Understanding Outcomes After Flail Chest Injury and Rib Fixation

For patients with unstable chest wall and flail chest injury, surgical rib fixation did not lead to improvement in ventilator-free days (VFDs) or other outcomes, compared with nonsurgical treatment. However, patients treated surgically had lower rates of mortality. These findings were presented at the AAOS 2021 Annual Meeting by Niloofar Dehghan, MD, from the CORE Institute in Phoenix, Arizona.

The prospective, randomized trial included patients recruited from 15 sites across Canada and the United States who had flail chest injury (defined as ≥3 consecutive, segmental, displaced rib fractures) or severe deformity of the chest wall. Researchers followed patients for one year after fixation or nonsurgical treatment.

Of the 207 enrolled patients, 99 were randomized to nonsurgical treatment and 108 to surgical fixation. The average number of rib fractures was 10.

Mean VFDs in the first 28 days following injury (the primary outcome) were 22.7 for the surgical group and 20.6 for the nonsurgical group. Mortality rates were higher in the nonsurgical group (6% vs. 0%), but no difference was seen between the two groups regarding complications or length of stay in the intensive care unit or hospital.

Researchers also conducted a prespecified subgroup analysis of patients who were intubated and mechanically ventilated at the time of randomization. In this group, patients treated surgically had an average of 2.8 more VFDs compared with those treated without surgery.

Taken together, these findings suggest that patients who are not on mechanical ventilation do not benefit from surgical fixation over nonoperative treatment, the authors reported. However, among those who require mechanical ventilation, a surgical approach may reduce time on ventilation and length of stay in the hospital.

The researchers stressed the importance of proper patient selection in this setting.