The Role of Minimally Invasive Plate Osteosynthesis in Rib Fixation: A Review

Abstract

More than a century ago, the first scientific report was published about fracture fixation with plates. During the 1950's, open reduction and plate fixation for fractures were standardized by the founders of Arbeitsgemeinschaft für osteosynthesefragen/Association for the Study of Internal Fixation. Since the introduction of plate fixation for fractures, several plates and screws have been developed, all with their own characteristics. To accomplice more fracture stability, it was thought the bigger the plate, the better. The counter side was a compromised blood supply of the bone, often resulting in bone necrosis and ultimately delayed or non-union. With the search and development of new materials and techniques for fracture fixation, less invasive procedures have become increasingly popular. This resulted in the minimally invasive plate osteosynthesis (MIPO) technique for fracture fixation. With the MIPO technique, procedures could be performed with smaller incisions and thus with less soft tissue damage and a better preserved blood supply. The last 5 years rib fixation has become increasingly popular, rising evidence has become available suggesting that surgical rib fixation improves outcome of patients with a flail chest or isolated rib fractures. Many surgical approaches for rib fixation have been described in the old literature, however, most of these techniques are obscure nowadays. Currently mostly large incisions with considerable surgical insult are used to stabilize rib fractures. We think that MIPO deserves a place in the surgical treatment of rib fractures. We present the aspects of diagnosis, preoperative planning and operative techniques in regard to MIPO rib fixation.

Keywords: Minimally invasive surgery; Plate; Ribs.

Figures

Fig. 1

Three-dimensional reconstruction of the computed tomography scan of a patient with multiple rib fractures on the left side.

Fig. 2

Schematic of a patient with rib fractures; the symbol/indicates a non-displaced rib fracture,

Fig. 3

A patient with anterior rib fractures localised using ultrasound.

Fig. 4

Overview of the minimally invasive plate osteosynthesis instruments. (A) The 90 degree angle drill and screwdriver in combination with the drill guide and plate holding clamps. (B) Trocar in the plate with the clamp lifting up the soft tissue creating a working window, enabling visualisation of the plate on the rib.

Fig. 5

Specific drill guides with four different angles ensuring perpendicular drilling in the centre of the hole of the plate. For the more experienced surgeon, additional notches have been created on the side, making it possible to drill three holes sequentially.

Fig. 6

(A, B) The position of the trocar in the plate and with the clamp around the trocar lifting up the soft tissue. In this patient, the plate was held in position with two threaded reduction tool devices.

Fig. 7

(A, B) The upright clamp enabling fixation of the plate through a small incision in a perpendicular fashion.