A Sanford Health trauma surgeon has invented what he believes may be a less-invasive way to surgically treat more serious cases of broken ribs.
Rib fractures are one of the most common trauma injuries in the U.S., nearly 10% of all such cases. Most of those people recover without surgery.
For the more serious fractures, doctors have a new option: rib fixation surgery. The surgical stabilization of a rib fracture involves manual re-approximation, or reconnection, of the fractured bone and placement of a titanium plate across the fracture site to hold it in place and restore the chest wall anatomy.
“With surgical stabilization of rib fractures, what we’ve found is that by doing an intervention, we can significantly reduce the pain. We can significantly reduce the disability that goes with rib fractures for a period of time. The patient’s back on their feet quicker, more active, and can get back to their normal life faster,” said Steven Briggs, M.D., a Sanford Health trauma surgeon in Fargo, North Dakota, and one of the organization’s more than 50 innovators.
One of the biggest challenges is identifying who is likely to benefit from the intervention. Physicians currently assess the number of fractures and the severity of chest wall injury with continuous re-evaluation of pain, mobility and breathing effort to decide.
“Those that are hurt the worst appear to benefit from more aggressive interventions up front, which would be the surgical intervention,” he said.
Rib fracture surgical options
Surgeons currently repair fractures by screwing a plate onto the bone to hold the rib in place, so it heals properly.
“It works very well but does require an incision that is quite significant, at times, to accomplish it,” Dr. Briggs said. “So what does the next evolution of surgical stabilization of ribs look like? I kept coming back to the hollow space in the middle of the rib. It’s there on every rib. Is there a way to utilize that canal to stabilize the rib such that you don’t need to make the big incision to put a plate on it?”
Dr. Briggs began brainstorming about medical devices common to endovascular surgery: stents and catheters. He began to re-imagine these endovascular tools for orthopedic trauma surgery and envision their potential benefits in smaller incision sites and greater access to difficult fracture sites. His brainstorming led to three possible options:
- Stent fixation: The surgeon drills a hole into the middle of the rib, uses a flexible drill bit to clear out the marrow, inserts a stent and fills the cavity with bone cement to hold everything in place.
- Hook-and-loop with tension wire: The surgeon drills a hole into the middle of the rib, uses a flexible drill bit to clear out the marrow and drills another hole on the other side of the break. They then guide a looped tension wire from one hole to the other, use a small hook to grab the wire and pull it out. The physician finally fills the cavity with bone cement and uses threaded plugs on both ends of the wire to pull the bone tightly together.
- Breakaway drill bit: The surgeon drills a hole into the bone then uses a special breakaway drill bit to bore all the way through to the other side of the break. They break off the bit, leaving the rest of the metal in place to secure the bone.
”Right now we’re working on prototyping and trying to identify an industry partner,” said Andrew Larson, project manager with Sanford Health’s commercialization team.
Less invasive surgery
Ideally, the procedure could eventually be akin to how many hip surgeries and other procedures are already done.
“It gives us potential options in the future of looking at making the procedure less invasive, once it’s really refined such that you may only need very small incisions to get down to the rib. And then once you’re in the rib, you could deploy the device from a distance and avoid having to make the large incisions to get to where you need to go to stabilize the rib,” he said.
Dr. Briggs said two common rib fractures in particular could benefit from his approach.
One of the most difficult fracture locations is under the scapula, the large bone that covers the back of the shoulder. Currently, the surgeon must work under the bone in a very small space to move the plate in position and screw it to the rib. The procedure often involves making a large incision and lifting the scapula, dividing muscles in the process. Alternatively, the rib fixation device could allow the surgeon to enter the canal of the rib from a more accessible location, tunnel through the bone across the fracture and stabilize the rib with the device.
The other tricky location is a para-spinal fracture, a fracture near the vertebrae where the rib connects with the transverse process, a bony protrusion off each side of the vertebra where muscles, ligaments and ribs come together. A significant number of fractures occur near that interface and can affect the person’s breathing.
Because of the curvature of the rib in this area, it’s difficult to affix a plate to the rib. Dr. Briggs said his breakaway drill bit could work well because it could run through the broken rib and implant itself in the canal or the transverse process.
May help aging population
The rib fixation devices could also allow for treatment of fractures in other areas of the rib cage, Dr. Briggs said.
“And it may evolve into a procedure that’s much more tolerable to the patients, particularly as the population ages. We have more geriatric patients, and many of our rib-fracture patients are elderly. Having a procedure that is less invasive is much easier for them to tolerate and has the potential to get them more functional more quickly than medicines alone or medicines with a larger incision,” he said.
“We’re in the first phase of treating rib fractures. And it’s really about where do we go next. And where we go next should provide more options to patients.”
Sanford Health values the ideas and problem-solving ability of its physicians, researchers, clinical workers and support staff. Any employee with an idea for a device, therapy, software, tool or other method that helps patients is encouraged to contact the commercialization team and join the dozens of people at Sanford Health who are already inventing.
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