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Bhogadi SK, Hejazi O, Nelson A, Stewart C, Hosseinpour H, Spencer AL, Anand T, Ditillo M, Magnotti LJ, Joseph B. Surgical stabilization of rib fractures: The impact of volume and the need for standardized indications. Am J Surg 2024; 234:112-116. [PMID: 38553337 DOI: 10.1016/j.amjsurg.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/13/2024] [Accepted: 03/19/2024] [Indexed: 07/06/2024]
Abstract
INTRODUCTION We aimed to examine impact of trauma center (TC) surgical stabilization of rib fracture (SSRF) volume on outcomes of patients undergoing SSRF. METHODS Blunt rib fracture patients who underwent SSRF were included from ACS-TQIP2017-2021. TCs were stratified according to tertiles of SSRF volume:low (LV), middle, and high (HV). Outcomes were time to SSRF, respiratory complications, prolonged ventilator use, mortality. RESULTS 16,872 patients were identified (LV:5470,HV:5836). Mean age was 56 years, 74% were male, median thorax-AIS was 3. HV centers had a lower proportion of patients with flail chest (HV41% vs LV50%), pulmonary contusion (HV44% vs LV52%) and had shorter time to SSRF(HV58 vs LV76 h), less respiratory complications (HV3.2% vs LV4.5%), prolonged ventilator use (HV15% vs LV26%), mortality (HV2% vs LV2.6%) (all p < 0.05). On multivariable regression analysis, HV centers were independently associated with reduced time to SSRF(β = -18.77,95%CI = -21.30to-16.25), respiratory complications (OR = 0.67,95%CI = 0.49-0.94), prolonged ventilator use (OR = 0.49,95%CI = 0.41-0.59), but not mortality. CONCLUSIONS HV SSRF centers have improved outcomes, however, there are variations in threshold for SSRF and indications must be standardized. LEVEL OF EVIDENCE Level III. STUDY TYPE Therapeutic/Care Management.
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Affiliation(s)
- Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Omar Hejazi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Adam Nelson
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Collin Stewart
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Audrey L Spencer
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Tanya Anand
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Michael Ditillo
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Louis J Magnotti
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
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Hylands M, Gomez D, Tillmann B, Haas B, Nathens A. Surgical stabilization of rib fractures for flail chest: Analysis of center-based variability in practice and outcomes. J Trauma Acute Care Surg 2024; 96:882-892. [PMID: 38196120 DOI: 10.1097/ta.0000000000004254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND Given the lack of high-quality data on patient selection for surgical stabilization of rib fractures (SSRF), significant variability in practice likely exists across trauma centers. We aimed to determine whether centers with a more liberal approach to SSRF had improved outcomes. METHODS We performed a retrospective cohort study of adult patients with flail chest admitted to Level I or II trauma centers participating in the American College of Surgeons' Trauma Quality Improvement Program. The primary outcome was hospital mortality; secondary outcomes included discharge status, tracheostomy, duration of mechanical ventilation, and hospital length of stay. Logistic regression was performed to calculate center-level observed/expected rates of SSRF and centers were grouped into quintiles from "most liberal" to "most restrictive." Multivariable regression was used to determine the association between these quintiles and outcomes. We also used an instrumental variable analysis to evaluate the association between SSRF and mortality at the patient level. RESULTS Among 23,619 patients with flail chest across 354 centers, 22% underwent SSRF. Center rates of fixation ranged from 0% to 88%. Higher rates of SSRF were not associated with lower mortality overall (highest vs. lowest quintile: odds ratio, 0.86; 95% confidence interval, 0.63-1.17). However, centers with a more liberal approach to SSRF had lower rates of independent status at discharge, higher tracheostomy rates, longer duration of mechanical ventilation, and longer hospital and ICU length of stay. The patient level analysis demonstrated that SSRF as was associated with a 25% lower risk of death. CONCLUSION Overall, centers with a liberal approach to SSRF do not show improved outcomes among patients with a flail chest, but have higher resource utilization. Results at the patient level suggest that there is a population likely to benefit but these patients remain to be identified through further research. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Mathieu Hylands
- From the Division of General Surgery Department of Surgery, (M.H.), Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie-Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC; Department of Surgery, St. Michael's Hospital-Unity Health and the Temerty Faculty of Medicine (D.G.), Tory Trauma Program, Sunnybrook Health Sciences Center and the Temerty Faculty of Medicine (B.T., B.H., A.N.), University of Toronto; Division of Respirology and Critical Care Medicine, Department of Medicine, University Health Network (B.T.), Toronto, ON, Canada
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Cruz-De La Rosa KX, Ramos-Meléndez EO, Ruiz-Medina PE, Arrieta-Alicea A, Guerrios-Rivera L, Rodríguez-Ortiz P. Surgical Rib Fixation is Associated With Lower Mortality in Patients With Traumatic Rib Fractures. J Surg Res 2024; 295:647-654. [PMID: 38103322 DOI: 10.1016/j.jss.2023.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 10/14/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Nonoperative management (NOM) along with supportive care has been the adopted approach for traumatic rib fractures; however, surgical approaches have emerged recently to treat this common pathology. Despite this, there are no guidelines for surgical rib fixation in patients with traumatic rib fractures. METHODS An institutional review board-approved retrospective cohort study was performed at the Puerto Rico Trauma Hospital aiming to compare the outcomes and complications between patients with traumatic rib fractures who undergo surgical fixation and their counterparts with NOM. The study period comprised from January 2016 through July 2020. Outcomes were evaluated with negative binomial and logistic regressions. RESULTS Fifty patients were identified for the surgical rib fixation group, who were matched to 150 patients who received NOM. The majority of patients were male (91.5%), with a median (interquartile range) age of 53 (29) years. Concomitant chest injuries were significantly more prevalent in the operative group, such as flail segment (P < 0.001), number of fractures (P < 0.001), and displaced rib fractures (P < 0.001). Although hospital length of stay was 25% (95% confidence interval: 1.02-1.54) longer in the surgical group, this intervention was associated with an 85% (95% confidence interval: 0.03-0.70) lower mortality rate when compared to conservative management. CONCLUSIONS Rib fixation may offer some benefits in selected patients with traumatic rib fractures, such as those with bilateral rib fractures, multiple displaced rib fractures, flail segment, and concomitant thoracic injuries. This study may serve as a guide for treatment strategy and patient selection regarding the surgical management of traumatic rib fractures.
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Affiliation(s)
- Kerwin X Cruz-De La Rosa
- Department of Surgery, Trauma Research Program, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico.
| | - Ediel O Ramos-Meléndez
- Department of Surgery, Trauma Research Program, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
| | - Pedro E Ruiz-Medina
- Department of Surgery, Trauma Research Program, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
| | - Antonio Arrieta-Alicea
- Department of Surgery, Trauma Research Program, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
| | - Lourdes Guerrios-Rivera
- Department of Surgery, Trauma Research Program, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
| | - Pablo Rodríguez-Ortiz
- Department of Surgery, Trauma Research Program, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico; Puerto Rico Trauma Hospital, San Juan, Puerto Rico
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Hu M, Sun M, Bao C, Luo J, Zhuo L, Guo M. 3D-printed external fixation guide combined with video-assisted thoracoscopic surgery for the treatment of flail chest: a technical report and case series. Front Surg 2023; 10:1272628. [PMID: 37829598 PMCID: PMC10564999 DOI: 10.3389/fsurg.2023.1272628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/14/2023] [Indexed: 10/14/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Ming Guo
- Department of Cardiothoracic Surgery, Xiamen University Affiliated Chenggong Hospital (Army 73rd Group Military Hospital), Xiamen, China
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Simmonds A, Smolen J, Ciurash M, Alexander K, Alwatari Y, Wolfe L, Whelan JF, Bennett J, Leichtle SW, Aboutanos MB, Rodas EB. Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review. J Trauma Acute Care Surg 2023; 94:532-537. [PMID: 36949054 DOI: 10.1097/ta.0000000000003809] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND Rib fractures are a common in thoracic trauma. Increasingly, patients with flail chest are being treated with surgical stabilization of rib fractures (SSRF). We performed a retrospective review of the Trauma Quality Improvement Program database to determine if there was a difference in outcomes between patients undergoing early SSRF (≤3 days) versus late SSRF (>3 days). METHODS Patients with flail chest in Trauma Quality Improvement Program were identified by CPT code, assessing those who underwent SSRF between 2017 and 2019. We excluded those younger than 18 years and Abbreviated Injury Scale head severity scores greater than 3. Patients were grouped based on SSRF before and after hospital Day 3. These patients were case matched based on age, Injury Severity Score, Abbreviated Injury Scale head and chest, body mass index, Glasgow Coma Scale, and five modified frailty index. All data were examined using χ2, one-way analysis of variance, and Fisher's exact test within SPSS version 28.0. RESULTS For 3 years, 20,324 patients were noted to have flail chest, and 3,345 (16.46%) of these patients underwent SSRF. After case matching, 209 patients were found in each group. There were no significant differences between reported major comorbidities. Patients with early SSRF had fewer unplanned intubations (6.2% vs. 12.0%; p = 0.04), fewer median ventilator days (6 days Q1: 3 to Q3: 10.5 vs. 9 Q1: 4.25 to Q3: 14; p = 0.01), shorter intensive care unit length of stay (6 days Q1: 4 to Q3: 11 vs. 11 Q1: 6 to Q3: 17; p < 0.01), and hospital length of stay (15 days Q1: 11.75 to Q3: 22.25 vs. 20 Q1: 15.25 - Q3: 27, p < 0.01. Early plating was associated with lower rates of deep vein thrombosis and ventilator-acquired pneumonia. CONCLUSION In trauma-accredited centers, patients with flail chest who underwent early SSRF (<3 days) had better outcomes, including fewer unplanned intubations, decreased ventilator days, shorter intensive care unit LOS and HLOS, and fewer DVTs, and ventilator-associated pneumonia. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Alexander Simmonds
- From the Division of Acute Care Surgery, Department of Surgery (A.S., K.A., Y.A., L.W., J.F.W., J.B., S.W.L., M.B.A., E.B.R.), Virginia Commonwealth University, and Virginia Commonwealth University School of Medicine (J.S., M.C.), Richmond, Virginia
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Lian KH, Yang CC, Hu FC, Lin WY, Hsiao WL, Lin TH, Hu RH, Chen JS, Liao HC. Quality of life outcomes after surgical intervention in patients with multiple rib fractures: A prospective cohort study. Surgery 2023; 173:1066-1071. [PMID: 36658082 DOI: 10.1016/j.surg.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/02/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Kuan-Hsun Lian
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital-Yunlin branch, Taiwan
| | - Chi-Cheng Yang
- Department of Psychology, National Chengchi University, Taipei, Taiwan
| | - Fu-Chang Hu
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Ying Lin
- Department of Anesthesiology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Wei-Ling Hsiao
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzu-Hsin Lin
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Rey-Heng Hu
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jin-Shing Chen
- Department of Surgical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Hsien-Chi Liao
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
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Liao CA, Kuo LW, Huang JF, Fu CY, Chen SA, Tee YS, Hsieh CH, Liao CH, Cheng CT, Young TH, Hsu CP. Timely surgical fixation confers beneficial outcomes in patients' concomitant flail chest with mild-to-moderate traumatic brain injury: a trauma quality improvement project analysis - a cohort study. Int J Surg 2023; 109:729-736. [PMID: 37010189 PMCID: PMC10389630 DOI: 10.1097/js9.0000000000000271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/26/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Traumatic flail chest results in respiratory distress and prolonged hospital stay. Timely surgical fixation of the flail chest reduces respiratory complications, decreases ventilator dependence, and shortens hospital stays. Concomitant head injury is not unusual in these patients and can postpone surgical timing due to the need to monitor the status of intracranial injuries. Reducing pulmonary sequelae also assists in the recovery from traumatic brain injury and improves outcomes. No previous evidence supports that early rib fixation can improve the outcome of patients with concomitant flail chest and traumatic brain injury. RESEARCH QUESTION Can early rib fixation improve the outcome of patients with concomitant flail chest and traumatic brain injury? STUDY DESIGN AND METHODS Adult patients with blunt injuries from the Trauma Quality Improvement Project between 2017 and 2019 were eligible for inclusion. Patients were divided into two treatment groups: operative and nonoperative. Inverse probability treatment weighting was used to identify the predictors of mortality and adverse hospital events. RESULTS Patients in the operative group had a higher intubation rate [odds ratio (OR), 2.336; 95% CI, 1.644-3.318; p <0.001), a longer length of stay (coefficient β , 4.664; SE, 0.789; p <0.001), longer ventilator days (coefficient β , 2.020; SE, 0.528; p <0.001), and lower mortality rate (OR], 0.247; 95% CI, 0.135-0.454; p <0.001). INTERPRETATION Timely rib fixation can improve the mortality rate of patients with flail chest and a concomitant mild-to-moderate head injury.
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Affiliation(s)
- Chien-An Liao
- Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Ling-Wei Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Jen-Fu Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Szu-An Chen
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Yu-San Tee
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Tai-Horng Young
- Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei
| | - Chih-Po Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
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Alvarado F, Kaban J, Chao E, Meltzer JA. Surgical stabilization of rib fractures in patients with pulmonary comorbidities. Injury 2023; 54:1287-1291. [PMID: 36759310 DOI: 10.1016/j.injury.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 01/04/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Prior studies have shown that the surgical stabilization of rib fractures (SSRF) for patients with multiple rib fractures is associated with improved outcomes by restoring chest wall integrity and decreasing time to return to prior functional status. It is unclear if patients with pulmonary comorbidities (PCM) would benefit from this procedure. OBJECTIVE To compare the difference in morbidity and mortality of patients with multiple rib fractures undergoing SSRF who have underlying PCM to those who do not have PCM. METHODS We performed a retrospective cohort study of patients with multiple rib fractures using data from the Trauma Quality Improvement Program (January 2015 to December 2018). Patients with penetrating injuries, those who died within the first 24 h, those with substantial head, spine, or abdominopelvic injuries, and those who were pregnant, were excluded. A PCM was defined as chronic lower respiratory disease, active smoking, or morbid obesity. Dichotomous outcomes were adjusted for potential confounders by creating a propensity score for PCM and applying inverse probability weighting. The propensity score accounted for multiple patient-level and hospital level covariates. Continuous outcomes were adjusted for these same covariates using multivariable quantile regression. RESULTS Of the 4,084 patients who underwent SSRF, 3048 (75%) were males, the median age was 57 years [IQR 47, 66], and 1504 (37%) had at least one PCM. After adjusting for the propensity score, patients with PCM who underwent SSRF had no significant difference in mortality compared to those without PCM (absolute difference, 0.7% [95% CI -0.2, 1.7]). Similarly, there was no significant difference in time on the ventilator (0.6 days [-0.1, 1.4]). Patients with PCM, however, had a statistically significantly longer hospital LOS (0.8 days [0.3, 1.3]) and ICU LOS (0.6 days [0.1, 1.1]), higher risk of tracheostomy (2.7% [0.1, 4.6]) and higher probability of pulmonary complications (2.7% [1.2, 4.2]), compared to those without PCM. CONCLUSION Among patients with multiple rib fractures who undergo SSRF, having a PCM did not result in a clinically important higher probability of dying or experiencing substantial morbidity. This factor should not exclude patients with PCM from receiving SSRF for multiple rib fractures but the small increased risk in morbidity should be discussed with patients prior to SSRF.
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Affiliation(s)
- Francisco Alvarado
- Jacobi Medical Center, Department of Surgery, 1400 Pelham Parkway South, Bronx, NY 10461, United States of America
| | - Jody Kaban
- Jacobi Medical Center, Department of Surgery, Division of Trauma, 1400 Pelham Parkway South, Bronx, NY 10461, United States of America
| | - Edward Chao
- Jacobi Medical Center, Department of Surgery, Division of Trauma, 1400 Pelham Parkway South, Bronx, NY 10461, United States of America
| | - James A Meltzer
- Jacobi Medical Center, Department of Pediatrics, Division of Emergency and Research, 1400 Pelham Parkway South, Bronx, NY 10461, United States of America.
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Surgical Rib Fixation in Obese Patients with Isolated Flail Chest Improves Outcomes: A Matched Cohort Study. World J Surg 2022; 46:2890-2899. [PMID: 36151336 DOI: 10.1007/s00268-022-06748-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Obesity is associated with adverse outcomes after major operations. The role of operative rib fixation (RF) in obese patients with flail chest is not clear. The presence of other associated injuries may complicate the interpretation of outcomes. This study compared outcomes after RF to nonoperative management (NOM) in obese patients with isolated flail chest injury. METHODS Adult obese patients (BMI > 29.9) with flail chest were identified from the Trauma Quality Improvement Program (TQIP) database (2016-2018). Hospital transfers, death within 72 h, and extrathoracic injuries were excluded. RF patients were propensity score matched (1:2) to similar NOM patients. Multivariate regression identified independent factors predicting adverse outcomes. RESULTS Overall, 367 patients with isolated flail chest who underwent RF were matched with 734 in the NOM group. After matching, the mortality rate was significantly lower in the RF group (1.4% vs. 3.7%; p < 0.05). RF had longer HLOS (15.7 days vs. 12.8 days; p < 0.05) and ICU LOS (10.1 days vs. 8.6 days; p < 0.05), shorter ventilator days (9.2 days vs. 11.5 days; p < 0.05), and a higher rate of venous thromboembolism (7.1% vs. 3.5%, p < 0.05). On multivariate analysis, RF was associated with decreased mortality (OR 0.27; p < 0.05). Early RF (≤ 72 h) was associated with shorter ICU stay and mechanical ventilation. CONCLUSION RF for isolated flail chest in obese patients is associated with decreased mortality and fewer ventilator days. When performed early, fixation decreases the need for prolonged ventilator use and ICU stay. A more aggressive VTE prophylaxis should be considered in patients undergoing RF.
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Spardy J, Kornblith L, Elkbuli A. Surgical stabilization of iatrogenic rib fractures following cardiopulmonary resuscitation. Am J Emerg Med 2022; 59:195-197. [DOI: 10.1016/j.ajem.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/06/2022] [Accepted: 05/14/2022] [Indexed: 11/27/2022] Open
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Richman AP, Brahmbhatt TS, Litle VR. Let's not fail the flail chest. Ann Thorac Surg 2021; 113:1865-1866. [PMID: 34270969 DOI: 10.1016/j.athoracsur.2021.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Aaron P Richman
- Division of Trauma and Acute Care Surgery, Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Tejal S Brahmbhatt
- Division of Trauma and Acute Care Surgery, Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Virginia Ruth Litle
- Division of Thoracic Surgery, Department of Cardiovascular Surgery, Intermountain Healthcare, 5169 S Cottonwood St, Ste 640, Murray, UT 84107.
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