Slipping Rib Surgery in EDS with Adam Hansen, MD

[00:35] Dr. Linda Bluestein: Welcome back, every bendy body. This is the Bendy Bodies Podcast, and I'm your host and founder, Dr. Linda Bluestein, the Hypermobility MD. This is going to be a great episode, so be sure to stick around until the very end so you don't miss any of our special hypermobility hacks. As always, this information is for educational purposes only and is not a substitute for personalized medical advice. Today I am so excited to have Dr. Adam Hansen here with me, who describes himself as a craftsman, inventor, and tinkerer with a side hobby of thoracic surgery. He's found the perfect place to combine his interest in complex chest wall reconstruction, which has become his area of expertise. In his bio, he says, a patient introduced me to slipping rib syndrome several years ago and asked me to devise a way to fix his ribs. I agreed, and luckily we succeeded in eliminating his pain. Word travels quickly when you invent a solution to a debilitating problem, so I've had the honor of treating close to 1,000 slipping rib syndrome, or SRS, patients since. Many of these patients are challenged with Ehlers-Danlos syndrome and other skeletal hypermobility disorders. Out of necessity, I've become quite familiar with these complex problems and have made it my life's work to create durable solutions to help affected patients overcome the pain, organ dysfunction, and instability that affects them. It has been highly rewarding to watch people turn from a life of crippling disability to one of satisfaction and return to productivity. It has been obvious to me that my patients are like beautiful butterflies just waiting to emerge from their cocoons.
[02:24] Dr. Hansen, when I read that, I thought, wow, that is so incredible. That's so beautiful. And I just want to welcome you to Bendy Bodies, and I'm so thrilled to chat with you.

[02:33] Adam Hansen, MD: Thank you. It's my pleasure to be here. Appreciate it.

[02:37] Dr. Linda Bluestein: I'm so excited to dig right in to this very important topic. We're going to get some background information covered first, and then we'll dive into some specifics regarding surgery. So can you start off by describing slipping rib syndrome, or SRS, and other conditions that require complex chest wall reconstruction, like 12th rib syndrome and rib tip syndrome?

[03:00] Adam Hansen, MD: Yes. So I think very simply, I think of all of these disorders as essentially nerve compressions — basically two bones compressing a nerve in between. If you think about it in those terms, it makes everything very simple. You can also find the area where the pain is and basically just locate the intercostal space, or the space between the ribs, that's affected. And it always affects certain dermatomes. So it's very simple. If you just trace that source back, you can figure out why you're hurting in multiple places typically, because that's all essentially one or a couple of nerves that are affected.
[03:41] So again, you boil this down into slipping rib syndrome and the floating rib disorders — those are probably the best differentiation between this set of problems. Slipping rib syndrome is the most common one. It seems to have the most attention, and it definitely does present more than the others. But that is essentially just dislocated ribs in the front. So the costal margin and the costal arch up front are basically the weakest links in the chain of the thoracic rib cage, right? They're made to be flexible. They're made to stretch. That's where we get all of our expansion in our chest, and when we're able to twist and bend, that's where that occurs for the most part.
There are ligamentous attachments that connect these lower ribs together in the front. The false ribs are the ones that are affected by slipping rib syndrome, so that's typically 8 through 10. Once in a while you can have a 7th rib that's slipped, but I've never seen anything above that be slipped, and that's because everything above rib 8 is a true rib — it has a direct connection to the sternum. So I think of the false ribs as basically hitching a ride up to the sternum by way of the rib above them. So these weakest links in the chain, since they are so flexible, can become fully detached. And when they do detach, they become hypermobile — not to be confused with hypermobility syndrome — but they become more mobile than they're supposed to be. And when they do that, they just aggravate the nerves that live in between.
[05:15] Each rib has its own intercostal nerve assigned to it. So for example, rib 8 has nerve 8 that runs just below it and just on the inside surface of the rib cage, below rib 8. And if you have a slipped 9th rib, that's going to typically aggravate nerve 8. And the problem is in the front — where do these nerves go? They follow that rib all the way back to the spine. So it's not confusing if you understand the dermatomal distribution of these nerves. If you look at a simple dermatome map, you can see where these nerves go to. Essentially that's a stripe around the torso, and that's where, along this whole stripe, the pain can occur when a slipping rib is irritating the nerve typically above it.
[06:00] So people get confused — especially doctors. They think that a patient has a spine problem or an organ problem like gallbladder dysfunction or something like that, when indeed it is just a stripe of pain in that one region of one or multiple nerves that are affected.
[06:16] Now, the floating rib disorders are essentially the same thing, but they don't involve ribs coming loose or slipping, right? Because the floating ribs are never attached. So ribs 11 and 12 are supposed to be floating. And I would argue that in a substantial number of patients, we've found that the 10th rib can be naturally floating. So it's anatomically variable — some people have a connected 10th rib and some people, like me, don't have a connected 10th rib. And that's not a problem until it starts aggravating the nerve between the rib above it and itself.
[06:49] At any rate, the 11th and 12th ribs being the floating ribs for the most part, they can do the same thing. Basically they can pinch their own nerve, or the nerve above them, between either a rib or the hip bone. So the iliac crest, or the top of the pelvis, is where rib tip syndrome can occur. The tip of the 12th rib and sometimes the tip of the 11th rib can be so low slung and far migrated downward that they can start striking the iliac crest. And what do they do when they do that? They pinch their own nerves. So that's also known as costoiliac impingement syndrome. I typically use that term, but a lot of people are using the term rib tip syndrome — it's the same thing.
Also, there are two more problems that can occur. The 12th rib can either angle down way too far and strike its base — basically the neck of the rib just beyond the joint near the spine — and it can strike the first lumbar vertebra transverse process. So the little side wing that hangs out from the side of the L1 vertebra can be an impingement point upon nerve 12. The 12th rib is the problem, not L1. The 12th can hang down and pinch its own nerve against L1. The final thing that can occur is the 12th rib can also angle and curve up, maybe with a little bit of rotation where it twists upward at the tip, and it can aggravate nerve 11. That's called 12th rib syndrome.
[08:25] So let's just go back through this one more time. Slipping rib syndrome is the false ribs. Ribs 12 and very rarely 11 can hit the hip and cause costoiliac impingement. And rib 12 can cause two additional problems: 12th rib syndrome, where it reaches up at its tip, or L1 syndrome, where it hits the L1 transverse process. So a lot of potential contact points, but they're all the same thing — intercostal nerve compressions.

[08:55] Dr. Linda Bluestein: What a great explanation. I really like how you started with what they have in common, and I think that's a really helpful way to think about it because it can get pretty complicated pretty quickly otherwise.

[09:07] Adam Hansen, MD: Yeah. Hopefully that wasn't too complex of a description, but essentially it's like 4 things that I look for on an exam.

[09:14] Dr. Linda Bluestein: Sure. And regardless of which of these syndromes you're looking at — and maybe you want to address each one separately or group them together for some of these questions, however you feel most comfortable — what is the relationship between these various compression syndromes and skeletal hypermobility disorders?

[09:34] Adam Hansen, MD: Okay, so you think about Ehlers-Danlos and all of the hypermobile spectrum disorders like Loeys-Dietz and Marfan syndrome. They all result in connective tissue mutations and weaknesses. If you think about how many joints there are in the thorax — I think I counted them up one time, pardon me if I'm speaking wrong, but it's somewhere around 56 or something like that — there's a whole bunch of joints in the chest. That's a big box of potential problems. So the overarching problem is the laxity of the ligamentous tissue that connects all of these joints together. You can have a problem at any number of joints in the body, and the thorax being so concentrated in the number of joints that it has — it's basically a setup for many disorders to occur.
[10:27] Now, these 4 or 5 issues that I've just mentioned, they're all the same thing. Basically, it's just laxity of these ligaments that allows the ribs to slip, or allows them to hang low, or allows them to be at the wrong angle. I think of all of these disorders as: if the ribs just maintain etiquette and stay parallel with each other, driving their own lane, everything's fine. If you think about being on the interstate and somebody's bumping into you in the fast lane and somebody's going too slow in the slow lane, bumping into you — that's when problems occur in traffic. And it's the same thing with ribs. If they would just stay in their own lanes, none of these compressions would occur. It's a problem of all these ribs coming out of their own lanes and finding their way into some other compression.

[11:17] Dr. Linda Bluestein: I love that analogy. That's a really great way to think about it. And are there other etiologies that can lead to these conditions?

[11:25] Adam Hansen, MD: Yes. So as much as Marfan syndrome and Loeys-Dietz — there's probably a whole host of disorders that may even be undefined hypermobility disorders. In my practice, there's a subset of patients, probably around 15 to 20%, that have known Ehlers-Danlos syndrome. These are people that are usually affected pretty heavily and have multiple joint disorders. It's obvious when they come to me what I'm getting into. And then there's probably a larger subset that I know are on the hypermobile spectrum — they may not be that severe, or maybe they're extremely severe and just haven't had a diagnosis made yet.
[12:08] I've made the claim to many of my patients that you could blindfold me and put 10 patients in front of me, one of them having a hypermobile skeletal disorder, and I could just feel the front of their ribs and tell which one has this hypermobile skeletal disorder. It's that obvious to me. I feel like the ribs are just formed a little differently than the average person who is not affected. If you look at a skeletal model — I have a million skeletal models in my office — you see the front of the ribs is all connected and nice and firm. But then in these patients, you could just put your fingers on the front of the rib cage and all of those ribs don't converge at the front to form one big chunk of cartilage. Basically they all run up to the sternum by way of ligaments, and they're all separated like an unwound rope with the strands being separate. You could almost play these ribs like piano keys in certain cases. They're that obviously completely disconnected.
[13:11] So I can't tell you whether that patient I could locate blindfolded has EDS, but I can tell you they have a hypermobile skeletal disorder. I think we're just scratching the surface, and thank God for you and a very few others that really understand these disorders. I only happened upon this stuff by accident when patients started coming to me, and I had to learn about their disorders out of necessity to be able to understand them. But we need to understand that these hypermobility syndromes affect everything. I mean, think about it — we're just a big bag of collagen, right? And if our collagen is not formed correctly, we're not going to have good connections.

[13:59] Dr. Linda Bluestein: Definitely. And I'm so grateful to you, and I know the patients are too, for instead of running away from this complex population that can definitely be really challenging, you dove headfirst and really made sure you're providing good care. I think it's so important. I know a lot of surgeons are very reluctant to operate on people with EDS. And of course, you should always be thinking about potential complications and whether this is the best approach for that patient. But a lot of people, I think, don't even want to learn, basically. So I think it's great how you've described yourself and how you've approached this.

[14:39] Adam Hansen, MD: Well, thank you. I appreciate that. I feel bad for people that have hypermobile skeletons. It's a lifelong set of complex problems, and it's like a game of whack-a-mole. You fix one and three more pop up. And so I found certain ones that we can fix. You can't fix everything — at least so far we haven't been able to fix everything. We're certainly working towards solutions in other areas, but there are some that we can fix that will take a patient from a terrible crippling disorder over to a very manageable set of disorders that they can then focus on exercise and things like that.
[15:16] So I've taken the stance that if I see a patient where it's a very difficult challenge operatively, I want those patients to come to me because we've certainly made some mistakes along the way and gotten ahead of the learning curve at this point, and I'd like to be the one to take care of the bad ones. I refer the easy ones to other partners that may not have as much practice on this. I don't want other surgeons to fail at the outset if they're interested in slipping rib syndrome repair. I don't want them to get an Ehlers-Danlos hypermobile patient with 8 slipped ribs and expect them to succeed on their first 1 or 10 cases, because they're probably not going to. So I'm not asking for the bad cases, but I'm happy to do them.

[16:08] Dr. Linda Bluestein: Sure. And the learning curve is so steep with so many of these things, and it certainly was for me. Those of us that are really passionate continue to learn and try to provide the best possible care. Can you describe to us what the symptoms are of these compression syndromes, whether it's slipping rib or 12th rib or various other conditions?

[16:38] Adam Hansen, MD: Yes. The bulk of the problem is pain, right? Probably 80% of the issue is just pain. But the more of these patients that I've seen, the more I realize how other bodily functions can be affected. Some of the newer thought processes — stuff I haven't really worked out all the details for yet, and this is why it's excellent to collaborate with other specialists that aren't surgeons — but I'm realizing more and more that breathing is affected, that resting elevated heart rate is affected or caused by this. There are a lot of things like gastroparesis and irritable bowel syndrome that could potentially go away should these nerves stop being compressed. And I've even spared a couple of patients from having their kidney removed for suspected Nutcracker syndrome when indeed it was just a 12th rib syndrome or an L1 syndrome all along.
[17:41] These issues are very notorious for masquerading as other, probably even more complicated problems. We've done a little bit of collaboration with a surgeon who is expert in abdominal vascular compression syndromes. I think that some people really do have those, and some people have symptoms that look like an AVCS and may just be a slipped rib. We have to realize that we don't know very much about this yet, but that one thing can affect another. I'm convinced that the intercostal nerves, as they run back toward the spinal cord, pass through junctions in the autonomic nervous system — that's just lateral to the spine. And I think they pass through these intersections and send haywire signals or crosstalk or short-circuit signals into the autonomic nervous system, which can then cause numerous problems like gut dysfunction and the resting tachycardia that I've been seeing a lot of, or POTS, Postural Orthostatic Tachycardia Syndrome. I think a lot of these are either caused by these slipped ribs, or at least the slipped ribs can contribute to them.
[19:05] So there's a host of other symptoms, but the vast majority of people are going to have pain. Probably the one other thing that I've noticed a huge improvement in after we repair slipped ribs and do these other floating rib issues is breathing. Breathing function improves drastically. Now, that one I don't think particularly has anything to do with nerves. I think it's just a stability issue for the lower costal margin. If you think about where the diaphragm attaches on the inside, it attaches to the false ribs. So if you have unstable, wiggly lower false ribs, you're not going to have a stable rim for the diaphragm to contract against. I talk to patients like a trampoline. If you took part of your trampoline bar around the edge and cut it, you wouldn't have a very bouncy trampoline, right? It would be all flaccid and basically just floppy. I think the diaphragm is the same way — if it has a nice stable ring of rib cage to pull against, you can have an effective contraction and draw air in.
[20:12] So even with a single slipped rib, we've noticed a big deficit in breathing. And after you stabilize that rib, we've gotten a huge increase in breathing function. I had no idea we were doing this until patients started coming back and saying, hey, I'm breathing a lot better. So I had to go back and reverse engineer this and figure out what the issue was.

[20:39] Dr. Linda Bluestein: Interesting. And is the pain usually pretty well localized? Do people also feel things like clicking or that displacement that can occur, the subluxation and dislocation?

[20:51] Adam Hansen, MD: Yeah, thank you for bringing that up — I neglected that. I would say not the majority of patients have a clicking. It's probably a minority of patients. You think of clicking or popping in the front as the classic presentation, and you think of pain in the front as the classic presentation, but it has never ceased to amaze me that a lot of patients don't even have pain in the front. They don't have pain where the actual issue is. So the nerve compression is happening in the front, in between the upward hooks of these ribs as they're curving toward the sternum. That's where the actual problem is happening, but it may not manifest there.
The pain manifests, I would say, most commonly just under the tip of the scapula. That's probably the most common site. So it wraps around to the back — it's like paravertebral pain, a little bit off to the side. People don't generally notice it right in the midline of the spine, but they notice it about 2 inches over. That's the most common site of the pain. People may not realize that they have pain along that whole stripe around their torso. But if you start just lightly touching in that intercostal space, you'll note that they can have pain anywhere along that stripe. It doesn't have to be the whole way. That's probably one of the bigger diagnostic challenges — to figure out this dermatome — because you may have pain at 2 or 3 sites along the way in that dermatome and not the whole way around.

[22:13] Dr. Linda Bluestein: And is the pain more often unilateral or bilateral?

[22:23] Adam Hansen, MD: It just depends on where the slipped ribs are. There are a lot of unilateral slipped rib patients, and there are a lot of bilateral slipped rib patients. Probably the vast majority have some element on both sides. But there are a lot of different etiologies why people can have this — it's not just hypermobile patients. So let's say someone falls off their four-wheeler and breaks or dislocates their rib in the front. They're probably just going to have unilateral pain.
[22:46] It's also interesting — you can have the exact same anatomy on both sides, with 1 or 2 slipped ribs on both sides, and only 1 side will hurt. I think of it like 1 dog barking louder than the other small dog that's still barking, but you can't hear him. Oftentimes, once we fix the bad side, the patient will say, oh yeah, I've been hurting all along on this other side, and now it's manifesting itself.
[23:15] I think a lot of patients who have bilateral slipped ribs, especially the hypermobile patients, may also have an element of scoliosis or some kind of spine disorder. And whichever way the spine leans — say you have a levoscoliosis to the left — you're probably going to have more symptoms on that side because the inside of that curvature leads to more rib compression, whereas it splays the ribs out on the other side. So the splayed outside is not going to contact the nerves very often, and they're more likely to have pain on the lesser curve.

[23:54] Dr. Linda Bluestein: Okay. And what are some emerging areas of discovery related to slipping rib syndrome? Are there areas of the chest wall that are affected in the same way?

[24:12] Adam Hansen, MD: We've mostly covered some of this topic already, but I think the more undefined stuff is the posterior joints — the costovertebral joints. We haven't worked out any solutions for those issues yet. That seems to be a big area. A lot of people call this rib head syndrome. We don't really have any great solutions for that yet. I think it would require some pretty intense collaboration between a neurosurgeon or spine surgeon and a thoracic surgeon to figure out a solution. I did have an idea in mind that we worked out on a model in the operating room, and we were about ready to pull the trigger and start doing it, but I backed out because I thought it could create more problems at these nerve roots than what we solved. So that one is still pending. That's a big one I'd like to solve.
[25:12] There is one more recent discovery that I've made in patients that also have slipped ribs — it's not always present in a patient that has slipped ribs, but it usually is — and that is an issue that we've dubbed a bridging cartilage fracture. It's not really a fracture; it's still the same thing, just a separation of an interchondral joint. This occurs typically between ribs 5 and 6. It can occur between 4 and 5, and 6 and 7, but there are these what they call secondary interchondral joints — I think of them like a little 2x4 being nailed between 2 beams to give additional support in the front of the chest. Typically these are located in the inframammary folds, so right where an underwire would hit on a woman's bra or right under the pec muscle in a man. These are prone to separation and they cause intense pain. A lot of patients tell me it feels like an ice pick is being stabbed right under their pec or right under the breast constantly. And that can radiate out through the armpit or the axilla all the way up to the upper scapula.
[26:18] This is a new discovery that we've made, and this one is very simple. I don't have to rebuild it — I just go and excise that little piece of cartilage that's up front in between those ribs that's compressing that nerve. As long as the ribs are nice and stable otherwise, it's a very simple solution. This bridging cartilage separation is one that I've been excited about recently because it's a huge payoff for a very small operation.

[26:45] Dr. Linda Bluestein: And does everyone have that bridging cartilage, or is that an anatomic variant?

[26:49] Adam Hansen, MD: It's a variant, yes. Men typically have them more than women, and the same patient may have them on the right and not on the left. It's just a little variation, and they're not consistent between rib spaces, but they're most commonly found between ribs 5 and 6. Just because you have them doesn't mean it's a problem — it's a normal structure that you want, right? It's just additional support in the front of the ribs. The mere presence of them is not a problem. It's when they become separated.
[27:26] What I usually see on a CT scan is that they become calcified. If you don't have hardly any calcium in the front of your rib cage in the cartilage and then you have this one heavily focally calcified area at that joint, it's a red flag to me that it has been separated and the body's trying to heal it. It's basically the same thing as slipping rib syndrome — it's just not slipped. It's just a separated joint.

[27:51] Dr. Linda Bluestein: Okay. Well, let's talk about the evaluation of someone with a possible chest wall problem. You have a great video on the physical exam, and we'll have a link to that in the show notes. That was a really highly informative video on YouTube. What else can you tell us about the physical exam, imaging, etc.?

[28:11] Adam Hansen, MD: So most of us physicians or providers that are interested in this are kind of guilty of just following the leader. We all look at these few old papers that have been published on slipping rib syndrome, and we're all prone to doing the hooking maneuver. It's sort of the one diagnostic maneuver that anyone is aware of. I don't even use that typically. Once in a while I will, but it's just a really forceful grab of the lower rib cage and pull upward, and it's not a detailed assessment at all. It basically just tells if they have pain in the front, so there's really not a lot of point to that.
[28:48] What I do is I put the patient in what's called lateral decubitus position — I just put them on their side. I have them bend their knees so that they can make their whole torso nice and soft and basically try to keep the muscle spasms out, and just get to where I can feel the ribs individually. I start low. I start at the spine at rib 12, and I work my way up. I feel the very lowest rib. It's very important to really work on that 12th rib because a lot of people have little short 12th ribs, or some even don't have a 12th rib, so you have to be very aware of where your starting point is because your count is always going to be based on the lowest rib. It's really hard to count the ribs from top down. I don't think I could even do that unless the patient is very emaciated without any body fat.
[29:37] But at any rate, you start at rib 12, and I'm assessing for L1 syndrome, 12th rib syndrome, and rib tip syndrome — all of those things I can elicit from ribs 11 and 12. I just use my fingers to walk up and make sure I'm on each rib, and I assess which ones are hurting. As you find ribs 10, then 9, then 8, I'm working my way out to the front, out to the costal arch along the costal margin. It's very easy to feel a separation point at the tip of the 9th and 10th ribs — it almost feels kind of soggy as you basically just lightly push these ribs in. You can feel that rib give way. It's not attached like it's supposed to be. And typically the patient will hurt at that point.
[30:23] Now if they don't, and they still have a slipped rib, I always walk my fingers back through that intercostal space all the way back to the spine and see if they're hurting anywhere along that dermatome. It's very easy to figure out for the most part which rib is at fault. Now if they have a slipped 10th rib, for example, and there's zero pain there, it's probably a naturally floating 10th rib. Especially if they have them on both sides, they're probably naturally floating 10th ribs. It's not a problem unless it's a problem, right? If it is a problem, I don't care whether they were floating at birth or whether it separated later in life. If it hurts, it's still a candidate for treatment.
[31:08] So then I just keep walking my way up. To assess this bridging cartilage separation, I'll have the patient lie on their back and I just palpate right where the underwire hits and find that space. That's usually right a little bit medial of the nipple, so a little bit more toward the center. If they have excruciating pain at that site, that makes me think that's probably an issue.
[31:35] I didn't used to get any imaging — I may have been a little proud at the beginning, thinking I could diagnose this all just on physical exam. And then I found a few situations that changed my mind. For example, I once missed a patient who had no 12th ribs, and so I left a 10th rib untreated because I counted wrong. A few issues like that showed me that it is very useful to have a CT. I pull the CT up in the room with the patient and look at the scan, look at the patient, and correlate these findings. I don't treat the CT by itself, of course, but it helps me know where my starting point is, know what their 12th rib looks like, and get my bearings. And the bridging cartilage thing — I really need to see that on the CT before I offer a patient surgery for it because it is very difficult to diagnose with physical exam alone.
With regards to the CT, I request that all my patients get a CT of the chest and abdomen without contrast. The reason for that is because a chest CT usually does not include the entire thorax. The entire rib cage is not visible on a chest CT — you have to have the abdomen to be able to get down to the lower floating ribs, especially in a hypermobile patient where the ribs are very low slung and hang down well into the abdomen, even all the way down to the pelvis in some cases. I look at the coronal view, where basically I'm looking straight on, and I can just move back and forth through that patient and see. I believe I can see most slipped ribs now — there's a separation that you can see in the front.
[33:31] I don't use any other imaging. I know a lot of people want to use dynamic ultrasound to watch the movement of these ribs. I feel like I can do the same thing with my physical exam that a dynamic ultrasound does, but there are a few findings on a CT that I can't get on a physical exam, and I feel like that's the most useful study.

[33:51] Dr. Linda Bluestein: And as you were talking about the 12th rib and doing the abdominal CT, it was occurring to me — I have a lot of patients with pelvic pain. Do you think that sometimes pelvic pain can even be related?

[33:56] Adam Hansen, MD: Absolutely. I think a lot of patients with 12th rib syndrome or rib tip syndrome, especially ones that affect the 12th nerve — if you look at the 12th intercostal nerve on a dermatome map, it goes quite low in the front. Our ribs are angled from high in the back to very low in the front, especially in hypermobile patients where they're almost vertical. So this 12th intercostal nerve may very well end up in a place well down into the groin.
[40:35] There are a lot of patients, especially with L1 syndrome where the 12th nerve is being compressed, that have actual groin pain. I had a gentleman last week who said it hurt in his testicles. I saw him the day after surgery, and that was already gone — once I took out his 12th rib. So this is a very common thing, and it's commonly mistaken as either ovarian pain or testicular pain, or as a labral tear in a hip. A lot of patients have already gone through hip surgery for a labral repair, and it made no difference in their pain, when all the while it was just a pesky 12th rib hitting the hip causing that same pain.
Lately I've been referred quite a few patients from our urologists as well. They have people they think have kidney stones, they get the non-contrast CT scan, there are zero kidney stones, and it hurts exactly where the kidney is, and they're dumbfounded. They don't know what the issue is, so they refer them to me now. And it's usually the 12th rib. Interesting how it masquerades as many different problems.

[40:49] Dr. Linda Bluestein: That is really fascinating. And we talked a little bit about some of the other organ dysfunction that can occur, and I loved your talk that you gave with the vascular surgeon. That was a really great conversation. Abdominal compression syndromes are so tricky. Can you share any additional thoughts regarding abdominal compression syndromes and chest wall disorders?

Adam Hansen, MD: Yes. Being that a lot of times they have the same subset of symptoms, it seems to me that if you have obvious slipped ribs or an obvious anatomical problem that I feel like fits one of these issues we've discussed, and you also have findings on a CT that suggest MALS or Nutcracker syndrome or May-Thurner or SMA syndrome — it seems easiest to fix the ribs first, because it's much less invasive than doing a large abdominal operation. Rerouting the intestines, putting a vascular graft in, or going as far as taking out a kidney — those are pretty large operations. I trained in general surgery and did some vascular surgery, and I know what goes into those operations. It's a big deal when you could just do a very superficial repair on a rib that may very well be causing the same pain.
[43:14] Even if you do have imaging findings that suggest an abdominal compression syndrome, you probably should do the ribs first, just because it's not as big a deal. Worst case scenario, we don't solve the problem, then you attack the abdominal compression syndrome. There are some obvious cases where you'd want to go ahead and do the abdominal operation, but I would say the vast majority of them are going to have confusing findings that cross over.
One of the differentiation points — I mentioned the two patients that were teed up and ready to go for a nephrectomy for Nutcracker syndrome. The pain was in the correct distribution for NCS, but they had palpable tenderness. An abdominal visceral pain should not present where you can push on the 12th rib and make it hurt. So I think that's a differentiating point, and it just emphasizes the importance of a physical examination. If I'm pushing on your 12th rib and all of a sudden your Nutcracker syndrome flares up, it's probably not Nutcracker syndrome that's causing it. It's probably the 12th rib.

Dr. Linda Bluestein: Very interesting. And imaging — you have to be so skilled at interpreting the findings. I love that you're looking at the CT, then looking at the patient, then looking at the CT again, because otherwise — I know he mentioned in that talk when he was interviewing you about silent abdominal compression syndromes. And you don't want to be operating on somebody if they have imaging findings that suggest something but that's not really the cause of the person's problem.

Adam Hansen, MD: For sure. In my trauma training when I was a general surgeon, we had an attending that said, don't succumb to VOMIT — VOMIT being victim of modern imaging technology. Never operate on a scan alone, right? You have to put your hands on the patient and find out if it really correlates to those findings. You may have a very dilated left renal vein, it may look like Nutcracker syndrome, but if that's not the source of the problem, certainly don't operate on it.

Dr. Linda Bluestein: Yeah, definitely. And surgical selection is obviously a huge part of your job, and any good surgeon is going to be very methodical about that. We'll definitely get into that a little bit more in just a few minutes. But first I wanted to talk about self-help strategies that people can use. I got quite a few questions about this — is there taping, exercises, etc.? We know that there are a lot of muscles that act on and also affect movement of the ribs. Are there things people can do to help avoid surgery?

Adam Hansen, MD: Yeah. I think especially the floating rib disorders can often be helped simply with better posture. But I do feel like with slipping rib syndrome, once they detach, they're going to be a problem. So in my mind, it's about how often is a slipping rib compressing the nerve. If you're leaning forward, you're going to be closing that space and compressing the nerve. So if you're spending 98% of your day in a very good upright posture, you're probably going to have very few episodes where that's going to hurt.
[43:14] So if you don't want surgery or you're not a candidate for surgery and you want to try the best management strategy while still having slipping ribs, I think there are a couple of exercises that can, with little effort, help you to stand up straighter all the time. Of course, I'm talking to my patients constantly and incessantly, telling them until I'm blue in the face, "You've got to have better posture." But you can't just think about your posture all day — there are a billion different things running through your mind and you forget 2 minutes later as soon as you focus on something else.
[43:14] I did a little experiment with myself. I'm by no means a gym rat, but I did planks — just planks, and no other exercises, for about 2 weeks. And I found that my usual slouchy posture in the office when I sit down, or even in the operating room, improved — I was standing straighter without even thinking about it. And I actually have a 12th rib syndrome, a real mild one that hurts me sometimes, especially after a long operative day. When I was doing these planks for a couple of weeks, that did not occur. I had zero pain. So there are some mild cases of this that can be helped with simple exercise and keeping your posture good.
There are 3 exercises. I mentioned the planks. Superman exercises — people can look this up, but basically you just lay on your floor and fly like Superman taking off in the sky, and it doesn't take any equipment. If you work on planks and Supermans and nothing else, you'll probably improve a lot of this pain, especially if you have a floating rib disorder. And then if you do go to a gym or even have elastic bands, you can do seated rows — and I'm not talking rows like a rowing machine. I'm talking sitting up straight and pulling back. That'll help roll your shoulders back and keep that posture nice and open.

[43:27] Dr. Linda Bluestein: Like this?

[43:28] Adam Hansen, MD: Yes. So it helps with your trapezius. It helps with your rhomboids. It helps with a lot of those upper back muscles. And if you're rolling your shoulders back and keeping them there all the time, you're going to be, without even trying, opening those intercostal spaces in the front and avoiding the pinching of these nerves.
[43:48] Things that I don't like are crunches, twisting, oblique exercises. Those are going to be twanging these ribs with every repetition. So I tell my patients to avoid those and just specifically overcorrect your posture, overcorrect your strength in your back, because if you have just an average front and a strong back, you're going to be standing upright.
[44:11] Now, that's not going to fix a slipped rib. It's not going to grow back together or heal itself — I've never seen one heal itself. But if you have less time where that nerve is compressed, you're going to be in less pain.

[44:26] Dr. Linda Bluestein: Yeah, that makes a lot of sense. And what about taping strategies that people can do?

[44:31] Adam Hansen, MD: Yeah, some of the patients use KT Tape — I don't know if there are other brands, so I'm not trying to be specific to that brand. But if you think about it, if you're trying to avoid the pain and still have untreated slipped ribs, and you tape your ribs down and away from each other — instead of taping them up where they're supposed to be, possibly tape them down away from each other — that could result in less compression throughout the day.
There are a couple of other things too. Let's say you have an office job and you're sitting at a desk most of the time. If you get a sit-to-stand desk, that could probably help the situation a lot. If you have to sit — let's say you're watching TV at night — get a lumbar pillow and stick it behind your lower back, and that forces your midsection forward and does the same thing even when you're resting. But the key is, if you're strong in your back, you're going to be sitting and standing better without thinking about it.

[45:31] Dr. Linda Bluestein: That makes a lot of sense. And you mentioned a couple of things that people should avoid doing, like crunches and some of the lateral exercises. Are there other things people should avoid, for example, like high-velocity manipulation?

[45:45] Adam Hansen, MD: Yeah. I've had a lot of patients who think that their slipping rib syndrome started after an aggressive chiropractic manipulation or an aggressive deep tissue fascial release type massage or something like that. I don't know if they actually caused the injury, but I think the condition comes to light at some point. Let's say someone has a naturally floating 10th rib and they didn't ever have pain, and then they had some event like a chiropractic manipulation that suddenly sparked it off. It kind of is like a domino effect. Once it starts, it spirals downward — it gets more and more painful because the muscles get spasmed when the nerves are unhappy. So it may not be the source of the problem, but it certainly can exacerbate it by doing these high-velocity manipulations.

[46:39] Dr. Linda Bluestein: Yeah, that's exactly what I meant.

[46:42] Adam Hansen, MD: So I just don't think you're going to get a permanent solution from that. I believe in chiropractic — I loved it when I went to a chiropractor a few times and I felt great afterward. But let's say you have a subluxed 10th rib that's subluxed under rib 9, and they manipulate and get your rib back out of its subluxed locked-in position. Sure, that's going to help for a few minutes, but it's going to go back. So it's not fixing the problem. It might make you temporarily feel better, and I'm not opposed to it by any means, but I just don't think it solves the problem.

[47:19] Dr. Linda Bluestein: Okay. Makes sense. Now let's talk about the surgical process. What makes someone a good candidate for the different surgeries that you do?

[47:25] Adam Hansen, MD: A few things come to mind. Someone coming in strong — so someone who has already been doing planks and Supermans and seated rows, and their core is strong — they seem to have much better and much quicker outcomes because they can sort of hold their posture up. As you're healing from my reconstruction, I want them to be open and spread out. That's what we're trying to accomplish — for the ribs to be in a neutral space. So if you're all hunched over, you've got bad posture, and you're trying to heal like that, sitting in your lazy boy chair, it's not going to be a very good recovery. It's going to hurt all the time and will probably heal with the ribs compressed together more than it should.
[48:17] Those coming in strong do have a better outcome. I would also say that for people who are already on a number of pain medications, if they're already on opioids, reducing preoperatively or trying to get off of them at least for a while before surgery makes the postoperative recovery so much nicer. It's very difficult to manage someone's pain after we add insult to injury. If they're already on a high dose of opioids, it becomes very difficult and they're not going to have adequate pain relief even with the things that I can legitimately prescribe to them postoperatively.
[49:03] One more thing — just having realistic expectations. Especially if we have a case where there are multiple joints involved, it might be a project that takes a year or so to get everything better. Not everybody — we can't throw a Hail Mary on everybody and fix it all in one shot. Some people have very complicated situations that are going to require a few different operations. We might need to split it up into a reasonable amount of repair, and they need to know that they're not going to be all the way better until we've got both sides fully addressed.
This is also a fairly complex orthopedic operation. If you had your hip replaced, you wouldn't expect to be better in 3 weeks. You would expect it might take a full year to get the results. So people that have reasonable expectations and patience are going to mentally do a lot better as they heal.

[50:14] Dr. Linda Bluestein: Yeah, and besides the things that you've already mentioned, I often talk to my patients about their nutrition and things like that before surgery. And same thing — prehab, getting yourself as strong as possible. No matter what the surgery is, you're going to have a better result if you go in as strong as you possibly can be. Besides those factors, is there anything else you recommend people do to prepare?

[50:43] Adam Hansen, MD: Yeah, I like what you just said. I mean, I'm a hammer in my world — the nail is surgery. So I don't often think about things like nutrition and all that, but that's huge. A big associated problem is mental health. Going in very depressed is going to make it very difficult to recover. So I think having appropriate treatment for that ahead of time would be of significant benefit.
[51:21] Speaking of the mental health aspect — a lot of my patients have been told numerous times that they're crazy or it's all in their head. This is a very common story that my patients relate to me. Doctors sometimes chuckle at them and walk out of the room. You can walk into a room and see that a patient does have some mental health issues sometimes — not every patient, but some of them do — and I give every one of them a pass because I think pain makes them that way in the vast majority of cases. And it's very pleasant to see the back end. I mentioned that little butterfly getting out of its cocoon. You see this ugly cocoon when you first meet the patient, and then 6 months later you're talking to a very smiley, happy patient. They don't have that same mental health issue anymore because it was always the pain causing it. It's very satisfying to see that on the back end. But going in, managing that stuff the best you can ahead of time is very useful so that you don't feel defeated as you're healing.

[52:34] Dr. Linda Bluestein: Yeah, that makes sense. And can you describe the actual surgical procedure or procedures — or at least maybe a couple of the most common ones that you do?

[52:44] Adam Hansen, MD: Yeah. I've got a version 1, 2, and 3, and the fact that there's a 1 and 2 shows that those weren't as good. In surgery, there's always named operations that have version numbers behind them, and you always go for the highest number.
[52:56] The simple technique that I came up with about 5 or 6 years ago was just simply suturing the ribs back together. There are basically 3 things you can do for slipped ribs. You can do the old school costal cartilage excision, where you just basically trim off the front end of the rib and leave it hanging in space and hope for the best. I don't do that because I don't believe in it — I don't think it works well in most cases. When I had my first patient that we decided together to repair, we just simply sutured the ribs back up. I asked my orthopedic surgeons to help me choose the best sutures that would hold cartilage well. We came up with these tape sutures, which we always use — they're strong, they're like shoelaces, they're kind of flat so they don't saw through the cartilage. That's simply what I was doing: just suturing the front end of the ribs back in a place where I thought they would be neutral and away from the nerves.
[54:02] That worked in about 75% of cases. It worked really well for the first 6 months to a year in most cases, but over time we saw that some of those would fail and we'd have to consider a revision. So I went back to the drawing board and came up with version 3, which is a more complicated reconstruction.
[54:21] I've come up with about 4 or 5 basic tenets of things we need to accomplish to achieve a successful slipping rib repair. The first is that I don't feel like the ribs want to be at their originally attached position. I think the body mechanics have pulled them downward for a reason, and if we force them to be in a place they don't want to be, I think that's when they're going to try to get loose again. So I have found that neutral rib spacing is a key factor. I let them be where they want to be, but I make them stay there.
[54:58] So step one on this reconstruction: as I mentioned, these ribs kind of hook upward as they go toward the sternum. Those hooks are where the nerve compression is occurring. I have changed my thought process — I didn't used to think that you needed to remove any of that rib or cartilage, but now I do feel like taking off those hooks is necessary because it decompresses the nerve where it's being compressed. So I just excise a very limited, conservative amount of that front end of the cartilage to get that nerve decompressed. And then I use that cartilage as a little spacer to place between the ribs so that they can stay apart from each other.
[55:51] Now some people get this nuance and say, well, isn't that going to pinch the nerve itself by having that cartilage where that nerve is? And the answer is no, because it's placed outside of the muscle. The intercostal muscle that lies between the ribs is a pillow — if I place these little cartilage pieces out front of them, the nerve is on the back inside of the rib, and that intercostal muscle functions as a pillow. So I suture all that together with that same tape suture, and then I lay across a plate — a dissolvable plate that acts like a cast on a broken leg. It lays across everything that I just rebuilt. Unlike a cast that you would have to remove after a few months of bone healing, I don't have to remove this dissolvable plate because it's biodegradable and will eventually go away. Once it's gone, it has already served its function. The plate in itself is not the end result — it's a means to an end that gets us there, holds that repair steady while the person heals. And then once they've established scar tissue between those grafts and the ribs, everything is very solid.
I've had the opportunity 4 times to be back in one of those sites and observe the reconstruction, and it has healed very, very strongly. The last tenet is flexibility, and the scar tissue almost functions like ligaments because it's a little stretchy. So once that plate is gone and the healing has occurred, it's a little flexible, which is ideal. You don't want it to be rock solid like bone up front — you want it to be flexible yet sturdy.

[57:32] Dr. Linda Bluestein: Can you explain why the — I know people are calling it the Hansen 3.0 technique — is the preferred technique and why the 1.0 and 2.0 are not?

[57:45] Adam Hansen, MD: Yeah. This has been a learning process. I thought version 1 was the greatest thing to hit Earth when I first came up with it, and the results were great at first. But over time some of them weren't great. Being introspective and realizing that maybe we hadn't achieved perfection with that technique led me to go back to the drawing board and find solutions to the failure points that we observed. That led me to version 2, which was a subtle difference in how I sutured the ribs to try to avoid the nerve, but I felt like that had issues over time as well and did not solve all the problems.
[58:30] With version 3, I was probably the most careful and the most interested in long-term follow-up compared to my earlier versions, because I didn't want more failures. So I've been very obsessive about following my patients out to 2 and 3 years for every patient. I'm not just looking to see if we needed to do another revision — I'm also looking at quality of life over the long term. We use a quality of life measurement tool. It's a fairly basic one, but it gives me a snapshot at each time point before surgery and multiple time points afterward, to see how they're doing and what improvement they've made.
[59:16] To date, we've only had one person fail the 3.0 — or what I call the costal margin reconstruction technique. The sutured slipped rib repair, you can lump versions 1 and 2 together in that. I don't do the sutured repairs anymore because they just weren't as good as I wanted. So version 3, which is my go-to operation now, I use it for essentially everyone, and it has had excellent results over the long term. I've got 3-year data on a good number of patients — out to the point where the plate is no longer there, so we're not relying on the plate strength anymore. We're relying on the scar tissue and the cartilage that's essentially formed at that reconstruction site. The results are far superior to the sutured repair techniques.
[1:00:15] And comparing to costal cartilage excision — you can look at the results in the literature, and the results of costal margin reconstruction are far superior to that. Since I don't do that operation, I can't do a head-to-head comparison. But just seeing the papers out there with about a 25 to 35% failure rate on that operation, we're not having that with this new reconstruction.
[1:00:49] So let's call it the costal margin reconstruction technique. It's really the only one I want to use anymore because it solves all the problems. I feel a little bad because I taught my earlier techniques to a lot of surgeons and they're currently still using them, but I'm on a mission to teach everybody what we've learned with this newer one and hopefully get others able to do that technique around the world.
[1:01:22] Now let me just state one thing — I'm not married to any of my techniques. If someone comes up with something that I feel works better, I will use it. I'm introspective enough to know that I'm not perfect. This repair is not perfect, but it's pretty darn good, and it's showing really good results. We've only had one real complete failure of this operation, and unfortunately the plate broke early within the first month on one patient, so we had to go back in and fix it several months later. I've had a couple of cases go back in because a few of these little rib tips that we excised had grown back with a little bony tip — kind of like a lizard tail, they regenerated the tip of their rib in 3 cases. So I had to go back in and take those little tips back out. Those were the cases where I got to observe the work and see what kind of strength that repair had, and it was actually very useful.
In essence, 3.0 is good for all comers. Some of my patients have had up to 12 operations before they came to me, and it works excellently for those. It works well for first-timers. It works well for people with 3 slipped ribs on each side, and it works well for a very simple case of 1 slipped rib. I can't find a reason not to use it. I've wanted to go back and use the easy chip shot suture repair at times, but it's like having an iPhone 15 and going back to an iPhone 6. You can't do it. The results are just that much better that I can't get myself to go back to the earlier technique.

[1:03:12] Dr. Linda Bluestein: And that's a great analogy because I think people are very accepting of the various software updates for all the apps, and of course the different evolution of the phones. Surgery evolves the same way.

[1:03:27] Adam Hansen, MD: Yeah, we learn over time.

[1:03:30] Dr. Linda Bluestein: Exactly. And you've had patients that have had 12 surgeries on their chest wall?

[1:03:37] Adam Hansen, MD: Yes. One patient had 12 attempts at fixing slipped ribs on both sides in total — so about 6 times on each side. I can think of another one that had 5. So a lot of these times these patients come to me for a salvage — basically, how do we salvage this horrible scenario where many different approaches have been tried and never really succeeded? And this one works. I've actually separated my outcome data between first-time operations and redos, and the results are not significantly different. This works just as well for a salvage case as it does for a first-timer.

[1:04:23] Dr. Linda Bluestein: Well, that's really great to hear, and that was one of my questions. I love that you're following people for such a long period of time and really looking at their functional capacity and quality of life. That's so important.

[1:04:28] Adam Hansen, MD: Yeah.

[1:04:42] Dr. Linda Bluestein: Anything more you can share either for short-term or long-term outcomes?

[1:04:47] Adam Hansen, MD: So we're looking at several data points. This quality of life tool measures pain, function, am I able to work, am I able to sleep, how anxious am I, how depressed am I, do I feel like I can go back to work in a short time — those are all the questions it asks, and all of those are improved significantly. I've put together an overall score — I give it a percentage. I don't want to steal my own thunder because this hasn't been published yet, but on average, a patient coming to my clinic discussing whether they want SRS surgery has a quality of life of 38% by my calculation. And that's pretty bad. What we're seeing at 6 months is a quality of life measured at 83% on average.
[1:05:44] More than double, right? With regards to what dysfunction that was causing, we're seeing more than double their quality of life and better. And then the numbers out to 1 year and 2 years continue to climb. You get your biggest jump in the first 6 months, but we're up around 90% at a year, 92% at 2 years. Pretty significant outcomes. And I've only had 1 complete failure of this at this point out of 320 or 330 cases or so. So it not only doesn't fail, but it succeeds in making someone have a better life.
There are another couple of issues that I've been anecdotally watching — the resting tachycardia and the gut function. Those things in patients who describe them preoperatively seem to get better, although I have not measured it yet. That's a focus of an upcoming study. One of the things we do monitor is self-reported breathing function. We're not getting pulmonary function tests — it's just difficult to get that from patients who are all over the country or the world. But if I just ask them, how do you feel like your breathing is at this point compared to what you feel should be normal? The average for those who report a deficit — which is about half of them — is somewhere around 56% before surgery. And we're up to the high 90s at 6 months and beyond.

[1:07:15] Dr. Linda Bluestein: Wow.

[1:07:15] Adam Hansen, MD: That shows how important rib stability is for breathing function, as we discussed earlier. And besides pain, that's been one of the biggest outcome improvements that I've noted.

[1:07:25] Dr. Linda Bluestein: That's really remarkable. And are there potential complications? Surgery always carries the possibility of complications, of course. And I really appreciate your being so transparent about the evolution of these procedures because I think it's really important for people to understand how this works. Are there potential complications that people should be aware of?

[1:07:33] Adam Hansen, MD: Probably the biggest — and I wouldn't call it a complication, but the biggest failure would be just not getting the relief you're looking for. We've discussed what the odds of that are, but we've had very few actual complications. The good news about this operation, even though it's a big orthopedic reconstruction, is that it is very superficial. It doesn't involve any organs, and we only have to basically get through a couple of muscle layers to get to the ribs. So it's actually a fairly easy access point and it's very safe.
[1:08:35] Earlier on, we had a couple of collapsed lungs — I think we had 3 or 4 pneumothoraxes that occurred with my earlier techniques. But with the later technique, we've only had that once, because you have to go really close with the sutures, and if you have a really thin patient, there's a little bit higher risk. I have had 2 hematomas that I had to reoperate on the same day out of my whole experience, and I have had 2 wound infections. There have also been a couple of minor skin reactions to the surgical glue, but really the only significant complications total about 6 or 7 of them. It's a very low number considering we've done probably 700 of these operations if you combine all the versions together.

[1:09:24] Dr. Linda Bluestein: Those are great numbers. And what can people do post-operatively to optimize their healing and recovery?

[1:09:31] Adam Hansen, MD: Getting up and moving, just like with almost every other surgery, is probably the best thing they can do. Just walking and resting, then walking again — just stay moving. Icing the area helps for the first week or two to keep the swelling down. But I am very strict about the activity restrictions I impose on patients because you wouldn't walk on a broken leg for a while — you'd need it to heal and be immobilized. How do you immobilize the torso? That's difficult because everything we do relies on that. You can't even live for 5 minutes without engaging your torso. But I do ask patients to avoid twisting, avoid bending, and avoid lifting more than about 20 pounds for 3 months.
[1:10:23] Seems like a long time, but I think that's the key. The 3-month mark seems to be the time point where enough scar tissue is laid down around the repair site to keep everything stable. And then we're not relying on the plate any longer. We don't want to rely only on that plate — it has a breakpoint. So if everything is relying on that plate for the first 3 months, we need to protect it for those first 3 months. After that, it can break whenever it wants to. So the lifting and activity restrictions are important.

[1:10:51] Dr. Linda Bluestein: That makes sense. And there were some questions submitted online that I want to go through in a little rapid-fire style. The first question is, do you see any difference in patients diagnosed with hypermobility spectrum disorder, or HSD, versus those diagnosed with EDS or Ehlers-Danlos syndrome?

[1:11:19] Adam Hansen, MD: Maybe I'm not as educated on this as I need to be, but I think of HSD as a bell curve. There's probably a lot of people on the front end of that curve that aren't that severe. I think they have a lot of the same findings, but they're probably much less severe than a severe hypermobile EDS case. Those I think of as being the biggest challenge.
[1:11:41] I did separate my outcome data between hypermobile patients and non-hypermobile patients, and it's not really any different. Anecdotally, I felt like all the hypermobile patients were going to be the most difficult and would have very poor outcomes. They're not showing that. They're showing fairly equal outcomes to patients who had trauma or some other reason for their slipping rib syndrome. I think the EDS cases do have a big challenge and it probably takes longer to get better, but they're still going to get there.

[1:12:22] Dr. Linda Bluestein: Sure. And what about male-female differences? Do you see anything there?

[1:12:27] Adam Hansen, MD: It's about 70% female, the patients who have slipping rib syndrome and other rib disorders that we can treat, and 30% male. It seems to be more common in slight, thin-framed people, who most of the time describes a typical hypermobile patient. I've certainly had some larger patients diagnosed with EDS, so you don't have to be the typical thin white female. EDS seems to affect a broad portion of the population, as does slipping rib syndrome.

[1:13:15] Dr. Linda Bluestein: Okay, and what is the likelihood of a recurrence or a different rib slipping after repair?

[1:13:24] Adam Hansen, MD: I've learned this the hard way — on a lot of my earlier cases I fixed a lot of 10th ribs and didn't fix a slightly wiggly 9th rib because I didn't feel like it was totally slipped. That's been a learning point. So if there's any mobility of that 9th rib in addition to the 10th rib, I go ahead and treat it. Some of my earlier cases had to go back in and fix the 9th rib because fixating the 10th rib to a partially loose 9th rib created a new slip.
[1:14:03] I'm very careful with this reconstruction. I try to extend the plate all the way up to rib 7 so that it shares the load for, say, a slipping 9th and 10th or just a slipping 10th. I try to share the load with the upper ribs because this newly reattached rib is going to exert some downward force on the repair. Sharing that load seems to make sense. With this reconstruction, we haven't had any additional slipped ribs.
[1:14:36] Now, what I have seen — and sorry to jump back in — is that the bridging cartilage or interchondral separation between ribs 5 and 6, if that is already there to a degree, does seem to get worse after we do the reconstruction on the lower ribs for similar reasons, probably pulling on it. So I have had to go back in for a handful of patients to remove those because that became more of a problem after the lower rib reconstruction.

[1:15:02] Dr. Linda Bluestein: That makes sense from a physics standpoint. Okay, and what do you want physicians to know about slipping rib syndrome and other chest wall problems?

[1:15:15] Adam Hansen, MD: Man, that's a big one — everything. Probably at least once or twice a week, I have a surgeon from somewhere in the world call me or email me and say, hey, I have this patient that needs to get fixed with slipped ribs. Can you tell me how to do this? And I say, it's not just a 5-minute conversation. You really want to be successful, and there's a lot of learning that needs to happen.
[1:15:53] I think just being aware of it and realizing it's real — some surgeons think it doesn't exist. I have numerous patients say that they saw a surgeon who said, what are you talking about? Ribs don't slip. If they could come into the operating room with me and see what these ribs are doing, it becomes quite obvious. Just by seeing it, that's all it takes.
[1:16:23] So I've made the offer to numerous surgeons that are interested in this and feel like they're capable of doing these cases, to just come out and spend 2 days with me. See 4 or 5 new patients in clinic and some follow-ups and see what goes into the diagnosis. Then the next day, we'll do 4 cases and they can look over my shoulder and watch. We've had several surgeons from around the world do that, and a few more are set up to do that. I think I can get someone who already knows how to fix broken ribs completely up to speed in about 2 days. But if you're trying to figure this out in less time than that, it's going to be very difficult to get it up and running successfully.

[1:17:11] Dr. Linda Bluestein: That makes a lot of sense. And it's incredible that you are teaching so many other surgeons how to address these problems.

[1:17:31] Adam Hansen, MD: Well, it makes sense. If I had this condition, I wouldn't want to have to go to Australia for it. I'd want to be treated locally. So we've built a network of surgeons around the world — we've got some in Scandinavia, some in Australia and England. We haven't gotten Canada figured out yet, but we're trying. And there are several places in the U.S. I feel like there are people that know how to do this now. So it's been nice because we can now tell patients, let's send you to the closest person to you that knows how to do this.

[1:18:02] Dr. Linda Bluestein: Okay. And last of these rapid-fire questions: what correlation, if any, have you observed between cervical instability and slipping ribs?

[1:18:11] Adam Hansen, MD: It seems to be present in at least 5 to 10% of patients — it appears on their diagnosis list. They have like 5 or 6 common diagnoses, all the difficult ones like POTS and MCAS and all that. But craniocervical instability is common. I mean, you just think about it — the same problem exists in all of these joints. This is not isolated to the lower ribs. The same problem happens everywhere. The only reason I'm focused on these slipping ribs and these functional lower rib disorders is because I can fix them. If there were fixes to all these other issues, certainly we could offer like a whole skeletal rebuild to patients that are very unstable.
[1:18:59] I think about it all day long. Hypermobile skeletal disorders — it's a problem that a person's born with and it's going to carry their whole life. You can't change the genetics of it, at least at this point in time, but we can change some of the phenotypic, or the outward, manifestations of a few of these problems. And I think that's where the money's at — let's fix what we can as we're working toward further solutions. There are some very fixable problems at this point that can make a huge difference and help the patient deal with the overall full-body manifestations of this hypermobility syndrome. Back to your original question — yeah, craniocervical instability, same problem. I don't know what they do about it. I'm no spine surgeon, but I don't know if that's fixable.

[1:19:51] Dr. Linda Bluestein: And we did — I don't remember the number, but I think it might be episode 78 — a conversation with a neurosurgeon, Dr. Paolo Bolognese, where we discussed craniocervical instability, Chiari malformation, Eagle syndrome, a lot of these different conditions. And you're absolutely right — this is what I observe in my patients. Some are hypermobile but they're able to build enough muscle that they don't have much joint instability, and other people, their connective tissue is clearly just falling apart and they're unstable all over the place. They have just incredible difficulties trying to build any stability, and you do feel like you're playing whack-a-mole a lot of the time. It's really challenging.

[1:20:34] Adam Hansen, MD: Yeah, for sure. I think there are probably a few key areas in the skeleton. If someone's got these problems everywhere, there are a few key areas that can really give you that springboard into being able to exercise and make your muscles better. If your core is totally floppy because none of your lower ribs are attached to each other, we can fix that and get you a lot more rigid and structurally sound. Then you can work on the other stuff with the muscles to try to maintain the more minor problems and keep them down to a dull roar.

[1:21:12] Dr. Linda Bluestein: Sure. And I want to jump into our last question before we talk about where people can find you online, and that is hypermobility hacks. I like to end every episode with having the guest share one of their favorite hypermobility hacks.

[1:21:29] Adam Hansen, MD: Well, I think I already shared it. I'm very simple with what I think about, but all day long, the best hack is the planks and Supermans. If you focus on one thing in your overall care, let it be those two exercises because that will make the biggest difference compared to anything else I know. I wouldn't chase down a bunch of intercostal nerve blocks and prolotherapy and nerve ablations and all that stuff. I would chase down the strength. That's the biggest payoff.

[1:22:07] Dr. Linda Bluestein: Okay, great. That makes sense. And where can people find you online?

[1:22:13] Adam Hansen, MD: I have to admit, I'm not even on any social media. Maybe that's a good thing or a bad thing, but I know there's a lot of discussion about slipping rib on the Slipping Rib Syndrome Facebook page. There's a big group of, I think, like 6,000 or 7,000 members, if I'm not mistaken. And there's a lot of people that really know their stuff, that are very educated on this, that can really help a newcomer shorten their learning curve on how to manage this.
[1:22:47] I've put forth a little bit of an effort to put up a few videos. The video on the exam that you were referencing earlier was made for patients to show their surgeon, or for surgeons to look up so they can learn how to do the exam. I think that one's pretty useful. There is also a forum for cardiothoracic surgeons called ctsnet.org, and I put up a video of my reconstruction there for other surgeons to use in learning the technique. But it would be equally useful for a patient that's not squeamish to get on there and see what the actual reconstruction entails. There's also one I put up there about the bridging cartilage separation if anybody's interested. It's on ctsnet.org. Other than that, if someone needs a consultation, I just have people call my office and we can give the basic information that way. You have to put your hands on a patient to be able to get the diagnosis, so you can't make that diagnosis over the phone.

[1:24:02] Dr. Linda Bluestein: Right, for sure. I'll make sure to have all those links in the show notes as well. Is it okay to share the phone number if people want to get a consultation?

[1:24:15] Adam Hansen, MD: Yes, that'll be fine.

[1:24:17] Dr. Linda Bluestein: Okay, great. Well, you have been listening to the Bendy Bodies with the Hypermobility MD Podcast, and my guest today was Dr. Adam Hansen, thoracic surgeon with expertise in complex chest wall reconstruction. Dr. Hansen, thank you so much for coming on the Bendy Bodies Podcast and sharing your incredible wisdom, knowledge, and expertise with us.

[1:24:38] Adam Hansen, MD: It's been my pleasure. Thank you for joining the fight. This is a big fight, but we're going to win it eventually.

[1:24:46] Dr. Linda Bluestein: Yes, it is a big fight. And I think we're getting more and more people involved. We're making some headway.

[1:24:56] Adam Hansen, MD: Yeah, for sure. Thank you. I appreciate it.

[1:24:57] Dr. Linda Bluestein: Thank you for listening to this week's episode of the Bendy Bodies with the Hypermobility MD Podcast. Visit our new website at bendybodiespodcast.com where you can now view guest profiles and show notes with links to products and journal articles. Leave me a comment, sign up for updates, leave a review or a voicemail, and access the podcast on your favorite player, all directly from our website. You may hear your voicemail in a future episode where we answer your question or dive into your gracious feedback.
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