Ruben J Hoepelman1, Frank J P Beeres2, Reinier B Beks3, Arthur A R Sweet3, Frank F Ijpma4, Koen W W Lansink5, Bas van Wageningen6, Tjarda N Tromp6, Björn-Christian Link2, Nicole M van Veelen2, Jochem M Hoogendoorn7, Mirjam B de Jong3, Mark C P van Baal3, Luke P H Leenen3, Rolf H H Groenwold8,9, Roderick M Houwert3. 1. Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands. rjhoepelman@gmail.com. 2. Department of Orthopedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland. 3. Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands. 4. Department of Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. 5. Department of Trauma Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands. 6. Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, The Netherlands. 7. Department of Trauma Surgery, Haaglanden Medical Center, The Hague, The Netherlands. 8. Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands. 9. Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands.
Abstract
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.
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.
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