Costal Margin Reconstruction for Complex Slipping Rib Syndrome

Costal margin reconstruction is a challenging technique but addresses the needs of slipping rib syndrome patients with complicating features including skeletal hypermobility disorders, multiple ipsilateral slipping ribs, rib deformities, and failed prior slipping rib operations. In this video, surgeons demonstrate the technique.

To begin the surgery, a single-lumen endotracheal tube was placed. The patient was placed in the semilateral decubitus position with the slipped rib tips facing directly upward. The operative table was kept level to normalize rib spacing. The slipping rib anatomy was palpated, and correct rib count confirmed. Nerve blocks were then placed.

Next, a 4 cm incision was centered between the slipping rib tips. External oblique fascia was divided, and muscle fibers were separated along their course. Areolar tissue was divided radially outward to expose the external surface of the lower ribs, and a small wound protector was placed submuscularly.

This patient had slipping ninth and tenth ribs and Ehlers-Danlos skeletal hypermobility disorder. In this disorder and related hypermobility disorders, an appearance of the entire costal margin being “unwound” as the costal cartilages sweep around the arch medially, rather than being fused into one solid bundle of cartilage, is often found. The eighth rib, in this case, was robust and could serve as the anchor point for reconstruction.

The tips of ribs nine and ten were completely disconnected from the costal margin and had lost all joints with the surrounding ribs. They were only retained in place by ligaments that extended up to the sternum. Each slipping rib can sublux internally, traumatizing the nerve above it. The hooked tips can jab inward and become locked up or irritate the diaphragm. The minimal intercostal space between these hooks is inadequate for the intercostal nerves to exist without impingement. The surgical team excised most of the hooked portions in this case to relieve the compression points and harvest donor cartilage for use in reconstruction.

Costal cartilage excision technique shells out the cartilage but leaves the adjacent intercostal muscles, perichondrium, and neurovascular bundles. Gentle electrocautery and a small periosteal elevator were used to scrape the perichondrium away from the cartilage. A useful technique to use once perichondrial flaps are elevated is to divide the cartilage at the point of desired length using small rongeurs. The cartilage can then be gently dissected out working medially.

At this point, the ninth and tenth costal cartilages had been removed back to where the ribs were straight. This allowed for linear reconstruction along the plane created by the remaining arch as a new costal margin was constructed.

The autograft cartilage spacers were then prepared. Two 1.5 cm segments were cut and two small drill holes were placed through each graft, superior to inferior. The grafts were then placed into the recipient sites parallel with the ribs. The perichondrium on the ribs was left intact to ensure structural integrity. If the intercostal muscle were to divided, it would risk allowing the graft to rest directly on the intercostal nerve, which lies immediately deep to the muscle layer. This should be avoided.

A 2 mm permanent tape suture was then placed with a free needle through the eighth rib, starting superior and penetrating through most of the rib’s height without penetrating the underlying pleura. The needle was then drawn out of the rib just above its inferior border, avoiding the nerve. The suture was then threaded through a predrilled hole in the graft and driven through the ninth rib, the second graft, and then the tenth rib. It was then passed in reverse direction through the same structures and tied above the eighth rib. The new costal margin was complete and ready for bioabsorbable plating. The plate was cut to the appropriate length to span from rib eight and along the new costal margin down to rib ten. Each rib was sutured firmly to the plate, avoiding the nerves.

At this point, the reconstruction was complete. Palpation of the intercostal spaces revealed adequate territory for the intercostal nerves to exist without compression. Pressure applied to any of the lower ribs demonstrated the entire construct to move as a unit, rather than with individual rib hypermobility. Flexibility of the bioabsorbable plate allowed for natural costal margin flexion with normal body movements. Finally, the incision was closed in multiple layers to complete the operation.

References

1. Hansen AJ, Toker A, Hayanga J, Buenaventura P, Spear C, Abbas G. Minimally Invasive Repair of Adult Slipped Rib Syndrome Without Costal Cartilage Excision. Ann Thorac Surg. 2020 Sep;110(3):1030-1035. doi: 10.1016/j.athoracsur.2020.02.081. Epub 2020 Apr 21. PMID: 32330472; PMCID: PMC7953350.
2. McMahon LE, Salevitz NA, Notrica DM. Vertical rib plating for the treatment of slipping rib syndrome. J Pediatr Surg. 2021 Oct;56(10):1852-1856. doi: 10.1016/j.jpedsurg.2020.09.062. Epub 2020 Oct 6. PMID: 33127061.

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