Early surgical stabilization of multiple rib fractures and flail chest is associated with better outcomes compared
Junsik Kwon1, Bishoy Zakhary, Bruno C Coimbra
1From the Comparative Effectiveness and Clinical Outcomes Research Center (J.K., B.Z., R.C.), Riverside University Health System, Moreno Valley, California; Division of Trauma Surgery, Department of Surgery (J.K.), Ajou University School of Medicine, Suwon, Korea; George Washington University School of Medicine and Health Sciences (B.C.C.); Department of Surgery (B.C.C., B.S.), Center for Trauma and Critical Care, George Washington University School of Medicine and Health Sciences, Washington, DC; Division of Trauma and Acute Care Surgery (R.C.), Riverside University Health System Medical Center, Moreno Valley; and Department of Surgery (R.C.), Loma Linda University School of Medicine, Loma Linda, California.
Background:
Surgical stabilization of rib fractures (SSRF) is increasingly performed. Nationwide data comparing its outcomes with nonoperative management (NOM) and defining the best timing for SSRF are scarce.
Methods:
We analyzed data from the American College of Surgeons Trauma Quality Improvement Program, 2017-2021. Adults with three or more blunt rib fractures and no major extrathoracic injury were included. Surgical fixation was compared with risk-weighted NOM using inverse probability of treatment weighting. Primary outcome was in-hospital mortality. Secondary outcomes were hospital and intensive care length of stay, ventilator duration, ventilator-free days, acute respiratory distress syndrome, and ventilator-associated pneumonia. Subgroup analyses examined flail chest and the impact of timing of fixation, which was modeled as a continuous exposure with a generalized additive spline; its discriminatory performance was evaluated with receiver-operating-characteristic curve analysis to calculate the Youden's index.
Results:
A total of 3,806 patients underwent SSRF, and 3,753 weighted controls received NOM. After weighting, an association of SSRF with lower mortality (1.5% vs. 2.7%, p < 0.001) but longer hospital (median, 10 vs. 5 days) and intensive care stays (5 vs. 3 days, both p < 0.001) were observed. In the flail chest subgroup, SSRF was associated with a mortality of 4.2% compared with 10.1% with NOM ( p = 0.002). In the nonflail group, mortality was 1.3% after SSRF versus 2.0% in NOM ( p = 0.003). Early SSRF within 82 hours had similar mortality to delayed fixation (1.6% vs. 1.4%, p = 0.647). However, early SSRF was associated with lower rates of acute respiratory distress syndrome (0.5% vs. 1.5%), ventilator-associated pneumonia (0.9% vs. 2.3%), and shorter hospital stays compared with delayed SSRF.
Conclusion:
Nationwide data demonstrated that SSRF is associated with higher survival, particularly in patients with flail chest, at the cost of increased resource utilization. Surgical stabilization of rib fractures performed within 82 hours is associated with higher survival, lower pulmonary morbidity, and additional resource utilization.
Level Of Evidence:
Therapeutic/Care Management; Level III.
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