Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries
Authors: Dehghan Niloofar , Nauth Aaron , Schemitsch Emil , Vicente Milena , Jenkinson Richard , Kreder Hans , McKee Michael ,   Canadian Orthopaedic Trauma Society and the Unstable Chest Wall RCT Study Investigators, Hall Jeremy , Nathens Avery , Baker Andrew , Rizoli Sandro , Pollard Brian , Hidy Jennifer , Schemitsch Christine , Suthar Paril , MacNevin Melanie , Hameed Syed Morad , Joos Emilie , Slobogean Gerard P , Abercromby Shelley , Malthaner Richard , Fortin Dalilah , Lawendy Abdel , Lewis Deb , Furey Andrew , Stone Craig , Anthony Sarah , Keough Valisha , Parsons Minnie , Baker Erin , Stephen David , Henry Patrick , Tremblay Lorraine , Tien Homer , Milner Katrine , Kunz Monica , Ghent Wesley , Theriault Aimee , Sivananthan Araby , Adamsahib Fathima , Polihronidis Katerina , Shrikumar Mopina , Petrisor Brad A , Ristevski Bill , Williams Dale , Engels Paul , Al-Asiri Jamal , Johal Herman , Simunovic Nicole , Ratcliffe Jenna , Leonard Jordan , Crouch Sarah , Abdul Mannan Hiba , Bzovsky Sofia , Skelly Matthew , Marcano-Fernández Francesc A , Korley Robert , Duffy Paul , Schneider Prism , Martin Ryan , Buckley Richard , Kennedy Leah , Akbari Aftab , Yee Stephanie , Harrison Tanja , Tufescu Ted V , Srinathan Sadeesh , Pilkey Brad , Graham Chris , Sultana Nigar , Angeles Ramon , Harvey Edward , Berry Gregory , Reindl Rudolf , Talbot Max , Bernstein Mitchell , Khwaja Kosar , Ferri Lorenzo , Razek Tarek , Deckelbaum Dan , Spicer Jonathan , Grushka Jeremy , Beckett Andrew , Amedeo Mary , Campisi Josie , Alam Norine , Liew Allan , Papp Steven , Gofton Wade , Lalonde Karl-Andre , Pagliarello Guiseppe , Yelle Jean Denis , Foxall Julia , Harris Nicole , Cole Peter , Lafferty Paul , Vang Sandy , Jones Clifford , Endres Terence , Gregory Dennis , Scholten Donald , Sietsema Debra , Walker Jane , Padley Michelle A , Behrend Lindsey , Smith Singares Eduardo , Omi Ellen , Lelo Diane , Chamberlain Lisa , Braun Diane , Floyd Nicole M , Fielder Drew , Stahl Daniel L , Thorpe Kevin , Juni Peter , Da Costa Bruno , Bhandari Mohit , Singh Jeffrey , Aarts Mary-Anne , Madden Kim 
Published: September 2022

ImportanceUnstable chest wall injuries have high rates of mortality and morbidity. In the last decade, multiple studies have reported improved outcomes with operative compared with nonoperative treatment. However, to date, an adequately powered, randomized clinical trial to support operative treatment has been lacking.ObjectiveTo compare outcomes of surgical treatment of acute unstable chest wall injuries with nonsurgical management.Design, Setting, and ParticipantsThis was a multicenter, prospective, randomized clinical trial conducted from October 10, 2011, to October 2, 2019, across 15 sites in Canada and the US. Inclusion criteria were patients between the ages of 16 to 85 years with displaced rib fractures with a flail chest or non–flail chest injuries with severe chest wall deformity. Exclusion criteria included patients with significant other injuries that would otherwise require prolonged mechanical ventilation, those medically unfit for surgery, or those who were randomly assigned to study groups after 72 hours of injury. Data were analyzed from March 20, 2019, to March 5, 2021.InterventionsPatients were randomized 1:1 to receive operative treatment with plate and screws or nonoperative treatment.Main Outcomes and MeasuresThe primary outcome was ventilator-free days (VFDs) in the first 28 days after injury. Secondary outcomes included mortality, length of hospital stay, intensive care unit stay, and rates of complications (pneumonia, ventilator-associated pneumonia, sepsis, tracheostomy).ResultsA total of 207 patients were included in the analysis (operative group: 108 patients [52.2%]; mean [SD] age, 52.9 [13.5] years; 81 male [75%]; nonoperative group: 99 patients [47.8%]; mean [SD] age, 53.2 [14.3] years; 75 male [76%]). Mean (SD) VFDs were 22.7 (7.5) days for the operative group and 20.6 (9.7) days for the nonoperative group (mean difference, 2.1 days; 95% CI, −0.3 to 4.5 days; P = .09). Mortality was significantly higher in the nonoperative group (6 [6%]) than in the operative group (0%; P = .01). Rates of complications and length of stay were similar between groups. Subgroup analysis of patients who were mechanically ventilated at the time of randomization demonstrated a mean difference of 2.8 (95% CI, 0.1-5.5) VFDs in favor of operative treatment.Conclusions and RelevanceThe findings of this randomized clinical trial suggest that operative treatment of patients with unstable chest wall injuries has modest benefit compared with nonoperative treatment. However, the potential advantage was primarily noted in the subgroup of patients who were ventilated at the time of randomization. No benefit to operative treatment was found in patients who were not ventilated.Trial RegistrationClinicalTrials.gov Identifier: NCT01367951