Randomized controlled trial of surgical rib fixation to non-operative management in severe chest wall injury

Abstract

Objective: To compare the effectiveness of surgical stabilization of rib fractures (SSRFs) to nonoperative management in severe chest wall injury. Background: SSRF has been shown to improve outcomes in patients with clinical flail chest and respiratory failure. However, the effect of SSRF outcomes in severe chest wall injuries without clinical flail chest is unknown. Methods: Randomized controlled trial comparing SSRF to nonoperative management in severe chest wall injury, defined as: (1) a radiographic flail segment without clinical flail or (2) ≥5 consecutive rib fractures or (3) any rib fracture with bicortical displacement. Randomization was stratified by the unit of admission as a proxy for injury severity. Primary outcome was hospital length of stay (LOS). Secondary outcomes included intensive care unit (ICU) LOS, ventilator days, opioid exposure, mortality, and incidences of pneumonia and tracheostomy. Quality of life at 1, 3, and 6 months was measured using the EQ-5D-5L survey. Results: Eighty-four patients were randomized in an intention-to-treat analysis (usual care = 42, SSRF = 42). Baseline characteristics were similar between groups. The numbers of total fractures, displaced fractures, and segmental fractures per patient were also similar, as were the incidences of displaced fractures and radiographic flail segments. Hospital LOS was greater in the SSRF group. ICU LOS and ventilator days were similar. After adjusting for the stratification variable, hospital LOS remained greater in the SSRF group (RR: 1.48, 95% CI: 1.17–1.88). ICU LOS (RR: 1.65, 95% CI: 0.94–2.92) and ventilator days (RR: 1.49, 95% CI: 0.61–-3.69) remained similar. Subgroup analysis showed that patients with displaced fractures were more likely to have LOS outcomes similar to their usual care counterparts. At 1 month, SSRF patients had greater impairment in mobility [3 (2–3) vs 2 (1–2), P = 0.012] and self-care [2 (1–2) vs 2 (2–3), P = 0.034] dimensions of the EQ-5D-5L. Conclusions: In severe chest wall injury, even in the absence of clinical flail chest, the majority of patients still reported moderate to extreme pain and impairment of usual physical activity at one month. SSRF increased hospital LOS and did not provide any quality of life benefit for up to 6 months.

A meta-analysis and trial sequential analysis of randomised controlled trials comparing nonoperative and operative management of chest trauma with multiple rib fractures

“…Excluding duplicates, 580 articles underwent primary screening and 20 underwent secondary screening. Ultimately, 9 articles were included in the final analysis [ 10 , 11 , 20 – 26 ]. Of the total of 862 patients included in the articles under review, 423 were treated with operative treatment, and 439 were treated with conservation treatment.…”

“…Of the total of 862 patients included in the articles under review, 423 were treated with operative treatment, and 439 were treated with conservation treatment. Seven RCTs [ 10 , 20 – 24 , 26 ] involved patients with flail segment and clinical flail chest, one study [ 11 ] involved patients with flail segment but no clinical flail chest, one study [ 25 ] involved patients with simple rib fractures without clinical or radiological flail chest, and one study included only men [ 23 ]. The characteristics of the included studies are summarised in Table 1 .…”

“…Complete data were shown in 6 studies [ 10 , 11 , 20 , 22 – 24 ], with statistical heterogeneity noted between groups ( I 2 = 63%, P = 0.02). A combined 105 events occurred in the 588 patients.…”

“…Complete data were shown in 8 studies [ 10 , 11 , 20 – 24 , 26 ], with statistical heterogeneity noted between groups ( I 2 = 96%, P < 0.01). There was a significant difference favouring the operative group (MD -3.05; 95% CI -5.87 to -0.22; P = 0.03) (Fig.…”

“…As mentioned above, the optimal strategy for traumatic multiple rib fractures is controversial due to limited available evidence. However, novel large-scale RCTs performed by Dehghan et al [ 10 ] and Meyer et al [ 11 ] were recently published. Here, we describe our systematic review and meta-analysis of RCTs performed to assess the certainty of evidence for determining the optimal strategy for patients with traumatic rib fractures.…”