Surgical and traditional methods for the treatment of multiple rib fractures: A systematic review and meta-analysis of randomized controlled trials_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

 ZHANG Hao ^1,2 , FENG Ting ³ , PEI Zhijie ² , GUO Zhitao ¹ , GUAN Wanpeng ¹

1. Trauma Treatment Center, Tianjin Xiqing Hospital, Tianjin, 300380, P.R.China;
2. Department of Thoracic Surgery, Tianjin Xiqing Hospital, Tianjin, 300380, P.R.China;
3. Medical Imaging Center, Tianjin Xiqing Hospital, Tianjin, 300380, P.R.China;

Corresponding author：

ZHANG Hao, Email: ctjd_zh@126.com

Keywords：

Rib fractures; surgery; traditional treatment; systematic review; meta-analysis

DOI：

10.7507/1007-4848.201907076

Video：

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Objective To evaluate the effect of surgical and traditional treatments for multiple rib fractures through systematic review and meta-analysis.Methods CNKI, Wanfang, VIP, PubMed, OVID, EMbase, The Cochrane Library, Thieme and Springer Link database for information from inception to July 2019 were screened by computer. Randomized controlled trials (RCTs) of surgical and conventional methods for the treatment of multiple rib fractures were screened, assessed and extracted. RevMan 5.3 software was used for meta-analysis.Results Twelve studies were included, including 1 039 patients. There were 512 patients in the operation group and 527 patients in the traditional treatment group. The results of meta-analysis showed that there was a significant difference between the two groups in the incidence of pneumonia (RR=0.41, 99%CI 0.29 to 0.58, P<0.000 01), incidence of atelectasis (RR=0.24, 99%CI 0.06 to 0.94, P=0.007), duration of mechanical ventilation (SMD=–2.64, 99%CI –4.38 to –0.91, P<0.000 1), duration of intensive care unit stay (SMD=–1.33, 99%CI –2.26 to –0.40, P=0.000 2), duration of hospital stay (SMD=–2.25, 99%CI –3.30 to –1.19, P<0.000 01)and incidence of chest wall deformity (RR=0.08, 99%CI 0.04 to 0.17, P<0.000 01). There was no significant difference between the two groups in the hospital mortality (RR=0.75, 99%CI 0.23 to 2.46, P=0.53), incidence of tracheostomy (RR= 0.69, 99%CI 0.39 to 1.21, P=0.09), ventilator support rate (RR=0.65, 99%CI 0.41 to 1.05, P=0.02) and chest drainage time (SMD=–2.58, 99%CI –6.41 to 1.25, P=0.08).Conclusion Surgical treatment of multiple rib fractures can reduce pulmonary complications, shorten hospital stay, and reduce the incidence of chest wall deformity, which is conducive to rapid recovery and improves quality of life.

Citation： ZHANG Hao, FENG Ting, PEI Zhijie, GUO Zhitao, GUAN Wanpeng. Surgical and traditional methods for the treatment of multiple rib fractures: A systematic review and meta-analysis of randomized controlled trials. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2020, 27(5): 558-568. doi: 10.7507/1007-4848.201907076 Copy

1.	Ten Duis K, IJpma FF. Surgical treatment of snapping scapula syndrome due to malunion of rib fractures. Ann Thorac Surg, 2017, 103(2): e143-e144.
2.	Marasco S, Lee G, Summerhayes R, et al. Quality of life after major trauma with multiple rib fractures. Injury, 2015, 46(1): 61-65.
3.	Lafferty PM, Anavian J, Will RE, et al. Operative treatment of chest wall injuries: indications, technique, and outcomes. J Bone Joint Surg Am, 2011, 93(1): 97-110.
4.	Veysi VT, Nikolaou VS, Paliobeis C, et al. Prevalence of chest trauma, associated injuries and mortality: a level Ⅰ trauma centre experience. Int Orthop, 2009, 33(5): 1425-1433.
5.	Jayle CP, Allain G, Ingrand P, et al. Flail chest in polytraumatized patients: surgical fixation using Stracos reduces ventilator time and hospital stay. Biomed Res Int, 2015, 624723.
6.	Vana PG, Neubauer DC, Luchette FA. Contemporary management of flail chest. Am Surg, 2014, 80(6): 527-535.
7.	Velasquez M, Ordoñez CA, Parra MW, et al. Operative versus nonoperative management of multiple rib fractures. Am Surg, 2016, 82(5): e103-e105.
8.	Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what is the benefit? J Am Coll Surg, 2012, 215(2): 201-205.
9.	Schulte K, Whitaker D, Attia R. In patients with acute flail chest does surgical rib fixation improve outcomes in terms of morbidity and mortality? Interact Cardiovasc Thorac Surg, 2016, 23(2): 314-319.
10.	Girsowicz E, Falcoz PE, Santelmo N, et al. Does surgical stabilization improve outcomes in patients with isolated multiple distracted and painful non-flail rib fractures? Interact Cardiovasc Thorac Surg, 2012, 14(3): 312-315.
11.	Pieracci FM, Lin Y, Rodil M, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg, 2016, 80(2): 187-194.
12.	Majercik S, Vijayakumar S, Olsen G, et al. Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema. Am J Surg, 2015, 210(6): 1112-1117.
13.	Majak P, Næss PA. Rib fractures in trauma patients: does operative fixation improve outcome? Curr Opin Crit Care, 2016, 22(6): 572-577.
14.	DeFreest L, Tafen M, Bhakta A, et al. Open reduction and internal fixation of rib fractures in polytrauma patients with flail chest. Am J Surg, 2016, 211(4): 761-767.
15.	Swart E, Laratta J, Slobogean G, et al. Operative treatment of rib fractures in flail chest injuries: a meta-analysis and cost-effectiveness analysis. J Orthop Trauma, 2017, 31(2): 64-70.
16.	Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review. Eur J Trauma Emerg Surg, 2017, 43(2): 163-168.
17.	Liang YS, Yu KC, Wong CS, et al. Does surgery reduce the risk of complications among patients with multiple rib fractures? A meta-analysis. Clin Orthop Relat Res, 2019, 477(1): 193-205.
18.	Ingoe HM, Coleman E, Eardley W, et al. Systematic review of systematic reviews for effectiveness of internal fixation for flail chest and rib fractures in adults. BMJ Open, 2019, 9(4): e023444.
19.	宋锐强, 邓彦超, 王志鹏, 等. 保守治疗与切开复位内固定术治疗多发肋骨骨折疗效的系统评价. 中国循证医学杂志, 2018, 18(12): 1329-1336.
20.	曹伯雄, 李琴, 卢明水, 等. 切开复位内固定术与非手术治疗多发肋骨骨折疗效的 Meta 分析. 中华创伤杂志, 2017, 33(3): 275-280.
21.	Jørgensen L, Paludan-Müller AS, Laursen DR, et al. Evaluation of the Cochrane tool for assessing risk of bias in randomized clinical trials: overview of published comments and analysis of user practice in Cochrane and non-Cochrane reviews. Syst Rev, 2016, 5: 80.
22.	Granetzny A, Abd El-Aal M, Emam E, et al. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg, 2005, 4(6): 583-587.
23.	Liu T, Liu P, Chen J, et al. A randomized controlled trial of surgical rib fixation in polytrauma patients with flail chest. J Surg Res, 2019, 242: 223-230.
24.	Marasco SF, Davies AR, Cooper J, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg, 2013, 216(5): 924-32.
25.	Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma, 2002, 52(4): 727-732.
26.	Wu WM, Yang Y, Gao ZL, et al. Which is better to multiple rib fractures, surgical treatment or conservative treatment? Int J Clin Exp Med, 2015, 8(5): 7930-7936.
27.	岑小波, 刘浩, 陈光明, 等. TiNi 环抱式接骨器内固定治疗多发性肋骨骨折. 中国胸心血管外科临床杂志, 2013, 20(4): 476-478.
28.	张子腾, 艾仕文, 胡志亮, 等. 肋骨骨折切开复位内固定术与保守治疗在重症胸外伤治疗中的临床效果比较. 医学综述, 2016, 22(6): 1198-1200.
29.	李彦玉, 刘斌, 王四海. 多发性肋骨骨折内固定术与保守治疗的成本-效果分析. 医学综述, 2014, 20(17): 3224-3226.
30.	熊健, 王长涛, 吴蕾, 等. 疼痛和动脉血二氧化碳分压作为肋骨骨折患者手术指征的临床分析. 中国胸心血管外科临床杂志, 2011, 18(5): 474-475.
31.	王立, 古丽尼格尔·吐尔逊, 康迪, 等. 内固定手术治疗多发性肋骨骨折的疗效与安全性的随机对照试验. 中国胸心血管外科临床杂志, 2014, 21(2): 228-232.
32.	胡为才, 邵换璋, 张全, 等. 胸腔镜辅助下形状记忆肋骨环抱接骨板内固定治疗多发性肋骨骨折的临床研究. 创伤外科杂志, 2018, 20(2): 88-91.
33.	陈勇杰, 张德锋, 易宏, 等. 损伤控制性肋骨接骨板手术在创伤性连枷胸中的应用价值. 中华全科医学, 2016, 14(10): 1657-1659.
34.	Topcu I, Ekici Z, Sakarya M. Comparison of clinical effectiveness of thoracic epidural and intravenous patient-controlled analgesia for the treatment of rib fractures pain in intensive care unit. Ulus Travma Acil Cerrahi Derg, 2007, 13(3): 205-210.
35.	Dehghan N, De Mestral C, Mckee MD, et al. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg, 2014, 76(2): 462-468.
36.	Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma, 2003, 54(3): 615-625.
37.	Brasel KJ, Guse CE, Layde P, et al. Rib fractures: relationship with pneumonia and mortality. Crit Care Med, 2006, 34(6): 1642-1646.
38.	Fagevik Olsén M, Slobo M, Klarin L, et al. Physical function and pain after surgical or conservative management of multiple rib fractures-a follow-up study. Scand J Trauma Resusc Emerg Med, 2016, 24(1): 128.
39.	乔贵宾, 陈刚. 创伤性肋骨骨折的处理: 广东胸外科行业共识 (2017 年版). 中国胸心血管外科临床杂志, 2018, 25(5): 362-367.
40.	Brasel KJ, Moore EE, Albrecht RA, et al. Western Trauma Association Critical Decisions in Trauma: Management of rib fractures. J Trauma Acute Care Surg, 2017, 82(1): 200-203.
41.	Kasotakis G, Hasenboehler EA, Streib EW, et al. Operative fixation of rib fractures after blunt trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg, 2017, 82(3): 618-626.
42.	Dumans-Nizard V, Guezennec J, Parquin F, et al. Feasibility and results of a fast-track protocol in thoracic surgery. Minerva Anestesiol, 2016, 82(1): 15-21.
43.	Loop T. Fast track in thoracic surgery and anaesthesia: update of concepts. Curr Opin Anaesthesiol, 2016, 29(1): 20-25.

1. Ten Duis K, IJpma FF. Surgical treatment of snapping scapula syndrome due to malunion of rib fractures. Ann Thorac Surg, 2017, 103(2): e143-e144.
2. Marasco S, Lee G, Summerhayes R, et al. Quality of life after major trauma with multiple rib fractures. Injury, 2015, 46(1): 61-65.
3. Lafferty PM, Anavian J, Will RE, et al. Operative treatment of chest wall injuries: indications, technique, and outcomes. J Bone Joint Surg Am, 2011, 93(1): 97-110.
4. Veysi VT, Nikolaou VS, Paliobeis C, et al. Prevalence of chest trauma, associated injuries and mortality: a level Ⅰ trauma centre experience. Int Orthop, 2009, 33(5): 1425-1433.
5. Jayle CP, Allain G, Ingrand P, et al. Flail chest in polytraumatized patients: surgical fixation using Stracos reduces ventilator time and hospital stay. Biomed Res Int, 2015, 624723.
6. Vana PG, Neubauer DC, Luchette FA. Contemporary management of flail chest. Am Surg, 2014, 80(6): 527-535.
7. Velasquez M, Ordoñez CA, Parra MW, et al. Operative versus nonoperative management of multiple rib fractures. Am Surg, 2016, 82(5): e103-e105.
8. Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what is the benefit? J Am Coll Surg, 2012, 215(2): 201-205.
9. Schulte K, Whitaker D, Attia R. In patients with acute flail chest does surgical rib fixation improve outcomes in terms of morbidity and mortality? Interact Cardiovasc Thorac Surg, 2016, 23(2): 314-319.
10. Girsowicz E, Falcoz PE, Santelmo N, et al. Does surgical stabilization improve outcomes in patients with isolated multiple distracted and painful non-flail rib fractures? Interact Cardiovasc Thorac Surg, 2012, 14(3): 312-315.
11. Pieracci FM, Lin Y, Rodil M, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg, 2016, 80(2): 187-194.
12. Majercik S, Vijayakumar S, Olsen G, et al. Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema. Am J Surg, 2015, 210(6): 1112-1117.
13. Majak P, Næss PA. Rib fractures in trauma patients: does operative fixation improve outcome? Curr Opin Crit Care, 2016, 22(6): 572-577.
14. DeFreest L, Tafen M, Bhakta A, et al. Open reduction and internal fixation of rib fractures in polytrauma patients with flail chest. Am J Surg, 2016, 211(4): 761-767.
15. Swart E, Laratta J, Slobogean G, et al. Operative treatment of rib fractures in flail chest injuries: a meta-analysis and cost-effectiveness analysis. J Orthop Trauma, 2017, 31(2): 64-70.
16. Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review. Eur J Trauma Emerg Surg, 2017, 43(2): 163-168.
17. Liang YS, Yu KC, Wong CS, et al. Does surgery reduce the risk of complications among patients with multiple rib fractures? A meta-analysis. Clin Orthop Relat Res, 2019, 477(1): 193-205.
18. Ingoe HM, Coleman E, Eardley W, et al. Systematic review of systematic reviews for effectiveness of internal fixation for flail chest and rib fractures in adults. BMJ Open, 2019, 9(4): e023444.
19. 宋锐强, 邓彦超, 王志鹏, 等. 保守治疗与切开复位内固定术治疗多发肋骨骨折疗效的系统评价. 中国循证医学杂志, 2018, 18(12): 1329-1336.
20. 曹伯雄, 李琴, 卢明水, 等. 切开复位内固定术与非手术治疗多发肋骨骨折疗效的 Meta 分析. 中华创伤杂志, 2017, 33(3): 275-280.
21. Jørgensen L, Paludan-Müller AS, Laursen DR, et al. Evaluation of the Cochrane tool for assessing risk of bias in randomized clinical trials: overview of published comments and analysis of user practice in Cochrane and non-Cochrane reviews. Syst Rev, 2016, 5: 80.
22. Granetzny A, Abd El-Aal M, Emam E, et al. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg, 2005, 4(6): 583-587.
23. Liu T, Liu P, Chen J, et al. A randomized controlled trial of surgical rib fixation in polytrauma patients with flail chest. J Surg Res, 2019, 242: 223-230.
24. Marasco SF, Davies AR, Cooper J, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg, 2013, 216(5): 924-32.
25. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma, 2002, 52(4): 727-732.
26. Wu WM, Yang Y, Gao ZL, et al. Which is better to multiple rib fractures, surgical treatment or conservative treatment? Int J Clin Exp Med, 2015, 8(5): 7930-7936.
27. 岑小波, 刘浩, 陈光明, 等. TiNi 环抱式接骨器内固定治疗多发性肋骨骨折. 中国胸心血管外科临床杂志, 2013, 20(4): 476-478.
28. 张子腾, 艾仕文, 胡志亮, 等. 肋骨骨折切开复位内固定术与保守治疗在重症胸外伤治疗中的临床效果比较. 医学综述, 2016, 22(6): 1198-1200.
29. 李彦玉, 刘斌, 王四海. 多发性肋骨骨折内固定术与保守治疗的成本-效果分析. 医学综述, 2014, 20(17): 3224-3226.
30. 熊健, 王长涛, 吴蕾, 等. 疼痛和动脉血二氧化碳分压作为肋骨骨折患者手术指征的临床分析. 中国胸心血管外科临床杂志, 2011, 18(5): 474-475.
31. 王立, 古丽尼格尔·吐尔逊, 康迪, 等. 内固定手术治疗多发性肋骨骨折的疗效与安全性的随机对照试验. 中国胸心血管外科临床杂志, 2014, 21(2): 228-232.
32. 胡为才, 邵换璋, 张全, 等. 胸腔镜辅助下形状记忆肋骨环抱接骨板内固定治疗多发性肋骨骨折的临床研究. 创伤外科杂志, 2018, 20(2): 88-91.
33. 陈勇杰, 张德锋, 易宏, 等. 损伤控制性肋骨接骨板手术在创伤性连枷胸中的应用价值. 中华全科医学, 2016, 14(10): 1657-1659.
34. Topcu I, Ekici Z, Sakarya M. Comparison of clinical effectiveness of thoracic epidural and intravenous patient-controlled analgesia for the treatment of rib fractures pain in intensive care unit. Ulus Travma Acil Cerrahi Derg, 2007, 13(3): 205-210.
35. Dehghan N, De Mestral C, Mckee MD, et al. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg, 2014, 76(2): 462-468.
36. Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma, 2003, 54(3): 615-625.
37. Brasel KJ, Guse CE, Layde P, et al. Rib fractures: relationship with pneumonia and mortality. Crit Care Med, 2006, 34(6): 1642-1646.
38. Fagevik Olsén M, Slobo M, Klarin L, et al. Physical function and pain after surgical or conservative management of multiple rib fractures-a follow-up study. Scand J Trauma Resusc Emerg Med, 2016, 24(1): 128.
39. 乔贵宾, 陈刚. 创伤性肋骨骨折的处理: 广东胸外科行业共识 (2017 年版). 中国胸心血管外科临床杂志, 2018, 25(5): 362-367.
40. Brasel KJ, Moore EE, Albrecht RA, et al. Western Trauma Association Critical Decisions in Trauma: Management of rib fractures. J Trauma Acute Care Surg, 2017, 82(1): 200-203.
41. Kasotakis G, Hasenboehler EA, Streib EW, et al. Operative fixation of rib fractures after blunt trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg, 2017, 82(3): 618-626.
42. Dumans-Nizard V, Guezennec J, Parquin F, et al. Feasibility and results of a fast-track protocol in thoracic surgery. Minerva Anestesiol, 2016, 82(1): 15-21.
43. Loop T. Fast track in thoracic surgery and anaesthesia: update of concepts. Curr Opin Anaesthesiol, 2016, 29(1): 20-25.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Surgical and traditional methods for the treatment of multiple rib fractures: A systematic review and meta-analysis of randomized controlled trials

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