VATS view of a broken rib (circle)
The technique of SSRF can broadly be broken down into three steps: (1) intraoperative localization of each fracture line; (2) reduction of the fracture; and (3) stabilization of the fracture via implantation of a titanium plate/screw system. Although the process of implantation of the hardware differs among the various product vendors, there are currently three general approaches: (1) implantation of anterior plates; (2) implantation of U-plates; and (3) implantation of intrathoracic plates. Each of these will be discussed individually. There have been no head-to-head studies comparing outcomes between these systems. Lastly, the decision to drain the pleural space is surgeon-dependent, based on the probability of violation of the pleural space and the need for drainage of fluid, be it blood or effusion, from the pleural space.
Implantation of anterior plates requires elevation of periosteal soft tissue from the anterior aspect of the rib for approximately 4–5 cm on each side of the fracture line in order to obtain at least three points of fixation on each side of the fracture line. Depending on the system being used, there may be a need to measure the thickness of the rib if the intent is to secure the plate using bicortical locking screws (i.e., screws that are locked to the plate but pierce the posterior cortex of the rib as well). This is not necessary when using a screw system that is unicortical. In this system, the screws are placed at an angle, thereby making it less likely that they will pull out, and theoretically obviating the need for fixation to the posterior cortex (Fig. 5.3).
Implantation of U-plates requires elevation of periosteal soft tissue along the superior aspect of the rib where the U-brackets will serve as hinges over the rib (Fig. 5.4). Because the screws holding these plates are locked to the back portion of the U-hinge (plate-anterior cortex-posterior cortex-plate), these plates require fixation at two points on each side of the fracture line. This means that less exposure is needed as compared to anterior plates. The system self-measures the thickness of the rib to determine the length of screw needed. However, there is a higher incidence of pleural space violation given that the plates are situated partly behind the rib.
Intrathoracic plates require VATS to identify the site of each fracture. A small incision is then made overlying this area and a drill guide is used to make a hole and introduce a guide across the rib. The plate, which has two guidewires affixed to it, is introduced via the trocar site into the chest. The guidewire is pulled up across the previously drilled hole in the rib and the plate itself is used to reduce the fracture. The plate is then secured to the rib via a screw-and-nut system from the outside of the chest wall, and the guidewire is removed (Figs. 5.5, 5.6, and 5.7).