Discussion
This case demonstrates that effective CPR after rib plating is possible without prosthetic fracture, periprosthetic fracture, screw pullout, or other deformation of the reconstructed chest wall.
Key metrics for high-quality CPR according to the American Heart Association include insuring adequate CCC depth and achieving complete chest wall recoil (7). The forces needed for effective compressions put significant stress on the rib cage. Skeletal chest injuries from CPR are well documented among individuals without prior rib fractures. The incidence of rib fractures after CPR is reported in over 70% of CPR cases, with a mean number of 7.6 broken ribs per person (8). Despite their rarity, these fractures can result in fatal injuries such as cardiac laceration and pericardial tamponade (1,2). Significant forces required for effective CCC raises the potential concern that a reconstructed chest wall with plate may impede the delivery of chest compressions. Successful CPR implies both ROSC and an uncomplicated neurological recovery (9). Our patient was neurologically intact and achieved ROSC after the first cardiac arrest. Likewise, he had ROSC after the second arrest, but the extent of neurological impairment remains unknown. We conclude that effective CPR is feasible after SSRF.
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While SSRF does not appear to impede the delivery of CPR, hardware failure is a legitimate concern due to the application of significant forces to the rib plating system and landing site. For the SSRF hardware to withstand the compressive dynamics of CCC, the implants must be capable of demonstrating both immense strength and dynamic flexibility. Newer systems demonstrated low profile and easier insertion, but achieved the optimal balance of flexibility and strength to mimic normal rib function. Anatomic, pre-contoured plates have been designed and tested to permit not only regular breathing but also to withstand the stress of respiration and other functions of the chest wall. One prospective study following patients that had been treated with the MatrixRIB fixation system found no accounts of hardware failure or loss of initial fixation among 91 rib plates placed at their 6-month follow-up (10). Additionally, the use of bicortical engagement screws through the chest wall cortex and pleural cortex, along with the threaded screw head that engages in threaded plate holes that lock the screw, confers additional plate security and prevents pullout (11). In fact, an in vitro biomechanical study estimated that the combined approach of flexible rib plating with locking screw fixation not only prevents screw loosening and pullout, but can restore up to 77% of the native rib strength (12).
Despite the advances in the rib plating system technology, hardware failure such as screw pullout and additional rib fractures as a result of a single cycle of CPR after SSRF is possible (6). However, our patient experienced neither hardware failure nor additional rib fractures even after receiving multiple extended rounds of CPR at less than 1 week postoperatively. Further reports are needed to elucidate a more delayed effect of CPR on rib plates.
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Category: WHY
