First rib fractures (FRFs) have historically been a marker for severe trauma and poor outcomes. The aim of this study was to assess whether an association still exists between a fractured first rib and global trauma scores suffered by the patient, examine mortality rate and identify other commonly associated injuries. This study examined patients who presented to the Rockhampton Hospital with a traumatic FRF between the dates of July 2015 to June 2020. Patient demographics, mortality rate and additional injuries sustained by the patients were collected. The Injury Severity Score (ISS) was utilised and calculated for each patient. Analysis was conducted to determine associations between trauma scores and FRFs, mortality rate and other injuries sustained at the time of rib fracture. In total, 545 patients had a rib fracture with 48 patients identified as having an FRF. Median age was 50 years. Thirty-seven (77%) were male. The most common mechanism of FRF was motor vehicle/motorbike accidents (71%). Fifty percent of patients with an observed FRF had the highest global ISS of very severe, with 13% severe, 22% moderate and 15% mild. No patients died from their injuries. Of those with an FRF, 79% experienced fractures other than ribs, 75% had other rib fractures and 52% had chest injuries. A larger than expected proportion of FRFs were not associated with severe trauma scores or high mortality. These findings suggest that patients with an FRF may have a greater chance of surviving their traumatic FRF than previously reported. Clinicians should be aware of the potential for severity and other associated injuries, such as chest wall fractures and thoracic injuries, when treating a patient with a fracture of their first rib

Abstract. Purpose. Intracanal rib head penetration is a well-known entity in dystrophic scoliotic curves in neurofibromatosis type 1. There is potential for spinal cord injury if this is not recognised and managed appropriately. No current CT-based classification system is currently in use to quantify rib head penetration. This study aims to propose and evaluate a novel CT-based classification for rib head penetration primarily for neurofibromatosis but which can also be utilised in other conditions of rib head penetration. Materials and methods. The grading was developed as four grades: normal rib head (RH) position—Grade 0, subluxed ext-racanal RH position—Grade 1, RH at pedicle—Grade 2, intracanal RH—Grade 3. Grade 3 was further classified depending on the head position in the canal divided into thirds. Rib head penetration into proximal third (from ipsilateral side)—Grade 3A, into the middle third—Grade 3B and into the distal third—Grade 3C. Seventy-five axial CT images of Neurofibromatosis Type 1 patients in the paediatric age group were reviewed by a radiologist and a spinal surgeon independently to assess interobserver and intraobserver agreement of the novel CT classification. Agreement analysis was performed using the weighted Kappa statistic. Results. There was substantial interobserver correlation with mean Kappa score (k = 0.8, 95% CI 0.7–0.9) and near perfect intraobserver Kappa of 1.0 (95% CI 0.9–1.0) and 0.9 (95% CI 0.9–1.0) for the two readers. Conclusion. The novel CT-based classification quantifies rib head penetration which aids in management planning

This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or non-operative management at our center over a six-year time period. Retrospective analysis was performed to identify all patients with complex rib fractures at our center from May 2016 to September 2022. Outcome measures included mechanical ventilation, tracheostomy, pneumonia, and mortality at one year. 388 patients with complex rib fractures were identified. 37 (10%) patients fulfilled criteria for surgical management and underwent rib fracture fixation; 351 patients were managed non-operatively with anaesthetic block or analgesia alone. The fixation group had a significantly higher proportion of patients with flail chest (30 (81%) vs 94 (27%), p<0.001) and were significantly more likely to require ICU admission (30 (81%) vs. 16 (5%), p<0.001) than the non-operative group. At one year follow-up, no significant differences were seen for mortality between these groups (1 (3%) vs. 27 (7%), p=0.276). Of the surgical management group, those that underwent fixation <72 hours post injury were significantly less likely to develop pneumonia than those who were delayed >72 hours (2 (18%) vs 15 (58%), p=0.038), with downward trends noted for ICU length of stay (6 vs 10 days, p=0.140) and duration of mechanical ventilation (5 vs 8 days, p=0.177); no significant differences were seen for tracheostomy (3 vs. 5, p=0.588) or mortality (0 vs 1, p=0.856). Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Early surgical fixation led to reduced rates of pneumonia and may improve other outcome measures

Rib fracture fixation by orthopaedic and cardiothoracic surgeons has become increasingly popular for the treatment of chest injuries in trauma. The literature, though mainly limited to Level II and III evidence, shows favourable results for operative fixation. In this paper we review the literature and discuss the indications for rib fracture fixation, surgical approaches, choice of implants and the future direction for management. With the advent of NICE guidance and new British Orthopaedic Association Standards for Trauma (BOAST) guidelines in production, the management of rib fractures is going to become more and more commonplace

Historically rib fractures have been managed conservatively but over recent years evidence has continued to grow in support of fixation in select cases. Rib fractures can affect patients’ ability to adequately ventilate and increase the morbidity and mortality of patients with multiple injuries. There is increasing evidence that rib fracture fixation in certain patients is of benefit, reducing length of stay both in the Intensive Care Unit (ICU) and overall hospital stay, as well as resulting in a decreased rate of tracheostomy and pneumonia. We commenced rib fracture fixation two years ago as a combined procedure between Trauma Orthopaedics and Cardiothoracic surgery for carefully identified patients. We instituted a multi-disciplinary decision making process involving the Orthopaedic, Cardiothoracic and ICU teams. We present the initial results for these patients. Fourteen patients with a total of 49 ribs were fixed between November 2015 and August 2017. Nine patients were acute and multiply injured, with five patients treated with delayed fixation for ventilation problems following non-union of existing fractures. The average length of stay was 13 days. Follow up is ongoing with a mean follow up of 192 days. There have been no deep infections or acute complications and no incidence of peri-operative pneumothorax in this initial cohort. There have been no deaths, and all of these patients have since been discharged to their own home. The initial outcomes following the introduction of this new procedure to our unit have been encouraging, although the long term results are awaited

Rib fractures (RF) represent the most common bone fracture after blunt trauma, occurring in 10–20% of all trauma patients and leading to concomitant injuries of the inner organs in severe cases. However, a standardized classification system for serial rib fractures (SRF) does still not exist. Basic knowledge about the facture pattern of SRF would help to predict organ damage, support forensic medical examinations, and provide data for in vitro and in silico studies regarding the thoracic stability. The purpose of our study was therefore to identify specific SRF patterns after blunt chest trauma. All SRF cases (≥3 subsequent RF) between mid-2008 and end of 2015 were extracted from the CT database of our University Hospital (n=383). Fractures were assigned to anterior, antero-lateral, lateral, postero-lateral, and posterior location within the transverse plane (36° each) using an angular measuring technique (reliability ±2°). Rib level, fracture type (transverse, oblique, multifragment, infracted), as well as degree of dislocation (none, </≥ rib width) were recorded and each related to the cause of accident. In total, 3747 RF were identified (9.7 per patient, ranging from 3 (n=25) to 33 (n=1)). On average, most RF occurred in crush/burying injuries (15.9, n=13) and pedestrian accidents (12.2, n=14), least in car/truck accidents (8.8, n=76). Altogether, RF gradually increased from rib 1 (n=140) towards rib 5 (n=517) and then decreased towards rib 12 (n=49), showing a bell-shaped distribution. More RF were detected on the left thorax (n=2027) than on the right (n=1720). Overall, most RF were found in the lateral (33%) and postero-lateral (29%) segment. Posterior RF mostly occurred in the lower thorax (63%), whereas anterior (100%), antero-lateral (87%), and lateral (63%) RF mostly appeared in the upper thorax. RF were distributed symmetrically to the sagittal plane, showing a hotspot (up to 98 RF) at rib levels 4 to 7 in the lateral segment and rib level 5 in the antero-lateral segment. In the car/truck accident group, 47% of all RF were in the lateral segment, in case of frontal collision (n=24) even 60%. Fall injuries (n=141) entailed mostly postero-lateral RF (35%). In case of falls >3 m (n=45), 48% more RF were detected on the left thorax compared to the right. CPR related SRF (n=33) showed a distinct fracture pattern, since 70% of all RF were located antero-laterally. Infractions were the most observed fracture type (44%), followed by oblique (25%) and transverse (18%) fractures, while 46% of all RF were dislocated (15% ≥ rib width). SRF show distinct fracture patterns depending on the cause of accident. Additional data should be collected to confirm our results and to establish a SRF classification system

Background. The improvement of the rib cage deformity (RCD) after surgery correction has not been correlated in detail with the correction of vertebral axial rotation (AR). The loss of at the rib cage after correction has been never monitored. The hypothesis of this work was that the aesthetic improvement of RCD in adolescent idiopathic scoliosis (AIS) does not follow completely the reduction of thoracic AR after correction surgery. Moreover, lesser correction of thorax deformity could be expected in mature patients with more rigid curves. Methods. Multicenter prospective study of the modifications of the rib cage deformity in 24 patients operated because of AIS Lenke type 1A. RDC was assessed in the preoperative MRI exams including the thoracic perimeter. Vertebral AR was quantified by the RaSac angle. Anterior and posterior rib hump, and the translation of the sternum were measured in mm according to standard protocols. All these parameters were assessed in the immediate post-op period and 2-years after surgery using CT-scan axial slides. In all cases, a vertebral derotation technique performed by asymmetric rod bending was used. Immature (Risser 0–2) and mature (Risser 3–4) patients were compared. Results. Mean age of patients was 14±2 years. The preoperative curve magnitude was 56.2±8.3 Cobb degrees. RaSac at the apex was 27.2±2.8 degrees. There were 10 immature and 14 mature patients. There were no differences between the two groups in all the radiological measurements of the curves. Immature patients showed lesser posterior rib hump as compared to mature cases (14.9±4.1 mm versus 38.1±22.9; p<0.001). Postoperative vertebral AR was lesser in immature patients (2.0±1.2 versus 7.9±2.4 degrees) and increased slightly at 2-year check-up. The posterior rib hump showed also a slightly increased 2 years after surgery. In 18 cases (75%), a contralateral anterior rib hump less than 3 mm emerged after surgery that diminished but not disappeared at 2-year check-up. Conclusions. The rib cage deformity showed a lesser correction than the vertebral axial rotation. Besides this finding, immature patients showed more rib cage plasticity showing both greater modifications after surgery, and higher loss of correction during follow-up. Level of evidence. Level IV

Flail chest and multiple rib fractures are common injuries in trauma patients. Several small randomized studies have suggested significant improvements in patient outcomes with surgical fixation, compared to nonoperative management, yet emerging population-level data report some conflicting results. The objectives of this study were to compare the results of surgical fixation and nonoperative management of multiple rib fractures and flail chest injuries and to assess whether effects varied by study design limitations, including risk of confounding by indication. A comprehensive search of electronic databases (Medline, Embase, Web of Science) was performed to identify randomized controlled trials and observational studies. Random effects models were used to evaluate weighted risk ratios (RR) and mean differences (MD). Risk of confounding by indication was assessed for each study (low, medium, and high risk), and this categorization was used to stratify results for clinical outcomes. Publication bias was assessed. Thirty-nine studies, with a total of 19,357 patients met inclusion criteria. Compared to nonoperative treatment, surgical fixation of flail chest and multiple rib fractures was associated with decreased risk of death (overall RR 0.40, 95% confidence interval (CI) 0.28–0.56), pneumonia (overall RR 0.70, 95% CI 0.52–0.93), tracheostomy (overall RR 0.62, 95% CI 0.41–0.93), and chest wall deformity (overall RR 0.16, 95% CI 0.06–0.42). However, many of the observational studies were at risk of confounding by indication, and results varied according to risk of confounding by indication. Differences in ventilator time, intensive care unit length of stay (LOS), hospital LOS, and return to work will be assessed (results pending). Compared to nonoperative treatment, surgical fixation of flail chest and multiple rib fractures is associated with improved clinical outcomes. Discrepancies between some study results may be due to confounding by indication. Additional prospective randomized trials and high-quality observational studies are required to overcome potential threats to validity and to expand on existing evidence around optimal treatment of these injuries

Aim:. To evaluate the effect of intraoperative manoeuvres on the rib hump. Methods:. Patients with AIS and a thoracic rib hump that underwent a modified Suk technique of scoliosis correction were included. The Scoligauge (Ockenden net) scolimeter app was used to measure the rib hump in Adam's position and the prone position preoperatively. The Scoligauge was used again with the patient prone in theatre, at the end of exposure of the spine, after a 90 degree rod rotation manoeuvre (CD), after a segmental derotation manoeuvre (SDR) and finally at skin closure. The patients were consented for the use of the app on the senior author's mobile device. The device was double bagged for use in theatre. Results:. A sample of 15 patients were enrolled. The biggest difference to the preoperative rib hump measurement seemed to come from simply lying the patient prone. The 90 degree rod rotation manoeuvre did not make a significant further change. In contrast, the segmental derotation manoeuvre did have a positive trend to further correction of the rib hump. No infections occurred. Discussion:. The prone position makes the biggest correction to the rib hump. Further correction is achieved with the SDR. The CD manoeuvre seems to make little difference to the rib hump. In this small study, there was a definite trend to improving the rib hump by lying prone and pursuing SDR. The numbers in this study are small, and the significance of the additional correction to patient outcome is unknown. Conflict of interest:. Depuy-Synthes fund a fellow in our unit. Conflict Of Interest Statement: No conflict of interest

Purpose: To introduce our new surgical technique for better correction of scoliosis and rib hump deformity. Surgical technique: The technique consists of rib mobilization (RM) and hook rotation maneuver (HRM). RM is to release costo-vertebral connection bilaterally from T5 to T10 to mobilize ribs obtaining more flexibility of the spine. HRM is to rotate convex side hooks on transverse process ventrally pushing down the ribs, thus giving derotational force while compression force is applied. Subjects: Forty-six idiopathic cases with minimum 1 year follow-up were reviewed. The average F-up period is 15.1m( 12 – 24). The average age at surgery was 20.1 y(12–57). Conventional multiple hooks, screws, wires and rod system was used. Results: The average Cobb angle was 56.0 ( 40 – 93) degrees. The average rib hump was 22.5 mm in height and 13.9 degrees by scoliometer. At 3 w post-op, 6 m post-op, and at F-up, the average Cobb angle was 13.0 (77.9%), 15.6 (73.4%), and 16.0 (72.6%, 43 – 100%)) respectively. The average rib hump at 6m post-op and at F-up was 9.7 mm in height and 6.8 degrees, and 10.3mm and 6.4 degrees respectively. The hump index at thoracic level was 5.49 pre-op, 3.73 at 6m and 4.25 at F-up. Conclusion: Our new technique improved the correction of not only scoliosis but also thoracic hump significantly. The derotational force by HRM is weaker than direct derotation by pedicle screw. However, it is undoubtedly a safer and less expensive technique than thoracic pedicle screw, providing significant correction of rib hump

High energy chest trauma resulting in flail chest injury is associated with increased rates of patient morbidity. Operative fixation of acute rib fractures is thought to reduce morbidity by reducing pain and improving chest mechanics enabling earlier ventilator weaning. A variety of operative techniques have been described and we report on our unit's experience of acute rib fracture fixation. Over 18 months, 10 patients have undergone acute rib fracture fixation. Outcome measures included; patient demographics, time ventilated pre-operatively, time ventilated post-operatively and time spent on ITU/HDU post operatively. The mean time from presentation to surgery was 5 days (range 2–12 days). The mean time ventilated post operatively was 2 days (range 1–4 days) and the mean number of days spent on ITU/HDU post-operatively was 6 days (range 2–11 days). Our results appear positive in terms of time spent ventilated post-operatively but no conclusion can be drawn as we have no comparable non-operative group. We have however shown, that rib fracture fixation can be carried out successfully and safely in a trauma centre. Further evidence on rib fracture fixation is required from a large, multi-centre randomised controlled trial

We described a technique of measuring the flexibility of the rib prominence clinically before surgery, and aimed to analyse the results in patients with adolescent idiopathic scoliosis who underwent posterior correction with pedicle screw instrumentation. This prospective study investigated the magnitude of rib humps before and after the operation when the patient was in Adam's forward bending posture. Also preoperatively, a flexion and derotation manoeuvre was performed and the corrected rib prominence was measured. This is compared to the magnitude of the rib hump present postoperatively at three months' follow up. Seven consecutive patients with adolescent idiopathic scoliosis that underwent posterior surgical correction. Clinical measurement of rib prominence using scoliometer. The magnitude of the curve improved from a mean preoperative Cobb angle of 53.6+/−11.2° (range 45.3–72.5°) to a mean postoperative Cobb angle of 7.8+/−9.3° (range 0.4–17.6°). The mean preoperative magnitude of the rib hump was 12.3+/−6.9° (range 5-20°) which was then corrected to a mean magnitude of 1.3+/−2.2° (range 0-5°) by performing the above described flexion derotation manoeuvre. The mean postoperative magnitude of the rib hump was 3.0+/−3.1° (range 0-8°) with the patient in Adam's forward bend position. There was positive correlation between the postoperative residual rib hump and the reduced rib hump measured preoperatively using our described technique (r=0.8,p=0.05). This flexion derotation test is a useful in assessing the amount of postoperative persistent rib hump after posterior correction of adolescent idiopathic scoliosis using pedicle screw instrumentation with derotation technique

A retrospective review of patients with spinal growing rods in a single institution. Demographic data including age at first surgery, diagnosis, pre- and post-operative cobb angles from erect standardised radiographs were collected. The type of construct used i.e. spine to rib or spine to spine was noted along with the type of growing mechanism used (magnetic or cassette). Any complications were collated for each technique. Our results include 26 patients who had growing rod insertion, 12 in the spine - spine group and 14 in rib - spine group. Pre-operative cobb angles of 71 and 78 degrees respectively with a correction to 36 and 35 degrees. Mean age at surgery was 63 months in spine to spine group and 67 months in rib to spine group. Spine to spine group had 2 proximal pull out of hooks and the rib spine group had one pull out of hook. The correction achieved by the new technique is comparable to the spine – spine constructs. Complications are seen in both groups. The perceived benefit of the new technique is the proximal spine is not violated so there is a reduced risk of mass fusion. The canal and pedicles are not included proximally, so there will be no effect on the growing diameter of the canal. Biomechanically the construct is more robust and should allow greater control of the curve. Further follow up and analysis of this new technique is warranted

To evaluate the efficacy of VEPTR in preventing further progression of scoliosis without impeding spinal growth in the treatment of children with progressive early onset scoliosis (EOS) without rib abnormalities. Prospective, multi-center, observational cohort study on patients with EOS treated with VEPTR with 2-year follow up. Data were analysed based on measurements done pre-implant, immediate post-op and at 2-yr f/u. Sixty-three patients met inclusion: 35 males and 28 females. Mean age at time of implantation was 6.1±2.4 yrs. Etiologies included congenital (n=6), neuromuscular (n=36), syndromic (n=4), and idiopathic (n=17). Mean follow up was 2.2±0.4 yrs. Scoliosis (72o±18o) decreased after implant surgery (47o±17o) followed by slight increase at 2-yr f/u (57o±18o), p<0.0001. At 2-yr f/u, VEPTR was effective in treating EOS without rib abnormalities with 86% of patients having an improvement in scoliosis and 94% of patients having an increased spinal height as compared to pre-operatively. VEPTR provided greater than 100% of expected age-matched spine growth and the instrumented spinal segment continued to grow during distraction phase. This large prospective, multicentre study demonstrated the ability of VEPTER to effectively treat EOS without rib abnormalities. Goals of preventing further scoliosis progression and of maintaining normal spine growth were achieved

Subjects. A prospective study of 127 patients who underwent posterior spinal arthrodesis and segmental spinal instrumentation with iliac crest bone graft for correction of adolescent idiopathic scoliosis. Patients were divided according to their Cobb angle into two groups. Group 1 (n= 78) with a Cobb angle > 70° who underwent an additional concave rib osteotomy (CRO) and group 2 (n= 49) with a Cobb angle < 70° who did not (NCRO). All patients received a pulmonary rehabilitation programme post-operatively. Vital capacity (VC) and peak expiratory flow rate (PEF) were measured pre-operatively, at 3 months and 12 months post-operatively. Summary of background data. Concave rib osteotomy technique is used for giving more mobility and flexibility of the spine during correction especially in rigid and severe curves. Only a few studies in the literature have looked at the effect of concave rib osteotomy on pulmonary function. Results. ∗Curve correction: the mean Cobb angles at the pre-operative and final follow-up for group 1 (CRO) were 82.2° and 10.9° respectively (87% correction). In group 2 (NCRO), the mean Cobb angle was 62.77% pre-operatively and 6.9% at the final follow-up (89% correction achieved). ∗Pulmonary function: Pre-operative: there was no significant difference between the 2 groups. 3 Months post-operative: the mean VC was 40.4% in group 1 and 48.05% in group 2 (p=0.05). The mean PEF was 27.38 % in group 1and 34.1% in group 2 (p = 0.02). 12 Months post-operative: the mean VC in group 1 was 102.4% versus 103.5% in group 2 (p = 0.43). The mean PEF in group 1 was 76.2% versus 73.5% in group 2 (p = 0.32). Conclusions. Concave Rib Osteotomy technique has a definite effect on the pulmonary function in the early post-operative period. However, this difference resolves with time and both groups had a similar outcome a year post-operatively

Introduction: Concave ribs are in a position to act as a butttress preventing the reduction of the spine towards the midline. Segmental concave ribs osteotomy decrease the buttress effect increases the flexibility of the curve and allow the spine to approach a more mideline position. Purpose: To analyze radiographic and perioperative data in patients undergoing posterior thoracic instrumented fusion and concave ribs osteotomies. Methods: 34 patients with rigid thoracic curves treated with hybrid constructs (hooks, wires and pedicle screw) and concave rib osteomies( averaged 5) between 2000 and 2003 are included. All patients obtained pre-operative upright and bending films and postoperative upright films. Cobb angle was collected and three parameters were assessed: percent flexibility, percent scoliosis correction and the percent bend corecction. Main age was 14 years with 20 females and minimun follow up 1 year. Results: There were 13 A.I.S., 8 neuromuscular cases and the rest associate to different pathologies (syringomyelia, cardiopathy ect.). Preoperative thoracic curve averaged 78(60–112); percent bend correction veraged 25% and postoperative correction averaged 58%. There were no neurological complications, 4 patients developed pulmonary complications ( pleural effusion) who required suction drenage. Conclusions. Rigid curves undergoing concave rib osteotomies achieved a postoperative curve that was 58% of the preoperative bend curve. Concave rib osteomomies increase flexibility of severe rigid curves avoiding anterior realese in the great majority of large curves with minimmal pulmorary complication. Overlapping the osteotomized ribs on the concave rod the chest asymmetry improves and the cosmetical result of the operation is improved

Study Design: Retrospective chart review. Objective: To assess the pulmonary function and rib deformity of patients following Schollner and modified Schollner costoplasty. Little is described in the literature concerning the long term effects of costoplasty. Methods: Retrospective analysis of patients undergoing costoplasty at our institution with a minimum of three year and a maximum of 22 years follow-up. Subjects: 23 (20 female) patients with a primary diagnosis of late-onset idiopathic scoliosis with a rib hump deformity underwent costoplasty at age 25 (16–36). 10 had surgery on the convexity alone and 13 had additional ‘concave surgery’ (6 of these had silastic implants). 3 patients had simultaneous correction of spinal deformity and costoplasty. The remainder underwent delayed procedures (0.6–19 years) following the index operation. Harrington instrumentation was used in all patients for primary curve correction. Outcome measures: Forced Vital Capacity (FVC) – including % normal expected for age and rib hump (clinically and from radiographs) were measured pre and post-operatively at each attendance to assess the outcome of the procedure. Results: The mean follow up was 10.7 years (3–22). Average reduction in rib hump was 33 mm at 6 months and 25 mm at the latest follow-up. There was no significant difference in the pre-operative and long-term FVC (p=0.4, paired t-test), although 6 months post-operatively there was a significant reduction in FVC (p=0.03, paired t-test). Subgroup analysis (convex only, convex/concave without silastic implant, convex/concave with silastic implant) revealed a similar pattern for rib hump correction and maintenance of FVC in all 3 groups at latest follow-up. However for patients undergoing convex surgery alone, the difference between FVC at 6 months and at latest follow-up was significant (p=0.01, paired t-test). Conclusions: Rib hump correction and lung function (even accounting for age) are preserved in the long term following costoplasty. This study does not show any benefit of additional surgery on the concavity of the curve in reducing the rib hump on the convexity or on the FVC

Introduction. Adolescent idiopathic scoliosis accounts for 80–85% of all lateral curvatures, and negatively affects pulmonary functions. The concave rib osteotomy technique is designed to provide additional mobility and flexibility of the spine, especially for rigid curves during correction. Only a few studies have investigated the effect of concave rib osteotomy on pulmonary functions. Methods. We undertook a prospective study of 127 patients who underwent posterior spinal fusion for correction of adolescent idiopathic scoliosis. Patients were divided according to their Cobb angle into two groups: group 1 (n=78) with a Cobb angle greater than 70° who underwent an additional concave rib osteotomy (CRO); and group 2 (n=49) with a Cobb angle less than 70° who did not (NCRO). All patients received a programme of pulmonary rehabilitation immediately after the operation for 1 year. Vital capacity (VC) and peak expiratory flow rate (PEF) were measured preoperatively, at 3 months and 12 months postoperatively, and at 5 years postoperatively. Results. In group 1 (CRO), the mean Cobb angle was 82·2° (□}22·78°) preoperatively and 10·9°(□}8·33°) at 1 year follow-up (87% correction). In group 2 (NCRO), the mean Cobb angle was 62·77° (□}18·43°) preoperatively and 6·9°(□}7·69°) at 1 year follow-up (89% correction). Preoperatively there was no significant difference in pulmonary functions between the two groups, with mean VC of 85·2% (□}33·7) in the CRO group and 90·1% (□}38·9) in the NCRO group (p=0·22) and mean PEF of 59·8% (□}27·4) and 52·2% (□}30·3), respectively (p=0·32). Postoperatively, mean VC was 40·4% (□}23·74) in the CRO group (52% reduction) and 48·05% (□}29·13) in the NCRO group (47% reduction) (p=0·05). Mean PEF was 27·38% (□}17·35) in the CRO group (54% reduction) and 34·1% (□}21·8) in the NRCO group (45% reduction) (p=0·02). 12 months postoperatively, mean VC was 102·4% (□}31·5; 150% improvement) and 103·5% (□}40; 115% improvement), respectively (p=0·43). Mean PEF was 76·2% (□}24·5; 170% improvement) and 73·5% (□}35·6; 117% improvement), respectively (p=0·32). 5 years postoperatively, mean VC was 111·84% (□}33·95; 0·09% improvement) and 114% (□}29·6; 0·10% improvement), respectively (p=0·086). Mean PEF was 82·56% (□}36·8; 0·08% improvement) and 82·3% (□}27·1; 0·11% improvement), respectively (p=0·26). Conclusions. Concave rib osteotomy technique has a definite immediate effect on pulmonary functions postoperatively; however, this difference resolves with application of pulmonary rehabilitation programme in both groups and outcome is similar 1 year postoperatively. 5 years later we recorded no significant differences between groups

130 patients with idiopathic thoracic scoliosis were operated on by means of the same anterior instrumentation principle in the period from 1987 through 1998. There were 21 males and 109 females in the age of 16(±4). Patients were randomly chosen in the group with rib hump apical osteotomy added to the anterior instrumentation (group 1) and the group with the anterior instrumentation without rib hump osteotomies (group 2). A prospective study was performed. Preoperative and postoperative gibbometry was performed. Results were as follows: frontal correction: 67% for group 1., and 74% for group 2. Rib hump changed from 23 ± 15 to 6 ± 6.2 (74%) for group 1, and 20 ± 1.5 mm (62%) for group 2. Rib valley changed from 21 ± 11 to 7 ± 4 (63%) (group 1) and 37 ± 2.8 to 16 ± 3.4 (56%) (group 2). There were 4 hematothoraxes in group 2. and no haematothoraxes in group 1. It seems that rib hump osteotomy has no inßuence upon frontal scoliosis correction, and little inßuence upon rib valley correction. Signiþcant inßuence was noted upon rib hump correction. It might be that better spinal release and consecutive smaller corrective forces resulted in absence of haematothoraxes in group 1

Most workers consider that ribcage changes in AIS are secondary to spinal deformity. Others claim that ribs are pathogenic in curve initiation or aggravation. In 117 consecutive patients referred from school screening in 1996–99 and routinely scanned by ultrasound, 24 had thoracic and 33 thoracolumbar scolioses (right 37, left 20; mean age 14.9 years, range 12–18 years, girls 44 postmenarcheal 37, boys 13). On anteroposterior standing radiographs, Cobb angle (CA), apical vertebral rotation (AVR, Perdriolle) and apical vertebral translation (AVT from the T1-S1 line) were measured (mean & range: CA 19°, 6–42°; AVR 15°, 0–39°; AVT 17 mm, 0–38 mm). Real-time ultrasound in the prone position recorded laminal rotation (LR) and rib rotation (RR) segmentally and the spine-rib rotation difference (SRRD) as LR minus RR to estimate the combined rib deformity in the transverse plane using for thoracic curves apical LR and RR and for thoracolumbar curves T12 LR and T12 RR (mean LR 8.3°, RR 3.8°, SRRD 5.2° absolute). All deformity parameters, radiological and ultrasound, are unrelated to age. SRRD correlates significantly with each of AVR (r=0.753 p< 0.0001), Cobb angle (r=0.738 p< 0.0001), and AVT (r=0.725 p< 0.0001). Partial correlation analysis shows AVR rather than AVT is associated with the transverse plane rib deformity (SRRD/AVR controlling for AVT r=0.386 p=0.004; SRRD/AVT controlling for AVR r=0.257 p=0.058; SRRD/CA controlling for AVR r=0.260 p=0.055 and for AVT r=0.223 p=0.101). These and other findings suggest that rib rotation in thoracic curves is associated with AVR and AVT and in thoracolumbar curves more with AVR than AVT each within the 4. th. column of the spine