Tóm tắt tiếng anh chỉ Định, quy trình kĩ thuật, hiệu quả Điều trị chấn thương ngực kín có cố Định xương sườn bằng nẹp vít

HA NOI MEDICAL UNIVERSITY NGUYEN VAN DAI INDICATIONS, TECHNICAL PROCEDURES, EFFECTIVENESS OF TREATMENT OF BLUNT THORACIC TRAUMA WITH BY SURGICAL RIB FIXATION WITH PLATES THESIS SUMMA

HA NOI MEDICAL UNIVERSITY

NGUYEN VAN DAI

INDICATIONS, TECHNICAL PROCEDURES, EFFECTIVENESS

OF TREATMENT OF BLUNT THORACIC TRAUMA WITH BY

SURGICAL RIB FIXATION WITH PLATES

THESIS SUMMARY

HA NOI - 2024

THESIS COMPLETED IN:

HA NOI MEDICAL UNIVERSITY

Supervisor: 1 Pr.PhD Doan Quoc Hung

2 Assoc Prof Pham Huu Lu

Reviewer 1: Pr.PhD.Nguyen Sinh Hien

Reviewer 2: Pr.PhD.Le Tuan Linh

Reviewer 3: Pr.PhD Cong Quyet Thang

Thesis will be defended at University level Doctoral thesis assessment committee in Ha Noi Medical University

At: Date:

Thesis can be found out in:

 National library of Viet Nam

 Ha Noi Medical University library

RESEARCH WORKS HAVE BEEN PUBLISHED RELATED

TO THE THESIS CONTENT

1 Nguyen Van Dai, Phung Duy Hong Son, Vu Ngoc Tu, Nguyen Viet Anh, Nguyen The May, Vu Kim Duy, Nguyen Viet Dang Quang, Truong Cao Nguyen,Vu Huu Vinh, Nguyen Huu Uoc, Pham Huu Lu, Doan Quoc Hung Comparison of In-Hospital Outcomes of Surgical Stabilization of Rib Fractures with Nonsurgical Management: A

Multicenter, Prospective, Cohort Study Original paper / Acta

Informatica Medica 2023, 31(4): 275-279

2 Nguyen Van Dai, Phung Duy Hong Son, Vu Ngoc Tu, Nguyen Viet Anh, Nguyen The May, Vu Kim Duy, Vo Hoang Long, Nguyen Viet Dang Quang, Truong Cao Nguyen,Vu Huu Vinh, Nguyen Huu Uoc, Pham Huu Lu, Doan Quoc Hung Evaluation of the results of surgical rib fixation with plate in blunt thoracic trama with at Viet Tiep

Friendship Hospital in 2022 Vietnam Medical Journal June - Special

Issue 2023: 259-266

INTRODUCTION

The ribs are an important part of the thoracic cage, the origin and attachment of many muscles that participate in the process of breathing, shoulder and waist movement In the US, the number of patients with rib fractures tends to increase (in 2004 and 2017, 300,000 and 350,000 people, respectively) In Vietnam (2006), patients requiring surgery due to blunt thoracic trauma accounted for 7.1% of the total number of trauma emergencies

Rib fractures suggest a very serious injury with a high mortality rate of 12%, accompanied by many combined injuries in the thoracic and extrathoracic cages

In Vietnam, from 2015 to present, surgical rib fixation by plates has been evaluated as a safe, effective and highly feasible surgery that helps patients completely stop pain caused by bone fractures, heal bones quickly, restore chest volume, and reduce length

of hospital stay Currently, there are not many studies evaluating the overall treatment of surgical rib fixation with screws and plates

Therefore, we conducted the topic "Indications, technical

procedures, and effectiveness of treatment of blunt thoracic trauma with surgical rib fixation by plates" with two objectives:

1 Comments on indications and technical procedures of blunt thoracic trauma with surgical rib fixation by plates

2 Evaluation of the effectiveness of treatment of blunt thoracic trauma with surgical rib fixation by plates

NEW CONCLUSIONS OF PHD’S DISSERTATION

- Describe in detail and comprehensively the characteristics, pathology, and nature of the injury of blunt thoracic trauma with multiple rib fractures At the same time, provide comments on the indications for surgery to treat blunt thoracic trauma with surgical rib fixation by plates for different levels of rib fractures and complications at Viet Duc Friendship Hospital, Viet Tiep Friendship Hospital, and Cho Ray Hospital This comment is a reference for surgeons in considering the indications for surgical rib fixation

- The study has provided a complete technical process as well

as pointed out the key technical points of the s surgical rib fixation by plates The study has certain value in training and application, technical implementation, as well as providing a data foundation for the data warehouse in Vietnam and for future studies

- The study has evaluated in detail the short-term and medium-term results as well as confirmed the effectiveness of surgical treatment combined with surgical rib fixation in blunt thoracic trauma at hospitals in

a scientific manner with convincing treatment results equivalent to surgical results in developed countries in the world

- The study recommends that patients with blunt thoracic trauma with multiple displaced rib fractures or complex fractures or flail chest should be operated on starting from 16 years of age, especially in elderly patients The surgery should be performed as soon as possible after the injury when the patient has escaped traumatic shock and the extrathoracic injuries are stable

THESIS STRUCTURE

In the thesis, there were 131 pages dividing four chapters as following:

- Chapter 1: Background 32 pages

- Chapter 2: Subjects and methods 37 pages

- Chapter 3: Results 27 pages

- Chapter 4: Discussions 30 pages

- Conclusions 1 pages

- Recommendations 1 pages There were 36 tables, 38 figures and 4 graphs in the thesis We used 151 references in which 16 Vietnamese documents, 135 English ones There were two publishing articles related to the thesis

CHAPTER 1 LITERATURE REVIEW

1.1 Summary of applied anatomy of the ribs

1.1.1 Applied anatomy of the ribs

The thoracic cage is made up of the sternum, 12 thoracic vertebrae, 12 pairs of ribs and costal cartilages The 8th, 9th, 10th ribs are all attached to each other in the front and to the 7th rib via costal cartilages and synovial joints The 11th, 12th ribs have no connection

in the front and are called free ribs

1.1.2 Respiratory physiology

The movement of the chest wall is the result of passive and active contraction of the diaphragm and chest wall muscles During inspiration, the chest expands due to contraction of the respiratory muscles, increasing the size of the chest, reducing the pressure in the pleural cavity, reducing the pressure in the alveoli so that O2-rich air from the outside environment moves into the lungs During expiration, the respiratory muscles relax, the chest automatically returns to its original size, increasing the pressure in the pleural cavity and in the alveoli to push air carrying CO2 out of the lungs

1.1.3 Mechanism of injury of rib fractures

The main cause of rib fractures in blunt thoracic trauma is traffic accidents Every 14 seconds, there is an injury due to a traffic accident, of which blunt thoracic trauma with rib fractures accounts for 7% Next are domestic accidents (accidents at home or violence) and work accidents Rib fractures occur when the impact force is higher than the strength of the rib cage The weakest point of the rib cage is around the sternum at 60 degrees, so if there is a direct impact

on the rib cage from the side or an anterior-posterior compressive force, the fracture will be at the position around the sternum at 60 degrees and at the position behind the rib arch

1.1.4 linical and paraclinical diagnosis of rib fracture

* Clinical: Signs of rib fractures, flail chest may include

on chest X-rays, so an oblique or lateral chest X-ray should be taken to increase the likelihood of detecting rib fractures

- Chest Ultrasound

+ More sensitive than chest X-ray (78% vs 12%)

+ Detects rib cartilage fractures and costochondral junction fractures better than X-ray

+ View on multiple planes in real time: we can scan the ultrasound probe over the entire rib from the patient's most painful position, then examine the adjacent ribs, when detecting rib fractures,

we can detect pneumothorax and hemothorax on ultrasound

- Chest CT scan

+ Is the best method to reconstruct the ribs

+ Detects fracture lines, broken bone plates, broken rib cartilage, hemothorax, pneumothorax

+ Detects lung contusions, lung hernias, lung parenchyma tears, hemothorax, aortic contusions

1.1.5 Classification of rib fractures

All rib fractures detected on chest CT scan are classified as follows:

+ Type A (non-displaced rib fracture): when the rib fracture is displaced < 2mm

+ Type B (displaced rib fracture): When the two ends of the rib fracture are displaced ≥ 2mm, with a maximum of one fragment + Type C (complex fracture): rib fracture is displaced and has more than two fragments or multiple rib fractures on one bone shaft

1.2 Indications and contraindications for rib fusion surgery

Currently, surgical rib fixation is being considered by some surgeons to treat patients with blunt thoracic trauma with complex and displaced rib fractures When studying documents, domestic and international authors sometimes have situations that require surgical treatment of rib fractures All indications are currently considered relative, there are no absolute indications based on published studies Treatment must be individualized based on the general condition, associated injuries, and specific rib fracture characteristics

Indications and contraindications include:

Indication

1) Flail chest with one of the following factors:

+ There is lung contusion, however the airway is still clear, there is no pulmonary edema, requiring early surgery to correct the ribs

+ There is no lung contusion

+ There is no brain parenchyma injury

+ Brain parenchyma injury: Glasgow coma score ≥13 points, the patient is breathing on his own, there is no indication for cranial surgery, no mechanical ventilation

+ Severe lung contusion and severe brain injury require mechanical ventilation, however, to reduce the time of immobilization

by mechanical ventilation or failure to wean from mechanical ventilation, surgery is required to correct and fix the broken ribs + Failure to wean from mechanical ventilation within 12 hours + The patient needs thoracotomy due to trauma to the organs in the chest

2) Pain relief (fractures of ≥ 3 displaced or complex ribs, accompanied by one of the following factors):

+ The patient has severe pain, the broken ends of the ribs move continuously during the respiratory phase

+ Failure to use regional anesthesia or epidural anesthesia for pain relief

+ Severe pain at the site of the broken rib

3) Chest wall deformity or defect, with one of the following conditions:

+ Trauma causing collapse of the rib cage, reducing ≥ 20% of the volume of the chest cavity on chest CT

+ Fractures of ≥ 3 displaced ribs or defects in the chest wall causing chest wall deformity or lung herniation

+ Fractures of ≥ 3 complex displaced ribs

4) Symptomatic nonunion of ribs (pseudoarthritis of ribs) when: + Chest CT scan shows that the ribs have not united after 2 months; 5) Thoracic surgery for other reasons: Patients with multiple displaced rib fractures or mobile ribs with open chest due to pneumothorax, pneumothorax that is not treated with minimal pleural drainage, lung parenchyma tears, diaphragmatic tears

Contraindications

1) Chest wall infection

2) Associated injuries requiring prolonged mechanical ventilation: severe traumatic brain injury, high cervical spine injury ≥ C5, trauma with severe pulmonary contusion requiring prolonged mechanical ventilation

Timing of rib fusion surgery

Here is a summary of some authors on the timing of rib fusion surgery However, surgery should be performed as soon as possible

when the patient is out of traumatic shock and has stable extrathoracic injuries

CHAPTER 2 METHODOLOGY

2.1 Study subject

This study is a non-randomized, prospective, multicenter, descriptive study with a controlled group conducted on patients diagnosed with blunt chest trauma with rib fractures admitted to the following hospitals: Viet Duc Friendship Hospital, Cho Ray Hospital, and Viet Tiep Friendship Hospital The study subjects were divided into 2 groups, group 1: blunt chest trauma group with rib fixation surgery with screws and plates, group 2: blunt chest trauma group without rib fixation surgery with screws and plates (conservative treatment) All patients in both groups met the same inclusion and exclusion criteria

2.2 Research methods

2.2.1 Research design

A prospective, multicenter, non-randomized, descriptive study

2.2.2 Sample size and sampling method

Use a convenient sampling method that is consistent with the selection and exclusion criteria of the study

Apply the formula for estimating sample size by comparing two mean values:

+ N: sample size for both the surgical rib fixation group and the conservative treatment group

+ n3: sample size of the group with surgical rib fixation by plates after 1 month and 3 months of discharge (some patients did not return for examination or could not be contacted)

+ n4: sample size of the conservative treatment group after 1 month and 3 months of discharge

+ N3: total sample size of the group with surgical rib fixation and conservative treatment after 1 month and 3 months of discharge

μ1 is the mean of group 1 (group surgical rib fixation by plates)

μ2 is the mean of group 2 (group without rib fusion surgery with only conservative treatment of rib fractures), so μ1- μ2 is the difference between the mean results of the 2 groups Based on the systematic review by Liu Xin, rib fusion surgery reduces the average number of days of hospitalization by μ1- μ2=7.48 days

Z(1-α/2) is the value from the normal distribution, calculated based on the probability of type I error (Z(1-α/2) = 1.96 if the probability of type 1 error = 5% and the test is 2-sided)

Z(1-β) is the value calculated based on statistical power (Z(1-β) = 0.842 if the statistical power is 80%)

ES is the difference, calculated by the formula above

σ is the common standard deviation between the 2 groups, choose σ = 13

We calculate the minimum sample size for each group is 48 patients Allowing for errors for the group lost to contact, the expected sample size for each group is at least 50 patients

2.3 Research steps

The indicators are fully and detailedly designed in the prospective study medical records from the time of admission to discharge The prospective study period starts from October 2020 The research team is carefully and meticulously trained and patients are invited for re-examination or research team members come to the patient's place of residence after 1 month, 3 months of agreement at 3 research hospitals according to the following 5 steps:

- Step 1: select patients at 3 research hospitals according to the selection criteria

- Step 2: participate in patient examination, testing, diagnosis, indications and surgery Explain to patients and their families about the disease condition, conservative treatment methods, surgical methods, benefits as well as complications of treatment methods that may occur during treatment and participate in the study Patients or their families sign a commitment to surgery (if they choose to agree

to surgery) and participate in the study

- Step 3: screen selected patients into two groups: group 1: group treated with surgical rib fixation by plates; group 2: group without surgery combined with rib screws (conservative treatment group)

- Step 4: monitor, care for, treat patients during hospitalization, re-examine after 1 month, 3 months, evaluate treatment results according to a unified process until October 2023

a) Group 1: surgical rib fixation by plates

b) Group 2: conservative treatment of rib fractures

- Step 5: Collect and compile data according to the research form, find more references, analyze and process data, write the thesis

2.4 Surgical equipment and instruments

- Surgical instruments

+ Rib plate: is a multi-purpose plate used for all ribs on both sides Made of pure titanium alloy with high ductility, high strength, flexibility, good strength, long-term use in the chest and low allergy The contour of both sides of the plate is suitable for the physiological structure of the ribs The plate is 1.6mm thin with screw holes with countersunk locking threads

+ Rib screw: drilling screw is designed with deep drilling threads that are screwed directly into the bone without the need for pre-drilling The screw plate with locking threads helps to firmly fix the screw head into the plate hole while the screw tip is held at the other end of the dura mater

self-+ Plate bending tool

+ Bayomet-type plate holding pliers

+ Plate cutting pliers

+ Rib lifting tool

+ Screw driver

+ Shoulder blade lifting tool

2.5 Surgical rib fixation procedure by plates at Viet Duc Friendship Hospital, Viet Tiep Friendship Hospital, Cho Ray Hospital

+ General anesthesia and patient positioning

Rib fractures are located in the

patient's left lateral, anterior, and

posterior arches

Rib fracture is located in the left anterior arch and right posterior arch of the patient