Ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF): Reduction and Fixation techniques to minimize the surgical wound

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Surgical Stabilization of Rib Fractures (SSRF) has become increasingly prevalent in treating severe cases. However, traditional approaches, like posterolateral thoracotomy, are invasive and cause significant muscle damage. Recently, muscle-sparing minimally invasive techniques have been introduced, yet they still require advanced reduction and fixation techniques to avoid complications. This study presents an "ultra" minimally invasive SSRF (uMI-SSRF) technique designed to minimize surgical wounds and soft tissue damage while maintaining the benefits of rib fixation. Methods: This study involved 76 patients with multiple rib fractures treated using the uMI-SSRF technique between August 2021 and December 2023. Preoperative chest tomography with 3D reconstruction was used for surgical planning. The technique employed small incisions (3-5 cm), muscle-sparing approaches, and advanced fixation techniques. Data on patient demographics, intraoperative details, and postoperative outcomes were collected. Results: The mean patient age was 58 years, with 66% being male. On average, patients had 6.4 fractured ribs, and 4 ribs were fixed per surgery, achieving a fixation ratio of 59%. The average wound length was 4.2 cm, with a mean operation time of 122 minutes. Most patients required one incision (74%). Median hospital length of stay was 7 days, with a pneumonia rate of 5%. No wound infections or implant-related complications were observed. Conclusions: The uMI-SSRF technique effectively reduces wound size and soft tissue damage in rib fracture stabilization while maintaining high fixation quality. This method shows promise for improving patient outcomes, reducing recovery time, and minimizing complications. Further studies with larger sample sizes and comparisons with other methods are warranted to verify the advantages of uMI-SSRF. Surgical Stabilization of Rib Fractures SSRF Ultra Minimally Invasive Surgery Flail Chest Postoperative Complications Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Rib fractures have been identified in as many as 39% of patients with blunt chest trauma and in up to 10% of all trauma admissions(1, 2). Surgical Stabilization of Rib Fractures (SSRF) is becoming more common in treating these injuries. Properly performed SSRF can reduce the risk of pneumonia, tracheostomy rates, mechanical ventilation days, length of stays in intensive care units and hospitals, and mortality rates in patients with flail chest or multiple ribs fracture(3–7). Flail chest is generally accepted as an indication for SSRF among different guidelines(8–10). However up to 80% of these patients may not have received the surgery, and rates of fixation among different hospitals ranged from 0–88%(11). A possible reason may be the unfamiliarity of surgical exposures, fixation techniques, and instrumentation(12). Traditionally, SSRF was performed using a posterolateral thoracotomy incision(13). This extensive approach can damage soft tissue and compromise neurovascular due to muscle division. Postoperative muscle pain and dysfunction hinder the progress of fracture healing, as the benefits of the procedure may be reduced by morbidities iatrogenically produced from the large incision(14). Recently, muscle-sparing minimally invasive techniques have been introduced to decrease morbidity(13–20). Most technical papers have addressed the surgical exposures of SSRF, but little has been mentioned about the reduction and fixation of the fractures. Due to the extensiveness and complexity of rib fractures, without precise surgical planning and advanced reduction and fixation technique, a minimally invasive incision may need to be extended, ultimately resembling a thoracotomy incision. The benefits of fixation may therefore be compromised by the complications of the large wound. Our paper focuses on novel and modified techniques that enables SSRF to be performed safely through a small incision and limited window. We introduce an "ultra" minimally invasive technique for SSRF(uMI-SSRF) to further reduce wound size and soft tissue damage while maintaining the benefits of SSRF. Methods Preoperation and planning When a patient is preparing for Surgical Stabilization of Rib Fractures(SSRF), a routine chest tomography with three dimensional(3D) reconstruction of the ribs is obtained to help the surgeon identify the fracture sites and develop a clear operation plan(Fig. 1 ). The priority of surgical stabilization is given to fractures that most impact pulmonary function, typically those that are severely displaced between the 4th and 9th ribs. Fractures outside this range are less commonly operated on unless they are severely displaced or show clinical significance. In cases of flail chest, the site with the greatest displacement is prioritized for repair. Generally, a fixation ratio of over 50% of the fractured ribs is targeted to ensure adequate stabilization while balancing the risks and benefits of the surgery. Patient positioning, Video-assisted thoracoscopic surgery (VATS) Under one-lung ventilation, the patient is placed in the lateral decubitus position with the affected side up and the arm abducted over the head. Video-Assisted Thoracoscopic Surgery (VATS) is routinely performed to examine any interstitial lung lesions, check for lung entrapment at the fracture site, and ensure proper lung deflation during the stabilization procedure. Initial hemothorax is irrigated and suctioned, and the fracture location is confirmed intrathoracically. Incision and Exposure: The edges of fractured ribs can cause skin tenting or create an indentation during chest wall palpation. The sites of the ribs planned for fixation are marked, and a longitudinal incision is made connecting these marks(Fig. 2 A). A 3-5cm incision is performed to fix up to 5 consecutive ribs, and the fascia is incised in line with skin incision. For posterolateral rib fractures, the incision should pass through the auscultation triangle(Fig. 2 B). The fat or bursa at the auscultation triangle is separated transversely, parallel to the latissimus dorsi muscle below. A finger is inserted under the scapula to mobilize it, then the scapula is retracted laterally to widen the created window. This window is sufficient for fixing the 5th to 7th ribs. To fix the 3rd and 4th ribs, or the 8th and 9th ribs, perform a longitudinal transection of less than 3 cm on the rhomboid and latissimus dorsi muscles, respectively. Alternatively, when only the upper or lower ribs require fixation, a window can be created by dividing the muscle parallel to their fibers. When the fracture lies beneath the erector spinae muscle, elevate the muscle instead of transecting it. For anterolateral rib fractures, the skin incision is designed by connecting the fracture marks. The serratus muscle window beneath is created parallel to the muscle fibers, which is sufficient for up to three fractured ribs. For more than four fractured ribs, two separate muscle windows within the same incision can be made. When rib fractures occur in different regions, such as posterior and lateral, a double incision is made. This approach is also used when more than six consecutive ribs require fixation or when a long plate is necessary for specific fracture patterns. (Fig. 3 ) Double incision for patients with flail chest and sliding a long plate within two wounds. Bone Reduction The cornerstone of fracture fixation, crucial for avoiding postoperative complications and achieving bone union, is the quality of the fracture reduction. One of three reduction techniques can be employed. First, bone reduction forceps or a towel clamp can directly pick up the bone. Second, the lever arm technique is used for ribs hidden under the skin flap or scapula. This involves sliding a mini-Hohmann retractor under the depressed bone segment and using the neighboring intact or fixed rib as a fulcrum to raise the bone (Fig. 4 ). Finally, for osteoporotic or comminuted bones, a right angle forcep or mini-Langenbeck retractor is inserted from the rib's upper end to lift it. The level arm technique for temporary reduction. A mini Hohmann retractor is slid under the depressed bone segment, using a neighboring rib as a fulcrum to elevate the rib. Plate Positioning and Fixation After achieving temporary reduction, a 6 or 7-hole short segment plate is carefully contoured and positioned centrally with three holes on each side of the fracture. Using an instrument, usually the suction tip, the plate is held in place. The second to the last hole on each side of the fracture is drilled without a drill guide(Fig. 2 C). Compression nonlocking screws are used to firmly press the plate against the bone, ensuring perfect contouring and shortening the fracture gap. The axis of the screw does not need to be perpendicular to the plate; it can be oblique to adapt to the limited visible operational space. An alternative to compression lag screws are cerclage wires, which are useful when the bone is osteoporotic or comminuted, and the compression effect of the screw fails. Sometimes, longer plates are necessary to bridge comminuted fracture patterns. After ensuring adequate plate positioning and fracture reduction, the remaining screw holes are filled with locking screws, with a minimum of three screws on each side of the fracture. The nonlocking screws are subsequently replaced with locking screws. An additional movie file shows this in more detail [see Additional file 1]. In remote areas, a 90-degree drill and screwdriver may be used for locking screw holes located beneath the scapula. Stab incisions can also be made for drill holes that are too far from the main wound. Self-drilling screws are suitable for use in anatomically sensitive areas, such as near vital organs like a hypertrophied heart, where the risk of injury is higher. Variable angle (VA) screws can be useful when plate positioning or contouring is suboptimal. Final VATS Examination After properly fixing the fracture, ensure thorough irrigation and hemostasis before closing the wound. Perform VATS to validate the fixation intrathoracically, check for penetrated screws, remove any remaining hemothorax, and insert a 14 French pigtail or 28 French chest tube for drainage. Subcutaneous wound drains are not routinely placed. Data collection and analyses We recorded the following baseline characteristics: age, sex, body mass index (BMI), smoking status, injury mechanism, Injury Severity Score (ISS), presence of flail chest, time to surgery, and the side and number of fractures. During the operation, we recorded the total number of ribs fixed, operation time, blood loss, and the number and length of incision wounds. All operative and postoperative outcomes, including mechanical ventilation days, intensive care unit (ICU) length of stay, and hospital length of stay, were recorded in this study. Complications included tracheostomy, pneumonia, wound infection, implant-related issues, and mortality. Implant-related complications were defined as implant breakage, dislodgment, or removal due to irritation. Approval was obtained from the Institutional Review Board(KMUHIRB-E(II)-20240265).Statistical analyses of the data were performed using SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). Continuous data are described as means and standard deviations or as medians and interquartile ranges (IQR). Categorical data are presented as absolute and relative frequencies. Result From August 2021 through December 2023, our team performed Ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF) on 76 patients with multiple rib fractures. The characteristics of these patients are reported in Table 1 . Among these patients, the mean age was 58 years, and 50 patients (66%) were men. The average Injury Severity Score (ISS) was 21.3 (range 9–36), and 40 patients (52.6%) had flail chest. On average, the patients had 6.4 (range 3–14) fractured ribs, with an average of 4 ribs fixed (range 2–6), resulting in a fixation ratio of 59% (range 29–100%). Table 1 Characteristics of the patients (N = 76) who received the Ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF). Characteristic mean ± SD or n% Range N 76 Age, mean ± SD 58 ± 13.4 21–81 Sex, n(%) Male 50(66%) Female 26(34%) Body Mass Index, mean ± SD 24.51 ± 3.42 17.3–32.5 Smoking, n(%) Nonuse 57(75%) Use 17(22%) Quit 2(3%) Injury Mechanism, n(%) Motorvehicle collision 62(82%) Fall from Heights 5(7%) Ground Fall 5(7%) Fall from Stairs 3(4%) Direct contusion (hit) 1(1%) Injury Severity Score (ISS), mean ± SD 21.26 ± 6.17 9–36 Flail Chest, n(%) No 36(47%) Yes 40(53%) Rib Fracture Side, n(%) Left 44(58%) Right 28(37%) Bilateral 4(5%) Total Fracture, mean ± SD 6.4 ± 2.1 3–14 Time to surgery(hr), mean ± SD 39 ± 30.1 4-152 The intraoperative results are listed in Table 2 . Fifty-six patients (74%) required one surgical incision for their fracture fixation, while the rest needed two or three separate incisions. The average wound length was 4.2 cm (range 2.5-5 cm). The average operation time for each surgery was 122 minutes (range 55–300 minutes), with an average time to fix each rib of 35 minutes (range 20–102 minutes). Table 2 Intraoperative Results for the patients (N = 76) who received the Ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF). Intraoperative Results Total Range N 76 Fixed Ribs, mean ± SD 4 ± 0.9 2–6 Fixation Fracture Ratio %, mean ± SD 59 ± 17% 29–100% Wound Length Average(cm) a , mean ± SD 4.2 ± 0.7 2.5-5.0 Wound number 1 56 (74%) 2 18 (24%) 3 2 (3%) Operation time(min), mean ± SD 122 ± 50.3 50-300min Operation Time/Rib(min), mean ± SD 35 ± 13.7 13.7-102min Blood loss(ml), mean ± SD 40.6 ± 51.0 5-200 ml a If a patient has two or more wounds, the wound length is the average of the wounds The outcome results are listed in Table 3 . The patients stayed in the hospital for a median of 7 days (range 2–37 days). Four patients (5%) acquired pneumonia, and one patient (1.3%) with the underlying disease of chronic obstructive pulmonary disease (COPD) expired within 3 months. No wound infections or implant-related complications were noted in this patient series. Table 3 Overall Postoperative Results for the patients (N = 76) who received the Ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF). Overall Results Total Range N 76 ICU patients, n (%) 27 (36%) ICU Length Of Stay, median (IQR) 4 (2.0–6.0) 1-12days Hospital Length of Stay, median (IQR) 7 (6.0–11.0) 2-37days Mechanical Ventilation, n(%) 20 (26%) Mechanical Ventilation Days, median (IQR) 2 (1.0-3.5) 1-23days Complications Tracheostomy, n(%) 0 (0) Pneumonia, n(%) 4 (5%) Wound Infection, n(%) 0 (0) Implant Related Complication, n(%) 0 (0) Mortality, n(%) 1 (1%) Any outcome 0 72(95%) ≥1 4 (5%) Discussion Surgical stabilization of rib fractures (SSRF) began in the 1950s with instruments like cerclage wires, intramedullary devices, and clamping devices. However, it became widely accepted and popular in chest wall trauma surgery only in the past 15 years with the introduction of anatomically precontoured plates with locking screws.(12, 21) We successfully performed uMI-SSRF in 76 patients, fixing an average of 4 ribs with an average wound length of 4.2 cm. A fixation-fracture ratio of 59% was achieved, demonstrating sufficient stability for chest wall injuries(22, 23). The average surgery time was 122 minutes, or 35 minutes per rib. In the series by Schulz-Drost et al., they were able to fix 4 ribs with an average wound length of 6 to 7 cm, both posteriorly and laterally. Their average operation time was 100 minutes(18). We achieved equivalent rib fixation with a shorter surgical wound and comparable operation time. Our surgical approach follows the general principles mentioned in previous studies, utilizing a longitudinal incision through the auscultation triangle or the serratus muscle window, and minimal dissection of the trapezius, rhomboid, or latissimus dorsi muscles(19, 20, 24). We were able to minimize our wound length due to modified reduction and plate holding techniques including level arm reduction technique, freehand drilling and plate compression screw technique. The optimal approach for SSRF remains controversial and largely depends on the surgeon's familiarity with the exposure techniques. Posterolateral thoracotomy incision is a common approach for SSRF, especially among thoracic and trauma surgeons, as it provides a large view of the complete chest wall. However, the extensive muscle dissection associated with this approach can result in significant morbidity. The introduction of muscle-sparing techniques has minimized damage to soft tissues. Nonetheless, due to the extensiveness and complexity of rib fractures, without precise surgical planning and meticulous technique, a minimally invasive incision may need to be extended, ultimately resembling a thoracotomy incision. This can compromise the benefits of fixation due to the complications of a large wound. Currently, several minimally invasive surgical instruments, including upright plate holding forceps, 90-degree drills and screwdrivers, and Alexis wound retractors (Applied Medical, Rancho Santa Margarita, CA, USA), have proven helpful in reducing wound size and soft tissue damage(17). However, each of these instruments may have its own limitations. Therefore, we successfully modified current SSRF techniques by integrating common fracture reduction and fixation techniques from orthopedic procedures, which we named 'ultra' Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF). There is no standard incision length for minimally invasive SSRF; however, most studies regarding this technique indicate an incision wound length ranging from 6 to 10 cm for fixing 3 to 4 fractured ribs. (15, 18, 20, 25). Our results demonstrate that it is possible to fix the same number of ribs with an even shorter incision length. Additionally, our study includes the largest number of patients among similar studies, highlighting the feasibility and consistency of this technique. Obesity can influence surgical outcomes and affect the incision size necessary for a successful surgery(26). Our technique can be successfully performed in patients with a body mass index (BMI) as high as 32.5 (Figure. 5). A 3 cm incision was sufficient to fix 3 posterolateral rib fractures. Langenbach et al. studied the accessible rib area with different wound lengths on cadavers and found that a minimum of 6 ribs can be accessed via a 5 cm wound through both posterior and lateral approaches(14), This provides strong evidence of the feasibility of our technique. An obese patient(BMI 32.5) with fractured 5-7th ribs fixed in a 3 cm wound. A common technique for temporary fixation involves using plate holding forceps on both sides of the plate. This requires a larger incision to secure both ends of the plate simultaneously. The fixed angle nature of the clamps limits their effectiveness in small exposures. In osteoporotic bone, the compressive force of bone clamps may further shatter the fractured bone, leaving a more comminuted fracture pattern to fix. Additionally, they can potentially injure the intercostal artery and nerves while assessing either from the superior or inferior border of the rib. It is commonly understood that the intercostal artery runs inside the concave intercostal groove. However, in certain areas, such as 6 cm from the spinous process, the artery may not be shielded by the rib.(27) Routine clamping underneath the bone poses a threat to the underlying artery and nerves, potentially resulting in unnecessary blood loss and nerve damage. Our article discusses three reduction techniques that can all hold the fracture in a reduced state while providing sufficient counterforce during drilling of screw holes in the bone. These techniques are minimally invasive to the intercostal space and underlying structures. The lever arm technique is particularly useful when the rib is well under the skin flap. Many studies on minimally invasive techniques have addressed the use of a 90-degree drill and screwdriver.(15, 17, 18) We prefer performing freehand drilling instead. The ability to alter the drilling angle makes it more flexible in a small surgical exposure. A deviation of less than 30 degrees does not significantly affect the compression force of the screw.(28) A potential drawback of using a 90-degree drill is the lack of clear sensation when penetrating the cortical bone during drilling. Locking screws can be secured to the plate regardless of whether they are fully within the bone, therefore screw misplacement is a common technical error with this technique. Freehand drilling without a threaded drill guide poses the risk of penetrating underlying vital organs. However, bi-cortical drilling is a well-established technique in orthopedic procedures. With sufficient practice, a surgeon can perform this technique with minimal risk to underlying organs. In our series, no complications from penetration were encountered. In specific anatomical areas requiring special attention, such as ribs near the heart, diaphragm, or liver, using a drilling guide or self-drilling screws can minimize the risk of critical complications. Ribs, though classified as 'flat' bones, are typically curved in anatomy, with inconsistent curvature radii. The outer surface of the rib is also not uniformly flat and smooth, becoming more convex to triangular posterior to the costal angle. These unique features make contouring and positioning the plate more challenging. A short segment plate reduces the effort required for contouring, particularly in addressing the 'frowning' or 'smiling' in-plane curvature. Even when plate positioning is suboptimal, using variable angle screws can improve screw purchase and, consequently, increase construct stability. Conventional non-locking screws (Fig. 6 ) offer three benefits in uMI-SSRF. First, the smooth screw head presses the plate down to the bone, indirectly elevating the depressed bone. Second, the compression effect further contours the flexible titanium plate to perfection. Third, by inserting the screw eccentrically to the fracture site, it provides a dynamic compression effect. Together with the curved plate placed on the tension side of the rib, this acts as a tension band construct, shortening the fracture gap, increasing stability, and decreasing the chance of nonunion.(29) There are several limitations to our study. First, this is a single center study which may affect the generalizability of the results to other settings or surgical teams with different levels of expertise. Second, the absence of a control group makes it difficult to assess whether the uMI-SSRF technique offers superior outcomes compared to traditional or other minimally invasive methods. Further studies with larger sample sizes and comparisons with other methods are warranted to verify the advantages of uMI-SSRF. Conclusion In conclusion, uMI-SSRF is an effective, safe, and feasible technique for treating patients with rib fractures. It effectively reduces wound size and soft tissue damage in rib fracture stabilization while maintaining high fixation quality. This method shows promise for improving patient outcomes, reducing recovery time, and minimizing complications in rib fracture patients who require surgery. Declarations Ethics approval Approval for patient data was obtained from the Kaohsiung Medical University Institutional Review Board(KMUHIRB-E(II)-20240265). Consent for publication Not applicable Competing interests Hon Lok Lo and all authors, or any member of his or her immediate family has no funding or commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements) that might pose a conflict of interest in connection with the submitted article. I agree and confirm that this statement is true. Funding Not applicable Author Contribution HLL ,DLT, CKL initiated the conception and design of study. HLL, DLT, CKL, JYL acquired the data. HLL, DLT, JYL, OYL, CCL analyzed and interpreted the data. HLL drafted the manuscript primarily, DLT, CCL, and OYL contributed. HLL, DLT, CCL, JYL, OYL helped revising the manuscript critically for important intellectual content. All authors reviewed the manuscript and agreed for publication. Acknowledgements The authors would like to acknowledge Monal MEDillustration for their illustration of Fig. 4. 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Supplementary Files AdditionalFile1.mp4 Cite Share Download PDF Status: Published Journal Publication published 15 Nov, 2024 Read the published version in World Journal of Emergency Surgery → Version 1 posted Editorial decision: Revision requested 24 Oct, 2024 Reviews received at journal 24 Oct, 2024 Reviews received at journal 18 Oct, 2024 Reviews received at journal 15 Oct, 2024 Reviewers agreed at journal 14 Oct, 2024 Reviewers agreed at journal 12 Oct, 2024 Reviewers agreed at journal 11 Oct, 2024 Reviewers invited by journal 10 Oct, 2024 Editor assigned by journal 08 Oct, 2024 Submission checks completed at journal 08 Oct, 2024 First submitted to journal 05 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5208749","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370088737,"identity":"9198964f-3c8c-4460-bfca-f6d163822875","order_by":0,"name":"HON LOK LO","email":"","orcid":"","institution":"Ph.D. Program in Biomedical Engineering, College of Medicine, Kaohsiung Medical University, Kaohsiung","correspondingAuthor":false,"prefix":"","firstName":"HON","middleName":"LOK","lastName":"LO","suffix":""},{"id":370088738,"identity":"19bdfdbe-90d6-4cba-b52a-a300916078fe","order_by":1,"name":"Jui-Ying Lee","email":"","orcid":"","institution":"Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung","correspondingAuthor":false,"prefix":"","firstName":"Jui-Ying","middleName":"","lastName":"Lee","suffix":""},{"id":370088739,"identity":"9b99fcc2-81a6-41c7-bf42-e41648ddface","order_by":2,"name":"Chun Kuan Lu","email":"","orcid":"","institution":"Department of Orthopedics, Park One International Hospital, Kaohsiung","correspondingAuthor":false,"prefix":"","firstName":"Chun","middleName":"Kuan","lastName":"Lu","suffix":""},{"id":370088740,"identity":"3880554f-2fa4-4e33-8195-305e9b0be9e6","order_by":3,"name":"On-Yee Lo","email":"","orcid":"","institution":"Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA","correspondingAuthor":false,"prefix":"","firstName":"On-Yee","middleName":"","lastName":"Lo","suffix":""},{"id":370088742,"identity":"b2c5f943-6498-42fe-b934-f7aba4e4073b","order_by":4,"name":"Cheng-Chang Lu","email":"","orcid":"","institution":"Department of Orthopedics, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung","correspondingAuthor":false,"prefix":"","firstName":"Cheng-Chang","middleName":"","lastName":"Lu","suffix":""},{"id":370088745,"identity":"f9c96b9f-1192-44b0-bfc9-4823c4afece0","order_by":5,"name":"Dong-Lin Tsai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYHACZoYEhv88bMyMDQc+VID4zA3EaGGW4WNnbjw44wyIz0iEFiC2keNnbz7M2wYSIKCFf3bzY4OHO9ggDuOdVxvN3w7U8qNiG04tEneOGScknuGBaJHcdjx3xmHGBsaeM7dxW3MjwfhAYpsERIvhtmO5DUAtzIxtuLXI30j/DNRiANGSOOdY7nxCWgxu5AAd1pYA0XKwoSZ3AyEthjdyig0S2w6AtRxsOHYgdyNQy0F8fpG7kb5Z8mfbAXv5/uOPP/+pqcudd/7wwQc/KvB4Hw0cBpMHiFYPBHWkKB4Fo2AUjIIRAgChF13jKrJuagAAAABJRU5ErkJggg==","orcid":"","institution":"Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung","correspondingAuthor":true,"prefix":"","firstName":"Dong-Lin","middleName":"","lastName":"Tsai","suffix":""}],"badges":[],"createdAt":"2024-10-05 11:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5208749/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5208749/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13017-024-00566-3","type":"published","date":"2024-11-15T15:56:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68654483,"identity":"cb081906-e589-44df-b2ec-0e2d6c33145d","added_by":"auto","created_at":"2024-11-10 13:53:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":780570,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurgical Stabilization of Rib Fractures (SSRF) of 5\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003econsecutive ribs in 4.5m wound.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA: Preoperative chest tomography with 3D reconstruction shows Left posterolateral 5th to 9th ribs fracture with displacement B: Chest radiograph of post Surgical stabilization of the rib fractures(SSRF) C: Final incision wound of 4.5 cm.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5208749/v1/7a715b3b6b7bd12d8f9a5ade.jpg"},{"id":68654485,"identity":"f52e1db1-c852-4346-b3ec-4ad00bc530b3","added_by":"auto","created_at":"2024-11-10 13:53:43","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":772658,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF) surgical technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA: Dotted lines show the target ribs, “X” indicates the fracture edge, a longitudinal incision is made B:The Auscultation triangle, “*” stands for rhomboid muscle, “†” stands for latismus dorsi muscle, “r” stands for Erector Spinae muscle. C: Free hand drilling of 4th rib after temporary reduction with level arm technique D: Compression nonlocking screw for pressing the plate to the bone\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5208749/v1/c0b79c5f6bc8906ec9c1ebed.jpg"},{"id":68654488,"identity":"e5a166d1-6846-4a9b-b17b-8c25ea821774","added_by":"auto","created_at":"2024-11-10 13:53:43","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2317314,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDouble incision for Long plate placement in flail chest patient\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5208749/v1/69c192d3ae3ca6abfaa8bd78.jpg"},{"id":68654487,"identity":"b850beca-3604-4e61-89b1-35401ee14381","added_by":"auto","created_at":"2024-11-10 13:53:43","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":8069774,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Level Arm Technique\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5208749/v1/66b2536be1b97d15c8ce5930.jpg"},{"id":68655149,"identity":"4f9e1dad-c726-423c-a7c8-65ddb179a91e","added_by":"auto","created_at":"2024-11-10 14:01:43","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":506067,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF) performed in an obese patient\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5208749/v1/1d310681c01717e3e2233a14.jpg"},{"id":68654484,"identity":"abcb40b3-b742-4b21-8130-a983c9e09e0a","added_by":"auto","created_at":"2024-11-10 13:53:43","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":268870,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBenefits of plate compression with nonlocking screws and fracture gap reduction with eccentric screw placement. \u003c/strong\u003e\u003cbr\u003e\nA. Nonlocking screws presses the plate against the bone, indirectly reduces the depressed bone to the plate. B. Inserting 2 nonlocking screws eccentrically at both side of the fracture further shortens the fracture gap, increases stability. From AO Surgery Reference, https://surgeryreference.aofoundation.org, with copyright by AO Foundation, Switzerland.(30)\u003c/p\u003e","description":"","filename":"Figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5208749/v1/f07b28459c6d6f49b5b5e150.jpg"},{"id":69274739,"identity":"0af8630c-8601-4db6-ad00-a2e5800f27cd","added_by":"auto","created_at":"2024-11-18 16:20:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":13332088,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5208749/v1/d36e59e8-d7f5-4dd5-970d-470b2ebb2f4d.pdf"},{"id":68654489,"identity":"d42773a9-d790-476c-927b-92803dbc8aac","added_by":"auto","created_at":"2024-11-10 13:53:43","extension":"mp4","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":16254460,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-5208749/v1/6fad41edd2392870d4adbf9c.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF): Reduction and Fixation techniques to minimize the surgical wound","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRib fractures have been identified in as many as 39% of patients with blunt chest trauma and in up to 10% of all trauma admissions(1, 2). Surgical Stabilization of Rib Fractures (SSRF) is becoming more common in treating these injuries. Properly performed SSRF can reduce the risk of pneumonia, tracheostomy rates, mechanical ventilation days, length of stays in intensive care units and hospitals, and mortality rates in patients with flail chest or multiple ribs fracture(3\u0026ndash;7). Flail chest is generally accepted as an indication for SSRF among different guidelines(8\u0026ndash;10). However up to 80% of these patients may not have received the surgery, and rates of fixation among different hospitals ranged from 0\u0026ndash;88%(11). A possible reason may be the unfamiliarity of surgical exposures, fixation techniques, and instrumentation(12).\u003c/p\u003e \u003cp\u003eTraditionally, SSRF was performed using a posterolateral thoracotomy incision(13). This extensive approach can damage soft tissue and compromise neurovascular due to muscle division. Postoperative muscle pain and dysfunction hinder the progress of fracture healing, as the benefits of the procedure may be reduced by morbidities iatrogenically produced from the large incision(14). Recently, muscle-sparing minimally invasive techniques have been introduced to decrease morbidity(13\u0026ndash;20). Most technical papers have addressed the surgical exposures of SSRF, but little has been mentioned about the reduction and fixation of the fractures. Due to the extensiveness and complexity of rib fractures, without precise surgical planning and advanced reduction and fixation technique, a minimally invasive incision may need to be extended, ultimately resembling a thoracotomy incision. The benefits of fixation may therefore be compromised by the complications of the large wound.\u003c/p\u003e \u003cp\u003eOur paper focuses on novel and modified techniques that enables SSRF to be performed safely through a small incision and limited window. We introduce an \"ultra\" minimally invasive technique for SSRF(uMI-SSRF) to further reduce wound size and soft tissue damage while maintaining the benefits of SSRF.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003ePreoperation and planning\u003c/h2\u003e\n\u003cp\u003eWhen a patient is preparing for Surgical Stabilization of Rib Fractures(SSRF), a routine chest tomography with three dimensional(3D) reconstruction of the ribs is obtained to help the surgeon identify the fracture sites and develop a clear operation plan(Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The priority of surgical stabilization is given to fractures that most impact pulmonary function, typically those that are severely displaced between the 4th and 9th ribs. Fractures outside this range are less commonly operated on unless they are severely displaced or show clinical significance. In cases of flail chest, the site with the greatest displacement is prioritized for repair. Generally, a fixation ratio of over 50% of the fractured ribs is targeted to ensure adequate stabilization while balancing the risks and benefits of the surgery.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003ePatient positioning, Video-assisted thoracoscopic surgery (VATS)\u003c/h3\u003e\n\u003cp\u003eUnder one-lung ventilation, the patient is placed in the lateral decubitus position with the affected side up and the arm abducted over the head. Video-Assisted Thoracoscopic Surgery (VATS) is routinely performed to examine any interstitial lung lesions, check for lung entrapment at the fracture site, and ensure proper lung deflation during the stabilization procedure. Initial hemothorax is irrigated and suctioned, and the fracture location is confirmed intrathoracically.\u003c/p\u003e\n\u003ch3\u003eIncision and Exposure:\u003c/h3\u003e\n\u003cp\u003eThe edges of fractured ribs can cause skin tenting or create an indentation during chest wall palpation. The sites of the ribs planned for fixation are marked, and a longitudinal incision is made connecting these marks(Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA). A 3-5cm incision is performed to fix up to 5 consecutive ribs, and the fascia is incised in line with skin incision.\u003c/p\u003e\n\u003cp\u003eFor posterolateral rib fractures, the incision should pass through the auscultation triangle(Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eB). The fat or bursa at the auscultation triangle is separated transversely, parallel to the latissimus dorsi muscle below. A finger is inserted under the scapula to mobilize it, then the scapula is retracted laterally to widen the created window. This window is sufficient for fixing the 5th to 7th ribs. To fix the 3rd and 4th ribs, or the 8th and 9th ribs, perform a longitudinal transection of less than 3 cm on the rhomboid and latissimus dorsi muscles, respectively. Alternatively, when only the upper or lower ribs require fixation, a window can be created by dividing the muscle parallel to their fibers. When the fracture lies beneath the erector spinae muscle, elevate the muscle instead of transecting it.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor anterolateral rib fractures, the skin incision is designed by connecting the fracture marks. The serratus muscle window beneath is created parallel to the muscle fibers, which is sufficient for up to three fractured ribs. For more than four fractured ribs, two separate muscle windows within the same incision can be made.\u003c/p\u003e\n\u003cp\u003eWhen rib fractures occur in different regions, such as posterior and lateral, a double incision is made. This approach is also used when more than six consecutive ribs require fixation or when a long plate is necessary for specific fracture patterns. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDouble incision for patients with flail chest and sliding a long plate within two wounds.\u003c/p\u003e\n\u003ch3\u003eBone Reduction\u003c/h3\u003e\n\u003cp\u003eThe cornerstone of fracture fixation, crucial for avoiding postoperative complications and achieving bone union, is the quality of the fracture reduction. One of three reduction techniques can be employed. First, bone reduction forceps or a towel clamp can directly pick up the bone. Second, the lever arm technique is used for ribs hidden under the skin flap or scapula. This involves sliding a mini-Hohmann retractor under the depressed bone segment and using the neighboring intact or fixed rib as a fulcrum to raise the bone (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Finally, for osteoporotic or comminuted bones, a right angle forcep or mini-Langenbeck retractor is inserted from the rib's upper end to lift it.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe level arm technique for temporary reduction. A mini Hohmann retractor is slid under the depressed bone segment, using a neighboring rib as a fulcrum to elevate the rib.\u003c/p\u003e\n\u003ch3\u003ePlate Positioning and Fixation\u003c/h3\u003e\n\u003cp\u003eAfter achieving temporary reduction, a 6 or 7-hole short segment plate is carefully contoured and positioned centrally with three holes on each side of the fracture. Using an instrument, usually the suction tip, the plate is held in place. The second to the last hole on each side of the fracture is drilled without a drill guide(Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eC). Compression nonlocking screws are used to firmly press the plate against the bone, ensuring perfect contouring and shortening the fracture gap. The axis of the screw does not need to be perpendicular to the plate; it can be oblique to adapt to the limited visible operational space. An alternative to compression lag screws are cerclage wires, which are useful when the bone is osteoporotic or comminuted, and the compression effect of the screw fails. Sometimes, longer plates are necessary to bridge comminuted fracture patterns. After ensuring adequate plate positioning and fracture reduction, the remaining screw holes are filled with locking screws, with a minimum of three screws on each side of the fracture. The nonlocking screws are subsequently replaced with locking screws. An additional movie file shows this in more detail [see Additional file 1].\u003c/p\u003e\n\u003cp\u003eIn remote areas, a 90-degree drill and screwdriver may be used for locking screw holes located beneath the scapula. Stab incisions can also be made for drill holes that are too far from the main wound. Self-drilling screws are suitable for use in anatomically sensitive areas, such as near vital organs like a hypertrophied heart, where the risk of injury is higher. Variable angle (VA) screws can be useful when plate positioning or contouring is suboptimal.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eFinal VATS Examination\u003c/h2\u003e\n\u003cp\u003eAfter properly fixing the fracture, ensure thorough irrigation and hemostasis before closing the wound. Perform VATS to validate the fixation intrathoracically, check for penetrated screws, remove any remaining hemothorax, and insert a 14 French pigtail or 28 French chest tube for drainage. Subcutaneous wound drains are not routinely placed.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eData collection and analyses\u003c/h3\u003e\n\u003cp\u003eWe recorded the following baseline characteristics: age, sex, body mass index (BMI), smoking status, injury mechanism, Injury Severity Score (ISS), presence of flail chest, time to surgery, and the side and number of fractures. During the operation, we recorded the total number of ribs fixed, operation time, blood loss, and the number and length of incision wounds. All operative and postoperative outcomes, including mechanical ventilation days, intensive care unit (ICU) length of stay, and hospital length of stay, were recorded in this study. Complications included tracheostomy, pneumonia, wound infection, implant-related issues, and mortality. Implant-related complications were defined as implant breakage, dislodgment, or removal due to irritation. Approval was obtained from the Institutional Review Board(KMUHIRB-E(II)-20240265).Statistical analyses of the data were performed using SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). Continuous data are described as means and standard deviations or as medians and interquartile ranges (IQR). Categorical data are presented as absolute and relative frequencies.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eFrom August 2021 through December 2023, our team performed Ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF) on 76 patients with multiple rib fractures. The characteristics of these patients are reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Among these patients, the mean age was 58 years, and 50 patients (66%) were men. The average Injury Severity Score (ISS) was 21.3 (range 9\u0026ndash;36), and 40 patients (52.6%) had flail chest. On average, the patients had 6.4 (range 3\u0026ndash;14) fractured ribs, with an average of 4 ribs fixed (range 2\u0026ndash;6), resulting in a fixation ratio of 59% (range 29\u0026ndash;100%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the patients (N\u0026thinsp;=\u0026thinsp;76) who received the Ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003emean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or n%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u0026ndash;81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50(66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26(34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody Mass Index, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.51\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.3\u0026ndash;32.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57(75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjury Mechanism, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotorvehicle collision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62(82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFall from Heights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGround Fall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFall from Stairs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect contusion (hit)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjury Severity Score (ISS), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.26\u0026thinsp;\u0026plusmn;\u0026thinsp;6.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u0026ndash;36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlail Chest, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36(47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40(53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRib Fracture Side, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44(58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28(37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Fracture, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to surgery(hr), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u0026thinsp;\u0026plusmn;\u0026thinsp;30.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4-152\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe intraoperative results are listed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Fifty-six patients (74%) required one surgical incision for their fracture fixation, while the rest needed two or three separate incisions. The average wound length was 4.2 cm (range 2.5-5 cm). The average operation time for each surgery was 122 minutes (range 55\u0026ndash;300 minutes), with an average time to fix each rib of 35 minutes (range 20\u0026ndash;102 minutes).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative Results for the patients (N\u0026thinsp;=\u0026thinsp;76) who received the Ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative Results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFixed Ribs, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFixation Fracture Ratio %, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u0026thinsp;\u0026plusmn;\u0026thinsp;17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u0026ndash;100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound Length Average(cm)\u003csup\u003ea\u003c/sup\u003e, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5-5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound number\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time(min), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122\u0026thinsp;\u0026plusmn;\u0026thinsp;50.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50-300min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation Time/Rib(min), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.7-102min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss(ml), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.6\u0026thinsp;\u0026plusmn;\u0026thinsp;51.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5-200 ml\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003ea\u003c/sup\u003eIf a patient has two or more wounds, the wound length is the average of the wounds\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe outcome results are listed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The patients stayed in the hospital for a median of 7 days (range 2\u0026ndash;37 days). Four patients (5%) acquired pneumonia, and one patient (1.3%) with the underlying disease of chronic obstructive pulmonary disease (COPD) expired within 3 months. No wound infections or implant-related complications were noted in this patient series.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverall Postoperative Results for the patients (N\u0026thinsp;=\u0026thinsp;76) who received the Ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU patients, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU Length Of Stay, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.0\u0026ndash;6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1-12days\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital Length of Stay, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6.0\u0026ndash;11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2-37days\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanical Ventilation, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanical Ventilation Days, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.0-3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1-23days\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTracheostomy, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonia, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound Infection, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant Related Complication, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny outcome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72(95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSurgical stabilization of rib fractures (SSRF) began in the 1950s with instruments like cerclage wires, intramedullary devices, and clamping devices. However, it became widely accepted and popular in chest wall trauma surgery only in the past 15 years with the introduction of anatomically precontoured plates with locking screws.(12, 21)\u003c/p\u003e \u003cp\u003eWe successfully performed uMI-SSRF in 76 patients, fixing an average of 4 ribs with an average wound length of 4.2 cm. A fixation-fracture ratio of 59% was achieved, demonstrating sufficient stability for chest wall injuries(22, 23). The average surgery time was 122 minutes, or 35 minutes per rib. In the series by Schulz-Drost et al., they were able to fix 4 ribs with an average wound length of 6 to 7 cm, both posteriorly and laterally. Their average operation time was 100 minutes(18). We achieved equivalent rib fixation with a shorter surgical wound and comparable operation time.\u003c/p\u003e \u003cp\u003eOur surgical approach follows the general principles mentioned in previous studies, utilizing a longitudinal incision through the auscultation triangle or the serratus muscle window, and minimal dissection of the trapezius, rhomboid, or latissimus dorsi muscles(19, 20, 24). We were able to minimize our wound length due to modified reduction and plate holding techniques including level arm reduction technique, freehand drilling and plate compression screw technique.\u003c/p\u003e \u003cp\u003eThe optimal approach for SSRF remains controversial and largely depends on the surgeon's familiarity with the exposure techniques. Posterolateral thoracotomy incision is a common approach for SSRF, especially among thoracic and trauma surgeons, as it provides a large view of the complete chest wall. However, the extensive muscle dissection associated with this approach can result in significant morbidity. The introduction of muscle-sparing techniques has minimized damage to soft tissues. Nonetheless, due to the extensiveness and complexity of rib fractures, without precise surgical planning and meticulous technique, a minimally invasive incision may need to be extended, ultimately resembling a thoracotomy incision. This can compromise the benefits of fixation due to the complications of a large wound. Currently, several minimally invasive surgical instruments, including upright plate holding forceps, 90-degree drills and screwdrivers, and Alexis wound retractors (Applied Medical, Rancho Santa Margarita, CA, USA), have proven helpful in reducing wound size and soft tissue damage(17). However, each of these instruments may have its own limitations. Therefore, we successfully modified current SSRF techniques by integrating common fracture reduction and fixation techniques from orthopedic procedures, which we named 'ultra' Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF).\u003c/p\u003e \u003cp\u003eThere is no standard incision length for minimally invasive SSRF; however, most studies regarding this technique indicate an incision wound length ranging from 6 to 10 cm for fixing 3 to 4 fractured ribs. (15, 18, 20, 25). Our results demonstrate that it is possible to fix the same number of ribs with an even shorter incision length. Additionally, our study includes the largest number of patients among similar studies, highlighting the feasibility and consistency of this technique.\u003c/p\u003e \u003cp\u003eObesity can influence surgical outcomes and affect the incision size necessary for a successful surgery(26). Our technique can be successfully performed in patients with a body mass index (BMI) as high as 32.5 (Figure. 5). A 3 cm incision was sufficient to fix 3 posterolateral rib fractures. Langenbach et al. studied the accessible rib area with different wound lengths on cadavers and found that a minimum of 6 ribs can be accessed via a 5 cm wound through both posterior and lateral approaches(14), This provides strong evidence of the feasibility of our technique.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAn obese patient(BMI 32.5) with fractured 5-7th ribs fixed in a 3 cm wound.\u003c/p\u003e \u003cp\u003eA common technique for temporary fixation involves using plate holding forceps on both sides of the plate. This requires a larger incision to secure both ends of the plate simultaneously. The fixed angle nature of the clamps limits their effectiveness in small exposures. In osteoporotic bone, the compressive force of bone clamps may further shatter the fractured bone, leaving a more comminuted fracture pattern to fix. Additionally, they can potentially injure the intercostal artery and nerves while assessing either from the superior or inferior border of the rib. It is commonly understood that the intercostal artery runs inside the concave intercostal groove. However, in certain areas, such as 6 cm from the spinous process, the artery may not be shielded by the rib.(27) Routine clamping underneath the bone poses a threat to the underlying artery and nerves, potentially resulting in unnecessary blood loss and nerve damage.\u003c/p\u003e \u003cp\u003eOur article discusses three reduction techniques that can all hold the fracture in a reduced state while providing sufficient counterforce during drilling of screw holes in the bone. These techniques are minimally invasive to the intercostal space and underlying structures. The lever arm technique is particularly useful when the rib is well under the skin flap.\u003c/p\u003e \u003cp\u003eMany studies on minimally invasive techniques have addressed the use of a 90-degree drill and screwdriver.(15, 17, 18) We prefer performing freehand drilling instead. The ability to alter the drilling angle makes it more flexible in a small surgical exposure. A deviation of less than 30 degrees does not significantly affect the compression force of the screw.(28) A potential drawback of using a 90-degree drill is the lack of clear sensation when penetrating the cortical bone during drilling. Locking screws can be secured to the plate regardless of whether they are fully within the bone, therefore screw misplacement is a common technical error with this technique.\u003c/p\u003e \u003cp\u003eFreehand drilling without a threaded drill guide poses the risk of penetrating underlying vital organs. However, bi-cortical drilling is a well-established technique in orthopedic procedures. With sufficient practice, a surgeon can perform this technique with minimal risk to underlying organs. In our series, no complications from penetration were encountered. In specific anatomical areas requiring special attention, such as ribs near the heart, diaphragm, or liver, using a drilling guide or self-drilling screws can minimize the risk of critical complications.\u003c/p\u003e \u003cp\u003eRibs, though classified as 'flat' bones, are typically curved in anatomy, with inconsistent curvature radii. The outer surface of the rib is also not uniformly flat and smooth, becoming more convex to triangular posterior to the costal angle. These unique features make contouring and positioning the plate more challenging. A short segment plate reduces the effort required for contouring, particularly in addressing the 'frowning' or 'smiling' in-plane curvature. Even when plate positioning is suboptimal, using variable angle screws can improve screw purchase and, consequently, increase construct stability.\u003c/p\u003e \u003cp\u003eConventional non-locking screws (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e) offer three benefits in uMI-SSRF. First, the smooth screw head presses the plate down to the bone, indirectly elevating the depressed bone. Second, the compression effect further contours the flexible titanium plate to perfection. Third, by inserting the screw eccentrically to the fracture site, it provides a dynamic compression effect. Together with the curved plate placed on the tension side of the rib, this acts as a tension band construct, shortening the fracture gap, increasing stability, and decreasing the chance of nonunion.(29)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThere are several limitations to our study. First, this is a single center study which may affect the generalizability of the results to other settings or surgical teams with different levels of expertise. Second, the absence of a control group makes it difficult to assess whether the uMI-SSRF technique offers superior outcomes compared to traditional or other minimally invasive methods. Further studies with larger sample sizes and comparisons with other methods are warranted to verify the advantages of uMI-SSRF.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, uMI-SSRF is an effective, safe, and feasible technique for treating patients with rib fractures. It effectively reduces wound size and soft tissue damage in rib fracture stabilization while maintaining high fixation quality. This method shows promise for improving patient outcomes, reducing recovery time, and minimizing complications in rib fracture patients who require surgery.\u003c/p\u003e "},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003e Approval for patient data was obtained from the Kaohsiung Medical University Institutional Review Board(KMUHIRB-E(II)-20240265).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eHon Lok Lo and all authors, or any member of his or her immediate family has no funding or commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements) that might pose a conflict of interest in connection with the submitted article. I agree and confirm that this statement is true.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHLL ,DLT, CKL initiated the conception and design of study. HLL, DLT, CKL, JYL acquired the data. HLL, DLT, JYL, OYL, CCL analyzed and interpreted the data. HLL drafted the manuscript primarily, DLT, CCL, and OYL contributed. HLL, DLT, CCL, JYL, OYL helped revising the manuscript critically for important intellectual content. All authors reviewed the manuscript and agreed for publication.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors would like to acknowledge Monal MEDillustration for their illustration of Fig.\u0026nbsp;4.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eAll data generated or analysed during this study are included in this published article. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e 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(1):97\u0026ndash;110.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37(6):975-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Choi J, Gomez GI, Kaghazchi A, Borghi JA, Spain DA, Forrester JD. Surgical Stabilization of Rib Fracture to Mitigate Pulmonary Complication and Mortality: A Systematic Review and Bayesian Meta-Analysis. J Am Coll Surg. 2021;232(2):211-9.e2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Craxford S, Owyang D, Marson B, Rowlins K, Coughlin T, Forward D, et al. 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Three common exposures of the chest wall for rib fixation: anatomical considerations. J Thorac Dis. 2019;11(Suppl 8):S1034-S43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Zhang D, Zhou X, Yang Y, Xie Z, Chen M, Liang Z, et al. Minimally invasive surgery rib fracture fixation based on location and anatomical landmarks. Eur J Trauma Emerg Surg. 2022;48(5):3613-22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Bottlang M, Helzel I, Long WB, Madey S. Anatomically contoured plates for fixation of rib fractures. J Trauma. 2010;68(3):611-5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Marasco S, Liew S, Edwards E, Varma D, Summerhayes R. Analysis of bone healing in flail chest injury: do we need to fix both fractures per rib? J Trauma Acute Care Surg. 2014;77(3):452-8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Nickerson TP, Thiels CA, Kim BD, Zielinski MD, Jenkins DH, Schiller HJ. Outcomes of Complete Versus Partial Surgical Stabilization of Flail Chest. World J Surg. 2016;40(1):236\u0026thinsp;\u0026minus;\u0026thinsp;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Marasco S, Saxena P. Surgical rib fixation - technical aspects. Injury. 2015;46(5):929\u0026thinsp;\u0026minus;\u0026thinsp;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Hasenboehler EA, Bernard AC, Bottiggi AJ, Moghadamian ES, Wright RD, Chang PK, et al. Treatment of traumatic flail chest with muscular sparing open reduction and internal fixation: description of a surgical technique. J Trauma. 2011;71(2):494\u0026ndash;501.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Liu YF, Chen TL, Tseng CH, Wang JY, Wang WC. Impact of obesity on outcomes after surgical stabilization of multiple rib fractures: Evidence from the US nationwide inpatient sample. PLoS One. 2024;19(2):e0299256.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Helm EJ, Rahman NM, Talakoub O, Fox DL, Gleeson FV. Course and variation of the intercostal artery by CT scan. Chest. 2013;143(3):634-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Kuzma AL, Luo TD, De Gregorio M, Coon GD, Danelson K, Halvorson JJ, et al. Biomechanical Evaluation of Interfragmentary Compression of Lag Screw Versus Positional Screw at Different Angles of Fixation. J Orthop Trauma. 2019;33(5):e183-e9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Warner S, Sommer C, Zderic I, Woodburn W, Castle R, Penman J, et al. Lateral rim variable angle locked plating versus tension band wiring of simple and complex patella fractures: a biomechanical study. Arch Orthop Trauma Surg. 2024;144(5):2131-40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e AO Surgery Reference. https://surgeryreference.aofoundation.org. Accessed 30 June, 2024.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjes","sideBox":"Learn more about [World Journal of Emergency Surgery](http://wjes.biomedcentral.com)","snPcode":"13017","submissionUrl":"https://submission.nature.com/new-submission/13017/3","title":"World Journal of Emergency Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Surgical Stabilization of Rib Fractures, SSRF, Ultra Minimally Invasive Surgery, Flail Chest, Postoperative Complications","lastPublishedDoi":"10.21203/rs.3.rs-5208749/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5208749/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRib fractures are common in trauma patients, often leading to complications such as pneumonia and prolonged hospitalization. Surgical Stabilization of Rib Fractures (SSRF) has become increasingly prevalent in treating severe cases. However, traditional approaches, like posterolateral thoracotomy, are invasive and cause significant muscle damage. Recently, muscle-sparing minimally invasive techniques have been introduced, yet they still require advanced reduction and fixation techniques to avoid complications. This study presents an \"ultra\" minimally invasive SSRF (uMI-SSRF) technique designed to minimize surgical wounds and soft tissue damage while maintaining the benefits of rib fixation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study involved 76 patients with multiple rib fractures treated using the uMI-SSRF technique between August 2021 and December 2023. Preoperative chest tomography with 3D reconstruction was used for surgical planning. The technique employed small incisions (3-5 cm), muscle-sparing approaches, and advanced fixation techniques. Data on patient demographics, intraoperative details, and postoperative outcomes were collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean patient age was 58 years, with 66% being male. On average, patients had 6.4 fractured ribs, and 4 ribs were fixed per surgery, achieving a fixation ratio of 59%. The average wound length was 4.2 cm, with a mean operation time of 122 minutes. Most patients required one incision (74%). Median hospital length of stay was 7 days, with a pneumonia rate of 5%. No wound infections or implant-related complications were observed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe uMI-SSRF technique effectively reduces wound size and soft tissue damage in rib fracture stabilization while maintaining high fixation quality. This method shows promise for improving patient outcomes, reducing recovery time, and minimizing complications. Further studies with larger sample sizes and comparisons with other methods are warranted to verify the advantages of uMI-SSRF.\u003c/p\u003e","manuscriptTitle":"Ultra Minimally Invasive Surgical Stabilization of Rib Fractures (uMI-SSRF): Reduction and Fixation techniques to minimize the surgical wound","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-10 13:53:31","doi":"10.21203/rs.3.rs-5208749/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-24T17:01:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-24T12:29:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-18T16:15:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-15T18:30:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57784882159371915739913877048574946115","date":"2024-10-14T14:09:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59304939052677438763741709975575289040","date":"2024-10-12T14:05:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22323260581442309148645580213857863242","date":"2024-10-11T18:56:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-10T16:48:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-08T09:24:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-08T09:22:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Emergency Surgery","date":"2024-10-05T11:41:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjes","sideBox":"Learn more about [World Journal of Emergency Surgery](http://wjes.biomedcentral.com)","snPcode":"13017","submissionUrl":"https://submission.nature.com/new-submission/13017/3","title":"World Journal of Emergency Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d3df1906-db23-4525-861e-b1a2eafdb646","owner":[],"postedDate":"November 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-18T15:59:09+00:00","versionOfRecord":{"articleIdentity":"rs-5208749","link":"https://doi.org/10.1186/s13017-024-00566-3","journal":{"identity":"world-journal-of-emergency-surgery","isVorOnly":false,"title":"World Journal of Emergency Surgery"},"publishedOn":"2024-11-15 15:56:57","publishedOnDateReadable":"November 15th, 2024"},"versionCreatedAt":"2024-11-10 13:53:31","video":"","vorDoi":"10.1186/s13017-024-00566-3","vorDoiUrl":"https://doi.org/10.1186/s13017-024-00566-3","workflowStages":[]},"version":"v1","identity":"rs-5208749","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5208749","identity":"rs-5208749","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}