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Shahid A, Turner T, Bukhari A, Shaikh A, Malik A, Alsusa H, Bowdren K, Rutherford J. A Retrospective Two-Year Review of the Outcomes of Surgical Rib Fixation Following Chest Wall Injury by the Multidisciplinary Chest Wall Injury Group in a Major Trauma Centre and the Change in Outcomes as the Service Has Developed. Cureus 2023; 15:e44950. [PMID: 37818507 PMCID: PMC10561661 DOI: 10.7759/cureus.44950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2023] [Indexed: 10/12/2023] Open
Abstract
Aims All English major trauma centres (MTCs) offer rib fixation, which the National Institute for Health and Care Excellence (NICE) guidance indicates in patients with multiple rib fractures or a flail segment; however, the data does not identify the appropriate patients. Our aims were to establish improvements in outcomes following rib fixation at our trust and then determine if the rib fixation service has improved. Methods We performed a matched cohort study whereby 32 patients who underwent rib fixation were independently matched with conservatively managed patients. We then performed a retrospective re-audit to compare outcomes with the matched cohort study. The outcomes analysed were mortality, critical care length of stay (LOS) and total hospital LOS. Results Our initial study revealed a 33.4% reduction in mortality in patients over 55 years. There was also a reduction in average total hospital LOS by 4.5 days in patients under 55 years when comparing rib fixation to conservative management. The results also revealed an average of 4.1 days from admission to operation, 12.7 days of critical care LOS and 29.1 days of total hospital LOS. The re-audit showed improvements in all outcomes. Time from admission to fixation was reduced to 2.1 days, critical care LOS was reduced to 7.5 days and total hospital LOS was reduced to 20.7 days. Conclusions Reduced mortality and LOS reinforce evidence that rib fixation improves outcomes. The re-audit shows that patients are identified for fixation sooner, which is important as the evidence has not identified optimal time for fixation. LOS further decreased in our re-audit, which indicates that earlier fixation results in patients avoiding the sequelae of rib fractures.
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Affiliation(s)
- Abbas Shahid
- Orthopaedics, Manchester Medical School, University of Manchester, Manchester, GBR
| | - Thomas Turner
- Orthopaedics, Manchester Medical School, University of Manchester, Manchester, GBR
| | - Ali Bukhari
- Emergency Medicine, University Hospitals of North Midlands NHS Trust, Manchester, GBR
| | - Adil Shaikh
- Vascular Surgery, Northern Care Alliance NHS Group, Manchester, GBR
| | - Asad Malik
- Emergency Medicine, Warrington and Halton Hospitals NHS Trust, Manchester, GBR
| | - Hatim Alsusa
- Vascular Surgery, Manchester Medical School, University of Manchester, Manchester, GBR
| | - Kieran Bowdren
- Trauma and Orthopaedics, Salford Royal NHS Foundation Trust, Manchester, GBR
| | - Jill Rutherford
- Trauma and Orthopaedics, Salford Royal NHS Foundation Trust, Manchester, GBR
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Milson N, Treger I, Vered M, Acker A, Kalichman L. Hospital-Based Rehabilitation of Patients Who Had Undergone an Open Reduction and Internal Fixation of the Ribs Due to a Flail Chest: Case Series. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16026. [PMID: 36498097 PMCID: PMC9739889 DOI: 10.3390/ijerph192316026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/22/2022] [Accepted: 11/26/2022] [Indexed: 06/17/2023]
Abstract
Flail chest, a severe chest injury, is caused by multiple rib fractures. The open reduction and internal fixation (ORIF) of rib fractures is an effective treatment; however, the patients' subsequent condition remains unsatisfactory in terms of the activities of daily living (ADL) and pain. No research study has, as yet, reported on hospital-based rehabilitation of patients who had undergone an ORIF. Our aim was to evaluate the efficacy of hospital-based rehabilitation of flail chest post-ORIF patients. Physical therapists assessed the pain, functional independence measure (FIM), and the Berg balance test. A total of three females and four males (mean age 59.43 ± 18.88) were hospitalized. A significant reduction in pain was observed (7.00 ± 1.83 upon admission to 4.10 ± 2.05 pre-discharge (Z = -2.07, p = 0.027). A significant improvement in FIM (69.43 ± 14.86 upon admission to 113.57 ± 6.40 pre-discharge, Z = -2.37, p = 0.018), and the Berg balance test (35.23 ± 5.87 upon admission to 49.50 ± 3.40 pre-discharge, Z = -2.37, p = 0.018), was observed. Upon admission, all the patients required moderate to complete ADL assistance. Upon discharge, all were independent for all ADL functions. Patients after flail chest post-ORIF can benefit from hospital-based rehabilitation.
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Affiliation(s)
- Nehama Milson
- Rehabilitation Department, Soroka University Medical Center, Beer Sheva 84101, Israel
| | - Iuly Treger
- Rehabilitation Department, Soroka University Medical Center, Beer Sheva 84101, Israel
- Department of Medicine, Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84101, Israel
| | - Michal Vered
- Rehabilitation Department, Soroka University Medical Center, Beer Sheva 84101, Israel
| | - Asaf Acker
- Rehabilitation Department, Soroka University Medical Center, Beer Sheva 84101, Israel
- Department of Medicine, Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84101, Israel
| | - Leonid Kalichman
- Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel
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Muacevic A, Adler JR, Lin JB, Jones TJ, Taylor BC. Outpatient Surgery for Rib Fracture Fixation: A Report of Three Cases. Cureus 2022; 14:e31890. [PMID: 36579237 PMCID: PMC9792330 DOI: 10.7759/cureus.31890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2022] [Indexed: 11/27/2022] Open
Abstract
Rib fractures are common injuries observed in trauma patients that will often heal without operative intervention. However, patients can infrequently have continued pain. Operative fixation of these symptomatic rib fractures has traditionally led to the patient requiring hospital admission for observation and pain control. The purpose of this study was to review three cases of outpatient rib fracture, open reduction and internal fixation (ORIF) surgery. Three patients with symptomatic rib fractures treated with ORIF at a single urban level one trauma center underwent outpatient same-day surgery. Pertinent demographic, clinical, radiographic, and surgical data were collected. All patients had decreased preoperative pain and no complications. This case series demonstrates that outpatient surgery for rib fracture ORIF can be performed safely in a select patient population. Additionally, it has similar efficacy as inpatient operative fixation with the main added benefit being decreased costs to both the patient and the healthcare system. We suggest that outpatient operative fixation of rib fractures should be considered for select patients.
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Abstract
INTRODUCTION Rib fractures are common injuries in trauma patients that often heal without intervention. Infrequently, symptomatic rib fracture nonunions are a complication after rib fractures. There is a paucity of literature on the surgical treatment of rib fracture nonunion. The purpose of this study was to describe the efficacy of rib fracture nonunion operative fixation with particular focus on surgical technique, healing rates, and complications. MATERIALS AND METHODS Patients aged ≥ 18 years with symptomatic rib fracture nonunions treated with open reduction and internal fixation (ORIF) with locking plates at a single urban level 1 trauma center were retrospectively reviewed. Pertinent demographic, clinical, radiographic, and surgical data were collected and analyzed. RESULTS A total of 18 patients met inclusion criteria. The mean time from injury to undergoing ORIF for rib fracture nonunion was just under a year and the number of ribs plated was 2.95 ± 1.16 (1-5 ribs) with bone grafting used in six cases. All patients (100%) showed evidence of healing at an average of 2.65 ± 1.50 months (2-8 months). All patients reported a decrease in pain. No narcotic pain medication was used at an average of 3.88 ± 3.76 weeks (0-10 weeks) post-operatively. Intraoperative and postoperative complications were found in 4 (22.2%) patients. CONCLUSION This study concluded that operative fixation of symptomatic rib fracture nonunion demonstrated favorable outcomes with reduction in preoperative pain levels, decreased use of narcotic pain medication, minimal complications, and a high rate of fracture union. This described method provides symptomatic relief, reduction in pain, and promotes bony healing of the fracture nonunion without development of major complications. We suggest that operative fixation should be considered as the primary method of treatment of symptomatic rib nonunions.
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Reindl S, Jawny P, Girdauskas E, Raab S. Is it Necessary to Stabilize Every Fracture in Patients with Serial Rib Fractures in Blunt Force Trauma? Front Surg 2022; 9:845494. [PMID: 35756475 PMCID: PMC9218347 DOI: 10.3389/fsurg.2022.845494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Sebastian Reindl
- Department for Cardiothoracic Surgery, Medical Faculty, University Hospital Augsburg, Augsburg, Germany
| | - Philipp Jawny
- Department for Cardiothoracic Surgery, Medical Faculty, University Hospital Augsburg, Augsburg, Germany
| | - Evaldas Girdauskas
- Department for Cardiothoracic Surgery, Medical Faculty, University Hospital Augsburg, Augsburg, Germany
| | - Stephan Raab
- Department for Cardiothoracic Surgery, Medical Faculty, University Hospital Augsburg, Augsburg, Germany
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Chuang CH, Huang CK, Li CY, Hu MH, Lee PY, Wu PT. Surgical stabilization of the ipsilateral scapula and rib fractures using the mirror Judet approach: a preliminary result. BMC Musculoskelet Disord 2022; 23:105. [PMID: 35101018 PMCID: PMC8802444 DOI: 10.1186/s12891-021-04991-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 12/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We report our preliminary results using a single approach, the mirror Judet approach, for patients with both ipsilateral scapula and multiple rib fractures. METHODS Five consecutive patients [median age: 56 years (range: 44 ~ 60)] with ipsilateral scapula and multiple rib fractures that met the surgical indications were retrospectively reviewed. A single approach, the mirror Judet approach, was used for surgical stabilization of the scapula and targeted rib fractures. Thoracoscopic surgery was performed first for management of associated lung lesions and marking the targeted rib. All patients received the same rehabilitation protocol and a minimum 12-month follow-up. RESULTS All surgically-fixed fractures eventually united without malunion. No complaints of intercostal neuralgia, infection, or other complications were seen. The mean range of motion in the injured shoulder returned to at least 90% of the contralateral side range. The mean Disabilities of the Arm, Shoulder, and Hand score at the 12th month was 2.0 (range: 0-7). All patients were able to return to their previous work. CONCLUSION The mirror Judet approach allows for the surgical stabilization of the ipsilateral scapula and multiple rib fractures using the same approach and provides acceptable functional outcomes in well-selected patients. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Chang-Han Chuang
- Department of Orthopaedic Surgery, Show Chwan Memorial Hospital, 524 Sec. 1 Chung-Shan Rd., Changhua, 500, Taiwan.,Department of Life Sciences, National Chung Hsing University, Taichung, Taiwan.,Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Chin-Kai Huang
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chia-Ying Li
- Department of Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Ming-Hsien Hu
- Department of Orthopaedic Surgery, Show Chwan Memorial Hospital, 524 Sec. 1 Chung-Shan Rd., Changhua, 500, Taiwan.,Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Yuan Lee
- Department of Orthopaedic Surgery, Show Chwan Memorial Hospital, 524 Sec. 1 Chung-Shan Rd., Changhua, 500, Taiwan. .,College of Nursing and Health Sciences, Da-Yeh University, Changhua, Taiwan.
| | - Po-Ting Wu
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan. .,Department of Orthopedics, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan. .,Department of Orthopedics, National Cheng Kung University Hospital Dou-Liou branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan. .,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan.
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Schuette HB, Taylor BC, Rutkowski P, Huber G, Mehta V. Cartilage Plating in Flail Chest Fixation. Injury 2021; 52:2560-2564. [PMID: 34167761 DOI: 10.1016/j.injury.2021.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/21/2021] [Accepted: 06/05/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Operative stabilization of flail chest has been shown to have several benefits over nonoperative management. Often, flail chest injuries will involve the anterior ribs and their associated costal cartilage. In certain cases, operative fixation with open reduction and internal fixation (ORIF) of anterior rib fractures involving the costal cartilage may be warranted. Currently, there is scant literature regarding the surgical approach and clinical outcomes of ORIF involving the costal cartilage. The purpose of this study is to describe the surgical approach and first reported clinical series for patients undergoing anterior rib ORIF involving the costal cartilage. PATIENTS AND METHODS After Institutional Review Board approval was obtained, a retrospective case series was performed at a single urban level 1 trauma center including patients 18 years of age or older who underwent ORIF of anterior rib fractures involving the costal cartilage. All surgical approaches were performed with muscle-sparing techniques. Patients were followed during their hospitalization period and postoperatively as routinely scheduled. Data collection including patient demographics, injury characteristics, operative variables, and postoperative outcomes were collected and analyzed. RESULTS Thirty patients, with a mean age of 54.4 years, were included in this study. All patients had a flail chest injury and were treated with ORIF on average 4.1 days following injury. There were no intraoperative complications reported. Total hospital length of stay averaged 22.8 days with an intensive care unit stay averaging 6.1 days; total ventilator time averaged 5.2 days. Six patients were diagnosed with postoperative pneumonia and no postoperative superficial infections, deep infections, or seromas were noted. Eight patients required tracheostomy postoperatively. Only 1 patient had evidence of radiographic malunion, and a separate patient had evidence of screw loosening; no patients required or requested implant removal. Union rate was 100% and one-year mortality was 0%. CONCLUSION Open reduction and internal fixation of anterior rib fractures involving the costal cartilage is a safe procedure with low complication rates and favorable postoperative outcomes including hospital length of stay, intensive care unit length of stay, postoperative pneumonia, need for tracheostomy, and mechanical ventilation time.
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Affiliation(s)
- Hayden B Schuette
- OhioHealth/Doctors Hospital, Department of Orthopedics, Columbus, OH.
| | - Benjamin C Taylor
- OhioHealth/Grant Medical Center, Department of Orthopedic Trauma, Columbus, OH
| | - Paul Rutkowski
- Mount Carmel Health System, Department of Orthopedics, Columbus, OH
| | - Grant Huber
- OhioHealth/Grant Medical Center, Department of Orthopedic Trauma, Columbus, OH
| | - Vishvam Mehta
- OhioHealth/Grant Medical Center, Department of Orthopedic Trauma, Columbus, OH
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Schuette HB, Glazier MT, Triplet JJ, Taylor BC. Far posterior rib plating: Preliminary results of a retrospective case series. Injury 2021; 52:1133-1137. [PMID: 33468313 DOI: 10.1016/j.injury.2020.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/29/2020] [Accepted: 12/06/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Far posterior, or paraspinal rib fractures, defined as fractures that are medial to the medial border of the scapula (and may involve the costovertebral articulation), are often treated nonoperatively. However, in certain cases, including severe displacement, persistent pain, nonunion, or persistent respiratory distress, stabilization with open reduction and internal fixation (ORIF) may be warranted. There is a paucity of literature regarding the surgical approach and clinical outcomes following ORIF for far posterior rib fractures and fracture-dislocations. The purpose of this paper is to describe the surgical approach and to report the first collection of clinical outcomes for patients undergoing paraspinal rib ORIF. PATIENTS AND METHODS A retrospective case series was performed at a single urban level 1 trauma center. Patients 18 years of age or older who underwent ORIF of far posterior rib fractures were included in this study. Far posterior rib fractures were defined as fractures that occurred medial to the medial border of the scapula underneath the paraspinal musculature. Data collection including patient demographics, injury characteristics, operative variables, and postoperative outcomes were collected and analyzed. RESULTS Twenty-six patients, with a mean age of 50.7 years, who underwent paraspinal rib ORIF were included in this study. The mean follow-up was 12.1 months. 80.8% of patients had a flail chest injury. On average, 3.4 ribs were instrumented posteriorly with 22.8% of patients requiring fixation spanning the costotransverse articulation. No intraoperative complications occurred. Only one patient required a repeat procedure. Total hospital length of stay averaged 17.3 days with an intensive care unit stay averaging 6.2 days. Total ventilator time averaged 4 days. 7 patients were diagnosed with postoperative pneumonia and 6 patients required tracheostomy. CONCLUSION Open reduction and internal fixation for far posterior, or paraspinal rib fractures and fracture-dislocations is a safe procedure with low complications rates and favorable postoperative outcomes including hospital length of stay, ICU length of stay, need for tracheostomy, postoperative pneumonia, and mechanical ventilation time.
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Affiliation(s)
- Hayden B Schuette
- OhioHealth/Doctors Hospital, Department of Orthopedics, Columbus, OH 43228, United States.
| | - Matthew T Glazier
- OhioHealth/Doctors Hospital, Department of Orthopedics, Columbus, OH 43228, United States
| | - Jacob J Triplet
- OhioHealth/Doctors Hospital, Department of Orthopedics, Columbus, OH 43228, United States
| | - Benjamin C Taylor
- OhioHealth Orthopedic Trauma and Reconstructive Surgeons, Grant Medical Center, Columbus, OH 43215, United States
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Myers DM, McGowan SP, Taylor BC, Sharpe BD, Icke KJ, Gandhi A. A model for evaluating the biomechanics of rib fracture fixation. Clin Biomech (Bristol, Avon) 2020; 80:105191. [PMID: 33045492 DOI: 10.1016/j.clinbiomech.2020.105191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/12/2020] [Accepted: 09/28/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION High rates of morbidity and mortality following flail chest rib fractures are well publicized. Standard of care has been supportive mechanical ventilation, but serious complications have been reported. Internal rib fixation has shown improvements in pulmonary function, clinical outcomes, and decreased mortality. The goal of this study was to provide a model defining the biomechanical benefits of internal rib fixation. METHODS One human cadaver was prepared with an actuator providing anteroposterior forces to the thorax and rib motion sensors to define interfragmentary motion. Cadaveric model was validated using a prior study which defined costovertebral motion to create a protocol using similar technology and procedure. Ribs 4-6 were fixed with motion sensors anteriorly, laterally and posteriorly. Motion was recorded with ribs intact before osteotomizing each rib anteriorly and laterally. Flail chest motion was record with fractures subsequently plated and analyzed. Motion was recorded in the sagittal, coronal and transverse axes. FINDINGS Compared to the intact rib model, the flail chest model demonstrated an 11.3 times increase in sagittal plane motion, which was reduced to 2.1 times the intact model with rib plating. Coronal and sagittal plane models also saw increases of 9.7 and 5.1 times, respectively, with regards to flail chest motion. Both were reduced to 1.2 times the intact model after rib plating. INTERPRETATION This study allows quantification of altered ribcage biomechanics after flail chest injuries and suggests rib plating is useful in restoring biomechanics as well as contributing to improving pulmonary function and clinical outcomes.
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Affiliation(s)
- Devon M Myers
- Department Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA.
| | - Sean P McGowan
- Department Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA
| | - Benjamin C Taylor
- Fellowship Director, Orthopaedic Trauma and Reconstructive Surgery, Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA
| | - B Dale Sharpe
- Department Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA
| | - Kyle J Icke
- ZimmerBiomet Research Department, 1520 Tradeport Dr., Jacksonville, FL 32218, USA
| | - Anup Gandhi
- ZimmerBiomet Laboratory Department, 10225 Westmoor Dr., Westminster, CO 80021, USA
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Choi J, Gomez GI, Kaghazchi A, Borghi JA, Spain DA, Forrester JD. Surgical Stabilization of Rib Fracture to Mitigate Pulmonary Complication and Mortality: A Systematic Review and Bayesian Meta-Analysis. J Am Coll Surg 2020; 232:211-219.e2. [PMID: 33212228 DOI: 10.1016/j.jamcollsurg.2020.10.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 01/22/2023]
Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Department of Epidemiology and Population Health, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA.
| | - Giselle I Gomez
- Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - Aydin Kaghazchi
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - John A Borghi
- School of Medicine, Stanford University, Stanford, CA
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA
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Peek J, Beks RB, Hietbrink F, Heng M, De Jong MB, Beeres FJ, Leenen LP, Groenwold RH, Houwert RM. Complications and outcome after rib fracture fixation: A systematic review. J Trauma Acute Care Surg 2020; 89:411-418. [DOI: 10.1097/ta.0000000000002716] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
OBJECTIVES To present outcomes in a multicenter review of a large number of flail chest patients. DESIGN Retrospective case series. SETTING One urban Level I and 1 urban Level II trauma center. PATIENTS/PARTICIPANTS Fifty-two adult patients who underwent treatment of their flail chest injury with locking plate and screw constructs through muscle-sparing approaches, followed for a minimum of 1 year postoperatively. RESULTS All patients went on to successful union, with complication rates in line with recent published norms. Periscapular strength returned to greater than 90% of the noninjured side by 3 months postoperatively and to within a mean of 95% of the noninjured side by 6 months postoperatively. Glenohumeral range of motion similarly improved over this same interval. CONCLUSIONS Use of anatomically designed modern locking plate and screw fixation constructs with muscle-sparing approaches results in efficient return to function and restoration of shoulder function and strength as compared with the noninjured shoulder. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
OBJECTIVES To compare outcomes in patients with rib fractures (RFX) who underwent surgical stabilization of rib fractures (SSRF) to those treated nonoperatively. DESIGN Retrospective cohort study. SETTING Two Level 1 Trauma Centers. PATIENTS One hundred seventy-four patients with multiple RFX divided into 2 groups: patients with surgically stabilized RFX (n = 87) were compared with nonoperatively managed patients in the matched control group (MCG) (n = 87). INTERVENTION SSRF. OUTCOME MEASUREMENTS Age, sex, injury severity score, RFX, mortality, hospital length of stay (HLOS) and intensive care unit length of stay (ICULOS), duration of mechanical ventilation (DMV), co-injuries, and time to surgery. Patients were further stratified by presence or absence of flail chest and pulmonary contusion (PC). RESULTS Flail chest, displaced RFX, and PC were present significantly more often in SSRF patients compared with the MCG. Mortality was lower in SSRF group. HLOS and ICULOS were longer in SSRF group compared with the corresponding MCG patients regardless of timing to surgery (P < 0.01 for all). SSRF patients with flail chest had comparable HLOS, ICULOS, and DMV to MCG patients with flail chest (P > 0.3 for all). SSRF patients without flail chest had significantly longer HLOS and ICULOS than MCG patients without flail chest (P < 0.001 for both). Presence of PC did not affect lengths of stay. CONCLUSIONS SSRF patients had reduced mortality compared with nonoperatively managed patients. HLOS, ICULOS, and DMV were longer in SSRF patients than in MCG. When flail chest was present, lengths of stay were comparable. PC did not seem to affect the surgical outcome. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Does Surgery Reduce the Risk of Complications Among Patients with Multiple Rib Fractures? A Meta-analysis. Clin Orthop Relat Res 2019; 477:193-205. [PMID: 30247228 PMCID: PMC6345288 DOI: 10.1097/corr.0000000000000495] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple rib fractures are common in trauma patients, who are prone to trauma-associated complications. Surgical or nonsurgical interventions for the aforementioned conditions remain controversial. QUESTIONS/PURPOSES The purpose of our study was to perform a meta-analysis to evaluate the clinical prognosis of surgical fixation of multiple rib fractures in terms of (1) hospital-related endpoints (including duration of mechanical ventilation, ICU length of stay [LOS] and hospital LOS), (2) complications, (3) pulmonary function, and (4) pain scores. METHODS We screened PubMed, Embase, and Cochrane databases for randomized and prospective studies published before January 2018. Individual effect sizes were standardized; the pooled effect size was calculated using a random-effects model. Primary outcomes were duration of mechanical ventilation, intensive care unit length of stay (ICU LOS), and hospital LOS. Moreover, complications, pulmonary function, and pain were assessed. RESULTS The surgical group had a reduced duration of mechanical ventilation (weighted mean difference [WMD], -4.95 days; 95% confidence interval [CI], -7.97 to -1.94; p = 0.001), ICU LOS (WMD, -4.81 days; 95% CI, -6.22 to -3.39; p < 0.001), and hospital LOS (WMD, -8.26 days; 95% CI, -11.73 to -4.79; p < 0.001) compared with the nonsurgical group. Complications likewise were less common in the surgical group, including pneumonia (odds ratio [OR], 0.41; 95% CI, 0.27-0.64; p < 0.001), mortality (OR, 0.24; 95% CI, 0.07-0.87; p = 0.030), chest wall deformity (OR, 0.02; 95% CI. 0.00-0.12; p < 0.001), dyspnea (OR, 0.23; 95% CI, 0.09-0.54; p < 0.001), chest wall tightness (OR, 0.11; 95% CI, 0.05-0.22; p < 0.001) and incidence of tracheostomy (OR, 0.34; 95% CI, 0.20-0.57; p < 0.001). There were no differences between the surgical and nonsurgical groups in terms of pulmonary function, such as forced vital capacity (WMD, 6.81%; 95% CI: -8.86 to 22.48; p = 0.390) and pain scores (WMD, -11.41; 95% CI: -42.09 to 19.26; p = 0.470). CONCLUSIONS This meta-analysis lends stronger support to surgical fixation, rather than conservative treatment, for multiple rib fractures. Nevertheless, additional trials should be conducted to investigate surgical indications, timing, and followup for quality of life. LEVEL OF EVIDENCE Level I, therapeutic study.
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Wycech J, Fokin AA, Puente I. Evaluation of patients with surgically stabilized rib fractures by different scoring systems. Eur J Trauma Emerg Surg 2018; 46:441-445. [PMID: 30132024 DOI: 10.1007/s00068-018-0999-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 08/20/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Surgical Stabilization (SSRF) is gaining popularity as an alternative to non-operative management (NOM) of patients with rib fractures, however, there are no established guidelines for patients' quantifiable evaluation and for SSRF recommendation. Known rib scoring systems include: Rib Fracture Score (RFS), Chest Wall Trauma Score (CWTS), Chest Trauma Score (CTS) and RibScore (RS), but are underutilized. The purpose was to provide values of scoring systems in SSRF and NOM patients and correlate them with treatment assignment. METHODS Retrospective cohort study included 87 SSRF and 87 propensity matched NOM patients from two level-1 trauma centers. Clinical variables and score values were compared between two groups. RESULTS SSRF compared to NOM patients had significantly higher number of total rib fractures, displaced fractures, rates of pulmonary contusion and flail chest. RS and CTS values were significantly higher in SSRF compared to NOM patients (2.3 vs. 1.7, p = 0.001; 5.8 vs. 5.3, p = 0.005, respectively), but RFS and CWTS were similar. CONCLUSIONS Application of scoring systems could help with patients' objective and standardized assessment and may aid in treatment decisions. RibScore was superior to other scoring systems.
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Affiliation(s)
- Joanna Wycech
- Division of Trauma and Critical Care Services, Delray Medical Center, 5352 Linton Boulevard, Delray Beach, FL, 33484, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, 1600 S Andrews Ave, Fort Lauderdale, FL, 33316, USA
| | - Alexander Alexei Fokin
- Division of Trauma and Critical Care Services, Delray Medical Center, 5352 Linton Boulevard, Delray Beach, FL, 33484, USA.
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Delray Medical Center, 5352 Linton Boulevard, Delray Beach, FL, 33484, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, 1600 S Andrews Ave, Fort Lauderdale, FL, 33316, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Rd, Boca Raton, FL, 33431, USA.,Department of Surgery, Herbert Wertheim College of Medicine, Florida International University, 11200 SW 8th St, Miami, FL, 33199, USA
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de Moya M, Nirula R, Biffl W. Rib fixation: Who, What, When? Trauma Surg Acute Care Open 2017; 2:e000059. [PMID: 29766079 PMCID: PMC5877892 DOI: 10.1136/tsaco-2016-000059] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/08/2017] [Indexed: 11/24/2022] Open
Abstract
Rib fractures are among the most common traumatic injury found in ∼20% of all patients who suffer thoracic trauma. The majority of these are a result of a blunt mechanism and are often associated with other traumatic injuries. The most common associated injury is lung contusion. Rib fractures impart an increased morbidity and mortality with the highest mortality associated with a flail chest in the elderly population. Flail chest is defined radiographically as 3 or more consecutive ribs fractured in 2 or more places. This often translates to a clinical flail which is associated with paradoxical chest wall movement during respiratory cycles. The mainstay of treatment has been pain control and respiratory support with positive pressure ventilation. However, over the past 2 decades, there has been mounting evidence to suggest that open reduction and internal fixation of ribs benefits patients. The indications remain confined to the most severely injured patients with flail chest or chronic non-unions; however, there remains debate whether or not less severely injured patients would benefit as well. This article will review the current evidence and provide proposed indications based on available evidence and current expert opinion.
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Affiliation(s)
- Marc de Moya
- Division of Trauma, Acute Care Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ram Nirula
- Division of Trauma, Acute Care Surgery, University of Utah Health Care, Salt Lake City, Utah, USA
| | - Walter Biffl
- Department of Acute Care Surgery, The Queens Medical Center, Honolulu, Hawaii, USA.,Department of Surgery, John A Burns School of Medicine, University of Hawaii-Manoa, Honolulu, Hawaii, USA
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