Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis

Reinier B Beks; Jesse Peek; Mirjam B de Jong; Karlijn J P Wessem; Cumhur F Öner; Falco Hietbrink; Luke P H Leenen; Rolf H H Groenwold; Roderick M Houwert

doi:10.1007/s00068-018-1020-x

Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis

Reinier B Beks, Jesse Peek, Mirjam B de Jong, Karlijn J P Wessem, Cumhur F Öner, Falco Hietbrink, Luke P H Leenen, Rolf H H Groenwold, Roderick M Houwert

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Abstract

Purpose: The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. Methods: MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy. Results: Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I ² = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies. Conclusions: Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs.

Original language	English
Pages (from-to)	631-644
Number of pages	14
Journal	European Journal of Trauma and Emergency Surgery
Volume	45
Issue number	4
Early online date	2018
DOIs	https://doi.org/10.1007/s00068-018-1020-x
Publication status	Published - Aug 2019

Keywords

Journal Article
Review
Flail chest
Multiple rib fractures
Operative treatment
Current evidence
Nonoperative treatment
Flail Chest/mortality
Tracheostomy/mortality
Respiration, Artificial/mortality
Humans
Middle Aged
Length of Stay/statistics & numerical data
Male
Fracture Fixation/methods
Randomized Controlled Trials as Topic
Pneumonia/etiology
Conservative Treatment/methods
Critical Care/statistics & numerical data
Observational Studies as Topic
Female
Aged
Rib Fractures/mortality

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10.1007/s00068-018-1020-x

Beks2019_Article_FixationOfFlailChestOrMultipleFinal published version, 1.72 MB

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Beks, R. B., Peek, J., de Jong, M. B., Wessem, K. J. P., Öner, C. F., Hietbrink, F., Leenen, L. P. H., Groenwold, R. H. H., & Houwert, R. M. (2019). Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis. European Journal of Trauma and Emergency Surgery, 45(4), 631-644. https://doi.org/10.1007/s00068-018-1020-x

@article{6d805b9c7b494abaa546bfa55fbc72c1,

title = "Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis",

abstract = "Purpose: The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. Methods: MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy. Results: Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I 2 = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies. Conclusions: Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs. ",

keywords = "Journal Article, Review, Flail chest, Multiple rib fractures, Operative treatment, Current evidence, Nonoperative treatment, Flail Chest/mortality, Tracheostomy/mortality, Respiration, Artificial/mortality, Humans, Middle Aged, Length of Stay/statistics & numerical data, Male, Fracture Fixation/methods, Randomized Controlled Trials as Topic, Pneumonia/etiology, Conservative Treatment/methods, Critical Care/statistics & numerical data, Observational Studies as Topic, Female, Aged, Rib Fractures/mortality",

author = "Beks, {Reinier B} and Jesse Peek and {de Jong}, {Mirjam B} and Wessem, {Karlijn J P} and {\"O}ner, {Cumhur F} and Falco Hietbrink and Leenen, {Luke P H} and Groenwold, {Rolf H H} and Houwert, {Roderick M}",

year = "2019",

month = aug,

doi = "10.1007/s00068-018-1020-x",

language = "English",

volume = "45",

pages = "631--644",

journal = "European Journal of Trauma and Emergency Surgery",

issn = "1863-9933",

publisher = "Urban und Vogel",

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T2 - current evidence and how to proceed. A systematic review and meta-analysis

AU - Beks, Reinier B

AU - Peek, Jesse

AU - de Jong, Mirjam B

AU - Wessem, Karlijn J P

AU - Öner, Cumhur F

AU - Hietbrink, Falco

AU - Leenen, Luke P H

AU - Groenwold, Rolf H H

AU - Houwert, Roderick M

PY - 2019/8

Y1 - 2019/8

N2 - Purpose: The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. Methods: MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy. Results: Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I 2 = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies. Conclusions: Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs.

AB - Purpose: The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. Methods: MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy. Results: Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I 2 = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies. Conclusions: Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs.

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KW - Fracture Fixation/methods

KW - Randomized Controlled Trials as Topic

KW - Pneumonia/etiology

KW - Conservative Treatment/methods

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DO - 10.1007/s00068-018-1020-x

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JO - European Journal of Trauma and Emergency Surgery

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Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis

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