Outcome after surgical stabilization of symptomatic rib fracture nonunion: a multicenter retrospective case series

Abstract

Purpose This study aimed to determine the long-term level of pain after surgical treatment of one or more symptomatic rib fracture nonunions. Secondary aims were to evaluate the occurrence of adverse events, satisfaction, and activity resumption. The final aim was to assess the association between pain and the presence of bridging callus at the nonunified fracture. Hypothesized was that thoracic pain would diminish after surgery. Methods This retrospective case series included adults who underwent surgery for a symptomatic rib fracture nonunion from three hospitals. Symptomatic nonunion was defined as persistent pain associated with nonbridging callus of ≥1 rib fractures on a chest CT scan at ≥3 months after the initial injury. Patients completed questionnaires about pain, satisfaction, and activity resumption ≥3 months postoperatively. Results Thirty-six patients (26 men, 10 women), with a median age of 55 (P25–P75 49–62) years and 169 acute rib fractures were included. Nonunion occurred in 98 (58%) fractures of which 70 (71%) were treated surgically. After a median of 11 months (P25–P75 7–21), 13 (36%) patients reported severe pain, in contrast to 26 (72%) preoperatively. Patients who underwent intercostal neurectomy or neurolysis in addition to surgical stabilization less often reported pain reduction. Twenty-six (72%) had postoperative complications, for which 12 (33%) underwent additional surgery, mostly for persistent pain. The majority (n = 27; 75%) was satisfied with their functional recovery. Of patients who had paid work pre-trauma, 65% had resumed working. Conclusion Most patients reported less pain and better daily functioning after surgical stabilization of symptomatic rib fracture nonunions, although causality cannot be proven with this retrospective case series. Additional intercostal nerve treatment was not associated with pain relief. Despite surgery-related complications being common, patient satisfaction was high. Level of evidence: Level V. Study type: Therapeutic.

The evolution of a chest wall injury and reconstruction clinic during a pandemic

“…1 Many of these patients are managed medically, but more extreme cases of pain from the cartilaginous and bony chest wall benefit from surgical management. [2][3][4][5][6][7] Diagnosis and syndromes that can be improved with surgical intervention include acute and chronic rib/sternal fractures, nonunion/malunion rib fractures, slipped rib syndrome, thoracic hernia, thoracoabdominal hernia, and xiphodynia. [2][3][4][5][6]8,9 These disorders are often misdiagnosed and patients may undergo nondiagnostic evaluations and nontherapeutic procedures.…”

“…Musculoskeletal chest pain accounts for 21% to 49% of visits to primary care offices for chest pain 1 . Many of these patients are managed medically, but more extreme cases of pain from the cartilaginous and bony chest wall benefit from surgical management 2–7 . Diagnosis and syndromes that can be improved with surgical intervention include acute and chronic rib/sternal fractures, nonunion/malunion rib fractures, slipped rib syndrome, thoracic hernia, thoracoabdominal hernia, and xiphodynia 2–6,8,9 .…”

“…Several groups have recently published novel approaches and improved outcomes in the management of these diseases 2–6,8 . In the winter of 2019, we sought to develop a chest wall injury and reconstruction clinic (CWIRC) to serve these populations.…”

“…[2][3][4][5][6][7] Diagnosis and syndromes that can be improved with surgical intervention include acute and chronic rib/sternal fractures, nonunion/malunion rib fractures, slipped rib syndrome, thoracic hernia, thoracoabdominal hernia, and xiphodynia. [2][3][4][5][6]8,9 These disorders are often misdiagnosed and patients may undergo nondiagnostic evaluations and nontherapeutic procedures. 5 Even with the correct diagnosis, many of these patients have great difficulty finding physicians comfortable with the surgical management of these disorders.…”

“…Several groups have recently published novel approaches and improved outcomes in the management of these diseases. [2][3][4][5][6]8 In the winter of 2019, we sought to develop a chest wall injury and reconstruction clinic (CWIRC) to serve these populations. In the spring of 2020, the coronavirus disease 2019 (COVID-19) pandemic rapidly changed the landscape for outpatient medicine.…”