Rib Fixation Colloquium 2016: Consensus Statement Update

Transcription

1 Rib Fixation Colloquium 2016: Consensus Statement Update Fredric M. Pieracci MD, MPH, FACS Trauma Medical Director Denver Health Medical Center Associate Professor of Surgery University of Colorado SOM

2 Disclosures Paid faculty & consultant: DePuy Synthes Zimmer BioMet

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4 Author Group Fred Pieracci Sarah Majercik Francis Ali-Osman Darwin Ang Andrew Doben John Edwards Bruce French Mario Gasparri Silvana Marasco Christian Minshall Babak Sarani William Tisol Don VanBoerum Tom White

5 Author Group

6 Author Group

7 Author Group

8 Methodology 14 topic champions reviewed literature (136 references) and rendered graded recommendations Delphi method of consensus Anonymity, iteration, feedback, group response Binary outcome: Agree vs. disagree Consensus defined as 80% (at least 12 of 14 agree) Two rounds of voting

9 Consensus Statement Topics Topic # Recs 1 Indications for Surgery 5 2 Timing of Surgery 1 3 Regionalization of surgery 2 4 Preoperative planning 10 5 Surgical Approaches 4 6 Mode of fixation 4 7 Management of multiple fracture series 1 8 Management of bone loss 3 9 Management of muscle loss 2 10 Management of the pleural space 3 11 Loco-regional anesthesia 3 12 Postoperative care 5 13 Management of chronic non union 5

10 Results Degree of Consensus N % 100% (14 of 14 agree) % 92.9% (13 of 14 agree) % 85.7% (12 of 14 agree) % < 80% 0 0.0% Grade of Recommendation N % A 0 0.0% B % C % D %

11 Round in which Consensus was Achieved First round = 43 (89.6%) Second round = 5 (10.4%)

12 Second Round Consensus In general, repair of ribs 1, 2, 11 and 12 does not confer additional benefit in terms of either chest wall stability or pain control. In highly select circumstances, such as marked displacement, vascular impingement, or localized refractory pain, repair of these ribs may be considered (Level 5, Grade D) Fractures within 2.5 cm of the transverse process should not be repaired (Level 5, Grade D) Fractures within 2.5 cm of the costal cartilage may be repaired by fixation to either the cartilage or sternum (Level 5, Grade D).

13 Second Round Consensus Fracture gaps > 10 mm should not be bridged (Level 2c, Grade C) Thoracic epidural and paravertebral catheters provide equivalent loco-regional anesthesia for patients with rib fractures (Level 2, Grade B) using only a plate (Level 2c, Grade C).

14 Grade B Recommendations SSRF should be considered in all patients with flail chest (Level 2b, Grade B) In patients undergoing SSRF, peri-operative VTE prophylaxis with LMWH should be delayed for 24 hours following the placement of an epidural catheter. Furthermore, epidural catheter placement should occur at least 10 hours after the last dose of LMWH (Level 1c, Grade B) Patients being considered for SSRF should undergo CT chest (Level Grade B).

15 Grade B Recommendations Thoracic epidural and paravertbral catheters provide equivalent loco-regional anesthesia for patients with rib fractures (Level 2, Grade B) Nonunion should be suspected in patients with persistent chest wall pain three to six months following injury; these patients should undergo further testing/imaging with CT chest, even if the initial CXR appears normal (Level 3A, Grade B) Operative repair of chronic nonunions is indicated for persistent disabling pain refractory to conservative treatment methods, with thoughtful management of patient expectations. (Level 3A, Grade B).

16 Low Consensus Recommendations (12/14) In patients undergoing SSRF, peri-operative VTE prophylaxis with LMWH should be delayed for 24 hours following the placement of an epidural catheter. Furthermore, epidural catheter placement should occur at least 10 hours after the last dose of LMWH (Level 1c, Grade B) There is insufficient evidence to recommend the routine use of 3D reconstructions of the CT Chest (2B, Grade B) Rib fractures may be fixed using either plates or intramedullary struts (Level 5, Grade D).

17 Low Consensus Recommendations (12/14) Autologous graft and commercially available, nonautologous grafts are equally effective for bone grafting (Level 5, Grade C) Operative repair of chronic nonunions is indicated for persistent disabling pain refractory to conservative treatment methods, with thoughtful management of patient expectations. (Level 3A, Grade B).

18 Rib Fracture Colloquium 2016 Consensus Statement Strengths Contemporary, graded recommendations Multidisciplinary, experienced surgeons Precedent for future work from this group Weaknesses Selection bias General lack of high grade recommendations Future Directions RFC Guidelines 2.0

19 Rib Fixation Colloquium 2016: Consensus Statement Update Fredric M. Pieracci MD, MPH, FACS Trauma Medical Director Denver Health Medical Center Associate Professor of Surgery University of Colorado SOM