Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis

Reinier B Beks, Jesse Peek, Mirjam B de Jong, Karlijn J P Wessem, Cumhur F Öner, Falco Hietbrink, Luke P H Leenen, Rolf H H Groenwold, Roderick M Houwert, Reinier B Beks, Jesse Peek, Mirjam B de Jong, Karlijn J P Wessem, Cumhur F Öner, Falco Hietbrink, Luke P H Leenen, Rolf H H Groenwold, Roderick M Houwert

Abstract

Purpose: The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies.

Methods: MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy.

Results: Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I2 = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies.

Conclusions: Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs.

Keywords: Current evidence; Flail chest; Multiple rib fractures; Nonoperative treatment; Operative treatment.

Conflict of interest statement

Reinier Beks, Jesse Peek, Mirjam de Jong, Karlijn Wessem, Cumhur Öner, Falco Hietbrink, Luke Leenen, Rolf Groenwold, and Roderick Houwert declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Flowchart of the literature search
Fig. 2
Fig. 2
Mortality in a systematic review of rib fractures comparing operative to nonoperative treatment
Fig. 3
Fig. 3
Funnel plot of studies included in a meta-analysis reporting mortality rates after operative or nonoperative treatment of rib fractures (RR risk ratio, SE standard error)

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