Surgical rib fixation

Traumatic rib fracture injuries are being seen with increasing frequency in the hospital setting. They are often associated with other severe injuries and frequently require admission. The most severe form of rib fracture injury, flail chest, has a mortality of up to 33%. Rib fracture injuries have also been associated with chronic pain, malunion, deformity, disability and poor quality of life. Despite this, the standard of management for rib fracture injuries was, and in most hospitals remains, conservative management with ventilator support and analgesia where required. This thesis outlines the rising incidence and quality of life issues that occur in patients who have sustained these injuries. A pilot study of rib fixation is then presented and leads to a randomised controlled trial of rib fixation in ventilator dependent flail chest patients. Concurrently with this clinical work, finite computer modelling has been used to investigate the forces acting on ribs in more detail in order to allow a more targeted strategy of rib fixation. When I commenced this clinical work, there was little or no guidance as to how to perform rib fixation surgery in the literature. The surgery was based on orthopaedic advice and basic principles. The computer modelling work has allowed me to identify likely points of failure of rib fixation as well as design my own rib prosthesis (patent listed in the appendix). Meanwhile other investigators have also been designing specific rib prostheses, and during the time frame of this thesis (about 8 years of published works), multiple rib prostheses have come onto the market. This serves to demonstrate the increasing interest in this surgery as well as a steady acceptance and uptake by surgeons based on mounting evidence.