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General Surgery

Hardware Infection from Surgical Stabilization of Rib Fractures is Lower than Previously Reported

Thursday, September 15, 2022
2:00 PM – 2:20 PM East Coast USA Time
Location: JW Grand Ballroom 5-6
Reference 1: References:
1. Bauman ZM, Visenio M, Patel M, Sprigman C, Raposo-Hadley A, Pieper C, Holloway M, Orcutt G, Cemaj S, Evans C, Cantrell E. Comparison of long-term outcomes from rib fractures for patients undergoing both operative and non-operative management: a survey analysis. Eur J Trauma Emerg Surg. 2022 Aug;48(4):3299-3304. doi: 10.1007/s00068-022-01900-7. Epub 2022 Feb 25. PMID: 35212792.
2. Prins JTH, Van Lieshout EMM, Reijnders MRL, Verhofstad MHJ, Wijffels MME. Rib fractures after blunt thoracic trauma in patients with normal versus diminished bone mineral density: a retrospective cohort study. Osteoporos Int. 2020 Feb;31(2):225-231. doi: 10.1007/s00198-019-05219-9. Epub 2019 Dec 11. PMID: 31828365; PMCID: PMC7010612.
3. Lafferty PM, Anavian J, Will RE, Cole PA. Operative treatment of chest wall injuries: indications, technique, and outcomes. J Bone Joint Surg Am. 2011;93:97–110. doi: 10.2106/JBJS.I.00696.
4. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37:975–979. doi: 10.1097/00005373-199412000-00018.
5. Cameron P, Dziukas L, Hadj A, Clark P, Hooper S. Rib fractures in major trauma. Aust N Z J Surg. 1996;66:530–534. doi: 10.1111/j.1445-2197.1996.tb00803.x
6. Flagel BT, Luchette FA, Reed RL, Esposito TJ, Davis KA, Santaniello JM, Gamelli RL. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005;138:717–723. doi: 10.1016/j.surg.2005.07.022.
7. Pieracci FM, Leasia K, Hernandez MC, Kim B, Cantrell E, Bauman Z, Gardner S, Majercik S, White T, Dieffenbaugher S, Eriksson E, Barns M, Benjamin Christie D 3rd, Lasso ET, Schubl S, Sauaia A, Doben AR. Surgical stabilization of rib fractures in octogenarians and beyond-what are the outcomes? J Trauma Acute Care Surg. 2021 Jun 1;90(6):1014-1021. doi: 10.1097/TA.0000000000003140. PMID: 34016925.
8. Swart E, Laratta J, Slobogean G, Mehta S. Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost-Effectiveness Analysis. J Orthop Trauma. 2017;31(2):64–70.
9. Bauman ZM, Grams B, Yanala U, Shostrom V, Waibel B, Evans CH, Cemaj S, Schlitzkus LL. Rib fracture displacement worsens over time. Eur J Trauma Emerg Surg. 2021 Dec;47(6):1965-1970. doi: 10.1007/s00068-020-01353-w. Epub 2020 Mar 27. PMID: 32219487; PMCID: PMC7223740.
10. Cho SH, Sung YM, Kim MS. Missed rib fractures on evaluation of initial chest CT for trauma patients: pattern analysis and diagnostic value of coronal multiplanar reconstruction images with multidetector row CT. Br J Radiol. 2012;85:e845–e850.
11. Stephen Stopenski, Jana Binkley, Sebastian D. Schubl, Zachary M. Bauman. Rib fracture management: A review of surgical stabilization, regional analgesia, and intercostal nerve cryoablation. Surgery in Practice and Science, Volume 10, 2022, 100089. ISSN 2666-2620. https://doi.org/10.1016/j.sipas.2022.100089.
12. Marinovic M, Ivandcic A, Spanjol J, Pina M, Bakota B, Bandalovic A, Cukeljs F. Treatment of hardware infection after osteosynthesis of lower leg using negative pressure wound therapy and transforming powder dressing. Coll Antropol. 2014 Dec;38(4):1233–6.
13. Thiels CA, Aho JM, Naik ND, Zielinski MD, Schiller HJ, Morris DS, Kim BD. Infected hardware after surgical stabilization of rib fractures: Outcomes and management experience. J Trauma Acute Care Surg. 2016 May;80(5):819-23. doi: 10.1097/TA.0000000000001005. PMID: 26891160; PMCID: PMC4840052.
14. Wiese MN, Kawel-Boehm N, Moreno de la Santa P, Al-Shahrabani F, Toffel M, Rosenthal R, Schafer J, Tamm M, Bremerich J, Lardinois D. Functional results after chest wall stabilization with a new screwless fixation device. Eur J Cardiothorac Surg. 2015 May;47(5):868–75. Epub 2014 Sep 4
15. Nirula R, Allen B, Layman R, Falimirski ME, Somberg LB. Rib fracture stabilization in patients sustaining blunt chest injury. Am Surg. 2006 Apr;72(4):307–9.
16. Mayberry JC, Kroeker AD, Ham LB, Mullins RJ, Trunkey DD. Long-term morbidity, pain, and disability after repair of severe chest wall injuries. Am Surg. 2009 May;75(5):389–94.
17. Widmer AF. New developments in diagnosis and treatment of infection in orthopedic implants. Clin Infect Dis. 2001 Sep 1;33(Suppl 2):S94–106.
18. Berbari EF, Hanssen AD, Duffy MC, Steckelberg JM, Ilstrup DM, Harmsen WS, Osmon DR. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis. 1998 Nov;27(5):1247–54.
19. Sperling JW, Kozak TK, Hanssen AD, Cofield RH. Infection after shoulder arthroplasty. Clin Orthop Relat Res. 2001 Jan;(382):206–16.
20. Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med. 2004 Apr 1;350(14):1422–9.
21. Pieracci FM, Rodil M, Stovall R, et al. Surgical stabilization of severe rib fractures. J Trauma Acute Care Surg. 2015:78(4);883-887.
22. Bauman ZM, Beard R, Cemaj S. When less is more: A minimally invasive intrathoracic approach to surgical stabilization of rib fractures. Trauma Case Rep. 2021;32:100452.
23. Peek J, Beks RB, Hietbrink F, et al. Complications and outcome after rib fixation: a systemic review. J Trauma Acute Care Surg. 2020;89:411-418.
24. Junker MS, Kurjatko A, Hernandez MC, et al. Salvage of rib stabilization hardware with antibiotic beads. Am J Surg. 2019;218:869-875.
25. Prins JTH, Leasia K, Dull MB, et al. Surgical site infection after surgical stabilization of rib fractures: Rare but morbid. Surg Infect. 2022;23(1):5-11.
26. Choi J, Kaghazchi A, Sun Beatrice, et al. Systemic review and meta-analysis of hardware failure in surgical stabilization of rib fractures: Who, what when, where and why? J Surg Res. 2021;268:190-198.
27. Craig J, Fuchs T, Jenks M, et al. Systemic review and meta-analysis of the additional benefit of local prophylactic antibiotic therapy for infection rates in open tibia fractures treated with intramedullary nailing. Int Orthop. 2014;38:1025-1030.
28. McKee MD, Li-Bland EA, Wild LM, Schemitsch EH. A prospective, randomized clinical trial comparing an antibiotic-impregnated bioabsorbable bone substitute with standard antibiotic-impregnated cement beads in the treatment of chronic osteomyelitis and infected nonunion. J Orthop Trauma. 2010;24:483-490.
Reference 2: 0
Reference 3: 0

    Member Speaker(s)

  • Krysta M. Sutyak, DO

    Resident
    University of Nebraska Medical Center
    University of Nebraska Medical Center

    Disclosure(s): No financial relationships to disclose

    Slides
Disclosure(s):
Krysta M. Sutyak, DO: No financial relationships to disclose
Introduction/Purpose:

Surgical stabilization of rib fractures (SSRF) is an emerging therapy for the treatment of patients with traumatic rib fractures.  Despite the demonstrated benefits of SSRF, there remains a paucity of literature regarding the complications from SSRF, especially those related to hardware infection.  Currently, literature quotes hardware infection rates as high as 4%.  We hypothesize that the hardware infection rate is much lower than currently published.

Methods or Case Description: This is an IRB approved, four-year multicenter descriptive review of prospectively collected data from January 2016 - January 2020.  All patients undergoing SSRF were included in the study.  Exclusion criteria included those patients < 18 years of age.  Basic demographics were obtained: age, gender, Injury Severity Score (ISS), Abbreviate Injury Scale-chest (AIS-chest), flail chest (yes/no), delayed SSRF > 2 weeks (yes/no) and number of ribs fixated.  Primary outcome was hardware infection.  Secondary outcomes included mortality rate and hospital length of stay (HLOS).  Basic descriptive statistics were utilized for analysis.

Outcomes:

A total of 238 patients met criteria for inclusion in the study.  Mean age was 58 ± 15.2 years and 70% were male.  Mean ISS was 17.3 ± 8.5 with a mean AIS-chest of 3.2 ± 0.5.  Flail chest (two consecutive ribs with two or more fractures on each rib) accounted for 32% of patients.  26 patients (10.9%) underwent delayed SSRF.  The average number of ribs stabilized was 4 ± 2.8.  When analyzing the primary outcome, only 1 patient (0.4%) developed a hardware infection requiring reoperation to remove the plates.  This patient was a delayed SSRF.  Zero patients in the acute setting developed a hardware infection.  Overall HLOS was 10.5 ± 6.8 days.  Three patients suffered a mortality (1.3%), all three with ISS scores higher than 15 suggesting significant polytrauma.

Conclusion:

This is the largest case series to date examining SSRF hardware infection.  The incidence of SSRF hardware infection is very low ( < 0.5%), much less than quoted in current literature.  Furthermore, in this study, no patient developed hardware infection when the SSRF was completed within two weeks of injury.  This is likely due to advances in the surgical technique through muscle-sparing incisions and minimally invasive SSRF.  Overall, SSRF is a safe procedure with low morbidity and mortality.

Learning Objectives:

  1. Upon completion, participant will be able to discuss the benefits of the surgical stabilization of rib fractures.
  2. Upon completion, participant will be able to understand the risks associated with the surgical stabilization of rib fractures
  3. Upon completion, participant should be able to articulate the risk of hardware infection in the surgical stabilization of rib fractures
  4. Upon completion, participant should be able to discuss treatment options for hardware infection in the surgical stabilization of rib fractures