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Meta-Analysis
. 2013 Dec;258(6):914-21.
doi: 10.1097/SLA.0b013e3182895bb0.

Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis

Jennifer A Leinicke  1 , Leisha Elmore, Bradley D Freeman, Graham A Colditz
Affiliations
Meta-Analysis

Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis

Jennifer A Leinicke et al. Ann Surg. 2013 Dec.

Abstract

Objective: To perform a systematic review and meta-analysis of studies comparing operative to nonoperative therapy in adult FC patients. Outcomes were duration of mechanical ventilation (DMV), intensive care unit length of stay (ICULOS), hospital length of stay (HLOS), mortality, incidence of pneumonia, and tracheostomy.

Background: Flail chest (FC) results in paradoxical chest wall movement, altered respiratory mechanics, and frequent respiratory failure. Despite advances in ventilatory management, FC remains associated with significant morbidity and mortality. Operative fixation of the flail segment has been advocated as an adjunct to supportive care, but no definitive clinical trial exists to delineate the role of surgery.

Methods: A comprehensive search of 5 electronic databases was performed to identify randomized controlled trials and observational studies (cohort or case-control). Pooled effect size (ES) or relative risk (RR) was calculated using a fixed or random effects model, as appropriate.

Results: Nine studies with a total of 538 patients met inclusion criteria. Compared with control treatment, operative management of FC was associated with shorter DMV [pooled ES: -4.52 days; 95% confidence interval (CI): -5.54 to -3.50], ICULOS (-3.40 days; 95% CI: -6.01 to -0.79), HLOS (-3.82 days; 95% CI: -7.12 to -0.54), and decreased mortality (pooled RR: 0.44; 95% CI: 0.28-0.69), pneumonia (0.45; 95% CI: 0.30-0.69), and tracheostomy (0.25; 95% CI: 0.13-0.47).

Conclusions: As compared with nonoperative therapy, operative fixation of FC is associated with reductions in DMV, LOS, mortality, and complications associated with prolonged MV. These findings support the need for an adequately powered clinical study to further define the role of this intervention.

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Figures

Figure 1
Figure 1
Flow diagram of study selection for meta-analysis.
Figure 2
Figure 2
Forest plot of the pooled effect size (ES) in days for the outcome duration of mechanical ventilation (DMV). Pooled ES is −4.52 days; 95% confidence interval −5.54, −3.50. χ2 for heterogeneity=13.62, p=0.058, I2=48.6.
Figure 3
Figure 3
Forest plot of the pooled effect size (ES) in days for the outcome ICU length of stay (ICULOS). Pooled ES is −3.4 days; 95% confidence interval −6.01, −0.80. χ2 for heterogeneity=15.96, p=0.003; I2=74.9.
Figure 4
Figure 4
Forest plot of the pooled effect size (ES) in days for the outcome hospital length of stay (HLOS). Pooled ES is −3.83 days, 95% confidence interval −7.12, −0.54. χ2 for heterogeneity=12.87, p=0.012; I2=68.9.
Figure 5
Figure 5
Random effects regression model of the impact of total quality score on hospital length of stay (HLOS). Residual I2 after adjusting for total quality score=20.98
Figure 6
Figure 6
Forest plot of the pooled relative risk (RR) for the outcome of mortality. Pooled RR is 0.43, 95% confidence interval 0.28-0.69. χ2 for heterogeneity=0.85, p=0.932; I2=0.
Figure 7
Figure 7
Forest plot of the pooled relative risk (RR) for the outcome of pneumonia. Pooled RR is 0.45, 95% confidence interval 0.29-0.67. χ2 for heterogeneity=5.79, p=0.215; I2=31.
Figure 8
Figure 8
Forest plot of the pooled relative risk (RR) for the outcome of tracheostomy. Pooled RR is 0.25, 95% confidence interval 0.13-0.47. χ2 for heterogeneity=1.05, p=0.789; I2=0.
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