84. Slipping Rib Surgery in EDS with Adam Hansen, MD

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Linda Bluestein, MD (00:36.746)

Welcome back, every bendy body. This is the bendy bodies podcast and I'm your host and founder, Dr. Linda Blustein, the Hypermobility MD. This is going to be a great episode. So be sure to stick around until the very end so you won'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, oh my gosh, I already made a mistake, see? 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.

Linda Bluestein, MD (01:32.138)

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 for a way to devise.. 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 1000 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. Dr. Hansen, when I read that, I thought, wow, that is so incredible. It's so beautiful. And I just wanna welcome you to Bendy Bodies and I'm so thrilled to chat with you.

Adam Hansen (03:11.489)

Thank you. My pleasure to be here. I appreciate it.

Linda Bluestein, MD (03:14.35)

Oh, I'm so excited to dig right in to this very, very important topic. And so first we're going to get some background information covered, 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?

Adam Hansen (03:37.687)

Yes, so I think very simply and I think of all of these disorders as essentially nerve compressions and it's just basically two bones that are 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.

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. So again, you boil this down into slipping rib syndrome and the floating rib disorders were probably the best differentiation between this set of problems. The 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. 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. So there's ligamentous attachments.

they 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 eight through 10. Once in a while, you can have a seventh rib that slipped, but I've never seen anything above that be slipped. And that's because everything above rib eight is a true rib. It has a direct connection to the sternum. So I think of slip, the false ribs is basically hitching a ride up to the sternum by way of the rib above them.

So these weakest links in the chain are the ones that, since they are so flexible, they 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. So each rib has its own intercostal nerve assigned to it.

Adam Hansen (05:55.619)

So for example, rib eight has nerve eight that runs just below it and just on the inside surface of the rib cage, below rib eight. And if you have a slip ninth rib, that's going to typically aggravate nerve eight. And so if you think about the problem is in the front and it can, I mean, 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. So if you look at just a simple dermatome map, you can see where these nerves go to.

and essentially that's a stripe around the torso. And that's where along this whole stripe, that's where that pain can occur when a slipping rib is irritating the nerve typically above it. So people get confused, especially doctors, they get confused, they think that a patient has a spine problem or an organ problem like a gallbladder, dysfunction or something like that, when indeed it is just a stripe of pain in that one region of that one or multiple nerves that are affected. 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, there's some people that have a connected 10th rib, and some people like me that don't have a connected 10th rib. And that's not a problem until it starts aggravating the nerve between

Linda Bluestein, MD (07:13.347)

Hmm.

Linda Bluestein, MD (07:19.962)

Mm.

Adam Hansen (07:23.947)

the rib above it and itself. So 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 or the nerve above them between either rib or the hip bone. So the iliac crest or the top of the pelvis is where rib tip syndrome can occur, right? So the tip of the 12th rib and sometimes the tip of the 11th rib can be so far, so low slung and far

Migrated downward that they can start striking the iliac crest and what did they do when they do that? They pinch their own nerves, right? So that's also known as costo iliac impingement syndrome I typically use that term but a lot of people are using this term rib tip syndrome. It's the same thing Also, there's two more problems that can occur and I don't want to get too complicated with this but the 12th rib Can either angle down way too far

and strike its base, so basically the neck of the rib, just beyond the joint, near the spine. It can strike the first lumbar vertebrae transfers process, so the little side wing that hangs out from the side of the L1 vertebra can be an impingement point upon nerve 12. 12's the problem, it's not the L1. The 12 can hang down and pinch its own nerve against L1.

Linda Bluestein, MD (08:36.387)

Mm.

Adam Hansen (08:51.223)

The final thing that can occur is the 12th rib can also angle, curve up, maybe have a little bit of rotation in it where it twists upward at the tip and it can aggravate nerve 11. Okay, so that's called 12th rib syndrome. So let's just go back through this one more time. Slipped rib syndrome is the false 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 L1 transverse process. So a lot of potential contact points, but they're all the same thing, intercostal nerve compressions.

Linda Bluestein, MD (09:32.118)

What a great explanation, because I really like how you kind of started with what they have in common. And I think that's a really helpful way to think about it, because it can be pretty complicated pretty quickly, otherwise.

Adam Hansen (09:44.543)

Yeah, yeah, hopefully that wasn't too complex of a description, but essentially it's like four things that I look for on an exam.

Linda Bluestein, MD (09:51.778)

Sure, sure. And regardless of which of these syndromes that you're looking at, and maybe you want to address each one separately, or you want to group them together for some of these questions, and however you feel most comfortable doing it for sure. What is the relationship between these various different compression syndromes and skeletal hypermobility disorders?

Adam Hansen (10:12.003)

Okay, so you think about the Ehlers-Danlos and all of the hypermobile spectrum disorders like Loey-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, right? So that's a big box of potential problems, right?

Linda Bluestein, MD (10:34.607)

Mm, wow. Wow.

Adam Hansen (10:41.387)

So the overarching problem is the laxity of the ligamentous tissue that connects all of these joints together. So you can have a problem with any number of joints in the body and the thorax being so concentrated in the number of joints that it has, that's basically it's a setup for many disorders to occur. Now these four issues that I've just, or five issues that I've just mentioned are

They're all the same thing, basically. This 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 basically 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 just would stay in their own lanes, none of these compressions would occur. So this is a problem of all these ribs come out of their own lanes and find their way into some other compression.

Linda Bluestein, MD (11:54.622)

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?

Adam Hansen (12:03.199)

Yes, so as much as Marfan Syndrome, Loey Deitz, there's probably a whole host of disorders that maybe even be undefined, hypermobility disorders. But I think in my practice, there is a subset of patients that is probably around 15 to 20% that have known Ehlers-Danlos Syndrome. These are people that are usually affected pretty heavily and they have multiple joint disorders. These are people that, it's obvious when they come to me, I know what I'm getting into.

probably larger subset that I know are on that hypermobile spectrum that may be not that severe or may be extremely severe and just haven't had a diagnosis made yet. I think I've made the claim to many of my patients that you could blindfold me and put 10 patients in front of me, to one of them having 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 sort of are, they're just formed a little differently than the average person that is not affected. I think of these, I mean, if you look at like a skeletal model, I have a million skeletal models in my office, but you see the front of the ribs is all connected and it's all nice and firm, and then you have the one, 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 obvious that they're all completely disconnected. So I can't tell you whether that patient that can be blindfolded and locate.

I can't tell you whether they have Ehlers . Danlos but I can tell you they have hypermobile skeletal disorders. So I think we're just scratching the surface and thank God for you and a few others, very few that really understand these disorders. I think, you know, I only happened upon this stuff by accident when patients started coming to me and I had to of necessity learn about their disorders to be able to understand them. But I think we're just scratching the surface.

Linda Bluestein, MD (14:01.078)

Mm-hmm.

Adam Hansen (14:22.547)

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 gonna have good connections.

Linda Bluestein, MD (14:29.878)

Right.

Linda Bluestein, MD (14:36.566)

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, instead you've dove head first and really just kind of making sure that you're providing good care, and I think it's so important. And 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 what.

is your, you know, is this the best approach for that patient? But a lot of people, I think, don't even want to learn, basically. And so I think it's great how you described yourself and how you've approached this.

Adam Hansen (15:16.271)

Well, thank you. I appreciate that. I mean, I've taken the stance that, I mean, I feel bad for people that have hypermobile skeletons. I mean, they, it's a lifelong, uh, just 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 know, you can't fix everything, at least so far we haven't been able to fix everything. Yeah. We're certainly working towards solutions in other areas, but there are some that we can fix that will take us, you know, take our patients into.

Linda Bluestein, MD (15:31.342)

Mm-hmm. Right.

Adam Hansen (15:46.079)

a terrible crippling disorder over to a very manageable set of disorders that they can then focus on exercise and things like that. So I've taken the stance that if I see a patient that has, you know, is a very difficult challenge operatively to try to fix this, I want those patients to come to me because we certainly made some mistakes along the way and, you know, gotten ahead of the learning curve at this point. And I'd like to be the one to take care of bad ones.

I give away, refer to other partners that may not have as much practice on this, the easy ones. I don't want other surgeons to fail at the outset. Say they're interested in slipping rib syndrome repair. I don't want them to get an Ehlers-Danlos hypermobile patient that has eight slipped ribs and expect them to succeed on their first one or 10 cases because they're probably not going to. So at any rate...

Linda Bluestein, MD (16:31.522)

Hmm.

Linda Bluestein, MD (16:35.058)

All right. Right. Mm hmm.

Adam Hansen (16:41.087)

I'm not asking for the bad cases, but I'm happy to do that.

Linda Bluestein, MD (16:46.043)

Sure, sure. And the learning curve is so steep with so many of these things and it certainly was for me and it really is really challenging for sure. And those of us that are really passionate though, we continue to learn and try to provide the best possible care. So I think that's what's important. And so can you describe to us what the symptoms are of these compression syndromes, whether it's slipping rib or 12th rib or...

various different conditions.

Adam Hansen (17:15.903)

Yes, yes. I mean the bulk of the problem is pain, right? And let me just think about the, I mean, probably 80% of the issue is just pain. But the more and more of these patients that I've seen, the more I realize how other body-like functions can be affected by them. So, you know, some of my, 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 maybe aren't surgeons. But I'm realizing more and more the breathing is affected, that resting elevated heart rate is affected or caused by this. There's a lot of things like gastroparesis and irritable bowel syndrome that could potentially go away should these nerves stop being compressed.

and have even spared a couple of patients from having their kidney removed for suspected nutcracker syndrome, when indeed it was just the 12th rib syndrome all along, or an L1 syndrome. So 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 that 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. So I think we have to realize that we don't know very much about this yet, but realize that one thing can affect another. I'm convinced that the intercostal nerves as they run back toward the spinal cord, they

Linda Bluestein, MD (18:44.833)

Mm.

Adam Hansen (19:03.543)

pass through junctions in the autonomic nervous system, that's along, just lateral, just out to the side of the spine. And I think they pass through these intersections, and I think they send haywire signals, or crosstalk, or short circuit signals into the autonomic nervous system, which can then do numerous, cause numerous problems, like gut dysfunction, and this resting tachycardia that I've been seeing a lot of, or POTS.

postural orthostatic tachycardia syndrome. I think a lot of these either are caused by these slipped ribs or at least the slipped ribs can contribute to them. So, you know, there's a host of these other symptoms, but the vast majority of people are going to have the 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. And so if you have unstable, you know, wiggly lower false ribs, you're not going to have a stable rim for the diaphragm to contract against. I mean I think of it on

Linda Bluestein, MD (20:01.506)

Hmm.

Adam Hansen (20:27.523)

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. And I think the diaphragm is the same way, that if it has a nice stable ring of rib cage to pull against, then you can have an effective contraction and draw air in. 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, which is, you know, I had no idea we were doing this until patients started coming back and saying, hey, I'm breathing a lot better. And so I had to go back and reverse engineer this and figure out, I think that's what the issue was there.

Linda Bluestein, MD (21:16.446)

Interesting. And is the pain usually pretty well localized? And do people also feel things like clicking or, you know, that displacement that can occur the subluxation and dislocation?

Adam Hansen (21:28.395)

Yeah, thank you for bringing that up. I neglected that. I would say not the majority of patients have a clicking. There's probably a minority of patients. You think of that being the classic presentation of clicking or popping rib in the front. And you think of pain in the front being 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 sort of the upward hooks of these ribs as they're curving upward toward the sternum.

That's where the actual problem is happening, but it may not manifest there. The pain may manifest, I would say probably most commonly, just under the tip of the scapula. That's probably the most common site for people to have the pain. So it wraps around to the back. So it's like paravertebral pain, little bit off to the side. People don't generally notice it right in the middle line of the spine, but they notice it about two 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 basically 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. So that is probably one of the more diagnostic challenges is to figure out this dermatome because you may have pain at two or three sites along the way in that dermatome and not around the whole way.

Linda Bluestein, MD (22:55.362)

And is the pain more often unilateral or bilateral?

Adam Hansen (23:00.239)

So it just depends on where the slipped ribs are. So there are a lot of unilateral slipped rib patients and there's a lot of bilateral slipped rib patients. Probably the vast majority have some element on both sides. But I mean, there's 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 you know, breaks or dislocates their rib in the front. They're probably just gonna have a unilateral pain. It's also interesting. You can have the exact same anatomy on both sides. You can have, you know, one or two slipped ribs

on both sides and only one side will hurt. I think of it as like, you know, one dog is 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 know, oh yeah, I've been hurting all along on this other side, and now it's just kind of manifesting itself. I think a lot of patients though that have bilateral slipped ribs also

Linda Bluestein, MD (23:33.294)

Hmm.

Adam Hansen (23:57.439)

especially the hypermobile patients may have an element of scoliosis or some kind of spine disorder. And whichever way that the spine leans, so say you have a levoscoliosis to the left, you're probably going to have more symptoms on that side because the inside curvature of that, the inside of that curvature leads to more rib compression on that one side, whereas it splays it out on the other side. So the splayed out side is not going to contact the nerves very often. And so they're more likely to have pain.

on the lesser curve.

Linda Bluestein, MD (24:31.406)

Okay. And what are some emerging areas of discovery related to slipping rib syndrome? And are there areas of the chest wall that are affected in the same way? I know we've already kind of talked about what some of those syndromes are called, but what are some of the emerging areas of discovery?

Adam Hansen (24:49.327)

Well, yeah, we have mostly covered some of this topic already, but I think probably the more undefined stuff is the posterior joints, so the cost o vertebral 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 be able to figure out a solution. I did have a sort of 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 of that one because I thought it could create more problems at these nerve roots than what we solved. So...

That one still is sort of pending. So that's a big one I'd like to solve. There is one more recent discovery that I've made in patients that also have slipped ribs. And it's not always in a patient that has slipped ribs, but it usually is. And that is an issue that we've kind of dubbed a bridging cartilage fracture. It's not really a fracture. It's still the same thing. It's just a separation of an interchondrial joint.

This occurs typically between ribs five and six. It can occur between four and five and six and seven, but there are these, what they call, secondary interchondral joints where you have these up and down support, I think of like a little two by four being nailed between two 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. And these are...

prone to separation and they cause intense pain. Feels, 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. So 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 on, I just excise that little piece of cartilage that's up front in between those ribs that's compressing that nerve. And as long as the ribs are nice and stable otherwise.

Linda Bluestein, MD (26:47.906)

Hmm.

Adam Hansen (27:11.095)

That's a very simple solution. So this bridging cartilage separation thing is kind of one that I've been excited about recently because it's a huge payoff for a very small operation.

Linda Bluestein, MD (27:22.162)

And does everyone have that bridging cartilage or is that an anatomic variant?

Adam Hansen (27:26.815)

It's a variant, yes. So I would say men typically have them more than women. And the same patient may have them on the right and not have them on the left. It's just a little variation. Just, you know, they're not consistent between rib spaces, but they're typically probably the most commonly found between ribs five and six.

Linda Bluestein, MD (27:29.527)

Okay.

Adam Hansen (27:51.355)

And just because you have them, I mean that that's an it's a normal structure that you want, right? It's just additional support in the front of the ribs. So just the mere presence of them is not a problem It's when they become separated What I usually see on a CT scan is they become calcified Like if you don't have hardly any calcium in the front of your rib cage in the cartilage and then you have this one heavy Focally calcified area at that joint. It's a red flag to me that has been separated and the body's trying to heal it

So it's basically it's the same thing as a slip-rip syndrome. It's just not slipped. It's just, you know, it's a separated joint.

Linda Bluestein, MD (28:29.678)

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

Adam Hansen (28:47.895)

Yeah, I think, I mean, so we're, most of us physicians that are, or providers that are interested in this are kind of guilty of just doing, you know, follow the leader. And so we all look at these few old papers that have been published on slipping rib syndrome and we're all sort of prone to doing the hooking maneuver. It's sort of the one diagnostic maneuver that, maneuver that anyone is aware of. They don't even use that typically. Once in a while it will, but I mean, that's just the...

really forceful grab of the lower rib cage and pull upward. And it's not detailed at all. It's not a detailed assessment. Basically it just tells if they have pain in the front. So there's really not a lot of point to that. But what I do is I just start, 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.

Just get to where I can feel the ribs individually. And I start low, I start at the spine at rib 12, and I work my way, I feel the very lowest rib. It's very important to really work on that 12th rib because a lot of people have these 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 gonna 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 you know, you may see it and you don't have any body fat. But at any rate, you start at rib 12 and I'm assessing for L1 syndrome, rib tip or 12th rib syndrome and rib tip syndrome, all of those things I can elicit from ribs 11 and 12. And I just work, just use my fingers to just walk up and make sure I'm on each rib and I assess which ones are hurting. And as soon as you find ribs.

you know, 10 and then nine and eight. I'm working my way out to the front, out to the costal arch along the costal margin. And it's very easy to feel a separation point at the tip of the ninth and 10th ribs. They, 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.

Adam Hansen (31:00.491)

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, you know, like we've discussed before. And it's very easy to figure out for the most part, you know, which rib is at fault and which rib is the problem. Now if they don't have, if they have a slipped rib, the slipped temp rib for example, and there's zero pain there,

it's probably a floating 10th rib, one that they were born with. And 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? So if it is a problem, I don't care whether they were floating at birth or whether it's separated later on in life, if it hurts, it's still a candidate for treatment. So then I just keep walking my way up and then to assess this bridging cartilage separation, I'll have the patient lie on their back.

and I just basically palpate right up underneath, right where the underwire hits and just find that space. And that's usually right a little bit middle or medial of the nipple. So it's a little bit more toward the center. And that, if they have excruciating pain in that site, that makes me think that that's probably an issue. I didn't use to get any imaging. I've had this learning curve myself and I may be a little proud at the beginning thinking I could diagnose this stuff all.

just on physical exam. And then I found a few that maybe I, I found a person that had no 12th ribs. And so I had left a 10th rib untreated because I counted wrong. And a few other issues like that, that it is very useful to have a CT. And I pulled the CT up in the office, in the clinic, in the room with the patient. And I looked at the scan, I looked at the patient, and I'm correlating these findings. I don't treat.

Linda Bluestein, MD (32:50.836)

Mm.

Adam Hansen (32:51.599)

the CT by itself, of course, but it helps me to know where my starting point is, know what their 12th rib looks like, for example, and get my bearings. And then the bridging cartilage thing, I really need to see that on the CT before I will offer a patient surgery for that one, because it is very difficult to diagnose just with physical exam alone.

Now, just with remarks to the CT, I make all my patients or requests that they all get a CT of the chest and abdomen. And the reason, I don't need contrast for that. The reason for that is because a chest CT usually does not include the entire thorax. So the entire rib cage is not visible on a chest CT. And 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

Linda Bluestein, MD (33:24.185)

Mm.

Adam Hansen (33:46.527)

well into their abdomen, even all the way down to their pelvis in some cases. And I look at the view, it's called a coronal view, where basically it's like straight on, we're looking at, 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. And so that, I don't use any other imaging. I know a lot of people want to use the dynamic ultrasound.

just 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 cues and a few findings on a CT that I can't do on a physical exam. And I feel like that's the most useful study.

Linda Bluestein, MD (34:33.566)

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?

Adam Hansen (34:46.135)

Absolutely. This is one that, you know, maybe I didn't mention on your previous question of emerging disorders, but I think a lot of patients with 12th rib syndrome or rib tip syndrome, especially ones that affect the 12th nerve, right? So the 12th intercostal nerve, if you look at it on a dermatome map, it goes quite low in the front. So you think of, you know, our ribs are angled from back high in the back to very low in the front, especially hypermobile patients, they're almost vertical.

And so this 12th intercostal nerve may very well end up in a place in the front that is well down into the groin. And there's 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 that said that it hurt in his testicles. And 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 commonly can be also mistaken as like a labral tear in a hip. So 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 that was hitting the hip causing that same pain.

Linda Bluestein, MD (35:54.114)

Hmm. Wow.

Adam Hansen (36:07.327)

And lately I've been referred quite a few patients from our urologists as well, that they have people that they think have kidney stones and they get the non-contrast CT scan and there's zero kidney stones and it hurts exactly where the kidney is and they're confounded, they don't know, 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.

Linda Bluestein, MD (36:37.531)

Yeah, 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 that the two of you had. I thought that was really fascinating. And abdominal compression syndromes are so tricky, of course, you know. And so can you share any...

Adam Hansen (36:53.007)

Thank you.

Linda Bluestein, MD (36:59.198)

additional thoughts that you might have regarding abdominal compression syndromes and chest wall disorders.

Adam Hansen (37:05.751)

Yes, so being is that a lot of times they have the same subset of symptoms. It stands to reason to me to fix, let's say you have obvious slipped ribs or an obvious anatomical deformity or problem that I feel like you have, you know, one of these issues that we have just discussed with the ribs. And you have findings on a CT that suggest MALS or Nutcracker Syndrome or one of these, you know, what is it, the May-Thurner or SMA Syndrome.

Linda Bluestein, MD (37:35.246)

Mm-hmm.

Adam Hansen (37:36.487)

It seems easiest to me to fix the ribs first, because it's much less invasive than doing a large abdominal operation, rerouting the intestines or putting a vascular graft in or going as far as taking out a kidney. But those are pretty large operations. I mean, I trained in general surgery and did some vascular surgery, and I know what goes into those operations. And it's a big deal when, if you can just do a very superficial.

repair on a rib, then may very well be causing the same pain. Even if you do have findings, imaging findings that suggest an abdominal compression syndrome, you probably should do the ribs first, just because it's not as big a deal. And worst case scenario, if we don't solve the problem, then you attack the abdominal compression syndrome.

It's probably not, you know, I mean, there were some obvious cases where you'd want to just go ahead and do the abnormal operations, but I would say the vast majority of them are going to have confusing findings that, you know, cross over. One of the differentiation points, I mentioned the two patients that were teed up and ready to go for their nephrectomy for Nutcracker syndrome. It was...

You know, the pain was in the correct distribution for NCS, but they had palpable tenderness. And so an abdominal visceral pain should not present with any, you shouldn't be able to push on the 12th rib and make that hurt. Right? So I think that's a differentiation point and it just emphasizes the importance of a physical examination because if I am pushing on your 12th rib and all of a sudden your nutcracker syndrome flares up.

It's probably not Nut cracker syndrome that's causing it. It's probably the 12th rib.

Adam Hansen (39:37.494)

Interesting stuff.

Linda Bluestein, MD (39:39.006)

and very interesting stuff and that's where imaging is.

Of course, you have to be so skilled at interpreting the findings. And I love that you're looking at the CT, looking at the patient, looking at the CT, looking at the patient, because otherwise we can, you know, I know he mentioned in that talk that he was doing with you, when he was interviewing you, talking about silent abdominal compression syndromes, and you don't want to be operating on somebody if they have imaging findings that suggest that, but that's not really actually the cause of the person's problem.

Adam Hansen (39:53.336)

Yeah.

Adam Hansen (40:12.815)

For sure. In my trauma training when I was a general surgeon, we had an attending that said don't succumb to vomit. So vomit being victim of modern imaging technology. So never operate on the scan alone, right? You have to put your hands on the patient and find out if it really correlates to those findings. Yeah, you may have a very dilated left renal vein. Sure. It may look like a nutcracker syndrome.

Linda Bluestein, MD (40:32.107)

Right.

Adam Hansen (40:43.291)

But if that's not the source of the problem, you know, I certainly don't operate on it.

Linda Bluestein, MD (40:49.93)

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. And we'll definitely get into that a little bit more in just a few minutes. But I first wanted to just talk about if there are self-help strategies that people can use. This was, I got quite a few questions about this. Are there taping things that people can do, exercises, et cetera? We know that there's a lot of muscles that act on and also affect...

movement of the ribs. Are there anything like that people can do to help avoid surgery, I guess, basically?

Adam Hansen (41:26.519)

Yeah, I think especially the floating rib disorders that we've discussed, I think a lot of times those can be fixed simply with better posture. But I do feel like the slipping rib syndrome, once they detach, they're going to be a problem. So in my mind is how often is a slipping rib compressing the nerve, right? So...

If you're leaning forward, you're going to be closing that space and compressing the nerves. So if you're spending 98% of your day in a very good upright, good posture, you're probably going to have very few episodes of when that's going to hurt. And so if you do have, let's say you don't want surgery or you're not a candidate for surgery and you want to try to get the best management strategy and still have slipping

Adam Hansen (42:19.759)

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 until I'm blue in the face, like you gotta have better posture. You can't just think about your posture the whole day, right? I mean, there's a billion different things that run through your mind all day and you forget like two minutes later as soon as you focus on your posture. But I did a little experiment with myself. I'm by no means a gym rat or anything like that,

I did planks, just planks, and I didn't do any other exercises for like two weeks. And I found that my usual slouchy posture in the office when I sit down on a little stool in my clinic or even in the operating room, I found that 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. And when I was doing these planks for a couple of weeks, that did not occur. I had zero pain.

Linda Bluestein, MD (42:53.762)

Mm.

Linda Bluestein, MD (43:09.25)

Hmm.

Adam Hansen (43:18.763)

So there are some mild cases of this that can be helped with just simple exercise and keeping your posture good. So there's three exercises, I mentioned the planks, Superman exercises, people can look this up, but basically it doesn't take any equipment. You just lie on your floor and fly like Superman taking off into the sky. If you work on those in planks and nothing else, you'll probably improve a lot of the spine, especially if you have a floating rib disorder.

And then the other thing, you know, if you have, if you do go to a gym or even if you have bands, you know, elastic bands, you can do seated rows. And I'm not talking rows like a rowing machine. I'm talking sitting up straight, I'm doing this, and that'll help roll your shoulders back and keep that posture nice and open. Yes. So if you're in, so, yeah, yeah. 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,

Linda Bluestein, MD (43:56.881)

Mm.

Linda Bluestein, MD (44:04.47)

Like this. Okay, I'm working on those right now on PT.

Adam Hansen (44:17.187)

you're gonna be of, without even trying, you're gonna be opening those intercostal spaces in the front and avoiding the pinching of these nerves. Things that I don't like are crunches, twisting, oblique exercises, those are gonna be twanging, these ribs are gonna be twanging every time you do one of these repetitions. And so I tell my patients to avoid that and just specifically over-correct your posture, over-correct your strength in your back because if you have just an average front,

Linda Bluestein, MD (44:22.594)

Hmm.

Linda Bluestein, MD (44:29.174)

Mm.

Adam Hansen (44:45.623)

and a strong back, you're gonna be standing upright. So 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 gonna be in less pain.

Linda Bluestein, MD (45:03.17)

Yeah, that makes a lot of sense. And what about, is there any kind of taping strategies that people can do?

Adam Hansen (45:09.031)

Some of the patients use KT tape. I don't know if there's 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, then if you tape your ribs down and away from each other, and I don't know how you do that exactly, but instead of taping them up where they're supposed to be, possibly tape them down, away from each other, and that could do the same thing, could result in less compression throughout the day.

There's a couple of other things that, you know, 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 if you're just watching TV at night, get a lumbar pillow and stick it behind your lower back. And that forces your midsection forward and it'll do the same thing. Even when you're resting. But the key is if you're, if you're strong in your back, you're going to be sitting and you're going to be standing better without thinking about it.

Linda Bluestein, MD (46:08.386)

That makes a lot of sense. And you mentioned a couple of things that people should avoid doing like crunches and some of the kind of lateral things that people will do. Are there other things that people should avoid doing? For example, like high velocity manipulation?

Adam Hansen (46:23.083)

Yeah, I've had a lot of patients that think that their slipping rib syndrome started after an aggressive chiropractic manipulation or an aggressive deep tissue, deep fascial release type massage or something like that. I don't know if they actually caused the injury or anything like that, but I think that it comes to light at some point. rib, for example, and they didn't ever have pain and then they had some event like this chiropractic manipulation.

that suddenly sparked it off. It kind of is like a domino effect. Once it starts, it sort of spirals downward and again, it gets more and more painful because the muscles get spasmed when the nerves are unhappy. And so yeah, it may not be the source of the problem, but it certainly can exacerbate it by doing these high velocity manipulations. I don't, you know, I don't know if you're talking about like other exercises or anything like that. Is that what you meant? Like chiropractic and massage and that kind of stuff?

Linda Bluestein, MD (47:17.034)

Yeah, yeah, that's exactly what I meant.

Adam Hansen (47:19.191)

Yeah, so I just don't think that you're going, I mean, like, I believe in chiropractic. I mean, I loved it when I went to chiropractor a few times and I felt great afterward, but I don't think it's a solution. It's not a permanent solution. All they're doing is they're going to, let's say you have a subluxed 10th rib, say this is the 10th rib and it's subluxed under rib nine, and then 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. And so it's not fixing the problem.

but it might make you temporarily feel better. I'm not opposed to it by any means, but I just don't think it solves the problem.

Linda Bluestein, MD (47:57.134)

Okay, makes sense. Now let's talk about the surgical process. What makes someone a good candidate for the different surgeries that you do?

Adam Hansen (48:08.451)

Probably a few things come to mind. So 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 a much better outcome very quickly or much more quickly because now they can sort of hold their posture up. As you're healing from my reconstruction, we can talk about what the reconstruction entails later, but as you're healing, I want them to be...

open spread out. That's what we're trying to accomplish is the ribs to be in a neutral space. So if you're all hunched over and you got bad posture and you're trying to heal like this sitting in your, you know, your lazy boy chair, it's not going to be a very good recovery. It's going to hurt all the time and it probably would heal if the ribs compress together more than it should. So those coming in strong do have a better outcome. I would say those who, or if people are considering surgery and they are already like

a good number of patients are already on a number of pain medications. If they're already on narcotics, opioids, reducing preoperatively the amount 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 any pain relief even with, you know, the stuff that I can legitimately prescribe to them postoperatively. There's one more thing I was thinking of. Just having realistic expectations. I mean, especially if we have a case where there's multiple joints involved and it might be a project that takes us a year or so to get everything better. You know, not everybody has got, you know, we can't throw a hail Mary on everybody and fix it all in one shot.

Linda Bluestein, MD (49:31.606)

Mm-hmm.

Adam Hansen (50:00.311)

Some people have very complicated situations that are gonna require a few different operations. And we might need to split it up into a reasonable session, reasonable amount of repair. And just knowing that they're not gonna be all the way better until we've got both sides fully addressed. And just knowing that this is a fairly complex orthopedic operation, and if you had your hip replaced, you wouldn't expect to be better in three weeks.

Linda Bluestein, MD (50:01.655)

Mm-hmm.

Adam Hansen (50:26.947)

you would expect that it might take a full year to get the results. So I think people that have reasonable expectations and patients are going to mentally do a lot better as they heal. And some that may not have reasonable expectations that think that this is instantaneously going to get better probably would be disappointed after the surgery for a while.

Linda Bluestein, MD (50:51.146)

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 definitely same thing, prehab, you know, 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 that you recommend people do in order to prepare for these surgeries?

Linda Bluestein, MD (51:18.434)

You've already mentioned a lot of things, but I didn't know if there was.

Adam Hansen (51:20.043)

Yeah, yeah, not really. I mean, yeah, I mean, I like what you just said. Yeah, you know, again, I'm a hammer in my world. You know, the nail is surgery. So I don't often think about things like nutrition and all that, but that's huge. Maybe, you know, a big element of, or a big associated problem is mental health and having.

You're going in very depressed. That kind of stuff is going to make it very difficult to recover. So I think having appropriate treatment for that ahead of time would be of significant use. I speaking of the mental health aspect of it, I don't feel like me. A lot of my patients have been told numerous times that they're crazy or it's all in their head and that kind of stuff. And this is a very common story that my patients relate to me. I feel bad for them every time.

You know, doctors kind of chuckle at him and walk out of the room, that kind of thing. You can walk into a room and see that the 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 six 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 be able to see that on the back end. But I think going in, going in, you know, managing that stuff the best that you can ahead of time is very useful so that you just don't...

Linda Bluestein, MD (52:41.68)

Mm-hmm.

Adam Hansen (53:06.347)

You know, you don't feel defeated as you're healing.

Linda Bluestein, MD (53:10.73)

Mm-hmm. 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?

Adam Hansen (53:21.419)

Yeah, I mean, I've got a version one, two and three, and that shows that version one and two weren't as good. Right, so that's the funny thing in surgery, there's always named operations that have certain numbers behind them, and you always go for the highest number, right? The simple technique that came up with about six years ago was, five, six years ago, was just simply suturing the ribs back together. So I mean, there's basically like three things you can.

Linda Bluestein, MD (53:36.427)

Right.

Adam Hansen (53:51.043)

three basic things that 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. But when I had my first patient that I saw and we decided together to repair this, we just simply sutured the ribs back up and I asked my orthopedic surgeons to help me.

choose the best sutures and that kind of stuff that would hold cartilage the best. And we have come up with these tape sutures is what we always use. They're strong, they're like shoelaces, they're kind of flat so they don't saw through the cartilage. And that's simply what I was doing is just suturing the front end of the ribs back in a place where I thought they would be neutral and away from the nerves. And that worked in about 75% of the cases. It worked really well for the first six months to a year in most of the cases, but over time we saw that some of those would fail.

and we'd have to consider a revision. So over time I went back to the drawing board and came up with this version three, which is a more complicated reconstruction. I'll tell you, I've come up with like maybe four or five basic tenets of things we need to accomplish to achieve a successful slipping rib repair. Okay, and so the first is that I don't feel like the ribs want to be at their attached position. I think that the body mechanics have pulled them downward for a reason.

Linda Bluestein, MD (55:04.303)

Hmm.

Adam Hansen (55:18.751)

And if we force them to be in a place that they don't want to be, I think that's when they're going to try to get loose again and start to slip again. So I have found that neutral ribs spacing is a key factor. So I let them be where they want to be, but I make them stay there. Okay. So step one on this reconstruction is to, you know, as I mentioned, these ribs kind of hook upward as they go toward the middle, toward the sternum, those hooks are where that nerve compression is occurring.

Linda Bluestein, MD (55:19.906)

Hmm.

Adam Hansen (55:48.599)

So I have changed my thought process. I didn't used to think that you needed to remove any of the rib or the cartilage. And 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.

Linda Bluestein, MD (56:18.134)

Hmm.

Adam Hansen (56:18.559)

so that they can stay apart from each other. So this being a little piece of cartilage we removed, we can keep the ribs in an appropriate position away from each other by placing that cartilage in there. Now some people, they get these nuances. They 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 they place it outside of the muscle. So 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 that's a dissolvable plate that acts like a cast on a broken leg, right? So it lays across everything that I just rebuilt. But unlike a cast that you would have to remove after a few months of bone healing.

Linda Bluestein, MD (56:50.737)

Mm.

Adam Hansen (57:13.547)

I don't have to remove this dissolvable plate because it's biodegradable and eventually will go away. So once it's gone, it's already served its function. So the plate in itself, in my mind, is not the end results, the 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 opportunity.

four times to be back in one of those sites and observe the reconstruction. And it has healed very, very strongly. And the last tenet is flexibility. And the scar tissue almost functions like ligaments because it's a little stretchy. So once that plate's gone and the healing has occurred, it's a little flexible, which is ideal. You don't want it to be rock solid like a bone up front. You want it to be flexible yet sturdy.

Adam Hansen (01:06:32.867)

Yeah, yeah, I mean, this has been a learning process. You know, I thought that version one was, you know, the greatest thing to hit earth. When I first came up with it, when I started seeing the results, they were great at first, but over time, some of them weren't great. And so I think being introspective and realizing that maybe hadn't, we hadn't achieved perfection with that technique and go back to the drawing board and finding solutions to the new problems or the failure points that we observed.

That so that led me to version 2 which It just a subtle difference in how I sutured the ribs up to try to avoid the nerve But I felt like that was a problem over time as well and did not solve all the issues so with version 3 I would I was probably the most careful with that one and the most interested in long-term Follow-up compared to my earlier versions and that's because you know, I didn't want to have you know more failures

So, I've been very obsessive about following my patients out to two and three years, you know, for every patient. And we, you know, I'm not just looking to see if we needed to do another revision, but I'm also looking at quality of life over the long term. And so we use a quality of life measurement tool. It's a real basic one, but it gives me a snapshot at each of the time points that I've been following my patients.

Linda Bluestein, MD (01:07:40.344)

Wow.

Adam Hansen (01:08:00.567)

before surgery and then multiple time points afterward to see how they're doing and see what improvement they've made. So to date, we've only had one person fail the 3.0, or what I, by the way, I call that the cost of margin reconstruction technique, okay? That sutured slipped rib repair, you can probably lump one and two together in that. So I don't even do the sutured repairs anymore. I don't do version one or version two because they just weren't as good as I wanted. So.

Version three, which is my go-to operation now, I use it for essentially everyone, that has had excellent follow-up, okay? So excellent results over the long term. And I've got three-year data on a good number of patients. And so it's out to the point where the plate is no longer there. So we're not relying on the plate strength anymore. It's relying on the scar tissue and the cartilage is essentially formed at that reconstruction site.

So we're finding that the results are far superior to the sutured repair techniques. And comparing to costal cartilage excision, you can look at the results in the literature. The results of this costal margin reconstruction are far superior to that. Since I don't do that operation, I can't do a head-to-head comparison to show for sure, make this strong claim that it vastly exceeds the quality of a costal cartilage excision.

Just seeing the papers that are out there with about a 25 to 35 percent failure rate on that operation We're not having that with this new reconstruction so Let's call it the cost al margin Reconstruction technique we can throw away the numbers if we'd like because it's like the only one that we yeah Really the only one I want to use anymore because it solves all the problems I feel a little bit bad because I taught

Linda Bluestein, MD (01:09:50.798)

Mm-hmm.

Adam Hansen (01:09:53.183)

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 some others that are able to do that technique around the world. So everybody can have it. Now, let me just state one thing. I'm not married to any of my techniques. So if someone comes up with something that I feel like works better, I will use it. And 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 on 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 that have gone back in because I found that a few of these little rib tips that we had excised had grown back with a little bit of.

kind of pokey little bony tip of these ribs. So kind of like a lizard tail, they regenerated the tip of their rib in three cases. And so I had to go back in and take those little tips back out. And those are the cases that I got to observe the work and see what kind of a, you know, strength that this repair had. And it was actually very useful to go back in and see that. So in essence, 3.0 is, it's, I feel like it is a,

Linda Bluestein, MD (01:10:52.093)

Hmm.

Adam Hansen (01:11:18.295)

It's good for all comers because some of my patients have had up to like 12 operations before they came to me and it's excellent. It works well for that. It works well for first timers. It works well for people with three slipped ribs on each side and it works well for a very simple case of one slipped rib. So I can't find a reason not to use it. I've wanted to go back and use my little suture, easy chip shot repair at times, but it's like having an iPhone.

15 or whatever the number they have out and going back to an iPhone 6. It's like you can't do it You know, so it the results are just that much better that I just I can't get myself to go back and do the earlier

Linda Bluestein, MD (01:11:52.91)

Mm hmm. Right, right.

Linda Bluestein, MD (01:12:02.666)

And that's a great analogy because I think people are very accepting of the various different software updates that we do for all of the apps and then of course the different evolution of the phones and things. So I think that's a great analogy that surgery is the same way. And so, exactly. And you've had patients that have had 12 surgeries on their chest wall.

Adam Hansen (01:12:15.679)

Yeah, yeah, we learn. We learn over time.

Adam Hansen (01:12:24.847)

12, so one patient had 12 attempts at fixing slipped ribs on both sides in total. So about six times on each side. You can think of another one that had five. So I mean, a lot of these times, these patients come to me for a salvage, basically, how do we salvage this horrible scenario? And we've attempted many different ways of trying to fix it in the past and it just never really succeeded. And

Linda Bluestein, MD (01:12:34.443)

Wow.

Adam Hansen (01:12:53.303)

So I feel like this one, it works. I mean, actually I've even separated my data out, my followup data between first time operations and redo's from whatever. And the results are not significantly different. So what I'm saying is that this works just as well for a salvage case as it does for a first timer.

Linda Bluestein, MD (01:13:16.258)

Well, that's really great to hear. And that it was one of your questions was what were you seeing in terms of outcomes? And 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. Anything more you can share either for short term or long term outcomes?

Adam Hansen (01:13:34.695)

So the if you I mean we're looking at several data points, you know, so this quality of life tool and measures, you know pain Function I am able to work. I'm able to sleep. Am I how anxious am I how depressed am I? Do I feel like I can go back to work and you know a short time? Those are all the questions that have asked and all of those are improved significantly So I've put together this whole you know, like a basically an overall score Give it a percentage

I don't want to steal my own thunder because this hasn't been published yet, but we, on the average, a patient coming to me sitting in my clinic office discussing whether they want to look rib surgery has a quality of life of 38% by my calculation. And that's pretty bad. And so I want to make that significantly better. And what we're seeing at six months is a quality of life measured at 83% on the average.

Yeah, so more than double, more than double, right? I mean, it's not every aspect of a person's life, but with regards to what dysfunction that was causing, it's doubled their quality of life and better. And then the numbers out to one year and two years continue to climb. You get your biggest jump in the first six months, but we're up around 90% at a year, 92 at two years. I mean, it's showing pretty significant outcomes. And that said, I've only had one complete failure of this at this point out of...

Linda Bluestein, MD (01:14:31.991)

Wow.

Linda Bluestein, MD (01:14:43.746)

Mm-hmm.

Adam Hansen (01:15:01.455)

320 or 330 of them or something at this point. So it not only doesn't fail, but it succeeds in making someone have a better life. There's another couple of issues that I've been anecdotally watching, and that's 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. But that's the focus of hopefully an upcoming study.

Linda Bluestein, MD (01:15:20.423)

Mm. Mm-hmm.

Adam Hansen (01:15:29.647)

One of the things we do monitor is self-reported breathing function. So we're not getting pulmonary function tests. It's just difficult to get that from patients that are all over the world, country or wherever. But if I just ask them, Hey, what, how do you feel like your breathing is at this point compared to what you feel like you should be or what's normal? And the average is somewhere around 56% and those who report a deficit, which is about half of them, they're saying that their breathing is somewhere on the average of about 56% before surgery.

Linda Bluestein, MD (01:15:29.75)

Hmm.

Linda Bluestein, MD (01:15:39.434)

Right.

Adam Hansen (01:15:58.911)

And we're up to the high 90s at six months and beyond. So that shows like how important this is. The rib stability is for breathing function as we discussed earlier. And that's been one of the besides pain. That's been one of the biggest outcome improvements that I've noted is the breathing.

Linda Bluestein, MD (01:16:02.326)

Wow.

Linda Bluestein, MD (01:16:20.642)

That's really remarkable. And are there potential complications, I mean, surgery, you can always get complications, of course, with any surgery, 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, and this is a normal part of the process. But are there potential complications that people should be aware of?

Adam Hansen (01:16:38.008)

Yeah.

Adam Hansen (01:16:45.259)

I would say probably the biggest, I wouldn't call it a complication, but biggest failure would be you just don't get the relief you're looking for and that maybe we didn't get as high of a success on your case. We've discussed what are the odds of that, but we have 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 and so it doesn't involve any organs.

Linda Bluestein, MD (01:16:58.823)

Mm-hmm. Sure.

Adam Hansen (01:17:13.935)

and we only have to basically get through a couple muscle layers to get to the ribs. So it's actually a fairly easy access point and it's very safe. Earlier on, we had a couple of collapsed lungs. I think we had three or four pneumothoraxes that occurred with my earlier techniques, but with the later technique, we've only had that I think once because you have to go really close to the lung with the sutures and if you're a really thin patient, it's a little bit higher of a risk.

I have had two hematomas that I had to re-operate on the same day out of my whole experience and I have had two wound infections. And that is the sum total of the complications. I mean, we've had a couple of skin reactions to the surgical glue and whatnot, but I mean, really the only significant complications is about six or seven of them. So that's a very low number considering we've done probably 700 of these operations if you combine all the versions together.

Linda Bluestein, MD (01:17:52.299)

Mm.

Bye.

Linda Bluestein, MD (01:18:03.918)

Mm-hmm.

Linda Bluestein, MD (01:18:08.522)

Yeah, that's right. Those are great numbers. And what can people do post-operatively to optimize their healing and recovery?

Adam Hansen (01:18:18.371)

I think getting up and moving, just like with almost every other surgery is probably the best thing they can do. So I mean, I think just walking and, you know, just relax and then walk and relax, walk, just stay moving. I think icing the area helps for the first week or two to keep the swelling down. But I am very, pretty strict about the restrictions, the activity restrictions that I impose on patients because...

You wouldn't walk on a broken leg for a while. You'd need it to heal, be immobilized. So how do you immobilize the torso? That's difficult because everything we do relies on that, right? You can't even live for five minutes without engaging your torso. But I do ask patients to avoid twisting, avoid bending, and avoid lifting more than about 20 pounds for three months. Seems like a long time, but I think that's the key. The three months seems to be the mark, 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. So we don't wanna rely only on that plate, right? I mean, that plate has a break point. And so if everything is relying on that plate for the first three months, we need not to break it for the first three months. After that, it can break whenever it wants to. So the lifting and activity restrictions are important.

Linda Bluestein, MD (01:19:47.118)

That makes sense. And there were some questions that were submitted online that I wanna just kinda go through these 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 who are diagnosed with EDS or Ehlers-Danlos syndrome?

Adam Hansen (01:20:06.819)

Maybe I'm not as educated on this as I need to be, but I think the HSD spectrum, I mean, you think of a bell curve, right? There's probably a lot of people that are 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 going to find, I mean, it's probably much less severe than a severe hypermobile, HEDS case. I think of them as having the biggest challenge. I did separate...

my outcome data between hypermobile patients and non-hypermobile patients, and it's not really any different. So you would think, and I had anecdotally, I felt like all the hypermobile patients were gonna be the most difficult ones that would have very poor outcomes. They're not showing that. They're showing fairly equal outcomes to patients that had trauma or some other reason for their slipping ribs syndrome.

I hope that answered your question, but I think the EDS cases, they do have a big challenge. It's probably harder to get better. It takes longer, but they're still going to get there.

Linda Bluestein, MD (01:21:09.678)

And what about male-female differences? Do you see anything there?

Adam Hansen (01:21:14.359)

It's about 70% female, the patients that have slipping rib syndrome and other rib disorders that we can treat, 30% male. It just, I mean, it seems to be more common in the sort of slight frame, you know, the thin-framed people who are also probably that, most of the time that describes a hypermobile patient, they're usually of that build.

I've certainly had some larger patients that have EDS diagnosed, so you don't have to be the typical thin white female. Certainly I think EDS seems to affect a broad portion of the population, as does slipping rib syndrome.

Linda Bluestein, MD (01:22:02.542)

Okay, and what is the likelihood of a recurrence or a different rib slipping after repair?

Adam Hansen (01:22:11.6)

I've learned this the hard way that if I underappreciated or underassessed, like say, I think on a lot of my earlier cases I fixed a lot of 10th ribs and didn't fix a little bit wiggly 9th rib because I didn't feel like it was totally slipped. And that's been a learning point. So if there's any mobility of that 9th rib, for example, in addition to the 10th rib, I go ahead and treat it.

So some of my earlier cases had to go back in and fix the ninth rib because just fixating the 10th rib to a partially loose rib created that ninth rib slip. I'm very careful with this reconstruction. We show later on showed the picture of the reconstruction. I tried to extend the plate all the way up to rib seven so that it shares the load for say a slipping ninth and 10th or just a slipping 10th. I tried to share the load.

You know with the upper ribs because this newly reattached rib is going to exert some downward force some pull on the repair So trying to share that load seems to make sense to me

Linda Bluestein, MD (01:23:20.206)

Okay, oh sorry.

Adam Hansen (01:23:20.735)

So yeah, with this reconstruction, we haven't had any additional slipped ribs. Now what I have seen, sorry to jump back in, is that bridging cartilage, so the interchondrial separation between ribs five and six, if that is already there to a degree, it does seem to get worse after we do the reconstruction on the lower ribs for the same reason. It's probably pulling on it. And so I have had a handful of patients to go back in and remove those because that became more of a problem after we did the lower rib reconstruction.

Linda Bluestein, MD (01:23:31.662)

Hmm.

Linda Bluestein, MD (01:23:41.07)

Right.

Linda Bluestein, MD (01:23:49.006)

Mm-hmm, that makes sense. That makes sense from a physics standpoint, that that could happen. Okay, and what do you want physicians to know about slipping rib syndrome and other chest wall problems?

Adam Hansen (01:23:53.742)

Mm-hmm.

Adam Hansen (01:24:02.999)

Hmm. Man, that's a big one. Everything. Yeah. Now this is, it's a common scenario to have a surgeon. I mean, probably at least once or twice a week, I have a surgeon from somewhere in the world or in the country to call me or email me and say, Hey, how do you know, I have this patient that needs to get fixed with slip ribs. Can you tell me how to do this? And I'm like, it's not just

Linda Bluestein, MD (01:24:06.574)

Ha ha ha.

Adam Hansen (01:24:30.615)

you know, five minute conversation. I mean, you really, there's a lot to this, you know, you want to be successful. Um, you know, there's, there's some learning that needs to happen with this. I think just being aware of it and realizing that it's real and it's not, you know, some false disorder that, you know, some of them think that it doesn't exist. I mean, I have numerous patients say that they saw a surgeon that said, you know, what are you talking about? Ribs don't slip. Um, if they actually could see.

come into the operating room with me and see what these ribs are doing, it becomes quite obvious to anybody, you know, just by seeing it. That's all it takes. It's very obvious. So I've made the offer to numerous surgeons that are interested in this and they feel like, you know, are capable of doing these cases to just come out with, spend two days with me and see four or five new patients in clinic and some follow-ups and see.

what goes into the diagnosis. And then the next day we'll do four cases and they can just look over my shoulder and watch. So we've had several surgeons from around the world come over and do that. And a few more are set up to do that. I think that's, you know, I think I could do that in two days. I can get someone who already knows how to fix like broken ribs and stuff like that. If they already know that they're gonna be completely fine. They can come out and I can tell them everything I know in about two days. But I think if you're trying to get this

figure it out in less time than that. It's gonna be very difficult to get it up and running successfully.

Linda Bluestein, MD (01:26:05.998)

Yeah, that makes a lot of sense and that's incredible that you are teaching so many other surgeons how to address these problems. So that's an incredible thing that you're doing for the community.

Adam Hansen (01:26:18.379)

Well, I mean, it makes sense. I mean, if I had this and I wouldn't want to have to go to like Australia for it, you know, I mean, I'd want to be treated locally. And so, you know, we have built a network of surgeons around the world. We've got some in Scandinavia and some Australia and England and, you know, we haven't gotten Canada figured out yet. We're trying.

Linda Bluestein, MD (01:26:26.798)

Mm-hmm.

Adam Hansen (01:26:39.431)

And then several places in the US, I feel like there are people that know how to do this now. So it's been nice because now these patients, you know, let's just send you to the closest person to you that knows how to do this.

Linda Bluestein, MD (01:26:50.03)

Okay, and last of these rapid fire questions, what correlation, if any, have you observed between cervical instability and slipping ribs?

Adam Hansen (01:26:58.975)

It seems to be present in, it's probably at least five to 10% of the patients have that on their diagnosis list. And there's like five or six diagnoses that we see commonly. They're all the difficult ones like POTS and MCAS and all this other stuff. But cranioscorpital instability is common. I mean, you just think about it. The same problem exists in all of these joints, right? This is not isolated to the lower ribs. The same problem happens everywhere. It just...

Linda Bluestein, MD (01:27:07.374)

Mm-hmm.

Adam Hansen (01:27:28.491)

The only reason I'm focused on these slipping ribs and these functional lower rib disorders is because I can fix them. So if there were fixes to all these other issues, certainly we could offer a whole skeletal rebuild to patients that are very unstable. I mean, I think about it all day long, this is a problem, hypermobile skeletal disorders, it's a problem that a person's born with and it's gonna carry their whole life.

and 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 is that let's fix what we can as we're working toward further solutions. But 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.

So back to your original question, the cranios cervical instability is the 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.

Linda Bluestein, MD (01:28:38.894)

And we did, I don't remember the number, but I think it might be 78 was a conversation with a neurosurgeon, Dr. Paolo Bolognese, who 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. You know, they have just incredible difficulties with 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.

Adam Hansen (01:29:21.459)

Yeah, for sure. I mean, I think there's probably a few key areas in this in the skeleton. I'll say someone's got these problems everywhere. There's a few key areas that can really get you that springboard into being able to exercise and make your muscles better. Right. If your core is totally floppy and like a bobblehead because none of your ribs are attached to each other and, you know, lower ribs, we can fix that and get you a lot more rigid and structurally sound. Then you can then you can work on that other stuff.

with the muscles to try to maintain the more minor problems, keep them down to a dull roar.

Linda Bluestein, MD (01:29:59.438)

Sure. Okay, 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 guests share one of their favorite hypermobility hacks.

Adam Hansen (01:30:17.483)

I think I already shared it. The only thing, I'm not that smart, so I'm very simple with what I think about. But all day long, the only hack or the best hack is the planks and supermans. If you focus on one thing, your overall care, let it be those two exercises, because that will make the biggest difference compared to anything else I know. I would 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.

Linda Bluestein, MD (01:30:54.99)

Okay, great, that makes sense. And where can people find you online?

Adam Hansen (01:31:00.887)

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 and there's a lot of discussion about outcomes for what we do on the slipping rib syndrome Facebook page. There's a big group of, I think like six 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.

Linda Bluestein, MD (01:31:05.262)

Okay.

Adam Hansen (01:31:30.095)

to shorten their learning curve as well and how to manage this. I've done, put forth a little bit of an effort to try to put a few videos. The video on the exam that you were referencing earlier, that was made for patients to show their surgeon or 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 we have put, I put that video of my reconstruction for surgeons use, you know, 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 on there about that bridging cartilage separation. If anybody's interested in that, it's on that ctsnet.org. It's not only for surgeons, but that's the main users of that site.

Other than that, you know, needed a consultation. I just have people call my office and we can give the basic information that way. Some of the stuff you just, I mean, you have to just dive in and just, just talk. You know, we have to put our hands on a patient to be able to get the diagnosis. So you can't make a diagnosis of a phone.

Linda Bluestein, MD (01:32:39.982)

Great, so I will make, sorry.

Linda Bluestein, MD (01:32:49.87)

Right, right, for sure. I'll make sure to have all those links in the show notes as well as is it okay to share the phone number then if people want to get a consultation? Is it okay to share that phone number too in the show notes? Okay, great.

Adam Hansen (01:33:02.871)

Yes, that'll be fine.

Linda Bluestein, MD (01:33:06.798)

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.

Adam Hansen (01:33:26.187)

It's been my pleasure. Thank you for joining the fight. This is a big fight, but we're going to win it eventually.