Surgical management of flail chest with titanium plates: a French cohort series from a thoracic referral center

doi:10.21203/rs.3.rs-1427358/v1

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Surgical management of flail chest with titanium plates: a French cohort series from a thoracic referral center

https://doi.org/10.21203/rs.3.rs-1427358/v1

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published 18 Jan, 2023

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Background

The development of titanium claw plates has made rib osteosynthesis easy to achieve and led to a renewed interest for this surgery. We report the management of patients referred to the intensive care unit (ICU) of a referral center for rib fracture fixation after chest trauma.

Methods

A retrospective observational cohort study describing the patients’ characteristics and analyzing the determinants of postoperative complications.

Results

From November 2013 to December 2016, 42 patients were referred to our center: 12 patients (29%) suffered acute respiratory failure, 6 of whom were mechanically ventilated. The Thoracic Trauma Severity Score (TTSS) was 11.0 [9-12], with 7 [5-9] broken ribs and a flail chest in 92% of cases. A postoperative complication occurred in 18 patients (43%). Five patients developed ARDS (12%). Postoperative pneumonia occurred in 11 patients (26%). Two patients died in the ICU. In multivariable analysis, the TTSS (OR=1.89; CI95% 1.12-3.17; p=0.016) and the Simplified Acute Physiology Score II without age (OR=1.17; CI95% 1.02-1.34; p=0.024) were independently associated with the occurrence of a postoperative complication.

Conclusion

The TTSS score appears more accurate than the Injury Severity Score for determining thoracic trauma severity. Rib fixation may be harmful, and short and long-term benefit should be assessed, particularly in non-mechanically ventilated patients.

Thoracic trauma

Flail chest

Rib fracture fixation

complication

TTS Score

Chest trauma accounts for one-third of all trauma cases and may lead to fatal complications¹. Flail chest, defined as 3 or more broken ribs in at least 2 sites, is a severe thoracic injury associated with chest wall instability and significant morbidity and mortality². Patients may develop severe acute respiratory failure requiring mechanical ventilation and prolonged intensive care unit (ICU) and hospital stays. Long term morbidity may include chest deformity, chronic pain, disability and lung function compromise³. Age, pre-existing respiratory or cardiac disease, number of fractured ribs and pulmonary contusion ⁴^,⁵^,⁶are recognized factors of severity. The Thoracic Trauma Severity Score (TTSS) has been developed for predicting the occurrence of acute respiratory distress syndrome (ARDS) and mortality in patients with chest trauma⁷(Table e1). The Injury Severity Score (ISS) is an established medical score to assess trauma severity, and is associated with morbidity, length of hospital stay, and mortality⁸.

The usual management of flail chest is based on measures including oxygen therapy, multimodal analgesia, respiratory physiotherapy and early rehabilitation⁹^,¹⁰^,¹¹. The generalization of non-invasive ventilation has decreased the need for tracheal intubation and invasive ventilation, and its complications¹². Despite some promising prospective trials, the surgical fixation of rib fractures is still debated. French referentials¹³ recommend "surgical fixation in patients with flail chest and requiring mechanical ventilation if the respiratory status does not permit the weaning of mechanical ventilation within 36 hours of admission", on the basis of three small-size randomized controlled trials using different primary end points^,¹²^,¹³^,14. The development of titanium claw plates of the Stracos™ system (Strasbourg Costal Osteosynthesis System, MedXpert GmbH, Germany) makes easy to achieve rib fixation. This new technology has led to a renewed interest for the operative management approach and has led surgeons to consider expanding its indications.

We report our experience of the management of patients with rib fractures referred to the ICU of Tenon hospital, a University teaching hospital and referral thoracic center in Paris, France. This retrospective observational cohort study aimed at describing the patients’ characteristics, the surgical procedure, and the intra hospital outcomes, and at identifying the factors associated with the occurrence of postoperative complications.

Admission

From November 2013 to December 2016, all the consecutive patients admitted to the ICU of Tenon hospital for the perioperative management of chest trauma were eligible. Written informed consent was not required because of the retrospective nature of the investigation, which was approved by the Institutional Review Board of the French learned society for respiratory medicine - Société de Pneumologie de Langue Française (CEPRO 2019-010). Demographics and medical history were collected from the computerized medical records, as well as the existence of acute respiratory failure the day of trauma and the day of ICU admission. Respiratory failure was defined as the need for nasal high flow oxygen therapy (HFOT), non-invasive ventilation (NIV), or intubation with invasive ventilation. The TTSS was calculated on ICU admission, integrating the number of fractured ribs, the existence of pulmonary contusion and pleural involvement on computed tomography (CT)-scan. An expert radiologist from our center reviewed all CT scans.

Surgery

The characteristics of the surgical procedure were collected from the anesthesia and the operative reports: surgical approach, duration of surgery, number of red blood cells unit received intraoperatively, the duration of lung exclusion and the technique of regional analgesia. The surgical indications were based on the presence of a flail chest or a displaced or complex costal crash, regardless of the patient's respiratory status.

Postoperative period

Postoperative respiratory failure was defined as a failure of extubation within the first postoperative 24 hours, or as the need for HFOT, NIV or invasive ventilation. Postoperative hemodynamic failure was defined as the need for the administration of vasoactive drugs. Postoperative acute renal failure was defined as the need for renal replacement therapy. Post-operative pneumonia was defined by a clinical suspicion of pneumonia associated with a microbiological documentation. Lengths of ICU and hospital stay, and respective vital status at discharge were reported.

Statistical analysis

The primary endpoint was the rate of occurrence of postoperative complications, defined as at least one postoperative event among acute respiratory, hemodynamic or renal failure, postoperative pneumonia, surgical site infection or ICU death. The secondary endpoints were the factors associated with the occurrence of postoperative complications. Continuous variables are expressed as median and interquartile [25-75], and categorical variables as numbers (percentage). Continuous variables were compared Student's t-test or Mann-Whitney test, according to their parametric distribution. Categorical variables were compared by a chi2 test or a Fischer test. The predictors of the occurrence of postoperative complications were assessed by univariate and multivariable analyses. The first part of the analysis measured the crude associations between variables of interest and postoperative complications, using Odds Ratio (OR) and their corresponding 95% confidence interval (95% CI). The multivariable analysis was performed by a step-by-step logistic regression model, integrating the selected variables in univariate analysis with a p-value <0.1, and respecting the ratio of 1 to 10 events per variable. The area under the receiver operating characteristic (ROC) curve (Egan JP. Signal detection theory and ROC analysis. New York, NY: Academic Press ed. 1975) was used to evaluate discrimination to assess the discrimination of the model. Statistics were performed using Stata/tm 13.1 software (StataCorp, College Station, Texas, USA).

During the study period, 42 patients were referred to our ICU from the Emergency Departments or the ICUs of Paris area, for the perioperative management of chest trauma after a median duration of 3.0 days [2.0-5.75]. The patients were 58-year old [46.5-77] with few comorbidities. On preoperative assessment, 12 patients (29%) suffered acute respiratory failure, 6 of which were mechanically ventilated. The detailed clinical and radiological description of the chest injury and the assessment of its severity are reported Table 1. The TTSS was 11.0 [9-12] (Figure 1), with 7 [5-8.75] broken ribs. Pulmonary contusion was frequent (27/40, 67%). A flail chest was present in 39 patients (93%). The remaining three patients had 5 broken ribs (n=2), and 8 broken ribs associated with a sternal fracture (n=1).

Surgical rib fixation was performed 4 days [2-6] after the trauma, using a posterolateral thoracotomy. The characteristics of intraoperative anesthesia are detailed in Table 2. Intraoperative ventilation difficulties occurred in 13 patients. The main analgesia technique was performed by the insertion of a thoracic paravertebral catheter at the end of the surgical procedure (n=31; 77%).

Main postoperative outcomes

Main postoperative outcomes are summarized in Table 3. Extubation was performed in the operative room or within the first 24 hours after surgery in most patients (n=35; 83%). Among those latter, 2 required NIV and 3 required reintubation (Figure e1).

Seven patients (17%) could not be extubated within the first 24 hours after surgery (Figure e2). Two patients had tracheotomy.

Eleven patients (26%) developed a postoperative pneumonia, 8 of which were mechanically ventilated. Five patients (12%) developed a postoperative ARDS. The ICU and hospital lengths of stay were 6.5 days [4.0-9.0] and 11.5 days [9.0-16.0], respectively. Two patients (4%) died in the ICU.

Factors associated with postoperative complications

A postoperative complication occurred in 18 patients (43%). Factors associated with the occurrence of postoperative complications are detailed in Table 4. Comorbidities (diabetes and ischemic heart disease), high TTSS score, bilateral fractures, other chest trauma (clavicle, sternum, scapula or vertebrae fractures), initial clinical severity (initial respiratory failure, tracheal intubation with mechanical ventilation, SAPSII score) and the need for intraoperative transfusion (transfusion, number of units) were associated with the occurrence of postoperative complications. In multivariable analysis, the TTS (OR=1.89; IC95% 1.12 - 3.17; p=0.016) and the SAPSSII without age (OR=1.17; IC95% 1.02 - 1.34; p=0.024) were independently associated with the occurrence of postoperative complications, with good discrimination (area under the ROC curve 0.88) and calibration (Hosmer Lemeshow test 0.696) (Figure 2). The ISS score was not associated with the occurrence of postoperative complications.

In this observational retrospective cohort study, we describe the characteristics, the management and the outcomes of 42 patients referred to the ICU of a referral thoracic center for surgical rib fracture fixation after a severe chest trauma, using new equipment, the titanium plate of the Stracos™ system. Postoperative complications occurred in 43% of cases, including two ICU deaths.

Our cohort is original, as it included different patients than those described in previous randomized controlled trials^14–16 (Table e2). This discrepancy may be related to the fact that our center is not a trauma center. Consequently, our patients had more domestic accidents, were older, and were not mechanically ventilated before surgery in two third of the cases.

The optimal time for surgery is important, as delayed surgery may result in pathological bone consolidation. Recent case-control studies^17–19 have reported a shorter duration of post-operative mechanical ventilation in patients operated within the first 4 to 5 days after trauma. In our series, surgery was performed in a timely fashion, after a median time of 4 days, and surgical indications were based on the presence of a flail chest or a displaced or complex costal crash, regardless of the patient's respiratory status. Postoperative complications occurred in 18 patients (43%) including two ICU deaths. This high rate of postoperative complications may question the role of surgery in such a selected population, particularly in old patients with severe trauma. In a recent case-control series involving non-mechanically ventilated patients with flail chest, the patients who were treated non-surgically had better outcomes than their counterparts, with shorter duration of mechanical ventilation, lower rate of post-operative pneumonia and shorter ICU and hospital lengths of stay²⁰. They were however younger than our patients. The formalized experts French guidelines published in 2015 recommend surgical rib fixation «in mechanically ventilated patients if the respiratory condition does not allow weaning from mechanical ventilation within 36 hours of admission», on the basis of three small size randomized clinical trials, two of which no longer reflect current practices^14–16. However, the radiological severity (flail chest) of the chest trauma may out weight the clinical and respiratory status of the patient in the surgical decision. One of the main expected benefits of surgery is to decrease the duration of mechanical ventilation and reduce the associated morbidity. By restoring parietal rigidity, better wall mobility should be achieved, facilitating the restoration of proper ventilation. However, this hypothesis has not been confirmed in any controlled trial, and large variations in the duration of mechanical ventilation have been reported^14–16. In the most recent series by Marasco et al¹⁴ the duration of mechanical ventilation was similar in the surgical group (6.3 days ± 3.4), as compared with the conservative group (7.5 days ± 5.4). Several hypotheses may explain the lack of benefits of surgery on the duration of mechanical ventilation. First, the chest wall mobility restoration and the expected better pulmonary compliance could be insufficient due to the rigidity of the material used. In our series, the titanium claw plates were used. These clips simplify the fixation of screwless plates and reduce the risk of intercostal neurovascular damage. More flexible, this new material could allow better compliance. Second, the surgical procedure itself may be more deleterious than beneficial. The complications associated with selective intubation are known and feared^{21, 22}. Installation in lateral decubitus may be hazardous²³^,²⁴. Altogether, one-lung ventilation, perioperative fluid administration, and transfusion may be more deleterious than the expected physiological advantages sought by surgery. Data from the literature on other postoperative respiratory outcomes are unclear. The incidence of ARDS is not known but it increases with the number of fractured ribs²⁵. Its incidence has decreased since the introduction of protective ventilation²⁶. Postoperative pneumonia is not clearly defined in the literature and its incidence varies from 10% to 48%^{14, 16}. In our series, only the episodes with high clinical suspicion of pneumonia and bacteriological documentation were considered, accounting for an overall incidence of postoperative pneumonia of 26%. A reduction in the length of stay is also expected with the surgical treatment, but results are conflicting^{14, 15, 19, 27}. The most recent randomized controlled study conducted in the United Kingdom with the length of stay as the primary end point, reported a significantly shorter length of stay in surgical patients, as compared with their counterparts (14.5 days vs. 30 days)²⁷. The length of stay was longer than in other series^{19, 20, 28, 29}.

The three existing randomized controlled trials do not allow determining whether a surgical approach can benefit in non-intubated and elderly patients, as in our series. There are several retrospective series with similar population. Farquhar et al.²⁰ reported an increased length of stay in operated patients (7.4 ± 6.7 days), as compared with non-operated patients (3.7 ± 6.0 days), but surgery was performed a week after trauma. Wijffels et al.²⁸ reported a lower rate of postoperative pneumonia and a shorter hospital length of stay in operated patients, at a price of a higher number of surgery-related complications. Regarding geriatric population, Chen Zhu et al. ¹⁹ reported a decreased ICU and hospital lengths of stay in operated patients, as compared with non-operated patients (3 days versus 7 days). Ali-Osman et al. ²⁹ suggested an improved pulmonary function among operated patients despite an increased hospital length of stay.

Altogether, the benefits of surgery seem to exist when performed early after trauma in young patients with respiratory failure despite effective analgesia. In patients without respiratory failure or in elderly patients, surgical treatment may probably result in more complications than benefits.

Limitation of the study

The main limitations of our study are related to its retrospective and single center nature, as well as its sample size. The initial medical management of patients was not protocolized, as few patients benefited from multimodal analgesia administered within 12 hours ¹³. The impact of the surgery on respiratory function and chronic pain was not evaluated.

To summarize, we describe a cohort of 42 thoracic trauma patients with flail chest who received surgical rib fixation with titanium plates in an expert medical and surgical thoracic center. The TTSS and SAPSII score without age were independently associated with postoperative complications that occurred in 43% of cases. Conversely, the ISS score was not associated with such complications.

Further trials will help to provide answers about the real benefit of the surgery in non-mechanically ventilated elderly patients with isolated chest trauma.

Ethics approval and consent to participate:

All methods were performed in accordance with the Declaration of Helsinki. Written informed consent was not required because of the retrospective nature of the investigation, which was approved by the Institutional Review Board of the French learned society for respiratory medicine - Société de Pneumologie de Langue Française (CEPRO 2019-010).

Consent for publication:

Not applicable

Availability of data and material:

Consultation by the editorial board or interested researchers may be considered, subject to prior determination of the terms and conditions of such consultation and in respect for compliance with the applicable regulations.

Competing interests:

None

Funding: None

Authors’ contributions:

MF and SF conceived and designed the study. SF collected the data. MF and SF analysed and interpreted the data. SF drafted the article. MF revised the manuscript. All authors provided final approval to submit this version of the manuscript and have agreed to be accountable for all aspects of the work.

Acknowledgments:

The authors wish to thank all the participants who contributed to the conduct of the study in Tenon hospital.

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Table 1

Pre-operative characteristics

Variable	Value
Age (years), median [IQR 25-75]	58.3 [46.5-77.0]
Men, n (%)	28 (67)
SAPS II, median [IQR 25-75]	25.5 [18-33.5]
ISS, median [IQR 25-75]	21 [16-28]
TTSS, median [IQR 25-75]	11 [9-12]
Comorbidity Charlson score, median [IQR 25-75] Smoking, n (%)	0 [0-1] 17 (40)
Cause of thoracic trauma, n (%) Road traffic accident Domestic fall	20 (48) 17 (40)
Time from trauma to ICU admission (days), median [IQR 25-75]	3.0 [2-5.75]
Number of broken ribs, median [IQR 25-75]	7 [5-8.75]
Flail chest, n (%)	39 (93)
Pulmonary contusion, n (%) ⁽¹⁾ 1 lobe 2 lobes > 2 lobes	27 (67) 16 (40) 7 (17) 4 (10)
Pleural involvement, n (%) ⁽¹⁾ Isolated pleural effusion Pneumothorax/Hemopneumothorax unilateral Pneumothorax/Hemopneumothorax bilateral Tension pneumothorax	34 (85) 3 (7) 29 (72) 1 (2) 1 (2)
Associated intra-thoracic fractures, n (%) ⁽²⁾ Sternum Clavicle Scapula Vertebrae	20 (51) 3 (8) 5 (13) 9 (23) 3 (8)
Extra-thoracic injury, n (%) Abdomen, n (arterial embolisation needed), n Face, n (surgery needed), n Head or neck injury, n (specific intervention needed), n Extremities or pelvic girdle, n (osteosynthesis needed), n	17 (40) 2 (1) 4 (3) 2 (0) 9 (3)
Preoperative respiratory status, n (%) Respiratory failure * Invasive ventilation Non-invasive ventilation High flow oxygen therapy	12 (29) 6 (14) 6 (14) 1 (2)
* Respiratory failure was defined as the need to administer nasal high flow oxygen therapy (HFOT), non-invasive or invasive mechanical ventilation. Date available for 40 patients ⁽¹⁾ and 39 patients ⁽²⁾ Abbreviations: SAPS II, Simplified Acute Physiologic Score; ISS, Injury Severity Score; ICU, intensive care unit; TTSS, Thoracic Trauma Severity Score

Table 2

Operative characteristics

Variable	Value
Time from trauma to surgery (days), median [IQR 25-75]	4 [2-6]
Red blood cells transfusion, n (%)	6 (14)
Vasopressor support (norepinephrine), n (%) ⁽¹⁾	11 (27)
Crystalloid fluid administration (ml/kg/h)⁽²⁾	7.21 [4.4-10.4]
Ventilation Selective intubation, n (%) Ventilation difficulties, n (%) ⁽³⁾	42 (100) 13 (31)
Duration of surgery (hours), median [IQR 25-75] ⁽⁴⁾	2.33 [2.00-3.00]
Postoperative analgesia, n (%) Paravertebral catheter Epidural catheter None	40 (95) 31 (77) 9 (23) 2 (5)
Data available for 40 patients⁽¹⁾, 20 patients ⁽²⁾, 31 patients ⁽³⁾, and 35 patients ⁽⁴⁾

Table 3

Main postoperative outcomes

Variable

Value

Ventilatory support

Duration of postoperative mechanical ventilation (days), median [IQR 25-75]

Early extubation

NIV or nasal high flow oxygen therapy (HFOT)

Reintubation

Late extubation (no extubation possible within the first 24 hours)

0 [0-1.0]

35 (83)

7 (17)

Postoperative organ failure, n (%)

Postoperative respiratory failure

Postoperative hemodynamic failure*

Postoperative renal failure

12 (28)

6 (14)

1 (2)

Postoperative infectious events

Postoperative pneumonia, n (%)

Ventilator associated pneumonia

Surgical site infection, n (%)

11 (26)

ICU stay

Death

Length of stay (days), median [IQR 25-75]

2 (4)

6.5 [4.0-9.0]

Hospital stay

Death

Length of stay (days), median [IQR 25-75]

11.5[9.0-16.0]

* One patient had an acute coronary syndrome (ST+)

Abbreviations: NIV, Non-invasive ventilation

Table 4

Factors associated with postoperative complications

Variable	No postoperative complication, n=24	Postoperative complication, n=18	OR [CI95%]	p
Demographics
Age (years), median IQR [25-75]	52.4 [37.4-73.8]	69.01 [54.8-79.6]		0.09
Sex (M, F)	18, 6	10, 8	0.42 [0.11-1.62]	0.19
Charlson score, median IQR [25-75]	0 [0-1]	1 [0-2]		0.03
Active smoking, n (%)	12 (50)	5 (28)	0.38 [0.099-1.49]	0.15
Characteristics of trauma
Road traffic accidents, n (%)	12 (50)	8 (44)	0.80 [0.23-2.77]	0.72
Domestic fall, n (%)	9 (38)	8 (44)	1.33 [0.38-4.71]	0.65
Time from trauma to ICU referral (days), median [IQR 25-75]	2 [1-6]	1.5 [0-3]		0.34
TTSS, median [IQR 25-75]	10 [8-11]	12 [11-14.75]		0.0005
Bilateral thoracic trauma, n (%)	2 (8)	8 (44)	8.80 [1.29-59.92]	0.007
Other chest fractures, n (%)	7 (29)	13 (72)	5,20 [1.15-23.53]	0.017
Number of broken ribs, median IQR [25-75]	6.5 [5-7.25]	8 [5.25-11.5]		0.086
Extra-thoracic trauma	10 (42)	7 (38)	0.89 [0.25-3.15]	0.86
Severity factors at initial management
ISS, median IQR [25-75]	41.5[16-29]	26 [16-27]		0.59
SAPSII, median IQR [25-75]	19 [15-26]	33 [30-38]		0.0001
SAPSII without age, median IQR [25-75]	10 [7-17.5]	20 [14-25]		0.001
Respiratory failure, n (%)*	3 (13)	9 (50)	7.00 [1.29-37.93]	0.008
Peroperative management
Time from trauma to surgery (days), median [IQR 25-75]	4.5 [2-7.25]	3 [1-6]		0.24
Duration of surgery (minutes), median [IQR 25-75]	125 [120-150]	150 [120-180]		0.11
Transfusion of red blood cells, n (%) Number of red blood cells, median IQR [25-75]	1 (4) 0 [0-0]	5 (28) 0 [0-2]	8.85 [0.79-99.31]	0.03 0.004
Vasopressor support, n (%)	4 (9)	7 (17)	2.86 [0.64-12.81]	0.15
Loco regional analgesia	24 (100)	16 (88)		0.09
Postoperative support and outcomes
Mechanical ventilation duration (days), median IQR [25-75]	0 [0-0]	3.5 [0-8.0]		0.0004
ICU length of stay, median IQR [25-75]	5 [3.75-7]	9 [6.25-17.5]		0.0002
In-ICU mortality, n (%)	0 (0)	2 (11)		0.9
Hospital length of stay, median IQR [25-75]	10 [7-12.25]	17 [11.25-31.5]		0.0002
Abbreviations: COPD, Chronic Obstructive Pulmonary Disease; TTSS, Thoracic Trauma Severity Score; SAPSII, Simplified Acute Physiology Score; ISS, Index Severity Score; ICU, Intensive Care Unit *Respiratory failure: need for high flow oxygen therapy (HFOT), non-invasive ventilation (NIV), or intubation with invasive ventilation

No competing interests reported.

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Surgical management of flail chest with titanium plates: a French cohort series from a thoracic referral center

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Introduction

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Surgery

Postoperative period

Statistical analysis

Results

Main postoperative outcomes

Factors associated with postoperative complications

Discussion

Limitation of the study

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References

Tables

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