-
World Journal of Emergency Surgery :... Mar 2024Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last... (Meta-Analysis)
Meta-Analysis Review
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, I = 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, I = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I = 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.
Topics: Adult; Humans; Rib Fractures; Length of Stay; Thoracic Injuries; Pneumonia; Respiration, Artificial; Randomized Controlled Trials as Topic
PubMed: 38504282
DOI: 10.1186/s13017-024-00540-z -
Annals of Medicine and Surgery (2012) Feb 2024Fractures of the orbit are common injuries within the maxillofacial skeleton, and can often result in restrictions to ocular movement, diplopia, and enophthalmous if... (Review)
Review
INTRODUCTION
Fractures of the orbit are common injuries within the maxillofacial skeleton, and can often result in restrictions to ocular movement, diplopia, and enophthalmous if herniation of globe content occurs. Various studies have demonstrated the use of autologous cartilage grafts in the reconstruction of orbital fractures.
METHODS
A systematic review protocol was registered with PROSPERO, and reported in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses. Comprehensive electronic search strategies of four databases were developed. Studies were screened according to the inclusion and exclusion criteria by two independent reviewers.
RESULTS
Seven thousand one hundred seventy-one articles were identified following a comprehensive literature search. These articles were filtered for relevance and duplication, which reduced the number of articles to 16. A total of 259 patients underwent orbital reconstruction with the use of autologous cartilage. Conchal cartilage was harvested in 148 patients, auricular cartilage in 22 patients, nasoseptal cartilage in 72 patients, and costal cartilage in 17 patients. Thirty, seven, twelve, and four complications were observed in patients where cartilage was harvested from the concha, auricle, nasoseptum and rib, respectively. Most common complications included diplopia (=23), infra-orbital para/anaesthesia (=27), and enophthalmos (=7). No failure of graft or donor site morbidity were observed in the studies.
CONCLUSION
Autogenous materials such as cartilage can be used as an alternative for orbital reconstruction. Cartilage was considered by the authors to provide adequate structural support to the orbital contents, and that it was easy to harvest, shape, and position.
PubMed: 38333240
DOI: 10.1097/MS9.0000000000001598 -
The British Journal of Radiology Feb 2024To review studies on deep learning (DL) models for classification, detection, and segmentation of rib fractures in CT data, to determine their risk of bias (ROB), and to... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To review studies on deep learning (DL) models for classification, detection, and segmentation of rib fractures in CT data, to determine their risk of bias (ROB), and to analyse the performance of acute rib fracture detection models.
METHODS
Research articles written in English were retrieved from PubMed, Embase, and Web of Science in April 2023. A study was only included if a DL model was used to classify, detect, or segment rib fractures, and only if the model was trained with CT data from humans. For the ROB assessment, the Quality Assessment of Diagnostic Accuracy Studies tool was used. The performance of acute rib fracture detection models was meta-analysed with forest plots.
RESULTS
A total of 27 studies were selected. About 75% of the studies have ROB by not reporting the patient selection criteria, including control patients or using 5-mm slice thickness CT scans. The sensitivity, precision, and F1-score of the subgroup of low ROB studies were 89.60% (95%CI, 86.31%-92.90%), 84.89% (95%CI, 81.59%-88.18%), and 86.66% (95%CI, 84.62%-88.71%), respectively. The ROB subgroup differences test for the F1-score led to a p-value below 0.1.
CONCLUSION
ROB in studies mostly stems from an inappropriate patient and data selection. The studies with low ROB have better F1-score in acute rib fracture detection using DL models.
ADVANCES IN KNOWLEDGE
This systematic review will be a reference to the taxonomy of the current status of rib fracture detection with DL models, and upcoming studies will benefit from our data extraction, our ROB assessment, and our meta-analysis.
Topics: Humans; Rib Fractures; Deep Learning; Tomography, X-Ray Computed; Retrospective Studies
PubMed: 38323515
DOI: 10.1093/bjr/tqae014 -
Cureus Jan 2024Rib fractures, common among trauma victims, lead to significant morbidity and mortality. Managing the associated pain is challenging, with IV opioids and thoracic... (Review)
Review
Rib fractures, common among trauma victims, lead to significant morbidity and mortality. Managing the associated pain is challenging, with IV opioids and thoracic epidural analgesia (TEA) being utilized. While epidural analgesia is often preferred for fractured rib pain, existing data encompasses both lumbar and thoracic approaches. This review aimed to compare TEA and IV opioids for persistent rib fracture pain. A comprehensive search across five databases yielded 987 articles, of which seven met the eligibility criteria. Outcomes were categorized into primary (pain reduction) and secondary (mortality, hospital/ICU stays, analgesia-related complications) endpoints. Analyzed with Review Manager (RevMan) Version 5.4.1 (2020; The Cochrane Collaboration, London, United Kingdom), the pooled data from two sources showed TEA significantly more effective in reducing pain than IV opioids (standardized mean difference SMD): 2.23; 95%CI: 1.65-2.82; p < 0.00001). Similarly, TEA was associated with shorter ICU stays (SMD: 0.73; 95%CI: 0.33-1.13; p = 0.0004), while hospitalization duration showed no substantial difference (SMD: 0.82; 95%CI: -0.34-1.98). Mortality rates also did not significantly differ between TEA and IV opioids (risk ratio (RR): 1.20; 95%CI: 0.36-4.01; p = 0.77). Subgroup analysis revealed fewer pneumonia cases with TEA (RR: 2.06; 95%CI: 1.07-3.96; P = 0.03), with no notable disparities in other complications. While TEA's superiority in pain relief for rib fractures suggests it is the preferred analgesic, the recommendation's strength is tempered by the low methodological quality of supporting articles.
PubMed: 38318591
DOI: 10.7759/cureus.51740 -
Journal of Thoracic Disease Sep 2023There is no consensus on the effectiveness of surgical stabilization in multiple rib fractures in Asia, especially among patients with a non-flail rib fracture pattern....
BACKGROUND
There is no consensus on the effectiveness of surgical stabilization in multiple rib fractures in Asia, especially among patients with a non-flail rib fracture pattern. We aim to synthesize the evidence on the effectiveness of surgical stabilization of rib fractures (SSRF) in an Asian population with multiple non-flail rib fractures.
METHODS
The MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews were searched in this systematic literature review and meta-analysis to identify studies conducted in Asia that included patients with multiple non-flail rib fractures in at least one of their treatment groups. The intervention of interest was SSRF, and the comparator was a nonoperative treatment. The duration of mechanical ventilation (DMV) was the primary outcome. Posttreatment pain score, pneumonia, atelectasis, intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), need for tracheostomy, respiratory function, functional outcomes, quality of life (QoL), and mortality were identified as the secondary outcomes. A random effects model (REM) was used to pool data for outcomes reported in two or more studies.
RESULTS
A total of 12 studies (n=2,440 patients) were included. There was a significantly shorter DMV {mean difference (MD): -5.23 [95% confidence interval (CI): -9.64 to -0.81], P=0.02}, lower 4-week post-treatment pain score [standard mean difference (SMD): -2.24 (95% CI: -3.18 to -1.31), P<0.00001], lower risk for pneumonia [risk ratio (RR): 0.46 (95% CI: 0.23 to 0.95), P=0.04], lower risk for atelectasis [RR: 0.44, (95% CI: 0.29 to 0.65), P<0.0001], shorter ICU LOS [MD: -4.00 (95% CI: -6.33 to -1.66), P=0.0008], and shorter HLOS [MD: -6.54 (95% CI: -9.28 to -3.79), P<0.00001] in favor of SSRF. Effect estimates for the need for tracheostomy [RR: 0.67 (95% CI: 0.42 to 1.08), P=0.10] and mortality [RR: 0.94 (95% CI: 0.37 to 2.41), P=0.90] were nonsignificant.
CONCLUSIONS
In the Asian population with mainly non-flail rib fracture patterns, SSRF was associated with shorter DMV, ICU LOS, and HLOS as well as lower risks for atelectasis and pneumonia, and pain scores after 4 weeks. The risk of mortality was comparable between treatment groups.
PubMed: 37868848
DOI: 10.21037/jtd-23-1117 -
Cureus Jul 2023Chronic alcohol use has been associated with impaired pulmonary function, increased risk of pneumonia and poor outcomes after trauma. With a high incidence of rib... (Review)
Review
Chronic alcohol use has been associated with impaired pulmonary function, increased risk of pneumonia and poor outcomes after trauma. With a high incidence of rib fractures in this population, the clinical and physiological factors associated with alcohol dependence may influence how these patients recover from thoracic injuries. Therefore, the aim of the systematic review was to examine the effect of alcohol dependence on rib fracture outcomes. The Embase, PubMed and Web of Science databases were searched for studies examining adult patients with rib fractures, with and without a history of alcohol dependency. The outcomes of interest were mortality, pulmonary complications, intensive care length of stay, ventilator days and hospital length of stay. A meta-analysis was performed to combine the data and compare results. Three studies met the criteria for inclusion in the review and all studies were observational in design. Alcohol dependency was associated with increased mortality (OR 1.44 (95% CI: 1.33-1.56)), pneumonia (OR 2.14 (2.02-2.27)) and ARDS (OR 1.71(1.48-1.98)) as well as longer stays in hospital and intensive care (p<0.05). No difference was found in ventilator days between the two groups. Early intensive care review should be considered to reduce complications in this population alongside prompt management of withdrawal symptoms. However, limited primary research exists on this topic and the quality of current evidence is low. Additional primary research is needed to further understand this correlation and draw meaningful conclusions.
PubMed: 37644941
DOI: 10.7759/cureus.42639 -
European Review For Medical and... Feb 2023The aim of the study was to assess the efficacy of different peripheral nerve blocks, compared to conventional methods (analgesics and epidural block), for pain relief... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The aim of the study was to assess the efficacy of different peripheral nerve blocks, compared to conventional methods (analgesics and epidural block), for pain relief in rib fracture patients.
MATERIALS AND METHODS
PubMed, Embase, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched. The review included studies that were either randomized controlled trials (RCTs) or observational in design with propensity matching. The primary outcome of interest was patient's reported pain scores, both at rest and on coughing/movement. The secondary outcomes were length of hospital stay, length of stay at intensive care unit (ICU), need for rescue analgesic, arterial blood gas values and parameters of lung function test. STATA was used for statistical analysis.
RESULTS
The meta-analysis was conducted with 12 studies. Compared to conventional methods, peripheral nerve block was associated with better pain control at rest 12 hours (SMD -4.89, 95% CI: -5.91, -3.86) and 24 hours (SMD -2.58, 95% CI: -4.40, -0.76) after institution of block. At 24 hours after block, the pooled findings indicate better pain control on movement/coughing for the peripheral nerve block group (SMD -0.78, 95% CI: -1.48, -0.09). There were no significant differences in the patient's reported pain scores at rest and on movement/coughing at 24 hours post-block. There were no differences in the overall risk of any complications (RR 0.48, 95% CI: 0.20, 1.18), pulmonary complication (RR 0.71, 95% CI: 0.35, 1.41) and in-hospital mortality (RR 0.62, 95% CI: 0.20, 1.90) between the two groups. Peripheral nerve block was also associated with a relatively lower need for rescue analgesic (SMD -0.31, 95% CI: -0.54, -0.07). There were no differences in the length of ICU and hospital stay, risk of complications, arterial blood gas values or functional lung parameters, i.e., PaO2 and forced vital capacity between the two management strategies.
CONCLUSIONS
Peripheral nerve blocks may be better than conventional pain management strategies for immediate pain control (within 24 hours of initiation of block) in patients with fractured ribs. This method also reduces the need for rescue analgesic. The skills and experience of the health personnel, facilities for care available and the cost involved should guide the decision on which management strategy to utilize.
Topics: Humans; Pain Management; Rib Fractures; Nerve Block; Pain, Postoperative; Peripheral Nerves; Analgesics
PubMed: 36808336
DOI: 10.26355/eurrev_202302_31183 -
The South African Journal of... 2022Rib fractures are a common thoracic injury and notable source of chest pain. Chest pain may lead to compromised respiratory and physical function. (Review)
Review
Effectiveness of nonpharmacological therapeutic interventions on pain and physical function in adults with rib fractures during acute care: A systematic review and meta-analysis.
BACKGROUND
Rib fractures are a common thoracic injury and notable source of chest pain. Chest pain may lead to compromised respiratory and physical function.
OBJECTIVES
Our study aimed to synthesise the evidence on the effectiveness of nonpharmacological therapeutic interventions on pain and physical function in adults admitted with rib fractures to acute care settings. Secondary outcomes included length of stay (LOS), respiratory complications, respiratory function and mortality rate.
METHOD
A systematic literature search of English articles in nine databases was conducted. The Joanna Briggs Institute's System for the Unified Management, Assessment and Review of Information (SUMARI) was used to conduct our study. Articles written from January 2000 to December 2017 were considered and a search update was completed in 2021. Meta-analysis was conducted for pre- versus post-bundle of care implementation for LOS, pneumonia incidence and mortality rate. Certainty of evidence was appraised using the grading of recommendations, assessment, development and evaluation (GRADE) approach.
RESULTS
Sixteen studies were included ( = 2034). Certain interventions were shown to improve respiratory function and reduce pain, pulmonary complications, LOS and mortality rate. No interventions were identified which objectively improved physical function. Meta-analysis showed a statistically significant reduction in relative risk of developing pneumonia ( = 0.00) by 63% following bundled care implementation. Certainty of evidence for this outcome was rated as very low following GRADE appraisal.
CONCLUSION
Nonpharmacological therapeutic interventions used in combination with pharmacological management are viable treatment options to reduce pain, improve respiratory function and reduce the incidence of respiratory complications following acute rib fractures.
CLINICAL IMPLICATIONS
Acupuncture, transcutaneous electrical nerve stimulation (TENS), noninvasive ventilation (NIV) modalities, physiotherapy techniques and multidisciplinary pathways used alongside pharmacological interventions are effective modalities for use in the treatment of acute rib fractures. Multidisciplinary care pathways are important management strategies and reduce the risk of developing pneumonia.
PubMed: 35814044
DOI: 10.4102/sajp.v78i1.1764 -
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 -
Annals of the Royal College of Surgeons... Apr 2022Multiple traumatic rib fractures are associated with significant morbidity and mortality. The last decade has seen a significant increase in rates of surgical fixation... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Multiple traumatic rib fractures are associated with significant morbidity and mortality. The last decade has seen a significant increase in rates of surgical fixation for both flail and non-flail rib fractures; the evidence for this has come from largely retrospective studies. The aim of this meta-analysis was to compare the efficacy of this approach with that of non-operative management.
METHODS
A systematic search of the literature was performed to identify randomised controlled trials (RCTs) comparing surgical stabilisation to non-operative management. Both flail and non-flail injuries were included.
RESULTS
Five RCTs reported the results of 286 patients. Only one study assessed non-flail fractures. The studies were heterogenic in nature and of mixed quality. Surgical stabilisation was associated with a reduction in pneumonia (RR 0.46, 95% confidence intervals (CI) 0.29 to 0.73, I=42%, =0.001). The duration of mechanical ventilation (mean difference (MD) -6.3, 95% CI -12.16 to -0.43, I=95%, =0.05) and critical care length of stay was also shorter after surgery (mean difference -6.46 days, 95% CI 9.73 to -3.19, <0.001); however, the overall length of stay in hospital was not (MD -7.18, 95% CI -15.63 to -1.28, I=94%, =0.1). No study demonstrated a significant reduction in mortality (RR 0.54, 95% CI 0.18 to 1.8, I=0%, =0.28).
CONCLUSIONS
Surgical stabilisation of rib fractures is associated with some improved clinical outcomes. Further large RCTs are still needed to confirm if there is also a survival benefit.
Topics: Flail Chest; Humans; Length of Stay; Randomized Controlled Trials as Topic; Respiration, Artificial; Rib Fractures; Wounds, Nonpenetrating
PubMed: 34928718
DOI: 10.1308/rcsann.2021.0148