Disruption Junction: A Chest Wall Injury Society Survey on Costal Margin Rupture, Intercostal, Diaphragmatic, And Abdominal Wall Hernia Diagnosis and Management
Abstract
Mark Kryskow*, Mathieu Wijffels, Evert Eriksson, Joseph Forrester, Peter Cole, Andrew Doben, Zachary Bauman, Thomas White, SarahAnn Whitbeck and John Edwards
Background: Costal margin rupture (CMR), intercostal hernia (IH), diaphragm rupture (DR) non-union fracture (NURF) are poorly described and management remains unclear. CT analysis is recognized as essential for identifying CMR/IH/DR/NURFs. We hypothesized 1) CT recognition of these injuries is variable and, 2) debate exists regarding the non-operative and operative management.
Methods: We utilized the Chest Wall Injury Society (CWIS) Thoracic Injury Correlation Collaboration (TICC) to survey surgeons. Practice demographics were collected; 9 cases, all with standard 3-view CT were shown. Diagnoses were determined by surgical treatment and defined the gold standard. Participants were asked to 1.) identify the presence of CMR, IH, DR, or NURF and, 2.) select combined surgical/nonsurgical approaches.
Results: The TICC survey was sent to 493 individual surgeons with 36 responses. Surgeons characterized as trauma 61%, thoracic 56%, orthopedic 6%, and general 17%. They represented 15 countries. They treated the following number of patients with CMR per year: 0 – 11%, 1-2 39%, 3-5 31%, 6-10 8%, >10 11%. Agreement in diagnosis was made for CMR 80%, DR 66%, IH 84%, and NURF 81%. Agreement in identification of all components was a median of 43%. Comparing surgeon agreement to the number of CMR repairs per year 0 vs 1-2 vs 3-5 vs 6-10 vs >10 revealed the following results: 25% vs 83% vs 100% vs 89% vs 89%, p= 0.027. Favored techniques for repair are: CMR- titanium plates, 67 – 84%; DH- mesh 50 – 86% and suture 57 – 83%; IH- double layer mesh 12 – 61%; NURF-titanium plates 93 – 100%.
Conclusion: Identification and treatment of CMR, IH, DR, and NUF remains variable and detecting all 4 components of these injuries is uncommon. Experience with CMR seems to relate to ability to recognize injuries on CT scan. Further evaluation of methods to detect, characterize, and treat these injuries are warranted.