Chest wall stabilization with intercostal Z-suture and mesh for rib fractures.

Choosing an optimal procedure to stabilize the chest wall for multiple rib fractures can be challenging for surgeons. Stabilization with rib plates or intramedullary devices requires exposure of fractured bones, whereas chest stabilization with intercostal Z-suture and mesh does not, yet it offers the chest wall a sufficient level of stability. Here, we report a case of a flail chest due to multiple rib fractures for which a simple chest wall fixation using intercostal Z-suture and mesh was efficient. This method could be a treatment option for multiple rib fractures.

Introduction

In the United States, the Eastern Association for the Surgery of Trauma has developed guidelines that recommend operative rib fixation in adult patients with flail chest for several clinical outcomes compared to nonoperative management [1]. There have been reports on external fixation methods for multiple rib fractures, such as titanium rib plates [2], biomaterial ribs [3], intramedullary devices, and struts [4]; however, it is unclear which method we should choose, and treatments are dictated by individual cases. The method of repairing the chest wall is of major concern to thoracic surgeons. Generally, an easy procedure to perform that gives proper stability is preferred. We herein report a case of multiple rib fractures with a flail chest for which a simple chest wall fixation using mesh and intercostal Z-suture was effective.

Case report

An 83-year-old man fell in his home and was taken to hospital for bruises on his chest. He was diagnosis with right tension pneumothorax and a doctor inserted a thoracic drain, which accidentally injured the patient's lung. The patient was transferred to our hospital due to the difficulty of dealing with it for resource limitations at the initial hospital. Computed tomography showed that the drain was inserted into the right lower lobe from the 10th intercostal space, and there was one fracture each on the 5th and 6th ribs, two each on the 8th, 9th and 10th ribs, and three on the 7th ribs (Fig. 1). He had flail chest and paradoxical breathing but no respiratory failure. Since the drain had been inserted into the lung, we elected to perform surgery and thoracotomy in case removing the drain causes massive bleeding. The operation procedure was as follows: The patient was placed in a left lateral decubitus position under general anesthesia with double-lumen intubation. A lateral thoracotomy was performed at the 6th intercostal space. The drain was removed under direct vision without bleeding, and the lung part wounded by the drain was resected with three fires of a 60-mm thoracoscopic stapler. The other three lung regions that were wounded due to the fractured ribs were repaired with 4–0 proline. Thereafter, we proceeded to operation on the chest wall. The image of chest wall stabilization is illustrated in Fig. 2. An intercostal Z-suture with 1 Surgilon was placed at each fracture point. A 26 × 36 cm polypropylene mesh was folded in half with 2–0 silk ligation and covered the entire fractured area. Each Surgilon thread was passed through the mesh, tied, and fixed. The operating time was 133 min, and 100 ml of blood was lost. The postoperative flail chest improved, and paradoxical breathing resolved. The patient was extubated on the second day after surgery, moved from the intensive care unit to the general ward on the third day, and transferred to the initial hospital on the 11th day for rehabilitation. The chest radiographs at hospitalization and transfer are shown in Fig. 3.

Fig. 1

Computed tomography scan at hospitalization. (A) The 3D constructed image showed rib fractures, one on the 5th and 6th ribs, three on the 7th rib, and two on the 8th, 9th, and 10th ribs. (B) Gray circles indicate the point of each fracture.

Fig. 2

Illustration of chest wall stabilization. (A) Palpation identifies the fracture locations. (B) Intercostal Z-sutures with 1 Surgilons are placed on each fractured site. (C) Polypropylene mesh is placed on the whole lesion. (D) Threads tied through the mesh fix it on the rib cage.

Fig. 3

Chest radiographic findings on the hospitalization and the 10th postoperative day. (A) Multiple fractures of the right ribs caused a chest wall deformity. (B) The surgery improved the chest wall deformity, while several slightly displaced rib fractures are also seen.

Comment

For stabilization with titanium rib plates or intramedullary devices that fix fractured bones directly, it is necessary to peel the periosteum and expose the fractured area, which is challenging for traumatic fractures with multiple fragments. However, this intercostal Z-suture method does not need such a procedure. Once the fractured part is identified, the technically simple Z-suture is applied to the intercostal tissue. The mesh is then placed over it, and the threads of Z-suture are passed through the mesh. Ligation of the threads fixes the fractured bones, tissues around them, and the mesh. Furthermore, these materials are considerably cheaper than rib plates and can be used in many hospitals, as well as in emergency procedure.

This method has some disadvantages. First, the support provided to individual fractured ribs may be inferior to repairing bones directly with titanium plates or other devices. The mesh is placed outside of the ribcage and does not repair the fractured parts without an intermediary; however, it supports fractured ribs and prevents them from moving inward on inspiration. Second, the compliance of the rib cage may be reduced. Since the mesh fixes multiple ribs together, it potentially leads to a restrictive chest wall compared to operating individual ribs. Third, adhesion at the time of reoperation in the future can also concern us.

Fixation using mesh and intercostal Z-suture is easy, inexpensive, and can secure the chest wall a fair degree of stability. On the other hand, the disadvantages might be the inferiority of stability to direct bone fixes such as rib plate, possible restraint failure, and tissue adhesion. When implemented with an understanding of these features, chest wall stabilization with intercostal Z-suture and mesh can be a treatment option for multiple rib fractures.

Declaration of competing interest

The authors declare no conflicts of interest associated with this manuscript.