Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis

Abstract

Purpose The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. Methods MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy. Results Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I 2 = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies. Conclusions Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs. Electronic supplementary material The online version of this article (10.1007/s00068-018-1020-x) contains supplementary material, which is available to authorized users.

Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults

“…Furthermore, no difference was observed in effect estimates from RCTs and observational studies regarding the primary outcome measures. These results are in line with previous orthopedic trauma meta-analyses, [9][10][11][12] shown an increase of distal radius fractures in patients aged 17 to 64 years. 2 Hence, future studies should also focus on the nonelderly population, because traditionally most studies on this topic solely include patient populations 60 years or older.…”

“…including RCTs and observational studies, showing high-quality observational studies to result in similar treatment effects compared with RCTs.Reports 9,[11][12][13][14][15]18 have shown that differences in effect estimates between RCTs and observational studies tend to be small. Randomized clinical trials require strict conditions such as participant selection, inclusion and exclusion criteria, randomization method, and outcome measurements.…”

Study methodology in trauma care: towards question-based study designs

“…For certain type 3 comparisons an observational study design may therefore be suitable. Similar to type 2 comparisons, multiple recent meta-analyses where surgery was compared to conservative treatment indeed found that treatment groups appeared to be similar and effect estimates were comparable between observational studies and randomized trials [7][8][9]. In studies of type 3 comparisons, treatment groups may indeed be comparable if the surgeon's preference for one treatment option over the other is of greater influence on treatment decisions than (unmeasured) patient characteristics.…”

“…Provided observational studies are of high quality, adding information from observational studies to meta-analyses will increase the number of patients available for analysis and can lead to more precise effects estimates, possibilities for subgroup analysis, and may provide more insight in rare and longterm outcomes [7]. Obviously, only high quality observational studies should be included for meta-analysis, or at least sensitivity analysis, stratified by study quality, needs to be conducted [7][8][9]. Alternatively, statistical methodology has been developed to include external (observational) data in the analysis of randomized trials, that accounts for their (dis-)similarity [33,34].…”

“…RCTs in surgery may not always be ethical, feasible, or necessary to address a particular research question. If so, properly designed and conducted observational studies can be valuable alternatives for an RCT and produce credible results [7][8][9][10][11]. In this paper, we elaborate on complementary use of observational studies and RCTs and the need for both.…”