Surgical stabilization of severe flail chest with Judet and Sanchez-Lloret plates. A case report

CASE

REPORT

–

OPEN

ACCESS

InternationalJournalofSurgeryCaseReports81(2021)105805

ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

Surgical

stabilization

of

severe

flail

chest

with

Judet

and

Sanchez-Lloret

plates.

A

case

report

Alessandro

Stefani

_,

_Francesco

_Tormen

_,

_Adriana

_Scamporlino

_,

_Pamela

_Natali

_,

Giorgio

Cavallesco

_,

_Uliano

_Morandi

a_{DivisionofThoracicSurgery,UniversityofModenaandReggioEmilia,Modena,Italy}

b_{ClinicalandExperimentalMedicinePhDProgram,UniversityofModenaandReggioEmilia,Modena,Italy} c_{DivisionofThoracicSurgery,UniversityofFerrara,Ferrara,Italy}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received5March2021 Accepted18March2021 Availableonline22March2021

Keywords: Thoracictrauma Flailchest Surgery Casereport

a

b

s

t

r

a

c

t

INTRODUCTION:Flailchestisnowusuallytreatedbyconservativemethodsandsurgicalfixationremains

indicatedinselectedcases.Differenttechniquescanbeusedforfixation.Theaimofthispaperisto

presentacaseinwhichJudetandSanchez-Loretplateswereemployedandtodiscusstheusefulnessof

thistraditionaltechnique.

PRESENTATIONOFCASE:A79-year-oldwomanwasadmittedforleftthoracictraumawithsevere

antero-lateralflailchest.ShewasaffectedbyCOPDwithchronicrespiratoryfailure,ischemicheartdisease,

autoimmunethrombocytopeniatreatedonchronicsteroidtherapyandsevereosteoporosis.CT-scan

detectedmultipleribfractures,lefthemothoraxandlungcontusions.Aninitialconservativetreatment

offlailchestinvolvedcompressivebandageandtheninternalpneumaticstabilizationinICU,butitfailed.

Thepatientunderwentsuccessfulsurgicaltreatmentoftheflailchestbyfixationoftheanteriorfractures

fromthesecondtotheeightrib.JudetandSanchez-Lloretplateswereused.Abilateralpneumonia

developedduringtherehabilitationperiodandthepatientdiedtwomonthsafteroperation.

DISCUSSION:JudetandSanchez-Lloretplatesrepresentatraditionaltechniqueforfixationofflailchest.

Thistechniqueislessandlessusedandprogressivelyreplacedbynewermaterials,especiallytitanium

plateswithscrewsorintramedullarystruts.Ourpatienthadmultiplecomorbiditiesandaveryfragile

bonesthatadvisedagainstuseofscrewsorintramedullarystruts.

CONCLUSION:JudetandSanchez-Lloretplatescanbestillconsideredausefultoolforthefixationofflail

chestincasesofthinandfragilebones.

©2021TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen

accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Flailchest(FC)isdefinedasasegmentofthechestwallmoving paradoxicallywithrespecttotherestofthechestwallduring res-piration,resultingfrommultiplebifocalfracturesoftheribs.FCcan bealife-threateningcondition,leadingtoacuterespiratorydistress syndrome[1].SurgicalfixationofFChasnevergainedwidespread acceptanceandthemanagementofFChasgraduallychangedover theyears,asaconsequenceoftheimprovementinventilatoryand intensivecaretechniques.Therefore,themainstayofFCtreatment hasshiftedfromsurgicalstabilizationtowardsmoreconservative methods[2,3].However,thereareevidencessuggestingthat

surgi-∗ Correspondingauthorat:DivisionofThoracicSurgery,UniversityofModena andReggioEmilia,ViadelPozzo71,41120,Modena,Italy.

E-mailaddresses:Alessandro.stefani@unimore.it(A.Stefani),

tormen.francesco@gmail.com(F.Tormen),adrianascamporlino@gmail.com

(A.Scamporlino),natali.pamela@aou.mo.it(P.Natali),cgg@unife.it(G.Cavallesco),

uliano.morandi@unimore.it(U.Morandi).

caltreatmentremainsthebestoptionforFCinselectedcases[4–7]. Thesearethecasesinwhichtherespiratorydistressismainlydue totheparadoxicalmovementsofthechestwall,andthepatient cannotbeweanedfromthemechanicalventilation[8].

Theaimofthesurgicaltreatmentistheresolutionofthe para-doxicalmovementofchestwallthroughribfixation.Awidevariety oftechniqueshasbeenreportedand severaldifferentmaterials havebeenused,suchasplates,barswithorwithoutscrews,struts, wiresandsplints[9–13].Inthispaperwedescribeacaseofasevere FC,inaseverely-illpatient,successfullyfixedwithJudetplates(JP) andSanchez-Lloretplates(SLP).Theaimofthisreportistoshow thatthistraditionaltechnique,farfrombeingconsideredobsolete, remainsasimple,safeandeffectivemethodforFCstabilization.

ThisworkhasbeenperformedinlinewithSCAREcriteria[14].

2. Casepresentation

A79-year-oldwomanwasadmittedtotheEmergency Depart-mentforabluntthoracictraumafromanaccidentalfall.Shewasa

https://doi.org/10.1016/j.ijscr.2021.105805

2210-2612/©2021TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

CASE

REPORT

–

OPEN

ACCESS

A.Stefani,F.Tormen,A.Scamporlinoetal. InternationalJournalofSurgeryCaseReports81(2021)105805

Fig.1.Three-dimensionalCT-scanreconstructionsshowingmultipledoubleortripleribfracturesfromthesecondtotheeightrib,withcrushingoftheanterolateralchest wall,andsinglefracturesoftheninthandtenthrib.

formerheavysmokeraffectedbyCOPDonchronicrespiratory fail-ure,treatedwithlong-termoxygentherapy.Shewasalsoaffected bymildrenalfailure,ischemicheartdisease,autoimmune throm-bocytopenia treated withlong-term steroidtherapy and severe osteoporosis.Onphysicalexamination,asevereleftanterolateral FCwaspresent.Chestx-raysdetectedmultipleribfracturesonthe leftside,fromthesecondtothetenthrib.CT-scandetectedaleft hemothoraxandmultiplelungcontusionsandpreciselyidentified thesiteand thenumber ofribfractures(Fig.1a,b,c).The emer-gencytreatmentrequiredaclosed-tubethoracostomy,allowingthe evacuationof1300ccofblood,andbloodtransfusion.Thepatient wastransferredinourUnitandtheFCwasinitiallytreatedwith aconservativeapproachbyexternalstabilizationwitha compres-sivebandage.Aprogressiveimpairmentoftherespiratoryfunction wasobservedduringthefirstweek,requiringadmissiontotheICU. Aftertwodaysofnon-invasiveventilationthepatientwas intu-bated.BecausetheFCwasstillunstable,atreatmentwithinternal pneumaticstabilizationwasstartedandcontinuedfortwoweeks. Duringthistime,pulmonarycontusionsprogressivelydisappeared, atelectasiswassuccessfullytreatedwithrepeatedbronchial aspi-rations and a tracheostomywas performed.However,repeated attemptstoweanthepatientfromtheventilatorysupportfailed, duetothepersistentsevereinstabilityoftheleftchestwall. There-fore,thepatientunderwentsurgicalfixationoftheFC,onemonth afterthehospitaladmission.

Ananterolateralthoracotomywasperformedalongthefourth intercostal space. The serratus anterior muscle insertions were dividedfromthesecondtotheseventhrib;a shortsegment of theanterioraspectoflatissimusdorsiandofthelateralaspectof pectoralismajorweresectioned.Thepleuralcavitywasentered throughthefifthintercostalspaceandexploredthrougha thoraco-scope.Six-hundredmloffluidandaresidualclottedhemothorax wereevacuated.Nootherlesionswerefound.Twopleuraldrains werepositionedbeforestartingthecostalstabilizationAllthe ante-riorfractureswerefixed,fromthesecondtotheeighthrib.The ribs wereexposed, in orderto obtaina goodplacement of the metalplates;thedissectionwasperformedonlyinthesiteofthe fracture,preservingtheintegrityoftherestoftheintercostal mus-cle.Thedislocatedsegmentsweremanuallyreduced.Thedouble anteriorfracturesofthesecondandfourthribwerefixedwitha SLP(oneforeachrib),whilethesingleanteriorfracturesofthe third, fifth,sixthandseventhribswerefixedwithaJP(onefor eachrib).Toreachtheanteriorfractureoftheeighthribasecond shortincisionwasneeded,caudallytothethoracotomy,andthe fracturewasfixedwithaJP.Oncethemetalplateswereplaced, theywerereinforcedwithaheavynon-absorbablesutureateach anchoringsite(Fig.2).Chestwallwasclosedinlayers,anda com-pressive bandage wasapplied.The operationtimewas90 min.

Fig.2. Intra-operativepicturesattheendoofthefixation,showingthemetallic platesinplace:twoSLPonthesecondandfourthribandsixJPonthethird,fifth, sixth,seventhandeightrib.Thesuturesaroundtheplatesarealsovisible,twofor eachplate.

Postoperativechest-x-rayshowedthecorrectpositioningofthe plates(Fig.3).Mechanicalventilationwascontinuedforthreedays andthenweaningwasstarted.Theweaningwascompletedintwo weeksandthepatientwassupportedthroughnon-invasive ven-tilationforsevendaysmore.Noparadoxicalmovementoftheleft chestwallwasobservedduringspontaneousrespirationandthe chestwalladequatelyexpanded.ThepatientlefttheICU49days aftertheadmissionand wassent toaninpatient rehabilitation facility.Arespiratorysupportwithahigh-flownasalcannulawas initiallynecessary,thenthesupportwasshiftedtoconventional oxygentherapy,similartothatpreviouslyrequiredbythepatient. Unfortunately,anunexpectedbilateralpneumoniadeveloped dur-ingrecovery,witharapiddeteriorationoftherespiratoryfunction. ThepatientwasreadmittedtotheICUanddied6daysafter,thatis 3monthsafterthetrauma.

3. Discussion

Currently,it iscommonfor patientswithFCtobemanaged withnon-surgicalmethods,suchasconservativemethods (exter-nalcompressive bandage of the chest, pain control, aggressive pulmonary physiotherapy,non-invasive ventilation) or internal

CASE

REPORT

–

OPEN

ACCESS

A.Stefani,F.Tormen,A.Scamporlinoetal. InternationalJournalofSurgeryCaseReports81(2021)105805

Fig.3. Post-operativechestroentgenogramshowingtheleftchestarmormadeofmetallicplates.

pneumatic stabilizationthroughinvasivemechanicalventilation [8,15].Althoughsurgicalfixationofflailsegmentshasnevergained widespreadacceptance,thereisnowevidencethatitmaybe indi-catedinselectedcases[4–6].Arecentmeta-analysisbyApampa andcolleaguesincludedfourrandomizedcontrolledtrialsof surgi-calversusnon-surgicaltreatment[7]:lowermortality,lowerrisk ofpneumonia,reducedneedoftracheostomyanddecreased dura-tionofmechanicalventilationandICUstaywerefoundasaresultof fixation,comparedtonon-surgicaltreatment.However,although thepublishedliteratureonsurgicalfixationhasbeenrapidly grow-ing,thistechniqueremainsunfamiliartomostsurgeonsanditnow seemstobeunderutilized[16,17].

Itisgenerallyacceptedthatsurgicalfixationmaybeindicatedin patientspresentingwithanacuterespiratorydistresswhichneeds aventilatorsupport,providedthatsuchaclinicalconditionis def-initelysustainedbytheparadoxicalmovementsoftheFC[8].In thiscase,oncetherespiratoryandhemodynamicconditionsofthe patienthavebeenstabilized,theoperationshouldnotbedelayed. Ifotherlunginjuriesorclinicalconditionssignificantlycontribute

totherespiratorydistress(i.e.pulmonarycontusions)and/ortothe needofmechanicalventilation(i.e.cerebrallesions),aconservative treatmentshouldbepreferred[18].Thesurgicaltreatmentshould beconsideredafterallothertraumaticlesionshavedisappeared buttheFCremainsunstableanditisidentifiedastheonlypossible causeofapersistentrespiratorydistress,intheabsenceofother clinicalconditionscontraindicatinganoperation.Ourcasebelongs tothissecondclinicalscenario.Theoperationwasdelayedforafew daysbecauseofseveralco-morbiditiesofthepatient.Moreover, thesevereosteoporosisandlong-termsteroidtherapycouldhave madethefixationtroublesomeorevenineffective.Thishigh oper-ativeriskledustoanextremeattempttoweanthepatientfrom themechanicalventilation,beforeproposingsurgicalintervention. Manydifferenttechniqueshavebeendescribedforribfixation, eitherintramedullaryorexternaltothefracturedbones.Usually, notallthefracturesofaFCrequirefixationtoachievestabilization [7].Inourpatientthefixationoftheanteriorfractureswas ade-quatetostabilizetheFC.Agreatvarietyofmaterialsforfixation hasbeenproposed.Judetplates(forsimplefractures)and

CASE

REPORT

–

OPEN

ACCESS

A.Stefani,F.Tormen,A.Scamporlinoetal. InternationalJournalofSurgeryCaseReports81(2021)105805

Lloretplates(forcomminutedfractures)havebeenusedinthepast [9,13,19],butcurrentlytheyaremuchlessemployedandreplaced bynewermaterials,suchascontouredtitaniumplatesfixedtothe ribswithscrewsorintramedullarysplints[12].Butourpatientwas oldandonlong-termsteroidtherapyandshewasaffectedbysevere osteoporosis.Ribswerethinandextremelyfragile.Screwswould nothaveprobablyheldonandintramedullarysplintswouldhave brokenthebonefromtheinside.ThisiswhywedecidedtouseJP andSLP.Theplateswereplacedoverthefracturelineand,by grad-uallybendingthelateralhooks,theyprogressivelygraspedtherib andwerefirmlyanchoredtothebone.Thus,inthiscomplexcase,JP andSLPprovidedasimple,quickandeffectivefixationoffractured ribswithoutfurtherfracturingordamagingthebone.

4. Conclusions

SeveraldifferentmaterialsareavailableforribfixationofaFC. Atpresenttitaniumplatessecuredwithscrewsrepresentthe pre-ferredtechnique,whileJPandSLParelessandlessused.However, thetraditionaltechniqueusingthis typeofmaterialcanstillbe useful,especiallyincasesofthinandfragilebone.

DeclarationofCompetingInterest

Theauthorsreportnodeclarationsofinterest.

Sourcesoffunding

Thisresearchdidnotreceiveanyspecificgrantfromfunding agenciesinthepublic,commercial,ornot-for-profitsectors.

Ethicalapproval

Ethicalboardapprovalisnotrequiredforasinglecasereportin ourCenter.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontribution

FrancescoTormenandPamelaNatalicollecteddata.

AlessandroStefaniandFrancescoTormenwrotethemanuscript. AdrianaScamporlino,GiorgioCavallescoandUliano Morandi revisedandapprovedthemanuscript.

Registrationofresearchstudies

Notapplicable.

Guarantor

AlessandroStefaniistheguarantorofthisstudy.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

References

[1]B.T.Flagel,F.A.Luchette,R.L.Reed,T.J.Esposito,K.A.Davis,J.M.Santaniello,

etal.,Half-a-dozenribs:thebreakpointformortality,Surgery138(2005)

717–723.

[2]G.C.Clark,W.P.Schecter,D.D.Trunkey,Variablesaffectingoutcomeinblunt

chesttrauma:flailchestvspulmonarycontusion,J.Trauma28(1988)298.

[3]M.Freedland,R.F.Wilson,J.S.Bender,M.A.Levison,Themanagementofflail

chestinjury:factorsaffectingoutcome,J.Trauma30(December(12))(1990)

1460–1468.

[4]A.J.M.Cataneo,D.C.Cataneo,F.H.S.DeOliveira,K.A.Arruda,R.ElDib,P.E.De

OliveiraCarvalho,Surgicalversusnonsurgicalinterventionsforflailchest,

CochraneDatabaseSyst.Rev.29(2015),CD009919.

[5]R.B.Beks,J.Peek,M.B.deJong,K.J.P.Wessem,C.F.Oner,F.Hietbrink,etal.,

Fixationofflailchestormultipleribfractures:currentevidenceandhowto

proceed.Asystematicreviewandmeta-analysis,Eur.J.TraumaEmerg.Surg.

45(2019)631–644.

[6]J.A.Leinicke,L.Elmore,B.D.Freeman,G.A.Colditz,Operativemanagementof

ribfracturesinthesettingofflailchest:asystematicreviewand

meta-analysis,Ann.Surg.258(2013)914–921.

[7]A.A.Apampa,A.Ali,B.Kadir,Z.Ahmed,Safetyandeffectivenessofsurgical fixationversusnon-surgicalmethodsforthetreatmentofflailchestinadult populations:asystematicreviewandmeta-analysis,Eur.J.TraumaEmerg. Surg.(2021),http://dx.doi.org/10.1007/s00068-021-01606-2,published online6Feb2021.

[8]H.Pan,S.B.Johnson,Bluntandpenetratinginjuriesofthechestwall,pleura,

diaphragm,andlungs,in:J.LoCiceroIII,R.H.Feins,Y.L.Colsono,G.Rocco

(Eds.),Shield’sGeneralThoracicSurgery,8thedition,WoltersKluver,2018,

chapter110.

[9]R.Judet,Costalosteosynthesis,Rev.Chir.Orthop.ReparatriceAppar.Mot.59

(Suppl.1)(1973)334–335.

[10]J.Borrelly,G.Grosdidier,B.Wack,Surgicaltreatmentofflailchestbysliding

staples,Rev.Chir.Orthop.ReparatriceAppar.Mot.71(1985)241–250.

[11]R.J.Landreneau,J.M.HinsonJr.,S.R.Hazelrigg,J.A.Johnson,T.M.Boley,J.J.

Curtis,Strutfixationofanextensiveflailchest,Ann.Thorac.Surg.51(1991)

473–475.

[12]M.Bottlang,W.B.Long,D.Phelan,D.Fielder,S.M.Madey,Surgical

stabilizationofflailchestinjurieswithMatrixRIBimplants:aprospective

observationalstudy,Injury,Int.J.CareInjured44(2013)232–238.

[13]H.Tanaka,T.Yukioka,Y.Yamaguti,S.Shimizu,H.Goto,H.Matsuda,etal.,

Surgicalstabilizationorinternalpneumaticstabilization?Aprospective

randomizedstudyofmanagementofsevereflailchestpatients,J.Trauma52

(2002)727–732.

[14]R.A.Agha,M.R.Borrelli,R.Farwana,K.Koshy,A.Fowler,D.P.Orgill,Forthe

SCAREGroup,TheSCARE2018statement:updatingconsensusSurgicalCAse

REport(SCARE)guidelines,Int.J.Surg.60(2018)132–136.

[15]N.Dehghan,C.deMestral,M.D.McKee,etal.,Flailchestinjuries:areviewof

outcomesandtreatmentpracticesfromtheNationalTraumaDataBank,J.

TraumaAcuteCareSurg.76(2014)462–468.

[16]J.C.Mayberry,L.B.Ham,P.H.Schipper,etal.,SurveyedopinionofAmerican

trauma,orthopedic,andthoracicsurgeonsonribandsternalfracturerepair,J.

Trauma66(2009)875–879.

[17]J.D.Richardson,G.A.Franklin,S.Heffley,etal.,Operativefixationofchestwall

fractures:anunderusedprocedure?Am.Surg.73(2007)591–597.

[18]B.L.Pettiford,J.D.Luketich,R.J.Landreneau,Themanagementofflailchest,

Thorac.Surg.Clin.17(2007)25–33.

[19]D.DiFabio,D.Benetti,M.Benvenuti,G.Mombelloni,Surgicalstabilizationof

post-traumaticflailchest.Ourexperiencewith116casestreated,Minerva

Chir.50(March)(1995)227–233.

OpenAccess

ThisarticleispublishedOpenAccessatsciencedirect.com.ItisdistributedundertheIJSCRSupplementaltermsandconditions,which permitsunrestrictednoncommercialuse,distribution,andreproductioninanymedium,providedtheoriginalauthorsandsourceare credited.