Operative versus nonoperative treatment of multiple simple rib fractures: A systematic review and meta-analysis

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-2=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. (C) 2020 Elsevier Ltd. All rights reserved.