1
|
Lagazzi E, Rafaqat W, Argandykov D, de Roulet A, Abiad M, Proaño-Zamudio JA, Velmahos GC, Hwabejire JO, Paranjape C, Albutt KH. Timing matters: Early versus late rib fixation in patients with multiple rib fractures and pulmonary contusion. Surgery 2024; 175:529-535. [PMID: 38167568 DOI: 10.1016/j.surg.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/09/2023] [Accepted: 09/05/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Recent literature has shown that surgical stabilization of rib fractures benefits patients with rib fractures accompanied by pulmonary contusion; however, the impact of timing on surgical stabilization of rib fractures in this patient population remains unexplored. We aimed to compare early versus late surgical stabilization of rib fractures in patients with traumatic rib fractures and concurrent pulmonary contusion. METHODS We selected all adult patients with isolated blunt chest trauma, multiple rib fractures, and pulmonary contusion undergoing early (<72 hours) versus late surgical stabilization of rib fractures (≥72 hours) using the American College of Surgeons Trauma Quality Improvement Program 2016 to 2020. Propensity score matching was performed to adjust for patient, injury, and hospital characteristics. Our outcomes were hospital length of stay, acute respiratory distress syndrome, unplanned intubation, ventilator days, unplanned intensive care unit admission, intensive care unit length of stay, tracheostomy rates, and mortality. We then performed sub-group analyses for patients with major or minor pulmonary contusion. RESULTS We included 2,839 patients, of whom 1,520 (53.5%) underwent early surgical stabilization of rib fractures. After propensity score matching, 1,096 well-balanced pairs were formed. Early surgical stabilization of rib fractures was associated with a decrease in hospital length of stay (9 vs 13 days; P < .001), decreased intensive care unit length of stay (5 vs 7 days; P < .001), and lower rates of unplanned intubation (7.4% vs 11.4%; P = .001), unplanned intensive care unit admission (4.2% vs 105%, P < .001), and tracheostomy (8.4% vs 12.4%; P = .002). Similar results were also found in the subgroup analyses for patients with major or minor pulmonary contusion. CONCLUSION These findings suggest that in patients with multiple rib fractures and pulmonary contusion, the early implementation of surgical stabilization of rib fractures could be beneficial regardless of the severity of pulmonary contusion.
Collapse
Affiliation(s)
- Emanuele Lagazzi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA; Department of Surgery, Humanitas Research Hospital, Rozzano, MI, Italy. https://twitter.com/EmanueleLagazzi
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Amory de Roulet
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - May Abiad
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Charudutt Paranjape
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Katherine H Albutt
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA.
| |
Collapse
|
2
|
Abstract
BACKGROUND Pulmonary contusion has been considered a contraindication to surgical stabilization of rib fractures (SSRFs). This study aimed to evaluate the association between pulmonary contusion severity and outcomes after SSRF. We hypothesized that outcomes would be worse in patients who undergo SSRF compared with nonoperative management, in presence of varying severity of pulmonary contusions. METHODS This retrospective cohort study included adults with three or more displaced rib fractures or flail segment. Patients were divided into those who underwent SSRF versus those managed nonoperatively. Severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion 18 (BPC18) score. Outcomes (pneumonia, tracheostomy, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, mortality) were retrieved from patients' medical records. Comparisons were made using Fisher's exact and Kruskal-Wallis tests, and correction for potential confounding was done with regression analyses. RESULTS A total of 221 patients were included; SSRF was performed in 148 (67%). Demographics and chest injury patterns were similar in SSRF and nonoperatively managed patients. Surgical stabilization of rib fracture patients had less frequent head and abdominal/pelvic injuries ( p = 0.017 and p = 0.003). Higher BPC18 score was associated with worse outcomes in both groups. When adjusted for ISS, the ICU stay was shorter (adjusted β , -2.511 [95% confidence interval, -4.87 to -0.16]) in patients with mild contusions who underwent SSRF versus nonoperative patients. In patients with moderate contusions, those who underwent SSRF had fewer ventilator days (adjusted β , -5.19 [95% confidence interval, -10.2 to -0.17]). For severe pulmonary contusions, outcomes did not differ between SSRF and nonoperative management. CONCLUSION In patients with severe rib fracture patterns, higher BPC18 score is associated with worse respiratory outcomes and longer ICU and hospital admission duration. The presence of pulmonary contusions is not associated with worse SSRF outcomes, and SSRF is associated with better outcomes for patients with mild to moderate pulmonary contusions. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
Collapse
|
3
|
Sawyer E, Wullschleger M, Muller N, Muller M. Surgical Rib Fixation of Multiple Rib Fractures and Flail Chest: A Systematic Review and Meta-Analysis. J Surg Res 2022; 276:221-234. [PMID: 35390577 DOI: 10.1016/j.jss.2022.02.055] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/13/2022] [Accepted: 02/22/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been treated conservatively, there is increasing interest in the benefits of surgical fixation. However, strong evidence that supports surgical rib fixation and identifies the most appropriate patients for its application is currently sparse. METHODS A systematic review and meta-analysis following PRISMA guidelines was performed to identify all peer-reviewed papers that examined surgical compared to conservative management of rib fractures. We undertook a subgroup analysis to determine the specific effects of rib fracture type, age, the timing of fixation and study design on outcomes. The primary outcomes were the length of hospital and ICU stay, and secondary outcomes included mechanical ventilation time, rates of pneumonia, and mortality. RESULTS Our search identified 45 papers in the systematic review, and 40 were included in the meta-analysis. There was a statistical benefit of surgical fixation compared to conservative management of rib fractures for length of ICU stay, mechanical ventilation, mortality, pneumonia, and tracheostomy. The subgroup analysis identified surgical fixation was most favorable for patients with flail chest and those who underwent surgical fixation within 72 h. Patients over 60 y had a statistical benefit of conservative management on length of hospital stay and mechanical ventilation. CONCLUSIONS Surgical fixation of flail and multiple rib fractures is associated with a reduction in morbidity and mortality outcomes compared to conservative management. However, careful selection of patients is required for the appropriate application of surgical rib fixation.
Collapse
Affiliation(s)
- Emily Sawyer
- Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
| | - Martin Wullschleger
- Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Medicine, Griffith University, Southport, Queensland, Australia; Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Nicholas Muller
- Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Michael Muller
- Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Medicine, Griffith University, Southport, Queensland, Australia; Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
4
|
Owattanapanich N, Lewis MR, Benjamin ER, Jakob DA, Demetriades D. surgical rib fixation in isolated flail chest improves survival. Ann Thorac Surg 2021; 113:1859-1865. [PMID: 34214544 DOI: 10.1016/j.athoracsur.2021.05.085] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/20/2021] [Accepted: 05/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The presence of severe associated injuries in flail chest complicates the interpretation of outcomes and the role of rib fixation. This study aimed to examine the impact of fixation in isolated flail chest patients. METHODS All patients diagnosed with flail chest injuries were queried from the National Trauma Data Bank (2016-2017). Patients who died within 72 hours, transferred from an outside hospital, had associated thoracic aortic injuries or significant extrathoracic injuries were excluded. Patients with rib fixation were propensity score matched 1:3 with similar patients treated nonoperatively and outcomes were evaluated. Multivariate analysis was used to identify independent predictors for mortality and prolonged mechanical ventilation. RESULTS Of 287,947 patients with rib fractures, there were 12,110 (4.2%) patients with flail chest. After exclusion, 5,293 patients with isolated blunt flail chest injuries were included in the analysis. Rib fixation was performed in 575 (10.9%) and 4,718 (89.1%) were managed nonoperatively. After matching, the mortality rate was significantly lower in the fixation group (2.0% vs 5.5%, p= 0.001). On multivariate analysis, rib fixation was associated with improved mortality (OR 0.355, p= 0.002). The timing of operation was not a significant independent risk factor for mortality. However, early fixation (≤72 hours) was associated with a significantly lower need for prolonged ventilation (>7 days). CONCLUSIONS Operative fixation in patients with isolated flail chest is associated with improved survival and should be considered liberally. The timing of fixation did not affect mortality, but early fixation was associated with a reduced need for prolonged mechanical ventilation.
Collapse
Affiliation(s)
- Natthida Owattanapanich
- DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE, LAC+USC MEDICAL CENTER, UNIVERSITY OF SOUTHERN CALIFORNIA,LOS ANGELES, CA
| | - Meghan R Lewis
- DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE, LAC+USC MEDICAL CENTER, UNIVERSITY OF SOUTHERN CALIFORNIA,LOS ANGELES, CA
| | - Elizabeth R Benjamin
- DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE, LAC+USC MEDICAL CENTER, UNIVERSITY OF SOUTHERN CALIFORNIA,LOS ANGELES, CA
| | - Dominik A Jakob
- DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE, LAC+USC MEDICAL CENTER, UNIVERSITY OF SOUTHERN CALIFORNIA,LOS ANGELES, CA
| | - Demetrios Demetriades
- DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE, LAC+USC MEDICAL CENTER, UNIVERSITY OF SOUTHERN CALIFORNIA,LOS ANGELES, CA..
| |
Collapse
|
5
|
Pieracci FM, Schubl S, Gasparri M, Delaplain P, Kirsch J, Towe C, White TW, Whitbeck S, Doben AR. The Chest Wall Injury Society Recommendations for Reporting Studies of Surgical Stabilization of Rib Fractures. Injury 2021; 52:1241-1250. [PMID: 33795145 DOI: 10.1016/j.injury.2021.02.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/20/2021] [Accepted: 02/12/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Publications investigating the efficacy of surgical stabilization of rib fractures (SSRF) have increased exponentially. However, there is currently no standardized reporting structure for these studies, rendering both comparisons and extrapolation problematic. METHODS A subject matter expert group was formed by the Chest Wall Injury Society. This group conducted a review of the SSRF investigational literature and identified variable reporting within several general categories of relevant parameters. A compliment of guidelines was then generated. RESULTS The reporting guidelines consist of 26 recommendations in the categories of: (1) study type, (2) patient and injury characteristics, (3) patient treatments, (4) outcomes, and (5) statistical considerations. CONCLUSION Our review identified inconsistencies in reporting within the investigational SSRF literature. In response to these inconsistencies, we propose a set of recommendations to standardize reporting of original investigations into the efficacy of SSRF.
Collapse
Affiliation(s)
- Fredric M Pieracci
- Department Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO.
| | - Sebastian Schubl
- Department of Surgery, University of California-Irvine, Irvine, CA
| | - Mario Gasparri
- Department of Surgery, Division of CT Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Jordan Kirsch
- Department of Surgery, Section of Acute and Critical Care Surgery, Barnes-Jewish Hospital/Washington University, St. Louis, MI
| | - Christopher Towe
- Department of CT Surgery, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH
| | - Thomas W White
- Department of Surgery, Intermountain Medical Center, Murray, UT
| | | | - Andrew R Doben
- Department of Surgery, St. Francis Medical Center, Hartford, CT
| |
Collapse
|
6
|
Choi J, Gomez GI, Kaghazchi A, Borghi JA, Spain DA, Forrester JD. Surgical Stabilization of Rib Fracture to Mitigate Pulmonary Complication and Mortality: A Systematic Review and Bayesian Meta-Analysis. J Am Coll Surg 2020; 232:211-219.e2. [PMID: 33212228 DOI: 10.1016/j.jamcollsurg.2020.10.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 01/22/2023]
Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Department of Epidemiology and Population Health, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA.
| | - Giselle I Gomez
- Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - Aydin Kaghazchi
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - John A Borghi
- School of Medicine, Stanford University, Stanford, CA
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA
| |
Collapse
|
7
|
Peek J, Beks RB, Hietbrink F, Heng M, De Jong MB, Beeres FJ, Leenen LP, Groenwold RH, Houwert RM. Complications and outcome after rib fracture fixation: A systematic review. J Trauma Acute Care Surg 2020; 89:411-418. [DOI: 10.1097/ta.0000000000002716] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
8
|
Schulz-Drost S, Finkbeiner R, Lefering R, Grosso M, Krinner S, Langenbach A, DGU TT. Lung Contusion in Polytrauma: An Analysis of the TraumaRegister DGU. Thorac Cardiovasc Surg 2019; 69:735-748. [DOI: 10.1055/s-0039-1700505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Abstract
Background Thorax trauma frequently occurs in which injuries to the bony chest, lung contusions (LCs), and others are diagnosed. The significance of this violation is described very differently and is mostly based on monocentric data.
Methods A retrospective analysis of the TraumaRegister DGU® (TR-DGU) dataset (Project 2014–062) was performed between 2009 and 2014 (injury severity score [ISS] ≥ 16, primary admission to a trauma center, no isolated traumatic brain injury). Patients with LC (Abbreviated Injury Scale [AIS] 3 + 4) were compared with the control group, and an analysis of different age groups was performed.
Results A total of 49,567 patients were included, thereunder 14,521 (29.3%) without relevant thoracic trauma (TT); 95.9% blunt traumas. 18,892 patients (38.1%) had LC and 14,008 (28.3%) had severe LC with AIS 3 + 4; thereunder 72.7% males. For severe LC, the average age was the lowest (44.7 ± 19.7 years) and ISS the highest (30.4 ± 12.1 points).Intubation, intensive care, (multi-) organ failure, sepsis, and extrathoracic injuries were most common in severe LC. Shock, chest tubes, further thoracic injuries, and patient death occurred most frequently in TT without LC.Younger patients showed a higher incidence of LC than the older ones; however, high patient age was a highly significant risk factor for the development of complications and poor outcome.
Conclusion Since LC was present in almost 40% of the severely injured and was related to higher morbidity, LC should be detected and managed at the earliest possible time. Proper follow-ups employing chest X-rays and computed tomography (CT) scans are recommended.
Collapse
Affiliation(s)
- Stefan Schulz-Drost
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Erlangen, Germany
- Department of Trauma and Orthopedic Surgery, BG Hospital Unfallkrankenhaus Berlin GmbH, Berlin, Germany
| | - Rebekka Finkbeiner
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Rolf Lefering
- IFOM, Institute for Research in Operative Medicine, Faculty of Health, University Witten/Herdecke, Ostmerheimer Straße 200, 51109, Cologne, Germany
| | - Marco Grosso
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Sebastian Krinner
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Andreas Langenbach
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Erlangen, Germany
| | - the TraumaRegister DGU
- Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU)
| |
Collapse
|
9
|
Xiong M, Hu W, Lou Q, Yin S, Wang X. Efficacy of nickel-titanium memory alloy in the treatment of multiple rib fracture combined with sternal fracture. Exp Ther Med 2019; 18:537-542. [PMID: 31258691 PMCID: PMC6566122 DOI: 10.3892/etm.2019.7597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/16/2019] [Indexed: 11/05/2022] Open
Abstract
Clinical efficacy and complications of nickel-titanium memory alloy in the treatment of multiple rib fractures combined with sternal fractures was investigated. A retrospective analysis of 123 patients with multiple rib fractures combined with sternal fractures admitted to First People's Hospital of Fuzhou from January 2013 to December 2015 was performed, including study group (treated with internal fixation by the nickel-titanium memory alloy, n=68) and control group (treated with internal fixation by partial pressure bandage, n=55). Μean arterial pressure (MAP), heart rate (HR), and visual analogue pain score (VAS) of the two groups before and after treatment were compared and analyzed. No significant difference in MAP, HR and VAS scores between groups was detected before treatment (P>0.05). After treatment, MAP score of study group was significantly higher, and HR and VAS scores were significantly lower (P<0.05). Μethod of internal fixation by the nickel-titanium memory alloy, with better efficacy than the traditional method of internal fixation by partial pressure bandage and less postoperative complications in the treatment of flail chest caused by multiple rib fractures combined with sternal fractures, is worthy of clinical application and promotion.
Collapse
Affiliation(s)
- Ming Xiong
- Department of Cardiothoracic Surgery, First People's Hospital of Fuzhou, Fuzhou, Jiangxi 344000, P.R. China
| | - Wei Hu
- Department of Cardiothoracic Surgery, First People's Hospital of Fuzhou, Fuzhou, Jiangxi 344000, P.R. China
| | - Qiang Lou
- Department of Cardiothoracic Surgery, First People's Hospital of Fuzhou, Fuzhou, Jiangxi 344000, P.R. China
| | - Shi Yin
- Department of ICU, First People's Hospital of Fuzhou, Fuzhou, Jiangxi 344000, P.R. China
| | - Xin Wang
- Department of Thoracic Surgery, Xuzhou Central Hospital, Xuzhou, Jiangsu 221000, P.R. China
| |
Collapse
|
10
|
Ingoe HM, Coleman E, Eardley W, Rangan A, Hewitt C, McDaid C. Systematic review of systematic reviews for effectiveness of internal fixation for flail chest and rib fractures in adults. BMJ Open 2019; 9:e023444. [PMID: 30940753 PMCID: PMC6500198 DOI: 10.1136/bmjopen-2018-023444] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Multiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains controversial. Our aim is to synthesise the effectiveness of surgical rib fracture fixation as evidenced by systematic reviews. DESIGN A systematic search identified systematic reviews comparing effectiveness of rib fracture fixation with non-operative management of adults with flail chest or unifocal non-flail rib fractures. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Science Citation Index were last searched 17 March 2017. Risk of bias was assessed using the Risk Of Bias In Systematic reviews (ROBIS) tool. The primary outcome was duration of mechanical ventilation. RESULTS Twelve systematic reviews were included, consisting of 3 unique randomised controlled trials and 19 non-randomised studies. Length of mechanical ventilation was shorter in the fixation group compared with the non-operative group in flail chest; pooled estimates ranged from -4.52 days, 95% CI (-5.54 to -3.5) to -7.5 days, 95% CI (-9.9 to -5.5). Pneumonia, length of hospital and intensive care unit stay all showed a statistically significant improvement in favour of fixation for flail chest; however, all outcomes in favour of fixation had substantial heterogeneity. There was no statistically significant difference between groups in mortality. Two systematic reviews included one non-randomised studies of unifocal non-flail rib fracture population; due to limited evidence the benefits with surgery are uncertain. CONCLUSIONS Synthesis of the reviews has shown some potential improvement in patient outcomes with flail chest after fixation. For future review updates, meta-analysis for effectiveness may need to take into account indications and timing of surgery as a subgroup analysis to address clinical heterogeneity between primary studies. Further robust evidence is required before conclusions can be drawn of the effectiveness of surgical fixation for flail chest and in particular, unifocal non-flail rib fractures. PROSPERO REGISTRATION NUMBER CRD42016053494.
Collapse
Affiliation(s)
- Helen Ma Ingoe
- York Trials Unit, Health Sciences, University of York, York, UK
- Trauma and Orthopaedics, The James Cook University Hospital, Middlesbrough, UK
| | | | - William Eardley
- York Trials Unit, Health Sciences, University of York, York, UK
- Trauma and Orthopaedics, The James Cook University Hospital, Middlesbrough, UK
| | - Amar Rangan
- York Trials Unit, Health Sciences, University of York, York, UK
- Trauma and Orthopaedics, The James Cook University Hospital, Middlesbrough, UK
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Catriona McDaid
- York Trials Unit, Health Sciences, University of York, York, UK
| |
Collapse
|
11
|
Liu X, Xiong K. Surgical management versus non-surgical management of rib fractures in chest trauma:a systematic review and meta-analysis. J Cardiothorac Surg 2019; 14:45. [PMID: 30813961 PMCID: PMC6391832 DOI: 10.1186/s13019-019-0865-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/17/2019] [Indexed: 11/15/2022] Open
Abstract
Objective Rib fractures are common injuries sustained by patients who experience high-impact chest trauma, and they result in severe respiratory compromise because of the altered mechanics of respiration. Several studies have shown that the ventilation requirements and incidence of pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate the effect of surgical fixation treatments for rib fractures through systematic review and meta-analysis. Methods A literature search was performed in the PubMed, EMBASE, Web of Science and Cochrane Library databases for information from February 1958 to April 2018. Studies comparing the benefits of surgical management with that of non-surgical management of rib fractures were included. Statistical heterogeneity was evaluated by the X2 test with the significance set to P < 0.10 or I2 > 50%. Results Fourteen studies consisting of 839 patients were included (407 patients in the surgical management group; 432 patients in the non-surgical management group). The results showed that the surgical management group experienced a significant decrease in hospitalization time, intensive care time, mechanical ventilation time, mortality rate, pulmonary infection rate and tracheotomy rate compared with the non-surgical management group. However, the surgical management group incurred extra costs, and there was no significant difference in the duration of antibiotic use between the two groups. Conclusions Compared with non-surgical management, surgical management methods are of great value in the treatment of rib fractures despite the added expense.
Collapse
Affiliation(s)
- Xin Liu
- The Second Hospital of TianJin Medical University, Ping Jiang Road No.23, Hexi District, Tianjin, 300211, China.
| | - Kai Xiong
- Tianjin Medical University General Hospital, An Shan Road No.154, Heping District, Tianjin, 300192, China
| |
Collapse
|
12
|
Does Surgery Reduce the Risk of Complications Among Patients with Multiple Rib Fractures? A Meta-analysis. Clin Orthop Relat Res 2019; 477:193-205. [PMID: 30247228 PMCID: PMC6345288 DOI: 10.1097/corr.0000000000000495] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple rib fractures are common in trauma patients, who are prone to trauma-associated complications. Surgical or nonsurgical interventions for the aforementioned conditions remain controversial. QUESTIONS/PURPOSES The purpose of our study was to perform a meta-analysis to evaluate the clinical prognosis of surgical fixation of multiple rib fractures in terms of (1) hospital-related endpoints (including duration of mechanical ventilation, ICU length of stay [LOS] and hospital LOS), (2) complications, (3) pulmonary function, and (4) pain scores. METHODS We screened PubMed, Embase, and Cochrane databases for randomized and prospective studies published before January 2018. Individual effect sizes were standardized; the pooled effect size was calculated using a random-effects model. Primary outcomes were duration of mechanical ventilation, intensive care unit length of stay (ICU LOS), and hospital LOS. Moreover, complications, pulmonary function, and pain were assessed. RESULTS The surgical group had a reduced duration of mechanical ventilation (weighted mean difference [WMD], -4.95 days; 95% confidence interval [CI], -7.97 to -1.94; p = 0.001), ICU LOS (WMD, -4.81 days; 95% CI, -6.22 to -3.39; p < 0.001), and hospital LOS (WMD, -8.26 days; 95% CI, -11.73 to -4.79; p < 0.001) compared with the nonsurgical group. Complications likewise were less common in the surgical group, including pneumonia (odds ratio [OR], 0.41; 95% CI, 0.27-0.64; p < 0.001), mortality (OR, 0.24; 95% CI, 0.07-0.87; p = 0.030), chest wall deformity (OR, 0.02; 95% CI. 0.00-0.12; p < 0.001), dyspnea (OR, 0.23; 95% CI, 0.09-0.54; p < 0.001), chest wall tightness (OR, 0.11; 95% CI, 0.05-0.22; p < 0.001) and incidence of tracheostomy (OR, 0.34; 95% CI, 0.20-0.57; p < 0.001). There were no differences between the surgical and nonsurgical groups in terms of pulmonary function, such as forced vital capacity (WMD, 6.81%; 95% CI: -8.86 to 22.48; p = 0.390) and pain scores (WMD, -11.41; 95% CI: -42.09 to 19.26; p = 0.470). CONCLUSIONS This meta-analysis lends stronger support to surgical fixation, rather than conservative treatment, for multiple rib fractures. Nevertheless, additional trials should be conducted to investigate surgical indications, timing, and followup for quality of life. LEVEL OF EVIDENCE Level I, therapeutic study.
Collapse
|
13
|
Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis. Eur J Trauma Emerg Surg 2018; 45:631-644. [PMID: 30276722 PMCID: PMC6689030 DOI: 10.1007/s00068-018-1020-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/24/2018] [Indexed: 11/23/2022]
Abstract
Purpose The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. Methods MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy. Results Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I2 = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies. Conclusions Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs. Electronic supplementary material The online version of this article (10.1007/s00068-018-1020-x) contains supplementary material, which is available to authorized users.
Collapse
|
14
|
Development of a blunt chest injury care bundle: An integrative review. Injury 2018; 49:1008-1023. [PMID: 29655592 DOI: 10.1016/j.injury.2018.03.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/28/2018] [Accepted: 03/30/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Blunt chest injuries (BCI) are associated with high rates of morbidity and mortality. There are many interventions for BCI which may be able to be combined as a care bundle for improved and more consistent outcomes. OBJECTIVE To review and integrate the BCI management interventions to inform the development of a BCI care bundle. METHODS A structured search of the literature was conducted to identify studies evaluating interventions for patients with BCI. Databases MEDLINE, CINAHL, PubMed and Scopus were searched from 1990-April 2017. A two-step data extraction process was conducted using pre-defined data fields, including research quality indicators. Each study was appraised using a quality assessment tool, scored for level of evidence, then data collated into categories. Interventions were also assessed using the APEASE criteria then integrated to develop a BCI care bundle. RESULTS Eighty-one articles were included in the final analysis. Interventions that improved BCI outcomes were grouped into three categories; respiratory intervention, analgesia and surgical intervention. Respiratory interventions included continuous positive airway pressure and high flow nasal oxygen. Analgesia interventions included regular multi-modal analgesia and paravertebral or epidural analgesia. Surgical fixation was supported for use in moderate to severe rib fractures/BCI. Interventions supported by evidence and that met APEASE criteria were combined into a BCI care bundle with four components: respiratory adjuncts, analgesia, complication prevention, and surgical fixation. CONCLUSIONS The key components of a BCI care bundle are respiratory support, analgesia, complication prevention including chest physiotherapy and surgical fixation.
Collapse
|
15
|
Abstract
PURPOSE OF REVIEW Renewed interest in surgical fixation of rib fractures has emerged. However, conservative treatment is still preferred at most surgical departments. We wanted to evaluate whether operative treatment of rib fractures may benefit severely injured patients. RECENT FINDINGS Several studies report a reduction in mechanical ventilation time, ICU length of stay (LOS), hospital LOS, pneumonia, need for tracheostomy, pain and costs in operatively treated patients with multiple rib fractures compared with patients treated nonoperatively. Although patient selection and timing of the operation seem crucial for successful outcome, no consensus exists. Mortality reduction has only been shown in a few studies. Most studies are retrospective cohort and case-control studies. Only four randomized control trials exist. SUMMARY Conservative treatment, consisting of respiratory assistance and pain control, is still the treatment of choice in the vast majority of patients with multiple rib fractures. In selected patients, operative fixation of fractured ribs within 72 h postinjury may lead to better outcome. More randomized control trials are needed to further determine who benefits from surgical fixation of rib fractures.
Collapse
|
16
|
Abd-Elnaim MK, Ahmed El-Minshawy, Mohamed Abd-Elkader Osman, Ahmed MM. Plating versus wiring for fixation of traumatic rib and sternal fractures. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.jescts.2017.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
17
|
Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, Bosarge PL, Love J, Haut ER, Como JJ. Operative fixation of rib fractures after blunt trauma. J Trauma Acute Care Surg 2017; 82:618-626. [DOI: 10.1097/ta.0000000000001350] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
18
|
Schots JPM, Vissers YLJ, Hulsewé KWE, Meesters B, Hustinx PA, Pijnenburg A, Siebenga J, de Loos ER. Addition of Video-Assisted Thoracoscopic Surgery to the Treatment of Flail Chest. Ann Thorac Surg 2016; 103:940-944. [PMID: 27939010 DOI: 10.1016/j.athoracsur.2016.09.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 07/16/2016] [Accepted: 09/08/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Video-assisted thoracoscopic surgery (VATS) is increasingly used in chest trauma for diagnostic and therapeutic purposes. In this report we describe our single-institutional experience with VATS in the surgical treatment of patients with flail chest after high-energy trauma. METHODS From January 2013 to July 2014, 15 patients with flail chest after high-energy trauma were treated in our hospital. The Injury Severity Score (ISS) ranged from 16 to 44. Rib fixation was performed with precontoured plates or intramedullary splints. In all, patients we additionally used VATS to explore the thoracic cavity and evacuate any hemothorax. RESULTS In 10 patients a prominent hemothorax was present, which needed evacuation. The median operative time was 120 minutes (range, 60 to 180 minutes), with a median blood loss of 150 mL (range, <100 to 400 mL). The mean stay in the intensive care unit was 5.27 days (SD 6.79). Ten patients were extubated directly after operation in the operating room. The other 5 patients were extubated after 1 to 13 days. The mean duration of mechanical ventilation was 2 days (SD 4.17). No patient required a tracheostomy. Three patients had minor postoperative adverse events. All patients were discharged after 6 to 44 days (mean, 11.9 hospitalization days) (SD 9.57). CONCLUSIONS We believe VATS is effective and safe and can be of additional value by providing the possibility to adjust the planned incision for rib fixation and decrease the area of muscle destruction. Additional pulmonary or mediastinal pathologic conditions can be identified and complete evacuation of hemothorax can be achieved simultaneously.
Collapse
Affiliation(s)
- Judith P M Schots
- Department of Surgery, Division of Trauma Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands.
| | - Yvonne L J Vissers
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Karel W E Hulsewé
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Berend Meesters
- Department of Surgery, Division of Trauma Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Paul A Hustinx
- Department of Surgery, Division of Trauma Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Annette Pijnenburg
- Department of Surgery, Division of Trauma Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Jan Siebenga
- Department of Surgery, Division of Trauma Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands; Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Erik R de Loos
- Department of Surgery, Division of Trauma Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands; Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| |
Collapse
|
19
|
Zardo P, Zhang R, Tawab G, Busk H, Kreft T, Schilling T, Schreiber J, Kutschka I. Chest Wall Resection and Reconstruction. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0154-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
20
|
Schulte K, Whitaker D, Attia R. In patients with acute flail chest does surgical rib fixation improve outcomes in terms of morbidity and mortality?: Table 1:. Interact Cardiovasc Thorac Surg 2016; 23:314-9. [DOI: 10.1093/icvts/ivw092] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 03/08/2016] [Indexed: 11/13/2022] Open
|