Additional Outcomes and Limitations in the Treatment of Acute Unstable Chest Wall Injuries

Abstract

To the Editor We read with interest the randomized clinical trial presented by Dehghan et al 1 and were particularly interested in outcomes of patients without radiographic or clinical flail chest, a patient population for whom the benefit of surgical stabilization of rib fractures (SSRF) remains debated. However, we were concerned about the authors' recommendations against SSRF in patients without radiographic or clinical flail chest in light of several limitations in the study design.Although ventilator-free days, mortality, and both hospital and intensive-care-unit length of stay are important outcomes for patients with rib fractures, they are not the only outcomes that matter and may not occur with high enough frequency in patients without flail chest injuries to render meaningful comparisons. 2 Rather, we believe chronic pain, pleural space complications, disability, and other patientreported outcomes are more relevant. 2,3 According to Supplement 8 in the original article, these outcomes were captured but absent from analyses.We are also concerned about undiscussed limitations regarding patient volume and technical aspects of the surgery. Accrual of 207 participants occurred across 15 institutions over 8 years. 1 Most higher-volume trauma centers are commonly performing more than 50 SSRF cases per year. Patient accrual should have proceeded far more expediently if these centers were in fact high-volume centers. Additionally, more than 50% of patients underwent stabilization with pelvic fixation plates, a technology that has been abandoned in SSRF because modern prospective studies all use rib-specific systems. 1 Furthermore, no mention was made about surgical approach (eg, muscle sparring, minimally invasive) or time from injury to fixation; both are variables known to have associations with SSRF outcomes. 4 The age of a one-size-fits-all surgical approach to SSRF has passed, with minimally invasive and extrathoracic approaches using rib-specific plates and rightangle self-tapping screws now standard.To conclude, we have concerns about extrapolating the results of this study to modern-day surgical management of pa-tients with nonflail, severe chest wall injury. We suggest that future studies of this specific patient population (and really all studies of SSRF) take into account time from injury to surgery, operative technique, surgeon volume, and, perhaps most importantly, outcomes that are most relevant to the patient population: in this case, pleural space complications, pain, and quality of life. 5 By coming out strongly against offering surgery to patients with severe chest wall injury who are not intubated, the authors are limiting access to surgical therapy for patients who might benefit.