Benyan A.S., Medvedchikov-Ardiya M.A.
Samara State Medical University, Seredavin Samara Regional Clinical Hospital, Samara, Russia

Rib fractures are the most common injury in closed chest trauma which occur in 40 % of victims. The presence of fractures, as well as their quantitative and qualitative characteristics, are markers of the severity of chest trauma, being associated with injuries of internal organs and determining the prognostic values of complications and unfavorable outcomes [23]. Multiple rib fractures with violation of the thorax skeleton and floating rib fractures occur in 7-12 % of victims and represent the most difficult section of closed chest injury surgery with mortality rates up to 19-24 % [6, 30].
In long term period, more than 30 % of patients show late complications and consequences of closed chest injury - chest deformation, chronic pain, false rib joint, resulting in abnormal movement of the chest. All these conditions determine the sharp decrease in working capability and require for change of kind of activity or lead to disability [16].

The current strategy for the surgical treatment of multiple and floating rib fractures in the acute period of trauma extends towards the use of operative methods of internal fixation from sporadic to routine. The indications for methods of external and internal operative fixation of ribs and for internal pneumatic stabilization were determined [2]. More and more preference is given to rib osteosynthesis as a method that provides instant fixation of fractures and stabilization of the rib-sternum complex as a whole [20, 27]. Surgical interventions are carried out subject to stabilization of hemodynamic parameters and the absence of other prognostically unfavorable injuries of vital organs.

Most specialists are very restrained in determining the indications for surgical treatment with late complications and the consequences of the closed chest injury due to the lack of evidence and the dubious effect of the operation. In this case, only one of the conditions is considered as a point of application for operative methods of correction - a pseudocostal joint. The presented review of the literature is devoted to the study of the current state of the issues of surgical treatment of the false costal joint.

32 scientific articles in the databases PubMed, Google Scholar and ScienceDirect were studied and analyzed for the period from 1993 to 2021, which provide data on the epidemiology, clinical picture, as well as diagnosis of the false costal joint. The time interval of the research articles is generally determined by a small number of publications on this topic. The basic principles of surgical treatment of a false costal joint are reflected, including the use of bone grafts and internal fixation (the table).

Table. Distribution of articles relating to discussed issues and problems

Reviewed issues and problems

Number of articles

Authors and publication year

Rate of multiple and floating rib fractures after blunt chest trauma


J.T.H. Prins et al (2020) [23],
N. Dehghan et al (2018) [6],

M.G. Van Vledder et al (2019) [30],

L.W. Kong et al (2021) [16]

Surgical treatment of rib fractures


M. Bemelman et al (2016) [2],
M. de Moya et al (2017) [20],

N. Sedaghat et al (2021) [27],

Z. He
et al (2019) [12],

X. Liu et al (2019) [17],

H.B. Schuette et al (2021) [26]

Epidemiology and statistics of false rib joint


R.L. Morgan-Jones et al (1996) [19],
A. Billè et al (2013) [3],

S.E. van Oostendorp
et al (2018) [21],

Y.W. Wong et al (2021) [31],

T. Funakoshi
et al (2019) [9],

D.J. Kaplan
et al (2017) [14],

J.D. Richardson et al (2007) [25],

Y.H. Cho et al (2009) [4],

E.M. Marigi et al (2020) [18]

Clinical symptoms and diagnosis of false rib joint


D.J. Kaplan et al (2017) [14],
M.B. De Jong et al (2018) [7],

J. Anavian et al (2009) [1],

N.C. Dean et al (2014) [5],

A. Grosse
et al (2007) [11]

Principles of surgical treatment of false rib joint


W. Zuidema (2006) [32],
N.C. Dean et al (2014) [5],

J. Anavian et al (2009) [1],

D.J. Kaplan
et al (2017) [14],

Fabricant et al (2014) [8],

E.M. Marigi et al (2020) [18],

P. Reber et al (1993) [24],

C. Spering
et al (2020) [28],

M. Bemelman et al (2016) [2],

M.C. Hernandez
et al (2018) [13],

S.E. van Oostendorp
et al (2018) [21],

Y.H. Cho et al (2009) [4],

E.M. Gauger et al (2015) [10]

Outcomes and complications of false rib joint


E.M. Gauger et al (2015) [10],
N.C. Dean et al (2014) [5],

L. Fabricant et al (2014) [8],

M.B. De Jong et al (2018) [7],

Staggers et al (2020) [29],

T. Kazakova et al (2019) [15],

J. Peek et al (2020) [22]

Epidemiology, statistics

As for the long-term consequences of severe closed chest trauma with rib fractures, the most common conditions are the false costal joint and clinically significant post-traumatic deformities with restrictive breathing disorders [19]. The incidence of false costal joints is estimated from 5 to 10 % [3]. The most common cause of the false costal joint is the closed chest injury with multiple rib fractures. However, the literature also describes cases of spontaneous rib fractures during exercise, coughing and sneezing [21, 31]. The development of the pseudarthrosis after a spontaneous fracture of the first rib, described after heavy physical exertion in athletes, deserves special attention [9]. The causes of false joints are described and well known. Nevertheless, in the case of rib fractures, additional predisposing factors are also the presence of respiratory movements of the chest and the ineffectiveness of conservative methods of immobilization [14]. Despite the fact that the formation of a false costal joint can occur regardless of the type of previous fracture, in most cases, patients in the acute period were diagnosed with severe closed chest trauma with multiple or floating rib fractures.
Undoubtedly, the prerequisites for the formation of the false costal joint are not only the features of the fracture itself (multiple fractures, floating fractures, rib cartilage tears), but also the initial state of the bone tissue, which in some patients underwent pathological reconstruction due to age (osteoporosis) or diseases (cystic fibrosis, myeloma) [14]. Some authors regard the refusal of surgical fixation of rib fractures as a predisposing factor for the formation of a false costal joint in the long term [25]. At the same time, some cases of false costal joints have been described after surgical treatment of multiple and floating rib fractures using pins for intraosseous fixation [4]. A number of publications deal with the pathomorphology of the false costal joints, describing such processes as heterotopic ossification and the formation of costal synostosis with subsequent transformation into a pseudarthrosis [18].

Clinical picture and diagnostics

The clinical significance of the false costal joint consists in chronic persisting pain syndrome, which, in its turn, promotes the development of atelectasis, pneumonia, asthenization due to body weight loss and good sleep absence, decreasing physical activity and loss of working capability [14]. Symptomatic false costal joint is characterized by the presence of intense persistent localized pain syndrome, combined with confirmed nonunion of one or more ribs on CT more than 3 months after injury [7]. Pain syndrome is the leading one in the clinical picture in most patients with false costal joint [1]. In addition to the signs that directly characterize the presence of a mobile costal joint, the appearance or aggravation of the symptoms of various pulmonary diseases is often noted. Spontaneous rib fractures in patients with cystic fibrosis can lead to the development of exacerbations of the main process and aggravate background respiratory failure [5].
The program for diagnosing the false costal joint includes the complete physical examination, clarifying the nature and severity of a history of chest trauma, as well as evaluating the effectiveness of the treatment methods used. Of the instrumental diagnostic methods, MSCT and MRI have the greatest sensitivity and specificity, while MSCT can be considered as the most accessible and highly accurate method for confirming the presence of the false costal joint [11].

Basic principles of surgical treatment

Treatment of patients with the false costal joint in most cases consisted of recommendations for reducing physical activity or tight bandaging of the chest. Rare attempts at surgical treatment consisted of resection of the edges of the ribs. The development of implantology and the emergence of special rib plates with angular stability have opened up new possibilities in the treatment of this category of patients [32]. The basic principles of surgical treatment of traumatic and spontaneous rib fractures leading to the formation of the false costal joint are similar and include resection of the edges of the ribs, replacement of the defect with the bone graft, and internal fixation [5]. The time frame for determining the indications for surgical treatment of the false costal joint has not been finally determined. Most modern authors believe it expedient to consider the indications for surgical intervention already 3 months after the primary injury, but the average time for the operation itself often exceeds 1.2 years [1, 14]. In some publications, the terms of the operation reach 15 years [8].
In most cases, surgical treatment involves resection of costal synostosis and fixation of the rib using internal fixation devices, with preference given to bone osteosynthesis technologies using titanium plates [18]. One of the first publications on the use of internal operative fixation for the false costal joint was the article by P. Reber et al., in which the authors described the successful treatment of a patient with the consequences of severe closed chest trauma. The main syndrome, chest pain during breathing, was completely arrested after surgery [24].

Success of surgery for the false joint highly depends on appropriate planning of a surgical approach, which is also achieved with 3D reconstruction of bone structures of the chest, and computer navigation. Minimization of surgical trauma due to adequate planning of the surgical access allows, while maintaining the convenience of basic manipulations, to provide a smoother course of the postoperative period [28]. Improvement of rib osteosynthesis systems, the appearance of instruments with 90° arrangement of working parts contributes to the possibility of performing surgical interventions through mini-accesses. In operations carried out in a planned manner for long-term consequences, this technology is of particular importance and can be recommended for use in wide practice [2]. As for the technique of osteosynthesis and technical characteristics of the plate, most authors recommend using small projection approaches, which allow resection of the edges of the false joint and fixation with three screws on each side. Accordingly, plates with 6-8 holes are sufficient in length [32]. Despite the fact that in some patients it is sufficient to resect the edges of the false joint and excision of the scar tissue, in other cases it is necessary to replace the bone defect and to perform subsequent fixation. The determining factor is the length of the defect formed after resection [14]. Replacement of the rib defect after resection of the edges of the false joint using the bone graft is not only a method of additional stabilization of the “plate-rib” structure, but also a measure of preventing the formation of a pulmonary hernia in the long-term postoperative period [13]. With a combination of the false costal joint and a pulmonary hernia formed as a result of rupture of the intercostal muscles, in cases where the intercostal space cannot be brought together by the imposition of pulley sutures and other techniques, the surgical technique, in addition to the osteosynthesis of the ribs, includes prosthetics of the chest wall defect using the mesh implant [ 21].

In those cases when the cause of the development of the false costal joint was the nonunion of fragments against the background of previously performed intramedullary osteosynthesis, the optimal way is the removal of the intraosseous implant (wire, pin), resection of the rib edges, replacement of the defect with a bone graft, fixation using extramedullary plates and locking screws [4 , 10].

Outcomes and complications

The effectiveness of surgical treatment of false costal joints is assessed according to 2 main criteria: relief of chronic pain syndrome and increased physical activity. At the same time, clinical efficiency significantly outstrips the processes of complete rib repair. The average time for the repair of synthesized ribs after replacement of a defect with the bone graft is 14.7 weeks with minimum values up to 12 weeks and maximum periods up to 24 weeks [10]. The immediate and long-term results of external bone fixation demonstrate the effectiveness of the method even in patients with pathologically altered bone tissue, as in the case of cystic fibrosis [5].
In a comparative study, L. Fabricant et al. showed a decrease in the rate of use and a decrease in the dosage of opiates in operated patients [8]. Out of 19 operated patients, 13 patients with the false costal joint fixation demonstrated the complete recovery and relief of symptoms, 2 patients developed new fractures at the plate fixation sites, 3 patients required repeated surgeries to remove implants [7].

The stability of the structure after resection of the rib for the false post-traumatic joint and subsequent osteosynthesis is also evidenced by the observation of J.R. Staggers et al., which described a case of a repeated chest injury several months after surgery for the consequences of the closed chest injury. Thus, in a patient who underwent rib resection and osteosynthesis, rib fractures along the edge of the plate attachment were diagnosed, while the bone tissue in the plate projection and the plate itself remained intact [29].

Among complications of surgical treatment of the false costal joint, the most common ones are wound infectious complications (deep and superficial) relating to instability of a metal construct due to migration of locking screws, a fracture of the plate and abnormal fracture of the bone. The nature of repeated surgical interventions depends on the integrity of the previously restored rib. If consolidation and repair of the fracture has occurred, then re-intervention consists in removing the compromised plates and screws. In those cases when the repair of the damaged bone was not achieved or new fractures occurred along the lines of fixation of the implants, during the second operation, it is possible to perform reosteosynthesis using plates of greater length, different curvature, locking screws and cerclage sutures [15].

After surgical fixation of rib fractures, bone nonunion with the development of the false joint was observed in 1.3 % of patients [22]. In the case of resection of the bony edges of the false costal joint without subsequent replacement with the bone graft and the use of absorbable rib plates, there is a risk of postoperative pulmonary hernia development through a defect in the rib [8].


The study of the history and evolution of surgical interventions for closed chest trauma has always demonstrated greater attention and emphasis on the elimination of damage to internal organs, while surgical interventions on the musculoskeletal frame of the chest were performed either due to the inevitability of thoracotomy, or were not used at all, confining themselves to drainage of the pleural cavity, conservative and resuscitation measures [12]. It is obvious that the greatest contribution to the development of unfavorable outcomes in severe closed chest injury is made by damage to the lung tissue; however, injury to the bone frame, especially not eliminated in the acute period of injury, aggravates the severity of the initial injury to the lung tissue and causes a significantly longer recovery period [17].
The expediency of surgical treatment for fractures of the posterior segments of the ribs is a subject of discussion at the present time. Even with floating fractures and multiple fractures with pronounced displacement of fragments, most authors tend to conservative management, motivating this approach by the presence of large muscle mass of the paravertebral muscle group, which provides natural stabilization of the bone framework. And in patients on artificial lung ventilation, the supine position also provides some stabilization of the fragments of the posterior segments of the ribs due to compression by the natural mass of the chest. Nevertheless, despite these anatomical features, the formation of the false costal joint is also found in fractures of this localization. It should be noted that osteosynthesis of the posterior rib segments presents well-known difficulties due to the large curvature in the rib angle, variable thickness of the bone tissue, as well as the difficulty of providing a surgical approach that meets the principles of sufficiency and low trauma [26].


Treatment of patients with the false costal joint is the subject of elective thoracic reconstructive surgery. Operative fixation ensures the restoration of rib integrity and demonstrates good functional results. In some cases, a combination of osteosynthesis methods, the use of bone grafts and methods of soft tissue defects prosthetics is required.

 Information on funding and conflicts of interest

The study was not sponsored.
The authors declare no obvious and potential conflicts of interest related to the publication of this article.


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