Early Surgical Stabilization of Complex Chest Wall Injuries Improves Short-Term Patient Outcomes

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 Rib Fracture Fixation: Early Operative Intervention Improves Outcomes

Background

This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or nonoperative management at our major trauma center.

Methods

A retrospective review of all patients who were considered for surgical stabilization of rib fractures (SSRF) at a single major trauma center from May 2016 to September 2022 was performed.

Results

In total, 352 patients with complex rib fractures were identified. Thirty-seven patients (11%) fulfilled the criteria for surgical management and underwent SSRF. The SSRF group had a significantly higher proportion of patients with flail chest (32 [86%] vs. 94 [27%], p<0.001) or Injury Severity Score (ISS) >15 (37 [100%] vs. 129 [41%], p<0.001). No significant differences were seen between groups for 1-year mortality. Patients who underwent SSRF within 72 hours were 6 times less likely to develop pneumonia than those in whom SSRF was delayed for over 72 hours (2 [18%] vs. 15 [58%]; odds ratio, 0.163; 95% confidence interval, 0.029-0.909; p=0.036). Prompt SSRF showed non-significant associations with shorter intensive care unit length of stay (6 days vs. 10 days, p=0.140) and duration of mechanical ventilation (5 days vs. 8 days, p=0.177). SSRF was associated with a longer hospital length of stay compared to nonoperative patients with flail chest and/or ISS >15 (19 days vs. 13 days, p=0.012), whilst SSRF within 72 hours was not.

Conclusion

Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Delayed surgical fixation was associated with increased rates of pneumonia and a longer hospital length of stay.

Validity of the ACS NSQIP surgical risk calculator as a tool to predict postoperative outcomes in subacute orthopedic trauma diagnoses

Purpose

This retrospective study aimed to validate the ACS NSQIP Surgical Risk Calculator (SCR) to predict 30-day postoperative outcomes in patients with one of the following subacute orthopedic trauma diagnoses; multiple rib fractures, pelvic ring/acetabular fracture, or unilateral femoral fracture.

Methods

Data of patients with these diagnoses treated between January 1, 2015 and September 19, 2020 were extracted from the patients' medical files. Diagnostic performance, discrimination, calibration, and accuracy of the ACS NSQIP SRC to predict specific outcomes developing within 30 days after surgery was determined.

Results

The total cohort of the three diagnoses consisted of 435 patients. ACS NSQIP SRC underestimated the risk for serious complications, especially in patients with multiple rib fractures (8.3% predicted vs 17.2% observed) or pelvic ring/acetabular fracture (6.1% vs 19.8%). Underestimation was more pronounced for the composite outcome 'any complication'. Sensitivity ranged from 16.7% to 100% and specificity from 41.1% to 97.1%. Specificity exceeded sensitivity for pelvic ring/acetabular and femoral fractures. Discrimination was good for predicting death (femoral fracture), fair for readmission (femoral fracture), serious complication (multiple rib fractures), and any complication (multiple rib fractures), but poor in all other outcomes and diagnoses. Calibration and accuracy were adequate for all three diagnoses (p-value for Hosmer-Lemeshow test >0.05 and Brier scores <0.25).

Conclusion

Performance of the ACS NSQIP SRC in the studied cohort was variable for all three diagnoses. Although it underestimated the risk of most outcomes, calibration and accuracy seemed generally adequate. For most outcomes, adequate diagnostic performance and discrimination could not be confirmed.

Evolution of Pulmonary Contusions in Patients With Severe Rib Fractures: Cause for Concern?

INTRODUCTION

The progression of pulmonary contusions remains poorly understood. This study aimed to measure the radiographic change in pulmonary contusions over time and evaluate the association of the radiographic change with clinical outcomes and surgical stabilization of rib fractures (SSRF).

METHODS

This retrospective cohort study included adults admitted with three or more displaced rib fractures or flail segment on trauma CT and when a chest CT was repeated within one week after trauma. Radiographic severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion Score (BPC18). Logistic regression was performed to evaluate the relation between SSRF and worsening contusions on repeat CT, adjusted for potential confounders.

RESULTS

Of 231 patients, 56 (24%) had a repeat CT scan. Of these, 55 (98%) had pulmonary contusion on the first CT scan with a median BPC18 score of 5 (P25-P75 3-7). Repeat CTs showed an overall decrease of the median BPC18 score to 4 (P25-P75 2-6, P = .02), but demonstrated a worsening of the pulmonary contusion in 16 patients (29%). All repeat CTs conducted within 12 hours post-injury demonstrated increasing BPC18. Radiographic worsening of pulmonary contusions was not associated with SSRF, nor with worse respiratory outcomes or intensive care length of stay, compared to patients with radiographically stable or improving contusions.

DISCUSSION

In patients with severe rib fracture patterns who undergo repeat imaging, pulmonary contusions are prevalent and become radiographically worse within at least the first 12 hours after injury. No association between radiographic worsening and clinical outcomes was found.

Early Repair of Rib Fractures Is Associated with Superior Length of Stay and Total Hospital Cost: A Propensity Matched Analysis of the National Inpatient Sample

Background and Objectives: Previous studies have suggested that early scheduling of the surgical stabilization of rib fractures (SSRF) is associated with superior outcomes. It is unclear if these data are reproducible at other institutions. We hypothesized that early SSRF would be associated with decreased morbidity, length of stay, and total charges. Materials and Methods: Adult patients who underwent SSRF for multiple rib fractures or flail chest were identified in the National Inpatient Sample (NIS) by ICD-10 code from the fourth quarter of 2015 to 2016. Patients were excluded for traumatic brain injury and missing study variables. Procedures occurring after hospital day 10 were excluded to remove possible confounding. Early fixation was defined as procedures which occurred on hospital day 0 or 1, and late fixation was defined as procedures which occurred on hospital days 2 through 10. The primary outcome was a composite outcome of death, pneumonia, tracheostomy, or discharge to a short-term hospital, as determined by NIS coding. Secondary outcomes were length of hospitalization (LOS) and total cost. Chi-square and Wilcoxon rank-sum testing were performed to determine differences in outcomes between the groups. One-to-one propensity matching was performed using covariates known to affect the outcome of rib fractures. Stuart-Maxwell marginal homogeneity and Wilcoxon signed rank matched pair testing was performed on the propensity-matched cohort. Results: Of the 474 patients who met the inclusion criteria, 148 (31.2%) received early repair and 326 (68.8%) received late repair. In unmatched analysis, the composite adverse outcome was lower among early fixation (16.2% vs. 40.2%, p < 0.001), total hospital cost was less (USD114k vs. USD215k, p < 0.001), and length of stay was shorter (6 days vs. 12 days) among early SSRF patients. Propensity matching identified 131 matched pairs of early and late SSRF. Composite adverse outcomes were less common among early SSRF (18.3% vs. 32.8%, p = 0.011). The LOS was shorter among early SSRF (6 days vs. 10 days, p < 0.001), and total hospital cost was also lower among early SSRF patients (USD118k vs. USD183k late, p = 0.001). Conclusion: In a large administrative database, early SSRF was associated with reduced adverse outcomes, as well as improved hospital length of stay and total cost. These data corroborate other research and suggest that early SSRF is preferred. Studies of outcomes after SSRF should stratify analyses by timing of procedure.

Early Surgical Stabilization of Rib Fractures is Feasible in Patients With Non-Urgent Operative Pelvic Injuries

INTRODUCTION

The feasibility of prioritizing surgical stabilization of rib fractures (SSRF) in patients with other injuries is unknown. The purpose of this study was to evaluate the timing and outcomes of SSRF between patients with and without non-urgent operative pelvic injuries.

PATIENTS AND METHODS

In this retrospective observational study, all patients between 2010 and 2020 who underwent SSRF (SSRF group) and those who underwent SSRF and non-urgent operative management of pelvic fractures (SSRF + P group) were included. Demographics, injury characteristics, operative details, and outcomes were compared between the 2 groups.

RESULTS

Over 11 years, 154 SSRF patients were identified, with 143 patients in the SSRF group (93%) and 11 patients in the SSRF + P group (7%). Median number of rib fractures (7 vs 9, P = .04), total number of fractures (11 vs 15, P < .01), and flail segment (54% vs 91%, P = .02) were higher in SSRF + P group. Median time to SSRF was similar (0 vs 1 day, P = .20) between the 2 groups. Median time to pelvic fixation was 3 days in SSRF + P group and 8 out of 11 patients (73%) underwent SSRF prior to pelvic fixation. Median operative time (137 vs 178 mins, P = .14) and median number of ribs plated (4 vs 5, P = .05) were higher in SSRF + P group. There was no difference in SSRF-related complications, pelvic fracture-related complications from operative positioning, rates of pneumonia, or mortality between the 2 groups.

CONCLUSIONS

SSRF can be performed early in patients with non-urgent operative pelvic injuries without a difference in pelvic fracture-related complications, SSRF-related complications, pneumonia, or mortality.

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.

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

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.

Surgical Stabilization of Rib Fractures in Severe Injury Is Not Associated With Worse Outcomes

INTRODUCTION

This study aimed to determine whether surgical stabilization of rib fractures (SSRF) is associated with worse outcomes in individuals with multicompartmental injuries.

MATERIALS AND METHODS

A retrospective review of a prospective trauma registry was performed for adult blunt trauma patients (aged ≥ 18 y) with Injury Severity Score ≥ 15 and radiographic evidence of rib fractures (2015-2020). Individuals without concomitant head, abdomen/pelvis, or lower extremity Abbreviated Injury Scale scores ≥ 3 were excluded. Propensity match on demographic and clinical variables was performed comparing patients treated nonoperatively (NO) to those undergoing SSRF. A chart review was performed for additional data. Primary outcome was hospital length of stay (LOS). Secondary outcomes were in-hospital mortality, intensive care unit LOS, and duration of mechanical ventilation.

RESULTS

One thousand nine hundred ninety three patients fit the inclusion criteria (NO = 1,951, SSRF = 42). After matching, there were 98 in the NO group and 42 in the SSRF group. Mean age was 51 y, 61.4% were male, and 71.4% were of White race. Median time to fixation was 5 d. The SSRF group had more severe chest trauma as evidenced by a higher RibScore (3.2 versus 1.7, P < 0.001) and had a longer LOS (18 versus 9 d, P < 0.001), intensive care unit LOS (13 versus 3 d, P = 0.007), and duration of mechanical ventilation (8 versus 2 d, P = 0.013) on univariate analysis. Multivariable regression analysis demonstrated no association between SSRF and these short-term outcomes.

CONCLUSIONS

Despite delayed average time to intervention, SSRF in a trauma-patient population with multicompartmental injuries and competing management priorities is not associated with worse short-term outcomes.

Rib fixation for flail chest physiology and the facilitation of safe prone spinal surgery: illustrative case

BACKGROUND

Spine fractures are frequently associated with additional injuries in the trauma setting, with chest wall trauma being particularly common. Limited literature exists on the management of flail chest physiology with concurrent unstable spinal injury. The authors present a case in which flail chest physiology precluded safe prone surgery and after rib fixation the patient tolerated spinal fixation without further issue.

OBSERVATIONS

Flail chest physiology can cause cardiovascular decompensation in the prone position. Stabilization of the chest wall addresses this instability allowing for safe prone spinal surgery.

LESSONS

Chest wall fixation should be considered in select cases of flail chest physiology prior to stabilization of the spinal column in the prone position. Further research is necessary to identify patients that are at highest risk to not tolerate prone surgery.

Retrospective study of consecutive rib fracture patients treated by open reduction internal fixation in a single major trauma centre, UK

INTRODUCTION

Rib fractures are a common presentation in both patients presenting with high impact poly-trauma and as a result of low energy falls in the elderly. This injury can lead to various complications including prolonged hospital admission, pneumonia, need for ventilation and in admission to intensive care unit. There is much controversy around the management of this injury in the literature, with favourable outcomes for patients treated non-operatively as well as surgically.

METHODS

We collated a database for all rib fracture fixations between 2014 and 2019 that took place at the major trauma centre in Liverpool. The decision to undergo surgical fixation was after discussion with multidisciplinary team at trauma meeting. Following British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs), these injuries should ideally be operated on within 48 h.

RESULTS

Overall, a total of 220 patients were included in the study (143 male and 77 female). 142 (64%) patients were operated on within 48 h of admission. A total of 101 (45%) patients required admission to ITU. Those in the early surgical fixation group had a statistically significant decrease in their hospital length of stay (12.8 days compared to 15.5 days, p=<0.001). Mean length of ITU stay was shorter in the early surgical group with no statistical significance (p = 0.1). Those patients that required mechanical ventilation in turn stayed in hospital for a longer period compared to those who did not (p=<0.001). There is no statistical difference in survival between the 2 patient groups (p = 0.3).

DISCUSSION

To our knowledge, this is the largest data set published in the rib fracture fixation cohort. Our results agree with previous studies which have demonstrated that those who undergo ORIF tend require fewer days of hospital stay, less ventilatory support and overall have better outcomes in terms of pain when compared to those treated non-operatively. Our study adds that patients who receive treatment within 48-hours as per BOAST guidelines have better outcomes, specifically reducing hospital length of stay by nearly 4 days (p = 0.014).

CONCLUSION

Early surgical fixation of rib fractures leads to significantly favoured outcomes.

Is it Necessary to Stabilize Every Fracture in Patients with Serial Rib Fractures in Blunt Force Trauma?

Introduction

Management of traumatic rib fractures is subject of controversial discussions. Rib fractures are common, especially after traffic accidents and falls. There is no consensus on whether and how many rib fractures need reconstruction. Not every rib fracture needs to be stabilized, but conservative treatment by internal splinting and analgesia is not effective for all patients. Deformities of the chest wall with reduced thoracic volume and restrictive ventilation disorders must be avoided. Intraoperative assessment of fractures and chest stability plays a central role.

Material and methods

From 07/2016 to 07/2021, a total of 121 chest wall stabilizations were performed (m:f = 2:1, age 65 ± 14.5 a). Indications for surgery were the following criteria: (1) palpatory instability of the chest wall, (2) dislocated fracture endings, (3) concomitant injuries, (4) uncontrollable pain symptoms. In all patients, a computed tomography scan of the thorax was performed before the osteosynthetic treatment to assess dislocation of the fracture endings and possible concomitant injuries of intrathoracic organs.

Results

Video-assisted thoracoscopy was performed in all patients. Hemothorax and concomitant injuries of the lung, diaphragm and mediastinum could be assessed. This was followed by an intraoperative assessment of the rib fractures, in particular penetration of fracture endings and resulting instability and deformity. Relevant fractures could be identified and subsequent incisions for rib osteosynthesis precisely defined. 6.3 (±2.7) rib fractures were detected, but 2.4 (±1.2) ribs treated osteosynthetically. Bilateral rib fractures were present in 26 patients (21.5%). Post-operative bleeding occurred in seven patients (5.8%), a breakage of the osteosynthetic material in two patients (1.7%).

Discussion

Intraoperative assessment of relevant fractures and dislocation is the decisive criterium for osteosynthesis. Thoracoscopy is mandatory for this purpose - also to identify accompanying injuries. Not every fracture has to be approached osteosynthetically. Even with serial rib fractures or multiple fractures in a single rib, the thoracic contour can be restored by stabilizing only relevant fractures. Intraoperative palpation can adequately assess the stability and thus the result of the osteosynthesis. Even after surgical treatment of thoracic trauma, adequate analgesia and respiratory therapy are important to the healing process.

Surgical fixation of rib fractures improves 30-day survival after significant chest injury : an analysis of ten years of prospective registry data from England and Wales

AIMS

The last decade has seen a marked increase in surgical rib fracture fixation (SRF). The evidence to support this comes largely from retrospective cohorts, and adjusting for the effect of other injuries sustained at the same time is challenging. This study aims to assess the impact of SRF after blunt chest trauma using national prospective registry data, while controlling for other comorbidities and injuries.

METHODS

A ten-year extract from the Trauma Audit and Research Network formed the study sample. Patients who underwent SRF were compared with those who received supportive care alone. The analysis was performed first for the entire eligible cohort, and then for patients with a serious (thoracic Abbreviated Injury Scale (AIS) ≥ 3) or minor (thoracic AIS < 3) chest injury without significant polytrauma. Multivariable logistic regression was performed to identify predictors of mortality. Kaplan-Meier estimators and multivariable Cox regression were performed to adjust for the effects of concomitant injuries and other comorbidities. Outcomes assessed were 30-day mortality, length of stay (LoS), and need for tracheostomy.

RESULTS

A total of 86,838 cases were analyzed. The rate of SRF was 1.2%. SRF significantly reduced risk of mortality (odds ratio (OR) 0.27 (95 confidence interval (CI) 0.128 to 0.273); p < 0.001) and need for tracheostomy (OR 0.22 (95% CI 0.191 to 0.319); p < 0.001) after adjustment for other covariables across the whole cohort. SRF remained protective in patients with a serious chest injury (hazard ratio (HR) 0.24 (95% CI 0.13 to 0.45); p < 0.001). The benefit in more minor chest injury was less clear. Mean LoS for patients who survived was longer in the SRF group (24.29 days (SD 26.54) vs 16.60 days (SD 26.35); p < 0.001).

CONCLUSION

SRF reduces mortality after significant chest trauma associated with both major and minor polytrauma. The rate of fixation in the UK is low and potentially underused as a treatment for severe chest wall injury. Cite this article: Bone Joint J 2022;104-B(6):729-735.

Impact of Time of Surgery on the Outcome after Surgical Stabilization of Rib Fractures in Severely Injured Patients with Severe Chest Trauma—A Matched-Pairs Analysis of the German Trauma Registry

Purpose

In severely injured patients with multiple rib fractures, the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results, and the indication and especially the right timing of an operation are the subject of a broad discussion. The aim of this study was to determine the influence of the time point of surgical stabilization of rib fractures (SSRF) on the outcome in a multicenter database with special regard to the duration of ventilation, intensive care, and overall hospital stay.

Methods

Data from the TraumaRegister DGU collected between 2010 and 2019 were used to evaluate patients above 16 years of age with severe rib fractures [Abbreviated Injury Score (AIS)  ≥ 3] who received an SSRF in a matched-pairs analysis. In this matched-pairs analysis, we compared the effects of an early SSRF within 48 h after initial trauma vs. late SSRF 3–10 days after trauma.

Results

After the selection process, we were able to find 142 matched pairs for further evaluation. Early SSRF was associated with a significantly shorter length of stay in the intensive care unit (16.2 days vs. 12.7 days, p = 0.020), and the overall hospital stay (28.5 days vs. 23.4 days, p = 0.005) was significantly longer in the group with late SSRF. Concerning the days on mechanical ventilation, we were able to demonstrate a trend for an approximately 1.5 day shorter ventilation time for patients after early SSRF, although this difference was not statistically significant (p = 0.226).

Conclusions

We were able to determine the significant beneficial effects of early SSRF resulting in a shorter intensive care unit stay and a shorter length of stay in hospital and additionally a trend to a shorter time on mechanical ventilation.

A decade of surgical stabilization of rib fractures: the effect of study year on patient selection, operative characteristics, and in-hospital outcome

BACKGROUND

Many centers now perform surgical stabilization of rib fractures (SSRF). This single center study aimed to investigate temporal trends by year in patient selection, operative characteristics, and in-hospital outcomes We hypothesized that, over time, patient selection, time to SSRF, operative time, and in-hospital outcomes varied significantly.

METHODS

A retrospective review of a prospectively maintained SSRF database (2010 to 2020) was performed. Patients were stratified by year in which they underwent SSRF. The primary outcome was operative time, defined in minutes from incision to closure. Secondary outcomes were patient and operative characteristics, and in-hospital outcomes. Multivariable regression analyses were performed to assess for temporal trends, corrected for confounders. The outcomes ventilator-, Intensive Care Unit-, and hospital-free days (VFD, IFD, and HFD, respectively) were categorized based on the group's medians, and complications were combined into a composite outcome.

RESULTS

In total, 222 patients underwent SSRF on a median of one day after admission (P₂₅-P₇₅, 0-2). Patients had a median age of 54 years (P₂₅-P₇₅, 42-63), ISS of 19 (P₂₅-P₇₅, 13-26), RibScore of 3 (P₂₅-P₇₅, 2-5), and sustained a median of 8 fractured ribs (P₂₅-P₇₅, 6-11). In multivariable analysis, increasing study year was associated with an increase in operative time (p<0.0001). In addition, study year was associated with a significantly reduced odds of complications (Odds ratio [OR], 0.76; 95% Confidence Interval [95% CI], 0.63-0.92; p=0.005), VFD < 28 days (OR, 0.77; 95% CI, 0.65-0.92; p=0.003), IFD < 24 days (OR, 0.77; 95% CI, 0.66-0.91; p=0.002), and HFD < 18 days (OR, 0.64; 95% CI, 0.53-0.76; p<0.0001).

CONCLUSION

In-hospital outcomes after SSRF improved over time. Unexpectedly, operative time increased. The reason for this finding is likely multifactorial and may be related to patient selection, onboarding of new surgeons, fracture characteristics, and minimally invasive exposures. Due to potential for confounding, study year should be accounted for when evaluating outcomes of SSRF.

What is the optimal timing to perform surgical stabilization of rib fractures?

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.

surgical rib fixation in isolated flail chest improves survival

BACKGROUND

The presence of severe associated injuries in flail chest complicates the interpretation of outcomes and the role of rib fixation. This study aimed to examine the impact of fixation in isolated flail chest patients.

METHODS

All patients diagnosed with flail chest injuries were queried from the National Trauma Data Bank (2016-2017). Patients who died within 72 hours, transferred from an outside hospital, had associated thoracic aortic injuries or significant extrathoracic injuries were excluded. Patients with rib fixation were propensity score matched 1:3 with similar patients treated nonoperatively and outcomes were evaluated. Multivariate analysis was used to identify independent predictors for mortality and prolonged mechanical ventilation.

RESULTS

Of 287,947 patients with rib fractures, there were 12,110 (4.2%) patients with flail chest. After exclusion, 5,293 patients with isolated blunt flail chest injuries were included in the analysis. Rib fixation was performed in 575 (10.9%) and 4,718 (89.1%) were managed nonoperatively. After matching, the mortality rate was significantly lower in the fixation group (2.0% vs 5.5%, p= 0.001). On multivariate analysis, rib fixation was associated with improved mortality (OR 0.355, p= 0.002). The timing of operation was not a significant independent risk factor for mortality. However, early fixation (≤72 hours) was associated with a significantly lower need for prolonged ventilation (>7 days).

CONCLUSIONS

Operative fixation in patients with isolated flail chest is associated with improved survival and should be considered liberally. The timing of fixation did not affect mortality, but early fixation was associated with a reduced need for prolonged mechanical ventilation.

The Chest Wall Injury Society Recommendations for Reporting Studies of Surgical Stabilization of Rib Fractures

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.

Surgical stabilization of rib fractures in octogenarians and beyond-what are the outcomes?

BACKGROUND

Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older.

METHODS

Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management.

RESULTS

Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups.

CONCLUSION

Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/nonagenarians.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Early Outcomes of Surgical Stabilisation of Traumatic Rib Fractures: Single-Center Review With a Real-World Evidence Perspective

BACKGROUND

Randomized controlled trials have demonstrated that surgical stabilization of rib fractures (SSRF) in selected trauma patients is associated with potential benefits. This study evaluates the real-world outcomes of SSRF since its implementation at Westmead Hospital, Australia. We hypothesize these outcomes to be similar to that reported by best-evidence in the literature.

MATERIALS AND METHODS

A retrospective analysis of data on all consecutive SSRF performed between January 2013 to December 2018 was completed.

RESULTS

Sixty-three patients (54 male; average age 55.9 ± 14.1 y) with median ISS 24 (IQR 17;30) underwent SSRF. Thirty-seven patients were admitted to Intensive Care Unit (ICU), with median ICU length of stay (LOS) 10.0 (5.0-17.0) d. Median hospital LOS was 15.5 (10.0-24.8) d. Fifty-five (87.3%) patients did not have any surgery-specific complications. The highest observed surgical morbidity was wound infection (n = 4, 4.7%). There was one mortality after rib fixation that was not related to surgery. SSRF within 3 d of hospital presentation in ventilated patients with flail chest was associated with significantly reduced median ICU LOS (3.0 [2.0;4.0] versus 10.0 [9.3;13.0] d; P = 0.03). Early (2013-2015) versus late (2015-2018) phase SSRF implementation demonstrated no significant difference in outcome variables.

CONCLUSION

Experience with SSRF demonstrates early outcomes similar to best-evidence in the existing literature. As a quality assurance tool, ongoing evaluation of real-world data is needed to ensure that outcomes remain consistent with benchmarks available from best-evidence.

Complications of clavicle fracture surgery in patients with concomitant chest wall injury: a retrospective study

Background

The impact of associated chest wall injuries (CWI) on the complications of clavicle fracture repair is unclear to date. This study aimed to investigate the complications after surgical clavicle fracture fixation in patients with and without different degrees of associated CWI.

Methods

A retrospective review over a four-year period of patients who underwent clavicle fracture repair was conducted. A CWI and no-CWI group were distinguished, and the CWI group was subdivided into the minor-CWI (three or fewer rib fractures without flail chest) and complex-CWI (flail chest, four or more rib fractures) subgroup. Demographic data, classification of the clavicle fracture, number of rib fractures, and associated injuries were recorded. Overall complications included surgery-related complications and unplanned hospital readmissions. Univariate analysis and stepwise backward multivariate logistic regression were used to identify potential risk factors for complications.

Results

A total of 314 patients undergoing 316 clavicle fracture operations were studied; 28.7% of patients (90/314) occurred with associated CWI. Patients with associated CWI showed a significantly higher age, body mass index, and number of rib fractures. The overall and surgical-related complication rate were similar between groups. Unplanned 30-day hospital readmission rates were significantly higher in the complex-CWI group (p = 0.02). Complex CWI and number of rib fractures were both independent factor for 30-day unplanned hospital readmission (OR 1.59, 95% CI: 1.00–2.54 and OR 1.33, 95% CI: 1.06–1.68, respectively).

Conclusion

CWI did not affect surgery-related complications after clavicle fracture repair. However, complex-CWI may increase 30-day unplanned hospital readmission rates.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04148-1.

Outcome after surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures and moderate to severe traumatic brain injury (CWIS-TBI)

BACKGROUND

Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared with nonoperative management, is associated with favorable outcomes in patients with TBI.

METHODS

A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were intensive care unit length of stay and hospital length of stay, tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS score, 9-12) and severe (GCS score, ≤8) TBI.

RESULTS

The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. The SSRF was performed at a median of 3 days, and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.38-0.98; p = 0.043) and 30-day mortality (OR, 0.32; 95% CI, 0.11-0.91; p = 0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (OR, 0.19; 95% CI, 0.04-0.88; p = 0.034).

CONCLUSION

In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Nationwide cost-effectiveness analysis of surgical stabilization of rib fractures by flail chest status and age groups

BACKGROUND

Surgical stabilization of rib fracture (SSRF) is increasingly used to manage patients with rib fractures. Benefits of performing SSRF appear variable, and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of SSRF versus nonoperative management among patients with rib fractures younger than 65 years versus 65 years or older, with versus without flail chest. We hypothesized that, compared with nonoperative management, SSRF is cost-effective only for patients with flail chest.

METHODS

This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared with nonoperative management. We report quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios.

RESULTS

Compared with nonoperative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of US $150,000/QALY gained. Surgical stabilization of rib fracture costs US $25,338 and US $123,377/QALY gained for those with flail chest younger than 65 years and 65 years or older, respectively. Surgical stabilization of rib fracture was not cost-effective for patients without flail chest, costing US $172,704 and US $243,758/QALY gained for those younger than 65 years and 65 years or older, respectively. One-way sensitivity analyses showed that, under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest, and nonoperative management remained cost-effective for patients older than 65 years without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients younger than 65 years with flail chest to 35% among patients 65 years or older without flail chest.

CONCLUSIONS

Surgical stabilization of rib fracture is cost-effective for patients with flail chest. Surgical stabilization of rib fracture may be cost-effective in some patients without flail chest, but delineating these patients requires further study.

LEVEL OF EVIDENCE

Economic/decision, level II.

Isolated Thoracic Injury Patients With Rib Fractures Undergoing Rib Fixation Have Improved Mortality

BACKGROUND

Despite a lack of consensus recommendations for surgical stabilization of rib fractures (SSRF), SSRF has increased over the past decade. Outcomes of patients with isolated thoracic injuries undergoing SSRF are unknown. We hypothesized adult trauma patients with isolated thoracic injuries and rib fractures undergoing SSRF would have a decreased risk of mortality and in-hospital respiratory complications compared with those not undergoing SSRF.

MATERIALS AND METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a rib fracture. Patients who died in the emergency department or within 24-h, as well as those with a grade>1 for abbreviated injury scale of the head, face, neck, spine, abdomen, and extremities, were excluded. A multivariable logistic regression analysis was performed.

RESULTS

From 60,000 patients with isolated thoracic injuries and rib fractures, 688 (1.1%) underwent SSRF. Compared with patients without SSRF, those undergoing SSRF had a similar median age (P = 0.83) and higher injury severity score (P < 0.001). Patients undergoing SSRF had a longer length of stay (P < 0.001), higher rate of acute respiratory distress syndrome (P < 0.001), unplanned intubation (P < 0.001), and pneumonia (P < 0.001) but lower rate of mortality (0.9% versus 1.7%, P = 0.084). After adjusting for confounding variables, patients undergoing SSRF had a decreased associated risk of mortality (OR 0.40, P = 0.036) compared with those not undergoing SSRF.

CONCLUSIONS

The risk of mortality in trauma patients with isolated thoracic injuries and rib fractures is lower when undergoing SSRF despite being associated with a higher rate of respiratory complications during their increased length of stay.

Clinical efficacy of surgical versus conservative treatment for multiple rib fractures: A meta-analysis of randomized controlled trials

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.

Quantifying the expense of deferring surgical stabilization of rib fractures: Operative management of rib fractures is associated with significantly lower charges

INTRODUCTION

Surgical stabilization of rib fractures (SSRF) remains a relatively controversial operation, which is often deferred because of concern about expense. The objective of this study was to determine the charges for SSRF versus medical management during index admission for rib fractures. We hypothesize that SSRF is associated with increased charge as compared with medical management.

METHODS

This is a retrospective chart review of a prospectively maintained database of patients with ≥3 displaced rib fractures admitted to a level 1 trauma center from 2010 to 2019. Patients who underwent SSRF (operative management [OM]) were compared with those managed medically (nonoperative management [NOM]). The total hospital charge between OM and NOM was compared with univariate analysis, followed by backward stepwise regression and mediation analysis.

RESULTS

Overall, 279 patients were included. The majority (75%) were male, the median age was 54 years, and the median Injury Severity Scale score (ISS) was 21. A total of 182 patients underwent OM, whereas 97 underwent NOM. Compared with NOM, OM patients had a lower ISS (18 vs. 22, p = 0.004), less traumatic brain injury (14% vs. 31%, p = 0.0006), shorter length of stay (10 vs. 14 days, p = 0.001), and decreased complications. After controlling for the differences between OM and NOM patients, OM was significantly associated with decreased charges (β = US $35,105, p = 0.01). Four other predictors, with management, explained 30% of the variance in charge (R = 0.30, p < 0.0001): scapular fracture (β = US $471,967, p < 0.0001), ISS per unit increase (β = US $4,139, p < 0.0001), long bone fracture (β = US $52,176, p = 0.01), bilateral rib fractures (β = US $34,392, p = 0.01), and Glasgow Coma Scale per unit decrease (β = US $17,164, p < 0.0001). The difference in charge between NOM and OM management was most strongly, although only partially, mediated by length of stay.

CONCLUSION

Our analysis found that OM, as compared with NOM, was independently associated with decreased hospital charges. These data refute the prevailing notion that SSRF should be withheld because of concerns for increased cost.

LEVEL OF EVIDENCE

Economic, level II.

Comparison of Surgical Stabilization Time in Patients with Flail Chest

BACKGROUND

This study aimed to compare the clinical outcomes of early and late surgical stabilization of rib fractures (SSRFs) in patients with flail chest.

METHODS

A retrospective analysis was performed on patients with flail chest according to surgical stabilization time of rib fractures (early [≤ 72 hours] and late [>72 hours]). Outcome measures included duration of mechanical ventilation, intensive care unit (ICU) stay, hospital stay, and morbidity and mortality rates. A correlation analysis was performed between the time from trauma to stabilization and the clinical outcomes after stabilization.

RESULTS

A total of 70 patients were evaluated (36 and 34 in the early and late groups, respectively). The demographics and indicators of injury severity were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (23.7 vs. 165.6 hours; p = 0.003), ICU stay (6.5 vs. 19.7 days; p = 0.003), hospital stay (9 vs. 22.5 days; p = 0.001), and lower rate of atelectasis (11 vs. 58%; p = 0.01), pneumonia (8.8 vs. 50%; p = 0.001), and empyema (2.8 vs. 20.6%; p = 0.019). According to the correlation analysis, it was found that early surgical stabilization had a positive significant effect on clinical outcomes after stabilization.

CONCLUSION

Early SSRFs in patients with flail chest results in more favorable clinical outcomes. It should be performed as soon as possible in the presence of indication and if feasible.

Surgical management of multiple rib fractures/flail chest

Rib fractures in the setting of trauma carries a high morbidity and mortality. Forty-three percent of patients presenting with trauma will have rib fractures. Fifty-five percent of patients, greater than 60 years of age, who die following chest trauma, have isolated rib fractures. Mortality associated with rib fractures starts to increase from the age of 45. Rib fixation is being utilised more for the management of rib fractures. Following the review of literature, we propose a pathway for the management of both simple rib fractures and flail segments. Furthermore, we review the various methods of rib fixation, discussing the advantages and disadvantages of each.