Borrelly Jacques, Aazami Mathias Hossain
Medipole Gentilly-Saint Jacques, 54320 Maxeville, France.
Eur J Cardiothorac Surg. 2005 Nov;28(5):742-9. doi: 10.1016/j.ejcts.2005.08.017. Epub 2005 Oct 7.
The wisdom of surgery facing multiple and multi-focal ribs fractures (flail segment) remains controversial. By the present retrospective study, we sought to determine the advisability of surgery as well as the anatomical and biomechanical features of flail segment leading to secondary dislocation.
From 1970 to 2000, 127 patients underwent flail segment osteosynthesis. Clinical charts, operative reports and imaging data were reviewed retrospectively. Rib osteosynthesis was carried out with Judet staple and Kirschner wires until 1980, since then it has been undertaken with sliding-staples-struts. Postoperative chest X-ray was carried out to classify the flail segments into anterolateral and posterolateral types according to the location of anterior and posterior rib fractures. Each type was then divided into three subgroups of primary parietal, secondary parietal and retreat indications that were inferred retrospectively from final indications of rib osteosynthesis.
The mean age of patients (ranging in age from 20 to 84 years) was 56+/-14.4 years with a male predominance (108/19). Seventy percent of flail segments was considered as posterolateral. The mean number of rib fractures per patient was 6+/-0.35. Rib osteosynthesis was undertaken with sliding-staples-struts in 70% of patients. The overall hospital mortality was 16%; it was subsequently reduced to 8% since sliding-staples-struts were used. The mean duration of ventilation was reduced from 5.8+/-0.76 days to 2.98+/-0.83 days with sliding-staples-struts. Seventy-seven percent of patients with posterolateral flail segment and primary parietal indication were extubated within the first 48 h postoperatively, whereas 46% of patients from other subgroups required ventilation for more than 5 days. Similarly, 83% of patients of the former subgroup returned to full previous level of activity compared with a rate of 52% for the latter subgroups. The flail segments were dislocated superoposteriorly for both anterolateral and posterolateral types, evoking the action of anterior serratus muscle.
The anterolateral and posterolateral flail segments are rendered susceptible to secondary dislocation through a complex set of factors, of which the action of anterior serratus muscle is obvious. Restoration of parietal mechanics by early surgical reduction/fixation is a reliable therapeutic option in selected patients and offers encouraging results.
对于多发性和多节段肋骨骨折（连枷胸段）的手术治疗的合理性仍存在争议。通过本回顾性研究，我们试图确定手术的可行性以及导致继发性脱位的连枷胸段的解剖学和生物力学特征。
1970 年至 2000 年期间，127 例患者接受了连枷胸段骨固定术。对临床病历、手术报告和影像学资料进行回顾性分析。1980 年以前，肋骨骨固定术采用 Judet 钉和克氏针进行，此后则采用滑动钉棒系统。术后通过胸部 X 光检查，根据前后肋骨骨折的位置将连枷胸段分为前外侧型和后外侧型。然后根据肋骨骨固定术的最终指征，将每种类型再分为原发性胸壁型、继发性胸壁型和退缩指征型三个亚组。
患者的平均年龄为 56±14.4 岁（年龄范围为 20 至 84 岁），男性占优势（108/19）。70%的连枷胸段被认为是后外侧型。每位患者肋骨骨折的平均数量为 6±0.35 根。70%的患者采用滑动钉棒系统进行肋骨骨固定术。总体医院死亡率为 16%；自采用滑动钉棒系统后，死亡率降至 8%。使用滑动钉棒系统后，平均通气时间从 5.8±0.76 天缩短至 2.98±0.83 天。后外侧连枷胸段且有原发性胸壁指征的患者中，77%在术后 48 小时内拔管，而其他亚组的患者中有 46%需要通气超过 5 天。同样，前一亚组 83%的患者恢复到了之前的完全活动水平，而后一亚组的这一比例为 52%。前外侧型和后外侧型连枷胸段均向后上方脱位，提示前锯肌的作用。
前外侧和后外侧连枷胸段由于一系列复杂因素而易于发生继发性脱位，其中前锯肌的作用较为明显。对于选定的患者，早期手术复位/固定以恢复胸壁力学是一种可靠的治疗选择，并能取得令人鼓舞的效果。
