Randomized Controlled Trial of Surgical Rib Fixation to Non-Surgical Treatment in Severe Chest Wall Injuries
Aim:
To compare the effectiveness of surgical stabilization of rib fractures (SSRF) with non-surgical treatment in severe chest wall injuries.
Background data summary:
Surgical stabilization of rib fractures (SSRF) has been shown to improve outcomes in patients with clinical flail chest and respiratory failure . However, the effect of SSRF results on severe chest wall injuries without clinical flail chest is unknown.
Methods:
Randomized controlled trial comparing surgical stabilization of rib fractures (SSRF) with non-surgical treatment in severe chest wall injuries, defined as:
- An unstable radiographic segment without clinical instability.
- ≥5 consecutive rib fractures.
- Any rib fracture with bicortical displacement.
Randomization was stratified by admission unit as a proxy for injury severity.
The primary outcome was length of hospital stay (LOS).
Secondary outcomes included intensive care unit (ICU) length of stay, ventilator days, opioid exposure, mortality, and incidences of pneumonia and tracheostomy.
Quality of life (QoL) at 1, 3, and 6 months was measured using the EQ-5D-5L survey.
Results:
84 patients were randomized in an intention-to-treat analysis (usual care = 42, SSRF = 42).
Baseline characteristics were similar between groups. The number of total fractures, displaced fractures, and segmental fractures per patient was also similar, as was the incidence of displaced fractures and unstable radiographic segments.
Hospital stay was longer in the SSRF group.
The days of ICU stay and ventilation were similar.
After adjusting for the stratification variable, length of hospital stay (LOS) remained longer in the SSRF group (RR 1.48, 95% CI 1.17-1.88).
Length of ICU stay (RR 1.65, 95% CI 0.94-2.92) and days on ventilation (RR 1.49, 95% CI 0.61-3.69) were they remained similar.
Subgroup analysis showed that patients with displaced fractures were more likely to have LOS outcomes similar to their usual care counterparts.
At one month, patients with surgical stabilization of rib fractures (SSRF) had greater impairment in mobility (3 [2-3] vs. 2 [1-2], P = 0.012) and self-care (2 [1-2 ] versus 2 [2-3], P =0.034) dimensions of the EQ-5D-5L.
Conclusion:
In severe chest wall injuries, even in the absence of clinical flail chest, most patients still reported moderate to extreme pain and impairment of usual physical activity at 1 month.
Surgical stabilization of rib fractures (SSRF) increased length of hospital stay and provided no QoL benefit up to 6 months.
Final comments
According to the study results, the SSRF group had a longer hospital stay compared to the usual care group. ICU length of stay and ventilator days were similar between groups. However, the difference in length of hospital stay remained in favor of the usual care group.
Subgroup analysis indicated that patients with displaced fractures were more likely to have similar length of hospital stay outcomes as the usual care group.
At the 1-month follow-up, patients in the SSRF group experienced greater deterioration in mobility and self-care dimensions.
Overall, these findings show that in cases of severe chest wall injury, including those without clinical flail chest, a significant number of patients reported moderate to extreme pain and limitations in usual physical activity at one month.
| Surgical stabilization of rib fractures (SSRF) resulted in a longer hospital stay without providing any improvement in quality of life of up to six months. |
