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Dany James J, Choudhary N, Bagaria D, Boddeda J, Kumar A, Priyadarshini P, Mishra B, Sagar S, Kumar S, Gupta A. Benefits of Rib Fixation Utilizing Low-Cost Materials: A Randomized Pilot Trial. J Surg Res 2024; 299:322-328. [PMID: 38788469 DOI: 10.1016/j.jss.2024.04.019] [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: 07/24/2023] [Revised: 03/20/2024] [Accepted: 04/17/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION Surgical stabilization of rib fractures (SSRF) using standard rib plating systems has become a norm in developed countries. However, the procedure has not garnered much interest in low-middle-income countries, primarily because of the cost. METHODS This was a single-center pilot randomized trial. Patients with severe rib fractures were randomized into two groups: SSRF and nonoperative management. SSRF arm patients underwent surgical fixation in addition to the tenets of nonoperative management. Low-cost materials like stainless steel wires and braided polyester sutures were used for fracture fixation. The primary outcome was to assess the duration of hospital stay. RESULTS Twenty-two patients were randomized, 11 in each arm. Per-protocol analysis showed that the SSRF arm had significantly reduced duration of hospital stay (22.6 ± 19.1 d versus 7.9 ± 5.7 d, P value 0.031), serial pain scores at 48 h and 5 d (median score 5, IQR (3-6) versus median score 7, IQR (6.5-8), P value 0.004 at 48 h and median score 2 IQR (2-3) versus median score 7 IQR (4.5-7) P value 0.0005 at 5 d), significantly reduced need for injectable opioids (9.9 ± 3.8 mg versus 4.4 ± 3.4 mg, P value 0.003) and significantly more ventilator-free days (19.9 ± 8.7 d versus 26.4 ± 3.2 d, P value 0.04). There were no statistically significant differences in the total duration of ICU stay (median number of days 2, IQR 1-4.5 versus median number of days 7, IQR 1-14, P value 0.958), need for tracheostomy (36.4% versus 0%, P value 0.155), and pulmonary and pleural complications. CONCLUSIONS SSRF with low-cost materials may provide benefits similar to standard rib plating systems and can be used safely in resource-poor settings.
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Affiliation(s)
- Joses Dany James
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Narendra Choudhary
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Dinesh Bagaria
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Jogendra Boddeda
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Abhinav Kumar
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Pratyusha Priyadarshini
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Biplab Mishra
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Sagar
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
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Wang YJ, Tsai YM, Kuo YS, Lin KH, Wu TH, Huang HK, Lee SC, Huang TW, Chang H, Chen YY. The application of electrical impedance tomography and surgical outcomes of thoracoscope-assisted surgical stabilization of rib fractures in severe chest trauma. Sci Rep 2024; 14:9669. [PMID: 38671072 PMCID: PMC11053027 DOI: 10.1038/s41598-024-60392-0] [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: 11/03/2023] [Accepted: 04/23/2024] [Indexed: 04/28/2024] Open
Abstract
Serious blunt chest trauma usually induces hemothorax, pneumothorax, and rib fractures. More studies have claimed that early video-assisted thoracoscopic surgery with surgical stabilization of rib fractures (SSRF) results in a good prognosis in patients with major trauma. This study aimed to verify the outcomes in patients with chest trauma whether SSRF was performed. Consecutive patients who were treated in a medical center in Taiwan, for traumatic events between January 2015 and June 2020, were retrospectively reviewed. This study focused on patients with major trauma and thoracic injuries, and they were divided into groups based on whether they received SSRF. We used electrical impedance tomography (EIT) to evaluate the change of ventilation conditions. Different scores used for the evaluation of trauma severity were also compared in this study. Among the 8396 patients who were included, 1529 (18.21%) had major trauma with injury severity score > 16 and were admitted to the intensive care unit initially. A total of 596 patients with chest trauma were admitted, of whom 519 (87%) survived. Younger age and a lower trauma score (including injury severity scale, new injury severity score, trauma and injury severity score, and revised trauma score) account for better survival rates. Moreover, 74 patients received SSRF. They had a shorter intensive care unit (ICU) stay (5.24, p = 0.045) and better performance in electrical impedance tomography (23.46, p < 0.001). In patients with major thoracic injury, older age and higher injury survival scale account for higher mortality rate. Effective surgical stabilization of rib fractures shortened the ICU stay and helped achieve better performance in EIT. Thoracoscope-assisted rib fixation is suggested in severe trauma cases.
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Affiliation(s)
- Yi-Jie Wang
- Department of Surgery, Tri Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Yuan-Ming Tsai
- Division of Thoracic Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Section 2, Cheng-Kung Road, Taipei, 114, Taiwan, R.O.C
| | - Yen-Shou Kuo
- Division of Thoracic Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Section 2, Cheng-Kung Road, Taipei, 114, Taiwan, R.O.C
| | - Kuan-Hsun Lin
- Division of Thoracic Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Section 2, Cheng-Kung Road, Taipei, 114, Taiwan, R.O.C
| | - Ti-Hui Wu
- Division of Thoracic Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Section 2, Cheng-Kung Road, Taipei, 114, Taiwan, R.O.C
| | - Hsu-Kai Huang
- Division of Thoracic Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Section 2, Cheng-Kung Road, Taipei, 114, Taiwan, R.O.C
| | - Shih-Chun Lee
- Division of Thoracic Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Section 2, Cheng-Kung Road, Taipei, 114, Taiwan, R.O.C
| | - Tsai-Wang Huang
- Division of Thoracic Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Section 2, Cheng-Kung Road, Taipei, 114, Taiwan, R.O.C
- Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Hung Chang
- Division of Thoracic Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Section 2, Cheng-Kung Road, Taipei, 114, Taiwan, R.O.C
| | - Ying-Yi Chen
- Division of Thoracic Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Section 2, Cheng-Kung Road, Taipei, 114, Taiwan, R.O.C..
- Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan, R.O.C..
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Hisamune R, Kobayashi M, Nakasato K, Yamazaki T, Ushio N, Mochizuki K, Takasu A, Yamakawa K. A meta-analysis and trial sequential analysis of randomised controlled trials comparing nonoperative and operative management of chest trauma with multiple rib fractures. World J Emerg Surg 2024; 19:11. [PMID: 38504282 PMCID: PMC10949653 DOI: 10.1186/s13017-024-00540-z] [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: 02/07/2024] [Accepted: 03/15/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures. METHODS A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research. RESULTS From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P < 0.00001, I2 = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I2 = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I2 = 57%) was significantly lower. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment. GRADE showed this meta-analysis to have very low to low confidence. CONCLUSION Meta-analysis of large-scale trials showed that surgical stabilization of multiple rib fractures shortened the duration of mechanical ventilation and reduced the incidence of pneumonia but lacked clear evidence for improvement of mortality compared to conservative treatment. Trial sequential analysis suggested the need for more cases, and GRADE highlighted low certainty, emphasizing the necessity for further targeted RCTs, especially in mechanically ventilated patients. SYSTEMATIC REVIEW REGISTRATION UMIN Clinical Trials Registry UMIN000049365.
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Affiliation(s)
- Ryo Hisamune
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Mako Kobayashi
- Faculty of Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Karin Nakasato
- Faculty of Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Taiga Yamazaki
- Faculty of Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Noritaka Ushio
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Katsunori Mochizuki
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Akira Takasu
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan.
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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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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.
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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.
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Smith D, Kenigsberg BB. Management of Patients After Cardiac Arrest. Crit Care Clin 2024; 40:57-72. [PMID: 37973357 DOI: 10.1016/j.ccc.2023.06.005] [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] [Indexed: 11/19/2023]
Abstract
Cardiac arrest remains a significant cause of morbidity and mortality, although contemporary care now enables potential survival with good neurologic outcome. The core acute management goals for survivors of cardiac arrest are to provide organ support, sustain adequate hemodynamics, and evaluate the underlying cause of the cardiac arrest. In this article, the authors review the current state of knowledge and clinical intensive care unit practice recommendations for patients after cardiac arrest, particularly focusing on important areas of uncertainty, such as targeted temperature management, neuroprognostication, coronary evaluation, and hemodynamic targets.
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Affiliation(s)
- Damien Smith
- Department of Medicine, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA; Division of Cardiology, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA.
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Bethlahmy JM, Hanst BA, Giafaglione SM, Elia JM. Perioperative considerations for patients undergoing surgical stabilization of rib fractures: A narrative review. J Clin Anesth 2023; 91:111275. [PMID: 37797395 DOI: 10.1016/j.jclinane.2023.111275] [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: 07/14/2023] [Revised: 09/12/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023]
Abstract
Surgical stabilization of rib fractures (SSRF) has become an increasingly common management strategy for traumatic rib fractures. Although historically managed with supportive care, patients with multiple rib fractures and flail chest increasingly undergo SSRF, and so the anesthesiologist must be well-versed in the perioperative management and pain control for these patients, as controlling pain in this population is associated with decreased length of stay and improved outcomes. There are multiple modalities that can be used for both pain control and as part of the anesthetic plan in patients undergoing SSRF. This narrative review provides a comprehensive summary of anesthetic considerations for surgical rib fracture patients, covering the preoperative, intraoperative, and postoperative periods. We describe an approach to the assessment of high-risk patients, analgesic and anesthetic techniques including emerging techniques within locoregional anesthesia, ventilation strategies, and potential complications. This review also identifies areas where additional research is needed to ensure optimal anesthetic management for patients undergoing SSRF.
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Affiliation(s)
- Jessica M Bethlahmy
- UC Irvine School of Medicine, 1001 Health Sciences Road Irvine, CA 92617, USA
| | - Brian A Hanst
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA
| | - Sarah M Giafaglione
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA
| | - Jennifer M Elia
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA.
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Ferreira ROM, Pasqualotto E, Viana P, Schmidt PHS, Andrighetti L, Chavez MP, Flausino F, de Oliveira Filho GR. Surgical versus non-surgical treatment of flail chest: a meta-analysis of randomized controlled trials. Eur J Trauma Emerg Surg 2023; 49:2531-2541. [PMID: 37526708 DOI: 10.1007/s00068-023-02339-0] [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: 04/15/2023] [Accepted: 07/23/2023] [Indexed: 08/02/2023]
Abstract
PURPOSE Conflicting evidence exists on the choice of surgical or non-surgical treatment of flail chest injuries. We aimed to perform a meta-analysis comparing outcomes in patients presenting flail chest undergoing surgical or non-surgical treatment. METHODS Embase, PubMed, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing surgery to no surgery in patients with acute unstable chest wall injuries. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs). Random effects meta-analyses were performed. Heterogeneity was assessed using I2 statistics. RESULTS Six RCTs (544 patients) were included, and surgical treatment was used in 269 (49.4%). Compared to no surgery, surgery reduced mechanical ventilation days (WMD - 4.34, 95% CI - 6.98, - 1.69; p < 0.01; I2 = 87%; GRADE: very low; PI - 13.51, 4.84); length of intensive care unit stay (WMD - 4.62, 95% CI - 7.19, - 2.05; p < 0.01; I2 = 78%; GRADE: low; PI - 12.86, 3.61) and the incidence of pneumonia (RR 0.50, 95% CI 0.31, 0.81; p = 0.005; I2 = 54%; GRADE: moderate; PI 0.13, 1.91). No difference in mortality (RR 0.56, 95% CI 0.19, 1.65; p = 0.27; I2 = 23%; GRADE: moderate; PI 0.04, 7.25), length of hospital stay (WMD - 5.39, 95% CI - 11.38, - 0.60; p = 0.08; I2 = 89%; GRADE: very low; PI - 11.38, 0.60), or need for tracheostomy (RR 0.59, 95% CI 0.34, 1.03; p = 0.06; I2 = 54%; GRADE: moderate; PI 0.11, 3.24) was found. CONCLUSIONS Our results suggest that surgical treatment is advantageous compared to non-surgical treatment for patients with flail chest secondary to rib fractures.
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Affiliation(s)
- Rafael Oliva Morgado Ferreira
- Federal University of Santa Catarina, R. João Pio Duarte, 144, Córrego Grande, Florianópolis, SC, 88037-000, Brazil.
| | - Eric Pasqualotto
- Federal University of Santa Catarina, R. João Pio Duarte, 144, Córrego Grande, Florianópolis, SC, 88037-000, Brazil
| | - Patrícia Viana
- University of the Extreme South of Santa Catarina, Criciúma, Santa Catarina, Brazil
| | | | - Leonardo Andrighetti
- Federal University of Santa Catarina, R. João Pio Duarte, 144, Córrego Grande, Florianópolis, SC, 88037-000, Brazil
| | - Matheus Pedrotti Chavez
- Federal University of Santa Catarina, R. João Pio Duarte, 144, Córrego Grande, Florianópolis, SC, 88037-000, Brazil
| | - Felippe Flausino
- Federal University of Santa Catarina, R. João Pio Duarte, 144, Córrego Grande, Florianópolis, SC, 88037-000, Brazil
- Joana de Gusmão Children's Hospital, Florianópolis, Santa Catarina, Brazil
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Bauman ZM, Khan H, Cavlovic L, Raposo-Hadley A, Todd SJ, King T, Cahoy K, Kamien A, Cemaj S, Sheppard O, Matos M, Berning B, Evans CH, Cantrell E. Surgical stabilization of rib fractures is associated with better return on investment for a health care institution than nonoperative management. J Trauma Acute Care Surg 2023; 95:885-892. [PMID: 37710365 DOI: 10.1097/ta.0000000000004139] [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: 09/16/2023]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRFs) continues to gain popularity due to patient benefits. However, little has been produced regarding the economic benefits of SSRF and its impact on hospital metrics such as Vizient. The aim of this study was to explore these benefits hypothesizing SSRF will demonstrate positive return on investment (ROI) for a health care institution. METHODS This is a retrospective review of all rib fracture patients over 5 years at our Level I trauma center. Patients were grouped into SSRF versus nonoperative management. Basic demographics were obtained including case mix index (CMI). Outcomes included narcotic requirements in morphine milliequivalents prior to discharge, mortality, and discharge disposition. Furthermore, actual hospital length of stay (ALOS) versus Vizient expected length of stay were compared between cohorts. Contribution margin (CM) was also calculated. Independent t-test, paired t-test, and linear regression analysis were performed, and significance set at p < 0.05. RESULTS A total of 1,639 patients were included; 230 (14%) underwent SSRF. Age, gender, and Injury Severity Score were similar. Surgical stabilization of rib fracture patients had more ribs fractured (7 vs. 4; p < 0.001) and more patients with flail chest (43.5% vs. 6.7%; p < 0.001). Surgical stabilization of rib fracture patients also had a significantly higher CMI (4.33 vs. 2.78; p = 0.001). Narcotic requirements and mortality were less in the SSRF cohort; 155 versus 246 morphine milliequivalents ( p < 0.001) and 1.7% versus 7.1% ( p = 0.003), respectively. Surgical stabilization of rib fracture patients were more likely to be discharged home (70.4% vs. 63.7%; p = 0.006). Surgical stabilization of rib fracture patients demonstrated shorter ALOS where nonoperative management patients demonstrated longer ALOS compared with Vizient expected length of stay. Contribution margins for SSRF patients were significantly higher and linear regression analysis showed a CM $1,128.14 higher per patient undergoing SSRF ( p < 0.001). CONCLUSION Patients undergoing SSRF demonstrate a significant ROI for a health care organization. Despite SSRF patients having a higher CMI, they were able to be discharged sooner than expected by Vizient calculations resulting in better a CM. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Zachary M Bauman
- From the Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
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10
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Lagazzi E, Argandykov D, de Roulet A, Proaño-Zamudio JA, Romijn ASC, Abiad M, Rafaqat W, Velmahos GC, Hwabejire JO, Paranjape CN. Evaluating the impact of timing to rib fixation in patients with traumatic brain injury: A nationwide analysis. J Trauma Acute Care Surg 2023; 95:846-854. [PMID: 37822127 DOI: 10.1097/ta.0000000000004100] [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: 10/13/2023]
Abstract
BACKGROUND Early surgical stabilization of rib fractures (SSRF) is associated with improved inpatient outcomes in patients with multiple rib fractures. However, there is still a paucity of data examining the optimal timing of SSRF in patients with concomitant traumatic brain injury (TBI). This study aimed to assess whether earlier SSRF was associated with improved outcomes in patients with multiple rib fractures and TBI. METHODS We performed a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program 2017-2020, including adult patients with TBI and multiple rib fractures who had undergone SSRF. The outcomes were post-procedural length of stay (LOS), hospital LOS, intensive care unit (ICU) LOS, in-hospital mortality, ventilator days, and tracheostomy rate. Multilevel mixed-effects regression analyses accounting for patient, injury, and hospital characteristics as well as institutional SSRF volume were used to assess the association between timing to SSRF and the outcomes of interest. As a sensitivity analysis, propensity-score matching was performed to compare patients who underwent early (<72 hours) versus late SSRF (≥72 hours). RESULTS Of 1,041 patients included in this analysis, 430 (41.3%) underwent SSRF within the first 72 hours from admission. Delay to SSRF was associated with an increase in post-procedural LOS (partial regression coefficient (β) = 0.011; p = 0.036; 95% confidence interval [CI], 0.001-0.023), longer hospital LOS (β = 0.053; p < 0.001; 95% CI, 0.042-0.064), prolonged ICU LOS (β = 0.032; p < 0.001; 95% CI, 0.025-0.038), and more ventilator days (β = 0.026, p < 0.001; 95% CI, 0.020-0.032). CONCLUSION In patients with concurrent multiple rib fractures and TBI, a delay in SSRF is associated with an increase in postprocedural LOS, hospital LOS, ICU LOS, and ventilator days. These findings suggest that the early patient selection and implementation of SSRF may play a beneficial role in patients presenting with concomitant TBI and multiple rib fractures. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Emanuele Lagazzi
- From the Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery (E.L., D.A., A.d.R., J.A.P.-Z., M.A., W.R., G.C.V., J.O.H., C.N.P.), Massachusetts General Hospital, Boston, MA; Department of Surgery (E.L.), Humanitas Research Hospital, Rozzano MI, Italy; and Division of Trauma & Emergency Surgery, Department of Surgery (A.-S.C.R.), Amsterdam University Medical Center, Amsterdam, the Netherlands
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11
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Tarrant S, Poon J, Sanders D, Buckley R. Is rib plating for a significant chest injury worthwhile? Injury 2023; 54:111000. [PMID: 37597468 DOI: 10.1016/j.injury.2023.111000] [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] [Indexed: 08/21/2023]
Affiliation(s)
- Seth Tarrant
- Dept. of Traumatology, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Center 2310, Newcastle, NSW, Australia
| | - Jeff Poon
- London Health Science Center, Victoria Hospital Room E1-326, 800 Commissioners Rd E. London, N6A 5W9 Ontario, Canada
| | - Dave Sanders
- London Health Science Center, Victoria Hospital Room E1-326, 800 Commissioners Rd E. London, N6A 5W9 Ontario, Canada
| | - Richard Buckley
- University of Calgary, 0490 McCaig Tower, Foothills Hospital, 3134 Hospital Drive NW Calgary T2N 5A1, Alberta, Canada.
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12
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Jeanmougin T, Cole E, Duceau B, Raux M, James A. Heterogeneity in defining multiple trauma: a systematic review of randomized controlled trials. Crit Care 2023; 27:363. [PMID: 37736733 PMCID: PMC10515068 DOI: 10.1186/s13054-023-04637-w] [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: 08/08/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION While numerous randomized controlled trials (RCTs) have been conducted in the field of trauma, a substantial portion of them are yielding negative results. One potential contributing factor to this trend could be the lack of agreement regarding the chosen definitions across different trials. The primary objective was to identify the terminology and definitions utilized for the characterization of multiple trauma patients within randomized controlled trials (RCTs). METHODS A systematic review of the literature was performed in MEDLINE, EMBASE and clinicaltrials.gov between January 1, 2002, and July 31, 2022. RCTs or RTCs protocols were eligible if they included multiple trauma patients. The terms employed to characterize patient populations were identified, and the corresponding definitions for these terms were extracted. The subsequent impact on the population recruited was then documented to expose clinical heterogeneity. RESULTS Fifty RCTs were included, and 12 different terms identified. Among these terms, the most frequently used were "multiple trauma" (n = 21, 42%), "severe trauma" (n = 8, 16%), "major trauma" (n = 4, 8%), and trauma with hemorrhagic shock" (n = 4, 8%). Only 62% of RCTs (n = 31) provided a definition for the terms used, resulting a total of 21 different definitions. These definitions primarily relied on the injury severity score (ISS) (n = 15, 30%), displaying an important underlying heterogeneity. The choice of the terms had an impact on the study population, affecting both the ISS and in-hospital mortality. Eleven protocols were included, featuring five different terms, with "severe trauma" being the most frequent, occurring six times (55%). CONCLUSION This systematic review uncovers an important heterogeneity both in the terms and in the definitions employed to recruit trauma patients within RCTs. These findings underscore the imperative of promoting the use of a unique and consistent definition.
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Affiliation(s)
- Thomas Jeanmougin
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and critical care, Pitié-Salpêtrière Hospital, Paris, France
| | - Elaine Cole
- Centre of Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Baptiste Duceau
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and critical care, Pitié-Salpêtrière Hospital, Paris, France
| | - Mathieu Raux
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique; AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d'Anesthésie Réanimation, F-75013, Paris, France
| | - Arthur James
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and critical care, Pitié-Salpêtrière Hospital, Paris, France.
- Centre of Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK.
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13
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Meyer DE, Harvin JA, Vincent L, Motley K, Wandling MW, Puzio TJ, Moore LJ, Cotton BA, Wade CE, Kao LS. Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury. Ann Surg 2023; 278:357-365. [PMID: 37317861 PMCID: PMC10527348 DOI: 10.1097/sla.0000000000005950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To compare the effectiveness of surgical stabilization of rib fractures (SSRFs) to nonoperative management in severe chest wall injury. BACKGROUND SSRF has been shown to improve outcomes in patients with clinical flail chest and respiratory failure. However, the effect of SSRF outcomes in severe chest wall injuries without clinical flail chest is unknown. METHODS Randomized controlled trial comparing SSRF to nonoperative management in severe chest wall injury, defined as: (1) a radiographic flail segment without clinical flail or (2) ≥5 consecutive rib fractures or (3) any rib fracture with bicortical displacement. Randomization was stratified by the unit of admission as a proxy for injury severity. Primary outcome was hospital length of stay (LOS). Secondary outcomes included intensive care unit (ICU) LOS, ventilator days, opioid exposure, mortality, and incidences of pneumonia and tracheostomy. Quality of life at 1, 3, and 6 months was measured using the EQ-5D-5L survey. RESULTS Eighty-four patients were randomized in an intention-to-treat analysis (usual care = 42, SSRF = 42). Baseline characteristics were similar between groups. The numbers of total fractures, displaced fractures, and segmental fractures per patient were also similar, as were the incidences of displaced fractures and radiographic flail segments. Hospital LOS was greater in the SSRF group. ICU LOS and ventilator days were similar. After adjusting for the stratification variable, hospital LOS remained greater in the SSRF group (RR: 1.48, 95% CI: 1.17-1.88). ICU LOS (RR: 1.65, 95% CI: 0.94-2.92) and ventilator days (RR: 1.49, 95% CI: 0.61--3.69) remained similar. Subgroup analysis showed that patients with displaced fractures were more likely to have LOS outcomes similar to their usual care counterparts. At 1 month, SSRF patients had greater impairment in mobility [3 (2-3) vs 2 (1-2), P = 0.012] and self-care [2 (1-2) vs 2 (2-3), P = 0.034] dimensions of the EQ-5D-5L. CONCLUSIONS In severe chest wall injury, even in the absence of clinical flail chest, the majority of patients still reported moderate to extreme pain and impairment of usual physical activity at one month. SSRF increased hospital LOS and did not provide any quality of life benefit for up to 6 months.
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Affiliation(s)
- David E Meyer
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - John A Harvin
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Laura Vincent
- The Center for Translational Injury Research, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Kandice Motley
- The Center for Translational Injury Research, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Michael W Wandling
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Thaddeus J Puzio
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Laura J Moore
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Bryan A Cotton
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Charles E Wade
- The Center for Translational Injury Research, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Lillian S Kao
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
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Zhou X, Zhang D, Xie Z, Yang Y, Feng L, Hou C, Chen M, Liang Z, Zhang G, Lu H. Application of preoperative 3D printing in the internal fixation of posterior rib fractures with embracing device: a cohort study. BMC Surg 2023; 23:237. [PMID: 37580688 PMCID: PMC10426142 DOI: 10.1186/s12893-023-02128-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/28/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND To explore the impact of preoperative 3D printing on the fixation of posterior rib fractures utilizing a memory alloy embracing device of rib under thoracoscopy. METHODS The enrolled patients were divided into the 3D printing (11 patients) and the non-3D printing (18 patients) groups, based on whether a 3D model of ribs was prepared prior to surgery. Analysis was conducted comparing the average fixation time per fracture, postoperative fixation loss, and poor reduction of fractured end between the two groups. RESULTS The average fixation time of each fracture was 27.2 ± 7.7 min in the 3D printing group and 29.3 ± 8.2 min in the non-3D printing group, with no statistically significant difference observed between the two groups (P > 0.05). The incidence of poor fracture fixation in the 3D printing group was statistically lower than that in the non-3D printing group (12.9% vs. 44.7%, P < 0.05). Further stratified analysis revealed that the off-plate rate in the 3D printing group and the non-3D group was (3.2% vs. 12.8%, P > 0.05), and the dislocation rate of the fractured end was (9.7% vs. 31.9%, P < 0.05). CONCLUSIONS The application of 3D printing technology to prepare the rib model before surgery is proves beneficial in reducing the occurrence of poor fixation of fractures and achieving precise and individualized treatment.
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Affiliation(s)
- Xuetao Zhou
- Department of Cardiothoracic Surgery, Shijiazhuang Third Hospital, No.15 Tiyu South Street, Chang an District, Shijiazhuang, 050000, Hebei Province, China
| | - Dongsheng Zhang
- Department of Cardiothoracic Surgery, Shijiazhuang Third Hospital, No.15 Tiyu South Street, Chang an District, Shijiazhuang, 050000, Hebei Province, China.
| | - Zexin Xie
- Department of Cardiothoracic Surgery, Shijiazhuang Third Hospital, No.15 Tiyu South Street, Chang an District, Shijiazhuang, 050000, Hebei Province, China
| | - Yang Yang
- Department of Cardiothoracic Surgery, Shijiazhuang Third Hospital, No.15 Tiyu South Street, Chang an District, Shijiazhuang, 050000, Hebei Province, China
| | - Lei Feng
- Department of Cardiothoracic Surgery, Shijiazhuang Third Hospital, No.15 Tiyu South Street, Chang an District, Shijiazhuang, 050000, Hebei Province, China
| | - Chunjuan Hou
- Department of Cardiothoracic Surgery, Shijiazhuang Third Hospital, No.15 Tiyu South Street, Chang an District, Shijiazhuang, 050000, Hebei Province, China
| | - Menghui Chen
- Department of Cardiothoracic Surgery, Shijiazhuang Third Hospital, No.15 Tiyu South Street, Chang an District, Shijiazhuang, 050000, Hebei Province, China
| | - Zheng Liang
- Department of Cardiothoracic Surgery, Shijiazhuang Third Hospital, No.15 Tiyu South Street, Chang an District, Shijiazhuang, 050000, Hebei Province, China
| | - Guoliang Zhang
- Department of Cardiothoracic Surgery, Shijiazhuang Third Hospital, No.15 Tiyu South Street, Chang an District, Shijiazhuang, 050000, Hebei Province, China
| | - Huiqing Lu
- Department of Cardiothoracic Surgery, Shijiazhuang Third Hospital, No.15 Tiyu South Street, Chang an District, Shijiazhuang, 050000, Hebei Province, China
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15
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Lagazzi E, de Roulet A, Proaño-Zamudio JA, Argandykov D, Romijn AS, Abiad M, Rafaqat W, Hwabejire JO, Velmahos GC, Paranjape C. Is severe traumatic brain injury no longer a contraindication for surgical stabilization of rib fractures in patients with multiple rib fractures? A propensity-matched analysis. J Trauma Acute Care Surg 2023; 94:823-830. [PMID: 37079864 DOI: 10.1097/ta.0000000000003954] [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: 04/22/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is often considered a contraindication to surgical stabilization of rib fractures (SSRF). In this study, we hypothesized that, compared with nonoperative management, SSRF is associated with improved outcomes in TBI patients. METHODS Using the American College of Surgeons Trauma Quality Improvement Program 2016-2019, we performed a retrospective analysis of patients with concurrent TBI and multiple rib fractures. Following propensity score matching, we compared patients who underwent SSRF with those who were managed nonoperatively. Our primary outcome was mortality. Secondary outcomes included ventilator-associated pneumonia, hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, tracheostomy rate, and hospital discharge disposition. In a subgroup analysis, we stratified patients into mild and moderate TBI (GCS score >8) and severe TBI (GCS score ≤8). RESULTS Of 36,088 patients included in this study, 879 (2.4%) underwent SSRF. After propensity-score matching, compared with nonoperative management, SSRF was associated with decreased mortality (5.4% vs. 14.5%, p < 0.001), increased hospital LOS (15 days vs. 9 days, p < 0.001), increased ICU LOS (12 days vs. 8 days, p < 0.001), and increased ventilator days (7 days vs. 4 days, p < 0.001). In the subgroup analyses, in mild and moderate TBI, SSRF was associated with decreased in-hospital mortality (5.0% vs. 9.9%, p = 0.006), increased hospital LOS (13 days vs. 9 days, p < 0.001), ICU LOS (10 days vs. 7 days, p < 0.001), and ventilator days (5 days vs. 2 days, p < 0.001). In patients with severe TBI, SSRF was associated with decreased mortality (6.2% vs. 18%, p < 0.001), increased hospital LOS (20 days vs. 14 days, p = 0.001), and increased ICU LOS (16 days vs. 13 days, p = 0.004). CONCLUSION In patients with TBI and multiple rib fractures, SSRF is associated with a significant decrease in in-hospital mortality and with longer hospital and ICU LOSs. These findings suggest that SSRF should be considered in patients with TBI and multiple rib fractures. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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16
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Selvendran S, Cheluvappa R. Management Pathways for Traumatic Rib Fractures-Importance of Surgical Stabilisation. Healthcare (Basel) 2023; 11:healthcare11081064. [PMID: 37107898 PMCID: PMC10138113 DOI: 10.3390/healthcare11081064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/29/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Rib fractures occur in almost half of blunt chest wall trauma victims in Australia. They are associated with a high rate of pulmonary complications, and consequently, with increased discomfort, disability, morbidity, and mortality. This article summarises thoracic cage anatomy and physiology, and chest wall trauma pathophysiology. Institutional clinical strategies and clinical pathway "bundles of care" are usually available to reduce mortality and morbidity in patients with chest wall injury. This article analyses multimodal clinical pathways and intervention strategies that include surgical stabilisation of rib fractures (SSRF) in thoracic cage trauma patients with severe rib fractures, including flail chest and simple multiple rib fractures. The management of thoracic cage injury should include a multidisciplinary team approach with proper consideration of all potential avenues and treatment modalities (including SSRF) to obtain the best patient outcomes. There is good evidence for the positive prognostic role of SSRF as part of a "bundle of care" in the setting of severe rib fractures such as ventilator-dependent patients and patients with flail chest. However, the use of SSRF in flail chest treatment is uncommon worldwide, although early SSRF is standard practice at our hospital for patients presenting with multiple rib fractures, flail chest, and/or severe sternal fractures. Several studies report that SSRF in patients with multiple simple rib fractures lead to positive patient outcomes, but these studies are mostly retrospective studies or small case-control trials. Therefore, prospective studies and well-designed RCTs are needed to confirm the benefits of SSRF in patients with multiple simple rib fractures, as well as in elderly chest trauma patients where there is scant evidence for the clinical outcomes of SSRF intervention. When initial interventions for severe chest trauma are unsatisfactory, SSRF must be considered taking into account the patient's individual circumstances, clinical background, and prognostic projections.
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Affiliation(s)
- Selwyn Selvendran
- Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia
| | - Rajkumar Cheluvappa
- Nursing and Midwifery, Australian Catholic University, Watson, ACT 2602, Australia
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17
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Hoepelman RJ, Minervini F, Beeres FJP, van Wageningen B, IJpma FF, van Veelen NM, Lansink KWW, Hoogendoorn JM, van Baal MCP, Groenwold RHH, Houwert RM. Quality of life and clinical outcomes of operatively treated patients with flail chest injuries: A multicentre prospective cohort study. Front Surg 2023; 10:1156489. [PMID: 37009603 PMCID: PMC10050428 DOI: 10.3389/fsurg.2023.1156489] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/27/2023] [Indexed: 03/17/2023] Open
Abstract
IntroductionMost 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.MethodsA 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.ResultsSixty-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%).ConclusionsRib 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
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Affiliation(s)
- Ruben J. Hoepelman
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Fabrizio Minervini
- Department of Thoracic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
- Correspondence: Fabrizio Minervini
| | - Frank J. P. Beeres
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Bas van Wageningen
- Department of Trauma Surgery, Radboud University Medical Center Utrecht, Nijmegen, Netherlands
| | - Frank F. IJpma
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Nicole M. van Veelen
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Koen W. W. Lansink
- Department of Trauma Surgery, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | | | - Mark. C. P. van Baal
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Rolf H. H. Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Roderick M. Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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Retrospective comparison of operative technique for chest wall injuries. Injury 2023:S0020-1383(23)00248-6. [PMID: 36925375 DOI: 10.1016/j.injury.2023.03.012] [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: 01/18/2023] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Surgical management of chest wall injuries is a common procedure. However, operative techniques are diverse, and no universal guidelines exist. There is a lack of studies comparing the outcome with different operative techniques for chest wall surgery. The aim of this study was to compare hospital outcomes between patients operated for chest wall injuries with a conventional method with large incisions and often a thoracotomy or a minimally invasive, muscle sparing method. PATIENTS AND METHODS A retrospective study was carried out including patients ≥18 years operated for chest wall injuries 2010-2020. Patients were divided into two groups based on the surgery performed: conventional surgery (C-group) and minimally invasive surgery (M-group). Data on demographics, trauma, surgery, and outcomes were extracted from patient records. Primary outcome was length of stay on mechanical ventilator (MV-LOS). Secondary outcomes were length of stay in intensive care (ICU-LOS) and in hospital (H-LOS), and complications such as re-operation, incidence of empyema, tracheostomy, pneumonia, and mortality. RESULTS Of 311 included patients, 220 were in the C-group and 91 in the M-group. The groups were similar in demographics and injury pattern. MV-LOS was 0 (0-65) in the C-group vs 0 (0-34) in the M-group (p < 0.001). ICU-LOS and H-LOS were significantly shorter in the M-group as compared to the C-group (p < 0.001), however with a large overlap. Tracheostomy was performed in 22.3% of patients in the C-group vs 5.4% in the M-group (p < 0.001). Pneumonia was diagnosed in 32.3% of patients in the C-group vs 16.1% in the M-group (p = 0.004). In-hospital mortality was lower in the M-group compared to the C-group but there was no difference in mortality within 30 days or a year. CONCLUSIONS Our study indicates that a minimally invasive technique was favorable regarding clinical outcomes for patients operated for chest wall injuries.
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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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Schreyer C, Eckermann C, Neudecker J, Becker L, Schulz-Drost S. [VATS in Thorax Trauma]. Zentralbl Chir 2023; 148:74-84. [PMID: 36470290 DOI: 10.1055/a-1957-5511] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Since the early 1990s, video-assisted thoracoscopy (VATS) has been increasingly established for a variety of indications in the treatment of patients with thoracic trauma. During this time, one premise for the use of thoracoscopy has not changed. Its use is consistently recommended only for trauma patients with stable circulation and respiration. To define the indications of VATS for use in thoracic trauma, the Pulmonary Injury Group - as part of the Working Committee for Thoracic Trauma of the German Society for Thoracic Surgery (DGT) and the German Society for Trauma Surgery (DGU) - has developed treatment recommendations based on a current literature review (based on the PRISMA Checklist/here: MEDLINE via PubMed from 1993 to 2022). In the present study, after reviewing the available literature, the indications for VATS in the care of thoracic trauma were identified, in order to formulate clinical recommendations for the use of VATS in thoracic trauma. The analysis of 1679 references identified a total of 4 randomised controlled trials (RCTs), 4 clinical trials, and 5 meta-analyses or systematic reviews and 39 reviews, which do not allow a higher level of recommendation than consensual recommendations, due to the low evidence of the available literature. Over the past 30 years, stabilisation options in the care of trauma patients have improved significantly, allowing expansion of indications for the use of VATS. Moreover, the recommendation for more than 50 years to thoracotomise trauma patients in case of an initial blood loss ≥ 1500 ml via the inserted chest drainage or in case of continuous blood loss ≥ 250 ml/h over 4 h is now only relative with today's better stabilisation measures. For unstable/non-stabilisable patients with a thoracic injury requiring emergency treatment, thoracotomy remains the method of choice, while VATS is recommended for a wide range of indications in the diagnosis and treatment of stable patients with a penetrating or blunt thoracic trauma. The indications for VATS are persistent haemothorax, treatment of injuries and haemorrhages to the lung, diaphragm, thoracic wall and other organ injuries, and in the secondary phase, treatment of thoracic sequelae of injury (empyema, persistent pulmonary fistula, infected atelectasis, etc.).
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Affiliation(s)
- Christof Schreyer
- Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus, Koblenz, Deutschland
| | - Christoph Eckermann
- Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus, Koblenz, Deutschland
| | - Jens Neudecker
- Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Universitätsmedizin Berlin - Charité Campus Mitte, Berlin, Deutschland
| | - Lars Becker
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Stefan Schulz-Drost
- Klinik für Unfallchirurgie und Traumatologie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
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21
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Lin CJ, Yeh YS, Lin YK, Chen CW. K-Rod: An Innovative Method of Personalized Rib Splinting for Expeditious Management of Flail Chest in Acute Care Settings. Medicina (B Aires) 2022; 59:medicina59010076. [PMID: 36676700 PMCID: PMC9865151 DOI: 10.3390/medicina59010076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023] Open
Abstract
Flail chest is a severe type of multiple rib fracture that can cause ventilation problems and respiratory complications. Historically, flail chest has been mainly managed through pain control and ventilatory support as needed. Operative fixation has recently become popular for the condition, and some studies have revealed its potentially positive effects on the outcomes of patients with flail chest. However, for those for whom surgery is unsuitable, few treatment options, other than simply providing analgesia, are available. Herein, we introduce our innovative method of applying personalized rib splinting for quick management of flail chest, which is easy, tailor-made, and has significant effects on pain reduction.
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Affiliation(s)
- Chia-Jung Lin
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Yung-Sung Yeh
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei 11031, Taiwan
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Yen-Ko Lin
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Department of Emergency Medicine, Faculty of Medicine, College of Medicine, Kaohsiung 80708, Taiwan
| | - Chao-Wen Chen
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Department of Emergency Medicine, Faculty of Medicine, College of Medicine, Kaohsiung 80708, Taiwan
- Correspondence:
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22
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Brewer JM, Huselid R, Petitpas KM, Jayaraman V, Russel Hill T, Greig C, McGuiness C, McLaughlin E, Montgomery SC, Shapiro DS, Moutinho M, Doben AR. Creating a Chest Wall Injury and Reconstructive program: A single center experience with rib fractures. Injury 2022; 53:4013-4019. [PMID: 36210206 DOI: 10.1016/j.injury.2022.09.043] [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: 08/01/2022] [Revised: 09/08/2022] [Accepted: 09/23/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND New Chest Wall Injury and Reconstructive Centers (CWIRC) are emerging; this study aims to investigate the potential benefits of implementing a CWIRC at a single institution. We hypothesized that patients treated at CWIRC will have improved outcomes. METHODS We instituted a CWIRC in 2019 at our American College of Surgeons (ACS) Level One Trauma Center. We retrospectively compared trauma patients with rib fractures who presented to our center 18 months before (PRE-C) and 18 months after CWIRC implementation (POST-C). Outcomes measured included mortality, length of stay (LOS), intensive care unit (ICU-LOS), readmission rates, and unplanned ICU admission. RESULTS There were 192 PRE-C patients, compared to 388 POST-C. The mortality in PRE-C was not significantly different compared to the POST-C group (11.46% vs 8.8%, p=0.308). There were also no differences in LOS, ICU-LOS, readmission, and unplanned ICU admission. ICU utilization was dramatically different: PRE-C 17.8% were admitted to ICU compared to 35.6% POST-C (p<0.0001). CONCLUSIONS The number of patients admitted with rib fractures to our center nearly doubled after CWIRC establishment. Early diagnosis and triage led to significantly more admissions to higher levels of care. There are trends toward improved outcomes using practice management protocols, albeit with higher ICU utilization. Establishment of a CWIRC should be considered for level 1 ACS trauma centers and as utilization of established CWIRC protocols are increased, patients will have improved outcomes. LEVEL OF EVIDENCE IV STUDY TYPE: Retrospective chart review.
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Affiliation(s)
- Jennifer M Brewer
- Department of General Surgery, University of Connecticut School of Medicine, Farmington, USA.
| | - Rachel Huselid
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, USA.
| | - Kaitlyn M Petitpas
- Department of General Surgery, University of Connecticut School of Medicine, Farmington, USA.
| | - Vijay Jayaraman
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | - T Russel Hill
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | - Chasen Greig
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | - Carol McGuiness
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | - Erin McLaughlin
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | | | - David S Shapiro
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | - Manuel Moutinho
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
| | - Andrew R Doben
- Department of Surgery, St. Francis Hospital and Medical Center, Hartford, USA.
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23
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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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Hoepelman RJ, Beeres FJP, van Veelen N, Houwert RM, Babst R, Link BC, van de Wall BJM. Treatment and outcome in combined scapula and rib fractures: a retrospective study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03437-2. [PMID: 36401000 DOI: 10.1007/s00590-022-03437-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 11/14/2022] [Indexed: 06/16/2023]
Abstract
PURPOSE The primary aim was to describe the population characteristics of patients with combined scapula and rib fractures and outcomes associated with different treatment strategies. METHODS All adult (≥ 18 years) patients with concurrent ipsilateral scapula and rib fractures admitted to the study hospital between 1st January 2010 and 31st June 2021 were retrospectively reviewed. RESULTS A total of 223 patients were admitted with concurrent ipsilateral rib and scapula fractures. A total of 160 patients (72%) were treated conservatively, 63 patients (28%) operatively. Among operatively treated patients, 32 (51%) underwent rib fixation (RF) only, 24 (38%) underwent scapula fixation (SF) only, and seven patients (11%) underwent combined fixation of scapula and ribs (SRF). In general, more severely injured patients were treated with more extensive surgery. RF patients had a median hospital length of stay of 16 days, the SF patients 11 days and SRF patients 18 days. There were no significant differences in complications (pneumonia, recurrent pneumothorax and revision surgery) between groups. CONCLUSION Injury severity resulted in different treatment modalities. As a result, different patient characteristics between treatment groups were observed, which makes direct comparison between treatment modalities impossible. All treatment modalities seem feasible; however, the additional value of both rib and scapula fixation has yet to be proven in large multicentre studies.
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Affiliation(s)
- Ruben Joost Hoepelman
- Department of Trauma Surgery, UMC Utrecht, Utrecht, the Netherlands
- Department of Orthopaedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Frank Joseph Paulus Beeres
- Department of Orthopaedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Spitalstrasse 16, 6000, Lucerne, Switzerland
| | - Nicole van Veelen
- Department of Orthopaedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Reto Babst
- Department of Orthopaedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Spitalstrasse 16, 6000, Lucerne, Switzerland
| | - Björn-Christian Link
- Department of Orthopaedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Bryan Joost Marinus van de Wall
- Department of Orthopaedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland.
- Department of Health Sciences and Medicine, University of Lucerne, Spitalstrasse 16, 6000, Lucerne, Switzerland.
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25
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Dehghan N, Nauth A, Schemitsch E, Vicente M, Jenkinson R, Kreder H, McKee M. Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial. JAMA Surg 2022; 157:983-990. [PMID: 36129720 PMCID: PMC9494266 DOI: 10.1001/jamasurg.2022.4299] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/18/2022] [Indexed: 12/14/2022]
Abstract
Importance Unstable chest wall injuries have high rates of mortality and morbidity. In the last decade, multiple studies have reported improved outcomes with operative compared with nonoperative treatment. However, to date, an adequately powered, randomized clinical trial to support operative treatment has been lacking. Objective To compare outcomes of surgical treatment of acute unstable chest wall injuries with nonsurgical management. Design, Setting, and Participants This was a multicenter, prospective, randomized clinical trial conducted from October 10, 2011, to October 2, 2019, across 15 sites in Canada and the US. Inclusion criteria were patients between the ages of 16 to 85 years with displaced rib fractures with a flail chest or non-flail chest injuries with severe chest wall deformity. Exclusion criteria included patients with significant other injuries that would otherwise require prolonged mechanical ventilation, those medically unfit for surgery, or those who were randomly assigned to study groups after 72 hours of injury. Data were analyzed from March 20, 2019, to March 5, 2021. Interventions Patients were randomized 1:1 to receive operative treatment with plate and screws or nonoperative treatment. Main Outcomes and Measures The primary outcome was ventilator-free days (VFDs) in the first 28 days after injury. Secondary outcomes included mortality, length of hospital stay, intensive care unit stay, and rates of complications (pneumonia, ventilator-associated pneumonia, sepsis, tracheostomy). Results A total of 207 patients were included in the analysis (operative group: 108 patients [52.2%]; mean [SD] age, 52.9 [13.5] years; 81 male [75%]; nonoperative group: 99 patients [47.8%]; mean [SD] age, 53.2 [14.3] years; 75 male [76%]). Mean (SD) VFDs were 22.7 (7.5) days for the operative group and 20.6 (9.7) days for the nonoperative group (mean difference, 2.1 days; 95% CI, -0.3 to 4.5 days; P = .09). Mortality was significantly higher in the nonoperative group (6 [6%]) than in the operative group (0%; P = .01). Rates of complications and length of stay were similar between groups. Subgroup analysis of patients who were mechanically ventilated at the time of randomization demonstrated a mean difference of 2.8 (95% CI, 0.1-5.5) VFDs in favor of operative treatment. Conclusions and Relevance The findings of this randomized clinical trial suggest that operative treatment of patients with unstable chest wall injuries has modest benefit compared with nonoperative treatment. However, the potential advantage was primarily noted in the subgroup of patients who were ventilated at the time of randomization. No benefit to operative treatment was found in patients who were not ventilated. Trial Registration ClinicalTrials.gov Identifier: NCT01367951.
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Affiliation(s)
- Niloofar Dehghan
- The CORE Institute, Phoenix, Arizona
- University of Arizona College of Medicine Phoenix, Phoenix
| | - Aaron Nauth
- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Milena Vicente
- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Richard Jenkinson
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hans Kreder
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michael McKee
- University of Arizona College of Medicine Phoenix, Phoenix
- Banner University Medical Center, Phoenix, Arizona
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26
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Kawai Y, Takano K, Miyazaki K, Yamamoto K, Tada Y, Asai H, Maegawa N, Urisono Y, Saeki K, Fukushima H. Association of multiple rib fractures with the frequency of pneumonia in the post-resuscitation period. Resusc Plus 2022; 11:100267. [PMID: 35812719 PMCID: PMC9256829 DOI: 10.1016/j.resplu.2022.100267] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 06/11/2022] [Accepted: 06/20/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose Successful cardiopulmonary resuscitation is associated with a high incidence of chest wall injuries. However, few studies have examined chest wall injury as a risk factor for respiratory complications after cardiopulmonary resuscitation. Therefore, herein, we investigated the association of multiple rib fractures on the incidence of post-resuscitation pneumonia. Methods This single-centre retrospective cohort study enrolled adult, nontraumatic, out-of-hospital cardiac arrest patients who maintained circulation for more than 48 h between June 2015 and May 2019. Rib fractures were evaluated by computed tomography on the day of hospital admission. The association with newly developed pneumonia within 7 days of hospitalisation was analysed using a Fine-Gray proportional hazards regression model adjusted for the propensity score of multiple rib fractures estimated from age, sex, presence of witnessed status, bystander CPR, initial rhythm, and total CPR time and for previously reported risk factors for pneumonia (therapeutic hypothermia and prophylactic antibiotics). Results Overall, 683 patients with out-of-hospital cardiac arrest were treated; 87 eligible cases were enrolled for analysis. Thirty-two (36.8%) patients had multiple rib fractures identified on computed tomography, and 35 (40.2%) patients developed pneumonia. The presence of multiple rib fractures was significantly associated with a higher incidence of pneumonia, consistently both with and without adjustment for background factors (unadjusted hazard ratio 4.63, 95% confidence interval: 2.35–9.13, p < 0.001; adjusted hazard ratio 4.03, 95% confidence interval: 2.08–7.82, p < 0.001). Conclusions Multiple rib fractures are independently associated with the development of pneumonia after successful resuscitation.
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Retrospective study of consecutive rib fracture patients treated by open reduction internal fixation in a single major trauma centre, UK. Injury 2022; 53:2768-2773. [PMID: 35680436 DOI: 10.1016/j.injury.2022.05.055] [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: 02/05/2022] [Revised: 05/28/2022] [Accepted: 05/29/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Rib fractures are a common presentation in both patients presenting with high impact poly-trauma and as a result of low energy falls in the elderly. This injury can lead to various complications including prolonged hospital admission, pneumonia, need for ventilation and in admission to intensive care unit. There is much controversy around the management of this injury in the literature, with favourable outcomes for patients treated non-operatively as well as surgically. METHODS We collated a database for all rib fracture fixations between 2014 and 2019 that took place at the major trauma centre in Liverpool. The decision to undergo surgical fixation was after discussion with multidisciplinary team at trauma meeting. Following British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs), these injuries should ideally be operated on within 48 h. RESULTS Overall, a total of 220 patients were included in the study (143 male and 77 female). 142 (64%) patients were operated on within 48 h of admission. A total of 101 (45%) patients required admission to ITU. Those in the early surgical fixation group had a statistically significant decrease in their hospital length of stay (12.8 days compared to 15.5 days, p=<0.001). Mean length of ITU stay was shorter in the early surgical group with no statistical significance (p = 0.1). Those patients that required mechanical ventilation in turn stayed in hospital for a longer period compared to those who did not (p=<0.001). There is no statistical difference in survival between the 2 patient groups (p = 0.3). DISCUSSION To our knowledge, this is the largest data set published in the rib fracture fixation cohort. Our results agree with previous studies which have demonstrated that those who undergo ORIF tend require fewer days of hospital stay, less ventilatory support and overall have better outcomes in terms of pain when compared to those treated non-operatively. Our study adds that patients who receive treatment within 48-hours as per BOAST guidelines have better outcomes, specifically reducing hospital length of stay by nearly 4 days (p = 0.014). CONCLUSION Early surgical fixation of rib fractures leads to significantly favoured outcomes.
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Craxford S, Marson BA, Nightingale J, Forward DP, Taylor A, Ollivere B. Surgical fixation of rib fractures improves 30-day survival after significant chest injury : an analysis of ten years of prospective registry data from England and Wales. Bone Joint J 2022; 104-B:729-735. [PMID: 35638213 DOI: 10.1302/0301-620x.104b6.bjj-2021-1502.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS The last decade has seen a marked increase in surgical rib fracture fixation (SRF). The evidence to support this comes largely from retrospective cohorts, and adjusting for the effect of other injuries sustained at the same time is challenging. This study aims to assess the impact of SRF after blunt chest trauma using national prospective registry data, while controlling for other comorbidities and injuries. METHODS A ten-year extract from the Trauma Audit and Research Network formed the study sample. Patients who underwent SRF were compared with those who received supportive care alone. The analysis was performed first for the entire eligible cohort, and then for patients with a serious (thoracic Abbreviated Injury Scale (AIS) ≥ 3) or minor (thoracic AIS < 3) chest injury without significant polytrauma. Multivariable logistic regression was performed to identify predictors of mortality. Kaplan-Meier estimators and multivariable Cox regression were performed to adjust for the effects of concomitant injuries and other comorbidities. Outcomes assessed were 30-day mortality, length of stay (LoS), and need for tracheostomy. RESULTS A total of 86,838 cases were analyzed. The rate of SRF was 1.2%. SRF significantly reduced risk of mortality (odds ratio (OR) 0.27 (95 confidence interval (CI) 0.128 to 0.273); p < 0.001) and need for tracheostomy (OR 0.22 (95% CI 0.191 to 0.319); p < 0.001) after adjustment for other covariables across the whole cohort. SRF remained protective in patients with a serious chest injury (hazard ratio (HR) 0.24 (95% CI 0.13 to 0.45); p < 0.001). The benefit in more minor chest injury was less clear. Mean LoS for patients who survived was longer in the SRF group (24.29 days (SD 26.54) vs 16.60 days (SD 26.35); p < 0.001). CONCLUSION SRF reduces mortality after significant chest trauma associated with both major and minor polytrauma. The rate of fixation in the UK is low and potentially underused as a treatment for severe chest wall injury. Cite this article: Bone Joint J 2022;104-B(6):729-735.
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29
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Stopenski S, Binkley J, Schubl SD, Bauman ZM. Rib Fracture Management: A Review of Surgical Stabilization, Regional Analgesia, and Intercostal Nerve Cryoablation. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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30
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Kim D, Yoon SK, Lee GD, Kim DK. Nuss Procedure for Surgical Stabilization of Anterior Flail Chest with Mechanical Ventilation Weaning Failure: A Case Report. J Chest Surg 2022; 55:183-187. [PMID: 35193117 PMCID: PMC9005940 DOI: 10.5090/jcs.21.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/03/2021] [Accepted: 12/13/2021] [Indexed: 11/16/2022] Open
Abstract
Flail chest is a critical medical condition in which multiple segmentally fractured adjacent ribs cause paradoxical movement of the thoracic cage in patients with severe blunt trauma injury. Surgical stabilization is considered essential in patients who require mechanical ventilation. However, there is no consensus on which surgical procedure to choose among the various available techniques or when to perform surgery. We report the case of a patient with traumatic anterior flail chest due to bilateral multiple fractures of the ribs requiring surgical stabilization in whom weaning from mechanical ventilation had failed. The Nuss procedure using double bars with the bridge technique was performed for chest wall stabilization. The patient was weaned from mechanical ventilation on postoperative day 44 and she underwent bar removal on postoperative day 71. After extensive rehabilitation for multiple trauma, she was discharged successfully. The patient currently shows no recurrence of chest wall depression in outpatient follow-up.
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Affiliation(s)
- Donghee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Keun Yoon
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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31
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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.
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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
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32
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Management of Advanced Aged Patients with Rib Fractures: Current Evidence and Review of the Literature. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2020008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Elderly patients (age > 60 years old) represent the majority of the victims of major trauma, and rib fractures account for 10% of all trauma admissions. Due to the growing interest in surgical rib fixation and the lack of evidence on the best treatment available, we aimed to compare the conservative and operative approaches among the elderly population with multiple rib fractures. The systematic review identified seven eligible studies from over 321 papers collected through the database screening process. The mortality rate, considered the primary outcome, was higher in the conservative-treated group than the operatively-treated patients (8.3% vs. 3%). Considering the secondary outcomes investigated, the overall intensive care unit stay and in-hospital length of stay were longer in the operatively-treated patients (6.3 and 13.3 vs. 4.7 and 7.7, respectively). Conversely, the operative treatment showed favorable results regarding the pneumonia complication rate (5.8% vs. 9.6%), while the duration of mechanical ventilation was similar for both treatments. Surgical stabilization of rib fractures in the elderly population appears to be associated with a survival advantage and avoiding pulmonary complications. However, the individual contribution of operative and conservative treatment in reducing morbidity and mortality in the elderly with multiple rib fractures remains unclear.
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The incidence, clinical characteristics, and outcome of polytrauma patients with the combination of pulmonary contusion, flail chest and upper thoracic spinal injury. Injury 2022; 53:1073-1080. [PMID: 34625240 DOI: 10.1016/j.injury.2021.09.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 05/12/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chest trauma was the third most common cause of death in polytrauma patients, accounting for 25% of all deaths from traumatic injury. Chest trauma involves in injury to the bony thorax, intrathoracic organs and thoracic medulla. This study aimed to investigate the incidence, clinical characteristics, and outcome of polytrauma patients with pulmonary contusion, flail chest and upper thoracic spinal injury. METHODS Patients who met inclusion criteria were divided into groups: Pulmonary contusion group (PC); Pulmonary contusion and flail chest group (PC + FC); Pulmonary contusion and upper thoracic spinal cord injury group (PC + UTSCI); Thoracic trauma triad group (TTT): included patients with flail chest, pulmonary contusion and the upper thoracic spinal cord injury coexisted. Outcomes were determined, including 30-day mortality and 6-month mortality. RESULTS A total 84 patients (2.0%) with TTT out of 4176 polytrauma patients presented to Tongji trauma center. There was no difference in mean ISS among PC + FC group, PC + UTSCI group and TTT group. Patients with TTT had a longer ICU stay (21.4 days vs. 7.5 and 6.2; p<0.01), relatively higher 30-day mortality (40.5% vs. 6.0% and 4.3%; p<0.01), and especially higher 6-month mortality (71.4% vs. 6.5%, 13.0%; p<0.01), compared to patients with PC + FC or with PC + UTSCI. The leading causes of death for patients with TTT were ARDS (44.1%) and pulmonary infection (26.5%) during first 30 days after admission. For those patients who died later than 30 days during the 6 months, the predominant underlying cause of death was MOF (53.8%). CONCLUSIONS Lethal triad of thoracic trauma (LTTT) were described in this study, which consisting of pulmonary contusion,flail chest and the upper thoracic spine cord injury. Like the classic "lethal triad", there was a synergy between the factors when they coexist, resulting in especially high mortality rates. Polytrauma patients with LTTT were presented relatively high 30-day mortality and 6 months mortality. We should pay much more attention to the patients with LTTT for further minimizing complications and mortality.
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Prins JTH, Van Lieshout EMM, Ali-Osman F, Bauman ZM, Caragounis EC, Choi J, Christie DB, Cole PA, DeVoe WB, Doben AR, Eriksson EA, Forrester JD, Fraser DR, Gontarz B, Hardman C, Hyatt DG, Kaye AJ, Ko HJ, Leasia KN, Leon S, Marasco SF, McNickle AG, Nowack T, Ogunleye TD, Priya P, Richman AP, Schlanser V, Semon GR, Su YH, Verhofstad MHJ, Whitis J, Pieracci FM, Wijffels MME. Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury. Eur J Trauma Emerg Surg 2022; 48:3327-3338. [PMID: 35192003 PMCID: PMC9360098 DOI: 10.1007/s00068-022-01906-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 01/29/2022] [Indexed: 11/13/2022]
Abstract
Purpose Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients. Methods A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern. Results In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11–0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, − 2.96 days; 95% CI − 5.70 to − 0.23; p = 0.034). Conclusion In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.
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Affiliation(s)
- Jonne T H Prins
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Francis Ali-Osman
- Department of Surgery, HonorHealth John C. Lincoln Medical Center, Phoenix, AZ, 85020, USA
| | - Zachary M Bauman
- Division of Trauma, Emergency General Surgery, Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Eva-Corina Caragounis
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jeff Choi
- Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, CA, 94305, USA
| | - D Benjamin Christie
- Department of Trauma Surgery/Critical Care, Mercer University School of Medicine, The Medical Center Navicent Health, Macon, GA, 31201, USA
| | - Peter A Cole
- HealthPartners Orthopedics and Sports Medicine, Bloomington, MN, 55420, USA.,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, 55455, USA.,Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, 55101, USA
| | - William B DeVoe
- Department of Surgery, Riverside Methodist Hospital, Columbus, 43214 OH, USA
| | - Andrew R Doben
- Department of Surgery, Saint Francis Hospital, Hartford, CT, 06105, USA
| | - Evert A Eriksson
- Division of Trauma and Critical Care, Department of Surgery, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Joseph D Forrester
- Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, CA, 94305, USA
| | - Douglas R Fraser
- Department of Surgery, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, 89102, USA
| | - Brendan Gontarz
- Department of Surgery, Saint Francis Hospital, Hartford, CT, 06105, USA
| | - Claire Hardman
- Division of Trauma, Department of Surgery, Wright State University/Miami Valley Hospital, Dayton, OH, 45409, USA
| | - Daniel G Hyatt
- Department of Surgery, Riverside Methodist Hospital, Columbus, 43214 OH, USA
| | - Adam J Kaye
- Department of Surgery, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA
| | - Huan-Jang Ko
- Division of Trauma Surgery, Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, 30059, Taiwan
| | - Kiara N Leasia
- Department of Surgery, Denver Health Medical Center, Denver, CO, 80204, USA
| | - Stuart Leon
- Division of Trauma and Critical Care, Department of Surgery, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Silvana F Marasco
- CJOB Department of Cardiothoracic Surgery, The Alfred, Melbourne, Australia.,Department of Surgery, Monash University, Clayton, VIC, Australia
| | - Allison G McNickle
- Department of Surgery, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, 89102, USA
| | - Timothy Nowack
- Department of Trauma Surgery/Critical Care, Mercer University School of Medicine, The Medical Center Navicent Health, Macon, GA, 31201, USA
| | - Temi D Ogunleye
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, 55455, USA.,Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, 55101, USA
| | - Prakash Priya
- Department of Surgery, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA
| | - Aaron P Richman
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Victoria Schlanser
- Department of Trauma/Burn, John H Stroger Hospital of Cook County, Chicago, IL, 60612, USA
| | - Gregory R Semon
- Division of Trauma, Department of Surgery, Wright State University/Miami Valley Hospital, Dayton, OH, 45409, USA
| | - Ying-Hao Su
- Division of Trauma Surgery, Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, 30059, Taiwan
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Julie Whitis
- Department of Surgery, University of Texas Rio Grande Valley, Doctors Hospital at Renaissance, Edinburg, TX, 78539, USA
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, 80204, USA
| | - Mathieu M E Wijffels
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Niziolek G, Goodman MD, Makley A, Millar DA, Heh V, Pritts TA, Janowak C. "Early results after initiation of a rib fixation programme: A propensity score matched analysis". Injury 2022; 53:137-144. [PMID: 34565619 DOI: 10.1016/j.injury.2021.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 09/06/2021] [Accepted: 09/10/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Chest wall injuries are very common in blunt trauma and development of treatment protocols can significantly improve outcomes. Surgical stabilisation of rib fractures (SSRF) is an adjunct for the most severe chest injuries and can be used as a part of a comprehensive approach to chest injuries care. We hypothesized that implementation of a SSRF programme program would result in improved short-term outcomes. MATERIALS AND METHODS The characteristics of the initial group of SSRF patients (Early-SSRF) were used to identify matching factors. Patients prior to SSRF protocol underwent a propensity score match, followed by screening for operative indications and contraindications. After exclusions, a non-operative (Non-Op) cohort was defined (n=36) resulting in an approximately 1:1 match. An overall operative cohort, inclusive of Early-SSRF and all subsequent operative patients, was defined (All- SSRF). A before-and-after analysis using chi-squared, Students T-tests, and Mann-Whitney U-tests were used to assess significance at the level of 0.05. RESULTS Early-SSRF (n=22) and All-SSRF (n=45) were compared to Non-Op (n=36). The selection process resulted in well matched groups, and equally well-balanced operative indications between the groups. The Early-SSRF group demonstrated shortened duration of mechanical ventilation and a decreased frequency of being discharged a long-term acute care hospital. The All-SSRF group again demonstrated markedly shorter duration of mechanical ventilation compared to Non-Op (median 6 days vs 16 days, p < 0.01), more decrease discharge to a long-term acute care hospital (9% vs. 36%, p=0.01), and reduced risk for tracheostomy (8.9% vs. 33.3% respectively, p<0.01) CONCLUSION: The introduction of an operative rib fixation to a comprehensive chest wall injury protocol can produce improvements in clinical outcomes that decrease time on the ventilator and tracheostomy rates, and result in more patients being discharged to home. Creation and implementation of a chest wall injury protocol to include SSRF requires a multidisciplinary approach and thoughtful patient selection.
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Affiliation(s)
- Grace Niziolek
- Divisions of UCMC and WCH Trauma, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
| | - Michael D Goodman
- Divisions of UCMC and WCH Trauma, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
| | - Amy Makley
- Divisions of UCMC and WCH Trauma, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
| | - D Anderson Millar
- Divisions of UCMC and WCH Trauma, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
| | - Victor Heh
- Divisions of UCMC and WCH Trauma, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
| | - Timothy A Pritts
- Divisions of UCMC and WCH Trauma, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
| | - Christopher Janowak
- Divisions of UCMC and WCH Trauma, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
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Bauman ZM, Binkley J, Pieper CJ, Raposo-Hadley A, Orcutt G, Cemaj S, Evans CH, Cantrell E. Discrepancies in rib fracture severity between radiologist and surgeon: A retrospective review. J Trauma Acute Care Surg 2021; 91:956-960. [PMID: 34407008 DOI: 10.1097/ta.0000000000003377] [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: 11/26/2022]
Abstract
BACKGROUND Chest computed tomography (CT) scans are important for the management of rib fracture patients, especially when determining indications for surgical stabilization of rib fractures (SSRFs). Chest CTs describe the number, patterns, and severity of rib fracture displacement, driving patient management and SSRF indications. Literature is scarce comparing radiologist versus surgeon rib fracture description. We hypothesize there is significant discrepancy between how radiologists and surgeons describe rib fractures. METHODS This was an institutional review board-approved, retrospective study conducted at a Level I academic center from December 2016 to December 2017. Adult patients (≥18 years of age) suffering rib fractures with a CT chest where included. Basic demographics were obtained. Outcomes included the difference between radiologist versus surgeon description of rib fractures and differences in the number of fractures identified. Rib fracture description was based on current literature: 1, nondisplaced; 2, minimally displaced (<50% rib width); 3, severely displaced (≥50% rib width); 4, bicortically displaced; 5, other. Descriptive analysis was used for demographics and paired t test for statistical analysis. Significance was set at p = 0.05. RESULTS Four hundred and ten patients and 2,337 rib fractures were analyzed. Average age was 55.6(±20.6); 70.5% were male; median Injury Severity Score was 16 (interquartile range, 9-22) and chest Abbreviated Injury Scale score was 3 (interquartile range, 3-3). For all descriptive categories, radiologists consistently underappreciated the severity of rib fracture displacement compared with surgeon assessment and severity of displacement was not mentioned for 35% of rib fractures. The mean score provided by the radiologist was 1.58 (±0.63) versus 1.78 (±0.51) by the surgeon (p < 0.001). Radiologists missed 138 (5.9%) rib fractures on initial CT. The sensitivity of the radiologist to identify a severely displaced rib fracture was 54.9% with specificity of 79.9%. CONCLUSION Discrepancy exists between radiologist and surgeon regarding rib fracture description on chest CT as radiologists routinely underappreciate fracture severity. Surgeons need to evaluate CT scans themselves to appropriately decide management strategies and SSRF indications. LEVEL OF EVIDENCE Prognostic/Diagnostic Test, level III.
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Affiliation(s)
- Zachary M Bauman
- From the Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
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Kong LW, Huang GB, Yi YF, Du DY. The Chinese consensus for surgical treatment of traumatic rib fractures 2021 (C-STTRF 2021). Chin J Traumatol 2021; 24:311-319. [PMID: 34503907 PMCID: PMC8606596 DOI: 10.1016/j.cjtee.2021.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/18/2021] [Accepted: 07/26/2021] [Indexed: 02/04/2023] Open
Abstract
Rib fracture is the most common injury in chest trauma. Most of patients with rib fractures were treated conservatively, but up to 50% of patients, especially those with combined injury such as flail chest, presented chronic pain or chest wall deformities, and more than 30% had long-term disabilities, unable to retain a full-time job. In the past two decades, surgery for rib fractures has achieving good outcomes. However, in clinic, there are still some problems including inconsistency in surgical indications and quality control in medical services. Before the year of 2018, there were 3 guidelines on the management of regional traumatic rib fractures were published at home and abroad, focusing on the guidance of the overall treatment decisions and plans; another clinical guideline about the surgical treatment of rib fractures lacks recent related progress in surgical treatment of rib fractures. The Chinese Society of Traumatology, Chinese Medical Association, and the Chinese College of Trauma Surgeons, Chinese Medical Doctor Association organized experts from cardiothoracic surgery, trauma surgery, acute care surgery, orthopedics and other disciplines to participate together, following the principle of evidence-based medicine and in line with the scientific nature and practicality, formulated the Chinese consensus for surgical treatment of traumatic rib fractures (STTRF 2021). This expert consensus put forward some clear, applicable, and graded recommendations from seven aspects: preoperative imaging evaluation, surgical indications, timing of surgery, surgical methods, rib fracture sites for surgical fixation, internal fixation method and material selection, treatment of combined injuries in rib fractures, in order to provide guidance and reference for surgical treatment of traumatic rib fractures.
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Affiliation(s)
- Ling-Wen Kong
- Department of Cardiothoracic Surgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400014, China
| | - Guang-Bin Huang
- Department of Trauma Surgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400014, China
| | - Yun-Feng Yi
- Department of Cardiothoracic Surgery, Xiamen University Affiliated Southeast Hospital, Zhangzhou, 363000, Fujian Province, China,Corresponding author. Xiamen University Affiliated Southeast Hospital, Zhangzhou, 363000, Fujian Province, China.
| | - Ding-Yuan Du
- Department of Cardiothoracic Surgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400014, China,Department of Trauma Surgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400014, China,Corresponding author. Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400014, China.
| | - Consensus expert groupBaiXiang-JundChengLi-MingeCuiShu-SenfDuDing-YuangDuGong-LianghDengJiniDaiJi-GangjDangXing-BohFuXiao-BingkFuYonglGeBingmGaoJin-MougHouLi-JunnHuPei-YangoHouZhi-YongpJiangBao-GuoqJiangJian-XinrJiaYan-FeisJingJue-HuatKongLing-WengLiChun-MinguLvDe-ChengvLiuGuo-DongwLiangGui-YouxLianHong-KaiyLiKai-NanzLiLeiaaLiuLiang-MingrLinYi-DanabLiZhan-FeidLiuZhong-MinacShaoBiaoadShenYanaeTaoNingafTangPei-FukTanQun-YourHuangGuang-BingHuPinggWangChengagWuChunahWangDa-LiaiWangGangajWangHai-DongakWuJing-LanalWuQing-ChenamWangRu-WenrWangTian-BingsWuXuajWangZheng-GuorXuFenganXiaoRen-JuaoXiaoYing-BinapYuAn-YongaiYuBinajYangJunaqYangXiao-FengaeYiYun-FengarZhuDong-BoasZengJunatZhouJi-HongrZhangLian-YangauZhaoXing-JigZhongYong-FuavTongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyTongji Hospital, Tongji University School of MedicineChina-Japan Union Hospital of Jilin UniversityChongqing Emergency Medical Center, Chongqing University Central HospitalShanxi Province People's HospitalAffiliated Hospital of Guizhou Medical UniversityXinqiao Hospital, Army Military Medical UniversityGeneral Hospital of People's Liberation ArmyThe Second Hospital,University of South ChinaThe Fourth People's Hospital of GuiyangChangzheng Hospital, Second Military Medical UniversityTiantai People's Hospital of Zhejiang ProvinceThe Third Hospital of Hebei Medical UniversityPeking University People's Hospital, National Center for Trauma MedicineArmy Medical Center of People's Liberation ArmyThe Second Affiliated Hospital of Inner Mongolia Medical UniversityThe Second Hospital of Anhui Medical UniversityJilin Central HospitalFirst Affiliated Hospital of Dalian Medical UniversityEditorial Department of Chinese Journal of TraumaGuizhou Medical UniversityZhengzhou Central Hospital Affiliated to Zhengzhou UniversityAffiliated Hospital of Chengdu UniversityEditorial Department of Chinese Journal of Traumatology(English Edition)West China Hospital of Sichuan UniversityShanghai Oriental Hospital of Tongji UniversityThe First People's Hospital of KunmingThe First Affiliated Hospital, School of Medicine, Zhejiang UniversitySuining Central Hospital, Sichuan ProvinceThe First Affiliated Hospital of Hainan Medical UniversityChildren's Hospital of Chongqing Medical UniversityAffiliated Hospital of Zunyi Medical UniversitySouthern Hospital of Southern Medical UniversitySouthwest Hospital of Army Medical UniversityUnion Shenzhen Hospital, Huazhong University of Science and TechnologyThe First Affiliated Hospital of Chongqing Medical UniversityThe First Affiliated Hospital of Soochow UniversityPeople's Hospital of Xingyi City, Guizhou ProvinceXinqiao Hospital of Army Medical UniversityChongqing Emergency Medical Center, Central Hospital of Chongqing UniversityXiamen University Affiliated Southeast HospitalThe Affiliated Hospital of Nantong UniversitySichuan Provincial People's HospitalDaping Hospital, Army Military Medical UniversityChongqing University Three Gorges Hospital)
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Prins JTH, Wijffels MME, Pieracci FM. What is the optimal timing to perform surgical stabilization of rib fractures? J Thorac Dis 2021; 13:S13-S25. [PMID: 34447588 PMCID: PMC8371546 DOI: 10.21037/jtd-21-649] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/13/2021] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Jonne T H Prins
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, CO, USA
| | - Mathieu M E Wijffels
- Trauma Research Unit Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, CO, USA
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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.
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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..
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Sweet AAR, Beks RB, IJpma FFA, de Jong MB, Beeres FJP, Leenen LPH, Houwert RM, van Baal MCPM. Epidemiology of combined clavicle and rib fractures: a systematic review. Eur J Trauma Emerg Surg 2021; 48:3513-3520. [PMID: 34075434 PMCID: PMC9532289 DOI: 10.1007/s00068-021-01701-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022]
Abstract
Purpose The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries. Methods A systematic literature search was performed in the MEDLINE, EMBASE, and CENTRAL databases on the 14th of August 2020. Outcome measures were incidence, hospital length of stay (HLOS), intensive care unit admission and length of stay (ILOS), duration of mechanical ventilation (DMV), mortality, chest tube duration, Constant–Murley score, union and complications. Results Seven studies with a total of 71,572 patients were included, comprising five studies on epidemiology and two studies on treatment. Among blunt chest trauma patients, 18.6% had concomitant clavicle and rib fractures. The incidence of rib fractures in polytrauma patients with clavicle fractures was 56–60.6% versus 29% in patients without clavicle fractures. Vice versa, 14–18.8% of patients with multiple rib fractures had concomitant clavicle fractures compared to 7.1% in patients without multiple rib fractures. One study reported no complications after fixation of both injuries. Another study on treatment, reported shorter ILOS and less complications among operatively versus conservatively treated patients (5.4 ± 1.5 versus 21 ± 13.6 days). Conclusion Clavicle fractures and rib fractures are closely related in polytrauma patients and almost a fifth of all blunt chest trauma patients sustain both injuries. Definitive conclusions could not be drawn on treatment of the combined injury. Future research should further investigate indications and benefits of operative treatment of this injury. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01701-4.
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Affiliation(s)
- Arthur A R Sweet
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands.
| | - Reinier B Beks
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Frank F A IJpma
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Mirjam B de Jong
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands
| | - Frank J P Beeres
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands
| | - Roderick M Houwert
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands
| | - Mark C P M van Baal
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands
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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.
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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
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Sedaghat N, Chiong C, Tjahjono R, Hsu J. Early Outcomes of Surgical Stabilisation of Traumatic Rib Fractures: Single-Center Review With a Real-World Evidence Perspective. J Surg Res 2021; 264:222-229. [PMID: 33838406 DOI: 10.1016/j.jss.2021.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 02/13/2021] [Accepted: 02/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Randomized controlled trials have demonstrated that surgical stabilization of rib fractures (SSRF) in selected trauma patients is associated with potential benefits. This study evaluates the real-world outcomes of SSRF since its implementation at Westmead Hospital, Australia. We hypothesize these outcomes to be similar to that reported by best-evidence in the literature. MATERIALS AND METHODS A retrospective analysis of data on all consecutive SSRF performed between January 2013 to December 2018 was completed. RESULTS Sixty-three patients (54 male; average age 55.9 ± 14.1 y) with median ISS 24 (IQR 17;30) underwent SSRF. Thirty-seven patients were admitted to Intensive Care Unit (ICU), with median ICU length of stay (LOS) 10.0 (5.0-17.0) d. Median hospital LOS was 15.5 (10.0-24.8) d. Fifty-five (87.3%) patients did not have any surgery-specific complications. The highest observed surgical morbidity was wound infection (n = 4, 4.7%). There was one mortality after rib fixation that was not related to surgery. SSRF within 3 d of hospital presentation in ventilated patients with flail chest was associated with significantly reduced median ICU LOS (3.0 [2.0;4.0] versus 10.0 [9.3;13.0] d; P = 0.03). Early (2013-2015) versus late (2015-2018) phase SSRF implementation demonstrated no significant difference in outcome variables. CONCLUSION Experience with SSRF demonstrates early outcomes similar to best-evidence in the existing literature. As a quality assurance tool, ongoing evaluation of real-world data is needed to ensure that outcomes remain consistent with benchmarks available from best-evidence.
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Affiliation(s)
- Negin Sedaghat
- Department of General Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - Corinna Chiong
- Department of General Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - Richard Tjahjono
- Department of General Surgery, Westmead Hospital, Westmead, New South Wales, Australia; Trauma Service, Westmead Hospital, Westmead, New South Wales, Australia
| | - Jeremy Hsu
- Department of General Surgery, Westmead Hospital, Westmead, New South Wales, Australia; Trauma Service, Westmead Hospital, Westmead, New South Wales, Australia; Discipline of Surgery, Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Australia.
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Choi J, Mulaney B, Laohavinij W, Trimble R, Tennakoon L, Spain DA, Salomon JA, Goldhaber-Fiebert JD, Forrester JD. Nationwide cost-effectiveness analysis of surgical stabilization of rib fractures by flail chest status and age groups. J Trauma Acute Care Surg 2021; 90:451-458. [PMID: 33559982 DOI: 10.1097/ta.0000000000003021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Surgical stabilization of rib fracture (SSRF) is increasingly used to manage patients with rib fractures. Benefits of performing SSRF appear variable, and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of SSRF versus nonoperative management among patients with rib fractures younger than 65 years versus 65 years or older, with versus without flail chest. We hypothesized that, compared with nonoperative management, SSRF is cost-effective only for patients with flail chest. METHODS This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared with nonoperative management. We report quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios. RESULTS Compared with nonoperative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of US $150,000/QALY gained. Surgical stabilization of rib fracture costs US $25,338 and US $123,377/QALY gained for those with flail chest younger than 65 years and 65 years or older, respectively. Surgical stabilization of rib fracture was not cost-effective for patients without flail chest, costing US $172,704 and US $243,758/QALY gained for those younger than 65 years and 65 years or older, respectively. One-way sensitivity analyses showed that, under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest, and nonoperative management remained cost-effective for patients older than 65 years without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients younger than 65 years with flail chest to 35% among patients 65 years or older without flail chest. CONCLUSIONS Surgical stabilization of rib fracture is cost-effective for patients with flail chest. Surgical stabilization of rib fracture may be cost-effective in some patients without flail chest, but delineating these patients requires further study. LEVEL OF EVIDENCE Economic/decision, level II.
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Affiliation(s)
- Jeff Choi
- From the Department of Surgery (J.C., L.T., D.A.S., J.D.F.), Division of General Surgery, Department of Epidemiology and Population Health (J.C.), Surgeons Writing About Trauma (J.C., B.M., R.T., L.T., D.A.S., J.D.F.), and School of Medicine (B.M., R.T.), Stanford University, Stanford, California; Department of Surgery, Chulalongkorn University (W.L.), Bangkok, Thailand; and Stanford Health Policy (J.A.S., J.D.G.-F.), Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California
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Apampa AA, Ali A, Kadir B, Ahmed Z. Safety and effectiveness of surgical fixation versus non-surgical methods for the treatment of flail chest in adult populations: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2021; 48:1025-1034. [PMID: 33547910 PMCID: PMC7866961 DOI: 10.1007/s00068-021-01606-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/11/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE The objective of this systematic review is to compare the safety and efficacy of surgical fixation of rib fractures against non-surgical interventions for the treatment of flail chest in the adult population. METHODS A search was performed on the 22nd of July 2020 to identify articles comparing surgical fixation versus clinical management for flail chest in adults, with a description of the outcome parameters (resource utility, mortality, adverse effects of the intervention and adverse progression in pulmonary status). Relevant randomised controlled trials were selected, their risk of bias assessed, and the data then extracted and analysed. RESULTS 157 patients were included from four studies in the analyses, with 79 and 78 patients in the surgical and non-surgical groups, respectively. The pooled effects of all outcomes tended towards favouring surgical intervention. Surgical intervention was associated with lower rates of pneumonia (I2 = 46%, Tau2 = 0.16, p = 0.16), significantly lower rates of tracheostomy (I2 = 76%, Tau2 = 0.67, p = 0.02), and a significantly lower duration of mechanical ventilation (I2 = 88%, Tau2 = 33.7, p < 0.01) in comparison to the non-surgical management methods. CONCLUSION Our results suggest that surgical intervention reduces the need for tracheostomy, reduces the time spent in the intensive care unit following a traumatic flail chest injury and could reduce the risk of acquiring pneumonia after such an event. There is a need for further well-designed studies with sufficient sample sizes to confirm the results of this study and also detect other possible effects of surgical intervention in the treatment of traumatic flail chest in adults.
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Affiliation(s)
- Ayobobola A Apampa
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ayesha Ali
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Bryar Kadir
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
- Surgical Reconstruction and Microbiology Research Centre, National Institute for Health Research, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK.
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Research priorities in chest wall injury: A modified Delphi approach. J Trauma Acute Care Surg 2020; 89:e106-e111. [PMID: 33017139 DOI: 10.1097/ta.0000000000002854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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46
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Myers DM, McGowan SP, Taylor BC, Sharpe BD, Icke KJ, Gandhi A. A model for evaluating the biomechanics of rib fracture fixation. Clin Biomech (Bristol, Avon) 2020; 80:105191. [PMID: 33045492 DOI: 10.1016/j.clinbiomech.2020.105191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/12/2020] [Accepted: 09/28/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION High rates of morbidity and mortality following flail chest rib fractures are well publicized. Standard of care has been supportive mechanical ventilation, but serious complications have been reported. Internal rib fixation has shown improvements in pulmonary function, clinical outcomes, and decreased mortality. The goal of this study was to provide a model defining the biomechanical benefits of internal rib fixation. METHODS One human cadaver was prepared with an actuator providing anteroposterior forces to the thorax and rib motion sensors to define interfragmentary motion. Cadaveric model was validated using a prior study which defined costovertebral motion to create a protocol using similar technology and procedure. Ribs 4-6 were fixed with motion sensors anteriorly, laterally and posteriorly. Motion was recorded with ribs intact before osteotomizing each rib anteriorly and laterally. Flail chest motion was record with fractures subsequently plated and analyzed. Motion was recorded in the sagittal, coronal and transverse axes. FINDINGS Compared to the intact rib model, the flail chest model demonstrated an 11.3 times increase in sagittal plane motion, which was reduced to 2.1 times the intact model with rib plating. Coronal and sagittal plane models also saw increases of 9.7 and 5.1 times, respectively, with regards to flail chest motion. Both were reduced to 1.2 times the intact model after rib plating. INTERPRETATION This study allows quantification of altered ribcage biomechanics after flail chest injuries and suggests rib plating is useful in restoring biomechanics as well as contributing to improving pulmonary function and clinical outcomes.
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Affiliation(s)
- Devon M Myers
- Department Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA.
| | - Sean P McGowan
- Department Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA
| | - Benjamin C Taylor
- Fellowship Director, Orthopaedic Trauma and Reconstructive Surgery, Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA
| | - B Dale Sharpe
- Department Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA
| | - Kyle J Icke
- ZimmerBiomet Research Department, 1520 Tradeport Dr., Jacksonville, FL 32218, USA
| | - Anup Gandhi
- ZimmerBiomet Laboratory Department, 10225 Westmoor Dr., Westminster, CO 80021, USA
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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
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48
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Long R, Tian J, Wu S, Li Y, Yang X, Fei J. Clinical efficacy of surgical versus conservative treatment for multiple rib fractures: A meta-analysis of randomized controlled trials. Int J Surg 2020; 83:79-88. [PMID: 32931977 DOI: 10.1016/j.ijsu.2020.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/18/2020] [Accepted: 09/04/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND There are still controversies between surgical treatment and conservative treatment for multiple rib fractures (MRFs). No consensus has been reached concerning the indications and timing of surgery. In this meta-analysis, we aimed to determine the optimal treatment for MRFs. METHODS Six databases (PubMed, Medline, Embase, Cochrane, Cnki, Wanfang Database) were retrieved for all eligible randomized controlled trials (RCTs) published before January 2020. MRFs were treated either with operative reduction and internal fixation or conservative treatment. The pertinent data were retrieved. The quality of RCTs was evaluated by the modified Jadad rating scale and meta-analysis was performed using RevMan 5.3 software. RESULTS Seven RCTs involving 538 MRFs patients (260 were treated surgically vs. 278 conservatively) were included in this meta-analysis. Compared with conservative treatment, surgical treatment resulted in shorter length of hospital stay (WMD -8.48; 95% CI -11.34 to -5.63; P < 0.001), length of ICU stay (WMD -5.72; 95% CI -7.31 to -4.13; P < 0.001) and duration of mechanical ventilation (WMD -4.93; 95% CI -8.79 to -1.07; P = 0.01), with a lower risk of complications including pneumonia (RR 0.40; 95% CI 0.30 to 0.53; P < 0.001) and chest wall deformity (RR 0.07; 95% CI 0.03 to 0.14; P < 0.001). The sensitivity analysis carried out by excluding one study with significant heterogeneity showed that the rate of tracheostomy was lower in the surgical group than in the conservative group (RR 0.44; 95% CI 0.28 to 0.71; P = 0.0008). CONCLUSIONS For patients with MRFs, surgical treatment resulted in faster recovery, a lower risk of complications and better prognosis than conservative treatment.
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Affiliation(s)
- Rui Long
- Department of Emergency, Daping Hospital, Army Medical University, Chongqing, China; Medical Center of Trauma and War Injury, Daping Hospital, Army Medical University, Chongqing, China
| | - Junying Tian
- Department of Foreign Language, Chongqing Medical University, Chongqing, China
| | - Shasha Wu
- Intensive Care Unit, Daping Hospital, Army Medical University, Chongqing, China
| | - Yang Li
- Medical Center of Trauma and War Injury, Daping Hospital, Army Medical University, Chongqing, China
| | - Xiuhua Yang
- Department of Emergency, Daping Hospital, Army Medical University, Chongqing, China; Medical Center of Trauma and War Injury, Daping Hospital, Army Medical University, Chongqing, China
| | - Jun Fei
- Department of Emergency, Daping Hospital, Army Medical University, Chongqing, China; Medical Center of Trauma and War Injury, Daping Hospital, Army Medical University, Chongqing, China.
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Harrell KN, Jean RJ, Dave Bhattacharya S, Hunt DJ, Barker DE, Maxwell RA. Late Operative Rib Fixation is Inferior to Nonoperative Management. Am Surg 2020; 86:944-949. [PMID: 32841046 DOI: 10.1177/0003134820942185] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Operative rib fixation (ORF) of traumatic rib fractures has been shown to decrease hospital length of stay (LOS), ventilator days, and mortality. ORF performed within 1 day of admission has been shown to have favorable outcomes compared to later ORF. This report examines the ORF experience over 10 years at a level I trauma center. METHODS ORF patients from January 2007-January 2018 were matched to nonoperative controls in a 1:2 ratio based on age, injury severity score (ISS), chest Abbreviated Injury Score (AIS), and head AIS. Patient demographic, injury, and outcome data were collected from the trauma registry and medical records. Hospital day of ORF was identified for each ORF patient. Hospital LOS, ICU LOS, ventilator days, and mortality were compared against matched nonoperative controls. RESULTS Ninety-five ORF patients were matched to 190 nonoperative patients. ORF patients had a higher number of rib fractures (9.6 vs 6.4, P < .001). ORF patients with short time to operation (0-2 days) had a shorter average hospital stay than those with delayed operations (11.8 vs 12.6 vs 13.4 vs 19.6 days, P = .003). ORF patients with operations performed 3-4 days and >6 days after admission also had statistically significant longer ICU LOS and ventilator days. Patient mortality was higher when ORF was performed after 6 days. DISCUSSION Early ORF may improve pulmonary function, patient outcomes, and decrease LOS. Shifting practice toward early fixation may help further solidify the benefits of this procedure in the treatment of blunt chest trauma.
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Affiliation(s)
- Kevin N Harrell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, USA
| | - Robert J Jean
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, USA
| | - S Dave Bhattacharya
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, USA
| | - Darren J Hunt
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, USA
| | - Donald E Barker
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, USA
| | - Robert A Maxwell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, USA
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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]
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