Reinventing the Rib
by Will SansomPediatric orthopaedic surgeon Robert M. Campbell, Jr., M.D., had dreamed about the letter in his hands for many years. Sent by the U.S. Food and Drug Administration (FDA), it was a note of confirmation on the approval of the Vertical Expandable Prosthetic Titanium Rib, a device Dr. Campbell invented because of a caring surgical colleague and a baby born without ribs and without hope.
The colleague was Melvin Smith, M.D., of CHRISTUS Santa Rosa Children’s Hospital and the baby was Christopher Cardenas of San Antonio. Dr. Campbell, professor of orthopaedics at the Health Science Center and director of the Thoracic Institute at CHRISTUS Santa Rosa Children’s Hospital, and Dr. Smith, professor of pediatric general surgery at the Health Science Center, were surgeons at the hospital when Christopher was transferred there in 1987, missing seven ribs on one side. His malformed chest wall caused respiratory distress, prompting the newborn to be placed on a ventilator. Dr. Smith first saw Christopher at 7 months of age and after a two-month search found himself hailing Dr. Campbell in the hallway.
"I had heard he was some kind of engineer or something before he became a surgeon," Dr. Smith said. "I asked for his help to save Christopher." Soon the surgeons operated and gave Christopher an artificial chest wall. They placed three 4-inch-long stainless steel fracture rods vertically and attached them to the child’s few remaining ribs near the neck and the waist, bending the rods around the ribs with sterile surgical vice-grips.
Eight days after surgery, Christopher was able to breathe on his own. Faced now with a child likely to survive and grow, and not wanting to repeat the difficult fracture rod operation repeatedly with longer rods as the child grew, Dr. Campbell decided that he had to invent a rib replacement device for this child that was easy to implant and easy to expand with minor surgery to decrease the risk of complications.
"Inventing it turned out to be the easy part," Dr. Campbell said. "Finding a surgical company to manufacture a totally new surgical device for use in only one patient turned out to be almost impossible, but after many refusals, the Techmedica Corp. of California finally stepped up to the plate." By 1989, Dr. Campbell was ready to implant the titanium rib in Christopher.
The second operation also succeeded. It would be the first of 300 titanium rib surgeries performed to date. The titanium rib has proved to be an effective answer for a group of patients who have scoliosis (curved spine), fused ribs, small chests and missing ribs. These conditions harm respiration and lung growth, either at birth or in early childhood. The rib is expandable to allow for growth, and expansion surgeries are done on an outpatient basis every six months. The ultimate survivor, Christopher, is a walking miracle at 17. "We are starting to see several of the kids, like Christopher, reach skeletal maturity," Dr. Campbell said.
He and Dr. Smith developed five types of operations using the titanium rib and identified a new disease, thoracic insufficiency syndrome, in landmark papers in orthopaedics journals. The surgeons have taught titanium rib surgical techniques at children’s hospitals worldwide. The titanium rib is described as the first truly new spine deformity treatment to gain FDA approval since 1962. "The way we treat these kids at this point in time will become the new standard of care," Dr. Campbell said.
The titanium rib, about 12 inches long, is curved like a rib cage and has holes that allow the surgeons to expand the device in outpatient surgery every six months. The rib is implanted in infants as young as 6 months and in teenagers until skeletal maturity, typically age 14 in girls and age 16 in boys. "Our data suggest the earlier the better," Robert M. Campbell, Jr., M.D., said. "The lung growth curve is best in the first two years of life." The titanium rib is made of titanium, a material that is lightweight, compatible with body tissues and does not interfere with MRI scans.
His twin, Jordan, developed severe scoliosis within the past year. Jordan’s rib cage was narrowing on the left side, restricting breathing. "We went right to the titanium rib program," Kim said. "We took Andrew’s lead. In both boys, the titanium rib has done its job."
Dr. Campbell gets a hug from 6-year-old Patricia “Itzel” Rodriguez. Rodriguez underwent surgery in 2002 to straighten her little body, which was severely slanted because of scoliosis. She was the 153rd patient to receive the titanium rib at CHRISTUS Santa Rosa Children’s Hospital in San Antonio. A national clinical trial to test the titanium rib started in the 1990s under the sponsorship of the Synthes Spine Co. of West Chester, Pa. About 210 children underwent surgery at CHRISTUS Santa Rosa Children’s Hospital and 90 at children’s hospitals in Pittsburgh, Boston, Salt Lake City, Los Angeles, Seattle and Philadelphia.
Indeed, the titanium rib has done its job in 300 infants and children. The contributions Drs. Campbell and Smith have made to the literature of pediatric orthopaedic medicine cannot begin to outweigh the contributions they have made to these precious families.
As a result of his experience with developing the titanium rib, the National Organization of Rare Disorders and the American Academy of Orthopaedic Surgeons have sponsored Dr. Campbell as a participant on a government task force to report to Congress on the best way to remove current obstacles to pediatric device innovation and development in the United States.
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