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. 2022 Aug 22;35(3):ivac214. doi: 10.1093/icvts/ivac214

Table 1:

Summary of studies

Author, date, journal and country Study type (level of evidence) Patient group Outcomes Key results Comments

  • Girsowicz et al. (2012),

  • Interact CardioVasc Thorac Surg [2]

  • [R] Best Evidence Topic

 Critical synthesis of 9 studies (comprising level 3 and level 4 evidence) Surgical fixation is safe and effective at treating pain and disability Studies demonstrated:

  1. Reduced pain (McGill pain questionnaire)

  2. Improved quality of life (RAND 36-Item Health Survey)

  3. Reduced socio-professional disability

  • Selected studies represent low levels of evidence, including cohort studies with no comparison group and case reports

  • Authors acknowledge the absence of prospective trials at time of writing

  • Marasco et al. (2022),

  • J Trauma Acute Care Surg [3]

  • Prospective randomized trial

  • (level 2)

  • 124 patients

  • 61 randomized to operative management

  • 61 randomized to nonoperative management

 McGill Pain Rating Index, median (IQR)

  • 3 months:

  • Operative: 7.7 (1.7–19.8)

  • Nonoperative: 3.6 (0.7–15.3)

  • P = 0.17

  • 6 months:

  • Operative: 2.6 (0–17.1)

  • Nonoperative: 0 (0–5.7)

  • P = 0.04

  • Inclusion criteria are non-ventilated patients with at least 3 consecutive rib fractures

  • High number of cross overs
Short Form 12 physical component score, mean (SD)

  • 3 months:

  • Operative: 42.9 (10)

  • Nonoperative: 44.4 (9.6)

  • P = 0.43

  • 6 months:

  • Operative: 44.4 (11.5)

  • Nonoperative: 47.6 (9.5)

  • P = 0.16
Short Form 12 mental component score, mean (SD)

  • 3 months:

  • Operative: 51.8 (9.5)

  • Nonoperative: 50.9 (10.0)

  • P = 0.66

  • 6 months:

  • Operative: 51.6 (10.1)

  • Nonoperative: 50.5 (11.9)

  • P = 0.65
Return to work, %

  • 3 months:

  • Operative: 48.7%

  • Nonoperative: 40%

  • P = 0.42

  • 6 months:

  • Operative: 65.7%

  • Nonoperative: 36.8%

  • P = 0.01

  • Pieracci et al. (2020),

  • J Trauma Acute Care Surg [4]

  • Prospective controlled trial

  • (level 2)

  • 110 patients. 23 selected randomization, 87 selected observation

  • 51 patients in total underwent SSRF within 72 h of admission. 59 nonoperative

 Numeric pain scores

  • 2 weeks:

  • SSRF: 2.9

  • Nonoperative: 4.5

  • P < 0.01

  • 4 weeks:

  • SSRF: 2.4

  • Nonoperative: 3.3

  • P = 0.03

  • 8 weeks:

  • SSRF: 1.5

  • Nonoperative: 3.3

  • P = 0.02

  • Only a small subset of the total patients were randomized. Potential allocation bias

  • Loss to follow-up limiting the power of the analysis at longer durations of follow-up

  • Potential institutional bias due to variability in analgesic regimens
Narcotic consumption (narcotic equivalents)

  • 2 weeks:

  • SSRF: 0.5

  • Nonoperative: 1.2

  • P = 0.05

  • 4 weeks:

  • SSRF: 0.3

  • Nonoperative: 1.5

  • P = 0.13

  • 8 weeks:

  • SSRF: 0.2

  • Nonoperative: 0.5

  • P = 0.08
Respiratory disability- related quality of life at 2 weeks

  • 2 weeks:

  • SSRF: 21

  • Nonoperative: 25

  • P = 0.03

  • 4 weeks:

  • SSRF: 17

  • Nonoperative: 22

  • P = 0.07

  • 8 weeks:

  • SSRF: 16

  • Nonoperative: 10

  • P = 0.27
Spirometry values

  • 2 weeks:

  • SSRF: 87.0%

  • Nonoperative: 90.0%

  • P = 0.41

  • 4 weeks:

  • SSRF: 100.0%

  • Nonoperative: 100.0%

  • P = 0.72

  • 8 weeks:

  • SSRF: 100.0%

  • Nonoperative: 97.5%

  • P = 0.17
Pleural space complications (tube thoracostomy or surgery for retained haemothorax or empyema >24 h from admission)

  • SSRF: 0%

  • Nonoperative: 10.2%

  • P = 0.02

  • Li et al. (2020),

  • J Thoracic Dis [5]

  • Prospective cohort study

  • (level 3)

  • 98 patients with non-flail rib fractures

  • 66 underwent MIS fixation

  • 32 matched controls received nonoperative treatment

 Pain index as measured by VAS at time of discharge

  • MIS: 3

  • Nonoperative: 6

  • P < 0.001

 Only 75.8% of surgically treated patients and 75% of nonoperative patients completed follow-up, reducing the power of the analysis
Lung function at time of discharge

  • Vital capacity:

  • MIS: 42.1%

  • Nonoperative: 35.3%

  • P = 0.027

  • FEV1:

  • MIS: 44.2%

  • Nonoperative: 35.9%

  • P = 0.027

  • PEF:

  • MIS: 21.2%

  • Nonoperative: 19.6%

  • P = 0.127
Duration of pain [time required for complete disappearance of chest pain or for only occasional pain (VAS < 2) to remain]

  • MIS: 1.0 months

  • Nonoperative: 1.9 months

  • P < 0.001
Duration of chest discomfort

  • MIS: 1.1 months

  • Nonoperative: 2.9 months

  • P < 0.001
Time to return to daily self-care

  • MIS: 0.9 months

  • Nonoperative: 1.2 months

  • P < 0.001
Time to return to mental labour

  • MIS: 1.9 months

  • Nonoperative: 2.8 months

  • P < 0.001
Time to return to moderate–severe physical labour

  • MIS: 5.4 months

  • Nonoperative: 5.8 months

  • P = 0.001

  • Zhang et al. (2019), World

  • J Clin Cases [6]

  • Prospective cohort study

  • (level 3)

  • 78 patients enrolled (with 3 or more severely displaced fractures, excluding flail pattern)

  • 39 surgical fixation

  • 39 nonoperative management

 Digital pain score (from 0 to 10) at 72 h, 1 week, 2 weeks, 4 weeks, 6 weeks, 3 months and 6 months Mean pain scores for surgical group were significantly lower than nonoperative group at every timepoint (F = 84.830, P < 0.001). A variety of analgesic regimens were used in the conservative group. May introduce inter-subject variability
Quality of life (SF-36 score)

  • 3 months:

  • Surgical: 393.57 ± 68.51

  • Nonoperative: 335.12 ± 83.11

  • P = 0.001

  • 6 months:

  • Surgical: 493.07 ± 69.97

  • Nonoperative: 363.64 ± 72.02

  • P < 0.001
Return to pre-injury level of work at 6 months

  • Surgical: 94.87

  • Nonoperative: 64.10%

  • P < 0.05

  • Qiu et al. (2016),

  • Indian J Surg [7]

  • Retrospective cohort study

  • (level 3)

  • 162 patients in total

  • In non-flail subgroup of 124 patients:

  • 65 surgical management

  • 59 nonoperative management

 Mean hospital stay (days)

  • Surgical: 11.09 ± 1.88

  • Nonoperative: 15.93 ± 2.75

  • P = 0.013

 Potential selection bias due to non-randomized retrospective design
VAS pain score at 2 months

  • Surgical: 1.45 ± 0.65

  • Nonoperative: 4.50 ± 1.05

  • P = 0.003
Return to normal activity (days)

  • Surgical: 28.18 ± 9.21

  • Nonoperative: 42.42 ± 10.12

  • P = 0.028
Fracture healing

  • Surgical: 98.46%

  • Nonoperative: 93.22%

  • P = 0.154
Atelectasis

  • Surgical: 6.15%

  • Nonoperative: 22.03%

  • P = 0.010
Pulmonary infection

  • Surgical: 4.62%

  • Nonoperative: 16.95%

  • P = 0.025

CT: computed tomography; FEV1: forced expiratory volume in 1 second; IQR: interquartile range; MIS: minimally invasive surgery; PEF: peak expiratory flow; SD: standard deviation; SSRF: surgical stabilization of rib fractures; VAS: visual analogue scale.