Outcomes of rib fractures in the geriatric population: A 5-year retrospective, single-institution, Australian study

Surgical stabilization of rib fractures in anticoagulated patients: Proceed with caution?

BACKGROUND

Surgical stabilization of rib fractures (SSRF) is increasingly performed, however the outcome of patients undergoing SSRF while on pre-injury antithrombotic therapy remains unknown. We compared surgical variables and outcomes of patients who were and were not on antithrombotic therapy. We hypothesize pre-injury anticoagulation is associated with delay in SSRF and worse outcomes.

METHODS

For this retrospective cohort study, we queried the Chest Injury International Database, for patients undergoing SSRF between 08/2018 and 03/2022. Antithrombotic therapy was categorized into antiplatelet and anticoagulant use. Primary outcome was time from admission to SSRF. Secondary outcomes included SSRF duration and complications. Numerical data were presented as median (IQR), categorical data as number (%). Inverse probability weighting was used to control for confounding.

RESULTS

Two hundred and eighteen SSRF patients were included, 25 (11 %) were on antithrombotic therapy. These patients were older (72 years, (65-80) versus 57 years, (43-66); p < 0.001) with lower ISS (14, (10-20) versus 21, (14-30); p = 0.002). Time from admission to SSRF was comparable (2 days, (1-4) versus 2 days, (1-4); p = 0.37) as was operative time (154 mins, (120.0-212.0) versus 177 mins, (143.0-210.0); p = 0.34). Patients using antithrombotics had fewer ICU-free days (24 (22-26) versus 28 (23-28); p = 0.003) but more ventilator free days (28, (28-28) versus 27 (27-28); p < 0.008). After adjusting for confounding, pre-injury anticoagulation was not significantly associated with delayed SSRF (Relative Risk, RR=1.37, 95 % CI 0.30-6.24), operative time (RR=1.07, 95 % CI0.88-1.31), IFD <=28 (RR=2.05, 95 %CI:0.33-12.67), VFD<=27 (RR=0.71, 95 %CI:0.15-3.48) or complications (RR=0.55, 95 % CI0.06-5.01).

CONCLUSION

Pre-injury antithrombotic drug use neither delayed SSRF nor impacted operative time in patients requiring SSRF and was not associated with increased risk of complications. Our data suggest SSRF can be safely performed without delay in patients who use anticoagulation pre-injury.

LEVEL OF EVIDENCE

IV.

STUDY TYPE

Therapeutic/care management.

Surgical stabilization of rib fractures in the geriatric trauma population is associated with equivalent outcomes to a younger cohort: A propensity matched analysis

BACKGROUND

Surgical stabilization of rib fractures (SSRF) improves outcomes in chest wall trauma. Geriatric patients are particularly vulnerable to poor outcomes; yet, this population is often excluded from SSRF studies. Further delineating patient outcomes by age is necessary to optimize care for the aging trauma population.

METHODS

A retrospective cohort study was conducted examining outcomes among patients aged 40+ for whom an SSRF consult was placed between 2017 and 2022 at a level 1 trauma center. Patients were categorized into geriatric (65+) and adult (40-64), as well as 80 years and older (80+) and 79 and younger (40-79). Patient outcomes were assessed comparing non-operative and operative management of chest wall trauma. Propensity matched analysis was performed to evaluate mortality differences between adult and geriatric patients who did and did not undergo SSRF.

RESULTS

A total of 543 patients had an SSRF consult. Of these, 227 were 65+, and 73 were 80+. A total of 129 patients underwent SSRF (24 %). The percentage of patients undergoing SSRF did not vary between 40 and 64 and 65+ (23.7 % and 23.6 %, respectively, p = 0.97) or 40-79 and 80+ (24.0 vs 21.9, p = 0.69). Patients undergoing SSRF had higher chest injury burden and were more likely to require mechanical ventilation and ICU level care on admission. Overall, in-hospital mortality rate was 4.6 %. Among patients who underwent SSRF, mortality rate did not significantly differ between 65+ and 40-64 (7.8% vs 2.7 %, p = 0.18) or 80+ and 40-79 (6.3% vs 4.6 %, p = 0.77). This remained true in propensity matched analysis.

CONCLUSION

Geriatric and octogenarian patients with rib fractures underwent SSRF at similar rates and achieved equivalent outcomes to their younger counterparts. SSRF did not differentially affect mortality outcomes based on age group in propensity matched analysis. SSRF is safe for geriatric patients including octogenarians.

Incidence of adult rib fracture injuries and changing hospitalization practice patterns: a 10-year analysis

PURPOSE

Rib fractures are common after blunt thoracic trauma and can be associated with significant morbidity and mortality. We investigated trends of rib fracture injuries among adults presenting to United States (US) emergency departments, factors related to increased likelihood of hospitalization, and hospitalization practice patterns.

METHODS

We queried the National Electronic Injury Surveillance System database between 2012 and 2021 for all patients 18 years of age and older with rib fractures. These data were extrapolated to provide national estimates. Regression analysis was performed to identify trends for injury and risk factors for hospitalization.

RESULTS

We identified 32,233 adult patients with rib fractures; this extrapolated to a national estimate of 1,430,270 patients with rib fractures during the 10-year period. Between 2012 and 2021, there was a 52% increase in the incidence rate per 100,000 persons (R2 = 0.94, p < 0.001). Males accounted for 58% of patients with rib fractures, and 50% of patients were 65 years or older. Hospitalization was required in 38% of patients, and the hospitalization rate increased by 96% during the study period (R2 = 0.96, p < 0.001). When comparing hospitals of different sizes, a 20% greater increase in the odds of hospitalization over time was identified among patients presenting to "larger" hospitals compared to "smaller" hospitals.

CONCLUSION

The incidence of rib fractures and the associated hospitalization rates are both increasing nationally, with half of cases occurring in patients aged 65 years or older. Our findings emphasize the urgent need to implement evidence-based preventive measures and current management guidelines when managing the increasing caseload of rib fracture injuries.

[Surgery of old people-Thoracic surgery]

Background

The incidence of a large number of diseases relevant to thoracic surgery increases with age; however, old age is still frequently considered a contraindication per se for curative interventions and extensive surgical procedures.

Objective

Overview of the current relevant literature, derivation of recommendations for patient selection as well as preoperative, perioperative and postoperative optimization.

Material and methods

Analysis of the current study situation.

Results

Recent data show that for most thoracic diseases, age alone is not a reason to withhold surgical treatment. Much more important for the selection are comorbidities, frailty, malnutrition and cognitive impairment. A lobectomy or segmentectomy for stage I non-small cell lung cancer (NSCLC) in carefully selected octogenarians can provide acceptable to even comparably good short-term and long-term results as in younger patients. Selected > 75-year-old patients with stages II-IIIA NSCLC even benefit from adjuvant chemotherapy. With appropriate selection high-risk interventions, such as pneumonectomy in > 70-year-old patients and pulmonary endarterectomy in > 80-year-old patients can be performed without an increase in mortality rates. Even lung transplantation can lead to good long-term results in carefully selected > 70-year-old patients. Minimally invasive surgical techniques and nonintubated anesthesia contribute to risk reduction in marginal patients.

Discussion

In thoracic surgery the biological age rather than the chronological age is decisive. In view of the increasingly older population, further studies are urgently needed to optimize patient selection, type of intervention, preoperative planning and postoperative treatment as well as the quality of life.

Management Pathways for Traumatic Rib Fractures-Importance of Surgical Stabilisation

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.

[Surgery of old people-Thoracic surgery]

BACKGROUND

The incidence of a large number of diseases relevant to thoracic surgery increases with age; however, old age is still frequently considered a contraindication per se for curative interventions and extensive surgical procedures.

OBJECTIVE

Overview of the current relevant literature, derivation of recommendations for patient selection as well as preoperative, perioperative and postoperative optimization.

MATERIAL AND METHODS

Analysis of the current study situation.

RESULTS

Recent data show that for most thoracic diseases, age alone is not a reason to withhold surgical treatment. Much more important for the selection are comorbidities, frailty, malnutrition and cognitive impairment. A lobectomy or segmentectomy for stage I non-small cell lung cancer (NSCLC) in carefully selected octogenarians can provide acceptable to even comparably good short-term and long-term results as in younger patients. Selected > 75-year-old patients with stages II-IIIA NSCLC even benefit from adjuvant chemotherapy. With appropriate selection high-risk interventions, such as pneumonectomy in > 70-year-old patients and pulmonary endarterectomy in > 80-year-old patients can be performed without an increase in mortality rates. Even lung transplantation can lead to good long-term results in carefully selected > 70-year-old patients. Minimally invasive surgical techniques and nonintubated anesthesia contribute to risk reduction in marginal patients.

DISCUSSION

In thoracic surgery the biological age rather than the chronological age is decisive. In view of the increasingly older population, further studies are urgently needed to optimize patient selection, type of intervention, preoperative planning and postoperative treatment as well as the quality of life.

Management of Advanced Aged Patients with Rib Fractures: Current Evidence and Review of the Literature

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.