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Meta-Analysis
. 2024 Mar 19;19(1):11.
doi: 10.1186/s13017-024-00540-z.

A meta-analysis and trial sequential analysis of randomised controlled trials comparing nonoperative and operative management of chest trauma with multiple rib fractures

Ryo Hisamune  1 , Mako Kobayashi  2 , Karin Nakasato  2 , Taiga Yamazaki  2 , Noritaka Ushio  1 , Katsunori Mochizuki  1 , Akira Takasu  1 , Kazuma Yamakawa  3
Affiliations
Meta-Analysis

A meta-analysis and trial sequential analysis of randomised controlled trials comparing nonoperative and operative management of chest trauma with multiple rib fractures

Ryo Hisamune et al. World J Emerg Surg. .

Abstract

Background: Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures.

Methods: A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research.

Results: From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P < 0.00001, I2 = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I2 = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I2 = 57%) was significantly lower. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment. GRADE showed this meta-analysis to have very low to low confidence.

Conclusion: Meta-analysis of large-scale trials showed that surgical stabilization of multiple rib fractures shortened the duration of mechanical ventilation and reduced the incidence of pneumonia but lacked clear evidence for improvement of mortality compared to conservative treatment. Trial sequential analysis suggested the need for more cases, and GRADE highlighted low certainty, emphasizing the necessity for further targeted RCTs, especially in mechanically ventilated patients.

Systematic review registration: UMIN Clinical Trials Registry UMIN000049365.

Keywords: Chest trauma; Flail chest; Fracture stabilization; Rib fractures; Surgery fixation; Thoracic injury.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
PRISMA flow chart of study screening and selection. The search strategy in MEDLINE, Scopus, and Cochrane Central Registry of Controlled study yielded 580 studies. We reviewed 20 studies for inclusion and exclusion criteria and finally included 9 studies in the meta-analysis
Fig. 2
Fig. 2
Forest plot of studies for operative vs non-operative management. Forest plots of studies examining A mortality, B the incidence of pneumonia, C the need for tracheostomy, D the duration of echanical ventilation, E the length of ICU stay, and F the length of hospital stay for operative vs non-operative management. M-H, Mantel–Haenszel; CI, confidence interval; and SD, standard deviation; IV, inverse variance
Fig. 3
Fig. 3
Trial sequential analysis results. A Trial sequential analysis for mortality. B Trial sequential analysis for duration of mechanical ventilation
See this image and copyright information in PMC

References

    1. Haagsma JA, Graetz N, Bolliger I, Naghvi M, Higashi H, Mullany EC, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the global burden of disease study 2013. Inj Prev. 2016;22(1):3–18. doi: 10.1136/injuryprev-2015-041616. - DOI - PMC - PubMed
    1. Lafferty PM, Anavian J, Will RE, Cole PA. Operative treatment of chest wall injuries: indications, technique, and outcomes. J Bone Joint Surg Am. 2011;93(1):97–110. doi: 10.2106/JBJS.I.00696. - DOI - PubMed
    1. Baghai M, Whitaker D. Thoracic trauma. In: Moorjani N, Viola N, Walker WS, (eds). Key Questions in Thoracic Surgery. 1st edition. Shrewsbury, UK: TFM Publishing Ltd.; 2016. P.971–988.
    1. Nirula R, Mayberry JC. Rib fracture fixation: controversies and technical challenges. Am Surg. 2010;76:793–802. doi: 10.1177/000313481007600820. - DOI - PubMed
    1. Majercik S, Pieracci FM. Chest wall trauma. Thorac Surg Clin. 2017;27(2):113–121. doi: 10.1016/j.thorsurg.2017.01.004. - DOI - PubMed

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