Operative Rib Fixation Research Articles

National Trend of Surgical Stabilization of Rib Fractures: Indications, Approaches, and Disparities

IntroductionRib fractures are among the most frequent injuries in trauma. This study aims to assess the current nationwide trends in operative rib fixation and identify predictors of surgical stabilization of rib fractures (SSRFs). MethodsA 5-y (2017-2021) retrospective analysis of the Trauma Quality Improvement Program database was performed. Adult trauma patients who had at least one rib fracture were included. We analyzed data regarding type of SSRF including open and thoracoscopic approaches and its trends. ResultsA total of 780,275 patients were identified, of which 15,339 patients (1.9%) were managed with SSRF. Trends of both open and endoscopic approaches were increasing during the study period. Patients with ≤2 rib fractures had a decreasing rate of SSRF. Flail chest (odds ratio = 13.42, P < 0.001) was the strongest predictor of SSRF. ConclusionsSSRF is gaining popularity in the management of chest trauma. The presence of a flail segment and multiplicity of rib fractures is among the predictors of SSRF.

Erector Spinae Plane Block as an Analgesic Intervention in Acute Rib Fractures: A Scoping Review.

Rib fractures are a common sequelae of chest trauma and are associated with significant morbidity. The erector spinae nerve block (ESB) has been proposed as an alternative first-line regional technique for rib fractures due to ease of administration and minimal complication profile. We aimed to investigate the current literature surrounding this topic with a focus on pain and respiratory outcomes. A comprehensive literature search was performed on the Medline, Embase, Web of Science, Scopus, and Cochrane databases. Keywords of "erector spinae block" and "rib fractures" were used to form the search strategy. Papers published in English investigating ESB as an analgesic intervention for acute rib fracture were included. Exclusion criteria were operative rib fixation, or where the indication for ESB was not rib fracture. There were 37 studies which met the inclusion criteria for this scoping review. Of these, 31 studies reported on pain outcomes and demonstrated a 40% decrease in pain scores post administration within the first 24 hours. Respiratory parameters were reported in 8 studies where an increase in incentive spirometry was demonstrated. Respiratory complication was not consistently reported. ESB was associated with minimal complications; only 5 cases of haematoma and infection were (incidence 0.6%) reported, none of which required further intervention. Current literature surrounding ESB in rib fracture management provides a positive qualitative evaluation of efficacy and safety. Improvements in pain and respiratory parameters were almost universal. The notable outcome from this review was the improved safety profile of ESB. The ESB was not associated with complications requiring intervention even in the setting of anticoagulation and coagulopathy. There still remains a paucity of large cohort, prospective data. Moreover, no current studies reflect an improvement in respiratory complication rates compared to current techniques. Taken together, these areas should be the focus of any future research.

Surgical Rib Fixation in Obese Patients with Isolated Flail Chest Improves Outcomes: A Matched Cohort Study.

Obesity is associated with adverse outcomes after major operations. The role of operative rib fixation (RF) in obese patients with flail chest is not clear. The presence of other associated injuries may complicate the interpretation of outcomes. This study compared outcomes after RF to nonoperative management (NOM) in obese patients with isolated flail chest injury. Adult obese patients (BMI > 29.9) with flail chest were identified from the Trauma Quality Improvement Program (TQIP) database (2016-2018). Hospital transfers, death within 72h, and extrathoracic injuries were excluded. RF patients were propensity score matched (1:2) to similar NOM patients. Multivariate regression identified independent factors predicting adverse outcomes. Overall, 367 patients with isolated flail chest who underwent RF were matched with 734 in the NOM group. After matching, the mortality rate was significantly lower in the RF group (1.4% vs. 3.7%; p < 0.05). RF had longer HLOS (15.7days vs. 12.8days; p < 0.05) and ICU LOS (10.1days vs. 8.6days; p < 0.05), shorter ventilator days (9.2days vs. 11.5days; p < 0.05), and a higher rate of venous thromboembolism (7.1% vs. 3.5%, p < 0.05). On multivariate analysis, RF was associated with decreased mortality (OR 0.27; p < 0.05). Early RF (≤ 72h) was associated with shorter ICU stay and mechanical ventilation. RF for isolated flail chest in obese patients is associated with decreased mortality and fewer ventilator days. When performed early, fixation decreases the need for prolonged ventilator use and ICU stay. A more aggressive VTE prophylaxis should be considered in patients undergoing RF.

Operative Rib Fixation at a Rural Trauma Center.

Operative rib fixation is becoming more common in the management of rib fractures, with studies showing benefits of surgery in decreasing time on mechanical ventilation, ICU and total hospital length of stay, and mortality. This paper will review the data from our institution to determine if these benefits were seen in our trauma population. A retrospective review of the institution's trauma database was conducted, including operative patients (n = 36), control patients (nonoperative patients from October 2018 to October 2019, n = 207), and selected control patients based on similar injury severity score range as operative patients (n = 181). Data reviewed included time on mechanical ventilation, ICU and total hospital length of stay, and disposition at discharge, including mortalities. Operative complications were also reviewed. The operative group had a higher ISS compared to both controls, longer average time on mechanical ventilation, longer average ICU and total hospital length of stay, and a higher percentage of patients discharged to inpatient facilities. However, the operative group had lower mortality compared to the control groups. The operative group had 3 surgical site infections requiring readmission and hardware removal. Unlike other studies, our operative patients did not see improvements in time on mechanical ventilation, ICU and total hospital length of stay, or disposition at discharge, but did see a mortality benefit. Confounding factors include higher average ISS in the operative group, and over-sedation in the ICU. Data collection is ongoing, and refinements are being made to perioperative and ICU management to minimize these confounding variables.

“Early results after initiation of a rib fixation programme: A propensity score matched analysis”

IntroductionChest wall injuries are very common in blunt trauma and development of treatment protocols can significantly improve outcomes. Surgical stabilisation of rib fractures (SSRF) is an adjunct for the most severe chest injuries and can be used as a part of a comprehensive approach to chest injuries care. We hypothesized that implementation of a SSRF programme program would result in improved short-term outcomes. Materials and methodsThe characteristics of the initial group of SSRF patients (Early-SSRF) were used to identify matching factors. Patients prior to SSRF protocol underwent a propensity score match, followed by screening for operative indications and contraindications. After exclusions, a non-operative (Non-Op) cohort was defined (n=36) resulting in an approximately 1:1 match. An overall operative cohort, inclusive of Early-SSRF and all subsequent operative patients, was defined (All- SSRF). A before-and-after analysis using chi-squared, Students T-tests, and Mann-Whitney U-tests were used to assess significance at the level of 0.05. ResultsEarly-SSRF (n=22) and All-SSRF (n=45) were compared to Non-Op (n=36). The selection process resulted in well matched groups, and equally well-balanced operative indications between the groups. The Early-SSRF group demonstrated shortened duration of mechanical ventilation and a decreased frequency of being discharged a long-term acute care hospital. The All-SSRF group again demonstrated markedly shorter duration of mechanical ventilation compared to Non-Op (median 6 days vs 16 days, p < 0.01), more decrease discharge to a long-term acute care hospital (9% vs. 36%, p=0.01), and reduced risk for tracheostomy (8.9% vs. 33.3% respectively, p<0.01) ConclusionThe introduction of an operative rib fixation to a comprehensive chest wall injury protocol can produce improvements in clinical outcomes that decrease time on the ventilator and tracheostomy rates, and result in more patients being discharged to home. Creation and implementation of a chest wall injury protocol to include SSRF requires a multidisciplinary approach and thoughtful patient selection.

Late Operative Rib Fixation is Inferior to Nonoperative Management.

Operative rib fixation (ORF) of traumatic rib fractures has been shown to decrease hospital length of stay (LOS), ventilator days, and mortality. ORF performed within 1 day of admission has been shown to have favorable outcomes compared to later ORF. This report examines the ORF experience over 10 years at a level I trauma center. ORF patients from January 2007-January 2018 were matched to nonoperative controls in a 1:2 ratio based on age, injury severity score (ISS), chest Abbreviated Injury Score (AIS), and head AIS. Patient demographic, injury, and outcome data were collected from the trauma registry and medical records. Hospital day of ORF was identified for each ORF patient. Hospital LOS, ICU LOS, ventilator days, and mortality were compared against matched nonoperative controls. Ninety-five ORF patients were matched to 190 nonoperative patients. ORF patients had a higher number of rib fractures (9.6 vs 6.4, P < .001). ORF patients with short time to operation (0-2 days) had a shorter average hospital stay than those with delayed operations (11.8 vs 12.6 vs 13.4 vs 19.6 days, P = .003). ORF patients with operations performed 3-4 days and >6 days after admission also had statistically significant longer ICU LOS and ventilator days. Patient mortality was higher when ORF was performed after 6 days. Early ORF may improve pulmonary function, patient outcomes, and decrease LOS. Shifting practice toward early fixation may help further solidify the benefits of this procedure in the treatment of blunt chest trauma.

Surgical fixation of rib fractures decreases intensive care length of stay in flail chest patients.

BackgroundNonoperative treatment is currently the standard therapy for rib fractures. However, there is a trend towards surgical fixation from conservative management over the last decade. While surgical fixation of rib fractures has shown promising results, its impact on the clinical results remains unclear based on the current literature. As such, the present study aims to compare the short-term outcomes of multiple rib fracture patients treated by surgical fixation with traditional conservative management.MethodsData for patients with multiple (three or more) rib fractures admitted to our department between January 2012 and January 2019 were retrospectively collected and analyzed. Propensity score matched patients were compared between those treated with surgical rib fixation and those of nonoperatively treated. Primary outcomes were hospital length of stay for multiple rib fracture patients, and intensive care unit (ICU) length of stay for flail chest patients. Secondary outcomes included in hospital mortality, ICU usage rate, duration of ventilator support, ventilator usage rate, and pneumonia.ResultsThe study included 1,201 patients with mean age of 50.1±12.7 years, of whom 954 (79.4%) were male. The average number of rib fractures was 6.3±2.4, with a mean injury severity score of 20.5±7.3. Among them, 563 (46.9%) patients had surgical rib fixation and 638 (53.1%) patients received nonoperative treatment. There were 191 patients with a flail chest, 133 (69.6%) had operative rib fixation and 58 (30.4%) were nonoperatively treated. After propensity score match, the hospital length of stay was not significantly differed between surgery and conservative management in multiple rib fracture patients (10.7±3.4 vs. 10.2±3.8 days, P=0.067), nor were the secondary outcomes, in terms of in hospital mortality (0.9% vs. 1.1%, P=0.704), ICU usage rate (12.3% vs. 12.9%, P=0.820), duration of ventilator support (100.1±13.9 vs. 99.8±20.7 hours, P=0.822), ventilator usage rate (12.0% vs. 12.9%, P=0.732), and pneumonia (24.3% vs. 24.9%, P=0.861). For patients with a flail chest, shorter ICU length of stay was found to be associated with surgical rib fixation comparing with nonoperative treatment (5.5±1.9 vs. 6.7±2.1 days, P=0.011). No secondary outcomes such as in hospital mortality (4.4% vs. 4.4%, P=1.000), ICU usage rate (20.0% vs. 22.2%, P=0.796), duration of ventilator support (113.1±20.4 vs. 131.2±19.5 hours, P=0.535), ventilator usage rate (20.0% vs. 20.0%, P=1.000), pneumonia (28.9% vs. 31.1%, P=0.818) were significant different between the operative and nonoperative groups.ConclusionsSurgical rib fixation results in a shorter ICU length of stay in patients with a flail chest, and a comparable outcome for patients with multiple rib fractures when compared with nonoperative treatment.

Early results after operatively versus non-operatively treated flail chest: a retrospective study focusing on outcome and complications

PurposeFlail chest was traditionally treated non-operatively using mechanical ventilation and pain control. In order to reduce the occurrence of ventilation-associated complications and long-term disability, operative rib fixation is becoming a proven standard therapy for these patients. However, the consequences of the surgical complications may influence success rates negatively. The aim of this study was to compare the outcome of flail chest treatment by surgical rib fixation with non-operative treatment, with special focus on the impact of surgical complications.MethodsA retrospective case series of operatively treated flail chest patients was compared with non-operatively treated patients. Patients’ injury and treatment characteristics and outcome parameters (e.g., duration of mechanical ventilation, length of Intensive Care stay (ICLOS) and hospital length of stay (HLOS), mortality, surgery-related complications and pneumonia) were collected from the patients’ medical files. Crude and matched-pairs analyses were performed in SPSS.ResultsTwenty-three operatively and 47 non-operatively treated patients were enrolled. Operatively treated patients required significantly shorter mechanical ventilation; median 4 days versus 12 days for the non-operative group (p = 0.011). The matched-pairs analysis also showed a lower pneumonia rate (35% versus 80%; p = 0.035) and a shorter HLOS (median 21 versus 23 days; p = 0.028) in the operative group. No significant differences in duration of ICLOS, and occurrence of other injury-related adverse events were found between both groups. Seven surgery-related complications occurred, of which three required invasive solutions.ConclusionsOperative fixation of a flail chest in trauma patients results in a lower rate of pneumonia, less mechanical ventilation days and shorter hospital stay, compared with non-operative treatment, but at the cost of surgery-related complications requiring invasive solutions in some cases.

Surgical Management of Flail Chest: State of Art and Future Perspectives

Rib fractures are common among trauma patients with both blunt chest wall and thoraco-abdominal trauma, seen in up to 39% of patients following blunt chest trauma and present in 10% of all trauma admissions and, in these individuals, mortality rates can reach 9–16%. Notwithstanding, the objective of surgical stabilization is to recover thoracic wall rigidity and restore normal ventilation and functions, thus decreasing mortality and morbidity. Currently, all possible indications for surgical rib fixation are far away from a consensus statement backed up with strong evidence. The aim of this review article is to highlight both the usefulness and the pitfalls of operative rib fixation techniques.

Thoracoscopic, minimally invasive rib fixation after trauma

Rib fractures and flail chest are associated with significant morbidity and mortality. Operative rib fixation has been shown to improve patient outcomes. In an attempt to decrease postoperative pai...

Prospective Randomized Controlled Trial of Operative Rib Fixation in Traumatic Flail Chest

Traumatic flail chest injury is a potentially life threatening condition traditionally treated with invasive mechanical ventilation to splint the chest wall. Longer-term sequelae of pain, deformity, and physical restriction are well described. This study investigated the impact of operative fixation in these patients. A prospective randomized study compared operative fixation of fractured ribs in the flail segment with current best practice mechanical ventilator management. In-hospital data, 3-month follow-up review, spirometry and CT, and 6-month quality of life (Short Form-36) questionnaire were collected. Patients in the operative fixation group had significantly shorter ICU stay (hours) postrandomization (285 hours [range 191 to 319 hours] for the surgical group vs 359 hours [range 270 to 581 hours] for the conservative group; p = 0.03) and lesser requirement for noninvasive ventilation after extubation (3 hours [range 0 to 25 hours] in the surgical group vs 50 hours [range 17 to 102 hours] in the conservative group; p = 0.01). No differences in spirometry at 3 months or quality of life at 6 months were noted. Operative fixation of fractured ribs reduces ventilation requirement and intensive care stay in a cohort of multitrauma patients with severe flail chest injury.