The effectiveness of early surgical stabilization for multiple rib fractures: a multicenter randomized controlled trial

Clinical outcome analysis for surgical fixation versus conservative treatment on rib fractures: a systematic evaluation and meta-analysis

BACKGROUND

The efficacy of surgical intervention for traumatic rib fractures in improving clinical outcomes remains a subject of considerable debate. Over the past decade, the adoption of surgical stabilization for rib fractures (SSRF) has increased substantially. This study presents a systematic review and meta-analysis of the literature published over the past 20 years, with the objective of comparing the clinical outcomes of adult patients with multiple traumatic rib fractures who underwent SSRF, relative to those treated conservatively.

METHODS

We searched six online databases (PubMed, Web of Science, Embase, Cochrane Library, and the Sino-American Clinical Trials Database) for literature published between June 2004 and June 2024. The Cochrane Collaboration Risk of Bias 2 (RoB 2) and the Newcastle-Ottawa Scale (NOS) tool were employed to assess methodological quality, and relative risks (RR) with 95% confidence intervals (CI) were calculated to evaluate the outcome measures. The primary outcome was all-cause mortality, while the secondary outcomes included hospital length of stay (HLOS), ICU length of stay (ILOS), duration of mechanical ventilation (DMV), and the incidence of pneumonia. Subgroup analyses were performed to assess the effects of fracture type, age, timing of surgical fixation, and study design on treatment outcomes.

RESULTS

A total of 47 studies involving 1,078,795 patients were included, consisting of three randomized controlled trials and 44 case-control studies. The results demonstrated that patients who underwent SSRF experienced better outcomes than those receiving conservative treatment in terms of all-cause mortality. However, SSRF was not superior to conservative treatment regarding HLOS, ILOS, or health care costs. Subgroup analyses revealed that the SSRF group had a lower incidence of pneumonia and shorter DMV in patients with flail chest, and patients older than 60 years may also benefit from SSRF, Furthermore, those who underwent SSRF within 72 h had shorter HLOS and DMV compared to those treated conservatively.

CONCLUSION

SSRF reduces mortality in patients with multiple rib fractures compared to conservative management, particularly in those with flail chest and in patients over 60 years of age. It also offers benefits in terms of pneumonia incidence and DMV for patients with flail chest. Early SSRF may significantly reduce HLOS and DMV. However, careful screening of appropriate candidates is crucial to maximize the benefits of SSRF.

Effects of post rib plating tube thoracostomy output on the need for thoracic re-intervention: Does the volume matter?

BACKGROUND

Surgical stabilization of rib fractures (SSRF) has been demonstrated to improve early clinical outcomes. Tube thoracostomy (TT) is commonly performed with SSRF, however there is a paucity of data regarding when removal of TT following SSRF should occur. This study aimed to compare patients undergoing thoracic reinterventions (reintubation, reinsertion of TT/pigtail, or video-assisted thoracic surgery) to those not following SSRF+TT, hypothesizing increased TT output prior to removal would be associated with thoracic reintervention.

METHODS

We performed a single center retrospective (2018-2023) analysis of blunt trauma patients ≥ 18 years-old undergoing SSRF+TT. The primary outcome was thoracic reinterventions. Patients undergoing thoracic reintervention ((+)thoracic reinterventions) after TT removal were compared to those who did not ((-)thoracic reintervention). Secondary outcomes included TT duration and outputs prior to removal.

RESULTS

From 133 blunt trauma patients undergoing SSRF+TT, 23 (17.3 %) required thoracic reinterventions. Both groups were of comparable age. The (+)thoracic reintervention group had an increased injury severity score (median: 29 vs. 17, p = 0.035) and TT duration (median: 4 vs. 3 days, p < 0.001) following SSRF. However, there were no differences in median TT outputs between both cohorts post-SSRF day 1 (165 mL vs. 160 mL, p = 0.88) as well as within 24 h (60 mL vs. 70 mL, p = 0.93) prior to TT removal.

CONCLUSION

This study demonstrated over 17 % of SSRF+TT patients required a thoracic reintervention. There was no association between thoracic reintervention and the TT output prior to removal. Future studies are needed to confirm these findings, which suggest no absolute threshold for TT output should be utilized regarding when to pull TT following SSRF.

Short-term follow-up of single-port thoracoscopic rib fracture reduction and internal fixation for the treatment of multiple rib fractures

OBJECTIVE

The objective of this study was to evaluate the short-term outcomes of single-port thoracoscopic rib fracture reduction and internal fixation for the treatment of multiple rib fractures.

METHODS

This study included 149 patients with multiple rib fractures admitted to the Second People's Hospital Affiliated with Fujian University of Chinese Medicine between June 2021 and April 2024. The patients were divided into two groups based on the surgical method. The study group, consisting of 84 cases, underwent rib fracture reduction using a single-port thoracoscopy and internal fixation with a memory alloy reverse rib embrace device. The control group, consisting of 65 cases, underwent traditional open surgery for rib fracture internal fixation. Perioperative and follow-up data were collected and analyzed to assess incision length, total operation time, intraoperative blood loss, number of memory alloy embrasures placed, placement success rate, drainage tube placement time, time to mobilization, total hospitalization duration, total cost, preoperative and postoperative pain levels, postoperative complications, and rib CT results three months postoperatively.

RESULTS

There was no statistically significant difference in general conditions between the study group and the control group. All 149 patients successfully completed the surgery, with 3 to 10 intrathoracic memory alloy embrace devices placed in each patient, achieving a 100% success rate. Compared to the control group, the study group showed significant improvements in incision length (3.5 ± 0.6 vs. 6.5±1.6 cm), intraoperative blood loss (92.5 ± 15.1 vs. 113 ± 18.2 ml), drainage tube placement time (75.4 ± 13.1 vs. 90.6 ± 15.4 h), mobilization time (2.9 ± 1.1 vs. 3.3 ± 1.3 days), and hospital stay (10.8 ± 2.7 vs. 12 ± 3.5 days), with differences being statistically significant (P < 0.05). In terms of preoperative Visual Analogue Scale (VAS) pain scores, the study group had a significantly lower score on the first postoperative day compared to the control group (3.9 ± 1.1 vs. 4.5 ± 1.4, P < 0.05). A follow-up CT and 3D reconstruction at 3 months post-surgery showed that all patients had securely fixed plates, with the study group demonstrating a higher rate of excellent fracture healing (94% vs. 83.1%), which was statistically significant (P < 0.05).

CONCLUSION

The use of a memory alloy reverse rib embrasure device for intrathoracic rib fracture fixation via single-port thoracoscopic surgery is safe and reliable. This method demonstrates a high success rate of internal fixation, excellent clinical fracture healing, and advantages such as minimal trauma, rapid recovery, and the simultaneous treatment of other intrathoracic conditions. It significantly reduces postoperative pain and enhances the quality of life.

Comminuted Paraspinal Rib Fractures with Resultant Impending Penetrating Aortic Injury Requiring Costovertebral Rib Fixation: A Case Report

Background and Objectives: Rib fractures are common in patients with trauma, and patients with multiple rib fractures often require surgical stabilization. Because rib fractures may occur at different sites along the ribs, the technical approach to surgical stabilization varies. Here, we present a case of posterior rib fractures with multiple paraspinal fragmented rib segments that were successfully treated with costovertebral plate fixation. Case Presentation: A truck driver was injured after falling from the top of a truck. Computed tomography scans of the chest showed multiple flail segments along the paraspinal and posterolateral regions with a clinically evident flail chest. Owing to the proximity of the flail segments to the thoracic spine, rib plating was performed across the ribs and the transverse processes of the thoracic spine with the assistance of a neurosurgeon. The patient was extubated on postoperative day 1 and discharged successfully after the other traumatic injuries were treated. Discussion: Far posterior rib fractures close to the spine may be challenging, particularly if plates for rib fractures cannot be placed on the ribs alone. For such challenges, costotransverse plating is a feasible surgical option. However, the anatomical orientation of the rib and the transverse process of the thoracic spine are different, which complicates surgical planning and maneuvers. Therefore, a thorough understanding of the costotransverse anatomy is critical for successful surgical stabilization of fractured ribs. Conclusions: This is a good example of a challenging case of rib fractures requiring paraspinal plate stabilization.

Best Available Outcomes Evidence Informing Standard of Care

SUMMARY

Although nonoperative management is the mainstay for rib fracture treatment, surgical stabilization of rib fractures is becoming more common. Recently, the number of high-quality studies on management of rib fractures has also increased. The primary purpose of this review is to analyze the currently available prospective randomized studies on the management of rib fractures. In addition, we will summarize both short-term and long-term outcomes of patients with rib fractures.

Erector spinae plane block (ESPB) enhances hemodynamic stability decreasing analgesic requirements in surgical stabilization of rib fractures (SSRFs)

OBJECTIVE

To evaluate the efficacy of erector spinae plane block (ESPB) on intraoperative hemodynamic stability, opioid and inhalation anesthetic requirements and postoperative analgesic effects in patients undergoing surgical stabilization of rib fractures (SSRFs).

METHODS

We retrospectively reviewed 173 patients who underwent surgical stabilization of rib fractures between May 2020 and December 2023. The patients were allocated into the ESPB group or the control group. Demographic data, intraoperative hemodynamic parameters, total intraoperative opioid consumption, the average minimum alveolar concentration (MAC) of inhalational anesthetics, postoperative simple analgesics and opioid consumption and the length of hospital stay were included in the analysis.

RESULTS

Compared with the control group, the ESPB group had a lower heart rate (HR) in the first 90 min after surgical incision and lower systolic blood pressure (SBP) and mean arterial pressure (MAP) at the beginning of surgery. Intraoperatively, a notable reduction in fentanyl consumption was observed in the ESPB group (p = 0.004), whereas no significant difference was observed in the average MAC of inhalational agents (p = 0.073). Postoperatively, the ESPB group required fewer doses of simple analgesics in the first 24 h (p < 0.001) and 48 h (p = 0.029). No statistically significant difference in the length of hospital stay (p = 0.608) was observed between the groups.

CONCLUSION

ESPB was shown to enhance intraoperative hemodynamic stability, reduce opioid consumption and decrease postoperative analgesic consumption in patients who underwent SSRF. These results suggest that ESPB may serve as a valuable component of multimodal analgesia protocols for SSRF. Larger prospective studies are warranted to confirm the results and evaluate long-term outcomes.

Surgical management of multiple rib fractures in polytrauma patients: semi-damage control surgery

Background: To investigate the timing and extent of surgery for rib fractures in polytrauma patients. Methods: Data from polytrauma patients who underwent early and partial rib fracture fixation after successful resuscitation were retrospectively analyzed. The study encompassed demographic data, clinical data, and outcomes. Results: In total, 71 patients with polytrauma were included. ISS ranged from 16 to 50 with a mean score of 25.3±7.5. The median lactate level was 3.6 mmol/L (IQR: 3.1 to 4.5), the median base deficit (BD) was 8.2 mmol/L (IQR: 6.4 to 9.8) and the shock index (SI) median was 1.2 (IQR: 0.9 to 1.3). Total fractured ribs in 71 patients were 726; individually, the minimum and maximum number of fractured ribs was 3 and 22, respectively (median, 10; mean, 10.2 ± 4.0). The average time to surgery was 42.9±42.6 h. Specifically, 41(57.7%) received the surgery within 24h and 52 (73.2%) patients received the surgery within 3 days following successful resuscitation. A total of 246 (33.9%) ribs underwent open reduction and internal fixation with plate, 3.46 ribs for each patient, with high frequencies of the 6th (49, 19.9%), 5th (46, 18.7%), 4th and 7th ribs (both 36, 14.6%). The average length of ICU stay was 11.5 ± 7.5 days and the duration of hospitalization was 16.3 ± 9.9 days. No surgical site infection or mortality was observed. Conclusions: Early and partial rib fracture fixation to restore the relative stability of the thorax is safe and effective for polytrauma patients after successful resuscitation. This surgery strategy is called semi-damage control surgery.

Prognostic factors for outcomes following surgical stabilization of rib fractures: A review of the literature

Rib fractures are a common injury following blunt thoracic trauma, often resulting in high levels of morbidity and mortality. With the ageing global population, the incidence of rib fractures is expected to increase, posing a significant burden on healthcare systems worldwide. With advancements in surgical techniques and pioneering research on the topic the use of surgical stabilisation of rib fractures (SSRF) has increased significantly over the past two decades. However, the relationship between certain prognostic factors and patient outcomes following surgery is still contested and there lacks a consensus on definitive indications for the operation. This literature review presents the current research on SSRF outcomes for; patients with flail chest injuries and multiple-non flail rib fractures, optimal timing between injury and operation, and patient age. This article contributes to the ongoing dialogue surrounding chest wall trauma management and may be drawn upon to aid future research and develop clinical practice guidelines.

Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper

BACKGROUND

Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements.

RESULTS

A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection.

CONCLUSION

This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research.

Time-to-operation delays and in-hospital complications in operative facial trauma: A national analysis

BACKGROUND

Management of facial fractures is variable. Understanding how time to operative management impacts outcomes can help standardize practice.

METHODS

Retrospective analysis of the ACS Trauma Quality Improvement Program (TQIP) database between 2016 and 2019. Adult patients with operative facial fractures were isolated by ICD-10 procedure codes, and further stratified by fracture location, including the mandible, orbit, maxilla, zygoma, and frontal bone. Multivariable logistic regression was conducted to predict in-hospital complications (both surgical and systemic complications) adjusting for time-to-operation, comorbidities, fracture location, AIS, and demographics.

RESULTS

1678 patients with operative facial fractures were identified. The median time-to-operation was 2 days (IQR 1.0-2.0 days). Most patients only had one operative fracture (95 %) and orbital fracture was the most common (44 %). The overall complication rate was higher for those operated after 2 days compared to those operated between 1 and 2 days and within 24 h (2.8 % vs 0.6 % vs 0.7 %; p < 0.001). Patients who were operated on after 48 h exhibited an increased risk of any complication (OR 4.72, 95 % CI 1.49-16.6, p = 0.010) on multivariable models.

CONCLUSION

Delays in the management of facial fractures are associated with more in-hospital complications. However, the incidence of short-term postoperative complications remains low. Injury characteristics are the primary predictor of delays in operation, however Hispanic patients independently experienced delays in care.

Perioperative considerations for patients undergoing surgical stabilization of rib fractures: A narrative review

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.

Evaluating the impact of timing to rib fixation in patients with traumatic brain injury: A nationwide analysis

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.

Early Internal Fixation of Concomitant Clavicle Fractures in Severe Thoracic Trauma Prevents Posttraumatic Pneumonia

BACKGROUND

Severe thoracic trauma can lead to pulmonary restriction, loss of lung volume, and difficulty with ventilation. In recent years, there has been increasing evidence of better clinical outcomes following surgical stabilization of clavicle fractures in the setting of this combination of injuries. The aim of this study was to evaluate surgical versus non-surgical treatment of clavicle fractures in severe thoracic trauma in terms of clinical and radiological outcomes in order to make a generalized treatment recommendation based on the results of a large patient cohort.

PATIENTS AND METHODS

This retrospective study included 181 patients (42 women, 139 men) from a European level I trauma centre with a median of 49.3 years in between 2005 and 2021. In 116 cases, the clavicle fracture was stabilized with locking plate or hook plate fixation (group 1), and in 65 cases, it was treated non-surgically (group 2). Long-term functional outcomes at least one year postoperatively using the disabilities of the arm, shoulder and hand (DASH) questionnaire and the Nottingham Clavicle Score (NCS) as well as radiological outcomes were collected in addition to parameters such as hospital days, intensive care days, and complication rates.

RESULTS

The Injury Severity Score (ISS) was 17.8 ± 9.8 in group 1 and 19.9 ± 14.4 in group 2 (mean ± SEM; p = 0.93), the time in hospital was 21.5 ± 27.2 days in group 1 versus 16 ± 29.3 days in group 2 (p = 0.04). Forty-seven patients in group 1 and eleven patients in the group 2 were treated in the ICU. Regarding the duration of ventilation (group 1: 9.1 ± 8.9 days, group 2: 8.1 ± 7.7 days; p = 0.64), the functional outcome (DASH group 1: 11 ± 18 points, group 2: 13.7 ± 18. 4 points, p = 0.51; NCS group 1: 17.9 ± 8.1 points, group 2: 19.4 ± 10.3 points, p = 0.79) and the radiological results, no significant differences were found between the treatment groups. With an overall similar complication rate, pneumonia was found in 2% of patients in group 1 and in 14% of patients in group 2 (p = 0.001).

DISCUSSION

This study could demonstrate that surgical locking plate fixation of clavicle fractures in combination with CWI significantly reducing the development of posttraumatic pneumonia in a large patient collection and, therefore, can be recommended as standard therapeutic approach for severe thoracic trauma.