|Year : 2019 | Volume
| Issue : 1 | Page : 10-13
Surgical rib fixation: Does increase case volume lead to improved outcomes?
Bhavik M Patel, Gary S L. Hung, Martin E Wullschleger
Division of Trauma, Gold Coast University Hospital, Southport, Queensland, Australia
|Date of Web Publication||30-Dec-2019|
Bhavik M Patel
Division of Trauma, Gold Coast University Hospital, Southport, Queensland
Source of Support: None, Conflict of Interest: None
Background: Surgical rib fixation in displaced rib fracture has been associated with positive patient outcomes in the literature. There is no data in the literature detailing the volume related outcomes in centres that offer surgical rib fixation in these patients.
Methods: A retrospective review was conducted on surgical rib fixation cases performed from 2014 to 2018, with the early phase (EP) consisting of cases performed in the 2014-2017 period and the recent phase (RP) consisting of cases performed in 2018 to date. Variables for comparison included, indication for intervention, pain outcomes, and length of stay (LOS).
Results: The five-year period yielded 37 cases. In the EP, 17 cases were performed, compared to 20 cases in the RP. The chest AIS scores were >3 for all cases with an average ISS of 21 in the EP compared to 19 in the RP. All patients underwent surgical rib fixation within 96 hours of admission. Pain was the predominant indication for intervention in the EP (65%, n = 11) compared to the RP where deformity and respiratory support (55%, n = 11) were the chief indicators. Subjective pain improvement was in favour of RP by 2.5 days. The average LOS was 546 hours days in the EP group, and 391 hours in the RP group. More anatomically difficult posterior and bilateral rib fixation cases were carried out in the RP group. Follow-up rate between the EP and RP were 75% vs 85% respectively with no hardware or pulmonary complications.
Conclusion: Preliminary data analysis from the authors' institution suggests surgical rib fixation can be conducted with minimal complication. Increased case volume might improve outcomes related to subjective pain scores, length of stay, and complexity of surgical technique.
Keywords: Rib fractures, surgical rib fixation, volume-related outcomes
|How to cite this article:|
Patel BM, L. Hung GS, Wullschleger ME. Surgical rib fixation: Does increase case volume lead to improved outcomes?. J Cardiothorac Trauma 2019;4:10-3
|How to cite this URL:|
Patel BM, L. Hung GS, Wullschleger ME. Surgical rib fixation: Does increase case volume lead to improved outcomes?. J Cardiothorac Trauma [serial online] 2019 [cited 2020 May 24];4:10-3. Available from: http://www.jctt.org/text.asp?2019/4/1/10/274211
| Introduction|| |
Rib fractures are often associated with blunt traumatic chest injuries. The number of ribs fractured and the complexity of fracture pattern are associated with an increase in morbidity and mortality., Traditionally, rib fractures are managed with focus on adequate pain control, oxygen supplementation, and early mobilization. The management of complex rib fractures by traditional means alone may be challenging as these patients will often require respiratory support in the intensive care unit setting with prolonged hospital stays during the recovery phase.
Surgical rib fixation (SRF) has been widely used to manage complex rib fractures and follow the same principle of orthopedic reduction and fixation of fractured bones with a view to stabilize the chest wall, reduce pain, and prevent delays to union.,, Adjunct interventions can also be performed in conjunction with SRF such as placement of analgesic catheters, evacuation of retained hemothorax, and exploration of other thoracic pathologies. The benefits of SRF for complex rib fractures have been widely recognized in reducing pain.
In our institution, a standardized SRF technique had been developed with adaption to previous literature. Patients for consideration have three-dimensional computed tomography reconstruction of the chest wall for operative planning. Anesthesia is administered via single lumen tube with the patient in lateral position. A minimal muscle-splitting surgical approach is used using a wound protector (ALEXIS-Applied Medical, CA, USA) with minimal rib dissection, followed by reduction and plating (MatrixRib® Fixation System, West Chester, PA, USA or Rib Loc® Rib Fracture Plating System, Acute Innovations, Hillsboro, OR, USA) depending on surgeon preference and site of the fractures. The pleural cavity is then lavaged and a curved intercostal catheter is inserted. Postoperative chest X-ray determines the need for suction on the drainage system. Paravertebral blocks are either left in situ or placed at the end of the procedure. Follow-up clinical review of the patient with plain chest X-ray films occurred at 4 weeks postdischarge from hospital for early return to basic function.,
| Subjects and Methods|| |
A retrospective chart review was conducted on cases performed from January 2014 to December 2018. Data were retrieved via the trauma registry managed by the trauma unit at Gold Coast University Hospital (GCUH).
The GCUH is a 750-bed tertiary, verified Level I Trauma Centre by the Royal Australasian College of Surgeons with approximately 300 major trauma (as defined by an Injury Severity Score 1 >12) presentations annually. Since 2014, this center has implemented a robust multidisciplinary-driven protocolized rib fracture management algorithm for patients who present with blunt chest trauma.
We included all patients who underwent SRFs irrespective of their head injury status, age, and gender. Penetrating injuries and rib fractures managed without surgical intervention were not included in this study.
Ethics approval was provided from the Internal Review Board (LNR/2018/QGC/49835).
Data were collected from the electronic medical records which included patient demographical data (age, gender), admission data (mechanism of injury, diagnosis, length of hospital and intensive care stay and ISS), operative procedures, and duration of mechanical ventilation. The pain specialist's team would monitor subjective pain scores for the duration of stay recorded utilizing a Numeric/Verbal Rating Scale. The days required for the patient to have subjective pain improvement by a drop in the pain scores of severe (10–7), moderate (6–4), mild (1–3), or none (0) were recorded.
For this study, we divided our cases into two phases, the early phase (EP) consisting of cases performed in the 2014–2017 period and the recent phase (RP) consisting of cases performed from January to December 2018. Starting as novices for this procedure, we had regular cardiothoracic subspecialty involvement in the preoperative, intraoperative, and postoperative management of these patients. As the experience with the procedure advanced, these cases were then carried out with the trauma surgeon as the primary decision maker.
Statistical analysis was performe using IBM SPSS statistics for windows (Version 23.0. Armonk, NY: IBM Corp). T-test (two sample assuming unequal variances) was conducted specifically to evaluate the differences in outcomes of the early and recent phases. Variables for comparison included the ISS, new ISS (NISS), indications for intervention, pain outcomes, ventilation times, and hospital length of stay (HLOS).
| Results|| |
Thirty-seven cases with 81% males and a mean age of 56 met the inclusion criteria. In the EP, there was 17 cases, 2014–2015 (n = 2), 2016 (n = 5), and 2017 (n = 10), compared to 20 cases in the RP. [Figure 1] depicts distribution of patients over the duration of the study.
The chest Abbreviated Injury Scale (AIS) scores were ≥3 for all cases with similarity in ISS and NISS scores between the phases. [Figure 2] demonstrates the distribution of severity of the ISS and NISS.
|Figure 2: Injury Severity Score/New Injury Severity Score groups and phase of study|
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The mean number of days for a patient to undergo SRF was 4 in the EP compared to 3.5 in the RP. Pain was the main indication for intervention, EP (65%, n = 11) and RP (55%, n = 11). However, in RP, intervention was also carried out for deformity and respiratory support (45%, n = 9).
Five patients were excluded due to severe head injury (EP n = 1, RP n = 4) as it was not possible to record pain scores 48 h either pre- or post-SRF. The mean days after SRF where patients (n = 32) described a pain improvement was 5.13 days in the EP and 2.63 days in the RP, with a difference of 2.5 days (P = 0.004).
Postoperative ventilation time in hours was compared between the two phases showing the EP group with a mean ventilation time of 84.1 h and RP of 56.5 h (P = 0.57). When excluding severe head injury of AIS ≥3, the mean ventilation hours were significantly decreased in the RP group 13.7 h compared to the EP group at 80.9 h (P = 0.007).
[Figure 3] demonstrates the length of in-hospital stay. The mean HLOS was 546 h in the EP compared to 391 h in the RP with a mean difference of 155 h (P = 0.25).
There was an increased number of posterior and bilateral rib fixation cases in the RP (n = 4) compared to the EP (n = 0).
Follow-up rate between the EP and RP was 75% versus 85%, respectively, with no hardware or pulmonary complications reported in plain films.
In the EP, there was a superficial wound infection managed nonoperatively with intravenous antibiotics. Complications in the recent phase series consisted of a postoperative bleed requiring operative intervention with intercostal catheter placement. Complications not related to the procedure in EP was pneumonia (1) and mortality due to traumatic brain injury (1), while in the RP, pneumonia (1) and a case of pulmonary embolism (1). Providing an overall complication rate of 16.2% with an overall procedure-related complication rate of 5.4%.
| Discussion|| |
At our institute, the rationale for performing SRF has changed between phases which anecdotally can be due to increased experience and confidence of surgical teams involved.
Pain is the main reason, and management of this is often a challenge for patients with complex rib fractures. Once supportive pain management options are exhausted, and pain is still ongoing, SRF is considered. The postoperative time to subjective pain improvement favored RP group by 2.5 days. The HLOS also favored the RP by 155 h. This suggests a correlation between improvement in pain and length of hospital stay.
Since the introduction of SRF at this institution in 2014, there has been a steady increase in volume to perform these cases. This could be attributed to accomplishing the learning curve of the surgical technique in the EP. As experience was gained, there was an increase in trauma surgeon confidence for taking on cases for indications other than pain. In the EP, the predominant reason to performing SRF was improving pain experienced by the group of affected patients. As time progressed with increasing volumes, the reason for SRF cases performed expanded to the other selection criteria involving improving chest wall deformity and increase in ventilator requirements. This was reflected by the case load performed for deformity and ventilation being on par with number of cases performed for pain in the RP.
The comparison of means for the ISS and NISS between the groups indicates similarity for the two cohorts. The distribution of NISS suggests that the RP group experienced increased number of significant injuries compared to the EP.
It is recommended for novice surgeons to perform the technique on anterolateral rib fractures. This was reflected in the EP group as all cases were formed on anterolateral fractures. As the experience in the surgical technique increased, there was more confidence in performing the more challenging posterior and bilateral fractures as reflected in the RP with four cases performed for the same.
The improvement in subjective pain favoring the RP group may be due to reduction in size of surgical incision and minimum muscle dissection. Another confounding factor could be the increased experience of pain specialist in managing these subsets of patients, leading to quicker subjective improvement in pain for these patients in the RP group.
Acute recovery from complex rib fractures might be measured by length of hospital stay. In identified patients who underwent SRF, the mean length of stay has shown a marked decrease in the RP. This suggests a direct correlation in terms of pain relief and length of hospital stay.
There are certain limitations of this study with the most distinct being the retrospective nature of this review of only a small cohort of patients at a single institution. The severity of associated injuries may be a confounder to the true HLOS, although attempts to minimize this confounder by eliminating severe head injury from the cohort were more favorable to our cause, with more statistical significance between mean HLOS and ventilator hours. As this may be the first review of volume-related outcomes, a prospective study at a multi-institutional approach might be beneficial in identifying more precise outcomes.
Some clinical studies are substantially smaller and often lack sufficient statistical power to detect clinically meaningful differences in operative mortality rates. Moreover, there is little evidence from these clinical studies to suggest that there are important volume-related differences in the case mix (i.e., that low-volume providers care for multiorgan failure patients). Although we cannot rule out confounders by unmeasured characteristics of the patients in our study, there is no reason to believe that such confounders would affect our analyses of hospital volume and surgeon volume disproportionately.
| Conclusion|| |
Preliminary data analysis from our institution suggests that SRF can be conducted with minimal complications. Volumes and outcomes related to subjective pain scores, ventilation hours, length of stay, and complexity of the surgical technique improved over the 5-year study period. We hope to see consistent results as case numbers increase in the following years and for fellow institutions to produce similar outcomes.
We would like to thank the Trauma Service at GCUH for their ongoing registry collection, the Cardiothoracic Surgeons involved in Surgical Rib Fixation – Dr. Andrie Stroebel and Dr. Gilbert Ford, and General Surgical Trauma Fellow – Dr. Tenzin Lamdark for his work during time of this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Witt CE, Bulger EM. Comprehensive approach to the management of the patient with multiple rib fractures: A review and introduction of a bundled rib fracture management protocol. Trauma Surg Acute Care Open 2017;2:e000064.
Chien CY, Chen YH, Han ST, Blaney GN, Huang TS, Chen KF. The number of displaced rib fractures is more predictive for complications in chest trauma patients. Scand J Trauma Resusc Emerg Med 2017;25:19.
Kane ED, Jeremitsky E, Pieracci FM, Majercik S, Doben AR. Quantifying and exploring the recent national increase in surgical stabilization of rib fractures. J Trauma Acute Care Surg 2017;83:1047-52.
de Campos JR, White TW. Chest wall stabilization in trauma patients: Why, when, and how? J Thorac Dis 2018;10:S951-62.
Pieracci FM, Majercik S, Ali-Osman F, Ang D, Doben A, Edwards JG, et al.
Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury 2017;48:307-21.
Fagevik Olsén M, Slobo M, Klarin L, Caragounis EC, Pazooki D, Granhed H, 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;24:128.
Kaplan DJ, Begly J, Tejwani N. Multiple rib nonunion: Open reduction and internal fixation and iliac crest bone graft aspirate. J Orthop Trauma 2017;31 Suppl 3:S34-5.
Pulley BR, Taylor BC, Fowler TT, Dominguez N, Trinh TQ. Utility of three-dimensional computed tomography for the surgical management of rib fractures. J Trauma Acute Care Surg 2015;78:530-4.
Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Hals EK, et al.
Assessment of pain. Br J Anaesth 2008;101:17-24.
Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the united states. N
Engl J Med 2003;349:2117-27.
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