Introduction
Methods
Search strategy and eligibility criteria
Data extraction
Outcome measures
Quality assessment
Statistical analysis
Subgroup and sensitivity analyses
Results
Search
Patient characteristics
Study | Study design | Country | Number of patients | Follow-up (months) | Age (years, range or ± SD) | Male (%) | Number of fractured ribs | ISS score | |
---|---|---|---|---|---|---|---|---|---|
Dehghan et al. (2018) [43] | RC | Canada | RF | 77 | NR | 52 ± 18 | 55 (76) | NR | NR |
NOM | 1631 | 58 ± 18 | 1176 (72) | ||||||
Ali-Osman et al. (2018) [42] | RC | USA | RF | 64 | NR | 68.5 [63–74] | 41 (64) | 7 [5.25-9] | 17.5 [9–25} |
NOM | 135 | 72 [66–81] | 73 (54) | 5 [3-7.25] | 14 [8–24] | ||||
Wijffels et al. (2018) [41] | CC | RF | 20 | NR | 60 [41–69] | 15 (75) | 9 [8–11] | 31 [21–48] | |
NOM | 20 | 57 [44–69] | 15 (75) | 10 [9–14] | 32 [21–41] | ||||
Kane et al. (2018) [44] | RC | RF | 116 | NR | 58.3 ± 14.4 | NR | NR | 21.6 (9.1) | |
NOM | 1000 | 46.9 ± 29.3 | 16.1 (11.4) | ||||||
Fitzgerald et al. (2017) [33] | CC | USA | RF | 23 | NR | 68 (63–89) | NR | NR | 21 (16–26) |
NOM | 50 | 75 (65–97) | 19 (14–23) | ||||||
Farquhar et al. (2016) [39] | CC | Canada | RF | 19 | 21.9 ± 13.2 | 53 ± 14 | 15 (79) | NR | 31.4 ± 9.6 |
NOM | 36 | 16.0 ± 12.1 | 57 ± 16 | 25 (69) | 29.3 ± 8.1 | ||||
Pieracci et al. (2016) [37] | PC | USA | NOM | 35 | 16.0 [10.0, 23.0] | 50 + 15 | 24 (69) | 9.0 [6.0, 13.0] | 22.0 [17.0,38.0] |
Defreest et al. (2016) [38] | RC | USA | RF | 41 | 28.3 (9–69) | 51 (19–80) | 32 (78) | 11.2 (6–19) | 27.5 (16–48) |
NOM | 45 | 13.0 (3–43) | 56 (23–89) | 39 (87) | 10.6 (6–23) | 29.3 (16–66) | |||
Uchida et al. (2016) [30] | CC | Japan | RF | 10 | NR | 63 [51, 72] | 7 (70) | 5 [4, 8] | NR |
NOM | 10 | 57 [53, 75] | 7 (70) | 5 [2, 7] | |||||
Velasquez et al. (2016) [47] | CC | USA | RF | 20 | 6 [4, 10] | 51 [41, 63] | NR | 5 [4, 8] | 9 [9, 16] |
NOM | 20 | 16 [11, 22] | 45 [36, 55] | 5 [4.6, 5] | 13 [9, 17] | ||||
Qiu et al. (2016a) [18] | RC | China | RF | 21 | NR | 35 ± 13 | 15 (48) | 6.0 ± 1.3 | NR |
NOM | 17 | 36 ± 14 | 12 (71) | 5.9 ± 1.3 | |||||
Qiu [18] | RC | China | RF | 65 | NR | 38 ± 12 | 46 (71) | 3.2 ± 1.2 | NR |
NOM | 59 | 36 ± 12 | 42 (71) | 3.5 ± 1.2 | |||||
Jayle et al. (2015) [51] | CC | France | RF | 10 | 21.7 ± 7.8 | 48 ± 11 | 8 (80) | 7.7 ± 2.4 | 21.7 ± 7.80 |
NOM | 10 | 32.3 ± 19.3 | 51 ± 13 | 8 (80) | 6.6 ± 2.9 | 32.3 ± 19.3 | |||
Zhang Y (2015) [25] | RC | China | RF | 24 | 38 33, 54.25] | 43 [34, 50] | 19 (79) | 11.5 [8, 15.3] | 38 [34, 43] |
NOM | 15 | 60 [38, 99.75] | 47 [35, 55] | 14 (93) | 11 [7, 16] | 38 [35, 43] | |||
Zhang X (2015) [46] | CC | China | RF | 23 | 419,4 ± 107.1 | 58 ± 12 | 21 (72) | 7.8 ± 1.5 | NR |
NOM | 29 | 419,4 ± 107.1 | 60 ± 10 | 16 (70) | 7.4 ± 1.7 | ||||
Wada et al. (2015) [34] | CC | Japan | RF | 84 | 33 (24–45) | NR | 59 (70) | NR | NR |
NOM | 336 | 42 (23–58) | 225 (76) | ||||||
Wu et al. (2015) [32] | PC | China | RF | 75 | 15.3 ± 6.4 | 52 ± 5 | 75 (100) | 8.1 (6–12) | NR |
NOM | 89 | 26.5 ± 6.9 | 51 ± 3 | 89 (100) | 7.9 (6–11) | ||||
Majercik et al. (2015) [16] | CC | USA | RF | 137 | 11.4 + 5.7 | 56 ± 16 | 110 (80) | 6.5 ± 2.0 | 21 ± 10.7 |
NOM | 274 | 12.3 + 9.1 | 55 ± 20 | 56 (80) | 4.6 ± 2.3 | 22 ± 11.8 | |||
Xu et al. (2015) [28] | RC | China | RF | 17 | NR | 36 ± 14 | 12 (71) | 6.8 ± 2.1 | 21.8 ± 7.8 |
NOM | 15 | 39 ± 12 | 12 (80) | 7.4 ± 1.6 | 24.0 ± 8.0 | ||||
Granhed and Pazooki (2014) [43] | CC | Sweden | RF | 60 | NR | NR | 53 (77) | 7.5 (2–14) | 21.7 ± 10.7 |
NOM | 153 | NR | NR | NR | 30.9 ± 13.3 | ||||
Doben et al. (2014) [40] | CC | USA | RF | 10 | 21.6 (8–59) | 47 ± 15 | 9 (90) | 8.3 (4–20) | 26.3 ± 9.5 |
NOM | 11 | 28.5 (6–50) | 57 ± 17 | 7 (64) | 9.2 (6–16) | 35.7 ± 12.7 | |||
Marasco et al. (2013) [50] | RCT | Australia | RF | 23 | 90 | 58 ± 17 | 20 (87) | 11.0 ± 3.1 | 35.0 ± 11.4 |
NOM | 23 | 90 | 59 ± 10 | 20 (87) | 11.3 ± 4.7 | 30.0 ± 6.3 | |||
Khandelwal et al. (2011) [29] | PC | India | RF | 31 | 30 | 47 | 40 (66) = total group | 3.1 | NR |
NOM | 29 | 30 | 45 | 3.3 | |||||
Moya et al. (2011) [31] | CC | USA | RF | 16 | 18 ± 12 | 45 ± 16 | 14 (88) | 8 ± 4 | 24 ± 7 |
NOM | 32 | 16 ± 11 | 47 ± 14 | 26 (81) | 8 ± 3 | 25 ± 9 | |||
Althausen et al. (2011) [26] | CC | USA | RF | 22 | 17.84 ± 4.51 | 48 | 17 (74) | 5.9 | 25.1 |
NOM | 28 | NR | 51 | 23 (79) | 7.3 | 24.3 | |||
Solberg et al. (2009) [24] | RC | USA | RF | 9 | 16.1 ± 6.7 | 39 ± 17 | 6 (67) | NR | 24.9 ± 6.5 |
NOM | 7 | 12.0 ± 2.3 | 41 ± 13 | 5 (71) | 24.8 ± 6.2 | ||||
Nirula et al. (2006) [35] | CC | USA | RF | 30 | NR | 52 | NR | NR | 25.7 |
NOM | 30 | 50 | 27.5 | ||||||
Granetzny [23] | RCT | Germany | RF | 20 | 2 | 41 ± 8 | 17 (85) | 4.4 | 16.8 ± 3.5 |
NOM | 20 | 2 | 36 ± 15 | 16 (80) | 4.0 | 18.0 ± 5.1 | |||
Balci et al. (2004) [45] | RC | Turkey | RF | 27 | NR | 35 ± 8 | 20 (74) | NR | 21.0 ± 7.4 |
NOM | 37 | 31 ± 10 | 28 (76) | 18.4 ± 8.1 | |||||
Tanaka et al. (2002) [22] | RCT | Japan | RF | 18 | 360 | 43 ± 12 | 12 (67) | 8,2 ± 3.3 | 33 ± 11 |
NOM | 19 | 360 | 46 ± 9 | 14 (74) | 8.2 ± 2.6 | 30 ± 8 | |||
Voggenreiter (1996a) [19] | RC | Germany | RF | 10 | NR | 55 ± 8 | NR | NR | 31.0 ± 7.0 |
NOM | 18 | 44 ± 19 | 36.6 ± 12.3 | ||||||
Voggenreiter (1996a) [19] | RC | Germany | RF | 10 | NR | 50 ± 16 | NR | NR | 37.0 ± 7.9 |
NOM | 4 | 48 ± 27 | 37.8 ± 19.5 | ||||||
Ahmed and Mohyuddin (1995) [37] | RC | United Arab Emirates | RF | 26 | (3–9) | 20–60 (range) | 23 (88) | NR | NR |
NOM | 38 | (3–9) | 10–60 (range) | 36 (95) | NR | ||||
Kim et al. (1981) [49] | RC | France | RF | 18 | NR | NR | NR | NR | NR |
NOM | 142 | ||||||||
Aubert et al. (1981) [48] | RC | France | NOM | 224 | NR | NR | NR | NR | NR |
Study | Treatment groups | Included fractures | Flail chest in surgery group n (%) | Indication for surgery |
---|---|---|---|---|
Dehghan et al. (2018) [43] | NR | FC | 77 (100%) | NR |
Ali-Osman et al. (2018) [42] | RF: plates + screws | FC + MRF | NR | Displaced rib fractures, uncontrolled pain, rib crepitus with breathing |
NOM: aggressive pain management | ||||
Wijffels et al. (2018) [41] | RF: plates + intramedullary nails | FC | 20 (100%) | Flail chest |
NOM: supportive management | ||||
Kane et al. (2018) [44] | RF: NR | FC + MRF | 75 (65%) | 3 consecutively displaced rib fractures plus FEV1 and FVC less than 50% predicted |
NOM: aggressive multimodal analgesia protocol | ||||
Fitzgerald et al. (2017) [33] | RF: plates + screws | FC + MRF | NR | NR |
NOM: NR | ||||
Farquhar et al. (2016) [39] | RF: plates + screws | FC | 19 (100%) | FC (≥ 3 fractures), displaced, segmental rib fractures with respiratory insufficiency |
NOM: standard conservative treatment | ||||
Pieracci et al. (2016) [37] | RF: titanium plates + screws | FC + MRF | 28 (80%) | FC (≥ 3 fractures), ≥ 3 displaced fractures; ≥ 30% thorax volume loss, failure treatment within first 72 h |
NOM: standard conservative treatment | ||||
Defreest et al. (2016) [38] | RF: titanium locking plates + screws | FC | 41 (100%) | Failure to wean, intractable pain, or respiratory failure |
NOM: NR | ||||
Uchida et al. (2016) [30] | RF: titanium plates + locking screws | FC + MRF | NR | Flail segment, massive dislocation, > 15 mm fracture overlapping, or pain |
NOM: conservative management + chest strap | ||||
Velasquez et al. (2016) [47] | RF: Thoracic Osteosynthesis System (STRATOS) | FC + MRF | NR | FC (≥ 3), ≥ 3 ribs fractured + respiratory failure, intractable pain, thorax deformity, or displacement |
NOM: NR | ||||
Qiu et al. (2016a) [18] | RF: AO standard plates + cancellous screws | FC | 21 (100%) | NR |
NOM: NR | ||||
Qiu (2016) [18] | RF: AO standard plates + cancellous screws | MRF | 0 (0%) | NR |
NOM: NR | ||||
Jayle et al. (2015) [51] | RF: titanium plates + screws | FC | 10 (100%) | FC (≥ 3 fractures) |
NOM: NR | ||||
Zhang Y (2015) [25] | RF: ORIF | FC with PC | 24 (100%) | NR |
NOM: NR | ||||
Zhang X (2015) [46] | RF: claw-type titanium plates | FC | 23 (100%) | FC (≥ 3 fractures) |
NOM: standard conservative treatment | ||||
Wada et al. (2015) [34] | RF: ORIF | FC + MRF | 84 (100%) | NR |
NOM: NR | ||||
Wu et al. (2015) [32] | RF: nickel–titanium alloy devices | FC + MRF | 31 (41%) | FC (≥ 3 fractures), ≥ 3 rib fractures, dislocation, thorax deformity, or chest cavity active bleeding |
NOM: conservative management + chest strap | ||||
Majercik et al. (2015) [16] | RF: plates + locking screws | FC + MRF | 101 (75%) | FC, severely displaced fractures, intractable pain, failure to wean, or combination of these |
NOM: standard conservative management | ||||
Xu et al. (2015) [28] | RF: titanium locking plates | FC | 17 (100%) | NR |
NOM: standard conservative management | ||||
Granhed and Pazooki (2014) [43] | RF: titanium plates + intramedullary splints | FC + MRF | 56 (93%) | Impaired saturation in spite of oxygen administration; intractable pain |
NOM: NR | ||||
Doben et al. (2014) [40] | RF: plates + intramedullary nails | FC | 10 (100%) | Failure of nonoperative management |
NOM: standard conservative management | ||||
Marasco et al. (2013) [50] | RF: inion resorbable plates + bicortical screws | FC | 23 (100%) | FC (≥ 3 fractures) and ventilator dependent without prospect of weaning within 48 h |
NOM: mechanical ventilator management | ||||
Khandelwal et al. (2011) [29] | RF: titanium plates + screws | FC + MRF | 2 (5.3%) | NRS score > 7 on 10 days after trauma |
NOM: NR | ||||
Moya et al. (2011) [31] | RF: titanium or steel plates | FC + MRF | 9 (56%) | Intractable pain, ≥ 2 severely displaced rib fractures with pain, and respiratory failure |
NOM: NR | ||||
Althausen et al. (2011) [26] | RF: locking plates + locking screws | FC | 22 (100%) | FC with displacement, failure to wean, respiratory failure, or need of thoracotomy |
NOM: NR | ||||
Solberg et al. (2009) [24] | RF: titanium plates | FC | 9 (100%) | Superolateral chest wall deformity |
NOM: ventilatory pneumatic stabilization | ||||
Nirula et al. (2006) [35] | RF: Adkin struts | FC + MRF | 15 (50%) | FC, intractable pain, bleeding, and inability to wean |
NOM: NR | ||||
Granetzny (2006) [23] | RF: K-wires and/or stainless steel wire | FC | 20 (100%) | FC (≥ 3 rib fractures) with paradoxical chest wall movement |
NOM: strapping and packing | ||||
Balci et al. (2004) [45] | RF: suture and traction | FC | 27 (100%) | FC with paradoxical chest wall movement, respiratory failure, dyspnea, and insufficient blood gas |
NOM: endotracheal intubation | ||||
Tanaka et al. (2002) [22] | RF: Judet struts | FC | 18 (100%) | FC (≥ 6 fractures) with respiratory failure requiring mechanical ventilation and failure to wean |
NOM: internal pneumatic stabilization | ||||
Voggenreiter (1996a) [19] | RF: ASIF reconstruction plates | FC without PC | 10 (100%) | FC and thoracotomy for other injury, respiratory failure, paradoxical chest wall movement, or deformity |
NOM: standard conservative management | ||||
Voggenreiter (1996a) [19] | RF: ASIF reconstruction plates | FC with PC | 10 (100%) | FC and thoracotomy for other injury, respiratory failure, paradoxical chest wall movement, severe deformity |
NOM: standard conservative management | ||||
Ahmed and Mohyuddin (1995) [37] | RF: K-wires | FC | 26 (100%) | NR |
NOM: endotracheal intubation | ||||
Kim et al. (1981) [49] | RF: Judet struts | FC | 18 (100%) | NR |
NOM: internal pneumatic stabilization | ||||
Aubert et al. (1981) [48] | RF: osteosynthesis | FC | 22 (100%) | NR |
NOM: ventilator assistance, physiotherapy |
Quality assessment
Mortality
Analysis description |
n
| Mortality |
n
| HLOS |
n
| ILOS | |||
---|---|---|---|---|---|---|---|---|---|
RR (95% CI) | P value | MD (95% CI) | P value | MD (95% CI) | P value | ||||
All studies | 25 | 0.41 (0.27, 0.61) | p < 0.001 | 21 | − 1.46 (− 4.31, 1.39) | 0.32 | 26 | − 2.00 (− 3.61, − 0.38) | 0.02 |
Subgroup analysis | |||||||||
RCT | 3 | 0.57 (0.13, 2.52) | 0.46 | 2 | − 8.33 (− 14.60, − 2.07) | 0.009 | 3 | − 6.37 (− 9.72, − 3.03) | p < 0.001 |
Observational studies | 22 | 0.40 (0.26, 0.60) | p < 0.001 | 19 | − 0.77 (− 3.72, 2.18) | 0.61 | 23 | − 1.53 (− 3.21, 0.15) | 0.07 |
Sensitivity analysis | |||||||||
High-quality studies | 13 | 0.71 (0.35, 1.44) | 0.34 | 15 | − 3.53 (− 7.27, 0.21) | 0.06 | 17 | − 2.83 (− 4.75, − 0.91) | 0.004 |
Studies after 2012 | 17 | 0.43 (0.25, 0.77) | 0.004 | 16 | − 0.64 (− 3.98, 2.69) | 0.71 | 19 | − 1.51 (− 3.40, 0.37) | 0.12 |
Analysis description |
n
| DMV |
n
| Pneumonia |
n
| Tracheostomy | |||
---|---|---|---|---|---|---|---|---|---|
MD (95% CI) | P value | RR (95% CI) | P value | RR (95% CI) | P value | ||||
All studies | 27 | − 4.01 (− 5.58, − 2.45) | p < 0.001 | 25 | 0.59 (0.42, 0.83) | p <0.001 | 16 | 0.59 (0.39, 0.90) | 0.01 |
Subgroup analysis | |||||||||
RCT | 3 | − 5.88 (− 11.32, − 0.44) | 0.03 | 3 | 0.36 (0.15, 0.85) | 0.02 | 2 | 0.38 (0.14, 1.02) | 0.05 |
Observational studies | 23 | − 3.79 (− 5.46, − 2.11) | p <0.001 | 22 | 0.63 (0.44, 0.92) | 0.02 | 14 | 0.63 (0.40, 1.01) | 0.05 |
Sensitivity analysis | |||||||||
High-quality studies | 17 | − 3.87 (− 6.06, − 1.68) | 0.000 | 16 | 0.55 (0.37, 0.82) | 0.004 | 10 | 0.57 (0.41, 0.80) | 0.001 |
Studies after 2012 | 18 | − 3.27 (− 5.11, − 1.43) | 0.000 | 16 | 0.73 (0.50, 1.06) | 0.10 | 12 | 0.73 (0.47, 1.14) | 0.16 |