Long-term follow-up after rib fixation for flail chest and multiple rib fractures

Parameters influencing health-related quality of life after severe trauma: a systematic review (part II)

INTRODUCTION

It is increasingly recognized that health-related quality of life (HRQoL) is a relevant outcome to study in populations comprising severely injured patients. Although some studies have readily demonstrated a compromised HRQoL in those patients, evidence regarding factors that predict HRQoL is scarce. This hinders attempts to prepare patient-specific plans that may aid in revalidation and improved life satisfaction. In this review, we present identified predictors of HRQoL in patients that have suffered severe trauma.

METHODS

The search strategy included a database search until the 1st of January 2022 in the Cochrane Library, EMBASE, PubMed, and Web of Science, and reference checking. Studies were eligible for inclusion when (HR)QoL was studied in patients with major, multiple, or severe injury and/or polytrauma, as defined by authors by means of an Injury Severity Score (ISS) cut-off value. The results will be discussed in a narrative manner.

RESULTS

A total of 1583 articles were reviewed. Of those, 90 were included and used for analysis. In total, 23 possible predictors were identified. The following parameters predicted reduced HRQoL in severely injured patients and came forward in at least more than three studies: higher age, female gender, lower extremity injuries, higher rate of injury severity, lower achieved educational level, presence of (pre-existing) comorbidities and mental illness, longer duration of hospital stay, and high level of disability.

CONCLUSION

Age, gender, injured body region, and severity of injury were found to be good predictors of health-related quality of life in severely injured patients. A patient-centered approach, based on individual, demographic, and disease-specific predictors, is highly recommended.

Management of a Flail Chest Caused by Multiple Costosternal Fractures: A Case Report

Costochondral separation is a rare consequence of blunt thoracic trauma and can lead to life-threatening complications such as a flail chest. The diagnosis of costochondral separation remains challenging due to the obscurity of the condition on chest radiographs. Surgical rib fixation is a viable treatment option and research regarding its effectiveness and long-term benefits is promising but still evolving. Here, we discuss a case of flail chest caused by multiple costosternal fractures definitively managed with surgical rib fixation.

3D-printed external fixation guide combined with video-assisted thoracoscopic surgery for the treatment of flail chest: a technical report and case series

Background

Flail chest is a common and serious traumatic condition in thoracic surgery. The treatment of flail chest often includes open reduction and internal fixation, which is relatively traumatic, complicated, and expensive. As three-dimensional (3D) printing technology is widely used in the clinical field, the application of 3D-printed products to chest trauma will become a new treatment option. To date, the use of 3D-printed external fixation guides for flail chests has not been reported. Thus, we aimed to assess the short-term efficacy of a new technology that treated flail chests with an individualized 3D-printed external fixation guide combined with video-assisted thoracoscopic surgery (VATS).

Patients and methods

A retrospective analysis was performed on patients with flail chest treated with this new technique at our center from January 2020 to December 2022. The following parameters were included: operative time, thoracic tube extraction time, intensive care unit time, thoracic volume recovery rate, visual analog scale score 1 month postoperatively, and postoperative complication rate. All patients were followed up for at least 3 months.

Results

Five patients (mean age: 45.7 years) were enrolled; they successfully underwent surgery without chest wall deformity and quickly returned to daily life. The average number of rib fractures was 8.4; all patients had lung contusion, hemopneumothorax, and anomalous respiration. The abnormal breathing of all patients was completely corrected on postoperative day 1, and the chest wall was stable. One case experienced mild loosening of the 3D-printed guide postoperatively; however, the overall stability was not affected. The other four cases did not experience such loosening because we replaced the ordinary silk wire with a steel wire. All cases were discharged from the hospital 2 weeks postoperatively and returned to normal life 1 month after the removal of the 3D-printed guide on average. Only one case developed a superficial wound infection postoperatively, and no perioperative death occurred.

Conclusions

The 3D-printed external fixation guide combined with video-assisted thoracoscopic surgery is a novel technique in the treatment of flail chest and is safe, effective, feasible, and minimally invasive, with satisfactory clinical efficacy.

Outcomes of surgical stabilization of rib fractures in a minority population: Retrospective analysis of a case series from an acute care facility

Objective

The aim of was to examine the postoperative outcomes and associated factors of surgical stabilization of rib fracture (SSRF) in a minority population.

Methods

A retrospective analysis with case series of 10 patients undergoing SSRF at an acute care facility in New York City was performed. Data, including patient demographic characteristics, comorbidities, hospital length of stay were collected. Results were presented in comparative tables and a Kaplan-Meier curve. Primary outcome was to compare outcomes of SSRF in minority patients to larger studies in nonminority populations. Secondary outcomes included various postoperative outcomes, including atelectasis, pain, and infection, and the influence of medical comorbidities on each.

Results

The median time (with accompanying interquartile range) from diagnosis to SSRF, SSRF to discharge, and overall length of stay was 4.5 days (4.25), 6.0 days (17.00) and 10.5 days (18.25) days, respectively. The time until SSRF and postoperative complication rate were found to be comparable to those in larger studies. The Kaplan-Meier curve demonstrates a correlation between persistence of atelectasis to increased length of stay (P = .05). Increased time to SSRF was seen in elderly patients and patients with diabetes (P = .012 and P = .019, respecively). Increased pain requirements by patients with diabetes (P = .007), and higher infectious complications in patients with flail chest and diabetes (P = .035 and P = .002, respectively) were also seen.

Conclusions

Preliminary outcomes and complication rates of SSRF in a minority population are shown to be comparable to larger studies in nonminority populations. Larger, higher-powered studies are required to further compare outcomes between these 2 populations.

Quality of life outcomes after surgical intervention in patients with multiple rib fractures: A prospective cohort study

BACKGROUND

Optimized conservative treatment of rib fractures has long been practiced, but surgical fixation has not been promising until recently. We aimed to examine and analyze immediate postoperative outcomes and 6-month quality of life after injury in patients with moderately severe traumatic rib fractures.

METHODS

We conducted a prospective cohort study between July 2017 and June 2019 at the National Taiwan University Hospital. Seventy-two patients with moderately severe thoracic trauma were enrolled; 38 received conservative treatment and 34 underwent surgical fixation. Quality of life was measured using the 36-item Short Form Survey at; the first 3 days of hospitalization; before discharge; and at 1-, 2-, and 6-month follow-ups (visits 1-5). Baseline characteristics and clinical outcomes were recorded, and linear regression analysis was conducted using the generalized estimating equation.

RESULTS

Among patients with moderately severe thoracic injury (chest Abbreviated Injury Scale score≥ 2), the operative group had more severe injuries and longer intensive care unit and in-hospital stays. However, they had a comparable quality of life 6 months after injury and higher physical component scores in the early postoperative period. Linear regression analysis obtained an equation with several factors positively affecting prediction of the mean physical component score, such as body mass index ≤25, age ≤36 years, fewer ribs requiring fixation, and diabetes mellitus. Mental component score did not show an upward trend, but the Work Quality Index largely determined the predicted mean value of the mental component score.

CONCLUSION

Surgical rib fixations hasten recovery in patients with severe thoracic injury (chest Abbreviated Injury Scale ≥3) to achieve 6-month quality of life comparable to patients injured less severely (chest Abbreviated Injury Scale ≥2). The ability to resume previous work positively influenced the mental component score; thus, surgical intervention should also aim to help patients regain their social function.

Outcomes of surgical versus nonsurgical treatment for multiple rib fractures: A US hospital matched cohort database analysis

BACKGROUND

Treatment for multiple rib fractures includes surgical stabilization of rib fractures (SSRF) or nonoperative management (NOM). Meta-analyses have demonstrated that SSRF results in faster recovery and lower long-term complication rates versus NOM. Our study evaluated postoperative outcomes for multiple rib fracture patients following SSRF versus NOM in a real-world, all-comer study design.

METHODS

Multiple rib fracture patients with inpatient admissions in the PREMIER hospital database from October 1, 2015, to September 30, 2020, were identified. Outcomes included discharge disposition, and 3- and 12-month lung-related readmissions. Demographics, comorbidities, concurrent injuries at index, Abbreviated Injury Scale and Injury Severity Scores, and provider characteristics were determined for all patients. Patients were excluded from the cohort if they had a thorax Abbreviated Injury Scale score of <2 (low severity patient) or a Glasgow Coma Scale score of ≤8 (extreme high severity patient). Stratum matching between SSRF and NOM patients was performed using fine stratification and weighting so that all patient data were kept in the final analysis. Outcomes were analyzed using generalized linear models with quasinormal distribution and logit links.

RESULTS

A total of 203,450 patients were included, of which 200,580 were treated with NOM and 2,870 with SSRF. Compared to NOM, patients with SSRF had higher rates of home discharge (62% SSRF vs. 58% NOM) and lower rates of lung-related readmissions (3 months, 3.1% SSRF vs. 4.0% NOM; 12 months, 6.2% SSRF vs. 7.6% NOM). The odds ratio (OR) for home or home health discharge in patients with SSRF versus NOM was 1.166 (95% confidence interval [CI], 1.073-1.266; p = 0.0002). Similarly, ORs for lung-related readmission at 3- and 12-month were statistically lower in the patients treated with SSRF versus NOM (OR [3 months], 0.764 [95% CI, 0.606-0.963]; p = 0.0227 and OR [12 months], 0.799 [95% CI, 0.657-0.971]; p = 0.0245).

CONCLUSION

Surgical stabilization of rib fractures results in greater odds of home discharge and lower rates of lung-related readmissions compared with NOM at 12 months of follow-up.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Quality of life and clinical outcomes of operatively treated patients with flail chest injuries: A multicentre prospective cohort study

Introduction

Most studies about rib fractures focus on mortality and morbidity. Literature is scarce on long term and quality of life (QoL) outcomes. Therefore, we report QoL and long-term outcomes after rib fixation in flail chest patients.

Methods

A prospective cohort study of clinical flail chest patients admitted to six level 1 trauma centres in the Netherlands and Switzerland between January 2018 and March 2021. Outcomes included in-hospital outcomes and long-term outcomes, such as QoL measurements 12 months after hospitalization using the EuroQoL five dimensions (EQ-5D) questionnaire.

Results

Sixty-one operatively treated flail chest patients were included. Median hospital length of stay was 15 days and intensive care length of stay was 8 days. Sixteen (26%) patients developed pneumonia and two (3%) died. One year after hospitalization the mean EQ5D score was 0.78. Complication rates were low and included hemothorax (6%) pleural effusion (5%) and two revisions of the implant (3%). Implant related irritation was commonly reported by patients (n = 15, 25%).

Conclusions

Rib fixation for flail chest injuries can be considered a safe procedure and with low mortality rates. Future studies should focus on quality of life rather than solely short-term outcomes.

Trial registration: Registered in the Netherlands Trial Register NTR6833 on 13/11/2017 and the Swiss Ethics Committees Registration Number 2019-00668

Clinical Outcomes of Minimally Invasive Surgical Stabilization of Rib Fractures Using Video-Assisted Thoracoscopic Surgery

Background

Multiple rib fractures are common in blunt chest trauma. Until recently, most surgical rib fixations for multiple rib fractures were performed via open thoracotomy. However, due to the invasive nature of tissue dissection and the resulting large wound, an alternative endoscopic approach has emerged that minimizes the postoperative complications caused by the manipulation of injured tissue and lung during an open thoracotomy.

Methods

Our study concentrated on patients with multiple rib fractures who underwent surgical stabilization of rib fractures (SSRF) between June 2018 and May 2020. We found 27 patients who underwent SSRF using video-assisted thoracoscopic surgery. The study design was a retrospective review of the patients' charts and surgical records.

Results

No intraoperative events or procedure-related deaths occurred. Implant-related irritation occurred in 4 patients, and 1 death resulted from concomitant trauma. The average hospital stay was 30.2±20.1 days, and ventilators were used for 12 of the 22 patients admitted to the intensive care unit. None of the patients experienced major pulmonary complications such as pneumonia or acute respiratory distress syndrome.

Conclusion

Minimally invasive rib stabilization surgery with the assistance of a thoracoscope is expected to become more widely used in patients with multiple rib fractures. This method will also assist patients in a quick recovery.

Respiratory Function Tolerance of Rats with Vaying Degrees of Thoracic Volume Reduction

OBJECTIVE

To compare the effects of respiratory function on different degrees of reduced thoracic volume and evaluate the tolerance of rats with reduced thoracic volume, and to assess the feasibility of thoracic volume as a measure of the severity of rib fractures.

METHODS

A total of 24 10-week-old female Sprague-Dawley (SD) rats were randomly divided into four groups (n = 6 in each group) according to the displacement degree of bilateral rib fractures (2, 4, 6, and 8 mm). The respiratory function of the rats（Tidal volume, Inspiration time, Expiration time, Breath rate, Minute volume, Peak inspiration flow) measured via whole-body barometric plethysmography before and after operation for 14 consecutive days. Respiratory function parameters of each group were analyzed. Chest CT scans were performed before and 14 days after operation, after that we reconstructed three-dimensional of the thoracic and lung and measured their volumes by computer software. We calculated the percentage of thoracic and lung volume reduction after operation.

RESULTS

At the 14th day after the operation, the decline of thoracic volume rates of in the 2, 4, 6, and 8 mm groups were 5.20%, 9.01%, 16.67%, and 20.74%, respectively. The 8 mm group showed a significant reduction in lung volume. The postoperative tidal volumes were lower in each of the groups than the baseline values before the operation. The tidal volume of the 2 mm group gradually recovered after the operation and returned to a normal level (1.54 ± 0.07 mL) at 14th day after the operation. The tidal volume of the 4, 6, and 8 mm groups recovered gradually after the operation, but did not return to baseline level at the 14th day. In particular, the tidal volume of the 8 mm group was significantly lower than that of the other groups during the 14 days (1.23 ± 0.12 mL, p < 0.05). There were no significant changes in the inspiratory and expiratory times, peak inspiratory and expiratory flows, respiratory rate, and minute ventilation during the 14 days after the operation in each group.

CONCLUSIONS

Displaced rib fractures lead to thoracic collapse and reduced thoracic volume, which can affect tidal volume in rats. The greater the decrease of thoracic volume, the more obvious the decrease of early tidal volume. The thoracic volume can be used as an objective parameter to evaluate the severity of multiple rib fractures. Early operation to restore thoracic volume may improve early respiratory function. Decreased thoracic volume affected respiratory function and can be compensated and recovered in the long term.

When to proceed to surgical rib fixation?-A single-institution clinical experience

Background

Surgical rib fixation for multiple rib fractures and flail chest has become more common in the 2000s with interesting results in selected patients. However, surgical rib fixation lacks a consensus on the delay to surgery and the benefits on postoperative clinical outcomes. Our goal was to determine if delay to surgery can affect postoperative outcomes.

Methods

We analyzed a retrospective database including all consecutive patients referred for surgical rib fixation. All outcomes were explored according to trauma mechanism, associated lesions, initial ventilatory status, delay to surgery, surgical technique and a specific focus was made towards post-operative care and pulmonary complications. Logistic regressions were performed to evaluate the association between delay to surgery [before 48 hours (early group), 48 hours to 7 days (mid group), more than 7 days (late group)] and pneumonia and failure of extubating.

Results

From 2010 to 2020, 159 patients underwent surgical rib fixation. The median hospital length of stay was 18 days (interquartile range, 13-30 days). Pulmonary infections were encountered in 67 patients (42.2%) with about two third of early pneumonia (<5 days). The one-month mortality rate was 1.9%. Delay to surgery was not associated with either pneumonia (P>0.05) or failure of extubating (P>0.05).

Conclusions

Surgical rib fixation can be delayed without increasing the risk of pulmonary complications. Stabilizing other clinical situations can be safely prioritized if needed. A global evaluation including characteristics of trauma and lung evaluation must be considered before surgical stabilization of rib fracture.

Complete uni-port video-assisted thoracoscopic surgery for surgical stabilization of rib fractures: a case report

BACKGROUND

Rib fractures are a common injury in trauma. Potential complications include pain, pneumonia, respiratory failure, disability, and death. Surgical stabilization of rib fractures (SSRF) has become an available treatment option, and complete video-assisted thoracoscopic surgery (VATS) for SSRF is gradually accepted because of minimally invasive and pain relief. To our knowledge, complete uni-port VATS for SSRF has not yet been reported.

CASE PRESENTATION

A 53-year-old man accidentally fell off a three-meter high scaffolding while working resulting in severe chest pain and shortness of breath. He was found with left 7th through 11th rib fractures with a pulmonary contusion from computed tomography (CT). A 4 cm incision was made in the 7th intercostal space in the midaxillary line, and complete uni-port VATS for SSRF were operated. The patient's pain was significantly relieved after the operation, and the scar was tiny and unapparent.

CONCLUSIONS

Complete uni-port VATS for SSRF is a novel and modificatory method of operation with the benefit of minimal invasion, meanwhile, intrathoracic injuries could be treated at the same time. Further study is warranted.

Outcomes after fixation of rib fractures sustained during cardiopulmonary resuscitation: A retrospective single center analysis

Background

Historically rib fractures have been typically treated non-operatively. Recent studies showed promising results after osteosynthesis of rib fractures in trauma patients with flail segments or multiple rib fractures. However, there is a paucity of data on rib fixation after cardiopulmonary resuscitation (CPR). This study evaluated the outcomes of patients who received rib fixation after CPR.

Methods

Adult patients who received surgical fixation of rib fractures sustained during CPR between 2010 and 2020 were eligible for inclusion in this retrospective study. Outcome measures included complications, quality of life (EQ 5D 5L) and level of dyspnea.

Results

Nineteen patients were included with a mean age of 66.8 years. The mean number of fractured ribs was ten, seven patients additionally had a sternum fracture. Pneumonia occurred in 15 patients (74%), of which 13 were diagnosed preoperatively and 2 post-operatively. Six patients developed a postoperative pneumothorax, none of which required revision surgery. One patient showed persistent flail chest after rib fixation and required additional fixation of a concomitant sternum fracture. One infection of the surgical site of sternal plate occurred, while no further surgery related complications were reported. Mean EQ-5D-5L was 0.908 and the average EQ VAS was 80. One patient reported persisting dyspnea.

Conclusion

To date, this is the largest reported cohort of patients who received rib fixation for fractures sustained during CPR. No complications associated with rib fixation were reported whereas one infection after sternal fixation did occur. Current follow-up demonstrated a good long-term quality of life after fixation, warranting further studies on this topic. Deeper knowledge on this subject would be beneficial for a wide spectrum of physicians.

Predicting pneumonia during hospitalization in flail chest patients using machine learning approaches

Objective

Pneumonia is a common pulmonary complication of flail chest, causing high morbidity and mortality rates in affected patients. The existing methods for identifying pneumonia have low accuracy, and their use may delay antimicrobial therapy. However, machine learning can be combined with electronic medical record systems to identify information and assist in quick clinical decision-making. Our study aimed to develop a novel machine-learning model to predict pneumonia risk in flail chest patients.

Methods

From January 2011 to December 2021, the electronic medical records of 169 adult patients with flail chest at a tertiary teaching hospital in an urban level I Trauma Centre in Chongqing were retrospectively analysed. Then, the patients were randomly divided into training and test sets at a ratio of 7:3. Using the Fisher score, the best subset of variables was chosen. The performance of the seven models was evaluated by computing the area under the receiver operating characteristic curve (AUC). The output of the XGBoost model was shown using the Shapley Additive exPlanation (SHAP) method.

Results

Of 802 multiple rib fracture patients, 169 flail chest patients were eventually included, and 86 (50.80%) were diagnosed with pneumonia. The XGBoost model performed the best among all seven machine-learning models. The AUC of the XGBoost model was 0.895 (sensitivity: 84.3%; specificity: 80.0%).Pneumonia in flail chest patients was associated with several features: systolic blood pressure, pH value, blood transfusion, and ISS.

Conclusion

Our study demonstrated that the XGBoost model with 32 variables had high reliability in assessing risk indicators of pneumonia in flail chest patients. The SHAP method can identify vital pneumonia risk factors, making the XGBoost model's output clinically meaningful.

Health-related quality of life after severe trauma and available PROMS: an updated review (part I)

Introduction

Throughout the years, a decreasing trend in mortality rate has been demonstrated in patients suffering severe trauma. This increases the relevance of documentation of other outcomes for this population, including patient-reported outcome measures (PROMs), such as health-related quality of life (HRQoL). The aim of this review was to summarize the results of the studies that have been conducted regarding HRQoL in severely injured patients (as defined by the articles’ authors). Also, we present the instruments that are used most frequently to assess HRQoL in patients suffering severe trauma.

Methods

A literature search was conducted in the Cochrane Library, EMBASE, PubMed, and Web of Science for articles published from inception until the 1st of January 2022. Reference lists of included articles were reviewed as well. Studies were considered eligible when a population of patients with major, multiple or severe injury and/or polytrauma was included, well-defined by means of an ISS-threshold, and the outcome of interest was described in terms of (HR)QoL. A narrative design was chosen for this review.

Results

The search strategy identified 1583 articles, which were reduced to 113 after application of the eligibility criteria. In total, nineteen instruments were used to assess HRQoL. The SF-36 was used most frequently, followed by the EQ-5D and SF-12. HRQoL in patients with severe trauma was often compared to normative population norms or pre-injury status, and was found to be reduced in both cases, regardless of the tool used to assess this outcome. Some studies demonstrated higher scoring of the patients over time, suggesting improved HRQoL after considerable time after severe trauma.

Conclusion

HRQoL in severely injured patients is overall reduced, regardless of the instrument used to assess it. The instruments that were used most frequently to assess HRQoL were the SF-36 and EQ-5D. Future research is needed to shed light on the consequences of the reduced HRQoL in this population. We recommend routine assessment and documentation of HRQoL in severely injured patients.

Blunt chest wall trauma: Rib fractures and associated injuries

ABSTRACT

Blunt injuries to the chest wall, specifically those related to rib fractures, need to be promptly identified and effectively managed to reduce patient morbidity and mortality. Furthermore, judicious use of multimodal pain management and early identification of patients who will benefit from the surgical stabilization of rib fractures are paramount to optimal outcomes.

Postoperative submuscular emphysema due to air leakage from the residual screw holes after plate removal in a patient who had undergone surgical stabilization of flail chest

Many studies have reported indications and complications of surgical stabilization of rib fractures. However, data about the postoperative complications after the removal of the plates are still lacking. The author reports a rare complication after plate removal, postoperative submuscular emphysema, due to air leakage from the residual screw hole. A 68-year-old male with a flail chest was successfully treated by surgical rib fixation. A few months later, the patient wanted his implants removed due to chest irritation. The removal operation was completed, and postoperative courses were not unusual. However, a large amount of submuscular emphysema was found in the follow-up period. The patient was successfully managed by applying a submuscular thoracic drainage catheter. Although postoperative subcutaneous emphysema due to residual screw holes after plate removal is rare, we need to pay more attention when selecting the proper length of screws during surgical rib fixation.

VATS-assisted surgical stabilization of rib fractures in flail chest: 1-year follow-up of 105 cases

OBJECTIVES

Early surgical stabilization of flail chest has been shown to improve chest wall stability and diminish respiratory complications. The addition of video‑assisted thoracoscopic surgery (VATS) can diagnose and manage intrathoracic injuries and evacuate hemothorax. This study analyzed the outcome of our 7-year experience with VATS-assisted surgical stabilization of rib fractures (SSRF) for flail chest.

METHODS

From January 2013 to December 2019, all trauma patients undergoing VATS-assisted SSRF for flail chest were included. Patient characteristics and complications during 1-year follow-up were reported.

RESULTS

VATS‑assisted SSRF for flail chest was performed in 105 patients. Median age was 65 years (range 21-92). Median injury severity score was 16 (range 9-49). Hemothorax was evacuated with VATS in 80 patients (median volume 200 ml, range 25-2500). In 3 patients entrapped lung was freed from the fracture site and in 2 patients a diaphragm rupture was repaired. Median postoperative ICU admission was 2 days (range 1-41). Thirty-two patients (30%) had a post‑operative complication during admission and six patients (6%) a complication within 1 year. In-hospital mortality rate was 1%. Six patients (6%) died after discharge, due to causes unrelated to the original injury.

CONCLUSIONS

Addition of VATS to SSRF for flail chest seems helpful to diagnose and manage intrathoracic injuries and adequately evacuate hemothorax. The majority of complications are low grade and occur during admission. Further prospective research needs to be conducted to identify potential risk factors for complications and better selection for addition of VATS to improve care in the future.

Surgical Infection Society: Chest Wall Injury Society Recommendations for Antibiotic Use during Surgical Stabilization of Traumatic Rib or Sternal Fractures to Reduce Risk of Implant Infection

Background: Surgical stabilization of rib fractures is recommended in patients with flail chest or multiple displaced rib fractures with physiologic compromise. Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involve open reduction and internal fixation of fractures with a plate construct to restore anatomic alignment. Most plate constructs are composed of titanium and presence of this foreign, non-absorbable material presents opportunity for implant infection. Although implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity often requiring prolonged antibiotic therapy, debridement, and potentially implant removal. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for antibiotic use during and after surgical stabilization of traumatic rib and sternal fractures. Clinical scenarios included patients with concomitant infectious processes (sepsis, pneumonia, empyema, cellulitis) or sources of contamination (open chest, gross contamination) incurred as a result of their trauma and present at the time of their surgical stabilization. PubMed, Embase, and Cochrane databases were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: For patients undergoing SSRF or SSSF in the absence of pre-existing infectious process, there is insufficient evidence to suggest existing peri-operative guidelines or recommendations are inadequate. For patients undergoing SSRF or SSSF in the presence of sepsis, pneumonia, or an empyema, there is insufficient evidence to provide recommendations on duration and choice of antibiotic. This decision may be informed by existing guidelines for the concomitant infection. For patients undergoing SSRF or SSSF with an open or contaminated chest there is insufficient evidence to provide specific antibiotic recommendations. Conclusions: This guideline document summarizes the current Surgical Infection Society and Chest Wall Injury Society recommendations regarding antibiotic use during and after surgical stabilization of traumatic rib or sternal fractures. Limited evidence exists in the chest wall surgical stabilization literature and further studies should be performed to delineate risk of implant infection among patients undergoing SSSRF or SSSF with concomitant infectious processes.

Prospective study of long-term quality-of-life after rib fractures

BACKGROUND

Long-term quality-of-life after rib fractures remains understudied. We aimed to evaluate quality-of-life of patients who had rib fractures 1 year after discharge. We hypothesized that patients with rib fractures, even as an isolated injury, have suboptimal long-term quality-of-life.

METHODS

We prospectively enrolled adults admitted to our level 1 trauma center with acute rib fractures. Primary outcome was quality-of-life at 1 year after discharge, characterized using the revised trauma-specific quality-of-life questionnaire and a supplemental survey. Secondary analysis evaluated association between baseline frailty (measured using the Rib Fracture Frailty Index) and quality-of-life. Patients with low versus moderate frailty risk underwent full matching and linear mixed model analysis.

RESULTS

We enrolled 139 patients, among whom 72 (52%) completed 1-year surveys. Patients reported excellent emotional well-being (median [interquartile range]: 4.8 [3.7-5.0]) and functional engagement (median [interquartile range]: 5.0 [4.3-5.0]) but poor physical well-being and recovery (median [interquartile range]: 3.2 [2.8-3.6]). Nearly 40% of patients reported some degree of rib pain, and 29% had not returned to preinjury working capacity. Patients with and without isolated rib fractures reported similar median revised trauma-specific quality-of-life scores. We did not find statistically significant association between low versus moderate frailty and any quality-of-life domain, but no patients in our cohort had high frailty risk and our study was underpowered to detect this association.

CONCLUSION

Rib fractures are associated with suboptimal quality-of-life 1 year after discharge, even after isolated injury. Our sample size was limited, but our findings highlight persistent long-term consequences of rib fractures despite advances in inpatient management. Patients should be counseled on the potential for prolonged convalescence.

Long-term pulmonary function, thoracic pain, and quality of life in patients with one or more rib fractures

BACKGROUND

Long-term outcomes after rib fractures and the effect of treatment modality or chest wall injury severity on these outcomes remains uncertain. This retrospective cohort study evaluated the long-term pulmonary function, thoracic pain, and quality of life in patients admitted with rib fractures.

METHODS

Patients admitted with rib fractures between January 1, 2012, and December 1, 2019, were included. Data on long-term outcomes were collected during one follow-up visit. Patients were stratified by chest wall injury severity (one or two rib fractures, ≥3 rib fractures, or a flail chest) and treatment modality (surgical stabilization of rib fractures [SSRF] or nonoperative management). Multivariable analysis was performed to compare outcomes after SSRF with nonoperative treatment in patients with three or more rib fractures.

RESULTS

In total, 300 patients were included. The median follow-up was 39 months (P25-P75, 18-65 months). At follow-up, the corrected forced vital capacity returned to 84.7% (P25-P75, 74.3-93.7) and the forced expiratory volume in 1 second to 86.3% (P25-P75, 75.3-97.0) of the predicted reference values. Quality of life was determined using the Short Form-12 version 2 and EuroQoL-5D-5L. The Short Form-12 version 2 physical and mental component summary were 45 (P25-P75, 38-54) and 53 (P25-P75, 43-60), respectively. The EuroQoL-5D-5L utility score was 0.82 (P25-P75 0.66-0.92) and visual analog scale score 75 (P25-P75 70-85). This indicated a quality of life within normal population ranges. Moderate to severe thoracic pain was reported by 64 (21.3%) patients. Long-term outcomes returned to values within population ranges and were similar across chest wall injury severity and for patients treated with SSRF or nonoperatively.

CONCLUSION

While long-term pulmonary function and quality of life recover to values considered normal, subjective thoracic complaints, such as pain and dyspnea, remain frequently present following rib fractures. No effect of chest wall injury severity or treatment modality on long-term outcomes was demonstrated.

LEVEL OF EVIDENCE

Therapeutic, level III.

What is the optimal timing to perform surgical stabilization of rib fractures?

The practice of surgical stabilization of rib fractures (SSRF) for severe chest wall injury has exponentially increased over the last decade due to improved outcomes as compared to nonoperative management. However, regarding in-hospital outcomes, the ideal time from injury to SSRF remains a matter of debate. This review aims to evaluate and summarize currently available literature related to timing of SSRF. Nine studies on the effect of time to SSRF were identified. All were retrospective comparative studies with no detailed information on why patients underwent early or later SSRF. Patients underwent SSRF most often for a flail chest or ≥3 displaced rib fractures. Early SSRF (≤48-72 hours after admission) was associated with shorter hospital and intensive care unit length of stay (HLOS and ICU-LOS, respectively), duration of mechanical ventilation (DMV), and lower rates of pneumonia, and tracheostomy as well as lower hospitalization costs. No difference between early or late SSRF was demonstrated for mortality rate. As compared to nonoperative management, late SSRF (>3 days after admission), was associated with similar or worse in-hospital outcomes. The optimal time to perform SSRF in patients with severe chest wall injury is early (≤48-72 hours after admission) and associated with improved in-hospital outcomes as compared to either late salvage or nonoperative management. These data must however be cautiously interpreted due the retrospective nature of the studies and potential selection and attrition bias. Future research should focus on both factors and pathways that allow patients to undergo early SSRF.

Systematic Review and Meta-Analysis of Hardware Failure in Surgical Stabilization of Rib Fractures: Who, What, When, Where, and Why?

BACKGROUND

Surgical stabilization of rib fractures (SSRF) is increasingly used to reduce pulmonary complications and death among patients with rib fractures. However, the five Ws of hardware failure -who, what, when, where, and why- remains unclear. We aimed to synthesize available evidence on the five Ws and outline future research agenda for mitigating hardware failure.

METHODS

Experimental and observational studies published between 2009 and 2020 evaluating adults undergoing SSRF for traumatic rib fractures underwent evidence synthesis. We performed random effects meta-analysis of cohort/consecutive case studies. We calculated pooled prevalence of SSRF hardware failures using Freeman-Tukey double arcsine transformation and assessed study heterogeneity using DerSimonian-Laird estimation. We performed meta-regression with rib fracture acuity (acute or chronic) and hardware type (metal plate or not metal plate) as moderators.

RESULTS

Twenty-nine studies underwent qualitative synthesis and 24 studies (2404 SSRF patients) underwent quantitative synthesis. Pooled prevalence of hardware failure was 4(3-7)%. Meta-regression showed fracture acuity was a significant moderator (P = 0.002) of hardware failure but hardware type was not (P = 0.23). Approximately 60% of patients underwent hardware removal after hardware failure. Mechanical failures were the most common type of hardware failure, followed by hardware infections, pain/discomfort, and non-union. Timing of hardware failure after surgery was highly variable, but 87% of failures occurred after initial hospitalization. Mechanical failures was attributed to technical shortcomings (i.e. short plate length) or excessive force on the thoracic cavity.

CONCLUSIONS

SSRF hardware failure is an uncommon complication. Not all hardware failures are consequential, but insufficient individual patient data precluded characterizing where and why hardware failures occur. Minimizing SSRF hardware failure requires concerted research agenda to expand on the paucity of existing evidence.

Complete Video-assisted Thoracoscopic Surgery for Rib Fractures: A Series of 35 Cases

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) for internal fixation of rib fracture is a promising approach for treating rib fractures and flail chest. Currently, the standard practice is to make one or several incisions on the chest wall, which will inevitably aggravate the original trauma.

METHODS

We retrospectively analyzed the data of patients with rib fractures who were treated with memory alloy for internal fixation by complete VATS using a thoracoscopic transthoracic memory alloy rib coaptation board and an implantation tool through the clip applier method or the puncture, traction and suspension method at our hospital from October 2016 to June 2019.

RESULTS

There were 35 patients, of whom 12 had traumatic flail chest injury, and 23 had simple multiple rib fractures. Of the 23 patients with multiple rib fractures, 9 had fracture ends in the scapular or paravertebral region, and 14 had fracture ends located in the anterior or lateral chest walls. All surgeries were performed with complete VATS, and it showed quick recovery and good thoracic appearance and function, with no complications for all patients. Follow-up for 6-24 months revealed no detachment of the internal fixation device.

CONCLUSIONS

Internal memory alloy fixation with complete VATS for the treatment of rib fractures is a simple and minimally invasive method, which enables fixing fractured ribs internally while treating thoracic trauma with a thoracoscope.

Early National Landscape of Surgical Stabilization of Sternal Fractures

BACKGROUND

Operative management of chest wall injuries aims to restore respiratory mechanics and mitigate pulmonary complications. Extensive studies support surgical stabilization of rib fractures (SSRF) for select patients, but role for surgical stabilization of sternal fractures (SSSF) remains unclear. We aimed to understand national prevalence of SSSF and compare outcomes after surgical stabilization and non-operative management of sternal fractures.

METHODS

We retrospectively analyzed adult patients (age ≥ 18 years) admitted with sternal fractures after blunt trauma using the 2016 National Trauma Data Bank. We compared odds of inpatient mortality, pneumonia, and respiratory failure for propensity score matched patients (4:1) who underwent non-operative management vs SSSF. We characterized subgroup of patients with concurrent rib and sternal fractures who underwent concomitant SSRF-SSSF.

RESULTS

We identified 14,760 encounters of adults admitted with sternal fractures; 270 (1.8%) underwent SSSF. Compared to matched patients who underwent non-operative management, patients who underwent SSSF had lower odds of mortality (OR [95%CI]: 0.19 [0.06-0.62], p = 0.006). Adjusted for trauma center level, Mantel-Haenszel mortality odds remained lower for patients who underwent SSSF. Odds of pneumonia and respiratory failure were similar between matched groups. Among 46% of patients who had concomitant rib fractures, 0.3% (n = 18) underwent concurrent SSRF-SSSF and these patients survived hospitalization without pneumonia or respiratory failure.

CONCLUSION

A vast majority of patients who suffer sternal fractures undergo non-operative management. Potential mortality benefit of SSSF and concurrent SSRF-SSSF's role for commonly concomitant rib and sternal fractures deserve further study. Our preliminary findings call for delineating heterogeneity of sternal fractures and establishing consensus SSSF indications.

Prospective study of short-term quality-of-life after traumatic rib fractures

BACKGROUND

Postdischarge convalescence after traumatic rib fractures remains unclear. We hypothesized that patients with rib fractures, even as an isolated injury, have associated poor quality of life (QoL) after discharge.

METHODS

We prospectively enrolled adult patients at our level I trauma center with rib fractures between July 2019 and January 2020. We assessed QoL at 1 and 3 months after discharge using the Trauma-specific Quality-of-Life (T-QoL; 43-question survey evaluating five QoL domains on a 4-point Likert scale, where 4 indicates optimal and 1, worst QoL) and supplementary questionnaires. We used generalized estimating equations to assess T-QoL score trends over time and effect of age, sex, injury pattern, self-perceived injury severity, and Injury Severity Score.

RESULTS

We enrolled 139 patients (108 completed the first and 93 completed both surveys). Three months after discharge, 33% of patients were not working at preinjury capacity, and 7% were still using opioid analgesia. Suffering rib fractures mostly impacted recovery and resilience (T-QoL score, mean [robust standard error] at 1 month, 2.7 [0.1]; 3 months, 3.0[0.1]) and physical well-being domains (1 month, 2.5 [0.1]; 3 months, 2.9[0.1]). Quality of life improved over time across all domains. Compared with patients who perceived their injuries as mild/moderate, patients who perceived their injuries as severe/very severe reported worse T-QoL scores across all domains. In contrast, Injury Severity Score did not affect QoL. Patients 65 years or older (-0.6 [0.1]) and women (-0.6 [0.2]) reported worse functional engagement compared with those 65 years or older and men, respectively.

CONCLUSION

We found that patients with traumatic rib fractures experience suboptimal QoL after discharge. Quality of life improved over time, but even 3 months after discharge, patients reported challenges performing activities of daily living, slower-than-expected recovery, and not returning to work at preinjury capacity. Perception of injury severity had a large effect on QoL. Patients with rib fractures may benefit from close short-term follow-up.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Long-term outcomes of surgical rib fixation in patients with flail chest and multiple rib fractures

Background

Recently, interest has increased in surgical fixation for severe thoracic wall injury with good short-term outcomes. However, few reports have evaluated long-term outcomes or complications. This study aimed to assess long-term quality of life and implant-related complications after rib fixation for flail chest and multiple rib fractures.

Methods

We interviewed patients who had undergone rib fixation from January 2014 to December 2019 about their current ability to work and their usual life.

Results

Twenty-two patients underwent rib fixation during the study period. Two patients with flail chest had already died after the surgery due to senescence; thus, follow-up information was obtained from 20 patients (91%), with a follow-up duration of 47.5 (IQR 22–58) months. The most undesirable event occurring during the study period was irritation caused by a palpable plate (n=2, 10%), probably due to the thin skin of patients over 70 years old. Eighteen patients were able to return to their usual life or same work as in the premorbid state with no complaints. Two patients are still undergoing rehabilitation due to concomitant extremities fractures. The median EQ-5D-5L index score was 0.89 (IQR 0.84–0.93). There were no implant-related complications requiring plate explantation.

Discussion

We concluded that rib fixation offers good long-term benefits, with the ability of the patient with flail chest or multiple rib fractures to return to activity in the premorbid state. Elderly patients especially with thin, soft tissue may complain of irritation caused by the plate and should be informed of this prior to surgery.

Level of evidence

Level IV therapeutic care/management.

Long-term quality of life and functional outcome after rib fracture fixation

PURPOSE

The primary aim of this study was to assess the long-term quality of life and functional outcome after rib fracture fixation for patients with multiple rib fractures or flail chest. Secondarily, this study sought to identify risk factors associated with the quality of life.

METHODS

A retrospective cohort study with a follow-up by questionnaire was performed at a level-1 trauma center in Switzerland. All adult patients with three or more rib fractures treated with rib fixation between 2010 and 2018 were eligible for inclusion. All outcomes were independently assessed for patients with multiple rib fractures and patients with a flail chest. The outcome measures were quality of life, level of dyspnea, return to work, implant irritation, and implant removal after a minimum of 12 months of follow-up. Quality of life was assessed using the EuroQol five-dimensional five-level questionnaire (EQ-5D-5L) and level of dyspnea was determined with the modified Medical Research Council dyspnea (mMRC) scale.

RESULTS

The survey was completed by 74 out of 102 patients (73%) at a median follow-up of 26 months (IQR 15-37). The median EQ-5D utility index score was 0.91 (0.89-1.0), which was equivalent to the reference population (0.902, p = 0.523). The vast majority of patients experienced 'no problems' or 'slight problems' in any of the EQ-5D-5L dimensions. The complication rate associated with rib fracture fixation was low, implant-related irritation was the most common long-term sequela and occurred in 31% of patients. In multivariable regression analyses, total length of stay on the intensive care unit (ICU-LOS) was independently associated with a worse quality of life.

CONCLUSIONS

Patients who underwent rib fracture fixation for multiple rib fractures or flail chest after severe chest trauma experienced a good quality of life at least 1 year after surgery. A longer ICU-LOS was independently associated with impaired quality of life. In addition, there were no significant differences in the long-term quality of life and functional outcome between patients with multiple rib fractures and a flail chest. Implant-related irritation was the most important long-term sequela and occurred in one-third of patients.

An unexpected fracture of a titanium rib plate in a patient with traumatic brain injury

Surgical stabilization of rib fractures has been accepted and successfully performed for the management of patients with multiple rib fractures. Several types of devices, such as titanium bar, plate, and screws, are used for rib stabilization. Titanium devices provide a strong support for rib fixation and chest wall reconstruction and are rarely associated with complications. Herein, we report an unusual case of mechanical failure associated with a broken titanium plate. A 47-year-old man was treated with surgical stabilization of rib fractures using titanium plates after blunt trauma leading to epidural hematoma and massive hemothorax. After decompressive craniectomy, bleeding control, and rib fixation for chest trauma, he developed hyperactive delirium, which was not well controlled. On the 17 day of operation, a chest radiograph showed a broken rib plate. Surgeons who perform surgical rib stabilization should be aware that titanium plates are vulnerable to breakage under some conditions, such as hyperactive delirium.

The evolution of trauma care in the Netherlands over 20 years

Introduction

In 1999 an inclusive trauma system was initiated in the Netherlands and a nationwide trauma registry, including all admitted trauma patients to every hospital, was started. The Dutch trauma system is run by trauma surgeons who treat both the truncal (visceral) and extremity injuries (fractures).

Materials and Methods

In this comprehensive review based on previous published studies, data over the past 20 years from the central region of the Netherlands (Utrecht) was evaluated.

Results

It is demonstrated that the initiation of the trauma systems and the governance by the trauma surgeons led to a region-wide mortality reduction of 50% and a mortality reduction for the most severely injured of 75% in the level 1 trauma centre. Furthermore, major improvements were found in terms of efficiency, demonstrating the quality of the current system and its constructs such as the type of surgeon. Due to the major reduction in mortality over the past few years, the emphasis of trauma care evaluation shifts towards functional outcome of severely injured patients. For the upcoming years, centralisation of severely injured patients should also aim at the balance between skills in primary resuscitation and surgical stabilization versus longitudinal surgical involvement.

Conclusion

Further centralisation to a limited number of level 1 trauma centres in the Netherlands is necessary to consolidate experience and knowledge for the trauma surgeon. The future trauma surgeon, as specialist for injured patients, should be able to provide the vast majority of trauma care in this system. For the remaining part, intramural, regional and national collaboration is essential