Systematic review of systematic reviews for effectiveness of internal fixation for flail chest and rib fractures in adults

Abstract

ObjectivesMultiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains controversial. Our aim is to synthesise the effectiveness of surgical rib fracture fixation as evidenced by systematic reviews.DesignA systematic search identified systematic reviews comparing effectiveness of rib fracture fixation with non-operative management of adults with flail chest or unifocal non-flail rib fractures. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Science Citation Index were last searched 17 March 2017. Risk of bias was assessed using the Risk Of Bias In Systematic reviews (ROBIS) tool. The primary outcome was duration of mechanical ventilation.ResultsTwelve systematic reviews were included, consisting of 3 unique randomised controlled trials and 19 non-randomised studies. Length of mechanical ventilation was shorter in the fixation group compared with the non–operative group in flail chest; pooled estimates ranged from −4.52 days, 95% CI (−5.54 to –3.5) to −7.5 days, 95% CI (−9.9 to –5.5). Pneumonia, length of hospital and intensive care unit stay all showed a statistically significant improvement in favour of fixation for flail chest; however, all outcomes in favour of fixation had substantial heterogeneity. There was no statistically significant difference between groups in mortality. Two systematic reviews included one non-randomised studies of unifocal non-flail rib fracture population; due to limited evidence the benefits with surgery are uncertain.ConclusionsSynthesis of the reviews has shown some potential improvement in patient outcomes with flail chest after fixation. For future review updates, meta-analysis for effectiveness may need to take into account indications and timing of surgery as a subgroup analysis to address clinical heterogeneity between primary studies. Further robust evidence is required before conclusions can be drawn of the effectiveness of surgical fixation for flail chest and in particular, unifocal non-flail rib fractures.PROSPERO registration numberCRD42016053494.

Complications of clavicle fracture surgery in patients with concomitant chest wall injury: a retrospective study

“…Therefore, the appropriate management of complex CWI may be an important step to reduce unnecessary readmission. In recent years, some studies have reported that SSRF in complex CWI provides short-term benefits that are superior to conservative treatment [33][34][35][36]. Furthermore, early SSRF may provide several advantages over late SSRF [37][38][39].…”

Effect of surgical stabilization of rib fractures in polytrauma - an analysis of the TraumaRegister DGU®

“…Recent studies have shown a positive effect on survival and outcome [16]. Nevertheless, it is still unclear whether a demonstrably positive effect can be achieved at with a surgical stabilization and for which patients overall or for which parameters there is a bene t [17].…”

Surgical stabilization of flail chest after trauma: when, why and how to do it?

“…Current opinion is to proceed with surgical stabilization when respiratory failure, intractable pain and subsequent dyspnoea appear or when failure to wean from invasive ventilation occurs (9)(10)(11). Mayberry et al (12) in a specific survey found that FC with failure to wean from ventilator after 7 and 14 days achieved 34% and 29% concordance as indications for surgery, while only 8% of surgeons would indicate surgical stabilization in presence of a FC not requiring mechanical ventilation.…”