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The Journal of Trauma and Acute Care... Aug 2020In recent years, there has been a growing interest in operative treatment for multiple rib fractures and flail chest. However, to date, there is no comprehensive study...
BACKGROUND
In recent years, there has been a growing interest in operative treatment for multiple rib fractures and flail chest. However, to date, there is no comprehensive study that extensively focused on the incidence of complications associated with rib fracture fixation. Furthermore, there is insufficient knowledge about the short- and long-term outcomes after rib fracture fixation.
METHODS
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The MEDLINE, EMBASE, and Cochrane databases were searched to identify studies reporting on complications and/or outcome of surgical treatment after rib fractures. Complications were subdivided into (1) surgery- and implant-related complications, (2) bone-healing complications, (3) pulmonary complications, and (4) mortality.
RESULTS
Forty-eight studies were included, with information about 1,952 patients who received rib fracture fixation because of flail chest or multiple rib fractures. The overall risk of surgery- and implant-related complications was 10.3%, with wound infection in 2.2% and fracture-related infection in 1.3% of patients. Symptomatic nonunion was a relatively uncommon complication after rib fixation (1.3%). Pulmonary complications were found in 30.9% of patients, and the overall mortality was 2.9%, of which one third appeared to be the result of the thoracic injuries and none directly related to the surgical procedure. The most frequently used questionnaire to assess patient quality of life was the EuroQol-5D (EQ-5D) (n = 4). Four studies reporting on the EQ-5D had a weighted mean EQ-5D index of 0.80 indicating good quality of life after rib fracture fixation.
CONCLUSION
Surgical fixation can be considered as a safe procedure with a considerably low complication risk and satisfactory long-term outcomes, with surgery- and implant-related complications in approximately 10% of the patients. However, the clinically most relevant complications such as infections occur infrequently, and the number of complications requiring immediate (surgical) treatment is low.
LEVEL OF EVIDENCE
Systematic Review, level III.
Topics: Flail Chest; Fracture Fixation, Internal; Fracture Healing; Fractures, Multiple; Fractures, Ununited; Humans; Internal Fixators; Postoperative Complications; Quality of Life; Respiration Disorders; Respiratory Tract Diseases; Rib Fractures; Surgical Wound Infection
PubMed: 32282759
DOI: 10.1097/TA.0000000000002716 -
Archives of Orthopaedic and Trauma... Feb 2023Multiple rib fractures are associated with significant morbidity and mortality, especially in elderly patients. There is growing interest in surgical stabilization in... (Review)
Review
BACKGROUND
Multiple rib fractures are associated with significant morbidity and mortality, especially in elderly patients. There is growing interest in surgical stabilization in this subgroup of patients. This systematic review compares conservative treatment to surgical fixation in elderly patients (older than 60 years) with multiple rib fractures. The primary outcome is mortality. Secondary outcomes include hospital and intensive care length of stay (HLOS and ILOS), duration of mechanical ventilation (DMV) and pneumonia rates.
METHODS
Multiple databases were searched for comparative studies reporting on conservative versus operative treatment for rib fractures in patients older than 60 years. Both observational studies and randomised clinical trials were considered.
RESULTS
Five observational studies (n = 2583) were included. Mortality was lower in operatively treated patients compared to conservative treatment (4% vs. 8%). Pneumonia rate and DMV were similar (5/6% and 5.8/6.5 days) for either treatment modality. Overall ILOS and HLOS of stay were longer in operatively treated patients (6.5 ILOS and 12.7 HLOS vs. 2.7 ILOS and 6.5 ILOS). There were only minimal reports on perioperative complications. Notably, the median number of rib fractures (8.4 vs. 5) and the percentage of flail chest were higher in operatively treated patients (47% vs. 39%).
CONCLUSION
It remains unknown to what extent conservative and operative treatment contribute individually to reducing morbidity and mortality in the elderly with multiple rib fractures. To date, the quality of evidence is rather low, thus well-performed comparative observational studies or randomised controlled trials considering all confounders are needed to determine whether operative treatment can improve a patient's outcome.
Topics: Humans; Aged; Rib Fractures; Flail Chest; Length of Stay; Fracture Fixation; Spinal Fractures; Pneumonia; Retrospective Studies
PubMed: 35137253
DOI: 10.1007/s00402-022-04362-z -
Revista Brasileira de Terapia Intensiva 2017To review the literature on the effects of expiratory rib cage compression on ventilatory mechanics, airway clearance, and oxygen and hemodynamic indices in mechanically... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE:
To review the literature on the effects of expiratory rib cage compression on ventilatory mechanics, airway clearance, and oxygen and hemodynamic indices in mechanically ventilated adults.
METHODS:
Systematic review with meta-analysis of randomized clinical trials in the databases MEDLINE (via PubMed), EMBASE, Cochrane CENTRAL, PEDro, and LILACS. Studies on adult patients hospitalized in intensive care units and under mechanical ventilation that analyzed the effects of expiratory rib cage compression with respect to a control group (without expiratory rib cage compression) and evaluated the outcomes static and dynamic compliance, sputum volume, systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, peripheral oxygen saturation, and ratio of arterial oxygen partial pressure to fraction of inspired oxygen were included. Experimental studies with animals and those with incomplete data were excluded.
RESULTS:
The search strategy produced 5,816 studies, of which only three randomized crossover trials were included, totaling 93 patients. With respect to the outcome of heart rate, values were reduced in the expiratory rib cage compression group compared with the control group [-2.81 bpm (95% confidence interval [95%CI]: -4.73 to 0.89; I2: 0%)]. Regarding dynamic compliance, there was no significant difference between groups [-0.58mL/cmH2O (95%CI: -2.98 to 1.82; I2: 1%)]. Regarding the variables systolic blood pressure and diastolic blood pressure, significant differences were found after descriptive evaluation. However, there was no difference between groups regarding the variables secretion volume, static compliance, ratio of arterial oxygen partial pressure to fraction of inspired oxygen, and peripheral oxygen saturation.
CONCLUSION:
There is a lack of evidence to support the use of expiratory rib cage compression in routine care, given that the literature on this topic offers low methodological quality and is inconclusive.
Topics: Adult; Blood Gas Analysis; Blood Pressure; Exhalation; Heart Rate; Humans; Oxygen; Pressure; Pulmonary Gas Exchange; Randomized Controlled Trials as Topic; Respiration, Artificial; Rib Cage
PubMed: 28444078
DOI: 10.5935/0103-507X.20170014 -
Injury Nov 2020Surgical rib stabilization in flail chest is proven to be beneficial over nonoperative treatment in terms of rate of pneumonia, Intensive Care (IC) length of stay... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Surgical rib stabilization in flail chest is proven to be beneficial over nonoperative treatment in terms of rate of pneumonia, Intensive Care (IC) length of stay (ICLOS) and mechanical ventilation days. The aim of this systematic review and meta-analysis was to evaluate the effect of operative versus nonoperative treatment on the occurrence of pneumonia and other relevant clinical outcomes in patients with multiple simple rib fractures.
METHODS
A search was performed in Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar. The primary outcome was the occurrence of pneumonia. Secondary outcomes were duration of mechanical ventillation, ICLOS, hospital length of stay (HLOS), mortality, and wound infections. Publication bias was assessed using funnel plots for the outcome measures and random-effect models were used when heterogeneity of data on outcome measures was significant (I≥40%).
RESULTS
The search resulted in 592 unique records, of which 14 studies on 13 cohorts were included. The 14 studies comprised five prospective and nine retrospective cohort studies with a cumulative total of 4565 patients. Meta-analysis showed a significant decrease of the occurrence of pneumonia (n=2659 patients; risk ratio, RR=0.66; 95% confidential interval [CI] 0.49 to 0.90; p=0.008), mortality (n=4456 patients; RR=0.32; 95% CI 0.19 to 0.54; p<0.001), and HLOS (n=648 patients; mean difference, MD=-5.78 days; 95% CI -10.40 to -1.15; p=0.01) in favor of operative treatment. No effect of operative treatment was found for the duration of mechanical ventilation (n=113 patients; MD=-6.01 days; 95% CI =-19.61 to 7.59; p=0.39), or ICLOS (n=524 patients; MD=-2.93 days; 95% CI -8.65 to 2.80; p=0.32). The postoperative wound infection rate ranged from 0 to 9.4%.
CONCLUSION
Surgical treatment of multiple simple rib fractures may result in a significant reduction of pneumonia, mortality, and hospital length of stay. A reducing effect of treatment on the duration of mechanical ventilation and IC length of stay, was not demonstrated. However, due to nonstandard or absent definitions of outcome measures as well as heterogenous patient groups and the observational design of studies, results must be interpreted with caution and high-quality studies are needed.
Topics: Flail Chest; Humans; Length of Stay; Prospective Studies; Retrospective Studies; Rib Fractures
PubMed: 32650981
DOI: 10.1016/j.injury.2020.07.009 -
The Journal of Surgical Research Dec 2021Surgical stabilization of rib fractures (SSRF) is increasingly used to reduce pulmonary complications and death among patients with rib fractures. However, the five Ws... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgical stabilization of rib fractures (SSRF) is increasingly used to reduce pulmonary complications and death among patients with rib fractures. However, the five Ws of hardware failure -who, what, when, where, and why- remains unclear. We aimed to synthesize available evidence on the five Ws and outline future research agenda for mitigating hardware failure.
METHODS
Experimental and observational studies published between 2009 and 2020 evaluating adults undergoing SSRF for traumatic rib fractures underwent evidence synthesis. We performed random effects meta-analysis of cohort/consecutive case studies. We calculated pooled prevalence of SSRF hardware failures using Freeman-Tukey double arcsine transformation and assessed study heterogeneity using DerSimonian-Laird estimation. We performed meta-regression with rib fracture acuity (acute or chronic) and hardware type (metal plate or not metal plate) as moderators.
RESULTS
Twenty-nine studies underwent qualitative synthesis and 24 studies (2404 SSRF patients) underwent quantitative synthesis. Pooled prevalence of hardware failure was 4(3-7)%. Meta-regression showed fracture acuity was a significant moderator (P = 0.002) of hardware failure but hardware type was not (P = 0.23). Approximately 60% of patients underwent hardware removal after hardware failure. Mechanical failures were the most common type of hardware failure, followed by hardware infections, pain/discomfort, and non-union. Timing of hardware failure after surgery was highly variable, but 87% of failures occurred after initial hospitalization. Mechanical failures was attributed to technical shortcomings (i.e. short plate length) or excessive force on the thoracic cavity.
CONCLUSIONS
SSRF hardware failure is an uncommon complication. Not all hardware failures are consequential, but insufficient individual patient data precluded characterizing where and why hardware failures occur. Minimizing SSRF hardware failure requires concerted research agenda to expand on the paucity of existing evidence.
Topics: Adult; Bone Plates; Equipment Failure; Hospitalization; Humans; Retrospective Studies; Rib Fractures
PubMed: 34333416
DOI: 10.1016/j.jss.2021.06.054 -
JAMA Facial Plastic Surgery 2015Although autologous rib cartilage is a preferred source of graft material in rhinoplasty, rib cartilage for dorsal augmentation has been continuously criticized for its... (Meta-Analysis)
Meta-Analysis Review
IMPORTANCE
Although autologous rib cartilage is a preferred source of graft material in rhinoplasty, rib cartilage for dorsal augmentation has been continuously criticized for its tendency to warp and for high donor-site morbidities. However, no meta-analysis or systemic review on complications associated with autologous rib cartilage use in rhinoplasty has been conducted.
OBJECTIVE
To carry out a systematic review and a meta-analysis of available literature to evaluate complications regarding autologous rib cartilage in rhinoplasty.
DATA SOURCES
The studies reporting complications associated with the autologous rib cartilage use in rhinoplasty were systematically reviewed by searching the MEDLINE, PubMed, and Embase databases for sources published from 1946 through June 2013.
STUDY SELECTION
The selected articles included clinical studies conducted with at least 10 patients and at least 1 postoperative long-term complication or donor-site morbidity in rhinoplasty. Excluded were nonhuman studies; review articles; case reports; abstracts; and reports of nasal reconstruction as indication for surgery, use of homologous rib cartilage, and diced or laminated methods.
DATA EXTRACTION AND SYNTHESIS
Two investigators independently reviewed all studies and extracted the data using a standardized form. A meta-analysis was performed using a random-effects model.
MAIN OUTCOMES AND MEASURES
Number of patients; follow-up duration; and rates of complication, donor-site morbidity, and revision surgery. Also noted were study authors and year of publication.
RESULTS
Ten studies involving a total 491 patients were identified. Mean follow-up across all studies was 33.3 months. In meta-analysis, the combined rates were 3.08% (95% confidence interval [CI], 0%-10.15%) for warping, 0.22% (95% CI, 0%-1.25%) for resorption, 0.56% (95% CI, 0%-2.61%) for infection, 0.39% (95% CI, 0%-1.97%) for displacement, 5.45% (95% CI, 0.68%-13.24%) for hypertrophic chest scarring, 0% (95% CI, 0%-0.32%) for pneumothorax, and 14.07% (95% CI, 6.19%-24.20%) for revision surgery.
CONCLUSIONS AND RELEVANCE
The overall long-term complications and donor-site morbidity rates associated with autologous rib cartilage use in rhinoplasty were low. Warping and hypertrophic chest scarring showed relatively higher rates, warranting a surgeon's attention. Because a limited number of studies and patients were eligible, and consistent definitions of complications were lacking in this meta-analysis, future studies with a larger series of patients and objective outcome measurements are needed to obtain more reliable results.
LEVEL OF EVIDENCE
4.
Topics: Costal Cartilage; Evidence-Based Medicine; Female; Follow-Up Studies; Graft Rejection; Graft Survival; Humans; Male; Postoperative Complications; Rhinoplasty; Ribs; Time Factors; Transplant Donor Site; Transplantation, Autologous
PubMed: 25429595
DOI: 10.1001/jamafacial.2014.914 -
Journal of Neurosurgery. Pediatrics Sep 2022Several growth-preserving surgical techniques are employed in the management of early-onset scoliosis (EOS). The authors' objective was to compare the use of traditional... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Several growth-preserving surgical techniques are employed in the management of early-onset scoliosis (EOS). The authors' objective was to compare the use of traditional growing rods (TGRs), magnetically controlled growing rods (MCGRs), Shilla growth guidance techniques, and vertically expanding prosthetic titanium ribs (VEPTRs) for the management of EOS.
METHODS
A systematic review of electronic databases, including Ovid MEDLINE and Cochrane, was performed. Outcomes of interest included correction of Cobb angle, T1-S1 distance, and complication rate, including alignment, hardware failure and infection, and planned and unplanned reoperation rates. The percent changes and 95% CIs were pooled across studies using random-effects meta-analysis.
RESULTS
A total of 67 studies were identified, which included 2021 patients. Of these, 1169 (57.8%) patients underwent operations with TGR, 178 (8.8%) Shilla growth guidance system, 448 (22.2%) MCGR, and 226 (11.1%) VEPTR system. The mean ± SD age of the cohort was 6.9 ± 1.2 years. The authors found that the Shilla technique provided the most significant improvement in coronal Cobb angle immediately after surgery (mean [95% CI] 64.3% [61.4%-67.2%]), whereas VEPTR (27.6% [22.7%-33.6%]) performed significantly worse. VEPTR also performed significantly worse than the other techniques at final follow-up. The techniques also provided comparable gains in T1-S1 height immediately postoperatively (mean [95% CI] 10.7% [8.4%-13.0%]); however, TGR performed better at final follow-up (21.4% [18.7%-24.1%]). Complications were not significantly different among the patients who underwent the Shilla, TGR, MCGR, and VEPTR techniques, except for the rate of infections. The TGR technique had the lowest rate of unplanned reoperations (mean [95% CI] 15% [10%-23%] vs 24% [19%-29%]) but the highest number of planned reoperations per patient (5.31 [4.83-5.82]). The overall certainty was also low, with a high risk of bias across studies.
CONCLUSIONS
This analysis suggested that the Shilla technique was associated with a greater early coronal Cobb angle correction, whereas use of VEPTR was associated with a lower correction rate at any time point. TGR offered the most significant height gain at final follow-up. The complication rates were comparable across all surgical techniques. The optimal surgical approach should be tailored to individual patients, taking into consideration the strengths and limitations of each option.
Topics: Humans; Child, Preschool; Child; Scoliosis; Prostheses and Implants; Reoperation; Titanium; Ribs; Retrospective Studies; Treatment Outcome; Follow-Up Studies
PubMed: 36152334
DOI: 10.3171/2022.8.PEDS22156 -
The Cochrane Database of Systematic... Jul 2015Thoracic trauma (TT) is common among people with multiple traumatic injuries. One of the injuries caused by TT is the loss of thoracic stability resulting from multiple... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Thoracic trauma (TT) is common among people with multiple traumatic injuries. One of the injuries caused by TT is the loss of thoracic stability resulting from multiple fractures of the rib cage, otherwise known as flail chest (FC). A person with FC can be treated conservatively with orotracheal intubation and mechanical ventilation (internal pneumatic stabilization) but may also undergo surgery to fix the costal fractures.
OBJECTIVES
To evaluate the effectiveness and safety of surgical stabilization compared with clinical management for people with FC.
SEARCH METHODS
We ran the search on the 12 May 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), EMBASE Classic and EMBASE (OvidSP), CINAHL Plus (EBSCO), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), and clinical trials registers. We also screened reference lists and contacted experts.
SELECTION CRITERIA
Randomized controlled trials of surgical versus nonsurgical treatment for people diagnosed with FC.
DATA COLLECTION AND ANALYSIS
Two review authors selected relevant trials, assessed their risk of bias, and extracted data.
MAIN RESULTS
We included three studies that involved 123 people. The methods used for blinding the participants and researchers to the treatment group were not reported, but as the comparison is surgical treatment with medical treatment this bias is hard to avoid. There was no description of concealment of the randomization sequence in two studies.All three studies reported on mortality, and deaths occurred in two studies. There was no clear evidence of a difference in mortality between treatment groups (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.13 to 2.42); however, the analysis was underpowered to detect a difference between groups. Out of the 123 people randomized and treated, six people died; the causes of death were pneumonia, pulmonary embolism, mediastinitis, and septic shock.Among people randomized to surgery, there were reductions in pneumonia (RR 0.36, 95% 0.15 to 0.85; three studies, 123 participants), chest deformity (RR 0.13, 95% CI 0.03 to 0.67; two studies, 86 participants), and tracheostomy (RR 0.38, 95% CI 0.14 to 1.02; two studies, 83 participants). Duration of mechanical ventilation, length of intensive care unit stay (ICU), and length of hospital stay were measured in the three studies. Due to differences in reporting, we could not combine the results and have listed them separately. Chest pain, chest tightness, bodily pain, and adverse effects were each measured in one study.
AUTHORS' CONCLUSIONS
There was some evidence from three small studies that showed surgical treatment was preferable to nonsurgical management in reducing pneumonia, chest deformity, tracheostomy, duration of mechanical ventilation, and length of ICU stay. Further well-designed studies with a sufficient sample size are required to confirm these results and to detect possible surgical effects on mortality.
Topics: Cause of Death; Flail Chest; Fracture Fixation; Fractures, Multiple; Humans; Length of Stay; Randomized Controlled Trials as Topic; Respiration, Artificial; Ribs
PubMed: 26222250
DOI: 10.1002/14651858.CD009919.pub2 -
Respiratory Care Nov 2018Chest wall motion is a vital component of the respiratory system. Body position changes disturb joint orientation around the chest wall and results in performance... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Chest wall motion is a vital component of the respiratory system. Body position changes disturb joint orientation around the chest wall and results in performance modifications of respiratory muscles and movement surrounding the rib cage and the abdomen. Body position is a priority treatment for preserving and promoting chest wall motion. The objective of the study was to conduct a meta-analysis to provide insight into which body position most effectively improves chest wall motion.
METHODS
Medical literature databases were systemically searched up to January 31, 2018. Methodological quality was evaluated by using a checklist for measuring quality. A meta-analysis was performed to evaluate the effects of body positions on chest wall motion. The quality of evidence was judged by using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.
RESULTS
Six studies (5 high- and 1 low-quality) were identified. Our results showed that the sitting position provided greater improvement in chest-wall diameter changes and volume related to rib-cage function versus other body positions (very low to moderate evidence). The supine position demonstrated greater enhancement of chest-wall-diameter changes and volume in the part of the abdomen than the other body positions with very low to moderate evidence.
CONCLUSIONS
The results of this review indicated that the sitting position improved the rib-cage compartment of the chest wall, whereas the supine position resulted in the superior enhancement in the part of the abdomen relative to other body positions. These changes in the body position could have some effect on the movements of the rib cage and abdomen and the variations in lung volumes, which need to be interpreted with caution when considering implementation in the clinical setting.
Topics: Healthy Volunteers; Humans; Movement; Posture; Thoracic Wall
PubMed: 30327334
DOI: 10.4187/respcare.06344 -
Australian Veterinary Journal Jan 2021Major health conditions in sheep contribute to substantial economic losses throughout the sheepmeat supply chain in Australia. A systematic review was undertaken to... (Review)
Review
Major health conditions in sheep contribute to substantial economic losses throughout the sheepmeat supply chain in Australia. A systematic review was undertaken to explore the measurable impact of six conditions: arthritis, sheep measles, pleurisy, pneumonia, grass seeds and rib fractures, on the production of lamb and mutton across the meat value chain. Peer-reviewed scientific literature from three databases and non-peer-reviewed articles and reports from Australian government and non-government websites were searched between 11 and 17 November 2019. Original articles, including studies conducted in Australia and New Zealand, that had measurable impacts on conditions of interest were included. The search yielded 16 articles and reports and were classified as producer impact and/or processor impact studies. Mortalities were quantified for pneumonia and arthritis, with pneumonia having the highest impact for producers. Grass seed infestation resulted in the highest impact on carcase and liveweight losses compared to arthritis and pneumonia. Arthritis had the highest trim weight losses for both lamb and mutton and the highest rate of carcase condemnation. Grass seed was the only condition where other impacts on the processor (chain speed and staff relocation to the boning room) were quantified. Although quantifiable production and processing losses were available for some conditions, this review has highlighted that limited quantifiable data based on scientifically sound research were not available for other conditions. The evidence for some conditions found in this review can be used to target future research activities and to further assist producers in making informed management decisions on prevention and control.
Topics: Animals; Australia; Meat; New Zealand; Red Meat; Sheep; Sheep, Domestic
PubMed: 33016335
DOI: 10.1111/avj.13026