Does Surgery Reduce the Risk of Complications Among Patients with Multiple Rib Fractures? A Meta-analysis

Abstract

Background: Multiple rib fractures are common in trauma patients, who are prone to trauma-associated complications. Surgical or nonsurgical interventions for the aforementioned conditions remain controversial.

Questions/purposes: The purpose of our study was to perform a meta-analysis to evaluate the clinical prognosis of surgical fixation of multiple rib fractures in terms of (1) hospital-related endpoints (including duration of mechanical ventilation, ICU length of stay [LOS] and hospital LOS), (2) complications, (3) pulmonary function, and (4) pain scores.

Methods: We screened PubMed, Embase, and Cochrane databases for randomized and prospective studies published before January 2018. Individual effect sizes were standardized; the pooled effect size was calculated using a random-effects model. Primary outcomes were duration of mechanical ventilation, intensive care unit length of stay (ICU LOS), and hospital LOS. Moreover, complications, pulmonary function, and pain were assessed.

Results: The surgical group had a reduced duration of mechanical ventilation (weighted mean difference [WMD], -4.95 days; 95% confidence interval [CI], -7.97 to -1.94; p = 0.001), ICU LOS (WMD, -4.81 days; 95% CI, -6.22 to -3.39; p < 0.001), and hospital LOS (WMD, -8.26 days; 95% CI, -11.73 to -4.79; p < 0.001) compared with the nonsurgical group. Complications likewise were less common in the surgical group, including pneumonia (odds ratio [OR], 0.41; 95% CI, 0.27-0.64; p < 0.001), mortality (OR, 0.24; 95% CI, 0.07-0.87; p = 0.030), chest wall deformity (OR, 0.02; 95% CI. 0.00-0.12; p < 0.001), dyspnea (OR, 0.23; 95% CI, 0.09-0.54; p < 0.001), chest wall tightness (OR, 0.11; 95% CI, 0.05-0.22; p < 0.001) and incidence of tracheostomy (OR, 0.34; 95% CI, 0.20-0.57; p < 0.001). There were no differences between the surgical and nonsurgical groups in terms of pulmonary function, such as forced vital capacity (WMD, 6.81%; 95% CI: -8.86 to 22.48; p = 0.390) and pain scores (WMD, -11.41; 95% CI: -42.09 to 19.26; p = 0.470).

Conclusions: This meta-analysis lends stronger support to surgical fixation, rather than conservative treatment, for multiple rib fractures. Nevertheless, additional trials should be conducted to investigate surgical indications, timing, and followup for quality of life.

Level of evidence: Level I, therapeutic study.

Conflict of interest statement

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Figures

Fig. 1

The flowchart shows the search strategy we used for this study.

Fig. 2

The forest plot shows the duration of mechanical ventilation, ICU length of stay, and hospital length of stay after surgical versus nonsurgical management. The size of the squares reflects the weight of the trial in pooled analysis. The horizontal bars represent the 95% CI; IV = inverse variance; df = degrees of freedom.

Fig. 3

The forest plot shows the incidence of pneumonia and mortality after surgical versus nonsurgical management. The size of the squares reflects the weight of the trial in pooled analysis. The horizontal bars represent the 95% CI; M-H = Mantel-Haenszel; df = degrees of freedom.

Fig. 4

The forest plot shows the incidence of complications including chest wall deformity, dyspnea, chest wall tightness, and tracheostomy after surgical versus nonsurgical management. The size of the squares reflects the weight of the trial in pooled analysis. The horizontal bars represent the 95% CI; M-H = Mantel-Haenszel; df = degrees of freedom.

Fig. 5

The forest plot shows the pulmonary function test including forced vital capacity (FVC), peak expiratory flow rate (PEFR), forced expiratory volume in 1 second (FEV1), and total lung capacity (TLC) after surgical versus nonsurgical management. The size of the squares reflects the weight of the trial in pooled analysis. The horizontal bars represent the 95% CI; IV = inverse variance; df = degrees of freedom.

Fig. 6

The forest plot shows the pain score and pain medications after surgical versus nonsurgical management. The size of the squares reflects the weight of the trial in pooled analysis. The horizontal bars represent the 95% CI; IV = inverse variance; M-H = Mantel-Haenszel; df = degrees of freedom.