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Malkoc A, Mamoun L, Vignaroli K, Gill H, Barmanwalla A, Phan A, Daoud A, Nguyen A, Woodward B. Conservative Treatment of Empyema Formation Following Intrathoracic Rib Fixation With Antibiotics and Tissue Plasminogen Activator/Dornase. J Med Cases 2024; 15:215-221. [PMID: 39205698 PMCID: PMC11349117 DOI: 10.14740/jmc4267] [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: 06/09/2024] [Accepted: 07/16/2024] [Indexed: 09/04/2024] Open
Abstract
Rib plating is a recommended intervention for patients with multiple rib fractures or flail chest to improve shortness of breath, significantly reduce pain, and shorten the length of hospital stay. Here, we report a unique and extremely rare finding in a patient with empyema following intrathoracic rib fixation. A 32-year-old male with a history of alcohol use disorder presented to the emergency department trauma bay after a motor vehicle accident. Computed tomography (CT) showed right hemopneumothorax and fourth to ninth rib fractures with displacement. The right fifth and sixth ribs were then plated using a titanium RibFix bridge, implanted intrathoracically along the posterior surface of the ribs. On postoperative day 11, the patient developed an empyema and a CT-guided drainage catheter was placed into the collection. The patient was given a 3-day course of tissue plasminogen activator (tPA) and DNase for the treatment of his empyema. On postoperative day 15, a repeat CT scan demonstrated significant improvement in the empyema with evidence of abscess resolution. Antibiotics were discontinued after a total of 7 days and the patient was discharged on postoperative day 20. This case report contributes information to the management of complications in intrathoracic rib fixation.
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Affiliation(s)
- Aldin Malkoc
- Arrowhead Regional Medical Center, Colton, CA 92324, USA
| | - Lana Mamoun
- California University of Science and Medicine, Colton, CA 92324, USA
| | | | - Harpreet Gill
- Arrowhead Regional Medical Center, Colton, CA 92324, USA
| | | | - Alexander Phan
- Arrowhead Regional Medical Center, Colton, CA 92324, USA
| | - Amanda Daoud
- Arrowhead Regional Medical Center, Colton, CA 92324, USA
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Haines K, Shin GJ, Truong T, Kuchibhatla M, Moore L, Rice W, Xu R, Swain S, Grisel B, Castillo-Angeles M, Agarwal S, Fernandez-Moure J. Age-Neutral Surgical Stabilization of Rib Fractures: Breaking the Ageism Barrier. J Surg Res 2024; 302:420-427. [PMID: 39153364 DOI: 10.1016/j.jss.2024.07.081] [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: 01/27/2024] [Revised: 07/10/2024] [Accepted: 07/19/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Surgical stabilization of rib fractures (SSRF) is associated with lower rates of mortality and fewer complications. This study evaluates whether the decision to undergo SSRF is associated with age, race, ethnicity, and insurance status and assesses associated clinical outcomes. METHODS This retrospective analysis included patients ≥45 y old with rib fractures who underwent SSRF in the Trauma Quality Improvement Program from 2016 to 2020. Race, ethnicity, and insurance statuses were collected. Age in years was dichotomized into two groups: 45-64 and 65+. Outcomes included ventilator-associated pneumonia, unplanned endotracheal intubation, acute respiratory distress syndrome, in-hospital mortality, failure to rescue (FTR) after major complications, and FTR after respiratory complications. Logistic regression models were fit to evaluate outcomes, controlling for gender, body mass index, Injury Severity Score, flail chest, chronic obstructive pulmonary disease, congestive heart failure, and smoking. RESULTS Two thousand eight hundred thirty-nine patients aged 45-64 and 1828 patients aged 65+ underwent SSRF. No significant difference in clinical outcomes was noted between these groups. Analysis showed that the association of SSRF with ventilator-associated pneumonia, unplanned intubation, acute respiratory distress syndrome, in-hospital mortality, FTR after a major complication, or FTR after a respiratory complication did not vary by age (P > 0.05). Black (odds ratio [OR] 0.67; 95% confidence interval [CI]: 0.59-0.77; P < 0.001), Hispanic (OR 0.80; 95% CI: 0.71-0.91; P < 0.001), and Medicaid (OR = 0.85; 95% CI = 0.76-0.95; P = 0.005) patients were less likely to receive SSRF. CONCLUSIONS No differences in clinical outcomes were measured between adults aged 45-64 and ≥65 who underwent SSRF. Older age should not preclude patients from receiving SSRF. Further work is needed to improve underutilization in Black, Hispanic and Medicaid patients.
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Affiliation(s)
- Krista Haines
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Gi Jung Shin
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Tracy Truong
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Maragatha Kuchibhatla
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Lauren Moore
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - William Rice
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ruidi Xu
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Sonal Swain
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Braylee Grisel
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Manuel Castillo-Angeles
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Joseph Fernandez-Moure
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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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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Bauer F, Haag S, Najafi K, Miller B, Kepros J. Surgical stabilization of rib fracture patients versus nonoperative controls treated by a multidisciplinary team in a single institution. Heliyon 2023; 9:e15205. [PMID: 37123889 PMCID: PMC10130754 DOI: 10.1016/j.heliyon.2023.e15205] [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: 09/12/2022] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction Despite promising evidence, surgical stabilization of rib fractures (SSRF) is not ubiquitously offered in all trauma centers. Some centers struggle with patient selection while some struggle due to surgeon comfort with the technique. To address this issue, our trauma center developed a multidisciplinary SSRF approach between orthopedic and trauma surgery. Methods This retrospective study compared 43 patients who underwent SSRF at a level 1 trauma center with 43 nonoperatively managed controls. Our study Indications were flail chest with >3 segments; non-flail with severe, bi-cortical displacement of >3 contiguous segments. Main outcome measures included mortality, ICU duration, hospital stay LOS, rates of ventilator-associated pneumonia (VAP) and ventilator days. Results Results of SSRF included decreases in mortality (2% vs 16.3%; p = 0.03) and in ICU duration. Patients with SSRF had a significantly shorter duration in the ICU than the nonoperative group (8.72 vs 14 days; p = 0.013) but a similar hospital duration (LOS mean, 12.81 vs 15.2; p = 0.29). Less patients in the SSRF group developed VAP but the difference was not significant (2% vs 14%, p = 0.055). Discussion SSRF patient outcomes supported prior evidence. The tandem approach had benefits as surgeons were able to leverage skills and expertise, increase collaboration between services, and complete more difficult reconstructions. Our experience may serve as a model for trauma centers interested in starting a new program or enhancing current service offerings.
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Zhang D, Jiao C, Xi S, Wang L, Li R, Zhang Q. Evaluation of surgical outcomes in elderly patients with rib fractures: A single-centre propensity score matching study. Front Surg 2023; 10:1174365. [PMID: 37143770 PMCID: PMC10151702 DOI: 10.3389/fsurg.2023.1174365] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 03/31/2023] [Indexed: 05/06/2023] Open
Abstract
Background Rib fractures are the most common injuries in chest trauma. Compared with younger patients, elderly patients with rib fracture have a higher incidence of complications and mortality. A retrospective study was conducted to investigate the effect of internal fixation compared with conservative treatment on the outcome of rib fracture in elderly patients. Material and methods We used a 1:1 propensity score matching method to perform a retrospective analysis of 703 elderly patients with rib fractures treated in the Thoracic Surgery Department of Beijing Jishuitan Hospital between 2013 and 2020. After matching, the length of hospital stay, death, symptom relief and rib fracture healing were compared between the surgery and the control group. Results The study included 121 patients receiving SSRF in the surgery group and 121 patients receiving conservative treatment in the control group. The length of hospital stay in the surgery group was significantly longer than that in the conservative group (11.39d vs. 9.48d, p = 0.000). After 9 months of follow-up, the fracture healing rate in the surgery group was significantly higher than that in the control group (96.67% vs. 88.89%, p = 0.020). The fracture healing time (p = 0.000), improvement in pain score (p = 0.000) and duration of pain medication use (p = 0.000) were also significantly better in the surgery group than in the control group. Conclusion Compared with conservative treatment, surgical treatment can prolong hospital stay to some extent. However, it has the advantages of more rapid healing and lessened pain. For rib fractures in elderly individuals, surgical treatment is a safe and effective option under strict surgical indications and is recommended.
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Affiliation(s)
- Dong Zhang
- Department of Thoracic Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Chenbo Jiao
- Health Science Center, Peking University, Beijing, China
| | - Siqi Xi
- Health Science Center, Peking University, Beijing, China
| | - Langran Wang
- Health Science Center, Peking University, Beijing, China
| | - Run Li
- Health Science Center, Peking University, Beijing, China
| | - Qiang Zhang
- Department of Thoracic Surgery, Beijing Jishuitan Hospital, Beijing, China
- Correspondence: Qiang Zhang
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Lucky number 13: Association between center-specific chest wall stabilization volumes and patient outcomes. J Trauma Acute Care Surg 2022; 93:774-780. [PMID: 35972185 DOI: 10.1097/ta.0000000000003764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Chest wall stabilization (CWS) improves outcomes for patients with chest wall injury (CWI). We hypothesized that patients treated at centers with higher annual CWS volumes experience superior outcomes. METHODS A retrospective study of adults with acute CWI undergoing surgical stabilization of rib or sternal fractures within the 2019 Trauma Quality Improvement Program database, excluding those with 24-hour mortality or any Abbreviated Injury Scale body region of six, was conducted. Hospitals were grouped in quartiles by annual CWS volume. Our primary outcome was a composite of in-hospital mortality, ventilator-associated pneumonia, acute respiratory distress syndrome, sepsis, and unplanned intubation or intensive care unit readmission. Regression was controlled for age, sex, Injury Severity Scale, flail chest, medical comorbidities, and Abbreviated Injury Scale chest. We performed cut-point analysis and compared patient outcomes from high- and low-volume centers. RESULTS We included 3,207 patients undergoing CWS at 430 hospitals with annual volumes ranging from 1 to 66. There were no differences between groups in age, sex, or Injury Severity Scale. Patients in the highest volume quartile (Q4) experienced significantly lower rates of the primary outcome (Q4, 14%; Q3, 18.4%; Q2, 17.4%; Q1, 22.1%) and significantly shorter hospital and intensive care unit lengths of stay. Q4 versus Q1 had lower adjusted odds of the primary outcome (odds ratio, 0.58; 95% confidence interval, 0.43-0.80). An optimal cut point of 12.5 procedures annually was used to define high- and low-volume centers. Patients treated at high-volume centers experienced significantly lower rates of the primary composite outcome, in-hospital mortality, and deep venous thrombosis with shorter lengths of stay and higher rates of home discharge. CONCLUSION Center-specific CWS volume is associated with superior in-hospital patient outcomes. These findings support efforts to establish CWI centers of excellence. Further investigation should explore the impact of center-specific volume on patient-reported outcomes including pain and postdischarge quality of life. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Adereti C, Fabien J, Adereti J, Pierre-Louis M, Chacon D, Adereti V. Rib Plating as an Effective Approach to Managing Traumatic Rib Injuries: A Review of the Literature. Cureus 2022; 14:e29664. [DOI: 10.7759/cureus.29664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 11/05/2022] Open
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The where, when, and why of surgical rib fixation: Utilization patterns, outcomes, and readmissions. Am J Surg 2022; 224:780-785. [DOI: 10.1016/j.amjsurg.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/26/2022] [Accepted: 04/04/2022] [Indexed: 11/23/2022]
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