Load Sharing, not Load Bearing Plates: Lessons Learned from Failure of Rib Fracture Stabilization

摘要

Surgical stabilization of rib fractures (SSRF) is becoming increasingly used for fixation of flail chest and bony reconstruction of the chest wall.1 Although current fixation hardware represents a significant improvement over prior modalities such as initial intramedullary splints and external fixation devices of the chest wall, it is not without limitations.2 Hardware failure has been reported perviously.3 We propose through this clinical case a mechanism of failure secondary to mechanical strain and our recommendations for treatment. Mr. M is a 40-year old longtime smoker. Over the span of several months after initiation of an angio-tensin-converting enzyme inhibitor, he developed chronic pain and clicking in his left chest after multiple episodes of forceful coughing. Evaluation at his local hospital demonstrated fractures of the left seventh, eighth, and ninth ribs. A trial of observation was unsuccessful. Eight months later, CT scan demonstrated a pulmonary hernia. He underwent resection of the pseudoarthroses at the affected ribs with absorbable plate SSRF with suture fixation. He presented to our institution approximately one year from his initial repair with continued pain and clicking sensation in the lower left chest. Repeated CT scan with 3-dimensional reconstruction demonstrated persistent nonunion of the left seventh rib with pseudoarthrosis, a 3 cm defect in the left eighth rib, and a 5.5 cm defect in the left ninth rib, with associated pulmonary herniation. His angio-tensin-converting enzyme inhibitor was changed to a calcium channel blocker with resolution of his cough. Bone mineral density testing revealed mild osteopenia and he was started on Calcium and Vitamin D. The three pseudoarthroses were excised and the pulmonary hernia was reduced and the defect excluded with GORE-TEX? Soft Tissue Patch (W.L. Gore and associates, Newark, DE) and the rib defects were bridged using Synthes MatrixRib? (Synthes Inc., West Chester, PA) titanium plates. Significant bony defects remained in the eighth and ninth rib-plate constructs (Fig. 1).