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Randomized Controlled Trial
. 2025 May 7;107(9):928-935.
doi: 10.2106/JBJS.24.01099. Epub 2025 Mar 7.

Operative Treatment of Flail Chest Injuries Does Not Reduce Pain or In-Hospital Opioid Requirements: Results from a Multicenter Randomized Controlled Trial

Niloofar Dehghan  1   2 , Jessica McGraw-Heinrich  3 , Christine Schemitsch  4 , Aaron Nauth  4 , Jennifer Hidy  4 , Milena Vicente  4 , Emil H Schemitsch  5 , Richard Jenkinson  6 , Hans Kreder  6 , Michael D McKee  2   7 ; the Canadian Orthopaedic Trauma Society; the Unstable Chest Wall RCT Study Investigators; the Canadian Orthopaedic Trauma Society and the Unstable Chest Wall RCT Study Investigators
Collaborators, Affiliations
Randomized Controlled Trial

Operative Treatment of Flail Chest Injuries Does Not Reduce Pain or In-Hospital Opioid Requirements: Results from a Multicenter Randomized Controlled Trial

Niloofar Dehghan et al. J Bone Joint Surg Am. .

Abstract

Background: A previous randomized controlled trial (RCT) evaluating operative versus nonoperative treatment of acute flail chest injuries revealed more ventilator-free days in operatively treated patients who had been ventilated at the time of randomization. It has been suggested that surgery for these injuries may also improve a patient's pain and function. Our goal was to perform a secondary analysis of the previous RCT to evaluate pain and postinjury opioid requirements in patients with operatively and nonoperatively treated unstable chest wall injuries.

Methods: We analyzed data from a previous multicenter RCT that had been conducted from 2011 to 2019. Patients who had sustained acute, unstable chest wall injuries were randomized to operative or nonoperative treatment. In-hospital pain medication logs were evaluated, and daily morphine milligram equivalents (MMEs) were calculated. The patients' symptoms were also assessed, including generalized pain, chest wall pain, chest wall tightness, and shortness of breath. Additionally, patients completed the 36-Item Short Form Health Survey (SF-36), and they were followed for 1 year postinjury.

Results: In the original trial, 207 patients were analyzed: 99 patients received nonoperative treatment, and 108 received operative treatment. There were no significant differences in pain medication usage between the 2 groups at any of the examined time points (p = 0.477). There were no significant differences in generalized pain, chest wall pain, chest wall tightness, or shortness of breath at any time postinjury in the 2 groups. There were also no significant differences in the SF-36 scores.

Conclusions: This secondary analysis of a previous RCT suggested that operative treatment of patients with flail chest injuries does not reduce in-hospital daily opioid requirements. There were also no reductions in generalized pain, chest wall pain, chest wall tightness, or shortness of breath with operative treatment. The SF-36 scores were similar for both groups. Further work is needed to identify those patients most likely to benefit from operative treatment of flail chest injuries.

Level of evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

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Conflict of interest statement

Disclosure: This study was funded by the AO Foundation, Canadian Institutes of Health Research (CIHR), and Physician Services, Inc. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I476 ).

References

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