Chest wall trauma is common in the world, and rib fracture is the most common type [6]. Surgical stabilization of rib fractures showed better outcomes when compared with conservative treatment in patients with flail chest, which had aroused great interest in thoracic surgeons [3–5]. Although CWS has been widely performed in China, the current situation of CWS is still unclear. This study is the first study to investigate the current situation of surgical treatment for rib fractures in China.
Our investigation showed 30.87% cases were performed in hospitals lower than grade III-A hospitals and 43.92% cases were performed by residents and attending doctors, which suggested the technique requirements of CWS may not be too high. The lower technical requirements make it very easy to popularize and apply CWS, which is confirmed by the rapid increased volume of CWS in 2017.
Our investigation also showed not all the CWS were performed by thoracic surgeons in China. It is generally accepted that rib fractures are usually associated with several complications, such as diaphragm rupture, intercostal blood vessel bleeding, pneumothorax and so on. For non-thoracic surgeons, lacking experience in dealing with above diseases may result in misdiagnosis, poor treatment effect and delayed treatment. So it is very important to ascertain the division of CWS.
Most surgeons believed that CWS should be performed for patients who had three or more displaced rib fractures, or flail chest, or patients with rib fractures needing thoracic surgeries for other reasons, or patients with chest wall deformity, or patients with severe pain cannot be relieved by conservative treatment. Compared with conservative treatment, most surgeons believed CWS can achieve better outcomes. However, our investigation also showed that it was not a minority to perform CWS for single rib fracture and two rib fractures. We can see that there is an obvious contradiction between the widely accepted operative indication and the specific operative indication. Although many studies about CWS have been published recently, no large-scale RCT studies on operative indication of CWS have been reported yet. Under this circumstance, it is very difficult to formulate a widely accepted guideline for CWS.
It is generally accepted that early fixation of rib fracture can reduce the rate of complications such as severe hematoma, inflammation, empyema, clotted hemothorax and so on. Previous study suggested the optimal operation intervention time for rib fractures was within 72 hours after injury [8].Our investigation showed most CWS cases were performed within two weeks. However, there were still 42.2% surgeons performed CWS for patients with rib fracture more than two weeks. Although most surgeons believed CWS should be performed for patients with rib fracture more than two weeks in some special cases, there was not sufficient data to evaluate the surgical outcomes of above patients. Whether CWS is needed and feasible for patients with rib fractures more than two weeks is still controversial.
It is generally accepted that CWS for ribs 1and 2 and paraspinal rib fractures and costal cartilage fractures is not necessary since they are very difficult to expose while contributes little to respiratory physiology [9]. Likewise, CWS for ribs 11and 12 and dislocation of sternoclavicular joinis is also not suggested for the same reasons. Our study showed partial surgeons had performed CWS for above patients easily. Since operation requirement is not the major obstacle in China, whether it is necessary to performed CWS for above patients is the question we should answer in future.
Whether internal fixation should be removed after CWS remains controversial. Our investigation showed only 33.93% of surgeons chose to remove internal fixation at one year after surgery. Operative morbidity, secondary rib fractures are the main obstacles for surgeons to remove internal fixation. Patients’ requirement, discomfort symptoms after CWS are the major reasons for patients seeking for internal fixation removal. Degradable material to fix bone fracture has developed rapidly in the past decade. It is expected the application of degradable material may solve the conflict between surgeons and patients.
Our investigation showed the rate of surgical treatment for multiple rib fractures is still very low in China. Under this circumstance, large-scale RCT studies on operative indication, developing better internal fixation materials, propagating technical experience, reducing operation related costs, giving attention and support from relevant academic organizations and activities, giving support from hospital management department or other departments are very important for the further development of CWS, which are also the major work we need to do in future.