An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers study (CWIS-CC2).

BACKGROUND: Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers. METHODS: A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded. RESULTS: Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF. CONCLUSION: Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Recent Advances in Rib Plating.

Rib fractures are a common injury in blunt trauma and are associated with high morbidity and mortality. Recent advances in surgical stabilization of rib fractures (SSRF) have led to better patient outcomes for those with highly unstable complex rib fractures, as well as those with less severe injuries. This result has been due in part to the expansion of indications for repair, as well as the development of new hardware systems to address a variety of fracture patterns and injuries. This joint advancement of operator techniques, outcomes research, and industry development has brought SSRF to the forefront of rib fracture management and challenged non-operative paradigms. The future of repair is now shifting focus, as surgeons develop minimally invasive approaches and challenge manufacturers to develop new systems, instruments, and materials to address increasingly complex fracture patterns. These expansions promise to make SSRF an increasingly effective form of management for traumatic rib fractures.

Expert consensus guidance on respiratory physiotherapy and rehabilitation of patients with rib fractures: An international, multidisciplinary e-Delphi study.

BACKGROUND: There is limited research supporting optimal respiratory physiotherapy or physical rehabilitation strategies for patients with rib fractures. The aim of this study was to develop key recommendations for the physiotherapy management of patients with rib fractures. METHODS: A three-round modified e-Delphi survey design, using an international Delphi panel including physiotherapy clinicians, researchers and lecturers, physician associates, trauma surgeons, and intensivists, was used in this study. The draft recommendations were developed by the Steering Group, based on available research. Over three rounds, panelists rated their agreement (using a Likert scale) with regard to recommendation for physiotherapists delivering respiratory physiotherapy and physical rehabilitation to patients following rib fractures. Recommendations were retained if they achieved consensus (defined as ≥70% of panelists ≥5/7) at the end of each round. RESULTS: A total of 121 participants from 18 countries registered to participate in the study, with 87 (72%), 77 (64%), and 79 (65%) registrants completing the three rounds, respectively. The final guidance document included 18 respiratory physiotherapy and rehabilitation recommendations, mapped over seven clinical scenarios for patients (1) not requiring mechanical ventilation, (2) requiring mechanical ventilation, (3) with no concurrent fracture of the shoulder girdle complex, (4) with a concurrent fracture of the shoulder girdle complex, (5) with/without concurrent upper limb orthopedic injuries, (6) undergoing surgical stabilization of rib fractures, and (7) at hospital discharge. CONCLUSION: This guidance provides key recommendations for respiratory physiotherapy and physical rehabilitation of patients with rib fractures. It could also be used to inform future research priorities in the field. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Interobserver agreement for the Chest Wall Injury Society taxonomy of rib fractures using computed tomography images.

BACKGROUND: In 2020, a universal nomenclature for rib fractures was proposed by the international Chest Wall Injury Society taxonomy collaboration. The purpose of this study is to validate this taxonomy. We hypothesized that there would be at least moderate agreement, regardless of the observers' background. METHODS: An international group of independent observers evaluated axial, coronal, and sagittal computed tomography images on an online platform from 11 rib fractures for location (anterior, lateral, or posterior), type (simple, wedge, or complex), and displacement (undisplaced, offset, or displaced) of rib fractures. The multirater κ and Gwet's first agreement coefficient (AC1) were calculated to estimate agreement among the observers. RESULTS: A total of 90 observers participated, with 76 complete responses (84%). Strong agreement was found for the classification of fracture location ( κ = 0.83 [95% confidence interval (CI) 0.69-0.97]; AC1, 0.84 [95% CI, 0.81-0.88]), moderate for fracture type ( κ = 0.46 [95% CI, 0.32-0.59]; AC1, 0.50 [95% CI, 0.45-0.55]), and fair for rib fracture displacement ( κ = 0.38 [95% CI, 0.21-0.54], AC1, 0.38 [95% CI, 0.34-0.42]). CONCLUSION: Agreement on rib fracture location was strong and moderate for fracture type. Agreement on displacement was lower than expected. Evaluating strategies such as comprehensive education, additional imaging techniques, or further specification of the definitions will be needed to increase agreement on the classification of rib fracture type and displacement as defined by the Chest Wall Injury Society taxonomy. LEVEL OF EVIDENCE: Diagnostic Test or Criteria; Level IV.

The Chest Wall Injury Society Recommendations for Reporting Studies of Surgical Stabilization of Rib Fractures.

BACKGROUND: Publications investigating the efficacy of surgical stabilization of rib fractures (SSRF) have increased exponentially. However, there is currently no standardized reporting structure for these studies, rendering both comparisons and extrapolation problematic. METHODS: A subject matter expert group was formed by the Chest Wall Injury Society. This group conducted a review of the SSRF investigational literature and identified variable reporting within several general categories of relevant parameters. A compliment of guidelines was then generated. RESULTS: The reporting guidelines consist of 26 recommendations in the categories of: (1) study type, (2) patient and injury characteristics, (3) patient treatments, (4) outcomes, and (5) statistical considerations. CONCLUSION: Our review identified inconsistencies in reporting within the investigational SSRF literature. In response to these inconsistencies, we propose a set of recommendations to standardize reporting of original investigations into the efficacy of SSRF.

Use of the Internet to Facilitate an Annual Scientific Meeting: A Report of the First Virtual Chest Wall Injury Society Summit.

INTRODUCTION: The COVID-19 pandemic has resulted in cancellation of medical peer meetings. The Chest Wall Injury Society Annual Summit was scheduled for April 2020. Due to safety concerns, the Society altered the meeting to an online format. The purpose of this paper is to describe how this was accomplished and also to highlight its outcomes. METHODS: An online survey of participants was carried out to assess their views on the educational yield and technical difficulties encountered as compared to in-person meetings. RESULTS: Sixty two of 275 (23%) registered participants filled out the survey. Eighty four percent felt that the educational quality was excellent/good. Seventy five percent and 95% felt in-person meetings are better for education and for networking, respectively. Eighty seven percent preferred in-person meetings in the future but would attend a virtual meeting again. Thirteen percent had technical difficulties accessing the meeting. CONCLUSION: Online meetings are feasible but in-person meetings have more educational and networking value.

Barriers to conducting a multi-center randomized controlled trial of surgical stabilization of rib fractures (and how to overcome them).

Surgical stabilization of rib fractures (SSRF) has become a standardized procedure, routinely performed at trauma centers over the last 40 years, however, it remains a controversial practice. Multicenter, randomized controlled trials (RCT) would provide compelling evidence in the efficacy of SSRF but there are theoretical obstacles involved with execution and design of this type of investigation. Through the systematic review of current literature on the topics of SSRF for flail and non-fail patterns, medical device industry conflicts of interests, working with international review boards (IRB), the surveyed opinions of surgeons, and through the experience gained from conducting a multicenter RCT on SSRF, it was possible to identify the major barriers that come with successful implementation of this type of study. In identifying these obstacles, it was then possible to propose their solutions, specifically to the issues that make the effort underpowered, underfunded, understaffed, with not enough time for completion. These barriers can be overcome with understanding, up front, that a mutlicenter RCT of SSRF will involve a multi-year and multi-hundred thousand dollar commitment, with support from parent organizations, and a dedicated, full-time research staff (and the solutions of how to overcome them). These barriers stem from poor planning which result specifically in an effort that is underpowered, under funded, under staffed, with not enough time for completion.