Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury

BACKGROUND Early surgical stabilization of rib fractures (SSRF) is associated with improved inpatient outcomes in patients with multiple rib fractures. However, there is still a paucity of data examining the optimal timing of SSRF in patients with concomitant traumatic brain injury (TBI). This study aimed to assess whether earlier SSRF was associated with improved outcomes in patients with multiple rib fractures and TBI. METHODS We performed a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program 2017–2020, including adult patients with TBI and multiple rib fractures who had undergone SSRF. The outcomes were post-procedural length of stay (LOS), hospital LOS, intensive care unit (ICU) LOS, in-hospital mortality, ventilator days, and tracheostomy rate. Multilevel mixed-effects regression analyses accounting for patient, injury, and hospital characteristics as well as institutional SSRF volume were used to assess the association between timing to SSRF and the outcomes of interest. As a sensitivity analysis, propensity-score matching was performed to compare patients who underwent early (<72 hours) versus late SSRF (≥72 hours). RESULTS Of 1,041 patients included in this analysis, 430 (41.3%) underwent SSRF within the first 72 hours from admission. Delay to SSRF was associated with an increase in post-procedural LOS (partial regression coefficient (β) = 0.011; p = 0.036; 95% confidence interval [CI], 0.001–0.023), longer hospital LOS (β = 0.053; p < 0.001; 95% CI, 0.042–0.064), prolonged ICU LOS (β = 0.032; p < 0.001; 95% CI, 0.025–0.038), and more ventilator days (β = 0.026, p < 0.001; 95% CI, 0.020–0.032). CONCLUSION In patients with concurrent multiple rib fractures and TBI, a delay in SSRF is associated with an increase in postprocedural LOS, hospital LOS, ICU LOS, and ventilator days. These findings suggest that the early patient selection and implementation of SSRF may play a beneficial role in patients presenting with concomitant TBI and multiple rib fractures. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.

Section: Discussionmentioning

confidence: 99%

Evaluating the impact of timing to rib fixation in patients with traumatic brain injury: A nationwide analysis

Lagazzi,

Argandykov,

de Roulet

et al. 2023

“…A majority of the 28 expert panel recommendations were based on low-level evidence, which highlighted an urgent need to generate more robust evidence. For example, a Grade D recommendation that “TBI should not be considered an absolute contraindication to SSRF; patients with TBI be evaluated for SSRF on an individual case basis” spurred a multi-institutional collaborative that has identified which patients with TBI may benefit from undergoing SSRF 17,18 . For other recommendations, nonstandardized ontology may be a barrier for implementing evidence-based practice.…”

Section: Discussionmentioning

confidence: 99%

“…For example, a Grade D recommendation that "TBI should not be considered an absolute contraindication to SSRF; patients with TBI be evaluated for SSRF on an individual case basis" spurred a multi-institutional collaborative that has identified which patients with TBI may benefit from undergoing SSRF. 17,18 For other recommendations, nonstandardized ontology may be a barrier for implementing evidence-based practice. For example, many institutional guidelines listed multiple, displaced rib fractures as an indication for SSRF but defined "displaced" heterogeneously.…”

Section: Discussionmentioning

confidence: 99%

Challenges in closing the gap between evidence and practice: International survey of institutional surgical stabilization of rib fractures guidelines

Choi

Badrinathan

Shine

et al. 2022

Self Cite

BACKGROUND:Surgical stabilization of rib fractures (SSRF) has gained increasing interest over the past decade, yet few candidates who could benefit from SSRF undergo operative management. We conducted an international survey of institutional SSRF guidelines comparing congruence between practice and contemporary evidence. We hypothesized that few guidelines reflect comprehensive evidence to facilitate standardized patient selection, operation, and postoperative management. METHODS:A request for institutional rib fracture guidelines was distributed from the Chest Wall Injury Society. Surgical stabilization of rib fractures-specific guideline contents were extracted using a priori-designed extraction sheets and compared against 28 SSRF evidence-based recommendations outlined by a panel of 14 international experts. Fisher's exact test compared the proportion of strong and weak evidence-based recommendations specified within a majority of institutional guidelines to evaluate whether strength of evidence is associated with implementation. RESULTS:A total of 36 institutions from 3 countries submitted institutional rib fracture management guidelines, among which 30 had SSRF-specific guidance. Twenty-eight guidelines (93%) listed at least one injury pattern criteria as an indication for SSRF, while 22 (73%) listed pain and 21 (70%) listed impaired respiratory function as other indications. Quantitative pain and respiratory function impairment thresholds that warrant SSRF varied across institutions. Few guidelines specified nonacute indications for SSRF or perioperative considerations. Seven guidelines (23%) detailed postoperative management but recommended timing and interval for follow-up varied. Overall, only 3 of the 28 evidence-based SSRF recommendations were specified within a majority of institutional practice guidelines. There was no statistically significant association (p = 0.99) between the strength of recommendation and implementation within institutional guidelines. CONCLUSION:Institutional SSRF guidelines do not reflect the totality of evidence available in contemporary literature. Guidelines are especially important for emerging interventions to ensure standardized care delivery and minimize low-value care. Consensus effort is needed to facilitate adoption and dissemination of evidence-based SSRF practices.

“…Surgical stabilization of rib fractures (SSRF) has gained increased popularity during the last decade and has been integrated into current clinical practice with new evidence showing improved outcomes in patients with multiple rib fractures, such as better pain management and superior pulmonary performance 9–11 . While the main indication for SSRF remains flail chest, several recent studies have investigated the role of this operative procedure in patients with different injury patterns, such as nonflail bicortical fractures, showing better pulmonary function test performance and pain management within this population 12–14 …”

mentioning

confidence: 99%

“…[9][10][11] While the main indication for SSRF remains flail chest, several recent studies have investigated the role of this operative procedure in patients with different injury patterns, such as nonflail bicortical fractures, showing better pulmonary function test performance and pain management within this population. [12][13][14] Historically, TBI has been seen as a contraindication to SSRF, and current clinical guidelines cite severe TBI (defined as a head injury with GCS score <8), as an absolute contraindication to surgical rib fixation. 15 A survey conducted among thoracic, trauma, and orthopedic surgeons reported that patients with severe and moderate TBI are less likely to be recommended surgical rib fixation regardless of pulmonary compromise.…”

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confidence: 99%

Is severe traumatic brain injury no longer a contraindication for surgical stabilization of rib fractures in patients with multiple rib fractures? A propensity-matched analysis

Lagazzi

Roulet

Proaño-Zamudio

et al. 2023

BACKGROUND:Traumatic brain injury (TBI) is often considered a contraindication to surgical stabilization of rib fractures (SSRF). In this study, we hypothesized that, compared with nonoperative management, SSRF is associated with improved outcomes in TBI patients. METHODS:Using the American College of Surgeons Trauma Quality Improvement Program 2016-2019, we performed a retrospective analysis of patients with concurrent TBI and multiple rib fractures. Following propensity score matching, we compared patients who underwent SSRF with those who were managed nonoperatively. Our primary outcome was mortality. Secondary outcomes included ventilator-associated pneumonia, hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, tracheostomy rate, and hospital discharge disposition. In a subgroup analysis, we stratified patients into mild and moderate TBI (GCS score >8) and severe TBI (GCS score ≤8). RESULTS:Of 36,088 patients included in this study, 879 (2.4%) underwent SSRF. After propensity-score matching, compared with nonoperative management, SSRF was associated with decreased mortality (5.4% vs. 14.5%,p < 0.001), increased hospital LOS (15 days vs. 9 days, p < 0.001), increased ICU LOS (12 days vs. 8 days, p < 0.001), and increased ventilator days (7 days vs. 4 days, p < 0.001). In the subgroup analyses, in mild and moderate TBI, SSRF was associated with decreased in-hospital mortality (5.0% vs. 9.9%, p = 0.006), increased hospital LOS (13 days vs. 9 days, p < 0.001), ICU LOS (10 days vs. 7 days, p < 0.001), and ventilator days (5 days vs. 2 days, p < 0.001). In patients with severe TBI, SSRF was associated with decreased mortality (6.2% vs. 18%, p < 0.001), increased hospital LOS (20 days vs. 14 days, p = 0.001), and increased ICU LOS (16 days vs. 13 days, p = 0.004). CONCLUSION:In patients with TBI and multiple rib fractures, SSRF is associated with a significant decrease in in-hospital mortality and with longer hospital and ICU LOSs. These findings suggest that SSRF should be considered in patients with TBI and multiple rib fractures.