Surgery May Hold Benefit in Acute Unstable Chest Wall Injuries in Select Patients

Patients with acute unstable chest wall injuries who were receiving mechanical ventilation experienced modest benefits with operative treatment, a randomized trial suggested.

In a modified intention-to-treat analysis involving 207 patients, those who underwent surgery to stabilize rib fractures had more ventilator-free days (VFDs) versus those who did not undergo surgery during the first 28 days after injury (22.7 vs 20.6 days), but this difference did not reach significance (mean difference 2.1 days, 95% CI -0.3 to 4.5, P=0.09), reported Niloofar Dehghan, MD, of the CORE Institute in Phoenix, Arizona, and colleagues.

However, a prespecified subgroup analysis of patients on mechanical ventilation at the time of randomization favored the operative group (mean difference 2.8 VFDs, 95% CI 0.1-5.5), they noted in JAMA Surgery.

“The potential advantage was primarily observed in the subgroup of patients at the time of randomization,” Dehghan and team wrote. “We found no benefit to operative treatment in patients who were not ventilated.”

Overall, lower mortality rates were seen in the operative group (0% vs 6%, P=0.01), while other secondary endpoints such as rates of complications (pneumonia, sepsis, tracheostomy) and length of hospital stay (median 16 vs 16.5 days) were similar.

Differences between the subgroups of patients ventilated and non-ventilated at the time of randomization were also similar for complications. A higher trend for mortality was seen in the subgroup who were ventilated at the time of randomization (P=0.06).

After highlighting the “methodological flaws” in the study in an accompanying editorial, Anthony G. Charles, MD, MPH, and colleagues of the University of North Carolina at Chapel Hill, concluded that “this trial demonstrates no role for routine surgical fixation of non-ventilated patients.”

“However, it does not adjudicate the need for routine operative management of mechanically ventilated patients with unstable chest wall injuries,” they noted. “A larger prospective randomized study with standardization of critical care management will be needed.”

Unstable chest wall injuries, including flail chest, are often caused by blunt force trauma, which increases the risk for morbidity and mortality, Dehghan’s group noted. Many complications can arise from these types of injuries, such as severe pulmonary restriction, chest wall instability, or even loss of lung volume, resulting in more patients requiring prolonged ventilation.

Nonoperative management strategies — consisting of intubation, chest tube drainage, and intermittent positive-pressure ventilation, among others — are the most common treatments for severe chest wall injuries, but these have not always led to the most optimal outcomes. While many prior studies have found improved outcomes with operative treatment for carefully selected patients, data are mixed on whether operative or nonoperative treatment is superior.

For this study, Dehghan and colleagues enrolled 207 patients ages 16 to 85 with acute unstable chest wall injuries and randomized them 1:1 to operative treatment with plate and screws (n=108) or nonoperative treatment (n=99) across 15 sites in the U.S. and Canada from October 2011 to October 2019. The nonoperative group received the standard of care, including pain management, chest tube drainage, chest physiotherapy/pulmonary toilet, or ventilation, if needed.

Baseline characteristics were similar between groups. Mean age was 53, and three-fourths were men. Most had injuries caused by motor vehicle collisions (30-37%), falls (17-26%), or motorcycle collisions (13-15%). Mean number of rib fractures was 10.

Common conditions included pneumothorax (89%), hemothorax (76%), and pulmonary contusion (54%). The most common types of plates used during surgery were pelvic reconstruction plates (53%) and pre-contoured locking rib plates (43%). Notably, 43% of patients received mechanical ventilation.

Six patients died while hospitalized, all in the nonoperative group. Four operative patients required repeat surgery.

Dehghan and team noted that their trial was “underpowered to detect statistical significance in outcomes that were potentially clinically significant” due to the small sample size. Variations in care may also have occurred across centers.