Surgical Stabilization for the Treatment of Severe Rib Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

J. Lentz Carvalho¹, S. Mazzola Poli de Figueiredo¹, S. Fortich¹, A. A.. Coleoglou Centeno¹, P. Marcolin², G. Levy³, R. Petrov^4
1The University of Texas Medical Branch, Galveston, Texas ²School of Medicine, Universidade Federal da Fronteira Sul, Passo Fundo, Rio Grande do Sul ³UTMB Galveston, Galveston, Texas ⁴UTMB, League City, Texas

Purpose: Rib fractures are the most common injury in thoracic trauma. These range from non-displaced fractures to extensive chest wall injury with concomitant intra-thoracic injuries, carrying significant morbidity and mortality. Surgical stabilization of rib fractures (SSRF) has emerged in popularity, demonstrating encouraging outcomes in recent randomized controlled trials (RCTs).

Methods: Following PRIMA guidelines, a systematic review and meta-analysis was conducted. PubMed, Embase, and Cochrane Library databases were searched to identify randomized controlled trials comparing SSRF to conservative management in patients with rib fractures. Outcome variables included total and intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation (MV), rates of pneumonia, tracheostomy, thoracic deformity, and mortality. Subgroup analyses were performed in patients with flail chest and those mechanically ventilated. Risk of bias was assessed using Cochrane’s Risk of Bias 2 tool. Outcomes were analyzed using pooled analysis and meta-analysis. Statistical tests were performed using RevMan 5.4, and heterogeneity was assessed with I2 statistics. Results are reported in mean differences (95% confidence interval [CI]), and odds ratios (OR) (95% CI).

Results: Initial search returned 424 studies, after screening for inclusion 13 were completely reviewed. One study was excluded due to lack of comparison group, and three studies were excluded due to lack of randomization. Thus, we included 9 RCTs, containing 851 patients (Figure 1). Overall, SSRF was statistically superior to conservative management for ICU LOS (mean difference 4.38 days [7.11, 1.65], P=0.002), mortality (OR 0.42 [0.18, 0.97], P=0.04), thoracic deformity (OR 0.04 [0.01, 0.26], P< 0.001), and need for tracheostomy (OR 0.37 [0.16, 0.84], P=0.02). Rates of pneumonia were lower in patients undergoing SSRF (OR 0.4 [0.16, 1.01]), although this did not reach statistical significance (P=0.05). In the subgroup of patients with flail chest, SSRF showed statistical benefit over conservative management for ICU LOS (mean difference 6.41 days [11.85, 0.97], P=0.02), and pneumonia (OR 0.16 [0.06, 0.38], P< 0.001). In the subgroup of patients requiring mechanical ventilation, SSRF patients had a decreased rate of tracheostomy (OR 0.23 [0.07, 0.76], P=0.02).

Conclusion: In the current meta-analysis, SSRF consistently demonstrated superior outcomes compared to conservative management in patients with severe rib fractures. This is further confirmed in subgroups of patients with flail chest and requiring mechanical ventilation. Surgical fixation should be considered standard of care in these patients.

Identify the source of the funding for this research project: No funding was received with the conduction or preparation of this research project.