The Journal of Cardiothoracic Trauma

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 4  |  Issue : 1  |  Page : 4--9

Current trends in the management of flail chest and the perceived role of the surgeon


J Brock Walker1, Sean M Mitchell1, Pierce Johnson1, Joshua W Hustedt1, Niloofar Dehghan2, Michael D Mckee1, Clifford B Jones2,  
1 Department of Orthopaedic Surgery, The University of Arizona College of Medicine - Phoenix, Phoenix, Arizona, USA
2 Department of Orthopaedic Surgery, The University of Arizona College of Medicine - Phoenix; The CORE Institute, Phoenix, Arizona, USA

Correspondence Address:
J Brock Walker
Department of Orthopaedic Surgery, The University of Arizona College of Medicine - Phoenix, Phoenix, Arizona
USA

Abstract

Background: Flail chest injuries typically occur in poly-traumatized patients and are often associated with prolonged hospital stays and high rates of morbidity and mortality. Despite multiple studies showing significantly improved outcomes with surgical fixation, the surgical community has been slow to adopt rib fixation as a part of practice and, as a result, many of these patients never undergo surgical fixation. Purpose: The purpose of this study is to determine the percentage of flail chest injuries that are being treated with surgical fixation in the United States. In addition, a survey of orthopedic trauma surgeons was conducted to assess their perception of the role of orthopedics in the treatment of patients with flail chest injuries. Methods: Patients diagnosed with a flail chest injury were identified using the National Inpatient Sample (NIS) database between 2001 and 2012 and divided into two groups based on whether or not surgical fixation of the chest wall was performed. In addition, we distributed a survey questionnaire to orthopedic trauma surgeons focusing on each individual's experience with rib fracture fixation both in training and practice. Results: A total of 45,202 patients with a flail chest injury were identified using the NIS database between 2001 and 2012. Of these, 2.1% underwent surgical fixation of the chest wall with an increase in rate of fixation from 0.8% to 3.3% over the study period. According to our survey, only 20% of orthopedic trauma surgeons performed any rib fracture fixation cases in training, and only 24% perform rib fracture fixation cases in their practice. Of those who do not perform rib fracture fixation, 72% would consider doing so if they received additional training on the topic. Of all participants surveyed, 60% believed that rib fracture fixation should be a part of the orthopedic residency curriculum and 89% believed that it should be a part of the orthopedic trauma fellowship curriculum. Conclusions: Very few flail chest injuries are being treated with surgical fixation despite the emerging literature showing improved outcomes when compared to nonoperative management. Our survey shows that there is significant interest in incorporating rib fracture fixation into surgeons' training curriculum, as well as providing specialized workshops for practicing surgeons. We hope this work encourages the surgical community to embrace rib fracture fixation as a part of our specialty so that patients with flail chest injuries receive optimal care.



How to cite this article:
Walker J B, Mitchell SM, Johnson P, Hustedt JW, Dehghan N, Mckee MD, Jones CB. Current trends in the management of flail chest and the perceived role of the surgeon.J Cardiothorac Trauma 2019;4:4-9


How to cite this URL:
Walker J B, Mitchell SM, Johnson P, Hustedt JW, Dehghan N, Mckee MD, Jones CB. Current trends in the management of flail chest and the perceived role of the surgeon. J Cardiothorac Trauma [serial online] 2019 [cited 2020 Dec 1 ];4:4-9
Available from: https://www.jctt.org/text.asp?2019/4/1/4/274206


Full Text



 Introduction



Flail chest injuries are defined as three or more consecutive, segmental rib fractures.[1],[2] This injury pattern creates a free segment of the chest wall that moves independently from the intact ribs. This, in combination with the underlying pulmonary contusion, creates significant aberrations in the respiratory cycle in an often critically ill polytrauma patient. Historically, the vast majority of these injuries have been treated nonoperatively with the use of positive pressure ventilation, pain medications, epidural analgesia, and pulmonary hygiene.[1],[2],[3],[4]

Even with optimal nonoperative treatment protocols, flail chest injuries have been associated with significant morbidity including high rates of pneumonia, sepsis, acute respiratory distress syndrome, prolonged ventilator dependency potentially leading to tracheostomy, and prolonged stay in the intensive care unit (ICU). In addition, flail chest injuries are associated with mortality rates of up to 33%.[2],[4]

Three randomized controlled trials and numerous retrospective studies have been published in recent years demonstrating improved outcomes in patients with flail chest injuries who are treated with surgical fixation of the chest wall.[3],[5],[6],[7],[8],[9],[10],[11],[12]

Despite emerging evidence showing improved outcomes with surgical fixation in patients with flail chest injury, the majority of these patients are treated nonsurgically. In a study from Canada in 2018, Dehghan et al. found that surgical fixation of the chest wall was performed in only 4.5% of patients diagnosed with flail chest injury.[10]

The purpose of this study is to determine the percentage of flail chest injuries that are being treated with surgical fixation nationwide in the United States. In addition, with the use of a survey, we evaluated orthopedic surgeons' perceptions with regard to the role of orthopedics in treating patients with flail chest injuries. Our hypothesis was that the rate of fixation of flail chest injuries would be low (<10%), and that hospital culture and lack of familiarity with rib fixation among orthopedic surgeons would be the driving factor for the low rate of fixation.

 Methods



To determine the percentage of flail chest injuries that were treated with surgical fixation, we utilized the National Inpatient Sample (NIS) database,[13] which is administered by the Agency for Healthcare Research and Quality. The NIS database randomly selects 20% of discharges from participating hospitals across the United States to be included in its dataset, making it an ideal database for determining nationwide trends.[14]

Patients with flail chest injuries were identified using the International Classification of Disease (ICD) code 807.4 (45,202 patients) between 2001 and 2012. The procedures underwent by these patients were evaluated and in an effort to err on the side of overestimating the incidence of surgical fixation, patients billed for any procedural code that may have referred to surgical fixation of the chest wall were included in the surgical group. This included ICD procedural codes 78.40, 78.41, 78.49, 78.50, 78.51, 78.59, 79.10, 79.19, 79.30, 79.39, 79.90, and 79.99, with the vast majority being reported as code 79.39.

To evaluate surgeons' perceptions with regard to the role of orthopedics in treating patients with flail chest injuries, a 10-question survey was created. This survey was hosted by the Orthopaedic Trauma Association (OTA) website and distributed to active members via E-mail. The survey focused on each respondent's training in rib fixation; case load; hospital culture surrounding flail chest management; and opinion of whether additional training should be available to residents, fellows, and practicing orthopedic surgeons.

 Results



A total of 45,202 patients were identified as having been diagnosed with flail chest using the NIS database between 2001 and 2012.[13] Of these, only 966 (2.1%) underwent surgical fixation. When analyzed by year, there was a steady increase in patients undergoing surgical fixation from 0.8% in 2001 to 3.3% in 2012, corresponding to a 400% increase over the study period (P< 0.00001). These results are summarized in [Figure 1].{Figure 1}

Forty-five members of the OTA completed the survey, and 94% of the respondents had completed a trauma fellowship. The year in which residency was completed among respondents ranged from 1986 to 2016. Only 20% of the participants had performed any rib fracture fixation cases during their residency or fellowship training, and only 22% are currently performing rib fracture fixation in their practice. In a “check all that apply-” type question, the most common reason cited for not performing rib fracture fixation was that other specialties are consulted to care for these patients (77%). Other reasons cited were lack of training in rib fixation (31%), lack of interest in performing the procedure (14%), the opinion that surgery is rarely indicated (11%), or having a colleague available who performs rib fixation (9%). These results are summarized in [Figure 2].{Figure 2}

Only 10% of the respondents had received any training in rib fracture fixation after fellowship. This included four participants who had attended specialized courses and one who had performed dual-surgeon cases with an orthopedic mentor. Among those who do not perform rib fixation, 72% stated that they would consider making it a part of their practice if they received additional training [Figure 3]. In addition, 60% of the respondents believed that rib fracture fixation should be a part of the orthopedic curriculum, and 89% believed that it should be a part of the orthopedic trauma fellowship curriculum [Figure 4].{Figure 3}{Figure 4}

 Discussion



Even with optimal nonoperative management, flail chest injuries are associated with significant morbidity and mortality. To address this, several authors have studied whether or not surgical fixation of the chest wall improves outcomes in patients with flail chest injuries.

In 2002, Tanaka et al. performed a randomized controlled trial comparing surgical fixation with Judet struts to nonoperative management in 37 patients. All patients received identical respiratory and intensive care management including epidural analgesia. This study found that surgical stabilization leads to improvements in the length of ICU stay (17 vs. 27 days), ventilatory period (11 vs. 18 days), and rate of pneumonia (24% vs. 77%). In addition, patient's percent forced vital capacity was higher at 1 month in the surgical group, and this difference persisted up to 1 year after injury. Finally, the percentage of patients who had returned to work was significantly higher in the surgical group 6 months after injury (61% vs. 5%).[5]

In 2005, Granetzny et al. published a prospective trial of forty patients who were randomized to either surgical or nonoperative management of a flail chest injury. Similarly, this study found that surgery was associated with improvements in the length of ICU stay (10 vs. 15 days), ventilatory period (2 vs. 12 days), and incidence of chest wall deformity (5% vs. 45%). This study also found improvements in pulmonary function testing in the surgical group at 2-month follow-up.[6]

In 2013, Marasco et al. reported a prospective, randomized controlled trial of 46 patients randomized to surgical or nonoperative management. This study found that surgery was associated with improvements in the length of ICU stay (14 vs. 19 days), duration of noninvasive ventilation after extubation (22 vs. 67 h), rates of tracheostomy (39% vs. 70%), and rates of pneumonia (48% vs. 74%). This study also evaluated the cost difference between the two groups, estimating that surgery was associated with an estimated cost savings of $14,443/patient.[7]

While these three randomized controlled trials are the highest quality evidence available pertaining to the management of flail chest injuries, they have been criticized for the use of outdated fixation modalities (Judet struts, Kirschner wires, and absorbable plates), poor inclusion criteria, and small sample sizes.

In 2013, Slobogean et al. published a meta-analysis evaluating the outcomes of surgical versus nonsurgical management of patients with flail chest injuries. This study analyzed 11 manuscripts with a total of 753 patients. The pooled data showed that surgery significantly improved the number of days spent on a ventilator (mean difference of 8 days) and days spent in the ICU (mean difference of 5 days). Surgery was also associated with a decreased risk of pneumonia (odds ratio [OR] = 0.2), septicemia (OR = 0.36), tracheostomy (OR = 0.06), and mortality (OR = 0.31).[15]

In 2019, Walters et al. published a retrospective study of 56 patients treated operatively compared with a matched, historical cohort of 89 nonoperative cases. Matching was performed for both Injury Severity Score and patient demographics. Their study found an improvement in 30-day mortality (1.8% vs. 12.4%) with surgical fixation. There was no difference in quality of life or any patient-reported measures at final follow-up. Length of stay was longer in the operative group (32.2 vs. 13.0 days), as was ICU length of stay (11.6 vs. 4.9 days).

Furthermore, in 2019, Gerakopoulos et al. published a similar retrospective study of 47 patients treated operatively compared with an unmatched, historical cohort of 36 nonoperative cases. Their study also found a lower mortality rate associated with the surgical fixation group (2.1% vs. 13.9%). Length of stay was reduced in the operative group (30.4 vs. 14.5 days).

Despite the emerging evidence showing improved outcomes, most notably mortality, with surgical fixation, there are numerous limitations to the available literature. Most of the available studies are published by proponents of rib fixation with poor methodology and small sample sizes. As such, questions still remain regarding the indications for surgery, the influence of concomitant injuries, the optimal timing of surgery, the number of ribs to fix, and fixation method. To address the limitations of the prior studies and some of the remaining questions, there are two large, multicentric, prospective, randomized controlled trials currently enrolling patients in North America.

Despite the available literature showing improvements in outcomes with surgical stabilization of the chest wall, the medical community has been slow to adopt surgical fixation as an integral part of the care for these patients. Our study shows that 2.1% of flail chest injuries between 2001 and 2012 were treated with surgical fixation, and that while this percentage increased over the study period, the percentage undergoing surgery was still only 3.3% at its conclusion.

The reason for the low percentage of fixation is likely multifactorial. These patients are typically polytrauma patients who are initially evaluated by the general surgery trauma team. Based on their training, experience, and the patient's associated injuries, it is typically up to their discretion as to which other specialties, if any, are consulted for the management of the flail chest injury. Thus, the treatment of the flail chest injury may be at the discretion of the general surgery trauma team or a consulting team, typically either orthopedic or cardiothoracic surgery. Accordingly, differences in hospital culture largely dictate which specialties are involved in the care of these patients. Once it is determined which team is managing the flail chest injury, whether or not the patient undergoes surgical fixation of the chest wall is typically dictated by that surgeon's training, experience, and interpretation of the literature along with the patient's overall clinical status and associated injuries.

In the second part of this study, we developed a survey to evaluate orthopedic traumatologists' perceptions regarding surgical fixation of flail chest injuries. We found that only 20% of the respondents had participated in any rib fixation cases during residency or fellowship and that only 10% had received any training in rib fixation while in practice. Notably, 60% of the respondents believed that rib fixation should be a part of the orthopedic residency curriculum, and 89% reported that it should be a part of the orthopedic trauma fellowship curriculum. Among practicing orthopedic surgeons that do not perform rib fixation, 72% stated that they would consider doing so if they received additional training. Given the robust interest among practicing surgeons, we urge the surgical community to embrace rib fixation as a part of the educational programs by incorporating it into the training curriculum and by providing specialized courses for practicing surgeons.

Among respondents that do not perform rib fixation as a part of their practice, the most commonly cited reason was that other services are consulted to manage patients with flail chest injuries. Thus, we recommend that each hospital system should evaluate its current practice patterns and management of patients with flail chest injuries. As a part of this management, each patient should receive consultation by a surgeon who is familiar with the literature and the indications for surgery and is adept at performing surgical fixation of the chest wall. While this may require additional education and training, it will ensure that patients with flail chest injuries are receiving optimal care based on the current literature.

 Conclusions



Despite emerging literature showing improved outcomes with surgical stabilization of flail chest injuries, very few patients undergo surgery. This study demonstrated that there is robust interest among practicing orthopedic trauma surgeons in embracing rib fracture fixation as a part of the surgical community. To do this, rib fixation should be integrated into the surgical curriculum and specialized courses should be provided for practicing surgeons.

Acknowledgments

We would like to thank the OTA for hosting our survey questionnaire, for distributing it to members via E-mail, and for posting it on the OTA website. We also thank all of those who responded to our survey.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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