Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial
Niloofar Dehghan1,2, Aaron Nauth3, Emil Schemitsch4
1The CORE Institute, Phoenix, Arizona.
JAMA Surgery
|September 21, 2022
Summary
Operative treatment for unstable chest wall injuries showed modest benefits, particularly for ventilated patients. Surgical intervention reduced mortality compared to nonoperative management in this randomized trial.
Area of Science:
- Trauma Surgery
- Thoracic Surgery
- Critical Care Medicine
Background:
- Unstable chest wall injuries are associated with high mortality and morbidity.
- Previous studies suggest improved outcomes with operative treatment, but lacked robust evidence from randomized clinical trials.
Purpose of the Study:
- To compare the outcomes of surgical treatment versus non-surgical management for acute unstable chest wall injuries.
Main Methods:
- A multicenter, prospective, randomized clinical trial involving 207 patients with unstable chest wall injuries.
- Patients were randomized to either operative treatment (plate and screws) or nonoperative management.
- Primary outcome was ventilator-free days (VFDs) within 28 days; secondary outcomes included mortality and complications.
Main Results:
- Operative treatment showed a trend towards increased VFDs (22.7 vs. 20.6 days), though not statistically significant (P=0.09).
- Mortality was significantly lower in the operative group (0%) compared to the nonoperative group (6%, P=0.01).
- A subgroup analysis revealed significantly more VFDs in ventilated patients treated operatively (mean difference 2.8 days).
Conclusions:
- Operative treatment offers a modest benefit for unstable chest wall injuries, primarily observed in mechanically ventilated patients.
- Surgical intervention significantly reduces mortality in this patient population.
- Non-ventilated patients did not demonstrate a benefit from operative treatment.
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