Reoperative Surgical Stabilization of a Painful Nonunited Rib Fracture Using Bone Grafting and a Metal Plate

Abstract

We report a case of a nonunited sixth rib in a patient with multiple rib fractures who underwent internal fixation using a wire and Judet strut 3 times. During the following 3 years, the patient continued to complain of pain and instability. At surgery, a pseudarthrosis between the ends of the sixth rib was excised. A longitudinal gutter crossing the fracture site was fashioned and splinted with an inlay block of cancellous bone grafted from the iliac crest; stabilization was accomplished with a reconstruction plate and screws. The following 2 years of follow-up demonstrated no instability or pain.

Chest Wall Injury Society recommendation for surgical stabilization of nonunited rib fractures to decrease pain, reduce opiate use, and improve patient reported outcomes in patients with rib fracture nonunion after trauma

“…12 Twelve months after the procedure pain medication was no longer required and at 30 months after the procedure bony union was achieved. 12 Weaknesses of this study included recall bias, it was a single patient, and authors did not report objective measures of opioid use or patient-reported outcomes. Finally, in 2009 Anavian et al 13 reported a case of a single patient who was found to have hypertrophic non-union of ribs 6 to 8 and underwent SSNURF 11 months after injury.…”

“…11 However, one patient was found to have "excellent relief; returned to full work 2 months postrepair." 11 The second patient was reported to have "excellent results," was employed, and had 12 published a case report of a 58-year old male who had undergone three prior attempts at SSNURF after a fall with multiple rib fractures. Preoperative visual analog pain scale (VAS) score was eight while the post-operative VAS score was zero.…”

Outcomes After Operative Reconstruction of Symptomatic Rib Nonunions

“…Four case reports and 2 retrospective case series that have also used similar techniques have been described in the literature. 9,10,16–18,38 At final follow-up, all 4 case report patients achieved union, remained pain free, and returned to original activities. In addition to the previous report from our institution, 9 the only other published case series using plate fixation and bone grafting is a study by Hernandez et al 18 These authors performed a retrospective review on 6 patients who had 15 rib nonunions and underwent rib plate fixation with autologous cancellous tibial bone graft.…”

“…8,9,15 To treat the chronic symptoms that develop due to rib nonunion, multiple studies have described fixation with various types of plates, bone grafts, reconstruction with resection, and masquelet for ribs. 9, [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]38,39 Our study details outcomes after rib nonunion reconstruction surgery using a consistent technique of iliac crest bone grafting with plating under compression.…”

“…Reports describing the operative treatment of rib nonunions include a total of 102 patients. [8][9][10][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] These include mostly case reports, with only 6 clinical case series of limited numbers of patients, and authors often describe various mixed operative techniques in the same series. The purpose of this study was to detail the outcomes after rib nonunion reconstruction by a single surgeon using a consistent technique of autogenous graft and plating.…”