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THE FALSE RIB JOINT: A LITERATURE REVIEW
Benyan A.S.,
Medvedchikov-Ardiya M.A.
Samara State
Medical University, Seredavin Samara
Regional Clinical Hospital, Samara, Russia
Rib
fractures are the most common injury in closed chest trauma which occur in 40 %
of victims. The presence of fractures, as well as their quantitative and
qualitative characteristics, are markers of the severity of chest trauma, being
associated with injuries of internal organs and determining the prognostic
values of complications and unfavorable outcomes [23]. Multiple rib fractures
with violation of the thorax skeleton and floating rib fractures occur in 7-12 %
of victims and represent the most difficult section of closed chest injury
surgery with mortality rates up to 19-24 % [6, 30].
In
long term period, more than 30 % of patients show late complications and
consequences of closed chest injury - chest deformation, chronic pain, false
rib joint, resulting in abnormal movement of the chest. All these conditions
determine the sharp decrease in working capability and require for change of
kind of activity or lead to disability [16].
The current strategy for the surgical treatment of
multiple and floating rib fractures in the acute period of trauma extends
towards the use of operative methods of internal fixation from sporadic to
routine. The indications for methods of external and internal operative
fixation of ribs and for internal pneumatic stabilization were determined [2]. More
and more preference is given to rib osteosynthesis as a method that provides
instant fixation of fractures and stabilization of the rib-sternum complex as a
whole [20, 27]. Surgical interventions are carried out subject to stabilization
of hemodynamic parameters and the absence of other prognostically unfavorable
injuries of vital organs.
Most specialists are very restrained in determining
the indications for surgical treatment with late complications and the
consequences of the closed chest injury due to the lack of evidence and the
dubious effect of the operation. In this case, only one of the conditions is
considered as a point of application for operative methods of correction - a
pseudocostal joint. The presented review of the literature is devoted to the
study of the current state of the issues of surgical treatment of the false costal
joint.
32 scientific articles in the databases PubMed,
Google Scholar and ScienceDirect were studied and analyzed for the period from
1993 to 2021, which provide data on the epidemiology, clinical picture, as well
as diagnosis of the false costal joint. The time interval of the research
articles is generally determined by a small number of publications on this
topic. The basic principles of surgical treatment of a false costal joint are
reflected, including the use of bone grafts and internal fixation (the table).
Table. Distribution of articles relating to discussed issues and problems
|
Reviewed issues and problems |
Number of articles |
Authors and publication year |
|
Rate of multiple and floating rib fractures after blunt chest trauma |
4 |
J.T.H. Prins
et al (2020) [23], |
|
Surgical treatment of rib fractures |
6 |
M. Bemelman et
al (2016) [2], |
|
Epidemiology and statistics of false rib joint |
9 |
R.L.
Morgan-Jones et al (1996) [19], |
|
Clinical symptoms and diagnosis of false rib joint |
11 |
D.J. Kaplan et al (2017) [14], |
|
Principles of surgical treatment of false rib joint |
13 |
W. Zuidema
(2006) [32], |
|
Outcomes and complications of false rib joint |
7 |
E.M. Gauger et
al (2015) [10], |
Epidemiology, statistics
As for the long-term consequences of severe closed
chest trauma with rib fractures, the most common conditions are the false costal
joint and clinically significant post-traumatic deformities with restrictive
breathing disorders [19]. The incidence of false costal joints is estimated
from 5 to 10 % [3]. The most common cause of the false costal joint is the
closed chest injury with multiple rib fractures. However, the literature also
describes cases of spontaneous rib fractures during exercise, coughing and
sneezing [21, 31]. The development of the pseudarthrosis after a spontaneous
fracture of the first rib, described after heavy physical exertion in athletes,
deserves special attention [9]. The causes of false joints are described and
well known. Nevertheless, in the case of rib fractures, additional predisposing
factors are also the presence of respiratory movements of the chest and the
ineffectiveness of conservative methods of immobilization [14]. Despite the fact
that the formation of a false costal joint can occur regardless of the type of
previous fracture, in most cases, patients in the acute period were diagnosed
with severe closed chest trauma with multiple or floating rib fractures.
Undoubtedly, the prerequisites for the formation of
the false costal joint are not only the features of the fracture itself (multiple
fractures, floating fractures, rib cartilage tears), but also the initial state
of the bone tissue, which in some patients underwent pathological
reconstruction due to age (osteoporosis) or diseases (cystic fibrosis, myeloma)
[14]. Some authors regard the refusal of surgical fixation of rib fractures as
a predisposing factor for the formation of a false costal joint in the long
term [25]. At the same time, some cases of false costal joints have been
described after surgical treatment of multiple and floating rib fractures using
pins for intraosseous fixation [4]. A number of publications deal with the
pathomorphology of the false costal joints, describing such processes as
heterotopic ossification and the formation of costal synostosis with subsequent
transformation into a pseudarthrosis [18].
Clinical picture and diagnostics
The clinical significance of the false costal joint
consists in chronic persisting pain syndrome, which, in its turn, promotes the
development of atelectasis, pneumonia, asthenization due to body weight loss
and good sleep absence, decreasing physical activity and loss of working
capability [14]. Symptomatic false costal joint is characterized by the
presence of intense persistent localized pain syndrome, combined with confirmed
nonunion of one or more ribs on CT more than 3 months after injury [7]. Pain
syndrome is the leading one in the clinical picture in most patients with false
costal joint [1]. In addition to the signs that directly characterize the
presence of a mobile costal joint, the appearance or aggravation of the
symptoms of various pulmonary diseases is often noted. Spontaneous rib
fractures in patients with cystic fibrosis can lead to the development of
exacerbations of the main process and aggravate background respiratory failure
[5].
The program for diagnosing the false costal joint
includes the complete physical examination, clarifying the nature and severity
of a history of chest trauma, as well as evaluating the effectiveness of the
treatment methods used. Of the instrumental diagnostic methods, MSCT and MRI
have the greatest sensitivity and specificity, while MSCT can be considered as
the most accessible and highly accurate method for confirming the presence of
the false costal joint [11].
Basic principles of surgical treatment
Treatment of patients with the false costal joint in
most cases consisted of recommendations for reducing physical activity or tight
bandaging of the chest. Rare attempts at surgical treatment consisted of
resection of the edges of the ribs. The development of implantology and the
emergence of special rib plates with angular stability have opened up new
possibilities in the treatment of this category of patients [32]. The basic
principles of surgical treatment of traumatic and spontaneous rib fractures
leading to the formation of the false costal joint are similar and include
resection of the edges of the ribs, replacement of the defect with the bone
graft, and internal fixation [5]. The time frame for determining the
indications for surgical treatment of the false costal joint has not been
finally determined. Most modern authors believe it expedient to consider the
indications for surgical intervention already 3 months after the primary
injury, but the average time for the operation itself often exceeds 1.2 years
[1, 14]. In some publications, the terms of the operation reach 15 years [8].
In most cases, surgical treatment involves resection
of costal synostosis and fixation of the rib using internal fixation devices,
with preference given to bone osteosynthesis technologies using titanium plates
[18]. One of the first publications on the use of internal operative fixation
for the false costal joint was the article by P. Reber et al., in which the
authors described the successful treatment of a patient with the consequences
of severe closed chest trauma. The main syndrome, chest pain during breathing,
was completely arrested after surgery [24].
Success of surgery for the false joint highly
depends on appropriate planning of a surgical approach, which is also achieved
with 3D reconstruction of bone structures of the chest, and computer
navigation. Minimization of surgical trauma due to adequate planning of the
surgical access allows, while maintaining the convenience of basic
manipulations, to provide a smoother course of the postoperative period [28].
Improvement of rib osteosynthesis systems, the appearance of instruments with
90° arrangement of working parts contributes to the possibility of performing
surgical interventions through mini-accesses. In operations carried out in a
planned manner for long-term consequences, this technology is of particular
importance and can be recommended for use in wide practice [2]. As for the
technique of osteosynthesis and technical characteristics of the plate, most
authors recommend using small projection approaches, which allow resection of
the edges of the false joint and fixation with three screws on each side.
Accordingly, plates with 6-8 holes are sufficient in length [32]. Despite the
fact that in some patients it is sufficient to resect the edges of the false
joint and excision of the scar tissue, in other cases it is necessary to
replace the bone defect and to perform subsequent fixation. The determining
factor is the length of the defect formed after resection [14]. Replacement of
the rib defect after resection of the edges of the false joint using the bone
graft is not only a method of additional stabilization of the “plate-rib”
structure, but also a measure of preventing the formation of a pulmonary hernia
in the long-term postoperative period [13]. With a combination of the false costal
joint and a pulmonary hernia formed as a result of rupture of the intercostal
muscles, in cases where the intercostal space cannot be brought together by the
imposition of pulley sutures and other techniques, the surgical technique, in
addition to the osteosynthesis of the ribs, includes prosthetics of the chest
wall defect using the mesh implant [ 21].
In those cases when the cause of the development of the
false costal joint was the nonunion of fragments against the background of
previously performed intramedullary osteosynthesis, the optimal way is the
removal of the intraosseous implant (wire, pin), resection of the rib edges,
replacement of the defect with a bone graft, fixation using extramedullary
plates and locking screws [4 , 10].
Outcomes and complications
The effectiveness of surgical treatment of false
costal joints is assessed according to 2 main criteria: relief of chronic pain
syndrome and increased physical activity. At the same time, clinical efficiency
significantly outstrips the processes of complete rib repair. The average time
for the repair of synthesized ribs after replacement of a defect with the bone
graft is 14.7 weeks with minimum values up to 12 weeks and maximum periods up
to 24 weeks [10]. The immediate and long-term results of external bone fixation
demonstrate the effectiveness of the method even in patients with
pathologically altered bone tissue, as in the case of cystic fibrosis [5].
In a comparative study, L. Fabricant et al. showed a
decrease in the rate of use and a decrease in the dosage of opiates in operated
patients [8]. Out of 19 operated patients, 13 patients with the false costal
joint fixation demonstrated the complete recovery and relief of symptoms, 2
patients developed new fractures at the plate fixation sites, 3 patients required
repeated surgeries to remove implants [7].
The stability of the structure after resection of
the rib for the false post-traumatic joint and subsequent osteosynthesis is
also evidenced by the observation of J.R. Staggers et al., which described a
case of a repeated chest injury several months after surgery for the
consequences of the closed chest injury. Thus, in a patient who underwent rib
resection and osteosynthesis, rib fractures along the edge of the plate
attachment were diagnosed, while the bone tissue in the plate projection and
the plate itself remained intact [29].
Among complications of surgical treatment of the
false costal joint, the most common ones are wound infectious complications
(deep and superficial) relating to instability of a metal construct due to
migration of locking screws, a fracture of the plate and abnormal fracture of
the bone. The nature of repeated surgical interventions depends on the
integrity of the previously restored rib. If consolidation and repair of the
fracture has occurred, then re-intervention consists in removing the
compromised plates and screws. In those cases when the repair of the damaged
bone was not achieved or new fractures occurred along the lines of fixation of
the implants, during the second operation, it is possible to perform
reosteosynthesis using plates of greater length, different curvature, locking
screws and cerclage sutures [15].
After surgical fixation of rib fractures, bone
nonunion with the development of the false joint was observed in 1.3 % of
patients [22]. In the case of resection of the bony edges of the false costal
joint without subsequent replacement with the bone graft and the use of
absorbable rib plates, there is a risk of postoperative pulmonary hernia
development through a defect in the rib [8].
DISCUSSION
The study of the history and evolution of surgical
interventions for closed chest trauma has always demonstrated greater attention
and emphasis on the elimination of damage to internal organs, while surgical
interventions on the musculoskeletal frame of the chest were performed either
due to the inevitability of thoracotomy, or were not used at all, confining
themselves to drainage of the pleural cavity, conservative and resuscitation
measures [12]. It is obvious that the greatest contribution to the development
of unfavorable outcomes in severe closed chest injury is made by damage to the
lung tissue; however, injury to the bone frame, especially not eliminated in
the acute period of injury, aggravates the severity of the initial injury to
the lung tissue and causes a significantly longer recovery period [17].
The expediency of surgical treatment for fractures
of the posterior segments of the ribs is a subject of discussion at the present
time. Even with floating fractures and multiple fractures with pronounced
displacement of fragments, most authors tend to conservative management,
motivating this approach by the presence of large muscle mass of the
paravertebral muscle group, which provides natural stabilization of the bone
framework. And in patients on artificial lung ventilation, the supine position
also provides some stabilization of the fragments of the posterior segments of
the ribs due to compression by the natural mass of the chest. Nevertheless,
despite these anatomical features, the formation of the false costal joint is
also found in fractures of this localization. It should be noted that
osteosynthesis of the posterior rib segments presents well-known difficulties
due to the large curvature in the rib angle, variable thickness of the bone
tissue, as well as the difficulty of providing a surgical approach that meets
the principles of sufficiency and low trauma [26].
CONCLUSION
Treatment of patients with the false costal joint is the subject of elective thoracic reconstructive surgery. Operative fixation ensures the restoration of rib integrity and demonstrates good functional results. In some cases, a combination of osteosynthesis methods, the use of bone grafts and methods of soft tissue defects prosthetics is required.
Information on funding and conflicts of interest
The study was not sponsored.
The authors declare no obvious and potential
conflicts of interest related to the publication of this article.
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