsPRINCIPLES OF SURGICAL APPROACHES • Minimise impact on chest wall to preserve function • Trauma patients - Non elective surgery •Versatility and knowledge of multiple thoracotomy approaches is fundamental •Prefer a combination of smaller incisions to long complex incisions •Need for a 90 degrees angle for the drill (at least before MIPO). •Protection of internal organs (lung, heart, spleen..)SURGICAL STRATEGY • VATS? • How many ribs should we fix? • When to perform rib fixation? •What technique? • Which surgical approach?SURGICAL STRATEGY: VATS •One retrospective study from 2017 •60% haemothorax were simultaneously eliminated •No authoritative data •My recommendation: always perform VATS, allows haemostasis and lung repairSURGICAL STRATEGY: HOW MANY RIBS? 2 retrospective studies • Index of fixed to broken ribs of 0.5-0.7, depending on personal preference • Not enough evidence to finally answer this question • Complete repair: better TLC after 3 Months • Partial repair: no chest deformities nor additional proceduresSURGICAL STRATEGY: WHEN? •Usually not a life saving procedure following blunt chest trauma •In literature between 3rd and 7th day post accident •No analysis nor evidence to define best moment •? Early days surgery may have higher complications rate due to systemic inflammatory responseSURGICAL STRATEGY: WHAT TECHNIQUE? • wires, claws, plates)ues were used (splints, • No evidence for best technique • basic knowledge about bone (AO principles) • Restoration of anatomy • Stable fracture fixation • Preservation of blood supply • Early mobilisation SURGICAL ANATOMY OF THE CHEST ANTERIOR CHEST WALL Pectoralis major • Largest, most superficial muscle • Two heads – clavicular and sternocostal • Inserts on lateral proximal humerus • Innervation: medial & lateral pectoral nerves • Action: flexion, adduction, medial rotation of arm Pectoralis minor • Runs from anterior ribs 3-5 to coracoid process of scapula •Innervation: medial pectoral nerve • Action: depresses scapulaSURGICAL ANATOMY OF THE CHEST ANTEROLATERAL CHEST WALL External oblique • Originates on 5th-12th ribs • Inserts on anterior iliac crest and linea alba • Acts to flex and rotate thorax • Innervated segmentally (intercostals, iliohypogastric, ilioinguinal n’s)SURGICAL ANATOMY OF THE CHEST LATERAL CHEST WALL Serratus anterior • Originates from 1st-8th (9th) lateral ribs • Inserts on medial border of scapula • scapula protract and stabilize the • Innervated by the long thoracic nerve • Injury = medial scapular wingingSURGICAL ANATOMY OF THE CHEST POSTEROLATERAL CHEST WALL Latissimus dorsi • Originates on spinous processes of T7-L5, iliac crest, inferior angle scapula, thoracolumbar fascia • Inserts on medial intertubercular groove of humerus • Innervated by thoracodorsal nerve • Adducts, extends and internally rotate the arm SURGICAL ANATOMY OF THE CHEST POSTERIOR CHEST WALL Rhomboid major • Originates from spinous processes of T2-T5 • Inserts on medial border of scapula • Innervated by dorsal scapular nerve Rhomboid minor • Originates from C7-T1 • Inserts on medial border of scapula • Innervated by dorsal scapular nerve Both act to retract scapula . Injury = lateral scapular wingingSURGICAL ANATOMY OF THE CHEST POSTERIOR CHEST WALL Trapezius • Originates on spinous processes C7- T12, external occipital protuberance •Inserts on acromion, scapular spine, lateral 1/3 of clavicle •Innervated by spinal accessory nerve •even depress scapulaate, elevate, andPLANNING THE SURGICAL APPROACH •Approach – depends on number and location(s) of fractures •Morbidity of approach – muscle transection vs sparing, extent of incisionSUMMARY ISOLATED HIGH ANTERIOR • If the rib fractures are anterior - 2d to 4 rib • Median incision • Pectoralis lifting • Pros: allows bilateral repair through a single incision, allows evaluation of the sternum +/- fixation • POSITION: SUPINESUMMARY EXTENDED ANTERIOR • If the rib fractures are anterior - 2d to 6 rib • Transpectoralis horizontal incision to fix 2 nd and 3 rib + • Inframammary incision to fix inferior fractures • Pros: minimal muscle damage • Con: does not allow evaluation of the sternum • POSITION: SUPINE WITH ARM OUTSUMMARY ISOLATED LATERAL nd th •If the rib fractures are lateral - 4 to 8 rib •Axillary incision •Pros: versatile, can be extended anteriorly, •POSITION: LATERALSUMMARY EXTENDED LATERAL • Rib fractures on 2 nd and 3 rdlaterally, inverted L- shaped incision with pectoralis lifting and occasionally horizontal muscle incision • Pros: versatile and extendable • Cons: careful preservation of pectoralis vascularisation • POSITION: SEMI LATERAL WITH 45 DEGREE ANGLE AND SURGICAL FIELD EXPOSING ANTERIOR CHESTSUMMARY POSTEROLATERAL HIGH • Rib fractures posterior to 2ndand 3 rd • Considerations: to be able to expose this technique requires lifting the scapula,nal” extensive damage to rhomboid and trapezius. MIPO or probably better not to fix •POSITION: LATERAL WITH “PANCOAST” SURGICAL FIELD SUMMARY POSTEROLATERAL • If the rib fractures are posterolateral 4 to 8 or lower, posterolateral incision • Can be extended anteriorly into axillary and inframammary incision or also can be performed lower to reach 9 or 10 alternatively special through small additional incisions be used • Pros: versatile and extendable • Cons: muscle damage • POSITION: LATERAL MUSCLE SPARING: excellent “on paper,” has limitations in real life application SUMMARY PARASPINAL • Paraspinal rib fractures you might consider fixing them • This isn’t a widespread practice • Strong muscles around that area naturally stabilise them • Thoracic surgeons not routinely trained • Can have wound healing issues • POSITION LATERAL IF SINGLE SIDE OR PRONE IF BILATERALWHERE AND HOW TO INCISE? HOW TO POSITION THE PATIENT? SUPIN SUPINE + ARM LATERA E OUT L PRONEPLANNING SURGICAL APPROACH •Scapula • Upper border T2 • Medial spine T3 • Lower border T7 • Usually 8th rib is just below inferior anglePLANNING SURGICAL APPROACH PLANNING SURGICAL APPROACH ANTERIOR INFRAMAMMARY CREASE • “Realistic” anatomical considerations INFRAMAMMARY CREASE •Anterior aspects of 4 , 5 ,and 6 ribPLANNING SURGICAL APPROACH •Ct david burr Inframmamary with potetntial posterior extension Always start with a small inicision, assess and then extend if needed PLANNING SURGICAL APPROACH AXILLARY INCISION • Used for lateral fractures • Can extend anteriorly into inframammary if needed • Can get up to rib 3 (difficult – rib 4 usual extent!) • Straight along mid-axillary line or oblique or L- shaped incision across mid-axillary line • Protect long thoracic NV bundle! PLANNING SURGICAL APPROACH ANTERIOR • 2ndrib badly fractured antero- medially + 3 rib Pectoralis lifting antero-laterally through median incision or • What incision? horizontal • Prolong axillary? transpectoral incisionPECTORALIS LIFTING AND TRANSPECTORAL INCISION 2 -3 rib nd th 2 to 4 rib Tip: Plan the patient position in order to keep your options open Pectoral lifting through a median incision even combined with a small medial infra-mammary incision can be performed with the patient in prone position and arms along the body. 2ndto 4th rib But if more lateral aspects needs to be exposed i.e. median pectoral lift + infra- mammary + axillary the ideal position is prone with the arm out and a sandbag positioned vertically behind the patient in order to lift the chest.BILATERAL ANTERIOR RIB FRACTURES + STERNAL “GAP” •Ct whitehy PLANNING SURGICAL APPROACH BILATERAL ANTERIOR RIB FRACTURES + STERNAL “GAP” LESSON LEARNED • Stabilise as much as possible  i.e. rib with 4 or more fractures • Be creative and adapt to situationBILATERAL ANTERIOR RIB FRACTURES + STERNAL “GAP”BILATERAL ANTERIOR RIB FRACTURES + STERNAL “GAP” •Ct whitehyNEW ON OLD TRAUMAWHICH APPROACH?WHICH APPROACH? Posterolateral 3d images 1 4 ribPLANNING SURGICAL APPROACH POSTERO-LATERAL APPROACHPOSTEROLATERAL APPROACH Pitfalls: • Tip of the scapula at 8 rib on CT 5 rib but at 5 -6 th rib in lateral position! • “Breaking” the surgical table can misalign rib fracture ends! Usually posterior ribs shift cranially • Pro: very versatile PLANNING SURGICAL APPROACH POSTERO-LATERAL APPROACH • Previous “gold standard” for accessing rib fractures • For posterior, posterolateral, or lateral fractures • Pro: Can extend anteriorly as well – very versatile 4 to 8 rib or lower • Downside: Transection of latissimus, +/- rhomboids, serratusPARASPINAL APPROACH • Vertical incision centred on the posterior fracture line(s) • Choice of line to best fit • Patient prone or semi- pronePLANNING SURGICAL APPROACH PARASPINAL APPROACH •Ct horse SURGICAL APPROACHES MUSCLE SPARING THORACOTOMY • Same indication of incision posterolateral • Muscles mobilisation • Use triangle of auscultation • Trans-muscular windows • Need to tack fascia back down to minimize postop seroma formation • Pro: preservation of function • Con: limited view, challenging drilling angles, lots of “pulling”, occasionally requires 2 assistants, probably better with MIPOSURGICAL APPROACHES MUSCLE SPARING THORACOTOMYADDITIONAL INCISIONSSURGICAL APPROACHES EVOLVING..EXTENSIVE INJURIES, COMBINED PROCEDURES WITH ORTHOPAEDIC SURGEONSALLOGRAFT STERNOCHONDRAL REPLACEMENT AFTER RESECTION OF LARGE STERNAL CHONDROSARCOMA  2009 Lessons learned: • How to use the MatrixRib Synthes system • The surgical approach is the answer to a problem. The solution, the surgeon has to find, that best suits the patient.THANK YOUTitanium MeshAlways Necessary?