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Adams-McGavin RC, Naveed A, Kishibe T, Beckett A, Nauth A, Hsu J, Gomez D. Management of non-union of rib fractures secondary to trauma: A scoping review. Injury 2024; 55:111553. [PMID: 38762403 DOI: 10.1016/j.injury.2024.111553] [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: 02/08/2024] [Revised: 03/12/2024] [Accepted: 04/05/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE Rib fracture non-union is an uncommon complication of traumatic rib fractures. Our objective was to perform a scoping review of the literature for the management of rib fracture non-union. This included analysis of the variations in surgical technique, complications experienced, and reported outcomes. METHODS We conducted a scoping review and searched databases (MEDLINE, CINAHL, and Embase). We performed abstract and full-text screening, and abstracted data related to pre-operative assessment, surgical technique, complications, and reported outcome measures. RESULTS We included 29 articles of which 19 were case reports and 10 were case series. The data quality was generally heterogeneous. The studies included 229 patients and the commonest symptoms of rib fracture non-union included chest pain, clicking, dyspnea and deformities. The patients underwent surgical management of rib fracture non-union (excluding first rib fractures) using various techniques. The majority used surgical stabilization of rib fracture with or without a graft. The reported outcomes were inconsistent between studies, but showed high rates of union (>94 %), reduction in reported VAS scores, and improved return to work when included. Implant failure occurred in 10 % of the 229 total patients reported in our studies, the re-operation rate was 13 %, and the overall complication rate was 27 %. CONCLUSION Surgical management of rib fracture non-union often involving locking plates and screws with or without a graft has been shown in several case reports and series as an effective treatment with acceptable implant failure and complication rates. Surgical management is therefore a viable option for symptomatic patients. Further research is required to determine optimal management strategies that further reduce surgical complications for these patients.
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Affiliation(s)
| | - Asad Naveed
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Division of General Surgery, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada.
| | - Teruko Kishibe
- Library Services, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Andrew Beckett
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Division of General Surgery, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada; Canadian Forces Health Services, Ottawa, Canada
| | - Aaron Nauth
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy Hsu
- Trauma Service, Westmead Hospital, Westmead; and Westmead Clinical School, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - David Gomez
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Division of General Surgery, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
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Forrester JD, Bauman ZM, Cole PA, Edwards JG, Knight AW, LaRoque M, Raffa T, White TW, Kartiko S. Chest Wall Injury Society recommendation for surgical stabilization of nonunited rib fractures to decrease pain, reduce opiate use, and improve patient reported outcomes in patients with rib fracture nonunion after trauma. J Trauma Acute Care Surg 2023; 95:943-950. [PMID: 37728432 DOI: 10.1097/ta.0000000000004083] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND Rib fractures are common injuries which can be associated with acute pain and chronic disability. While most rib fractures ultimately go on to achieve bony union, a subset of patients may go on to develop non-union. Management of these nonunited rib fractures can be challenging and variability in management exists. METHODS The Chest Wall Injury Society's Publication Committee convened to develop recommendations for use of surgical stabilization of nonunited rib fractures (SSNURF) to treat traumatic rib fracture nonunions. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject the recommendation. RESULTS No identified studies compared SSNURF to alternative therapy and the overall quality of the body of evidence was rated as low. Risk of bias was identified in all studies. Despite these limitations, there is lower-quality evidence suggesting that SSNURF may be beneficial for decreasing pain, reducing opiate use, and improving patient reported outcomes among patients with symptomatic rib nonunion. However, these benefits should be balanced against risk of symptomatic hardware failure and infection. CONCLUSION This guideline document summarizes the current CWIS recommendations regarding use of SSNURF for management of rib nonunion. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Joseph D Forrester
- From the Division of General Surgery, Department of Surgery (J.D.F., A.K.), Stanford University, Stanford, California; Division of Acute Care Surgery (Z.M.B.), University of Nebraska Medical Center, Omaha, Nebraska; HealthPartners Orthopaedics and Sports Medicine (P.A.C.), Bloomington, Minnesota; Department of Orthopaedic Surgery (P.A.C., M.L.), University of Minnesota, Minneapolis, Minnesota; Department of Orthopaedic Surgery (P.A.C.), Regions Hospital, Saint Paul, Minnesota; Sheffield Teaching Hospitals NHS Trust (J.G.E.), Sheffield, United Kingdom; and Center for Trauma and Critical Care (T.R., T.W.W.), Department of Surgery (T.R., S.K.), George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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Choi J, Kaghazchi A, Sun B, Woodward A, Forrester JD. Systematic Review and Meta-Analysis of Hardware Failure in Surgical Stabilization of Rib Fractures: Who, What, When, Where, and Why? J Surg Res 2021; 268:190-198. [PMID: 34333416 DOI: 10.1016/j.jss.2021.06.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/10/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) is increasingly used to reduce pulmonary complications and death among patients with rib fractures. However, the five Ws of hardware failure -who, what, when, where, and why- remains unclear. We aimed to synthesize available evidence on the five Ws and outline future research agenda for mitigating hardware failure. METHODS Experimental and observational studies published between 2009 and 2020 evaluating adults undergoing SSRF for traumatic rib fractures underwent evidence synthesis. We performed random effects meta-analysis of cohort/consecutive case studies. We calculated pooled prevalence of SSRF hardware failures using Freeman-Tukey double arcsine transformation and assessed study heterogeneity using DerSimonian-Laird estimation. We performed meta-regression with rib fracture acuity (acute or chronic) and hardware type (metal plate or not metal plate) as moderators. RESULTS Twenty-nine studies underwent qualitative synthesis and 24 studies (2404 SSRF patients) underwent quantitative synthesis. Pooled prevalence of hardware failure was 4(3-7)%. Meta-regression showed fracture acuity was a significant moderator (P = 0.002) of hardware failure but hardware type was not (P = 0.23). Approximately 60% of patients underwent hardware removal after hardware failure. Mechanical failures were the most common type of hardware failure, followed by hardware infections, pain/discomfort, and non-union. Timing of hardware failure after surgery was highly variable, but 87% of failures occurred after initial hospitalization. Mechanical failures was attributed to technical shortcomings (i.e. short plate length) or excessive force on the thoracic cavity. CONCLUSIONS SSRF hardware failure is an uncommon complication. Not all hardware failures are consequential, but insufficient individual patient data precluded characterizing where and why hardware failures occur. Minimizing SSRF hardware failure requires concerted research agenda to expand on the paucity of existing evidence.
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Affiliation(s)
- Jeff Choi
- Department of Surgery, Division of General Surgery, Stanford University, Stanford, California; Department of Epidemiology and Population Health, Stanford University, Stanford, California; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, California.
| | - Aydin Kaghazchi
- Department of Epidemiology and Population Health, Stanford University, Stanford, California; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, California
| | - Beatrice Sun
- Department of Surgery, Division of General Surgery, Stanford University, Stanford, California; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, California
| | - Amanda Woodward
- School of Medicine, Stanford University, Stanford, California
| | - Joseph D Forrester
- Department of Surgery, Division of General Surgery, Stanford University, Stanford, California; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, California
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