Reconstruction method for massive lateral chest wall sarcoma using titanium plates and mesh: a case report.

BACKGROUND: Very large chest wall resections can lead to acute thoracic insufficiency syndrome due to the interdependence of lung expansion and thoracic volume. Chest wall tumor surgeries often encounter complications, with the size of the chest wall defect being a significant predictor. Several methods for large chest wall reconstruction have been described, aiming to provide stability, prevent flail chest, and ensure airtight closure. However, no single method fulfills all requirements. Composite chest wall reconstruction using titanium plates and Gore-Tex patches has shown the potential to minimize physiologic abnormalities caused by extensive defects. CASE PRESENTATION: A 42-year-old man with myxofibrosarcoma underwent multiple surgeries, chemotherapies, and radiation therapies due to repeated local recurrences. After right arm amputation and resection of the right third to fifth ribs, a local recurrence was detected. A 30 × 40 cm chest wall defect was resected en bloc, and a titanium plate was used for three-dimensional formability, preventing flail chest and volume loss. The Gore-Tex patch was then reconstructed into an arch shape, allowing lateral thoracic mobility. The patient recovered well and did not experience respiratory dysfunction or local recurrence but later succumbed to distant metastasis. CONCLUSIONS: In this case, the combination of a titanium plate and a Gore-Tex patch proved effective for reconstructing massive lateral chest wall defects. The approach provided stability, preserved thoracic volume, and allowed for lateral mobility. While the patient achieved a successful outcome in terms of local recurrence and respiratory function, distant metastasis remained a challenge for myxofibrosarcoma patients, and its impact on long-term prognosis requires further investigation. Nevertheless, the described procedure offers promise for managing extensive chest wall defects.

Delayed flail chest from osteomyelitis and malnutrition that emerged 3 weeks after blunt chest trauma: a case report.

We present the case of a victim of a motor vehicle accident in his late 60s who suffered from severe torso injuries. He initially presented with abdominal and chest pain, and underwent emergency laparotomy for hemoperitoneum. After surgery, the patient developed pneumonia and septicemia, which were responsive to antibiotics. The patient was treated with mechanical ventilation in the intensive care unit for approximately 10 days and experienced a severe weight loss of approximately 30%, but slowly recovered without dyspnea. Notably, on hospital day 24, he experienced sudden respiratory distress and flail motion of the chest wall in a general ward. This late presentation of flail chest was attributed to non-union at rib fracture sites, and was likely exacerbated by malnutrition and osteomyelitis. Surgical stabilization of rib fractures and excision of the infected rib were successfully performed. The findings from this case highlight the complexity of managing delayed onset of flail chest. The findings from this case suggest the importance of vigilance for late emerging complications in patients with trauma, even when initial symptoms are absent.

[Surgical reconstruction of chest wall instability : Indications, contraindications and timing of surgery]. / Operative Rekonstruktion der Thoraxwandinstabilität : Indikationen, Kontraindikationen und Operationszeitpunkt.

The impact of energy on the thorax can lead to serial rib fractures, sternal fractures, the combination of both and to injury of intrathoracic organs depending on the type, localization and intensity. Sometimes this results in chest wall instability with severe impairment of the respiratory mechanics. In the last decade the importance of surgical chest wall reconstruction in cases of chest wall instability has greatly increased. The evidence for a surgical approach has in the meantime been supported by prospective randomized multicenter studies, multiple retrospective data analyses and meta-analyses based on these studies, including a Cochrane review. The assessment of form and severity of the trauma and the degree of impairment of the respiratory mechanism are the basis for a structured decision on an extended conservative or surgical reconstructive strategy as well as the timing, type and extent of the operation. The morbidity (rate of pneumonia, duration of intensive care unit stay and mechanical ventilation) and fatality can be reduced by a timely surgery within 72 h after trauma. In this article the already established and evidence-based algorithms for surgical chest wall reconstruction are discussed in the context of the current evidence.

Evolution of Pulmonary Contusions in Patients With Severe Rib Fractures: Cause for Concern?

INTRODUCTION: The progression of pulmonary contusions remains poorly understood. This study aimed to measure the radiographic change in pulmonary contusions over time and evaluate the association of the radiographic change with clinical outcomes and surgical stabilization of rib fractures (SSRF). METHODS: This retrospective cohort study included adults admitted with three or more displaced rib fractures or flail segment on trauma CT and when a chest CT was repeated within one week after trauma. Radiographic severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion Score (BPC18). Logistic regression was performed to evaluate the relation between SSRF and worsening contusions on repeat CT, adjusted for potential confounders. RESULTS: Of 231 patients, 56 (24%) had a repeat CT scan. Of these, 55 (98%) had pulmonary contusion on the first CT scan with a median BPC18 score of 5 (P25-P75 3-7). Repeat CTs showed an overall decrease of the median BPC18 score to 4 (P25-P75 2-6, P = .02), but demonstrated a worsening of the pulmonary contusion in 16 patients (29%). All repeat CTs conducted within 12 hours post-injury demonstrated increasing BPC18. Radiographic worsening of pulmonary contusions was not associated with SSRF, nor with worse respiratory outcomes or intensive care length of stay, compared to patients with radiographically stable or improving contusions. DISCUSSION: In patients with severe rib fracture patterns who undergo repeat imaging, pulmonary contusions are prevalent and become radiographically worse within at least the first 12 hours after injury. No association between radiographic worsening and clinical outcomes was found.

Is Traumatic Anterior Stove-In Chest Truly so Rare? A Single Institution Experience.

INTRODUCTION: The anterior stove-in chest (ASIC) is a rare form of flail chest involving bilateral rib or sternal fractures resulting in an unstable chest wall that caves into the thoracic cavity. Given ASIC has only been described in a handful of case reports, this study sought to review our institution's experience in the surgical management of ASIC injuries. METHODS: A retrospective review of patients with ASIC was conducted at our level I trauma center from 1//2021 to 3//2023. Information pertaining to patient demographics, fracture pattern, operative management, and outcomes was obtained and compared across patients in the case series. RESULTS: 6 patients met inclusion criteria, all males aged 37-78 years. 5 suffered motor vehicle collisions, and 1 was a pedestrian struck by an automobile. The median injury severity score was 28. All received ORIF within 5 days of admission, most commonly for ongoing respiratory distress. Patients 2 and 4 underwent bilateral ORIF of the ribs and sternum while patients 1, 5, and 6 underwent left-sided repair. Patient 3 required ORIF of left ribs and the sternum to stabilize their injuries. 5 of 6 patients were liberated from the ventilator and survived to discharge. CONCLUSIONS: This study demonstrates successful operative management of 6 patients with ASIC and suggests that early operative intervention with ORIF for affected segments may improve respiratory mechanics, ability to wean from the ventilator, and overall survival. Further research is needed to generate standardized guidelines for the management of this uncommon and complex thoracic injury.

Hardware failure for anterior chest wall and costal cartilage injuries: A single-center experience.

BACKGROUND: Often missed in blunt chest wall injury, costal cartilage injuries can cause chest wall instability, refractory pain, and deformity. Notably, there is only a small amount of evidence regarding hardware performance when applied to costal cartilage. In a prior multicenter study, hardware failure rate was found to be approximately 3% following surgical stabilization of rib fractures (SSRFs) for all fracture locations. The aim of the current study was to evaluate hardware performance for costal cartilage injuries. METHODS: All patients undergoing SSRF performed at our institution from 2016 to 2022 were queried, including both acute and chronic injuries. Both radiographic and clinical follow-up were retrospectively reviewed to evaluate for hardware failure defined as plate fracture, malposition, or screw migration following cartilage fixation. RESULTS: After screening 359 patients, 43 were included for analysis. Mean age was 64 years, and 67% of patients were male. Median number of fractures per patient was 7 with 60% of patients sustaining a flail chest injury pattern. Median total plates per operation was 6 and median costal cartilage plates was 3. In total, 144 plates were applied to the costal cartilage for the group. Mean follow-up was as follows: clinical 88 days, two-view plain radiography 164 days, and chest computed tomography 184 days. Hardware failure was observed in 3 of 144 plates (2.1%), in three separate patients. Two cases were asymptomatic and did not require intervention. One patient required revisional operation in the acute setting. CONCLUSION: In our institution, hardware failure for costal cartilage fractures was observed to be 2.1%. This aligns with prior reports of hardware failure during SSRF for all injury locations. Surgical stabilization of anterior and cartilaginous chest wall injury with appropriate plate contouring and fixation technique appears to provide adequate stabilization with a relatively low rate of hardware malfunction. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Long-term outcome after surgical management of symptomatic non-union rib fractures.

INTRODUCTION: Traumatic chest wall injuries are common however the incidence of non-union rib fractures is unknown. Previous studies have suggested that surgical management of symptomatic non-union rib fractures could be beneficial in selected patients, although many experience persisting pain despite surgery. The aim of this study is to investigate the long-term outcome after surgical management of symptomatic non-union rib fractures. METHODS: This is a cross-sectional study including adults (≥18 years) managed surgically for symptomatic non-union rib fractures with plate fixation during the period 2010-2020 at Sahlgrenska University Hospital. Patients operated for acute chest wall injury or injury due to cardiopulmonary resuscitation were excluded. Patients answered standardized questionnaires concerning remaining symptoms and satisfaction with surgery, quality of life (QoL, EQ-5D-5 L) and disability (Disability Rating Index, DRI). Lung function, movement of chest wall and thoracic spine, and shoulder function (Boström index) were assessed. RESULTS: Sixteen patients, 12 men and four women, with mean age 61.6± 11.1 were included in the study. The mechanism of injury was trauma in 10 patients and cough-induced injuries in five patients. Lung disease was significantly more prevalent in cough-induced injuries compared to traumatic injuries, 5 vs 1 (p = 0.008). The mean follow-up time was 3.5 years. Ninety-four percent were satisfied with the surgery and reported that their symptoms had decreased, although 69 % had remaining symptoms, especially pain, from the chest wall. Quality of Life was decreased with EQ-5D-5 L index 0.819 (0.477-0.976) and EQ-VAS 69 (10-100). Disability Rating Index was 31.5 (1.3-76.7) with problems running, lifting heavy objects, and performing heavy work. Predicted lung function was decreased with Forced Vital Capacity (FVC) 86.2 ± 14.2 %, Forced Expiratory Volume in 1 second (FEV1) 79.1 ± 10.7 % and Peak Expiratory Flow (PEF) 89.7 ± 14.5 %. Patients with cough-induced injuries had full shoulder mobility. CONCLUSIONS: Chest wall surgery for symptomatic non-union rib fractures results in decreased symptoms and patient satisfaction in most cases despite remaining symptoms, reduced lung function, chest wall movement, and QoL and persistent disability.

Extracorporeal Membrane Oxygenation During Surgical Stabilization of Rib Fractures in Successful Management of Severe Blunt Chest Trauma.

Early surgical stabilization of rib fracture (SSRF) improves outcomes in patients with flail physiology and severely displaced fractures. We present two cases of patients with severe chest injury and large flail segment who underwent SSRF while on veno-venous extracorporeal membrane oxygenation (VV-ECMO). The patients developed respiratory failure within 24 hours of admission requiring VV-ECMO. The extent of their chest wall injury limited pulmonary mechanics prohibiting transition off VV-ECMO. Therefore, SSRF was performed on hospital days 2 and 3 and while on VV-ECMO support. Stabilizing the chest wall allowed for improved ventilation and successful decannulation from VV-ECMO on postoperative days 3 and 4. Ultimately, both achieved a functional recovery and were discharged home. These cases demonstrate a unique thoracic damage control strategy wherein SSRF is performed while on VV-ECMO. Improving chest stability and pulmonary mechanics with SSRF allowed for safe transition off VV-ECMO and achieved a favorable long-term outcome.

A novel minimally invasive fixation method for flail chest management in a Canine model: an animal research.

BACKGROUND: Multiple rib fractures can lead to flail chest with up to 35% mortality rate due to severe pulmonary complications. Current treatments of flail chest remain controversial. Studies have shown that surgical treatments can improve outcomes and reduce mortality, comparing to non-operative treatments. Current surgical fixation methods focus on stabilization of ribs on the outward facing side, and they require division of intercostal muscles. Damages to surrounding nerves and vessels may lead to chronic pain. This study tests a novel interior fixation method that minimizes neurovascular injuries. METHODS: Twelve healthy canines were divided in two surgical operation groups for exterior and interior fixation using titanium metal plates. Osteotomy with oblique fractures was prepared under general anesthesia. Exterior fixation was performed in open surgery. Interior fixation was minimally invasive using custom made tools including a flexible shaft extension screwdriver, solid plate stand, guiding wire loop and metal plates with threaded holes. RESULTS: Respiratory and cardiovascular functions (RR, PO2, PCO2, SpO2, and HR) together with body temperature were measured before anesthesia and within 48 h after surgery. The difference in measurements was not statistically significant between the two groups before surgery with P values greater than 0.05. However, the interior group canines had better RR and PO2 values starting from the 24th hour, and better PCO2, SpO2, and HR values starting from the 48th hour. It took longer operation time to complete the minimally invasive interior fixation surgery (P value less than 0.001), but the total blood loss was less than the exterior fixation group (P value less than 0.001). Results also showed that interior group canines suffered less pain, and they had quicker recovery in gastrointestinal and physical mobility. CONCLUSIONS: The investigative interior fixation method was safe and effective in rib stabilization on a canine rib fracture model, comparing to the exterior fixation method. The interior fixation was minimally invasive, with less damages to tissues and nerves surrounding the ribs, leading to better postoperative outcomes.

Motor Vehicle Protective Device Usage Associated with Decreased Rate of Flail Chest: A Retrospective Database Analysis.

Background and Objectives: Protective equipment, including seatbelts and airbags, have dramatically reduced the morbidity and mortality rates associated with motor vehicle collisions (MVCs). While generally associated with a reduced rate of injury, the effect of motor vehicle protective equipment on patterns of chest wall trauma is unknown. We hypothesized that protective equipment would affect the rate of flail chest after an MVC. Materials and Methods: This study was a retrospective analysis of the 2019 iteration of the American College of Surgeons Trauma Quality Program (ACS-TQIP) database. Rib fracture types were categorized as non-flail chest rib fractures and flail chest using ICD-10 diagnosis coding. The primary outcome was the occurrence of flail chests after motor vehicle collisions. The protective equipment evaluated were seatbelts and airbags. We performed bivariate and multivariate logistic regression to determine the association of flail chest with the utilization of vehicle protective equipment. Results: We identified 25,101 patients with rib fractures after motor vehicle collisions. In bivariate analysis, the severity of the rib fractures was associated with seatbelt type, airbag status, smoking history, and history of cerebrovascular accident (CVA). In multivariate analysis, seatbelt use and airbag deployment (OR 0.76 CI 0.65-0.89) were independently associated with a decreased rate of flail chest. In an interaction analysis, flail chest was only reduced when a lap belt was used in combination with the deployed airbag (OR 0.59 CI 0.43-0.80) when a shoulder belt was used without airbag deployment (0.69 CI 0.49-0.97), or when a shoulder belt was used with airbag deployment (0.57 CI 0.46-0.70). Conclusions: Although motor vehicle protective equipment is associated with a decreased rate of flail chest after a motor vehicle collision, the benefit is only observed when lap belts and airbags are used simultaneously or when a shoulder belt is used. These data highlight the importance of occupant seatbelt compliance and suggest the effect of motor vehicle restraint systems in reducing severe chest wall injuries.

Surgical versus non-surgical treatment of flail chest: a meta-analysis of randomized controlled trials.

PURPOSE: Conflicting evidence exists on the choice of surgical or non-surgical treatment of flail chest injuries. We aimed to perform a meta-analysis comparing outcomes in patients presenting flail chest undergoing surgical or non-surgical treatment. METHODS: Embase, PubMed, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing surgery to no surgery in patients with acute unstable chest wall injuries. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs). Random effects meta-analyses were performed. Heterogeneity was assessed using I2 statistics. RESULTS: Six RCTs (544 patients) were included, and surgical treatment was used in 269 (49.4%). Compared to no surgery, surgery reduced mechanical ventilation days (WMD - 4.34, 95% CI - 6.98, - 1.69; p < 0.01; I2 = 87%; GRADE: very low; PI - 13.51, 4.84); length of intensive care unit stay (WMD - 4.62, 95% CI - 7.19, - 2.05; p < 0.01; I2 = 78%; GRADE: low; PI - 12.86, 3.61) and the incidence of pneumonia (RR 0.50, 95% CI 0.31, 0.81; p = 0.005; I2 = 54%; GRADE: moderate; PI 0.13, 1.91). No difference in mortality (RR 0.56, 95% CI 0.19, 1.65; p = 0.27; I2 = 23%; GRADE: moderate; PI 0.04, 7.25), length of hospital stay (WMD - 5.39, 95% CI - 11.38, - 0.60; p = 0.08; I2 = 89%; GRADE: very low; PI - 11.38, 0.60), or need for tracheostomy (RR 0.59, 95% CI 0.34, 1.03; p = 0.06; I2 = 54%; GRADE: moderate; PI 0.11, 3.24) was found. CONCLUSIONS: Our results suggest that surgical treatment is advantageous compared to non-surgical treatment for patients with flail chest secondary to rib fractures.

Injury pattern and clinical outcome in patients with and without chest wall injury after cardiopulmonary resuscitation.

BACKGROUND: Cardiopulmonary resuscitation (CPR), although lifesaving may cause chest wall injury (CWI) because of the physical force exerted on the thorax. The impact of CWI on clinical outcome in this patient group is unclear. The primary aim of this study was to investigate the incidence of CPR-related CWI and the secondary aim to study injury pattern, length of stay (LOS), and mortality in patients with and without CWI. METHODS: This is a retrospective study of adult patients who were admitted to our hospital due to cardiac arrest (CA) during 2012 to 2020. Patients were identified in the Swedish CPR Registry and those undergoing CT of the thorax within 2 weeks after CPR were included. Patients with traumatic CA, chest wall surgery prior or after CA were excluded. Demographic data, type and length of CPR, type of CWI, LOS on mechanical ventilator (MV), in intensive care unit (ICU) and in hospital (H), and mortality were studied. RESULTS: Of 1,715 CA patients, 245 met the criteria for inclusion. The majority (79%) of the patients suffered from CWI. Chondral injuries and rib fractures were more common than sternum fractures (95% vs. 57%), and 14% had a radiological flail segment. Patients with CWI were older (66.5 ± 15.4 vs. 52.5 ± 15.2, p < 0.001). No difference was seen in MV-LOS (3 [0-43] vs. 3 [0-22]; p = 0.430), ICU-LOS (3 [0-48] vs. 3 [0-24]; p = 0.427), and H-LOS (5.5 [0-85] vs. 9.0 [1-53]; p = 0.306) in patients with or without CWI. Overall mortality within 30 days was higher with CWI (68% vs. 47%, p = 0.007). CONCLUSION: Chest wall injuries are common after CPR and 14% of patients had a flail segment on CT. Elderly patients have an increased risk of CWI, and a higher overall mortality is seen in patients with CWI. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Watch Out for the Early Killers: Imaging Diagnosis of Thoracic Trauma.

Radiologists and trauma surgeons should monitor for early killers among patients with thoracic trauma, such as tension pneumothorax, tracheobronchial injuries, flail chest, aortic injury, mediastinal hematomas, and severe pulmonary parenchymal injury. With the advent of cutting-edge technology, rapid volumetric computed tomography of the chest has become the most definitive diagnostic tool for establishing or excluding thoracic trauma. With the notion of "time is life" at emergency settings, radiologists must find ways to shorten the turnaround time of reports. One way to interpret chest findings is to use a systemic approach, as advocated in this study. Our interpretation of chest findings for thoracic trauma follows the acronym "ABC-Please" in which "A" stands for abnormal air, "B" stands for abnormal bones, "C" stands for abnormal cardiovascular system, and "P" in "Please" stands for abnormal pulmonary parenchyma and vessels. In the future, utilizing an artificial intelligence software can be an alternative, which can highlight significant findings as "warm zones" on the heatmap and can re-prioritize important examinations at the top of the reading list for radiologists to expedite the final reports.

Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury.

OBJECTIVE: To compare the effectiveness of surgical stabilization of rib fractures (SSRFs) to nonoperative management in severe chest wall injury. BACKGROUND: SSRF has been shown to improve outcomes in patients with clinical flail chest and respiratory failure. However, the effect of SSRF outcomes in severe chest wall injuries without clinical flail chest is unknown. METHODS: Randomized controlled trial comparing SSRF to nonoperative management in severe chest wall injury, defined as: (1) a radiographic flail segment without clinical flail or (2) ≥5 consecutive rib fractures or (3) any rib fracture with bicortical displacement. Randomization was stratified by the unit of admission as a proxy for injury severity. Primary outcome was hospital length of stay (LOS). Secondary outcomes included intensive care unit (ICU) LOS, ventilator days, opioid exposure, mortality, and incidences of pneumonia and tracheostomy. Quality of life at 1, 3, and 6 months was measured using the EQ-5D-5L survey. RESULTS: Eighty-four patients were randomized in an intention-to-treat analysis (usual care = 42, SSRF = 42). Baseline characteristics were similar between groups. The numbers of total fractures, displaced fractures, and segmental fractures per patient were also similar, as were the incidences of displaced fractures and radiographic flail segments. Hospital LOS was greater in the SSRF group. ICU LOS and ventilator days were similar. After adjusting for the stratification variable, hospital LOS remained greater in the SSRF group (RR: 1.48, 95% CI: 1.17-1.88). ICU LOS (RR: 1.65, 95% CI: 0.94-2.92) and ventilator days (RR: 1.49, 95% CI: 0.61--3.69) remained similar. Subgroup analysis showed that patients with displaced fractures were more likely to have LOS outcomes similar to their usual care counterparts. At 1 month, SSRF patients had greater impairment in mobility [3 (2-3) vs 2 (1-2), P = 0.012] and self-care [2 (1-2) vs 2 (2-3), P = 0.034] dimensions of the EQ-5D-5L. CONCLUSIONS: In severe chest wall injury, even in the absence of clinical flail chest, the majority of patients still reported moderate to extreme pain and impairment of usual physical activity at one month. SSRF increased hospital LOS and did not provide any quality of life benefit for up to 6 months.

In- and out-of-hospital outcomes following surgical stabilization of rib fractures in 80 years and older: A single-institution experience.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) has demonstrated benefit in patients with flail chest and multiple displaced fractures. There is mounting evidence for SSRF following chest wall injury (CWI) for the geriatric trauma population. A recent multi-center retrospective study highlighted a mortality benefit even for those patients aged 80 years and older. The objective of this investigation was to review our institutional experience with both in- and out-of-hospital outcomes within this patient population following SSRF. METHODS: A retrospective review of patients 80 years and older was performed at a high-volume level 2 trauma center from 2017 to 2021. SSRF volume is routinely >60 cases per year. Perioperative, inpatient, and outpatient data were collected as available. Primary outcomes were inpatient and 90-day mortality. Secondary outcomes included discharge on narcotics and freedom from narcotics at 30 days. RESULTS: 50 patients were included for review. Mean age was 86 years and mechanism of injury was most often fall. 28 of 50 (56%) patients had flail chest (radiographic). Mean number of ribs fixated was 4.7 and time to surgery 2.5 days. Inpatient mortality was 3/50 (6%), 90-day mortality was 9/50 (18%) of which three were attributable primarily to CWI (6/50, 12%). Of patients with follow-up of 1 year and beyond, 27/28 were alive (96%). With respect to narcotic consumption, 45% (21/47) were discharged on narcotics with 90% (28/31; N limited by missing data) being narcotic-free at 30 days. CONCLUSION: In this high-risk patient population, inpatient mortality was comparably low to prior reports, though 90-day mortality was doubled when incorporating CWI-related deaths. Narcotic use was seen in the minority of patients upon discharge, and most progressed to being narcotic-free at 30 days post-hospitalization. Inpatient outcomes alone may not adequately define both the benefit and risk of SSRF performed in patients 80 years and older.

Timely surgical fixation confers beneficial outcomes in patients' concomitant flail chest with mild-to-moderate traumatic brain injury: a trauma quality improvement project analysis - a cohort study.

BACKGROUND: Traumatic flail chest results in respiratory distress and prolonged hospital stay. Timely surgical fixation of the flail chest reduces respiratory complications, decreases ventilator dependence, and shortens hospital stays. Concomitant head injury is not unusual in these patients and can postpone surgical timing due to the need to monitor the status of intracranial injuries. Reducing pulmonary sequelae also assists in the recovery from traumatic brain injury and improves outcomes. No previous evidence supports that early rib fixation can improve the outcome of patients with concomitant flail chest and traumatic brain injury. RESEARCH QUESTION: Can early rib fixation improve the outcome of patients with concomitant flail chest and traumatic brain injury? STUDY DESIGN AND METHODS: Adult patients with blunt injuries from the Trauma Quality Improvement Project between 2017 and 2019 were eligible for inclusion. Patients were divided into two treatment groups: operative and nonoperative. Inverse probability treatment weighting was used to identify the predictors of mortality and adverse hospital events. RESULTS: Patients in the operative group had a higher intubation rate [odds ratio (OR), 2.336; 95% CI, 1.644-3.318; p <0.001), a longer length of stay (coefficient ß , 4.664; SE, 0.789; p <0.001), longer ventilator days (coefficient ß , 2.020; SE, 0.528; p <0.001), and lower mortality rate (OR], 0.247; 95% CI, 0.135-0.454; p <0.001). INTERPRETATION: Timely rib fixation can improve the mortality rate of patients with flail chest and a concomitant mild-to-moderate head injury.

The effectiveness of early surgical stabilization for multiple rib fractures: a multicenter randomized controlled trial.

INTRODUCTION: Multiple rib fractures (≥ 3 displaced rib fractures and/or flail chest) are severe chest trauma with high morbidity and mortality. Rib fixation has become the first choice for multiple rib fracture treatment. However, the timing of surgical rib fixation is unclear. MATERIALS AND METHODS: The present study explored whether early rib fracture fixation can improve the outcome of multiple rib fractures. The present research included patients who were hospitalized in three Jiangsu hospitals following diagnosis with multiple rib fractures. Patients received early rib fracture fixation (≤ 48 h) or delayed rib fracture fixation (> 48 h) utilizing computer-based random sequencing (in a 1:1 ratio). The primary outcome measures included hospital length of stay, intensive care unit (ICU) stay, mechanical ventilation, inflammatory cytokine levels, infection marker levels, infection, and mortality. RESULTS: A total of 403 individuals were classified into two groups, namely, the early group (n = 201) and the delayed group (n = 202). Patients belonging to the two groups had similar baseline clinical data, and there were no statistically significant differences between them. Early rib fracture fixation greatly decreased the length of stay in the ICU (4.63 days vs. 6.72 days, p < 0.001), overall hospital stay (10.15 days vs. 12.43 days, p < 0.001), ventilation days (3.67 days vs. 4.55 days, p < 0.001), and hospitalization cost (6900 USD vs. 7600 USD, p = 0.008). Early rib fracture fixation can decrease inflammatory cytokine levels and infection marker levels, prevent hyperinflammation and improve infection in patients with multiple rib fractures. The timing of rib fracture fixation does not influence the surgical procedure time, operative blood loss, 30-day all-cause mortality, or surgical site infection. CONCLUSION: The findings from the present research indicated that early rib fracture fixation (≤ 48 h) is a safe, rational, effective and economical strategy and worth clinical promotion.

Stabilization of after-traumatic flail chest by minimally invasive modified NUSS procedure in patient with starting respiratory insufficiency.

A flail chest is one of the possible medical conditions suffered by individuals who were injured in traffic accidents, caused by multiple fractures of the ribs and sternum. Which often results in paradoxical chest movements. The consequence may be respiratory failure and need for long-term mechanical ventilation. Such treatment require Intensive Care Unit and may be associated with the possibility of numerous complications.Modified Nuss procedure was performed in 79-year-old man, a victim of a car crash to obtain stabilization of the flail chest. After compensation of paradoxical movements on the third day it was possible to end mechanical ventilation. A quick procedure dedicated to the congenital deformation of the chest made it possible to avoid long, expensive intensive therapy with possible respiratory complications.The NUSS procedure enables the effective and safe treatment of a flail chest in a selected group of patients.

Rib Fixation for Multiple Rib Fractures: Healthcare Professionals Perceived Barriers and Facilitators to Clinical Implementation.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) is associated with improved respiratory symptoms and shorter intensive care admission in patients with flail chest. For multiple rib fractures, the benefit of SSRF remains a topic of debate. This study investigated barriers and facilitators of healthcare professionals to SSRF as treatment for multiple traumatic rib fractures. METHODS: Dutch healthcare professionals were asked to complete an adapted version of the Measurement Instrument for Determinants of Innovations questionnaire to identify barriers and facilitators of SSRF. If ≥ 20% of participants responded negatively, the item was considered a barrier, and if ≥ 80% responded positively, the item was considered a facilitator. RESULTS: Sixty-one healthcare professionals participated; 32 surgeons, 19 non-surgical physicians, and 10 residents. The median experience was 10 years (P25-P75 4-12). Sixteen barriers and two facilitators for SSRF in multiple rib fractures were identified. Barriers included lack of knowledge, experience, evidence on (cost-)effectiveness, and the implication of more operations and higher medical costs. Facilitators were the assumption that SSRF alleviates respiratory problems and the feeling that surgeons are supported by colleagues for SSRF. Non-surgeons and residents reported more and several different barriers than surgeons (surgeons: 14; non-surgical physicians: 20; residents: 21; p < 0.001). CONCLUSION: For adequate implementation of SSRF in patients with multiple rib fractures, implementation strategies should address the identified barriers. Especially, improved clinical experience and scientific knowledge of healthcare professionals, and high-level evidence on the (cost-) effectiveness of SSRF potentially increase its use and acceptance.

Minimally invasive surgery for anterior flail chest injury in the acute phase: series of 10 cases.

OBJECTIVE: Anterior flail chest frequency represents a significant case of ventilator insufficiency. Surgical stabilization of acute phase of trauma is considered to effectively shorten the period of ventilation compared to conservative treatment using mechanical ventilation. We have applied minimally invasive surgery to stabilize the injured chest wall. METHODS: Surgical stabilization of predominantly anterior flail chest segments was performed using one or two bars as per the Nuss procedure, during the acute phase of chest trauma. Data from all patients were examined. RESULTS: Ten patients received surgical stabilization using the Nuss method between 1999 and 2021. All patients had already been mechanically ventilated prior to surgery. The mean period from trauma to surgery was 4.2 days (range, 1-8 days). The number of bars used was one for 7 patients, and two for 3 patients. The mean operation time was 60 min (range, 25-107 min). All patients were extubated from artificial respiration without surgical complications or mortality. Mean total ventilation period was 6.5 days (range, 2-15 days). All bars were removed in a subsequent surgery. No collapses or fracture recurrences were observed. CONCLUSION: This method is simple and effective for fixed anterior dominant frail segment.