Outcomes After Operative Reconstruction of Symptomatic Rib Nonunions.

OBJECTIVE: To assess the outcomes of patients after rib nonunion reconstruction. DESIGN: Retrospective case series. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Between January 2007 and August 2019, 25 consecutive patients with 51 nonunions with disabling pain or chronic instability were treated for nonunited rib fractures. INTERVENTION: Rib nonunion reconstructions performed using plate and screw fixation, recannalizing the medullary canal and augmented with autogenous iliac crest bone graft. MAIN OUTCOME MEASUREMENTS: Patient demographics, mechanism of injury, number of rib nonunions, and postoperative radiographs were assessed. Satisfaction, patient-reported complications, return to occupation and activity, and general health measures were captured using patient questionnaires. RESULTS: In 25 patients, 51 painful rib nonunions were surgically treated. The average length from injury to surgical rib reconstruction was 25.1 months (range = 3-118 months; median = 12 months). Follow-up was obtained in 18 of 25 patients (72%) with a mean of 46.1 months (range = 13-139 months). All ribs achieved radiographic union at an average of 12.3 weeks (range = 8-24 weeks) after surgery. Sixteen of 18 patients (89%) reported satisfaction with surgery and 15 patients (83%) reported mild to no pain at final follow-up. Five patients had complications that all resolved after subsequent treatment. CONCLUSIONS: Successful treatment of symptomatic rib nonunion is possible using rib plates in conjunction with bone grafting and has high union rates, satisfactory results, and limited complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ligamentous Lisfranc Injury: A Biomechanical Comparison of Dorsal Plate Fixation and Transarticular Screws.

OBJECTIVES: Optimal fixation technique after purely ligamentous Lisfranc injury remains controversial. This biomechanical study compares dorsal plate versus transarticular screw fixation by measuring dorsal and plantar joint diastasis. A unique protocol was developed, using reflective triad markers and positional cameras. METHODS: Eleven cadaveric matched pairs were assigned to either transarticular screw or dorsal plate fixation. Two reflective triad markers were placed into the medial cuneiform (C1) and second metatarsal base (MT2). Three cameras recorded the 3-dimensional location of triads to quantify C1-MT2 diastasis in the following states: intact Lisfranc ligament (INTACT), cut ligament (CUT), fixed (SCREW or PLATE) joint, and fixed joint after 10,000 loaded cycles. On completion, the plantar Lisfranc ligament insertions were identified, and plantar diastasis was determined using additional reflective triads. Statistical post hoc pairwise comparisons assessed differences in diastasis. RESULTS: C1-MT2 diastasis in the CUT state increased relative to INTACT (P < 0.001). SCREW fixation reduced C1-MT2 diastasis relative to CUT at dorsal (P < 0.007) and plantar (P = 0.015) locations after cycling. PLATE fixation significantly reduced dorsal diastasis relative to CUT (P < 0.001) but not for plantar diastasis (P > 0.99). PLATE plantar diastasis was numerically higher than INTACT but not significantly (P > 0.39). PLATE plantar diastasis tended to be greater than SCREW before cycling (P = 0.068) and after cycling (P = 0.080). CONCLUSIONS: Transection of the Lisfranc ligament complex yielded C1-MT2 diastasis. Both SCREW and PLATE fixation successfully reduced dorsal diastasis. However, upon load, the PLATE resulted in greater plantar diastasis, nearly statistically different relative to the SCREW. Cyclic loading at 343 N did not worsen diastasis.