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Annals of Surgery Jun 2023Neurogenic thoracic outlet syndrome (TOS) is a musculoskeletal condition in which the brachial plexus is dynamically compressed within the scalene triangle, an anatomic... (Review)
Review
INTRODUCTION
Neurogenic thoracic outlet syndrome (TOS) is a musculoskeletal condition in which the brachial plexus is dynamically compressed within the scalene triangle, an anatomic space bordered by the anterior and middle scalene muscles and the first rib. In some cases, an offending cervical rib is present. Traditional surgical approaches to first rib resection and scalenectomy are limited by exposure, require retraction of neurovascular structures, and result in morbidity.
METHODS
We describe a novel transthoracic robotic approach to first/cervical rib resection that overcomes these limitations, and we review its early clinical outcomes.
RESULTS
Robotic first rib resection (FRR) is crystallized into 12 distinct steps, each with detailed video commentary, and nuances specific to neurogenic and venous TOS cases are provided. Published data supports decreased surgical morbidity of robotic FRR compared with open cases.
CONCLUSIONS
Robotic FRR offers advantages over traditional operative approaches including improved exposure and elimination of retraction of neurovascular structures, which result in improved safety.
Topics: Humans; Cervical Rib; Robotic Surgical Procedures; Decompression, Surgical; Thoracic Outlet Syndrome; Ribs; Treatment Outcome
PubMed: 34596078
DOI: 10.1097/SLA.0000000000005232 -
The Journal of Trauma and Acute Care... Dec 2022Classical teaching of rib anatomy contends that the false ribs (7th to 10th) fuse anteriorly to form the costal margin of the chest. Slipped rib syndrome consists of...
BACKGROUND
Classical teaching of rib anatomy contends that the false ribs (7th to 10th) fuse anteriorly to form the costal margin of the chest. Slipped rib syndrome consists of false rib subluxation into the thorax with symptomatic impingement of the intercostal nerve. We sought to determine the incidence of this anatomic finding through anatomic study of the costal margin.
METHODS
Cadavers were evaluated for mobility and attachment of the ninth and tenth ribs. Experienced anatomists and chest wall surgeons conducted a standardized dissection and assessed rib tip mobility using predefined criteria. Videos of dissections were submitted to a single investigator who reviewed the findings.
RESULTS
Costal margins of 40 cadavers (45% male) were evaluated bilaterally. The average age was 83 years ± 11 years. The ninth rib was found to be attached to the eighth rib 100% of the time by an interchondral cartilaginous attachment along the body of the eighth and ninth ribs. Internal subluxation was noted in 19% (15 of 80), and the tip of the rib was mobile in 86% (69 of 80) evaluations. The tenth rib was attached to the ninth rib in 18%(14/80). A "floating" 10th rib was noted in 59% (47 of 80) of specimens. Subluxation was noted in 33% (26 of 60). Half of the ribs that subluxed moved medially to the ninth rib and half moved externally. An upwardly hooked tip was noted in 10% (8 of 80). Ribs with a hooked tip subluxed in 63% (5 of 8), and all of these ribs (5 of 5) moved to the interior of the chest ( p = 0.020).
CONCLUSION
The ninth rib is commonly attached to the eighth rib, but the tenth rib is often not attached to the ninth rib. Most commonly, the tenth rib is a "floating" rib. Internal subluxation of the tenth rib as well as the presence of a hooked tip may predispose individuals to the development of "slipped rib syndrome."
LEVEL OF EVIDENCE
Diagnostic Tests or Criteria; Level III.
Topics: Humans; Male; Aged, 80 and over; Female; Pilot Projects; Ribs; Cadaver; Thoracic Wall; Joint Dislocations
PubMed: 36121266
DOI: 10.1097/TA.0000000000003792 -
The Laryngoscope Aug 2022Current methods of assessing rib cartilage dimensions for laryngotracheal reconstruction (LTR) are inexact, making surgical planning difficult. The purpose of this study...
OBJECTIVES/HYPOTHESIS
Current methods of assessing rib cartilage dimensions for laryngotracheal reconstruction (LTR) are inexact, making surgical planning difficult. The purpose of this study was to determine the most appropriate rib for costal cartilage graft LTR to minimize the number of ribs harvested and improve surgical outcomes.
STUDY DESIGN
Retrospective review.
METHODS
Computed tomography imaging of chest scans in 25 children aged 1 to 18 years was evaluated. The lengths and widths of medial and lateral cartilaginous segments of ribs 4 to 7 were measured bilaterally. Right and left cartilaginous rib dimensions were compared using a two-sample t-test. Linear mixed-effect regression was performed to develop models quantifying the relationship between rib size and patient height, rib side, and rib number.
RESULTS
Regression analysis established strong models for medial rib length (R = 0.89) and for medial and lateral rib width (R = 0.71, 0.77, respectively). There was no difference in rib dimensions across chest sides. Rib length and width increased with child height. Total cartilaginous rib length increased from superiorly to inferiorly, primarily due to an increase in the dimensions of the medial portion of each rib.
CONCLUSION
Cartilaginous rib lengths and widths were associated with patient height, with taller children having longer ribs. Inferior ribs were longer than superior ribs, suggesting that inferior ribs may be preferred for LTR. There was no difference in cartilaginous rib length across chest side. Results may help surgeons with preoperative planning.
LEVEL OF EVIDENCE
NA Laryngoscope, 132:1682-1686, 2022.
Topics: Cartilage; Child; Costal Cartilage; Humans; Retrospective Studies; Ribs; Tomography, X-Ray Computed
PubMed: 34687469
DOI: 10.1002/lary.29914 -
Spine Deformity Nov 2023The Law Of Diminishing Returns (LODR) has been demonstrated for traditional growing rods, but there is conflicting data regarding the lengthening behavior of...
PURPOSE
The Law Of Diminishing Returns (LODR) has been demonstrated for traditional growing rods, but there is conflicting data regarding the lengthening behavior of Magnetically Controlled Growing Rods (MCGR). This study examines a cohort of patients with early-onset scoliosis (EOS) with rib-to-spine or rib-to-pelvis-based MCGR implants to determine if they demonstrate the LODR, and if there are differences in lengthening behaviors between the groups.
METHODS
A prospectively collected multicenter EOS registry was queried for patients with MCGR with a minimum 2-year follow-up. Patients with rib-based proximal anchors and either spine- or pelvis-based distal anchors were included. Patients with non-MCGR, unilateral constructs, < 3 lengthenings, or missing > 25% datapoints were excluded. Patients were further divided into Primary-MCGR (pMCGR) and Secondary-MCGR (sMCGR).
RESULTS
43 rib-to-spine and 31 rib-to-pelvis MCGR patients were included. There was no difference in pre-implantation, post-implantation and pre-definitive procedure T1-T12 height, T1-S1 height, and major Cobb angles between the groups (p > 0.05). Sub-analysis was performed on 41 pMCGR and 19 sMCGR rib-to-spine patients, and 31 pMCGR and 17 sMCGR rib-to-pelvis patients. There is a decrease in rod lengthenings achieved at subsequent lengthenings for each group: rib-to-spine pMCGR (rho = 0.979, p < 0.001), rib-to-spine sMCGR (rho = 0.855, p = 0.002), rib-to-pelvis pMCGR (rho = 0.568, p = 0.027), and rib-to-pelvis sMCGR (rho = 0.817, p = 0.007). Rib-to-spine pMCGR had diminished lengthening over time for idiopathic, neuromuscular, and syndromic patients (p < 0.05), with no differences between the groups (p > 0.05). Rib-to-pelvis pMCGR neuromuscular patients had decreased lengthening over time (p = 0.01), but syndromic patients had preserved lengthening over time (p = 0.65).
CONCLUSION
Rib-to-spine and rib-to-pelvis pMCGR and sMCGR demonstrate diminished ability to lengthen over subsequent lengthenings.
PubMed: 37450222
DOI: 10.1007/s43390-023-00718-6 -
The Korean Journal of Thoracic and... Aug 2017Rib fractures are a common injury resulting from blunt chest trauma. The most important complications associated with rib fractures include death, pneumonia, and the... (Review)
Review
Rib fractures are a common injury resulting from blunt chest trauma. The most important complications associated with rib fractures include death, pneumonia, and the need for mechanical ventilation. The development of new osteosynthesis materials has stimulated increased interest in the surgical treatment of rib fractures. Surgical stabilisation, however, is not needed for every patient with rib fractures or for every patient with flail chest. This paper presents an easy-to-use evidence-based algorithm, developed by the authors, for the treatment of patients with flail chest and isolated rib fractures.
PubMed: 28795026
DOI: 10.5090/kjtcs.2017.50.4.229 -
Seminars in Pediatric Surgery Jun 2018Slipping rib syndrome (SRS) is an under-diagnosed cause of intermittent, yet often debilitating lower rib and abdominal pain. SRS is caused by a hypermobility of the... (Review)
Review
Slipping rib syndrome (SRS) is an under-diagnosed cause of intermittent, yet often debilitating lower rib and abdominal pain. SRS is caused by a hypermobility of the anterior false ribs that allows the 8-10 ribs to slip or click as the cartilaginous rib tip abuts or slips under the rib above. Pain occurs from impingement of the intercostal nerve passing along the undersurface of the adjacent rib. Studies consistently find patients reporting months to years of typical pain symptoms, unnecessary tests and procedures prior to diagnosis. SRS is a clinical diagnosis, but dynamic ultrasound can be helpful for confirmation or diagnosis in difficult cases. Resection of the slipping rib cartilages is the mainstay of treatment, with good results for pain relief. Rib stabilization is an emerging option for recurrent symptoms.
Topics: Abdominal Pain; Humans; Musculoskeletal Diseases; Musculoskeletal Pain; Orthopedic Procedures; Ribs; Syndrome
PubMed: 30078490
DOI: 10.1053/j.sempedsurg.2018.05.009 -
Journal of Clinical Medicine Dec 2023Slipping rib syndrome (SRS) is a disorder that occurs when one or more of the eighth through tenth ribs become abnormally mobile. SRS is a poorly understood condition... (Review)
Review
Slipping rib syndrome (SRS) is a disorder that occurs when one or more of the eighth through tenth ribs become abnormally mobile. SRS is a poorly understood condition leading to a significant delay in diagnosis and therapeutic management. History and a physical exam are usually sufficient for a diagnosis of SRS. The utility of dynamic ultrasounds has also been studied as a useful diagnostic tool. Multiple surgical techniques for SRS have been described within the literature. Cartilage rib excision (CRE) has been the most common technique utilized. However, the literature has shown a high rate of recurrence and associated risks with the procedure. More recently, minimally invasive rib fixation and costal cartilage excision with vertical rib plating have been shown as successful and safe alternative techniques. This may be an effective, alternative approach to CRE in adult and pediatric populations with SRS.
PubMed: 38137739
DOI: 10.3390/jcm12247671 -
Journal of Anatomy Jan 2022The morphology of the rib cage affects both the biomechanics of the upper body's musculoskeletal structure and the respiratory mechanics. This becomes particularly...
The morphology of the rib cage affects both the biomechanics of the upper body's musculoskeletal structure and the respiratory mechanics. This becomes particularly important when evaluating skeletal deformities, as in adolescent idiopathic scoliosis (AIS). The aim of this study was to identify morphological characteristics of the rib cage in relation to the lung in patients with non-deformed and scoliotic spines. Computed tomography data of 40 patients without any visible spinal abnormalities (healthy group) and 21 patients with AIS were obtained retrospectively. All bony structures as well as the right and left lung were reconstructed using image segmentation. Morphological parameters were calculated based on the distances between characteristic morphological landmarks. These parameters included the rib position, length, and area, the rib cage depth and width, and the rib inclination angle on either side, as well as the spinal height and length. Furthermore, we determined the left and right lung volumes, and the area of contact between the rib cage and lung. Differences between healthy and scoliotic spines were statistically analysed using the t-test for unpaired data. The rib cage of the AIS group was significantly deformed in the dorso-ventral and medio-lateral directions. The anatomical proximity of the lung to the ribs was nearly symmetrical in the healthy group. By contrast, within the AIS group, the lung covered a significantly greater area on the left side of the rib cage at large thoracic deformities. Within the levels T1-T6, no significant difference in the rib length, depth to width relationship, or area was observed between the healthy and AIS groups. Inferior to the lung (T7-T12), these parameters exhibited greater variability. The ratio between the width of the rib cage at T6 and the thoracic spinal height (T1-T12) was significantly increased within the thoracic AIS group (1.1 ± 0.08) compared with the healthy group (1.0 ± 0.05). No statistical differences were found between the lung volumes among all the groups. While the rib cage was frequently strongly deformed in the AIS group, the lung and its surrounding ribs appeared to be normally developed. The observed rib hump in AIS appeared to be formed particularly by a more ventral position of the ribs on the concave side. Furthermore, the rib cage width to spinal height ratio suggested that the spinal height of the thoracic AIS-spine is reduced. This indicates that the spine would gain its growth-related height after correcting the spinal deformity. These are the important aspects to consider in the aetiology research and orthopaedic treatment of AIS.
Topics: Adolescent; Humans; Kyphosis; Lung; Retrospective Studies; Rib Cage; Scoliosis; Thoracic Vertebrae
PubMed: 34346505
DOI: 10.1111/joa.13528 -
Zentralblatt Fur Chirurgie Jun 2019The therapy of rib fractures is controversially discussed. Neither does an osteosynthesis have to be performed for each individual rib fracture, nor is the internal...
The therapy of rib fractures is controversially discussed. Neither does an osteosynthesis have to be performed for each individual rib fracture, nor is the internal splinting by ventilation or respiratory therapy sufficient for each patient. Rib fractures are common in polytrauma patients after car and motorcycle accidents or falls from great heights. However, rib fractures are also increasingly occurring in older patients with falls from low heights. Anamnesis and clinical examination are groundbreaking for the diagnosis and therapy decision of rib fractures. In radiological diagnostics, projection radiography comes first, followed by sonography and CT. Computed tomography should be required for planning an operation. Accompanying injuries must be taken into account when deciding on therapy. We see a complicated organ injury, dislocated rib serial fractures, flail chest and respiratory insufficiency as indications for rib stabilization. As a relative indication for rib stabilization, we see a high suffering pressure due to pain and an intrathoracic volume restriction due to dislocated rib serial fractures. New osteosynthesis material and minimally invasive techniques standardize the procedure and minimize surgical trauma. In any case, adequate pain and respiratory therapy are always crucial for successful treatment.
Topics: Flail Chest; Humans; Radiography; Respiratory Insufficiency; Rib Fractures
PubMed: 31167271
DOI: 10.1055/a-0774-3401 -
Bulletin of the Hospital For Joint... Jan 2017Rib fractures are extremely common injuries and vary in there severity from single nondisplaced fractures to multiple segmental fractures resulting in flail chest and... (Review)
Review
Rib fractures are extremely common injuries and vary in there severity from single nondisplaced fractures to multiple segmental fractures resulting in flail chest and respiratory compromise. Historically, rib fractures have been treated conservatively with pain control and respiratory therapy. However this method may not be the best treatment modality in all situations. Operative fixation of select rib fractures has been increasing in popularity especially in patients with flail chest and respiratory compromise. Newer techniques use muscle sparing approaches and precontoured locking plate technology to obtain stable fixation and allow improved respiration. Current reports shows that rib fracture fixation offers the benefits of improved respiratory mechanics and improved pain control in the severe chest wall injury with resultant improvement in patient outcomes by decreasing time on the ventilator, time in the intensive care unit, and overall hospital length of stay.
Topics: Fracture Fixation; Fracture Healing; Humans; Length of Stay; Postoperative Complications; Recovery of Function; Rib Fractures; Risk Factors; Time Factors; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 28214457
DOI: No ID Found