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Dany James J, Choudhary N, Bagaria D, Boddeda J, Kumar A, Priyadarshini P, Mishra B, Sagar S, Kumar S, Gupta A. Benefits of Rib Fixation Utilizing Low-Cost Materials: A Randomized Pilot Trial. J Surg Res 2024; 299:322-328. [PMID: 38788469 DOI: 10.1016/j.jss.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 03/20/2024] [Accepted: 04/17/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION Surgical stabilization of rib fractures (SSRF) using standard rib plating systems has become a norm in developed countries. However, the procedure has not garnered much interest in low-middle-income countries, primarily because of the cost. METHODS This was a single-center pilot randomized trial. Patients with severe rib fractures were randomized into two groups: SSRF and nonoperative management. SSRF arm patients underwent surgical fixation in addition to the tenets of nonoperative management. Low-cost materials like stainless steel wires and braided polyester sutures were used for fracture fixation. The primary outcome was to assess the duration of hospital stay. RESULTS Twenty-two patients were randomized, 11 in each arm. Per-protocol analysis showed that the SSRF arm had significantly reduced duration of hospital stay (22.6 ± 19.1 d versus 7.9 ± 5.7 d, P value 0.031), serial pain scores at 48 h and 5 d (median score 5, IQR (3-6) versus median score 7, IQR (6.5-8), P value 0.004 at 48 h and median score 2 IQR (2-3) versus median score 7 IQR (4.5-7) P value 0.0005 at 5 d), significantly reduced need for injectable opioids (9.9 ± 3.8 mg versus 4.4 ± 3.4 mg, P value 0.003) and significantly more ventilator-free days (19.9 ± 8.7 d versus 26.4 ± 3.2 d, P value 0.04). There were no statistically significant differences in the total duration of ICU stay (median number of days 2, IQR 1-4.5 versus median number of days 7, IQR 1-14, P value 0.958), need for tracheostomy (36.4% versus 0%, P value 0.155), and pulmonary and pleural complications. CONCLUSIONS SSRF with low-cost materials may provide benefits similar to standard rib plating systems and can be used safely in resource-poor settings.
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Affiliation(s)
- Joses Dany James
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Narendra Choudhary
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Dinesh Bagaria
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Jogendra Boddeda
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Abhinav Kumar
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Pratyusha Priyadarshini
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Biplab Mishra
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Sagar
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
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Chen K, Minasian B, Woodford E, Shivashankar P, Ho KA, Muralidaran S, Elhindi J, Hsu J. Together is better - RibScore and SCARF in the prediction of pulmonary complications and association with SSRF. Injury 2024:111562. [PMID: 38649314 DOI: 10.1016/j.injury.2024.111562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Optimal treatment of patients with rib fractures requires identification of those patients at risk of pulmonary complications. It is also important to determine which patients would benefit from Surgical Stabilisation of Rib Fractures (SSRF). This study aims to validate two scoring systems (RibScore and SCARF score) in predicting complications and association with SSRF in an Australian trauma population. Clinical observation suggests that complications and criteria for SSRF is associated with anatomical and physiological factors. Therefore it is hypothesized that utilisation of an anatomical (RibScore) and physiological (SCARF) in conjunction will have improved predictive ability. METHOD Retrospective cohort study of rib fracture patients admitted to an Australian Level I trauma centre from Jan 2017 to Jan 2021. RibScore and SCARF score were calculated. Multivariate logistic regression was performed to determine risk factors associated with complications and SSRF, as well the scoring systems' ability via ROC AUC. RESULTS 1157 patients were included. Higher median RibScore (1vs0; p < 0.001) and SCARF score (3vs1, p < 0.001) was associated with development of complications. Similarly for SSRF, RibScore (3vs0; p < 0.001), SCARF score (3vs1; p < 0.001) were higher. On multivariate analysis, increasing RibScore and SCARF score were associated with an increased risk of respiratory failure, pneumonia, death, and SSRF. The sensitivity for a patient with a high risk score in either RibScore or SCARF increased to 96.3 % in identifying pulmonary complications (from 66.7 % in RibScore and 88 % in SCARF, when used individually) and 91.9 % in identifying association with SSRF (from 86.5 % in RibScore and 70.3 % in SCARF). CONCLUSION RibScore and SCARF score demonstrate predictive ability for complications and SSRF in an Australian trauma rib fracture population. Combining a radiological score with a clinical scoring system demonstrates improved sensitivity over each score individually for identifying patients at risk of complications from rib fractures, those who may require SSRF, and those who are low risk. STUDY TYPE Retrospective Cohort Study LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
- Kabytto Chen
- Discipline of Surgery, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Trauma Service, Department of Surgery, Westmead Hospital, Sydney, Australia.
| | - Bayan Minasian
- Discipline of Surgery, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Trauma Service, Department of Surgery, Westmead Hospital, Sydney, Australia
| | - Evangeline Woodford
- Discipline of Surgery, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Trauma Service, Department of Surgery, Westmead Hospital, Sydney, Australia
| | - Pranav Shivashankar
- Discipline of Surgery, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Trauma Service, Department of Surgery, Westmead Hospital, Sydney, Australia
| | - Kah Ann Ho
- Discipline of Surgery, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Trauma Service, Department of Surgery, Westmead Hospital, Sydney, Australia
| | - Saimurooban Muralidaran
- Discipline of Surgery, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Trauma Service, Department of Surgery, Westmead Hospital, Sydney, Australia
| | - James Elhindi
- Discipline of Surgery, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jeremy Hsu
- Discipline of Surgery, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Trauma Service, Department of Surgery, Westmead Hospital, Sydney, Australia
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Eriksson EA, Wijffels MME, Kaye A, Forrester JD, Moutinho M, Majerick S, Bauman ZM, Janowak CF, Patel B, Wullschleger M, Clevenger L, Van Lieshout EMM, Tung J, Woodfall M, Hill TR, White TW, Doben AR. Incidence of surgical rib fixation at chest wall injury society collaborative centers and a guide for expected number of cases (CWIS-CC1). Eur J Trauma Emerg Surg 2024; 50:417-423. [PMID: 37624405 DOI: 10.1007/s00068-023-02343-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE Surgical stabilization of rib fractures (SSRF) improves outcomes in certain patient populations. The Chest Wall Injury Society (CWIS) began a new initiative to recognize centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). We sought to describe incidence and epidemiology of SSRF at our institutions. METHODS A retrospective registry evaluation of all patients (age > 15 years) treated at international trauma centers from 1/1/20 to 7/30/2021 was performed. Variables included: age, gender, mechanism of injury, injury severity score, abbreviated injury severity score (AIS), emergency department disposition, length of stay, presence of rib/sternal fractures, and surgical stabilization of rib/sternal fractures. Classification and regression tree analysis (CART) was used for analysis. RESULTS Data were collected from 9 centers, 26,084 patient encounters. Rib fractures were present in 24% (n = 6294). Overall, 2% of all patients underwent SSRF and 8% of patients with rib fractures underwent SSRF. CART analysis of SSRF by AIS-Chest demonstrated a difference in management by age group. AIS-Chest 3 had an SSRF rate of 3.7, 7.3, and 12.9% based on the age ranges (16-19; 80-110), (20-49; 70-79), and (50-69), respectively (p = 0.003). AIS-Chest > 3 demonstrated an SSRF rate of 9.6, 23.3, and 39.3% for age ranges (16-39; 90-99), (40-49; 80-89), and (50-79), respectively (p = 0.001). CONCLUSION Anticipated rate of SSRF can be calculated based on number of rib fractures, AIS-Chest, and age. The disproportionate rate of SSRF in patients age 50-69 with AIS-Chest 3 and age 50-79 with AIS-Chest > 3 should be further investigated, as lower frequency of SSRF in the other age ranges may lead to care inequalities.
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Affiliation(s)
- Evert Austin Eriksson
- Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas Drive CSB 420, MSC 613, Charleston, SC, 29425, USA.
| | - Mathieu Mathilde Eugene Wijffels
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Adam Kaye
- Department of Trauma, Overland Park Regional Medical Center, 10500 Quivira Rd., Overland Park, KS, 66215, USA
| | - Joseph Derek Forrester
- Department of Surgery, Stanford Healthcare, Chest Wall Injury Center, Stanford Healthcare, Center for Innovation in Global Health (CIGH), Stanford University, Stanford, USA
| | - Manuel Moutinho
- Department of Surgery, Saint Francis Hospital and Medical Center, UConn School of Medicine, Hartford, CT, USA
| | - Sarah Majerick
- Department of Trauma, Intermountain Health, Salt Lake City, USA
| | - Zachary Mitchel Bauman
- Trauma Surgery, Surgical Critical Care, Emergency General Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, TraumaOmaha, NE, 68198-3280, USA
| | - Christopher Francis Janowak
- Section of General Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA
| | - Bhavik Patel
- Gold Coast University Hospital, Gold Coast, QLD, 4215, Australia
| | - Martin Wullschleger
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- Griffith University, Gold Coast, Australia
| | - Leanna Clevenger
- Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas Drive CSB 420, MSC 613, Charleston, SC, 29425, USA
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Jamie Tung
- Department of Surgery, Stanford Healthcare, Chest Wall Injury Center, Stanford Healthcare, Center for Innovation in Global Health (CIGH), Stanford University, Stanford, USA
| | - Michelle Woodfall
- Department of Surgery, Stanford Healthcare, Chest Wall Injury Center, Stanford Healthcare, Center for Innovation in Global Health (CIGH), Stanford University, Stanford, USA
| | - Thomas Russell Hill
- Department of Surgery, Saint Francis Hospital and Medical Center, UConn School of Medicine, Hartford, CT, USA
| | | | - Andrew Ross Doben
- Department of Surgery, Saint Francis Hospital and Medical Center, UConn School of Medicine, Hartford, CT, USA
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Dixon J, Rankin I, Diston N, Goffin J, Stevenson I. Surgical Rib Fracture Fixation: Early Operative Intervention Improves Outcomes. J Chest Surg 2024; 57:120-125. [PMID: 38225829 DOI: 10.5090/jcs.23.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/19/2023] [Accepted: 10/20/2023] [Indexed: 01/17/2024] Open
Abstract
Background This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or nonoperative management at our major trauma center. Methods A retrospective review of all patients who were considered for surgical stabilization of rib fractures (SSRF) at a single major trauma center from May 2016 to September 2022 was performed. Results In total, 352 patients with complex rib fractures were identified. Thirty-seven patients (11%) fulfilled the criteria for surgical management and underwent SSRF. The SSRF group had a significantly higher proportion of patients with flail chest (32 [86%] vs. 94 [27%], p<0.001) or Injury Severity Score (ISS) >15 (37 [100%] vs. 129 [41%], p<0.001). No significant differences were seen between groups for 1-year mortality. Patients who underwent SSRF within 72 hours were 6 times less likely to develop pneumonia than those in whom SSRF was delayed for over 72 hours (2 [18%] vs. 15 [58%]; odds ratio, 0.163; 95% confidence interval, 0.029-0.909; p=0.036). Prompt SSRF showed non-significant associations with shorter intensive care unit length of stay (6 days vs. 10 days, p=0.140) and duration of mechanical ventilation (5 days vs. 8 days, p=0.177). SSRF was associated with a longer hospital length of stay compared to nonoperative patients with flail chest and/or ISS >15 (19 days vs. 13 days, p=0.012), whilst SSRF within 72 hours was not. Conclusion Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Delayed surgical fixation was associated with increased rates of pneumonia and a longer hospital length of stay.
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Affiliation(s)
- James Dixon
- Trauma and Orthopaedic Surgery, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, UK
| | - Iain Rankin
- Trauma and Orthopaedic Surgery, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, UK
| | | | - Joaquim Goffin
- Trauma and Orthopaedic Surgery, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, UK
| | - Iain Stevenson
- Trauma and Orthopaedic Surgery, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, UK
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Wang J, Sun Z, Liu Y, Gong W, Wang J, Deng J, Fu Y, Lan J. Clinical effect of the internal fixation for rib fracture with single utility port complete video-assisted thoracoscopic surgery. J Cardiothorac Surg 2024; 19:59. [PMID: 38317185 PMCID: PMC10840259 DOI: 10.1186/s13019-024-02517-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 01/28/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUNDS The internal fixation for rib fracture with single-operation-port (two ports) complete video-assisted thoracoscopic surgery (VATS) is a promising surgical approach for treating multiple rib fractures. The study aimed to investigate the minimally invasive surgical procedure's clinical effect in treating multiple rib fractures. METHODS Seventy-three patients with multiple rib fractures were divided into two groups according to surgical procedure. In the study group, 42 patients were operated on with the internal fixation of rib fracture with single-operation-port complete VATS. In the control group, this study performed the open operative internal fixation for rib fracture with traditional thoracotomy on 31 patients. The surgical-related indexes were retrospectively analyzed. These included the operative time, the intraoperative blood loss, the drainage amount of the chest tube, the placement time of the chest tube, the postoperative hospital stay, the incidence of postoperative complications, the imaging efficacy of rib fixation of rib fractures, and visual analog scale of pain scoring (VAS scoring). RESULTS There was no difference in the operative time between the study and control groups (P = 0.806). The intraoperative blood loss, the chest tube drainage amount, the chest tube placement time, the postoperative hospital stay, and the incidence of postoperative complications in the study group were lower than those in the control group (P < 0.05). There was no significant difference in the imaging efficacy of rib fixation of rib fractures between the two groups (P = 0.806). VAS scores in the study group on the seventh postoperative day were significantly reduced compared with the control group (P = 0.026). CONCLUSION The internal fixation for rib fractures with single-operation-port complete VATS is a feasible, safe, simple, and minimally invasive surgical procedure to treat multiple rib fractures, which is worthy of clinical application.
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Affiliation(s)
- Jindong Wang
- The Department of Cardiothoracic Surgery, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, 061000, Hebei, People's Republic of China.
| | - Zhiguang Sun
- The Department of Cardiothoracic Surgery, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, 061000, Hebei, People's Republic of China
| | - Yongshuai Liu
- The Department of Cardiothoracic Surgery, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, 061000, Hebei, People's Republic of China
| | - Weiyong Gong
- The Department of Cardiothoracic Surgery, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, 061000, Hebei, People's Republic of China
| | - Jianxin Wang
- The Department of Cardiothoracic Surgery, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, 061000, Hebei, People's Republic of China
| | - Junyi Deng
- The Department of Cardiothoracic Surgery, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, 061000, Hebei, People's Republic of China
| | - Yue Fu
- The Department of Anesthesiology, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, 061000, Hebei, People's Republic of China
| | - Jishan Lan
- The Department of Anesthesiology, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, 061000, Hebei, People's Republic of China
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Billings JD, Khan AD, Clement LP, Douville AA, Brown EW, Schroeppel TJ. A clinical practice guideline using percentage of predicted forced vital capacity improves resource allocation for rib fracture patients. J Trauma Acute Care Surg 2021; 90:769-775. [PMID: 33891571 DOI: 10.1097/ta.0000000000003083] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Predicting rib fracture patients that will require higher-level care is a challenge during patient triage. Percentage of predicted forced vital capacity (FVC%) incorporates patient-specific factors to customize the measurements to each patient. A single institution transitioned from a clinical practice guideline (CPG) using absolute forced vital capacity (FVC) to one using FVC% to improve triage of rib fracture patients. This study compares the outcomes of patients before and after the CPG change. METHODS A review of rib fracture patients was performed over a 3-year retrospective period (RETRO) and 1-year prospective period (PRO). RETRO patients were triaged by absolute FVC. Percentage of predicted FVC was used to triage PRO patients. Demographics, mechanism, Injury Severity Score, chest Abbreviated Injury Scale score, number of rib fractures, tube thoracostomy, intubation, admission to intensive care unit (ICU), transfer to ICU, hospital length of stay (LOS), ICU LOS, and mortality data were compared. A multivariable model was constructed to perform adjusted analysis for LOS. RESULTS There were 588 patients eligible for the study, with 269 RETRO and 319 PRO patients. No significant differences in age, gender, or injury details were identified. Fewer tube thoracostomy were performed in PRO patients. Rates of intubation, admission to ICU, and mortality were similar. The PRO cohort had fewer ICU transfers and shorter LOS and ICU LOS. Multivariable logistic regression identified a 78% reduction in odds of ICU transfer among PRO patients. Adjusted analysis with multiple linear regression showed LOS was decreased 1.28 days by being a PRO patient in the study (B = -1.44; p < 0.001) with R2 = 0.198. CONCLUSION Percentage of predicted FVC better stratified rib fracture patients leading to a decrease in transfers to the ICU, ICU LOS, and hospital LOS. By incorporating patient-specific factors into the triage decision, the new CPG optimized triage and decreased resource utilization over the study period. LEVEL OF EVIDENCE Therapeutic/Care Management. Trauma, Rib, Triage, level IV.
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Affiliation(s)
- Joshua D Billings
- From the Department of Trauma and Acute Care Surgery (J.D.B., A.D.K., T.J.S.), University of Colorado Health Memorial Hospital, Colorado Springs; Department of Surgery (J.D.B., A.D.K., T.J.S.), University of Colorado, Aurora; and Department of Pharmacy (L.P.C., A.A.D., E.W.B.), University of Colorado Health Memorial Hospital, Colorado Springs, Colorado
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Choi J, Kaghazchi A, Dickerson KL, Tennakoon L, Spain DA, Forrester JD. Heterogeneity in managing rib fractures across non-trauma and level I, II, and III trauma centers. Am J Surg 2021; 222:849-854. [PMID: 33612257 DOI: 10.1016/j.amjsurg.2021.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/10/2021] [Accepted: 02/10/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND We aimed to elucidate management patterns and outcomes of high-risk patients with rib fractures (elderly or flail chest) across non-trauma and trauma centers. We hypothesized highest-capacity (level I) centers would have best outcomes for high-risk patients. METHODS We queried the 2016 National Emergency Department Sample to identify adults presenting with rib fractures. Multivariable regression assessed ED and inpatient events across non-trauma and level III/II/I trauma centers. RESULTS Among 504,085 rib fracture encounters, 46% presented to non-trauma centers. Elderly patients with multiple rib fractures had stepwise increase in inpatient admission odds and stepwise decrease in pneumonia odds at higher-capacity trauma centers compared to non-trauma centers. Among patients with flail chest, odds of undergoing surgical stabilization (SSRF) increased at trauma centers. Undergoing SSRF was associated with reduced mortality but remained underutilized. CONCLUSION Half of patients with rib fractures present to non-trauma centers. Nationwide care-optimization for high-risk patients requires further effort.
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Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, Stanford University, USA; Department of Epidemiology and Population Health, Stanford University, USA; Surgeons Writing About Trauma, Stanford University, USA.
| | - Aydin Kaghazchi
- Department of Epidemiology and Population Health, Stanford University, USA; Surgeons Writing About Trauma, Stanford University, USA
| | - Katherine L Dickerson
- Surgeons Writing About Trauma, Stanford University, USA; Department of Emergency Medicine, Massachusetts General Hospital, Harvard University, USA
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, Stanford University, USA; Surgeons Writing About Trauma, Stanford University, USA
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, USA; Surgeons Writing About Trauma, Stanford University, USA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, USA; Surgeons Writing About Trauma, Stanford University, USA
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Weikert T, Noordtzij LA, Bremerich J, Stieltjes B, Parmar V, Cyriac J, Sommer G, Sauter AW. Assessment of a Deep Learning Algorithm for the Detection of Rib Fractures on Whole-Body Trauma Computed Tomography. Korean J Radiol 2020; 21:891-899. [PMID: 32524789 PMCID: PMC7289702 DOI: 10.3348/kjr.2019.0653] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 02/12/2020] [Accepted: 02/19/2020] [Indexed: 12/03/2022] Open
Abstract
Objective To assess the diagnostic performance of a deep learning-based algorithm for automated detection of acute and chronic rib fractures on whole-body trauma CT. Materials and Methods We retrospectively identified all whole-body trauma CT scans referred from the emergency department of our hospital from January to December 2018 (n = 511). Scans were categorized as positive (n = 159) or negative (n = 352) for rib fractures according to the clinically approved written CT reports, which served as the index test. The bone kernel series (1.5-mm slice thickness) served as an input for a detection prototype algorithm trained to detect both acute and chronic rib fractures based on a deep convolutional neural network. It had previously been trained on an independent sample from eight other institutions (n = 11455). Results All CTs except one were successfully processed (510/511). The algorithm achieved a sensitivity of 87.4% and specificity of 91.5% on a per-examination level [per CT scan: rib fracture(s): yes/no]. There were 0.16 false-positives per examination (= 81/510). On a per-finding level, there were 587 true-positive findings (sensitivity: 65.7%) and 307 false-negatives. Furthermore, 97 true rib fractures were detected that were not mentioned in the written CT reports. A major factor associated with correct detection was displacement. Conclusion We found good performance of a deep learning-based prototype algorithm detecting rib fractures on trauma CT on a per-examination level at a low rate of false-positives per case. A potential area for clinical application is its use as a screening tool to avoid false-negative radiology reports.
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Affiliation(s)
- Thomas Weikert
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Luca Andre Noordtzij
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jens Bremerich
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Bram Stieltjes
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Victor Parmar
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Joshy Cyriac
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gregor Sommer
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexander Walter Sauter
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
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Choi J, Gomez GI, Kaghazchi A, Borghi JA, Spain DA, Forrester JD. Surgical Stabilization of Rib Fracture to Mitigate Pulmonary Complication and Mortality: A Systematic Review and Bayesian Meta-Analysis. J Am Coll Surg 2020; 232:211-219.e2. [PMID: 33212228 DOI: 10.1016/j.jamcollsurg.2020.10.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 01/22/2023]
Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Department of Epidemiology and Population Health, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA.
| | - Giselle I Gomez
- Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - Aydin Kaghazchi
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - John A Borghi
- School of Medicine, Stanford University, Stanford, CA
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA
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10
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Duong W, Grigorian A, Nahmias J, Farzaneh C, Christian A, Dolich M, Lekawa M, Schubl S. An increasing trend in geriatric trauma patients undergoing surgical stabilization of rib fractures. Eur J Trauma Emerg Surg 2020; 48:205-210. [PMID: 33095279 PMCID: PMC7583690 DOI: 10.1007/s00068-020-01526-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/09/2020] [Indexed: 11/26/2022]
Abstract
Purpose The proportion of geriatric trauma patients (GTPs) (age ≥ 65 years old) with chest wall injury undergoing surgical stabilization of rib fractures (SSRF) nationally is unknown. We hypothesize a growing trend of GTPs undergoing SSRF, and sought to evaluate risk of respiratory complications and mortality for GTPs compared to younger adults (18–64 years old) undergoing SSRF. Methods The Trauma Quality Improvement Program (2010–2016) was queried for patients with rib fracture(s) who underwent SSRF. GTPs were compared to younger adults. A multivariable logistic regression analysis was performed. Results From 21,517 patients undergoing SSRF, 3,001 (16.2%) were GTPs. Of all patients undergoing SSRF in 2010, 10.6% occurred on GTPs increasing to 17.9% in 2016 (p < 0.001) with a geometric-mean-annual increase of 11.5%. GTPs had a lower median injury severity score (18 vs. 22, p < 0.001), but had a higher rate of mortality (4.7% vs. 1.2%, p < 0.001). After controlling for covariates, GTPs had an increased associated risk of mortality (OR 4.80, CI 3.62–6.36, p < 0.001). On a separate multivariate analysis for all trauma patients with isolated chest Abbreviated Injury Scale 3, GTPs were associated with a similar four-fold risk of mortality (OR 4.21, CI 1.98–6.32, p < 0.001). Conclusion Spanning 7 years of data, the proportion of GTPs undergoing SSRF increased by over 7%. Although GTPs undergoing SSRF had lesser injuries, their risk of mortality was four times higher than other adult trauma patients undergoing SSRF, which was similar to their increased background risk of mortality. Ultimately, SSRF in GTPs should be considered on an individualized basis with careful attention to risk–benefit ratio. Electronic supplementary material The online version of this article (10.1007/s00068-020-01526-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- William Duong
- Irvine Medical Center, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.
| | - Areg Grigorian
- Irvine Medical Center, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Jeffry Nahmias
- Irvine Medical Center, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Cyrus Farzaneh
- Irvine Medical Center, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Ashton Christian
- Irvine Medical Center, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Matthew Dolich
- Irvine Medical Center, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Michael Lekawa
- Irvine Medical Center, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Sebastian Schubl
- Irvine Medical Center, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
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11
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Li Y, Gao E, Yang Y, Gao Z, He W, Zhao Y, Wu W, Zhao T, Guo X. Comparison of minimally invasive surgery for non-flail chest rib fractures: a prospective cohort study. J Thorac Dis 2020; 12:3706-3714. [PMID: 32802450 PMCID: PMC7399395 DOI: 10.21037/jtd-19-2586] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To evaluate therapeutic efficacy of minimally invasive and small incision surgery [minimally invasive surgery (MIS)] in patients with non-flail chest rib fractures through a prospective cohort study. Methods This study included 98 patients with non-flail chest rib fractures (≥3 displaced fractures) and 66 patients undergoing MIS served as the experimental group and 32 patients receiving conservative treatment served as the matched control group. Pain index and indicators of pulmonary function [vital capacity (VC); forced expiratory volume in one second (FEV1); peak expiratory flow (PEF)] for the two groups were assessed and compared at the time of admission and before discharge. In addition, duration of pain, time required for the patient to regain the ability to perform daily self-care, mental labor, and moderate-to-severe physical labor, and duration of chest discomfort were measured during long-term follow-up and compared between the two groups. Results There were also no significant differences (P>0.05) in pain index (8 vs. 8) or indicators of pulmonary function (VC: 31.0% vs. 26.5%; FEV1: 29.9% vs. 26.7%; PEF: 15.2% vs. 12.0%) were found between the MIS and conservative treatment groups at the time of admission; while pain index (3 vs. 6), VC (42.1% vs. 35.3%), and FEV1 (44.2% vs. 35.9%) were significantly different between the two groups (P<0.05) but not in PEF (21.2% vs. 19.6%) before discharge. Long-term follow-up showed that duration of pain, time required for the patient to regain the ability to engage in daily self-care, mental labor, and moderate-to-severe physical labor, and duration of chest discomfort in the MIS group were significantly more improved than in the conservative treatment group (P<0.05). Conclusions MIS was a simple and safe treatment that significantly relieved chest pain and rapidly restored pulmonary function and improved the long-term quality of life of patients with non-flail chest rib fractures of ≥3 ribs with displacement.
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Affiliation(s)
- Yang Li
- Department of Thoracic surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Erji Gao
- Department of Thoracic surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yi Yang
- Department of Thoracic surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zongli Gao
- Department of Thoracic surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Weiwei He
- Department of Thoracic surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yonghong Zhao
- Department of Thoracic surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Weiming Wu
- Department of Thoracic surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Tiancheng Zhao
- Department of Thoracic surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiang Guo
- Department of Thoracic surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
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12
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Retrospective Analysis of the Clinical Outcome in a Matched Case-Control Cohort of Polytrauma Patients Following an Osteosynthetic Flail Chest Stabilization. J Clin Med 2020; 9:jcm9082379. [PMID: 32722527 PMCID: PMC7464248 DOI: 10.3390/jcm9082379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/24/2020] [Accepted: 07/24/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In polytrauma (PT) patients, osseous thoracic injuries are commonly observed. One of the most severe injuries is the flail chest where the rib cage is broken in such a way that leads to a partial functional detachment of the thoracic wall. Especially in PT patients, the integrity of the respiratory system and especially, of the respiratory muscles is essential to prevent respiratory failure. Besides conservative treatment options, flail chest injuries may be surgically stabilized. However, this treatment option is rarely carried out and evidence on the outcome of surgically treated flail chest patients is rare. OBJECTIVE This study intends to investigate the clinical outcome of PT patients with the diagnosis of a flail chest who received an osteosynthetic stabilization for that compared to the same group of patients without an operative treatment. The between-groups outcome was compared regarding the duration of the total hospital and the intensive care unit (ICU) stay, the total of the invasive ventilation days, the incidence of pneumonia, and the dosage of the pain medication at the hospital discharge. METHODS A retrospective analysis was conducted including all PT patients who received an osteosynthetic stabilization of a flail chest. Furthermore, another cohort of PT patients and the diagnosis of a flail chest but without operative treatment was determined. Both groups were case-control matched for the Injury Severity Score (ISS) and age. Further statistical analysis was performed using the Wilcoxon signed-rank test and the McNemar's test. RESULTS Out of eleven operatively and 59 conservatively treated patients, eleven patients per group were matched. Further analysis revealed no significant differences in the normal ward treatment duration (5.64 ± 6.62 and 6.20 ± 5.85 days), the invasive ventilation duration (was 6.25 ± 7.17 and 7.10 ± 6.14 days), the morphine equivalent dosage of the oral analgesia (61.36 ± 67.23 mg and 39.67 ± 65.65 mg), and the pneumonia incidence (36.4 and 54.5%) when conservatively and operatively treated patients were compared, respectively. However, surgically treated patients had a longer ICU (25.18 ± 14.48 and 15.27 ± 12.10 days, Z = -2.308, p = 0.021) and a longer total hospital treatment duration (30.10 ± 13.01 and 20.91 ± 10.34 days, Z = -2.807, p = 0.005) when compared to conservatively treated patients. CONCLUSION In the present study cohort, there was no outcome difference between conservatively and operatively treated patients with the diagnosis of a flail chest regarding the normal ward treatment duration, the invasive ventilation duration, the morphine equivalent dosage of the oral analgesia, and the pneumonia incidence while ICU treatment duration and hospital treatment duration was longer in operatively treated patients.
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13
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Xia H, Sun Z, Wang J, Tian A, Li J, Li X, Zhu S, Miao J, Wang D. Application of rib surface positioning ruler combined with volumetric CT measurement technique in endoscopic minimally invasive thoracic wall fixation surgery. Exp Ther Med 2020; 20:1616-1620. [PMID: 32742393 PMCID: PMC7388419 DOI: 10.3892/etm.2020.8862] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 03/04/2020] [Indexed: 12/20/2022] Open
Abstract
Application value of rib surface positioning ruler combined with volumetric CT measurement in selection of the incision for minimally invasive internal fixation of rib fracture was investigated. A total of 80 patients who received internal fixation of rib fractures in Tianjin Hospital Affiliated to Tianjin University (Tianjin, China) from May 2018 to April 2019 were selected. Patients were treated with the rib surface positioning ruler combined with volumetric CT measurement method (n=42) or traditional positioning method (n=38). The following parameters were compared between the two groups: Preset incision accuracy, operation incision length, operation time, intraoperative bleeding volume, postoperative wound drainage volume and postoperative pain score. Compared with the traditional positioning method, rib surface positioning ruler combined with volumetric CT measurement method can improve preset incision accuracy, reduce operation time, incision length, intraoperative bleeding volume, postoperative wound drainage volume, and postoperative pain score, with statistically significant differences (P<0.05). In conclusion, the application of rib surface positioning ruler combined with volumetric CT measurement technique has obvious effect on the selection of incision for internal fixation of rib fracture, and is an effective method worth promoting.
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Affiliation(s)
- Honggang Xia
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Zhongyi Sun
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Juping Wang
- Department of Cardiology, Beichen District Hospital of Traditional Chinese Medicine, Tianjin 300400, P.R. China
| | - Aixian Tian
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Jing Li
- Department of Basic Nursing, Tianjin Medical College, Tianjin 300222, P.R. China
| | - Xuan Li
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Shan Zhu
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Jun Miao
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Dongbin Wang
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
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14
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Staggers JR, Dennis PB, Eriksson EA. Stability of Surgical Rib Fixation Hardware after Repeat Chest Trauma. J Emerg Trauma Shock 2020; 13:84-87. [PMID: 32395057 PMCID: PMC7204963 DOI: 10.4103/jets.jets_67_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/20/2019] [Accepted: 01/30/2020] [Indexed: 11/10/2022] Open
Abstract
Surgical management of rib fractures has long been a controversial topic, but improvements in rib plating technology have led to a recent increase in interest among surgeons. Unfortunately, follow-up data are limited in patients following rib fracture plating. We present a unique case of an adult male who had multiple ribs plated for symptomatic rib fracture nonunions and developed periprosthetic fractures following repeat trauma several months later. A 57-year-old male with a history of trauma was treated for symptomatic nonunion of several left lateral ribs with surgical rib fixation. He tolerated the procedure well and had significant improvement in his symptoms on follow-up. Several months later, he was hit by a motor vehicle while riding his bicycle. He was found to have flail chest with lateral segmental rib fractures of the first through second ribs, posterior periprosthetic fractures of the seventh through tenth ribs, and lateral fractures of the eleventh and twelfth ribs. The rib plating hardware was completely intact, except for a single displaced seventh rib screw. To our knowledge, this is the first case report of repeat chest trauma following rib plating. Interestingly, the patient developed posterior periprosthetic fractures, and hardware was completely intact except for a single screw that was displaced. The goal of this report is to describe the unique fracture pattern of a flail chest with prior rib plating and to describe potential revision plating techniques and complications that surgeons may encounter in the management of trauma patients with prior rib plating.
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Affiliation(s)
- Jackson Rucker Staggers
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Patrick B Dennis
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Evert A Eriksson
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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15
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Dorman JR, Clarke PTM, Simpson RB, Edwards JG. Testing the clinical validity of the Bemelman Rib Fracture Management Guideline. Interact Cardiovasc Thorac Surg 2020; 30:597-599. [PMID: 31971227 DOI: 10.1093/icvts/ivz317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/06/2019] [Accepted: 12/19/2019] [Indexed: 11/13/2022] Open
Abstract
Whilst surgical stabilization of rib fractures (SSRF) results in better outcomes, selection algorithms are lacking. We aimed to validate the Rib Fracture Management Guideline proposed by Bemelman. From a cohort of 792 patients with multiple rib fractures, 2 sequential cohorts were selected: 48 patients who underwent SSRF and 48 patients who managed conservatively. Admission computed tomography scans and records were reviewed by an investigator blinded to the SSRF outcome. Adherence to the Bemelman guideline, revised to take account of consensus rib fracture definitions, was tested. Fifty-seven patients had multiple rib fractures only, and 39 patients also had a flail segment. Thirty-nine patients with flail segment underwent SSRF, and 18 patients were managed conservatively. Of the patients that the guideline predicted should have received surgery, 87% did. Of those that it predicted should not receive SSRF, 98% did not. The guideline displayed a sensitivity (95% confidence interval) and specificity for predicting the fixation of 0.98 (0.89-0.9995) and 0.83 (0.70-0.93), respectively. The positive and negative predictive values for surgical fixation were 0.87 (0.76-0.92) and 0.98 (0.85-0.99), respectively. The Bemelman guideline was thus a good predictor of SSRF in retrospective cohort but should be used in conjunction with clinical judgement. Further validation is indicated in a prospective study.
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Affiliation(s)
- Jessica R Dorman
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,The Medical School, University of Sheffield, Sheffield, UK
| | - Peter T M Clarke
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,The Medical School, University of Sheffield, Sheffield, UK
| | - Rosalind B Simpson
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,The Medical School, University of Sheffield, Sheffield, UK
| | - John G Edwards
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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16
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Simpson RB, Dorman JR, Hunt WJ, Edwards JG. Multiple rib fractures: A novel and prognostic CT-based classification system. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408619895683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The accepted classification for multiple rib fractures is binary: flail chest or not. There is a wide spectrum of morphology with subsequent variation in the impact on chest wall mechanics and clinical outcomes. As the practice of surgical stabilisation of rib fractures evolves, there is a need for a better taxonomy. The aim of this study was to create a data-driven radiological classification system for multiple rib fractures, prognostic of both complications and surgical stabilisation of rib fracture. Methods The radiological pattern of injury was assessed for cases undergoing surgical stabilisation of rib fracture (n = 48) over a five-year period and a consecutive sample of non-operative controls (n = 48). Every rib fracture (n = 1032) was assessed on CT scans for location, displacement and comminution. An iterative classification system was developed and tested for inter-observer agreement and outcome prediction. Results The fractures occurred in a ‘series’ (≥3 consecutive ribs at a similar location) in 72% of cases: these were more likely to be displaced (p < 0.001). Variables included in the classification were the anatomical pattern (presence, length and overlap of series) and degree of displacement. The classification was prognostic for complications (p < 0.001), discriminated for fixation (C = 0.907) and had acceptable inter-observer agreement (k = 0.50). Conclusions The Sheffield Multiple Rib Fracture Classification derived categories of short/long series, and short/long flail chest, with sub-division according to the presence of displacement. It was prognostic for clinical outcomes and of surgical fixation. It may facilitate communication, comparison of outcomes and selection for management protocols.
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Affiliation(s)
- Rosalind B Simpson
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| | - Jessica R Dorman
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| | - William J Hunt
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| | - John G Edwards
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
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17
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Xia H, Zhu D, Li J, Sun Z, Deng L, Zhu P, Zhang Y, Li X, Wang D. Current status and research progress of minimally invasive surgery for flail chest. Exp Ther Med 2019; 19:421-427. [PMID: 31885692 PMCID: PMC6913304 DOI: 10.3892/etm.2019.8264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/25/2019] [Indexed: 01/27/2023] Open
Abstract
Chest trauma accounts for ~13.5% of all traumas, and direct death from chest trauma accounts for 20–25% of all traumatic deaths. Chest trauma is the second cause of death from trauma. Frequent rib fractures, especially in patients with flail chest, often cause severe pain, chest wall softening, abnormal breathing and severe lung contusion and laceration, usually requiring thoracic surgery. In recent years, the open reduction and internal fixation treatment of rib fractures with flail chest has achieved satisfactory results, and some surgical indications have reached consensus. A number of scholars and medical centers have demonstrated the practicality and cost-effectiveness of rib fixation in flail chest, including the small incidence of pulmonary complications, the short ICU mechanical ventilation time, and the reduction of digestive tract inhibition. Open reduction and internal fixation of rib fractures involves multiple ribs. Conventional rib fractures require a large incision to achieve satisfactory exposure. Chest wall muscles, blood vessels and nerves (long thoracic and thoracodorsal nerves) are injured, resulting in a high infection rate of the incision and postoperative dysfunctions, such as limited upper limb, shoulder and back function, and long time numbness on the affected side of the chest. Therefore, the damage of muscles and nerves caused by conventional surgical methods limits the development of such surgical technique. Although the video-assisted thoracoscopic technique has become a necessary technical means for the treatment of thoracic trauma and has been applied to thoracic exploration and hemostasis, there is no report on the application of open reduction and internal fixation for rib fracture. The difficulty lies in the tightly combined bony thorax and the soft tissue of the chest wall. Therefore, experts have explored a variety of minimally invasive surgical methods for the flail chest. The current status and research progress of minimally invasive surgery for thoracic surgery are reviewed.
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Affiliation(s)
- Honggang Xia
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China.,School of Medical Engineering and Translational Medicine, Tianjin 300000, P.R. China
| | - Deqing Zhu
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Jing Li
- Teaching and Research Division, Tianjin Medical College, Tianjin 300000, P.R. China
| | - Zhongyi Sun
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Limin Deng
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Pengzhi Zhu
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Yongmin Zhang
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Xuan Li
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Dongbin Wang
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
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19
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Zhou X, Zhang D, Xie Z, Chen M, Yang Y, Liang Z, Zhang G. 3D printing and thoracoscopy assisted MIPO in treatment of long-range comminuted rib fractures, a case report. J Cardiothorac Surg 2019; 14:83. [PMID: 31036030 PMCID: PMC6489358 DOI: 10.1186/s13019-019-0892-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/01/2019] [Indexed: 11/10/2022] Open
Abstract
Background To investigate the application of 3D printing technology combined with percutaneous Minimally Invasive Plate Oseoynthesis (MIPO) and thoracoscopic techniques in the treatment of long comminuted rib fractures. Case presentation One case of multiple rib fractures with abnormal respiratory disease (including rib 3 and 4 of long comminuted fractures) due to a fall injury was selected. The 3D model of comminuted rib fracture was reconstructed and printed according to the thin-layer CT scan results. After the fracture model was restored to the normal rib anatomy, the metal plate was accurately shaped according to the 3D rib shape. Conclusions 3D printing technology combined with MIPO technology under thoracoscopy in the minimally invasive treatment of long-range comminuted rib fractures, greatly reduced the time and improved the accuracy of intraoperative fixation, reduced the difficulty of surgery, patient injury, and perfectly reconstructed the chest wall. Application of the 3D printing technique to make the rib model and pre-mold the metal plate combined the thoracoscopic MIPO technology provides less invasive and accurate individualized treatment for complex rib fractures.
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Affiliation(s)
- Xuetao Zhou
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang City, Shijiazhuang, 050000, China
| | - Dongsheng Zhang
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang City, Shijiazhuang, 050000, China.
| | - Zexin Xie
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang City, Shijiazhuang, 050000, China
| | - Menghui Chen
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang City, Shijiazhuang, 050000, China
| | - Yang Yang
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang City, Shijiazhuang, 050000, China
| | - Zheng Liang
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang City, Shijiazhuang, 050000, China
| | - Guoliang Zhang
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang City, Shijiazhuang, 050000, China
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20
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Xia H, Zhu P, Li J, Zhu D, Sun Z, Deng L, Zhang Y, Wang D. Thoracoscope combined with internal support system of chest wall in open reduction and internal fixation for multiple rib fractures. Exp Ther Med 2018; 16:4650-4654. [PMID: 30542416 PMCID: PMC6257545 DOI: 10.3892/etm.2018.6817] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/29/2018] [Indexed: 01/01/2023] Open
Abstract
This study aimed to investigate the feasibility of applying thoracoscope combined with internal support system of chest wall (ISSW) in minimally invasive internal fixation for rib fracture on patients with multiple rib fractures. A total of 84 patients undergoing open reduction and internal fixation for rib fracture from January 2017 to December 2017 in the Department of Cardiothoracic Surgery, Tianjin Hospital were selected into the study, and retrospective analyses were carried out. The clinical data, pain score, operating time, intraoperative blood loss, indwelling time of thoracic tube, total drainage volume of thoracic tube for 3 days after operation, indwelling time of wound drainage tube, total drainage volume of wound drainage tube, length of stay, hospitalization costs, postoperative complications, C-reactive protein (CRP) and pulmonary function of patients in the groups were compared. The patients were followed up for prognosis for 2–4 months via re-examination, and chest numbness at 1 month after operation was recorded. Compared with that (145.27±18.80 min) in the traditional group, the operating time in the minimally invasive group (112.20±21.40 min) was shorter (p<0.05). The total drainage volume of wound drainage tube was 145.75±61.03 ml in the minimally invasive group and 248.91±93.95 ml in the traditional group (p<0.05). In addition, the chest numbness at 1 month after operation (11.8%) in the minimally invasive group was better than that (34.00%) in the traditional group (p<0.05). Postoperative pain score, CRP and pulmonary function tests were also significantly different between the two groups (p<0.05). The results indicated that the application of thoracoscope combined with ISSW in minimally invasive internal fixation for rib fracture can effectively improve the prognosis of patients and reduce the length of stay and adverse reactions, and has high economic benefits, which is worthy of promotion and use in clinical practice.
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Affiliation(s)
- Honggang Xia
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| | - Pengzhi Zhu
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| | - Jing Li
- Department of Nursing, Tianjin Medical College, Tianjin 300222, P.R. China
| | - Deqing Zhu
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| | - Zhongyi Sun
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| | - Limin Deng
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| | - Yongmin Zhang
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| | - Dongbin Wang
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
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21
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de Campos JRM, White TW. Chest wall stabilization in trauma patients: why, when, and how? J Thorac Dis 2018; 10:S951-S962. [PMID: 29744222 DOI: 10.21037/jtd.2018.04.69] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Blunt trauma to the chest wall and rib fractures are remarkably frequent and are the basis of considerable morbidity and possible mortality. Surgical remedies for highly displaced rib fractures, especially in cases of flail chest, have been undertaken intermittently for more than 50 years. Rib-specific plating systems have started to be used in the last 10 years. These have ushered in the modern era of rib repair with chest wall stabilization (CWS) techniques that are safer, easier to perform, and more efficient. Recent consensus statements have sought to define the indications and contraindications, as well as the when, the how, and the technical details of CWS. Repair should be considered for patients who have three or more displaced rib fractures or a flail chest, whether or not mechanical ventilation is required. Additional candidates include patients who fail non-operative management irrespective of fracture pattern and those with rib fractures who need thoracic procedures for other reasons. Traditionally, unstable spine fracture and severe traumatic brain injury are definite contraindications. Pulmonary contusion's role in the decision to perform CWS remains controversial. A range of rib-specific plating systems are now commercially available.
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Affiliation(s)
| | - Thomas W White
- Trauma and Surgical Critical Care, Intermountain Medical Center, Salt Lake City, Utah, USA
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