Multicentre prospective cohort study of nonoperative versus operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: study protocol

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Background Patients with multiple rib fractures without a clinical flail chest are increasingly being treated with rib fixation; however, high-quality evidence to support this development is lacking. Methods We conducted a prospective multicenter observational study comparing rib fixation to non-operative treatment in all patients aged 18 years and older with computed tomography confirmed multiple rib fractures without a clinical flail chest. Three centers performed rib fixation as standard of care. For adequate comparison, the other three centers performed only non-operative treatment. As such clinical equipoise formed the basis for the comparison in this study. Patients were matched using propensity score matching. Results In total 927 patients with multiple rib fractures were included. In the three hospitals that performed rib fixation, 80 (14%) out of 591 patients underwent rib fixation. From the nonoperative centers, on average 71 patients were adequately matched to 71 rib fixation patients after propensity score matching. Rib fixation was associated with an increase in hospital length of stay (HLOS) of 4.9 days (95%CI 0.8–9.1, p = 0.02) and a decrease in quality of life (QoL) measured by the EQ5D questionnaire at 1 year of 0.1 (95% CI − 0.2–0.0, p = 0.035) compared to non-operative treatment. A subgroup analysis of patients who received operative care within 72 h showed a similar decrease in QoL. Up to 22 patients (28%) who underwent surgery experienced implant-related irritation. Conclusions We found no benefits and only detrimental effects associated with rib fixation. Based on these results, we do not recommend rib fixation as the standard of care for patients with multiple rib fractures. Trial registration Registered in the Netherlands Trial Register NTR6833 on 13/11/2017.

Section: Methodsmentioning

confidence: 99%

Non-operative vs. operative treatment for multiple rib fractures after blunt thoracic trauma: a multicenter prospective cohort study

Hoepelman

Beeres

Beks

et al. 2022

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“…An example of a study of a type 3 comparisons is the Opvent study, which is a multicenter prospective cohort study, including patients with three or more rib fractures admitted to one of the five participating centers [ 32 ]. In two centers, rib fixation is the standard-of-care for flail chest or multiple rib fractures, while in three other centers nonoperative treatment is.…”

Section: Different Research Questions In Surgical Intervention Studiementioning

confidence: 99%

Study methodology in trauma care: towards question-based study designs

Houwert

Beks

Dijkgraaf

et al. 2019

The randomized controlled trial (RCT) in surgery may not always be ethical, feasible, or necessary to address a particular research question about the effect of a surgical intervention. If so, properly designed and conducted observational (nonrandomized) studies may be valuable alternatives for an RCT and produce credible results. In this paper, we discus differences between RCTs and observational studies and differentiate between three types of comparisons of surgical interventions. We assert that results of different designs should be regarded as complementary to each other when evaluating surgical interventions. Criteria for credible observational research are presented to provide guidance for future observational research of surgical interventions. We argue that the research question that is being asked should guide the discussion about the value of a particular study design.

“…However, the comparison of operated patients with a historic patient cohort from the very same center obviates a selection bias that is present in any other study design except prospective randomized controlled clinical trials. The latter are hardly realizable in the acute trauma setting [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

“…Technically, surgical stabilization of rib fractures (SSRF) goes along with supplementary soft tissue trauma to the injured chest wall and may additionally impair respiratory mechanics by muscle injury. As a result, no clear-cut selection criteria exist so far what patients benefit from SSRF [10][11][12][13][14][15]. Numerous studies have shown that early SSRF within the first week after chest trauma is effective to prevent secondary lung injury and to improve patient recovery [10,12,13].…”

Section: Introductionmentioning

confidence: 99%

Surgical stabilization of serial rib fractures is advantageous in patients with relevant traumatic brain injury

Freitag

Bechmann

Eden³

et al. 2022

Purpose To evaluate the clinical benefit of surgical stabilization of rib fractures (SSRF) in polytrauma patients with serial rib fractures. Methods Retrospective single-center cohort analysis in trauma patients. Serial rib fracture was defined as three consecutive ribs confirmed by chest computer tomography (CT). Study cohort includes 243 patients that were treated conservatively and 34 patients that underwent SSRF. Demographic patient data, trauma mechanism, injury pattern, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) and hospital course were analyzed. Two matched pair analyses stratified for ISS (32 pairs) and GCS (25 pairs) were performed. Results The majority of patients was male (74%) and aged 55 ± 20 years. Serial rib fractures were associated with more than 6 broken ribs in average (6.3 ± 3.7). Other thoracic bone injury included sternum (18%), scapula (16%) and clavicula (13%). Visceral injury consisted of pneumothorax (51%), lung contusion (33%) and diaphragmatic rupture (2%). Average ISS was 22 ± 7.3. Overall hospital stay was 15.9 and ICU stay 7.4 days. In hospital, mortality was 13%. SSRF did not improve hospital course or postoperative complications in the complete study cohort. However, patients with a significantly reduced GCS (7.6 ± 5.3 vs 11.22 ± 4.8; p = 0.006) benefitted from SSRF. Matched pair analysis stratified for GCS showed shorter ICU stays (9 vs 15 days; p = 0.005) including shorter respirator time (143 vs 305 h; p = 0.003). Conclusion Patients with serial rib fractures and simultaneous moderate or severe traumatic brain injury benefit from surgical stabilization of rib fractures.