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Surgical Rib Fixation of Multiple Rib Fractures and Flail Chest: A Systematic Review and Meta-analysis

Published:April 04, 2022DOI:https://doi.org/10.1016/j.jss.2022.02.055

      Highlights

      • Rib fractures in multitrauma patients are associated with high morbidity and mortality.
      • We examined studies comparing surgical rib fixation to conservative management alone.
      • Surgical rib fixation is beneficial to a range of outcomes compared to conservative management.
      • This is particularly for surgery within 72 h and in patients with flail chest injuries.
      • Conservative management may be more beneficial to patients over 60 y old.

      Abstract

      Background

      Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been treated conservatively, there is increasing interest in the benefits of surgical fixation. However, strong evidence that supports surgical rib fixation and identifies the most appropriate patients for its application is currently sparse.

      Methods

      A systematic review and meta-analysis following PRISMA guidelines was performed to identify all peer-reviewed papers that examined surgical compared to conservative management of rib fractures. We undertook a subgroup analysis to determine the specific effects of rib fracture type, age, the timing of fixation and study design on outcomes. The primary outcomes were the length of hospital and ICU stay, and secondary outcomes included mechanical ventilation time, rates of pneumonia, and mortality.

      Results

      Our search identified 45 papers in the systematic review, and 40 were included in the meta-analysis. There was a statistical benefit of surgical fixation compared to conservative management of rib fractures for length of ICU stay, mechanical ventilation, mortality, pneumonia, and tracheostomy. The subgroup analysis identified surgical fixation was most favorable for patients with flail chest and those who underwent surgical fixation within 72 h. Patients over 60 y had a statistical benefit of conservative management on length of hospital stay and mechanical ventilation.

      Conclusions

      Surgical fixation of flail and multiple rib fractures is associated with a reduction in morbidity and mortality outcomes compared to conservative management. However, careful selection of patients is required for the appropriate application of surgical rib fixation.

      Keywords

      Introduction

      Rib fractures are prevalent injuries in trauma and carry a heavy burden of disease. Increased recognition of the contribution of rib fractures to both morbidity and mortality in multitrauma patients has fostered an interest in optimizing treatment regimes. While historically, rib fractures were managed nonoperatively, emerging evidence suggests that optimal treatment of these patients may sometimes involve primary surgical fixation.
      • Leinicke J.A.
      • Elmore L.
      • Freeman B.D.
      • Colditz G.A.
      Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis.
      ,
      • Liang Y.S.
      • Yu K.C.
      • Wong C.S.
      • Kao Y.
      • Tiong T.Y.
      • Tam K.W.
      Does surgery reduce the risk of complications among patients with multiple rib fractures? A meta-analysis.
      Early studies have identified benefits of surgical rib fixation across a range of outcomes, including mortality, length of mechanical ventilation, and pulmonary complications. However, evidence that identifies the most appropriate cohort of patients for surgical rib fixation is sparse.
      Rib fractures account for 10% of all trauma admissions and carry a heavy burden of morbidity and mortality.
      • Liang Y.S.
      • Yu K.C.
      • Wong C.S.
      • Kao Y.
      • Tiong T.Y.
      • Tam K.W.
      Does surgery reduce the risk of complications among patients with multiple rib fractures? A meta-analysis.
      ,
      • Flagel B.T.
      • Luchette F.A.
      • Reed R.L.
      • et al.
      Half-a-dozen ribs: the breakpoint for mortality.
      However, as this injury is often described as a marker of another injury, it may be difficult to isolate the specific effects of rib fractures on outcomes compared to the possible synergistic effects of a concomitant injury. Mortality directly associated with rib fractures typically occurs due to pulmonary complications such as ventilation-perfusion abnormality, hypoxemia, and infective sequelae resulting in sepsis. An estimated one-third of patients with rib fractures develop secondary pulmonary complications leading to significant morbidity and mortality.
      • Bauman Z.M.
      • Grams B.
      • Yanala U.
      • et al.
      Rib fracture displacement worsens over time.
      Across the literature, mortality rates of multitrauma patients with rib fractures range from 10% to 30%.
      • Flagel B.T.
      • Luchette F.A.
      • Reed R.L.
      • et al.
      Half-a-dozen ribs: the breakpoint for mortality.
      ,
      • Lafferty P.M.
      • Anavian J.
      • Will R.E.
      • Cole P.A.
      Operative treatment of chest wall injuries: indications, technique, and outcomes.
      ,
      • Peek J.
      • Beks R.B.
      • Hietbrink F.
      • et al.
      Epidemiology and outcome of rib fractures: a nationwide study in The Netherlands.
      Studies have identified several key risk factors associated with increased morbidity and mortality, including age, pre-existing comorbidities, higher numbers of rib fractures and patients with concomitant injuries.
      • Battle C.E.
      • Hutchings H.
      • Evans P.A.
      Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis.
      The heavy burden of rib fracture-associated morbidity and mortality has recently generated interest in optimizing treatment regimes. Rib fracture management aims to restore pulmonary function and treat underlying thoracic injury to avoid respiratory complications.
      • Pieracci F.M.
      • Lin Y.
      • Rodil M.
      • et al.
      A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures.
      Historically, rib fractures have been treated conservatively with analgesia, pulmonary hygiene, and ventilatory support.
      • Leinicke J.A.
      • Elmore L.
      • Freeman B.D.
      • Colditz G.A.
      Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis.
      Rib fracture stabilization adds another paradigm to their management. For achieving the primary goal of osteosynthesis, surgical approaches aim to restore chest wall stability and improve mechanical integrity while also utilizing conservative management options.
      • Pieracci F.M.
      • Leasia K.
      • Bauman Z.
      • et al.
      A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL).
      Surgical fixation was previously reserved for patients where conservative management alone had failed and in patients with severe flail chest. However, the indication for surgical fixation as a primary management option is expanding. The efficacy of surgical fixation compared to conservative management alone across a broader scope of rib fracture injury has been investigated in a small number of randomized controlled trials (RCTs) and observational studies. From these studies, several systematic reviews and meta-analyses have attempted to quantify the benefits of rib fixation compared to conservative management. Most of these meta-analyses examined patients with flail chest injuries only. All meta-analyses found some benefit of surgical rib fixation for outcomes, including length of stay in ICU and hospital,
      • Leinicke J.A.
      • Elmore L.
      • Freeman B.D.
      • Colditz G.A.
      Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis.
      ,
      • Liang Y.S.
      • Yu K.C.
      • Wong C.S.
      • Kao Y.
      • Tiong T.Y.
      • Tam K.W.
      Does surgery reduce the risk of complications among patients with multiple rib fractures? A meta-analysis.
      ,
      • Beks R.B.
      • Peek J.
      • de Jong M.B.
      • et al.
      Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis.
      • Cataneo A.J.
      • Cataneo D.C.
      • de Oliveira F.H.
      • Arruda K.A.
      • El Dib R.
      • de Oliveira Carvalho P.E.
      Surgical versus nonsurgical interventions for flail chest.
      • Coughlin T.A.
      • Ng J.W.
      • Rollins K.E.
      • Forward D.P.
      • Ollivere B.J.
      Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials.
      • Long R.
      • Tian J.
      • Wu S.
      • Li Y.
      • Yang X.
      • Fei J.
      Clinical efficacy of surgical versus conservative treatment for multiple rib fractures: a meta-analysis of randomized controlled trials.
      • Schuurmans J.
      • Goslings J.C.
      • Schepers T.
      Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review.
      • Slobogean G.P.
      • MacPherson C.A.
      • Sun T.
      • Pelletier M.E.
      • Hameed S.M.
      Surgical fixation vs nonoperative management of flail chest: a meta-analysis.
      • Swart E.
      • Laratta J.
      • Slobogean G.
      • Mehta S.
      Operative treatment of rib fractures in flail chest injuries: a meta-analysis and cost-effectiveness analysis.
      mechanical ventilation,
      • Leinicke J.A.
      • Elmore L.
      • Freeman B.D.
      • Colditz G.A.
      Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis.
      ,
      • Liang Y.S.
      • Yu K.C.
      • Wong C.S.
      • Kao Y.
      • Tiong T.Y.
      • Tam K.W.
      Does surgery reduce the risk of complications among patients with multiple rib fractures? A meta-analysis.
      ,
      • Cataneo A.J.
      • Cataneo D.C.
      • de Oliveira F.H.
      • Arruda K.A.
      • El Dib R.
      • de Oliveira Carvalho P.E.
      Surgical versus nonsurgical interventions for flail chest.
      • Coughlin T.A.
      • Ng J.W.
      • Rollins K.E.
      • Forward D.P.
      • Ollivere B.J.
      Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials.
      • Long R.
      • Tian J.
      • Wu S.
      • Li Y.
      • Yang X.
      • Fei J.
      Clinical efficacy of surgical versus conservative treatment for multiple rib fractures: a meta-analysis of randomized controlled trials.
      ,
      • Slobogean G.P.
      • MacPherson C.A.
      • Sun T.
      • Pelletier M.E.
      • Hameed S.M.
      Surgical fixation vs nonoperative management of flail chest: a meta-analysis.
      ,
      • Apampa A.A.
      • Ali A.
      • Kadir B.
      • Ahmed Z.
      Safety and effectiveness of surgical fixation versus non-surgical methods for the treatment of flail chest in adult populations: a systematic review and meta-analysis.
      mortality,
      • Beks R.B.
      • Peek J.
      • de Jong M.B.
      • et al.
      Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis.
      ,
      • Slobogean G.P.
      • MacPherson C.A.
      • Sun T.
      • Pelletier M.E.
      • Hameed S.M.
      Surgical fixation vs nonoperative management of flail chest: a meta-analysis.
      ,
      • Swart E.
      • Laratta J.
      • Slobogean G.
      • Mehta S.
      Operative treatment of rib fractures in flail chest injuries: a meta-analysis and cost-effectiveness analysis.
      ,
      • Choi J.
      • Gomez G.I.
      • Kaghazchi A.
      • Borghi J.A.
      • Spain D.A.
      • Forrester J.D.
      Surgical stabilization of rib fracture to mitigate pulmonary complication and mortality: a systematic review and bayesian meta-analysis.
      pulmonary complications,
      • Leinicke J.A.
      • Elmore L.
      • Freeman B.D.
      • Colditz G.A.
      Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis.
      ,
      • Liang Y.S.
      • Yu K.C.
      • Wong C.S.
      • Kao Y.
      • Tiong T.Y.
      • Tam K.W.
      Does surgery reduce the risk of complications among patients with multiple rib fractures? A meta-analysis.
      ,
      • Choi J.
      • Gomez G.I.
      • Kaghazchi A.
      • Borghi J.A.
      • Spain D.A.
      • Forrester J.D.
      Surgical stabilization of rib fracture to mitigate pulmonary complication and mortality: a systematic review and bayesian meta-analysis.
      and need for tracheostomy.
      • Beks R.B.
      • Peek J.
      • de Jong M.B.
      • et al.
      Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis.
      ,
      • Cataneo A.J.
      • Cataneo D.C.
      • de Oliveira F.H.
      • Arruda K.A.
      • El Dib R.
      • de Oliveira Carvalho P.E.
      Surgical versus nonsurgical interventions for flail chest.
      ,
      • Schuurmans J.
      • Goslings J.C.
      • Schepers T.
      Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review.
      ,
      • Slobogean G.P.
      • MacPherson C.A.
      • Sun T.
      • Pelletier M.E.
      • Hameed S.M.
      Surgical fixation vs nonoperative management of flail chest: a meta-analysis.
      ,
      • Apampa A.A.
      • Ali A.
      • Kadir B.
      • Ahmed Z.
      Safety and effectiveness of surgical fixation versus non-surgical methods for the treatment of flail chest in adult populations: a systematic review and meta-analysis.
      However, the efficacy of surgical fixation for certain outcomes was inconsistent between meta-analyses. These conflicting results are likely due to the significant heterogeneity of currently available primary studies. Difficulties in appropriately diagnosing and scoring rib fracture severity, variability of fracture patterns, and the significant influence of patient characteristics and comorbidities on outcomes make the pooled analysis of individual studies challenging. With the pooling of disparate primary studies, the applicability of these findings in clinical practice is currently limited.
      With increasing interest in the potential advantages of surgical fixation, new protocols are being established that aim to identify suitable patient cohorts for surgical fixation. However, no systematic reviews to date have attempted to stratify comparable primary studies by subgroups to determine if there is a benefit of surgical fixation for specific cohorts of patients. Consequently, there is currently limited evidence to inform decision-making regarding the appropriate selection of patients for surgical fixation.
      The aim of this systematic review was, therefore, to employ multiple subgroup analyses of primary literature to identify the patient cohorts that are most appropriate for surgical fixation compared to the conservative management of rib fractures.

      Methods

      A review protocol and data extraction methods were established by the authors according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      This review was registered with PROSPERO, an international database of prospectively registered systematic reviews (registration number: CRD42020208832).
      • Booth A.
      • Clarke M.
      • Dooley G.
      • et al.
      The nuts and bolts of PROSPERO: an international prospective register of systematic reviews.
      Database searches were conducted between June and July 2021.
      A systematic search strategy was developed to identify studies that compared surgical rib fixation and conservative (nonoperative, multimodal) management in flail chest or multiple rib fracture patients. An extensive search for relevant studies was completed using the following electronic databases: PubMed (via PubMed), Web of Science, EMBASE, and CINAHL (via Ebscohost). These databases were searched for relevant articles containing the keywords: (“Rib∗” OR “Chest”) AND (“Flail” OR “Fracture” OR “Segment∗”) AND (“Management” OR “Operat∗” OR “Non∗Operat∗” OR “ORIF” OR “Open Reduction Internal Fixation” OR “Fixat∗” OR “Plat∗”). Reference lists from the papers obtained via the database search were examined to identify potential papers for inclusion. Only publications in peer-reviewed journals were considered. The title and abstract of the papers identified in the electronic searches were inspected. The full text of each paper was then examined in greater detail as per the defined inclusion/exclusion criteria. All discrepancies during study selection, data extraction, and quality assessment were resolved by re-checking source papers.

      Inclusion and exclusion criteria

      For inclusion, studies were required to fulfill the following criteria: (a) original article, (b) quantitative observational studies, prospective studies, and RCTs, (c) injury occurring within the past 20 y (2001-2021), (d) available in the English language, (e) methodological comparison of surgical fixation and nonoperative management of rib fractures, (f) adult cohort (individuals over the age of 18). Studies were excluded if they were: (a) Case-reports, reviews, abstracts, animal studies, cadaveric studies, (b) opinions or abstracts, (c) papers that did not include a nonoperative control group, (d) papers of exclusive subgroups with confounding comorbidities (e.g., traumatic brain injury) not applicable to the general trauma population. While all attempts were made to obtain full-text articles, studies were excluded if they could not be accessed (n = 7).

      Outcome measures

      The primary outcome measure was the length of stay (ICU and hospital) and secondary outcome measures included: duration of mechanical ventilation, mortality, pneumonia, tracheostomy, respiratory function, pain, and adverse surgical outcomes.

      Methodological quality

      The methodological quality of non-RCT papers was assessed using an adapted Risk of Bias in Nonrandomized studies-I (ROBINS-I) assessment. The ROBINS-I instrument assesses the methodological quality of observational studies with two or more interventions.
      • Sterne J.A.
      • Hernán M.A.
      • Reeves B.C.
      • et al.
      ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions.
      This quality assessment tool was selected as it specifically stratifies bias into groups of low, moderate, serious, and critical risk of bias. For ease of assessment, serious and critical risk of bias was combined into a “high” group, and an additional “not described” group was also included. RCTs included in this systematic review were assessed using an equivalent tool, the Cochrane Risk of Bias (RoB-2).
      • Sterne J.A.C.
      • Savović J.
      • Page M.J.
      • et al.
      RoB 2: a revised tool for assessing risk of bias in randomised trials.
      The authors acknowledge that an overall quality assessment score assumes that each quality measure has equal weight and is not necessarily an accurate representation of a paper’s quality. However, an average of the seven assessment criteria was calculated in this paper in order to perform a sensitivity analysis of papers considered “high-risk” of bias during the meta-analyses.

      Statistical analyses

      We used Review Manager version 5.4 for Mac, a statistical software package designed to analyze Cochrane Collaboration systematic reviews. Where data was given as raw and matched groups, the matched sample was used for the meta-analysis. Standard deviations were estimated from the reported confidence intervals (CI), standard errors, or interquartile ranges based on Hozo et al. and Bland et al. calculations.
      • Giavarina D.
      Understanding Bland altman analysis.
      ,
      • Hozo S.P.
      • Djulbegovic B.
      • Hozo I.
      Estimating the mean and variance from the median, range, and the size of a sample.
      Where studies used the same scale for each outcome, the mean differences (MD) for continuous data were calculated. We reported the relative risk (RR) for any dichotomous outcome. The precision of the effect size was reported as 95% confidence intervals.
      Heterogeneity was assessed using the I2 statistic, as the measure is independent of the number of studies in the meta-analysis, and therefore, has greater power to detect heterogeneity when the quantity of studies is small. An estimate of 50% or greater was considered as possible heterogeneity, and scores of 75%-100% indicated considerable heterogeneity. A random-effects model was used for all analyses as we could not definitely exclude interstudy variation even in the absence of statistical heterogeneity given the range of inclusion criteria and surgical fixation types across papers. A two-sided P-value <0.05 was considered significant. For any outcomes where there were at least ten studies, we tested for publication bias using Egger’s regression test. This test uses a random-effects meta-regression to examine whether there is a statistically significant relationship between effect size and study precision.
      • Sterne J.A.C.
      • Egger M.
      Regression methods to detect publication and other bias in meta-analysis.
      We considered a two-sided P value of <0.05 as significant to suggest the presence of a small-study effect and potential publication bias. A sensitivity analysis was attempted to assess for the robustness of the pooled estimates and included evaluation of the risk of bias, Injury Severity Score (ISS), and for those studies where standard deviation was calculated rather than provided in the paper.

      Subgroup analysis

      For identifying whether surgical rib fixation is most appropriate for specific cohorts of patients, subgroup analyses were undertaken, including study type (RCT, prospective and retrospective), rib fracture pattern (flail, multiple, combined), and patient characteristics, including age (>60 versus all ages), the timing of fixation (<72 h versus > 72 h), number of rib fractures (average < 6 versus > 6), average ISS score (<20, 20-30, >30) and publication date (<2015, >2015).

      Results

      A total of 45 papers were identified, including four RCTs, five prospective (not randomized) studies, and 35 retrospective studies (Fig. 1). Of these studies, 40 were included in the meta-analysis (Appendix Table 1). Two studies included patients from the same cohort, and data was only included from one of the studies, where both reported on a particular outcome.
      • Majercik S.
      • Vijayakumar S.
      • Olsen G.
      • et al.
      Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema.
      ,
      • Majercik S.
      • Wilson E.
      • Gardner S.
      • Granger S.
      • VanBoerum D.H.
      • White T.W.
      In-hospital outcomes and costs of surgical stabilization versus nonoperative management of severe rib fractures.
      A total of 10,892 patients were included in the pooled analysis involving 2960 patients from the surgical fixation group and 7932 patients from the conservative group. A variety of surgical fixation types were used, such as Kirschner-wires, intramedullary nails, and plates (titanium, titanium-nickel, and polymer) with screws (locking, cancellous and bicortical), rib clips, or sutures. A summary of the fixation device utilized by each study is outlined in Appendix Table 2. Several studies did not indicate the rib fixation type. Nonoperative management primarily consisted of analgesia and ventilatory support, although few studies described their conservative treatment regimen in detail.

      Patient characteristics

      The weighted average age of surgical fixation patients across all studies was 54.7 y and for conservatively managed patients was 53.3 y (Appendix Table 1). Four studies examined patients over 60-year old and had an average age of surgically managed patients of 70 y and conservatively managed patients of 74.3 y. Across all studies, three out of four patients were males in both surgical and conservative groups. The weighted average number of ribs fractured was 6.6 for the surgical group and 7.4 for the conservative group.

      Quality assessment

      Ten reviews were rated overall as low risk of bias, 26 as moderate, and four as high (Table 1). Several studies did not supply sufficient information to assess bias across categories. The sensitivity analysis adjusting for study quality found no significant differences in outcomes when a high risk of biased studies was removed.
      Table 1Risk of bias assessment.
      AuthorConfoundingSelectionClassification of interventionsDeviationsMissing dataMeasurement outcomesSelection resultTotal
      Agababaoglu
      • Ağababaoğlu İ.
      • Ersöz H.
      The benefits of early rib fixation for clinical outcomes of flail chest patients in intensive care unit.
      +++-+-+++++
      Ali-Osman
      • Ali-Osman F.
      • Mangram A.
      • Sucher J.
      • et al.
      Geriatric (G60) trauma patients with severe rib fractures: is muscle sparing minimally invasive thoracotomy rib fixation safe and does it improve post-operative pulmonary function?.
      ++++++-++++
      Althausen
      • Althausen P.L.
      • Shannon S.
      • Watts C.
      • et al.
      Early surgical stabilization of flail chest with locked plate fixation.
      ++++++-++++
      Beks
      • Beks R.B.
      • Reetz D.
      • de Jong M.B.
      • et al.
      Rib fixation versus non-operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: a multicenter cohort study.
      ++++++++++
      Buyukkarabacak
      • Buyukkarabacak Y.B.
      • §engul A.T.
      • Qelik B.
      • et al.
      The usefulness of early surgical rib stabilization in flail chest.
      +++++++-+++++
      De Moya
      • de Moya M.
      • Bramos T.
      • Agarwal S.
      • et al.
      Pain as an indication for rib fixation: a bi-institutional pilot study.
      ++++++++-++++++
      Defreest
      • DeFreest L.
      • Tafen M.
      • Bhakta A.
      • et al.
      Open reduction and internal fixation of rib fractures in polytrauma patients with flail chest.
      ++++++++-++++++++
      Dehghan
      • Dehghan N.
      • Mah J.M.
      • Schemitsch E.H.
      • Nauth A.
      • Vicente M.
      • McKee M.D.
      Operative stabilization of flail chest injuries reduces mortality to that of stable chest wall injuries.
      ++++++--+++++
      Doben
      • Doben A.R.
      • Eriksson E.A.
      • Denlinger C.E.
      • et al.
      Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation.
      ++++++++++-++++++++
      Farquhar
      • Farquhar J.
      • Almarhabi Y.
      • Slobogean G.
      • et al.
      No benefit to surgical fixation of flail chest injuries compared with modern comprehensive management: results of a retrospective cohort study.
      ++-++-+++++++
      Fitzgerald 2017
      • Fitzgerald M.T.
      • Ashley D.W.
      • Abukhdeir H.
      • Christie 3rd, D.B.
      Rib fracture fixation in the 65 years and older population: a paradigm shift in management strategy at a Level I trauma center.
      +++++++++--++-+++
      Fitzgerald 2018
      • Fitzgerald M.T.
      • Ashley D.W.
      • Abukhdeir H.
      • Christie 3rd, D.B.
      Chest wall stabilization leads to shortened chest tube stay time in rib fracture patients after traumatic chest wall injury.
      +++----+++-+++
      Gerakopoulos
      • Gerakopoulos E.
      • Walker L.
      • Melling D.
      • Scott S.
      • Scott S.
      Surgical management of multiple rib fractures reduces the hospital length of stay and the mortality rate in major trauma patients: a comparative study in a UK major trauma center.
      ++++++++-+++++
      Granetzny
      • Granetzny A.
      • Abd El-Aal M.
      • Emam E.
      • Shalaby A.
      • Boseila A.
      Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status.
      ++++--+++++++++
      Jayle
      • Jayle C.
      • Allain G.
      • Ingrand P.
      • et al.
      Flail chest in Polytraumatized patients: surgical fixation using stracos reduces ventilator time and hospital stay.
      ++++++-++++++
      Jian
      • Jian X.
      • Lei W.
      • Yuyang P.
      • Yongdong X.
      A new instrument for surgical stabilization of multiple rib fractures.
      --++---+
      Jiang
      • Jiang Y.
      • Wang X.
      • Teng L.
      • Liu Y.
      • Wang J.
      • Zheng Z.
      Comparison of the effectiveness of surgical versus nonsurgical treatment for multiple rib fractures accompanied with pulmonary contusion.
      ++++++-+++++++
      Kane
      • Kane E.D.
      • Jeremitsky E.
      • Bittner K.R.
      • Kartiko S.
      • Doben A.R.
      Surgical stabilization of rib fractures: a single institution experience.
      ++++---++++++
      Liu 2018
      • Liu T.
      • Liu P.
      • Chen J.
      • Xie J.
      • Yang F.
      • Liao Y.
      A randomized controlled trial of surgical rib fixation in polytrauma patients with flail chest.
      ++++--+++++++++
      Liu 2019
      • Liu Y.
      • Xu S.
      • Yu Q.
      • et al.
      Surgical versus conservative therapy for multiple rib fractures: a retrospective analysis.
      +++-++++++++++
      Majeed
      • Majeed F.A.
      • Zafar U.
      • Imtiaz T.
      • Ali Shah S.Z.
      • Ali A.
      • Mehmood U.
      Rib fixation versus conservative management of rib fractures in trauma patients.
      ++++++++-+++++++
      Majercik 2014
      • Majercik S.
      • Vijayakumar S.
      • Olsen G.
      • et al.
      Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema.
      ++++++-++++++
      Majercik 2015
      • Majercik S.
      • Wilson E.
      • Gardner S.
      • Granger S.
      • VanBoerum D.H.
      • White T.W.
      In-hospital outcomes and costs of surgical stabilization versus nonoperative management of severe rib fractures.
      +++++-++++
      Marasco 2013
      • Marasco S.F.
      • Davies A.R.
      • Cooper J.
      • et al.
      Prospective randomized controlled trial of operative rib fixation in traumatic flail chest.
      ++++--++++++++
      Marasco 2019
      • Marasco S.F.
      • Martin K.
      • Niggemeyer L.
      • Summerhayes R.
      • Fitzgerald M.
      • Bailey M.
      Impact of rib fixation on quality of life after major trauma with multiple rib fractures.
      +++++--+++++++
      Muhm
      • Muhm M.
      • Härter J.
      • Weiss C.
      • Winkler H.
      Severe trauma of the chest wall: surgical rib stabilisation versus non-operative treatment.
      ++++++-++++
      Pieracci 2016
      • Pieracci F.M.
      • Leasia K.
      • Bauman Z.
      • et al.
      A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL).
      ++++++++++
      Qiu
      • Qiu M.
      • Shi Z.
      • Xiao J.
      • Zhang X.
      • Ling S.
      • Ling H.
      Potential benefits of rib fracture fixation in patients with flail chest and multiple non-flail rib fractures.
      --++-+++++
      Shibahashi
      • Shibahashi K.
      • Sugiyama K.
      • Okura Y.
      • Hamabe Y.
      Effect of surgical rib fixation for rib fracture on mortality: a multicenter, propensity score matching analysis.
      ++-+++-+++++++
      Uchida
      • Uchida K.
      • Nishimura T.
      • Takesada H.
      • et al.
      Evaluation of efficacy and indications of surgical fixation for multiple rib fractures: a propensity-score matched analysis.
      ++++++-+++
      Velasquez
      • Velasquez M.
      • Ordoñez C.A.
      • Parra M.W.
      • Dominguez A.
      • Puyana J.C.
      Operative versus nonoperative management of multiple rib fractures.
      +++-+++---+++++
      Wada
      • Wada T.
      • Yasunaga H.
      • Inokuchi R.
      • et al.
      Effectiveness of surgical rib fixation on prolonged mechanical ventilation in patients with traumatic rib fractures: a propensity score-matched analysis.
      ++++--++++++++
      Walters
      • Walters S.T.
      • Craxford S.
      • Russell R.
      • et al.
      Surgical stabilization improves 30-day mortality in patients with traumatic flail chest: a comparative Case series at a major trauma center.
      +++++++++++++
      Wifjffels
      • Wijffels M.M.E.
      • Hagenaars T.
      • Latifi D.
      • Van Lieshout E.M.M.
      • Verhofstad M.H.J.
      Early results after operatively versus non-operatively treated flail chest: a retrospective study focusing on outcome and complications.
      +++++++++++++
      Wu
      • Wu W.M.
      • Yang Y.
      • Gao Z.L.
      • Zhao T.C.
      • He W.W.
      Which is better to multiple rib fractures, surgical treatment or conservative treatment?.
      +++++-++++
      Xiao
      • Xiao X.
      • Zhang S.
      • Yang J.
      • Wang J.
      • Zhang Z.
      • Chen H.
      Surgical fixation of rib fractures decreases intensive care length of stay in flail chest patients.
      ++++++-++++
      Xu
      • Xu J.-Q.
      • Qiu P.-L.
      • Yu R.-G.
      • Gong S.-R.
      • Ye Y.
      • Shang X.-L.
      Better short-term efficacy of treating severe flail chest with internal fixation surgery compared with conservative treatments.
      +++-++-+++++
      Zhang 2014
      • Zhang Y.
      • Tang X.
      • Xie H.
      • Wang R.L.
      Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion.
      +++---+++++++
      Zhang 2015
      • Zhang X.
      • Guo Z.
      • Zhao C.
      • Xu C.
      • Wang Z.
      Management of patients with flail chest by surgical fixation using claw-type titanium plate.
      +++-++-+++++
      Zhang 2019
      • Zhang J.-P.
      • Sun L.
      • Li W.-Q.
      • Wang Y.-Y.
      • Li X.-Z.
      • Liu Y.
      Surgical treatment of patients with severe non-flail chest rib fractures.
      ++-++-+++++++
      Zhu 2020
      • Zhu R.
      • de Roulet A.
      • Ogami T.
      • Khariton K.
      Rib fixation in geriatric trauma: mortality benefits for the most vulnerable patients.
      ++++---+++++
      +++ = high risk; ++ = moderate risk; + = low risk; - = not indicated.

      Length of ICU stay

      Twenty-nine studies (n = 8671) reported on length of ICU stay (ILOS). Surgical rib fixation resulted in a statistically significant reduction of ILOS compared to conservative management (MD: –1.29 (–2.29, –0.29), P ≤ 0.03, I2 = 95%) (Table 2). Surgical fixation reduced ILOS in studies that included patients of any age, but in studies exclusively examining patients over 60 y old, there was a nonsignificant trend toward the benefit of conservative management (Table 3). When stratified by rib fracture pattern, ILOS had a statistically significant benefit in the surgical fixation group for flail chest although not for multiple fractures alone or combined injury (flail and multiple) (Fig. 2). When stratified by study type, there was only the benefit of surgical fixation on ILOS in prospective studies and the early surgical group (<72 h).
      Table 2Meta-analysis for pooled results of all available primary studies for outcomes.
      OutcomeSample size (S,C)Treatment favoringMD (95%CI)RR (95 CI%)NNTI2
      ICU LOS(2316,5392)Surgical–1.29 (–2.29, –0.29)--95%
      Hospital LOS(2371, 5141)Not significant–0.36 (–2.50, 1.79)--98%
      Mechanical ventilation (d)(1844,3685)Surgical–1.67 (–2.61, –0.72)--92%
      Mortality(2215, 7038)Surgical-0.63 (0.44, 0.92)2416%
      Pneumonia(1438,4510)Surgical-0.77 (0.62, 0.97)5671%
      Tracheostomy(1483, 2838)Surgical-0.63 (0.40, 0.99)5075%
      RR = relative risk; NNT = number needed to treat.
      Table 3Subgroup analysis of surgical versus conservative management.
      Subgroup analysisILOSHLOSMVMortalityPneumoniaTracheostomy
      MD (95% CI)P ValuenMD (95% CI)P ValuenMD (95% CI)P ValuenRR (95% CI)P ValuenRR (95% CI)P ValuenRR (95% CI)P Valuen
      Rib pattern
       Flail–1.79 (–3.57, –0.02)0.05231.33 (–1.92, 4.57)0.4213–2.81 (–4.33, –1.29)<0.001150.90 (0.44, 1.88)0.79160.63 (0.32, 1.26)0.19130.45 (0.2, 1.02)0.067
       Multiple–0.59 (–2.74, 1.55)0.164–1.75 (–4.66, 1.16)0.2930.87 (–2.16, 3.89)0.3520.29 (0.02, 3.55)0.3320.45 (0.16, 1.25)0.1230.20 (0.04, 0.98)0.051
       Combined–1.20 (–2.88, 0.48)0.5912–1.82 (–5.19, 1.55)0.2411–0.75 (–2.34, 0.83)0.57100.44 (0.31, 0.61)<0.001130.71 (0.44, 1.12)0.14110.60 (0.26, 1.39)0.237
      Age
       All–1.40 (–2.40, –0.41)0.00626–1.07 (–3.45, 1.3)0.3824–1.99 (–3.0, –0.99)<0.001230.54 (0.34, 0.85)0.008270.63 (0.43, 0.91)0.012300.00215
       >60 y1.35 (–1, 3.71)0.2646.20 (5.04, 7.36)<0.00141.02 (0.30, 1.75)0.00620.51 (0.34, 0.74)0.00240.52 (0.1, 2.66)0.4331.41 (0.32, 6.3)0.652
      Study design
       Prospective–3.79 (–4.57, –3.02)<0.0016–2.78 (–9.02, 0.46)0.822–1.22 (–2.9, 0.47)<0.00140.47 (0.14, 1.59)0.2350.41 (0.24, 0.71)0.00170.39 (0.18, 0.87)0.026
       Retrospective–0.00 (–0.18, 0.18)1220.31 (–2.03, 0.65)0.385–2.19 (–3.46, –0.92)0.16200.60 (0.38, 0.94)0.03240.76 (0.45, 1.15)0.19180.59 (0.27, 1.26)0.1710
      Timing of fixation
       Early: <72 h–0.55 (–0.76, –0.35)<0.0019–1.17 (–3.06, 0.72)0.228–1.90 (–3.78, –0.01)0.0580.77 (0.36, 1.62)0.4860.68 (0.49, 0.93)0.0270.28 (0.12, 0.65)0.0032
       Late: >72 h–1.09 (–2.66, 0.48)0.175–0.7 (–5.04, 0.64)0.754–2.81 (–5.4, –0.22)0.0351.97 (0.50, 7.85)0.3421.13 (0.41, 3.06)0.8230.73 (0.15, 3.44)0.692
      ISS score
       >30–0.75 (–1.52, 0.02)0.066–0.27 (–6.11, 5.56)0.934–2.82 (–5.98, 0.34)0.0860.75 (0.26, 2.14)0.5951 (0.61, 1.64)0.9950.13 (0.03, 0.55)0.0051
       20-300.13 (-0.09, 0.35)0.26102.38 (0.09, 4.67)0.0410–0.99 (–2.14, 0.17)0.09100.69 (0.35 1.36)0.28110.83 (0.67, 1.03)0.09120.73 (0.52, 1.04)0.0810
       <20–1.73 (–2.27, 1.20)0.00140.95 (–4.25, 6.14)0.724–2.42 (–4.91, 0.07)0.0640.64 (0.38, 1.09)0.0420.86 (0.37, 2.01)0.722--0
      Average number of fractured ribs
       <6 ribs–3.35 (–4.38, –2.32)0.0017–2.29 (–6.18, 1.60)0.256–2.80 (–4.30, –1.31)0.00270.42 (0.16, 1.08)0.0780.42 (0.21, 0.83)0.0160.42 (0.15, 1.18)0.15
       >6 ribs–0.55 (–1.60, 0.50)0.3220.42 (–1.97, 2.80)0.7321–1.67 (–2.61, –0.72)0.07170.69 (0.47, 1)0.05180.77 (0.62, 0.97)0.19180.71 (0.42, 1.18)0.1811
      n = number of studies.
      Figure thumbnail gr2
      Fig. 2Subgroup analysis of rib fracture pattern type on length of ICU stay comparing surgical and conservative management.

      Length of hospital stay

      Length of hospital stay (HLOS) was reported in 27 studies (n = 7138). For all included studies, there was no statistically significant reduction in HLOS in the surgical fixation group compared to nonoperative treatment (MD: –0.36 (–2.50, 1.79), P = 0.03, I2 = 95%). In studies of patients over 60 y old, the subgroup analysis of four studies greatly favored conservative management with a mean difference of 6.20 (95% CI: 5.04-7.36, P ≤ 0.001, I2 = 60%) (Fig. 3).
      Figure thumbnail gr3
      Fig. 3Subgroup analysis of age on length of hospital stay comparing surgical and conservative management.

      Duration of mechanical ventilation

      Twenty-five studies (n = 5568) reported on days of mechanical ventilation (MV), which showed a statistical benefit of surgical fixation compared to conservative management across all studies (MD: –1.67 (–2.61, –0.72), P ≤ 0.03, I2 = 92%). Surgical fixation demonstrated statistically significant benefit to MV in patients across all age groups. In comparison, conservative management was associated with a shorter MV in patients over 60 y, although only two studies were available for the pooled analysis (Table 3). There was the benefit of surgical fixation for flail chest but not for multiple rib fractures or combined studies (Fig. 4). Only retrospective studies demonstrated the advantage of surgical fixation, whereas prospective studies were not significant. The early surgical fixation group demonstrated a statistically significant reduction in MV compared to the late fixation group.
      Figure thumbnail gr4
      Fig. 4Subgroup analysis of rib fracture pattern type on length of mechanical ventilation comparing surgical and conservative management.

      Mortality

      Mortality rates were reported in 27 studies (n = 8818), which showed overall benefit in the surgical group (OR: 0.63 (0.44, 0.03), P ≤ 0.04, I2 = 16%). This result was statistically significant for all age groups (Table 3). When stratified by rib fracture pattern, studies that examined combined rib fractures (flail and multiple) found the benefit of surgical fixation on mortality rates. However, the pooled analysis of studies examining flail or multiple rib fractures only did not have a significant benefit. Prospective studies found no significant benefit to mortality, whereas retrospective studies showed a benefit of surgical fixation.

      Pneumonia

      The incidence of pneumonia was reported in 25 studies (n = 5948), which showed an overall benefit of surgical fixation (OR: 0.77 (0.62-0.97), P ≤ 0.0001, I2 = 71%). Subgroup analysis identified the statistical advantage of surgical fixation on rates of pneumonia for patients of all ages but was nonsignificant in studies of patients over 60 y (Table 3). When the pooled analysis was stratified by rib fracture pattern, no group showed significant benefit. Only prospective studies identified the advantage of surgical fixation on the incidence of pneumonia. There was a statistical benefit to rates of pneumonia in the early but not the late surgical group.

      Tracheostomy

      Sixteen studies (n = 3886) reported on the number of patients requiring tracheostomy. Compared to conservative management, surgical fixation resulted in an overall reduction in the requirement for tracheostomy (OR: 0.63 (0.40, 0.99), P = 0.03, I2 = 75%). This benefit was identified in patient groups across all ages but not in studies exclusively examining patients over 60 y old, although only two studies were available for comparison. The subgroup analysis found only prospective studies showed statistically significant benefit of surgical fixation on mechanical. When stratified by rib fracture pattern, flail and combined rib fracture studies found no significant benefit of surgical fixation on rates of tracheostomy.

      Adjusting for confounders

      We undertook a subgroup analysis comparing ISS score and average rib fracture number between original studies on outcomes (Table 3). This analysis identified no major differences in outcomes for these variables between groups. There was significant variability in reporting of comorbidities and other risk factors, such as smoking status, across studies, and we were unable to conduct a sensitivity analysis to account for these confounders.
      Five studies described the patient smoking status, and in the majority of these studies, there was a larger portion of patients actively smoking in the surgical group than the conservative group (Appendix Table 3). There was significant variation in the percentage of patients with underlying lung disease across seven studies and in three studies that indicated the percentage of patients with diabetes. BMI was recorded in four studies and ranged from an average of 25 to 28. Of the four studies that included only patients over 60 y old, three provided data on comorbidities. However, one study only provided a “modified comorbidities score” and did not provide a breakdown of comorbidity type (heart disease, lung disease, etc.).

      Other outcome measures

      Quality of life (QOL) was compared between groups in eight studies, but there were significant inconsistencies between measurement scales, and quantitative analysis could not be performed for this subjective clinical outcome.
      • Pieracci F.M.
      • Leasia K.
      • Bauman Z.
      • et al.
      A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL).
      ,
      • Ağababaoğlu İ.
      • Ersöz H.
      The benefits of early rib fixation for clinical outcomes of flail chest patients in intensive care unit.
      • Farquhar J.
      • Almarhabi Y.
      • Slobogean G.
      • et al.
      No benefit to surgical fixation of flail chest injuries compared with modern comprehensive management: results of a retrospective cohort study.
      • Fitzgerald M.T.
      • Ashley D.W.
      • Abukhdeir H.
      • Christie 3rd, D.B.
      Rib fracture fixation in the 65 years and older population: a paradigm shift in management strategy at a Level I trauma center.
      • Marasco S.F.
      • Davies A.R.
      • Cooper J.
      • et al.
      Prospective randomized controlled trial of operative rib fixation in traumatic flail chest.
      • Marasco S.F.
      • Martin K.
      • Niggemeyer L.
      • Summerhayes R.
      • Fitzgerald M.
      • Bailey M.
      Impact of rib fixation on quality of life after major trauma with multiple rib fractures.
      • Wu W.M.
      • Yang Y.
      • Gao Z.L.
      • Zhao T.C.
      • He W.W.
      Which is better to multiple rib fractures, surgical treatment or conservative treatment?.
      • Zhang J.-P.
      • Sun L.
      • Li W.-Q.
      • Wang Y.-Y.
      • Li X.-Z.
      • Liu Y.
      Surgical treatment of patients with severe non-flail chest rib fractures.
      A range of scales were used to assess QOL, including the Short Form 36, QOL Scale and EQ-5D-5L survey. Four studies
      • Ağababaoğlu İ.
      • Ersöz H.
      The benefits of early rib fixation for clinical outcomes of flail chest patients in intensive care unit.
      ,
      • Fitzgerald M.T.
      • Ashley D.W.
      • Abukhdeir H.
      • Christie 3rd, D.B.
      Rib fracture fixation in the 65 years and older population: a paradigm shift in management strategy at a Level I trauma center.
      ,
      • Wu W.M.
      • Yang Y.
      • Gao Z.L.
      • Zhao T.C.
      • He W.W.
      Which is better to multiple rib fractures, surgical treatment or conservative treatment?.
      ,
      • Zhang J.-P.
      • Sun L.
      • Li W.-Q.
      • Wang Y.-Y.
      • Li X.-Z.
      • Liu Y.
      Surgical treatment of patients with severe non-flail chest rib fractures.
      found a statistically significant benefit of surgical fixation on QOL but the other papers found no benefit. Pain was also measured in 13 studies using a range of scoring systems, including the Visual Analog Scale (VAS), numerical pain score, and questionnaires. Studies typically favored surgical fixation for improvements in pain scores compared to conservative management,
      • Pieracci F.M.
      • Leasia K.
      • Bauman Z.
      • et al.
      A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL).
      ,
      • Ağababaoğlu İ.
      • Ersöz H.
      The benefits of early rib fixation for clinical outcomes of flail chest patients in intensive care unit.
      ,
      • Liu Y.
      • Xu S.
      • Yu Q.
      • et al.
      Surgical versus conservative therapy for multiple rib fractures: a retrospective analysis.
      • Majeed F.A.
      • Zafar U.
      • Imtiaz T.
      • Ali Shah S.Z.
      • Ali A.
      • Mehmood U.
      Rib fixation versus conservative management of rib fractures in trauma patients.
      • Qiu M.
      • Shi Z.
      • Xiao J.
      • Zhang X.
      • Ling S.
      • Ling H.
      Potential benefits of rib fracture fixation in patients with flail chest and multiple non-flail rib fractures.
      • Wu W.M.
      • Yang Y.
      • Gao Z.L.
      • Zhao T.C.
      • He W.W.
      Which is better to multiple rib fractures, surgical treatment or conservative treatment?.
      • Zhang J.-P.
      • Sun L.
      • Li W.-Q.
      • Wang Y.-Y.
      • Li X.-Z.
      • Liu Y.
      Surgical treatment of patients with severe non-flail chest rib fractures.
      • Jiang Y.
      • Wang X.
      • Teng L.
      • Liu Y.
      • Wang J.
      • Zheng Z.
      Comparison of the effectiveness of surgical versus nonsurgical treatment for multiple rib fractures accompanied with pulmonary contusion.
      • Khandelwal G.
      • Mathur R.K.
      • Shukla S.
      • Maheshwari A.
      A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture.
      but some studies found no statistical benefit.
      • Beks R.B.
      • Peek J.
      • de Jong M.B.
      • et al.
      Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis.
      ,
      • Farquhar J.
      • Almarhabi Y.
      • Slobogean G.
      • et al.
      No benefit to surgical fixation of flail chest injuries compared with modern comprehensive management: results of a retrospective cohort study.
      ,
      • Marasco S.F.
      • Martin K.
      • Niggemeyer L.
      • Summerhayes R.
      • Fitzgerald M.
      • Bailey M.
      Impact of rib fixation on quality of life after major trauma with multiple rib fractures.
      ,
      • Walters S.T.
      • Craxford S.
      • Russell R.
      • et al.
      Surgical stabilization improves 30-day mortality in patients with traumatic flail chest: a comparative Case series at a major trauma center.
      The timeframe of data collection for follow-up of quality of life and pain scores varied across studies.
      No significant differences between groups were found for any outcomes when subgroup analyses were conducted for the average number of rib fractures, ISS score, plating device, and publication date.

      Heterogeneity of studies

      There was significant statistical heterogeneity between studies included in the meta-analysis and subgroup analyses. Based on the I2 analysis, only the pooled analysis of mortality had a low degree of heterogeneity. All other outcomes are likely to have considerable heterogeneity across studies. Egger’s regression test identified possible publication bias across studies for mortality and tracheostomy outcomes (Table 4 and Appendix Fig. 1). Interpretation of results from these outcomes were therefore considered judiciously.
      Table 4Egger’s Regression for publication bias.
      Outcomes2-Tailed P value (intercept)Standard error95% CIInterpretation
      ICU LOS0.4350.975–1.435, 0.639No evidence of publication bias
      Hospital LOS0.3410.153–0.501, 1.39No evidence of publication bias
      Mechanical ventilation0.110.003–0.126, 1.151No evidence of publication bias
      Mortality0.0180.102–3.021, –0.301Possible publication bias
      Pneumonia0.0650.003–0.051, 1.614No evidence of publication bias
      Tracheostomy0.0090.0010.375, 2.143Possible publication bias
      Assuming asymmetry as significant if P value = <0.05.
      • Sterne J.A.C.
      • Egger M.
      Regression methods to detect publication and other bias in meta-analysis.

      Discussion

      In this systematic review of 45 studies, including a meta-analysis of 40 studies, surgical fixation of patients with rib fractures resulted in a shorter ILOS, MV days, rates of mortality, pneumonia, and requirement for tracheostomy. Subgroup analyses of the pooled studies suggest that surgical fixation may only be beneficial when undertaken within 72 h and in patients with flail chest. Furthermore, our study indicates that surgical rib fixation may not be beneficial for patients over 60 y of age. Our findings reaffirm the important role of surgical fixation as an adjunct to conservative management.
      The pooled results of our meta-analysis concur with previous reviews. These studies have consistently demonstrated the benefit of surgical fixation for a range of outcomes, specifically ILOS, mechanical ventilation days, and rates of pulmonary complications.
      • Liang Y.S.
      • Yu K.C.
      • Wong C.S.
      • Kao Y.
      • Tiong T.Y.
      • Tam K.W.
      Does surgery reduce the risk of complications among patients with multiple rib fractures? A meta-analysis.
      ,
      • Beks R.B.
      • Peek J.
      • de Jong M.B.
      • et al.
      Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis.
      ,
      • Long R.
      • Tian J.
      • Wu S.
      • Li Y.
      • Yang X.
      • Fei J.
      Clinical efficacy of surgical versus conservative treatment for multiple rib fractures: a meta-analysis of randomized controlled trials.
      • Schuurmans J.
      • Goslings J.C.
      • Schepers T.
      Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review.
      • Slobogean G.P.
      • MacPherson C.A.
      • Sun T.
      • Pelletier M.E.
      • Hameed S.M.
      Surgical fixation vs nonoperative management of flail chest: a meta-analysis.
      • Swart E.
      • Laratta J.
      • Slobogean G.
      • Mehta S.
      Operative treatment of rib fractures in flail chest injuries: a meta-analysis and cost-effectiveness analysis.
      • Apampa A.A.
      • Ali A.
      • Kadir B.
      • Ahmed Z.
      Safety and effectiveness of surgical fixation versus non-surgical methods for the treatment of flail chest in adult populations: a systematic review and meta-analysis.
      • Choi J.
      • Gomez G.I.
      • Kaghazchi A.
      • Borghi J.A.
      • Spain D.A.
      • Forrester J.D.
      Surgical stabilization of rib fracture to mitigate pulmonary complication and mortality: a systematic review and bayesian meta-analysis.
      However, each review reports limitations of the validity of their results due to quantitative pooling of heterogeneous primary studies. Our systematic review identified significant discrepancies in the eligibility of patients for surgical management across studies regarding patient age, ISS score, concomitant injury, and definitions of rib fractures. This heterogeneity may be explained by an absence of a universal protocol for appropriate selection of patients and a lack of standardized rib fracture terminology, including definitions of flail chest, multiple rib fractures, and the degree of fracture displacement. Notably, there are efforts being made by organizations, such as the AO Thoracic Expert Group and Chest Wall Injury Society, to establish standardized rib fracture nomenclature and algorithms for appropriate patient selection for surgical management.
      • Simpson R.B.
      • Dorman J.R.
      • Hunt W.J.
      • Edwards J.G.
      Multiple rib fractures: a novel and prognostic CT-based classification system.
      • Delaplain P.
      • Schubi S.
      • Pieracci F.
      • et al.
      Chest Wall Injury Society Guideline For SSRF Indications, Contraindications and Timing.
      • Edwards J.G.
      • Clarke P.
      • Pieracci F.M.
      • et al.
      Taxonomy of multiple rib fractures: results of the chest wall injury society international consensus survey.
      However, these are yet to be widely promulgated. To our knowledge, this is the first meta-analysis that has attempted to identify the specific patient cohorts that are most appropriate for surgical fixation of rib fractures compared to those that should continue to be managed conservatively.

      Injury pattern type

      Our study identifies a reduction in ILOS and MV days for patients with flail chest who underwent surgical fixation compared to the conservatively managed group. Its benefit for multiple rib fractures is less clear. Compared to multiple rib fractures alone, flail chest injury is typically associated with greater respiratory complication, intractable pain, and long-term sequelae. Consequently, surgical fixation has until recently been reserved for flail chest injury, with previous systematic reviews consistently supporting its benefit on a range of outcomes.
      • Leinicke J.A.
      • Elmore L.
      • Freeman B.D.
      • Colditz G.A.
      Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis.
      ,
      • Cataneo A.J.
      • Cataneo D.C.
      • de Oliveira F.H.
      • Arruda K.A.
      • El Dib R.
      • de Oliveira Carvalho P.E.
      Surgical versus nonsurgical interventions for flail chest.
      ,
      • Coughlin T.A.
      • Ng J.W.
      • Rollins K.E.
      • Forward D.P.
      • Ollivere B.J.
      Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials.
      ,
      • Schuurmans J.
      • Goslings J.C.
      • Schepers T.
      Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review.
      • Slobogean G.P.
      • MacPherson C.A.
      • Sun T.
      • Pelletier M.E.
      • Hameed S.M.
      Surgical fixation vs nonoperative management of flail chest: a meta-analysis.
      • Swart E.
      • Laratta J.
      • Slobogean G.
      • Mehta S.
      Operative treatment of rib fractures in flail chest injuries: a meta-analysis and cost-effectiveness analysis.
      • Apampa A.A.
      • Ali A.
      • Kadir B.
      • Ahmed Z.
      Safety and effectiveness of surgical fixation versus non-surgical methods for the treatment of flail chest in adult populations: a systematic review and meta-analysis.
      While the general consensus is that the majority of multiple rib fractures heal nonoperatively without complication, it is clear from the number of studies included in this review that there is increasing interest in the potential benefit of surgical fixation for multiple rib fractures. Despite this, only a small number of studies independently examined multiple rib fractures, meaning that there was likely insufficient power to adequately identify any benefit of surgical fixation. Several studies combined flail chest and multiple rib fractures in their analysis and demonstrated statistically significant benefit of surgical fixation on mortality rates but not for any other outcome. Three retrospective primary studies stratified patients by multiple rib fractures and flail chest injury with mixed outcomes. In the largest study, Xiao et al.
      • Xiao X.
      • Zhang S.
      • Yang J.
      • Wang J.
      • Zhang Z.
      • Chen H.
      Surgical fixation of rib fractures decreases intensive care length of stay in flail chest patients.
      demonstrated the benefit of surgical fixation for flail chest on ILOS, but all outcomes were comparable with nonoperative management for the multiple rib fracture group. Qui et al.
      • Qiu M.
      • Shi Z.
      • Xiao J.
      • Zhang X.
      • Ling S.
      • Ling H.
      Potential benefits of rib fracture fixation in patients with flail chest and multiple non-flail rib fractures.
      demonstrated benefits of surgical fixation for both multiple rib fracture and flail chest groups, while Beks et al.
      • Beks R.B.
      • Reetz D.
      • de Jong M.B.
      • et al.
      Rib fixation versus non-operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: a multicenter cohort study.
      found no benefit for either rib fracture type on outcomes.

      Age

      Older age has been identified as a major risk factor for rib fracture-related morbidity and mortality, where the risk of overall mortality doubles in patients over 65 y old.
      • Cheema F.A.
      • Chao E.
      • Buchsbaum J.
      • et al.
      State of rib fracture care: a NTDB review of analgesic management and surgical stabilization.
      Interestingly, stratification of studies by age found that patients over 60 y benefitted from conservative management for HLOS and days of MVs, while rates of mortality were lower in the surgical fixation group. Although only four retrospective studies were available for comparison, this suggests that surgical fixation may not be beneficial in the older population. We postulate that varying outcomes between age groups may be due to differences in the mechanism of injury and patient characteristics between younger and older cohorts. Typically, rib fractures are associated with a low energy mechanism of injury in elderly patients, such as fall from standing height, compared to a higher energy impact in younger patients, most commonly motor vehicle collision.
      • Caragounis E.-C.
      • Xiao Y.
      • Granhed H.
      Mechanism of injury, injury patterns and associated injuries in patients operated for chest wall trauma.
      ,
      • Sirmali M.
      • Türüt H.
      • Topçu S.
      • et al.
      A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management.
      Cause of injury was underreported by included studies, meaning the impact of low compared to high energy mechanism on outcomes could not be determined in our review. Furthermore, older age is associated with higher rates of morbidity and mortality for any major surgery due to patients possessing a generally lower physiological reserve and higher burden of comorbidity.
      • Deiner S.
      • Silverstein J.H.
      Long-term outcomes in elderly surgical patients.
      Kane et al.
      • Kane E.D.
      • Jeremitsky E.
      • Bittner K.R.
      • Kartiko S.
      • Doben A.R.
      Surgical stabilization of rib fractures: a single institution experience.
      found that patients over 65 y had a considerably higher burden of comorbidities such as respiratory disease, diabetes, and hypertension than the total population. Interestingly, a higher proportion of patients in the over 65 y group that underwent surgical fixation had comorbidities compared to the conservative group, which likely reflects selection bias in this observational study.

      Timing of surgical fixation

      While there is an increasing foundation of literature examining surgical fixation of rib fractures, optimal timing and surgical approaches remain rebated. Proponents of early repair (usually within 72 h) suggest that there is less tissue inflammation and callus formation within this time, which results in fewer surgical complications and improves outcomes. In comparison, others suggest that a delayed repair provides sufficient time for optimization of medical therapy prior to surgical intervention.
      • Girotti P.N.C.
      • Tschann P.
      • Königsrainer I.
      Prosthetic-free ribs stabilization technique in critical complex chest wall traumas: first results and experiences.
      ,
      • Pieracci F.M.
      • Majercik S.
      • Ali-Osman F.
      • et al.
      Consensus statement: surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines.
      Our meta-analyses supports the benefit of early surgical fixation for mechanical ventilation, rates of pneumonia and tracheostomy compared to late fixation, which demonstrated no significant benefit over conservative management. Our findings concur with Pieracci et al.
      • Pieracci F.M.
      • Coleman J.
      • Ali-Osman F.
      • et al.
      A multicenter evaluation of the optimal timing of surgical stabilization of rib fractures.
      who found benefit across a range of outcomes for patients undergoing earlier surgery compared to delayed intervention.

      Study design

      Pooled analysis of prospective and retrospective studies included in this systematic review found the benefit of surgical fixation over conservative management, yet the treatment effect on outcomes varied significantly between study designs. This is likely due to both the increased risk of bias associated with observational studies and the lack of available RCTs for comparison. While several systematic reviews have previously attempted to pool the few available RCTs, heterogeneity across patient selection and insufficient power limit the applicability of these results. Choi et al.
      • Choi J.
      • Gomez G.I.
      • Kaghazchi A.
      • Borghi J.A.
      • Spain D.A.
      • Forrester J.D.
      Surgical stabilization of rib fracture to mitigate pulmonary complication and mortality: a systematic review and bayesian meta-analysis.
      attempted to circumvent this by conducting a Bayesian review of RCTs and observational studies. The pooled effects from this study were comparable to outcomes from this current review, which found that surgical fixation was associated with fewer pulmonary complications and risk of mortality. Unlike our current study, Choi et al. also demonstrated the benefit of surgical fixation on hospital LOS, although the number of patients included in their surgical group was significantly smaller. While there arguably exists an empirical basis for the comparison of different methodologies, further level one studies are required to better quantify the benefits of surgical fixation.

      Limitations

      Despite our attempt to undertake multiple subgroup analyses, a major limitation of our review was the lack of studies available to investigate several key factors that may affect appropriate patient selection for surgical fixation. For instance, we were unable to stratify patients by fixation device, the severity of rib fracture injury and degree of rib fracture displacement, or by patient comorbidities due to insufficient data from the primary studies. Furthermore, important outcome variables such as pain, time to return to baseline function, impact on quality of life, and healthcare cost could not be assessed in the meta-analysis due to being under-reported and heterogenous in reporting measures. We were also unable to adjust for differences across studies regarding their criteria for inclusion/exclusion and based on individual definitions of flail chest and multiple rib fractures.
      While we attempted to undertake a sensitivity analysis adjusting for patient characteristics, comorbidities, and injury severity (ISS score and the number of ribs fractured) our analysis was limited by several factors. A majority of studies failed to report pre-existing comorbidities and other risk factors such as smoking status and body mass index (BMI). Where these were reported (Appendix Table 3), no study performed a subgroup analysis comparing outcomes stratified by comorbidity. The effect of these potential confounders on outcomes of surgical rib fixation is therefore, still undetermined.

      Conclusion

      This meta-analysis of available studies supports the application of surgical rib fixation to improve morbidity and mortality outcomes in certain patient cohorts. While further delineation of criteria for appropriate selection of patients for surgical fixation is required, current evidence suggests that patients with flail chest may be best suited. Early surgery, within 72 h, also appears preferable. Conversely, older patients are more likely to benefit from conservative management. The current literature includes studies that are heterogeneous in design, patient selection, and outcome measurement. Further clarification of appropriate patient selection for surgery is necessitated for future studies through careful stratification by surgical technique, rib fracture pattern, and patient characteristics.

      Author Contributions

      Data were independently extracted by ES and NM. ES analyzed the data and drafted the manuscript. MM and MW provided content expertise and editing of the manuscript. The main changes to the updated manuscript were completed by ES and reviewed by MM and MW.

      Disclosure

      None declared.

      Funding

      None.

      Supplementary Data

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