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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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He W, Yang Y, Salonga R, Powell L, Greiffenstein P, Prins JTH, Abella SP. Surgical stabilization of multiple rib fractures in an Asian population: a systematic review and meta-analysis. J Thorac Dis 2023; 15:4961-4975. [PMID: 37868848 PMCID: PMC10586968 DOI: 10.21037/jtd-23-1117] [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: 07/18/2023] [Accepted: 09/08/2023] [Indexed: 10/24/2023]
Abstract
Background There is no consensus on the effectiveness of surgical stabilization in multiple rib fractures in Asia, especially among patients with a non-flail rib fracture pattern. We aim to synthesize the evidence on the effectiveness of surgical stabilization of rib fractures (SSRF) in an Asian population with multiple non-flail rib fractures. Methods The MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews were searched in this systematic literature review and meta-analysis to identify studies conducted in Asia that included patients with multiple non-flail rib fractures in at least one of their treatment groups. The intervention of interest was SSRF, and the comparator was a nonoperative treatment. The duration of mechanical ventilation (DMV) was the primary outcome. Posttreatment pain score, pneumonia, atelectasis, intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), need for tracheostomy, respiratory function, functional outcomes, quality of life (QoL), and mortality were identified as the secondary outcomes. A random effects model (REM) was used to pool data for outcomes reported in two or more studies. Results A total of 12 studies (n=2,440 patients) were included. There was a significantly shorter DMV {mean difference (MD): -5.23 [95% confidence interval (CI): -9.64 to -0.81], P=0.02}, lower 4-week post-treatment pain score [standard mean difference (SMD): -2.24 (95% CI: -3.18 to -1.31), P<0.00001], lower risk for pneumonia [risk ratio (RR): 0.46 (95% CI: 0.23 to 0.95), P=0.04], lower risk for atelectasis [RR: 0.44, (95% CI: 0.29 to 0.65), P<0.0001], shorter ICU LOS [MD: -4.00 (95% CI: -6.33 to -1.66), P=0.0008], and shorter HLOS [MD: -6.54 (95% CI: -9.28 to -3.79), P<0.00001] in favor of SSRF. Effect estimates for the need for tracheostomy [RR: 0.67 (95% CI: 0.42 to 1.08), P=0.10] and mortality [RR: 0.94 (95% CI: 0.37 to 2.41), P=0.90] were nonsignificant. Conclusions In the Asian population with mainly non-flail rib fracture patterns, SSRF was associated with shorter DMV, ICU LOS, and HLOS as well as lower risks for atelectasis and pneumonia, and pain scores after 4 weeks. The risk of mortality was comparable between treatment groups.
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Affiliation(s)
- Weiwei He
- Department of Thoracic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Yang
- Department of Thoracic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Ledford Powell
- Division of Thoracic Surgery, Providence St. Joseph Health, Mission Hospital, Mission Viejo, CA, USA
| | - Patrick Greiffenstein
- Division of Trauma, Department of Surgery, Louisiana State University Health Science Center, New Orleans, LA, USA
| | - Jonne T H Prins
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
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McGuinness MJ, Isles S, Xu W, Harmston C. Incidence and outcomes of major trauma patients with thoracic injuries and rib fractures in Aotearoa New Zealand. Injury 2023; 54:110787. [PMID: 37150724 DOI: 10.1016/j.injury.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 04/09/2023] [Accepted: 05/02/2023] [Indexed: 05/09/2023]
Abstract
INTRODUCTION Thoracic trauma represents a significant burden of disease in Aotearoa, New Zealand (AoNZ). To date, no study has examined the incidence or outcomes of patients suffering major thoracic trauma, or major trauma and rib fractures in AoNZ. METHODS A 6 year retrospective study of all major trauma (Injury Severity Score >12) patients in AoNZ was performed. The National Trauma Registry was searched to identify patients. The National Minimum Data Set was searched for all ICD-10 codes associated with surgical stabilisation of rib fractures (SSRF). Poisson regression was used to determine the change in incidence rate over the study period adjusted for age with the logarithm of population size as the offset variable. The incidence rate ratios (IRR) with 95% confidence intervals (CI) were reported. RESULTS 12,218 patients sustained major trauma. 7,059 (57.8%) of these patients sustained thoracic injuries. Of these patients, 5,585 (79.1%) sustained rib fractures, and 180 (3.2%) proceeded to SSRF. A flail segment was observed in 16% of patients with rib fractures. Transport was the mechanism of injury in 53% of patients. During the study the incidence (cases per 100,000 people per year) of major trauma increased from 39.5 to 49.3 (IRR 1.05, 95%CI 1.04 to 1.07, <0.001), the incidence of thoracic injuries from 21.3 to 28.7 (1.07, 95% CI 1.05 to 1.08, <0.001) and the incidence of rib fractures from 16.0 to 22.9 (1.08, 95% CI 1.06 to 1.09, <0.001). SSRF was performed in 3.2% of patients with rib fractures and increased from 0.2 to 0.8 cases per 100,000 people per year (1.27, 95% CI 1.15 to 1.41, <0.001) during the study. CONCLUSION This study reports the incidence of major trauma patients with thoracic injury, major trauma patients with rib fractures and the incidence of SSRF in AoNZ. Transport related injuries are the predominant mechanism of injury. The incidence of SSRF was low across AoNZ. To improve the quality of care in AoNZ for major trauma patients with rib fractures, consideration should be made to create national guidelines and robust referral pathways to specialist centres that provide multidisciplinary care including performing SSRF.
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Affiliation(s)
| | | | | | - Christopher Harmston
- University of Auckland, New Zealand; Whangarei Hospital, Te Whatu Ora, New Zealand
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Liu HY, Lin TH, Chen KC, Hsiao WL, Hu RH, Liao HC. Comparison between non-surgical and surgical management of rib fractures in major trauma patients without brain injuries. Am J Surg 2023; 226:350-355. [PMID: 37263888 DOI: 10.1016/j.amjsurg.2023.05.025] [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: 03/13/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND This study aimed to evaluate the different outcomes between the non-surgical and surgical groups in patients with major trauma without brain injuries. METHODS This study prospectively collected data from patients with traumatic rib fractures without brain injuries from June 2017 to November 2019. The primary outcomes were the pain score at admission and discharge and the length of hospital stay. We performed multiple regression analysis to compare the outcomes and surgical risk as the severity of chest trauma between both groups. RESULTS Fifty-three patients were enrolled. There was no statistically significant difference in baseline characteristics between both groups. However, the surgical group had more severe chest trauma than the non-surgical group. After the analysis, the pain score improved significantly in the surgical group. The hospital stay of the surgical group was four days shorter than that of the non-surgical group, and there was severe chest trauma in the surgical group. CONCLUSIONS Surgical management of rib fractures can reduce pain and hospital stay in major trauma patients.
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Affiliation(s)
- Hao-Yun Liu
- Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Tzu-Hsin Lin
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ke-Cheng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Ling Hsiao
- School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Rey-Heng Hu
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsien-Chi Liao
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan.
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Wang Z, Jia Y, Li M. The effectiveness of early surgical stabilization for multiple rib fractures: a multicenter randomized controlled trial. J Cardiothorac Surg 2023; 18:118. [PMID: 37038166 PMCID: PMC10084648 DOI: 10.1186/s13019-023-02203-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/31/2023] [Indexed: 04/12/2023] Open
Abstract
INTRODUCTION Multiple rib fractures (≥ 3 displaced rib fractures and/or flail chest) are severe chest trauma with high morbidity and mortality. Rib fixation has become the first choice for multiple rib fracture treatment. However, the timing of surgical rib fixation is unclear. MATERIALS AND METHODS The present study explored whether early rib fracture fixation can improve the outcome of multiple rib fractures. The present research included patients who were hospitalized in three Jiangsu hospitals following diagnosis with multiple rib fractures. Patients received early rib fracture fixation (≤ 48 h) or delayed rib fracture fixation (> 48 h) utilizing computer-based random sequencing (in a 1:1 ratio). The primary outcome measures included hospital length of stay, intensive care unit (ICU) stay, mechanical ventilation, inflammatory cytokine levels, infection marker levels, infection, and mortality. RESULTS A total of 403 individuals were classified into two groups, namely, the early group (n = 201) and the delayed group (n = 202). Patients belonging to the two groups had similar baseline clinical data, and there were no statistically significant differences between them. Early rib fracture fixation greatly decreased the length of stay in the ICU (4.63 days vs. 6.72 days, p < 0.001), overall hospital stay (10.15 days vs. 12.43 days, p < 0.001), ventilation days (3.67 days vs. 4.55 days, p < 0.001), and hospitalization cost (6900 USD vs. 7600 USD, p = 0.008). Early rib fracture fixation can decrease inflammatory cytokine levels and infection marker levels, prevent hyperinflammation and improve infection in patients with multiple rib fractures. The timing of rib fracture fixation does not influence the surgical procedure time, operative blood loss, 30-day all-cause mortality, or surgical site infection. CONCLUSION The findings from the present research indicated that early rib fracture fixation (≤ 48 h) is a safe, rational, effective and economical strategy and worth clinical promotion.
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Affiliation(s)
- Zhengwei Wang
- Department of Thoracic Surgery, The 904th Hospital of PLA Joint Logistic Support Force, Xing Yuan North Road 101, Wuxi, 214044, China
| | - Yifei Jia
- Department of Thoracic Surgery, Affiliated Hospital of Jiangnan University, Wuxi, 214044, China
| | - Mi Li
- Department of Thoracic Surgery, The 904th Hospital of PLA Joint Logistic Support Force, Xing Yuan North Road 101, Wuxi, 214044, China.
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Shiroff AM, Wolf S, Wu A, Vanderkarr M, Anandan M, Ruppenkamp JW, Galvain T, Holy CE. Outcomes of surgical versus nonsurgical treatment for multiple rib fractures: A US hospital matched cohort database analysis. J Trauma Acute Care Surg 2023; 94:538-545. [PMID: 36730674 PMCID: PMC10045967 DOI: 10.1097/ta.0000000000003828] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/04/2022] [Accepted: 10/25/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Treatment for multiple rib fractures includes surgical stabilization of rib fractures (SSRF) or nonoperative management (NOM). Meta-analyses have demonstrated that SSRF results in faster recovery and lower long-term complication rates versus NOM. Our study evaluated postoperative outcomes for multiple rib fracture patients following SSRF versus NOM in a real-world, all-comer study design. METHODS Multiple rib fracture patients with inpatient admissions in the PREMIER hospital database from October 1, 2015, to September 30, 2020, were identified. Outcomes included discharge disposition, and 3- and 12-month lung-related readmissions. Demographics, comorbidities, concurrent injuries at index, Abbreviated Injury Scale and Injury Severity Scores, and provider characteristics were determined for all patients. Patients were excluded from the cohort if they had a thorax Abbreviated Injury Scale score of <2 (low severity patient) or a Glasgow Coma Scale score of ≤8 (extreme high severity patient). Stratum matching between SSRF and NOM patients was performed using fine stratification and weighting so that all patient data were kept in the final analysis. Outcomes were analyzed using generalized linear models with quasinormal distribution and logit links. RESULTS A total of 203,450 patients were included, of which 200,580 were treated with NOM and 2,870 with SSRF. Compared to NOM, patients with SSRF had higher rates of home discharge (62% SSRF vs. 58% NOM) and lower rates of lung-related readmissions (3 months, 3.1% SSRF vs. 4.0% NOM; 12 months, 6.2% SSRF vs. 7.6% NOM). The odds ratio (OR) for home or home health discharge in patients with SSRF versus NOM was 1.166 (95% confidence interval [CI], 1.073-1.266; p = 0.0002). Similarly, ORs for lung-related readmission at 3- and 12-month were statistically lower in the patients treated with SSRF versus NOM (OR [3 months], 0.764 [95% CI, 0.606-0.963]; p = 0.0227 and OR [12 months], 0.799 [95% CI, 0.657-0.971]; p = 0.0245). CONCLUSION Surgical stabilization of rib fractures results in greater odds of home discharge and lower rates of lung-related readmissions compared with NOM at 12 months of follow-up. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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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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McGuinness MJ, Harmston C. Management and outcomes of rib fractures in patients with isolated blunt thoracic trauma: Results of the Aotearoa New Zealand RiBZ study. Injury 2022; 53:2953-2959. [PMID: 35489820 DOI: 10.1016/j.injury.2022.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 02/02/2023]
Abstract
AIM Rib fractures are common and associated with significant morbidity and mortality. There is limited literature on patient care and outcomes in Aotearoa New Zealand (AoNZ). The aim of this study is to describe key clinical outcomes and management interventions for patients with rib fractures across AoNZ. METHODS A national prospective multicenter observational cohort study was performed. Patients admitted between 1 December 2020 and 28 February 2021 with one or more radiologically proven rib fractures and an Abbreviated Injury Score of the head or abdomen of less than 3 were included. The primary outcomes of interest were the rates of thirty-day pneumonia, re-presentation and mortality. The secondary outcomes of interest were rate of surgical stabilisation of rib fractures (SSRF) and pain management of patients with rib fractures. Binomial logistic regression was performed for the primary outcomes and funnel plots were created of the inter-hospital variation in pneumonia. RESULTS Fourteen AoNZ hospitals and 407 patients were included. Mean age was 57.4 (SD 18.7), 28% were female, 15% Māori and 85% non-Māori. The median number of rib fractures was 4. The rate of pneumonia, re-presentation and mortality was 11%, 8% and 2%, respectively. Logistic regression found the odds of pneumonia increased with each additional rib fracture (OR 1.15 95% CI 1.05-1.25) and the odds of re-presentation increased with age (OR 1.028 95% CI 1.005-1.051) and Māori ethnicity (OR 2.754 95% CI 1.077-7.045). The funnel plot of inter-hospital variation in pneumonia rate adjusted for clinically plausible variables found no centre lay outside the 95% confidence interval. SSRF was performed in 2% of patients. 58% of patients had a pain team review and 23% a regional block. CONCLUSION This study describes clinical outcomes for patients with isolated rib fractures from multiple hospitals in AoNZ. A moderate pneumonia rate of 11% was found which is likely amendable to reduction with quality improvement initiatives. Consideration should be given to further resource and improve the access to SSRF and regional analgesia given the low utilization found across AoNZ. A higher re-presentation rate in Māori and elderly patients was found which needs further investigation.
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Affiliation(s)
- Matthew J McGuinness
- University of Auckland; Surgical Department, Whangārei Hospital, Manu Road, Whangārei, New Zealand.
| | - Christopher Harmston
- University of Auckland; Surgical Department, Whangārei Hospital, Manu Road, Whangārei, New Zealand
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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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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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11
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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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12
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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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13
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Rebollo Salazar D, Velez-Rosborough A, DiMaggio C, Krowsoski L, Klein M, Berry C, Tandon M, Frangos S, Bukur M. Race and Insurance Status are Associated With Different Management Strategies After Thoracic Trauma. J Surg Res 2021; 261:18-25. [PMID: 33401122 DOI: 10.1016/j.jss.2020.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/17/2020] [Accepted: 11/01/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Health-care disparities based on race and socioeconomic status among trauma patients are well-documented. However, the influence of these factors on the management of rib fractures following thoracic trauma is unknown. The aim of this study is to describe the association of race and insurance status on management and outcomes in patients who sustain rib fractures. METHODS The Trauma Quality Improvement Program database was used to identify adult patients who presented with rib fractures between 2015 and 2016. Patient demographics, injury severity, procedures performed, and outcomes were evaluated. Multivariate logistic regression analysis was used to determine the effect of race and insurance status on mortality and the likelihood of rib fixation surgery and epidural analgesia for pain management. RESULTS A total of 95,227 patients were identified. Of these, 2923 (3.1%) underwent rib fixation. Compared to White patients, Asians (AOR: 0.57, P = 0.001), Blacks or African-Americans (AA) (AOR: 0.70, P < 0.001), and Hispanics/Latinos (HL) (AOR: 0.78, P < 0.001) were less likely to undergo rib fixation surgery. AA patients (AOR: 0.67, P = 0.004), other non-Whites (ONW) (AOR: 0.61, P = 0.001), and HL (AOR 0.65, P = 0.006) were less likely to receive epidural analgesia. Compared to privately insured patients, mortality was higher in uninsured patients (AOR: 1.72, P < 0.001), Medicare patients (AOR: 1.80, P < 0.001), and patients with other non-private insurance (AOR: 1.23, P < 0.001). CONCLUSIONS Non-White race is associated with a decreased likelihood of rib fixation and/or epidural placement, while underinsurance is associated with higher mortality in patients with thoracic trauma. Prospective efforts to examine the socioeconomic disparities within this population are warranted.
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Affiliation(s)
| | | | - Charles DiMaggio
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Leandra Krowsoski
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Michael Klein
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Cherisse Berry
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Manish Tandon
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Spiros Frangos
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Marko Bukur
- Department of Surgery, New York University School of Medicine, New York, New York
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14
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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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15
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Uchida K, Miyashita M, Kaga S, Noda T, Nishimura T, Yamamoto H, Mizobata Y. Long-term outcomes of surgical rib fixation in patients with flail chest and multiple rib fractures. Trauma Surg Acute Care Open 2020; 5:e000546. [PMID: 33062899 PMCID: PMC7520900 DOI: 10.1136/tsaco-2020-000546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/08/2020] [Accepted: 08/27/2020] [Indexed: 11/23/2022] Open
Abstract
Background Recently, interest has increased in surgical fixation for severe thoracic wall injury with good short-term outcomes. However, few reports have evaluated long-term outcomes or complications. This study aimed to assess long-term quality of life and implant-related complications after rib fixation for flail chest and multiple rib fractures. Methods We interviewed patients who had undergone rib fixation from January 2014 to December 2019 about their current ability to work and their usual life. Results Twenty-two patients underwent rib fixation during the study period. Two patients with flail chest had already died after the surgery due to senescence; thus, follow-up information was obtained from 20 patients (91%), with a follow-up duration of 47.5 (IQR 22–58) months. The most undesirable event occurring during the study period was irritation caused by a palpable plate (n=2, 10%), probably due to the thin skin of patients over 70 years old. Eighteen patients were able to return to their usual life or same work as in the premorbid state with no complaints. Two patients are still undergoing rehabilitation due to concomitant extremities fractures. The median EQ-5D-5L index score was 0.89 (IQR 0.84–0.93). There were no implant-related complications requiring plate explantation. Discussion We concluded that rib fixation offers good long-term benefits, with the ability of the patient with flail chest or multiple rib fractures to return to activity in the premorbid state. Elderly patients especially with thin, soft tissue may complain of irritation caused by the plate and should be informed of this prior to surgery. Level of evidence Level IV therapeutic care/management.
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Affiliation(s)
- Kenichiro Uchida
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masahiro Miyashita
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinichiro Kaga
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tomohiro Noda
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiromasa Yamamoto
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasumitsu Mizobata
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
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16
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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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Wijffels MME, Prins JTH, Polinder S, Blokhuis TJ, De Loos ER, Den Boer RH, Flikweert ER, Pull Ter Gunne AF, Ringburg AN, Spanjersberg WR, Van Huijstee PJ, Van Montfort G, Vermeulen J, Vos DI, Verhofstad MHJ, Van Lieshout EMM. Early fixation versus conservative therapy of multiple, simple rib fractures (FixCon): protocol for a multicenter randomized controlled trial. World J Emerg Surg 2019; 14:38. [PMID: 31384292 PMCID: PMC6668138 DOI: 10.1186/s13017-019-0258-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/22/2019] [Indexed: 12/22/2022] Open
Abstract
Background Multiple rib fractures are common injuries in both the young and elderly. Rib fractures account for 10% of all trauma admissions and are seen in up to 39% of patients after thoracic trauma. With morbidity and mortality rates increasing with the number of rib fractures as well as poor quality of life at long-term follow-up, multiple rib fractures pose a serious health hazard. Operative fixation of flail chest is beneficial over nonoperative treatment regarding, among others, pneumonia and both intensive care unit (ICU) and hospital length of stay. With no high-quality evidence on the effects of multiple simple rib fracture treatment, the optimal treatment modality remains unknown. This study sets out to investigate outcome of operative fixation versus nonoperative treatment of multiple simple rib fractures. Methods The proposed study is a multicenter randomized controlled trial. Patients will be eligible if they have three or more multiple simple rib fractures of which at least one is dislocated over one shaft width or with unbearable pain (visual analog scale (VAS) or numeric rating scale (NRS) > 6). Patients in the intervention group will be treated with open reduction and internal fixation. Pre- and postoperative care equals treatment in the control group. The control group will receive nonoperative treatment, consisting of pain management, bronchodilator inhalers, oxygen support or mechanical ventilation if needed, and pulmonary physical therapy. The primary outcome measure will be occurrence of pneumonia within 30 days after trauma. Secondary outcome measures are the need and duration of mechanical ventilation, thoracic pain and analgesics use, (recovery of) pulmonary function, hospital and ICU length of stay, thoracic injury-related and surgery-related complications and mortality, secondary interventions, quality of life, and cost-effectiveness comprising health care consumption and productivity loss. Follow-up visits will be standardized and daily during hospital admission, at 14 days and 1, 3, 6, and 12 months. Discussion With favorable results in flail chest patients, operative treatment may also be beneficial in patients with multiple simple rib fractures. The FixCon trial will be the first study to compare clinical, functional, and economic outcome between operative fixation and nonoperative treatment for multiple simple rib fractures. Trial registration www.trialregister.nl, NTR7248. Registered May 31, 2018.
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Affiliation(s)
- Mathieu M E Wijffels
- 1Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Jonne T H Prins
- 1Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Suzanne Polinder
- 2Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Taco J Blokhuis
- 3Department of Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Erik R De Loos
- 4Department of Surgery, Zuyderland Medisch Centrum, P.O. Box 5500, 6130 MB Sittard-Geleen, The Netherlands
| | - Roeland H Den Boer
- 5Department of Surgery, Spaarne Gasthuis, P.O. Box 417, 2000 AK Haarlem, The Netherlands
| | - Elvira R Flikweert
- 6Department of Surgery, Deventer Ziekenhuis, P.O. Box 5001, 7400 GC Deventer, The Netherlands
| | | | - Akkie N Ringburg
- 8Department of Surgery, Ikazia Ziekenhuis, P.O. Box 5009, 3008 AA Rotterdam, The Netherlands
| | | | - Pieter J Van Huijstee
- Department of Surgery, Haga Ziekenhuis, P.O. Box 40551, 2504 LN The Hague, The Netherlands
| | - Gust Van Montfort
- 11Department of Surgery, Catharina Ziekenhuis, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands
| | - Jefrey Vermeulen
- 12Department of Surgery, Maasstad Ziekenhuis, P.O. Box 9100, 3007 AC Rotterdam, The Netherlands
| | - Dagmar I Vos
- 13Department of Surgery, Amphia Ziekenhuis, P.O. Box 90158, 4800 RK Breda, The Netherlands
| | - Michael H J Verhofstad
- 1Trauma 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
- 1Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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Dickson-Lowe RA, Buitendag JJP, Jolayemi OO, Oosthuizen G. Rib fracture fixation as a tool for extubation in a resource-poor environment. BMJ Case Rep 2019; 12:bcr-2018-227518. [PMID: 30739088 PMCID: PMC6441265 DOI: 10.1136/bcr-2018-227518] [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] [Accepted: 01/10/2019] [Indexed: 11/04/2022] Open
Abstract
An elderly female with multiple comorbidities was involved in a pedestrian vehicle accident and sustained blunt chest trauma, arriving at a resource-poor hospital in rural South Africa. She had multiple bilateral rib fractures with a unilateral flail segment that caused her to develop respiratory failure. She was intubated and sent to the intensive care unit (ICU) for ventilation. She developed hospital and ventilator acquired pneumonia. She subsequently had hypoxic arrests on two separate occasions and two failed extubations. Despite inadequate access to provisions, this patient was taken to theatre for rib fracture fixation as an attempt to improve her lung function and get her off the ventilator. She was extubated two days after the procedure and discharged from ICU 4 days thereafter. On her follow-up, she reported that she had returned to normal daily living and tasks.
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Affiliation(s)
| | - Johannes Jacobus Petrus Buitendag
- Department of General Surgery, Ngwelezana Hospital, Empangeni, KwaZulu Natal, South Africa
- Department of General Surgery, Tygerberg Hospital, Tygerberg, South Africa
| | | | - George Oosthuizen
- Department of General Surgery, Ngwelezana Hospital, Empangeni, KwaZulu Natal, South Africa
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