For patients who break just one rib, or who don’t have flail chest, the surgery usually isn’t worth the trauma; standard treatment is to leave the rib alone. “You take aspirin, go home, and suffer,” says Mackay. “For weeks.” He knows from personal experience: A few years ago he broke several ribs in a car accident. The native of South Africa with strong Scottish roots managed to play the bagpipes at his nephew’s wedding four weeks later, but it was excruciating.
A broken rib hurts like hell every time the broken ends move, which is every time you breathe. That can lead to more serious problems, especially for older patients and others whose lung capacity is limited. To minimize the pain, you breathe as shallowly as possible, which leads to fluid build-up in the lungs, which leads to infections, which puts you on a ventilator—or in the morgue. Because of how much they compromise the ability to breathe normally, broken ribs are the second leading cause of trauma deaths.
To devise a better way to ‘fix,’ or stabilize, broken ribs, Mackay and Dillon enlisted the help of Dr. Randy Haluck, chief of minimally invasive surgery at the Medical Center, and Barry Fell, a biomedical engineer whose company, TPC Design, specializes in orthopedic devices such as artificial hips and knees. Like Mackay, Fell has gone through the pain of broken ribs—in his case, many times, most due to his lifelong enthusiasm for playing ice hockey.
The Penn State group thought attaching the plate to the inner surface of the broken rib, the side facing the lungs, would be less traumatic than the standard procedure, because it would leave the overlying tissue largely undisturbed. A device already existed for doing some types of minimally invasive surgery in the chest: the thoracoscope, which carries a fiber-optic cable through a short slit in the chest wall and transmits live images to a video monitor. The view from a thoracoscope inserted low in the ribcage looks like a room in a cave, the smooth arched walls glistening pink and white. From this vantage point, many of the ribs are visible and could be fixed without repositioning the scope. The surgeon can see exactly where the break is—something not always possible from the outside or even with an x-ray. “Once you are oriented to where things are, you have a wonderful, magnified, high-definition view,” says Haluck.
While the surgeons considered how to use a thoracoscope to fix ribs, Fell did what comes naturally to an engineer: He tinkered.
“He ended up going to Giant and getting a side of ribs from the meat department,” says Dillon. “He called me up one day and said, ‘Hey, come on over. I put some plates and screws into some ribs; what do you think?’ ”
Fell’s plates looked good: solid, secure. Splinting ribs from the inside would work from a mechanical perspective. But was it do-able in real life? The thoracoscope would let them see into the chest; next they had to figure out how to get the hardware in and attach it to the broken ribs, without making a big incision.
“You need to hold the screw; you need to get the screw and the plate to the right angle and location,” says Haluck. “And how do you then introduce a screwdriver that goes in, down, and up? Consider all the angles that you have in here, and where the breaks might be.
“It’s like building a ship in a bottle, with two or three parts simultaneously.”