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

Surgical and perioperative management of flail chest with titanium plates: a French cohort series... 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 surgical rib fracture fixation (SRFF) after chest trauma. Methods We performed a retrospective observational cohort study describing the patients’ characteristics and ana- lyzing the determinants of postoperative complications. Results From November 2013 to December 2016, 42 patients were referred to our center for SRFF: 12 patients (29%) had acute respiratory failure, 6 of whom received invasive mechanical ventilation. 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 Thoracic Trauma Severity Score ( TTSS) (OR = 1.89; CI 95% 1.12–3.17; p = 0.016) and the Simplified Acute Physiology Score II without age (OR = 1.17; CI 95% 1.02–1.34; p = 0.024) were independently associated with the occurrence of a postoperative complication. Conclusion The TTSS score appears to be accurate for determining thoracic trauma severity. Short and long-term benefit of Surgical Rib Fracture Fixation should be assessed, particularly in non-mechanically ventilated patients. Keywords Thoracic trauma, Flail chest, Surgical rib fracture fixation, Complication, TTSS score Introduction Chest trauma accounts for one-third of all trauma cases *Correspondence: and may lead to fatal complications [1]. Flail chest, Sarah Féray defined as 3 or more broken ribs in at least 2 sites, is a sarah.feray@aphp.fr 1 severe thoracic injury associated with chest wall instabil- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Service de Médecine Intensive Réanimation, Sorbonne Université, 75020 Paris, ity and significant morbidity and mortality [2]. Patients France may develop severe acute respiratory failure requiring Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Service mechanical ventilation and prolonged intensive care d’Anesthésie-Réanimation et Médecine Péri-operatoire, Sorbonne Université, 75020 Paris, France unit (ICU) and hospital stays. Long term morbidity may Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Service de include chest deformity, chronic pain, disability and lung Chirurgie Thoracique et Vasculaire, Sorbonne Université, 75020 Paris, function compromise [3]. Age, pre-existing respiratory or France Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Service de cardiac disease, number of fractured ribs and pulmonary Radiologie, Sorbonne Université, 75020 Paris, France contusion [4–6] are recognized factors of severity. The © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Féray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 2 of 9 Thoracic Trauma Severity Score (TTSS) has been devel - existence of pulmonary contusion and pleural involve- oped for predicting the occurrence of acute respiratory ment on computed tomography (CT)-scan. All patients distress syndrome (ARDS) and mortality in patients with had a radiological diagnostic of chest trauma. An expert chest trauma [7] (Additional file  1: Table S1). The Injury radiologist from our center reviewed all CT scans in Severity Score (ISS) is an established medical score to order to describe all lesions accurately. assess trauma severity, and is associated with morbidity, length of hospital stay, and mortality [8]. Surgery The usual management of flail chest is based on meas - The indications for surgery were the following: anterior ures including oxygen therapy, multimodal analgesia, and anterolateral flail chest (radiological), displaced rib respiratory physiotherapy and early rehabilitation [9– fractures (more than 2  cm measured on CT scan), frac- 11]. The generalization of non-invasive ventilation has tures impaling the lung or threatening other organs, and decreased the need for tracheal intubation and invasive rib fractures causing pain refractory to medical treat- ventilation, and its complications [12]. Despite some ment, including paravertebral bloc or epidural analgesia. promising prospective trials, the surgical fixation of rib Patients with severe head injury were contra-indicated fractures (SRFF) is still debated. French referentials [13] for surgery. Surgery was postponed if the patient could recommend “surgical fixation in patients with flail chest not be installed on the lateral decubitus position or and requiring mechanical ventilation if the respiratory because of associated injuries (orthopedic or spinal status does not permit the weaning of mechanical ven- trauma) whose treatment was more urgent. tilation within 36  h of admission”, on the basis of three The surgical approach was a posterolateral thoracot - small-size randomized controlled trials using different omy. An initial exploration of the cavity was performed, primary end points [12–14]. The development of tita - and associated with hemothorax drainage, if necessary. A nium claw plates of the Stracos system (Strasbourg Cos- bubble test was performed to look for any parenchymal tal Osteosynthesis System, MedXpert GmbH, Germany) air leak. The parenchyma was then sutured. makes easy to achieve rib fixation. This new technology Osteosynthesis of the ribs of the flail chest or of the has led to a renewed interest for the operative manage- most displaced ribs was performed by placing the Stracos ment approach and has led surgeons to consider expand- plates. The remaining broken ribs were fixed with wire to ing its indications. the ribs repaired with the plate. Once the reduction was We report our experience of the ICU management of considered satisfactory, two anterior and posterior endo- thoracic trauma patients after SRFF referred to Tenon thoracic tubes were placed. After closing, the tubes were hospital, a University teaching hospital and referral tho- put under suction at − 20 cmH20. racic center in Paris, France. The aim of this retrospective The characteristics of the surgical procedure were col - cohort study was to describe the characteristics of the lected: surgical approach, duration of surgery, perio- patients, the surgical procedure, and the in-hospital out- perative transfusion and fluid intake, duration of lung comes, and to identify factors associated with the occur- exclusion and type of regional analgesia technique. rence of postoperative complications. Postoperative period Methods All patients received the same enhanced recovery after Admission surgery protocol from our center (detailed in the Addi- From November 2013 to December 2016, all the con- tional file  2), including early mobilization, early oral secutive patients admitted to the ICU of Tenon hospital feeding, daily respiratory physical therapy, and pain con- for the perioperative management of chest trauma were trol. Pain control was provided by multimodal analgesia eligible. Written informed consent was not required including regional analgesia: all patients received a para- because of the retrospective nature of the investigation, vertebral catheter, except if the trauma involved more which was approved by the Institutional Review Board than 6 levels or if the trauma was bilateral in which case of the French learned society for respiratory medicine - an epidural catheter was placed. Société de Pneumologie de Langue Française (CEPRO Postoperative respiratory failure was defined as a fail - 2019-010). Demographics and medical history were col- ure of extubation within the first postoperative 24  h, or lected from the computerized medical records, Respira- as the need for HFNO, NIV or invasive ventilation. Post- tory failure was defined as the need for high flow nasal operative hemodynamic failure was defined as the need oxygen (HFNO), non-invasive ventilation (NIV), or intu- for the administration of vasoactive drugs. Postopera- bation with invasive ventilation. The TTSS was calcu - tive acute renal failure was defined as the need for renal lated on ICU admission, including the age of patients, the replacement therapy. Postoperative pneumonia was PaO2/FiO2 ratio, the number of fractured ribs, and the defined by a clinical suspicion of pneumonia associated F éray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 3 of 9 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] 26 [18–34] ISS, median [IQR 25–75] 21 [16–28] TTSS, median [IQR 25–75] 11 [9–12] Comorbidity Charlson score, median [IQR 25–75] 0 [0–1] Smoking, n (%) 17 (40) Cause of thoracic trauma, n (%) Road traffic accident 20 (48) Domestic fall 17 (40) Time from trauma to ICU admission (days), median [IQR 25–75] 3.0 [2–5.8] Number of broken ribs, median [IQR 25–75] 7 [5–8.8] Flail chest, n (%) 39 (93) (1) Pulmonary contusion, n (%) 27 (67) 1 lobe 16 (40) 2 lobes 7 (17) > 2 lobes 4 (10) (1) Pleural involvement, n (%) 34 (85) Isolated pleural effusion 3 (7) Pneumothorax/Hemopneumothorax unilateral 29 (72) Pneumothorax/Hemopneumothorax bilateral 1 (2) Tension pneumothorax 1 (2) (2) Associated intra-thoracic fractures, n (%) 20 (51) Sternum 3 (8) Clavicle 5 (13) Scapula 9 (23) Vertebrae 3 (8) Extra-thoracic injury, n (%) 17 (40) Head and neck injury, n 2 (Specific intervention needed), n (0) Face, n 4 (Surgery needed), n (2) Extremities, n 5 (Surgery needed), n (3) Abdomen, n 3 (Specific intervention needed), n (1) Spine, n 3 (Surgical or radiological procedures needed), n (2) Preoperative respiratory status, n (%) Respiratory failure * 12 (29) Invasive ventilation 6 (14) Non-invasive ventilation 6 (14) High flow nasal oxygen therapy 1 (2) SAPS II, Simplified Acute Physiologic Score; ISS, Injury Severity Score; ICU, intensive care unit; TTSS, Thoracic Trauma Severity Score *NIV was used for hypoxemic and hypercapnic patients, while HFNO was administered to hypoxemic patients without hypercapnia. Without rapid clinical or biological improvement, patients received invasive mechanical ventilation (1) (2) Date available for 40 patients and 39 patients Féray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 4 of 9 Fig. 1 Diagram of the patient’s course with a microbiological documentation. Lengths of ICU Mann–Whitney test, according to their parametric dis- and hospital stay and respective vital status at discharge tribution. Categorical variables were compared by a chi2 were reported. 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 Statistical analysis measured the crude associations between variables of The primary endpoint was the rate of occurrence of post - interest and postoperative complications, using Odds operative complications, defined as at least one postop - Ratio (OR) and their corresponding 95% confidence erative event among acute respiratory, hemodynamic interval (95% CI). The multivariable analysis was per - or renal failure, postoperative pneumonia, surgical site formed by a step-by-step logistic regression model, inte- infection or ICU death. The secondary endpoints were grating the selected variables in univariate analysis with a the factors associated with the occurrence of postopera- p-value < 0.1, and respecting the ratio of 1–10 events per tive complications. Continuous variables are expressed variable. The area under the receiver operating character - as median and interquartile [25–75], and categorical istic (ROC) curve [33] was used to assess the discrimina- variables as numbers (percentage). Continuous vari- tion of the model. Statistics were performed using Stata/ ables were compared using the Student’s t-test or the tm 13.1 software (StataCorp, College Station, Texas, USA). F éray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 5 of 9 Fig. 2 Distribution of the TTSS Table 2 Operative characteristics Variable Value Time from trauma to surgery (days), median [IQR 25–75] 4 [2–6] Table 3 Main postoperative outcomes Red blood cells transfusion, n (%) 6 (14) Variable Value (1) Vasopressor support (norepinephrine), n (%) 11 (27) (2) Crystalloid fluid administration (ml/kg/h) 7.21 [4.4–10.4] Ventilatory support Ventilation Duration of postoperative mechanical ventilation 0 [0–1.0] (days), median [IQR 25–75] Selective intubation, n (%) 42 (100) (3) Early extubation 35 (83) Ventilation difficulties, n (%) 13 (31) (4) NIV or nasal high flow nasal oxygen (HFNO) 2 Duration of surgery (hours), median [IQR 25–75] 2.33 [2.0–3.0] Reintubation 3 Postoperative analgesia, n (%) 40 (95) Late extubation (no extubation possible within the 7 (17) Paravertebral catheter 31 (77) first 24 h) Epidural catheter 9 (23) Postoperative organ failure, n (%) None 2 (5) Postoperative respiratory failure 12 (28) (1) (2) (3) (4) Data available for 40 patients , 20 patients , 31 patients , and 35 patients Postoperative hemodynamic failure* 6 (14) Postoperative renal failure 1 (2) Postoperative infectious events** Results Postoperative pneumonia, n (%) 11 (26) During the study period, 42 patients were referred to Ventilator associated pneumonia 8 our ICU from the trauma centers of Paris area (either Emergency Departments or ICUs), for the perioperative Surgical site infection, n (%) 0 management of chest trauma after a median duration of ICU stay 3.0  days [2.0–5.75]. The patient course is described in Death 2 (4) Fig.  1. The patients were 58-year old [46.5–77] with few Length of stay (days), median [IQR 25–75] 6.5 [4.0–9.0] comorbidities (Table  1). On preoperative assessment, 12 Hospital stay patients (29%) had acute respiratory failure, 6 of them Death 0 required NIV and 6 required invasive ventilation. The Length of stay (days), median [IQR 25–75] 11.5 [9.0–16.0] mean duration of ventilation (invasive and non inva- NIV, Non-invasive ventilation sive) before surgery was 1 day [1–4]. The TTSS was 11.0 *One patient had an acute coronary syndrome (ST+) [9–12] (Fig.  2), with 7 broken ribs [5–8.75]. Pulmonary **The numbers of postoperative pneumonia are 3 and 8 in non-mechanically ventilated and mechanically ventilated patients, respectively Féray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 6 of 9 Table 4 Factors associated with postoperative complications Variable No postoperative Postoperative OR [CI 95%] p complication, n = 24 complication, n = 18 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 (%) 1 (4) 5 (28) 8.85 [0.79–99.31] 0.03 Number of red blood cells, median IQR [25–75] 0 [0–0] 0 [0–2] 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 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 nasal oxygen (HFNO), non-invasive ventilation (NIV ), or intubation with invasive ventilation Main postoperative outcomes contusion was frequent (27/40, 67%). A flail chest was Main postoperative outcomes are summarized in Table 3. present in 39 patients (93%). The remaining three patients Extubation was performed in the operative room or had 5 broken ribs (n = 2), and 8 broken ribs associated within the first 24  h after surgery in most patients with a sternal fracture (n = 1). Associated extra thoracic (n = 35; 83%). Among those latter, 2 required NIV and injuries are described in the Appendix (Additional file  1: 3 required reintubation due to hypercapnic respiratory Table S2). failure (Additional file  3: Fig.  S1). Seven patients (17%) SRFF was performed 4 days [2–6] after the trauma. The could not be extubated within the first 24  h after sur - characteristics of intraoperative anesthesia are detailed gery (Additional file  4: Fig. S2). Six of them were hypox- in Table 2. Intraoperative ventilation difficulties occurred emic with ventilator-associated pneumonia and one had in 13 patients. A thoracic paravertebral catheter was difficulty coughing. Eleven patients (26%) developed a inserted at the end of the surgical procedure in most patients (n = 31; 77%). F éray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 7 of 9 Discussion In this observational retrospective cohort study, we describe the characteristics, the management and the outcomes of 42 patients referred to the ICU of a refer- ral thoracic center for surgical rib fracture fixation after a severe chest trauma, using the titanium plate of the Stra- cos system. Our cohort is original, as it included different patients than those described in previous randomized controlled trials [14–16] (Additional file  1: Table  S3). This was a selected population of patients transferred from trauma center with only isolated chest trauma. Our patients had more domestic accidents, were older, and had no respira- Fig. 3 Diagnostic performance of TTSS and SAPSII without age for tory failure in two third of the cases. predicting postoperative complications Postoperative complications occurred in 18 patients (43%) including two ICU deaths. This high rate of post - operative complications may question the role of surgery postoperative pneumonia, 8 of whom were mechani- in such a selected population, particularly in old patients cally ventilated, and 5 patients (12%) developed a postop- with severe trauma. The formalized experts French erative ARDS. Two patients had a tracheotomy. The ICU guidelines published in 2015 and 2017 recommend sur- and hospital lengths of stay were 6.5  days [4.0–9.0] and gical rib fixation «in mechanically ventilated patients if 11.5 days [9.0–16.0], respectively. Two patients (4%) died the respiratory condition does not allow weaning from in the ICU. mechanical ventilation within 36  hours of admission», on the basis of three small size randomized clinical trials, Factors associated with postoperative complications two of which no longer reflect current practices [14–16]. A postoperative complication occurred in 18 patients These results are confirmed by more recent retrospec - (43%). Factors associated with the occurrence of post- tive series, where operative rib fixation has the poten - operative complications are detailed in Table  4. Comor- tial to reduce ventilator days and ICU stay in selected bidities (diabetes and ischemic heart disease), high patients with severe traumatic flail chest requiring TTSS, bilateral fractures, other chest trauma (clavicle, mechanical ventilation [22]. sternum, scapula or vertebrae fractures), initial clini- The radiological severity (flail chest) of the chest cal severity (initial respiratory failure, tracheal intuba- trauma may out weight  the clinical and respiratory sta- tion with mechanical ventilation, SAPSII score) and the tus of the patient in the surgical decision. However, the need for intraoperative transfusion (transfusion, number benefit of SRFF in non-ventilated patients remains to of units) were associated with the occurrence of postop- be determined. In a recent case–control series involv- erative complications. In multivariable analysis, the TTSS ing non-mechanically ventilated patients with flail chest, (OR = 1.89; IC95% 1.12–3.17; p = 0.016) and the SAP- the patients who were treated non-surgically had better SII without age (OR = 1.17; IC95% 1.02–1.34; p = 0.024) outcomes than their counterparts, with shorter dura- were independently associated with the occurrence of tion of mechanical ventilation, lower rate of post-oper- postoperative complications, with good discrimina- ative pneumonia and shorter ICU and hospital lengths tion (area under the ROC curve 0.88) and calibration of stay [21]. One of the main expected benefits of sur - (Hosmer Lemeshow test 0.696) (Fig.  3). The ISS score gery is to decrease the duration of mechanical ventila- was not associated with the occurrence of postoperative tion and reduce the associated morbidity. By restoring complications. parietal rigidity, better wall mobility should be achieved, facilitating the restoration of proper ventilation. How- Long‑term outcomes (planned post‑hospitalization visits) ever, this hypothesis has not been confirmed in any At one month, data were available for 37 patients (92%). controlled trial, and large variations in the duration of All were alive, and 8 patients had chronic neurological mechanical ventilation have been reported [15–17]. In pain assessed by DNA4 questionnaire. Treatment with the most recent series by Marasco et  al. [15] the dura- pregabalin was started. At one year, data were available tion of mechanical ventilation was similar in the surgical for 26 patients (65%) and all were alive. group (6.3  days ± 3.4), as compared with the conserva- tive group (7.5  days ± 5.4). Several hypotheses may explain the lack of benefits of surgery on the duration of Féray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 8 of 9 mechanical ventilation. First, the chest wall mobility res- [20] reported a decreased ICU and hospital lengths of toration and the expected better pulmonary compliance stay in operated patients, as compared with non-oper- could be insufficient, due to the rigidity  of the material ated patients (3  days vs. 7  days). Ali-Osman et  al. [32] used. In our series, the titanium claw plates were used. suggested an improved pulmonary function among oper- These clips simplify the fixation of screwless plates but ated patients despite an increased hospital length of stay. there is no evidence that they may  reduce the risk of Altogether, the benefits of surgery seem to exist when intercostal neurovascular damage. Second, the surgical performed early after trauma in young patients with res- procedure itself may be more deleterious than beneficial. piratory failure despite effective analgesia. In patients The complications associated with selective intubation without respiratory failure or in older patients, surgical [23, 24], one-lung ventilation, lateral decubitus position- treatment is probably more controversial. ning [25, 26] and the consequence of perioperative fluid administration and transfusion must be weighed against Limitation of the study the expected advantages of surgery. A muscle-sparing The main limitations of our study are related to its ret - approach, less invasive than posterolateral thoracotomy, rospective and single center nature, as well as its sample could be considered as suggested in a recent series [27]. size. The initial medical management of patients was not Data from the literature on other postoperative respira- protocolized, since they were taken care of in a trauma tory outcomes are unclear. The incidence of ARDS is not center before being referred to our hospital. Our popula- known but it increases with the number of fractured ribs tion was selected for receiving SRFF in an expert center, [28]. Its incidence has decreased since the introduction which makes the results less generalizable. The impact of protective ventilation [29]. Postoperative pneumo- of the surgery on long-term respiratory function and nia is not clearly defined in the literature and its inci - chronic pain was not evaluated. dence varies from 10 to 48% [15, 17]. In our series, only To summarize, we describe a cohort of 42 thoracic the episodes with high clinical suspicion of pneumonia trauma patients with flail chest who received SRFF with and microbiological documentation were considered, titanium plates in an expert thoracic center. The TTSS accounting for an overall incidence of postoperative and SAPSII score without age were independently asso- pneumonia of 26%. A reduction in the length of stay is ciated with postoperative complications that occurred in also expected with the surgical treatment, but results are 43% of cases. Conversely, the ISS score was not associ- conflicting [15, 16, 20, 30]. The most recent randomized ated with such complications. controlled study conducted in the United Kingdom with Further trials will help to provide answers about the the length of stay as the primary end point, reported a benefit of the surgery in non-mechanically ventilated significantly shorter length of stay in surgical patients, as patients with isolated chest trauma. compared with their counterparts (14.5 days vs. 30 days) [30]. The length of stay was longer than in other series Supplementary Information [20, 21, 31, 32]. The online version contains supplementary material available at https:// doi. The optimal time for surgery is also important, as org/ 10. 1186/ s13019- 023- 02121-8. delayed surgery may result in pathological bone con- solidation. Recent case–control studies [18–20] have Additional file 1: Table S1. Thoracic Trauma Severity Score. Table S2. Summary of characteristics and outcomes of patients treated with rib reported a shorter duration of post-operative mechanical fixation in different recent series. Table S3. Descriptive table of associated ventilation in patients operated within the first 4–5 days extra thoracic lesions. after trauma. In our series, surgery was performed after a Additional file 2: Protocol for enhanced rehabilitation after surgery. median time of 4 days. Additional file 3: Figure S1. Post-operative outcomes in early extubated The three existing randomized controlled trials do not patients (first 24 hours after surgery) allow determining whether a surgical approach can ben- Additional file 4: Figure S2. Post-operative outcomes in late extubated efit in non-intubated and old patients, as in our series. patients (beyond the first day of surgery). There are several retrospective series with similar popu - lation. Farquhar et  al. [21] reported an increased length Acknowledgements of stay in operated patients (7.4 ± 6.7 days), as compared The authors wish to thank all the participants who contributed to the conduct of the study in Tenon hospital. with non-operated patients (3.7 ± 6.0  days), but surgery was performed a week after trauma. Wijffels et  al. [31] Author contributions reported a lower rate of postoperative pneumonia and 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 and CQ revised a shorter hospital length of stay in operated patients, at the manuscript. All authors provided final approval to submit this version of a price of a higher number of surgery-related complica- the manuscript and have agreed to be accountable for all aspects of the work. tions. Regarding geriatric population, Chen Zhu et  al. F éray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 9 of 9 Funding 15. Marasco SF, Davies AR, Cooper J, et al. Prospective randomized controlled None. trial of operative rib fixation in traumatic flail chest. J Am Coll Surg. 2013;216:924–32. Availability of data and materials 16. Granetzny A. Surgical versus conservative treatment of flail chest. Consultation by the editorial board or interested researchers may be con- Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. sidered, subject to prior determination of the terms and conditions of such 2005;4:583–7. consultation and in respect for compliance with the applicable regulations. 17. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of manage- ment of severe flail chest patients. J Trauma. 2002;52:727–32 (discussion Declarations 732). 18. Xu J-Q, Qiu P-L, Yu R-G, Gong S-R, Ye Y, Shang X-L. Better short-term effi- Competing interests cacy of treating severe flail chest with internal fixation surgery compared The authors declare no competing interests. with conservative treatments. Eur J Med Res. 2015;20:55. 19. Zhang X, Guo Z, Zhao C, Xu C, Wang Z. Management of patients with flail Ethics approval and consent to participate chest by surgical fixation using claw-type titanium plate. J Cardiothorac All methods were performed in accordance with the Declaration of Helsinki. Surg. 2015;10:145. Written informed consent was not required because of the retrospective 20. Chen Zhu R, de Roulet A, Ogami T, Khariton K. Rib fixation in geriatric nature of the investigation, which was approved by the Institutional Review trauma: Mortality benefits for the most vulnerable patients. J Trauma Board of the French learned society for respiratory medicine - Société de Acute Care Surg. 2020;89:103–10. Pneumologie de Langue Française (CEPRO 2019-010). 21. Farquhar J, Almahrabi Y, Slobogean G, et al. No benefit to surgical fixation of flail chest injuries compared with modern comprehensive Consent for publication management: results of a retrospective cohort study. Can J Surg. Not applicable. 2016;59:299–303. 22. Kocher GJ, Sharafi S, Azenha LF, Schmid RA. Chest wall stabilization in Competing interest ventilator-dependent traumatic flail chest patients: who benefits? Eur J The authors declare that they have no competing interests. Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg. 2017;51:696–701. 23. Benumof JL, Partridge BL, Salvatierra C, Keating J. 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Surgical and perioperative management of flail chest with titanium plates: a French cohort series from a thoracic referral center

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Abstract

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 surgical rib fracture fixation (SRFF) after chest trauma. Methods We performed a retrospective observational cohort study describing the patients’ characteristics and ana- lyzing the determinants of postoperative complications. Results From November 2013 to December 2016, 42 patients were referred to our center for SRFF: 12 patients (29%) had acute respiratory failure, 6 of whom received invasive mechanical ventilation. 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 Thoracic Trauma Severity Score ( TTSS) (OR = 1.89; CI 95% 1.12–3.17; p = 0.016) and the Simplified Acute Physiology Score II without age (OR = 1.17; CI 95% 1.02–1.34; p = 0.024) were independently associated with the occurrence of a postoperative complication. Conclusion The TTSS score appears to be accurate for determining thoracic trauma severity. Short and long-term benefit of Surgical Rib Fracture Fixation should be assessed, particularly in non-mechanically ventilated patients. Keywords Thoracic trauma, Flail chest, Surgical rib fracture fixation, Complication, TTSS score Introduction Chest trauma accounts for one-third of all trauma cases *Correspondence: and may lead to fatal complications [1]. Flail chest, Sarah Féray defined as 3 or more broken ribs in at least 2 sites, is a sarah.feray@aphp.fr 1 severe thoracic injury associated with chest wall instabil- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Service de Médecine Intensive Réanimation, Sorbonne Université, 75020 Paris, ity and significant morbidity and mortality [2]. Patients France may develop severe acute respiratory failure requiring Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Service mechanical ventilation and prolonged intensive care d’Anesthésie-Réanimation et Médecine Péri-operatoire, Sorbonne Université, 75020 Paris, France unit (ICU) and hospital stays. Long term morbidity may Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Service de include chest deformity, chronic pain, disability and lung Chirurgie Thoracique et Vasculaire, Sorbonne Université, 75020 Paris, function compromise [3]. Age, pre-existing respiratory or France Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Service de cardiac disease, number of fractured ribs and pulmonary Radiologie, Sorbonne Université, 75020 Paris, France contusion [4–6] are recognized factors of severity. The © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Féray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 2 of 9 Thoracic Trauma Severity Score (TTSS) has been devel - existence of pulmonary contusion and pleural involve- oped for predicting the occurrence of acute respiratory ment on computed tomography (CT)-scan. All patients distress syndrome (ARDS) and mortality in patients with had a radiological diagnostic of chest trauma. An expert chest trauma [7] (Additional file  1: Table S1). The Injury radiologist from our center reviewed all CT scans in Severity Score (ISS) is an established medical score to order to describe all lesions accurately. assess trauma severity, and is associated with morbidity, length of hospital stay, and mortality [8]. Surgery The usual management of flail chest is based on meas - The indications for surgery were the following: anterior ures including oxygen therapy, multimodal analgesia, and anterolateral flail chest (radiological), displaced rib respiratory physiotherapy and early rehabilitation [9– fractures (more than 2  cm measured on CT scan), frac- 11]. The generalization of non-invasive ventilation has tures impaling the lung or threatening other organs, and decreased the need for tracheal intubation and invasive rib fractures causing pain refractory to medical treat- ventilation, and its complications [12]. Despite some ment, including paravertebral bloc or epidural analgesia. promising prospective trials, the surgical fixation of rib Patients with severe head injury were contra-indicated fractures (SRFF) is still debated. French referentials [13] for surgery. Surgery was postponed if the patient could recommend “surgical fixation in patients with flail chest not be installed on the lateral decubitus position or and requiring mechanical ventilation if the respiratory because of associated injuries (orthopedic or spinal status does not permit the weaning of mechanical ven- trauma) whose treatment was more urgent. tilation within 36  h of admission”, on the basis of three The surgical approach was a posterolateral thoracot - small-size randomized controlled trials using different omy. An initial exploration of the cavity was performed, primary end points [12–14]. The development of tita - and associated with hemothorax drainage, if necessary. A nium claw plates of the Stracos system (Strasbourg Cos- bubble test was performed to look for any parenchymal tal Osteosynthesis System, MedXpert GmbH, Germany) air leak. The parenchyma was then sutured. makes easy to achieve rib fixation. This new technology Osteosynthesis of the ribs of the flail chest or of the has led to a renewed interest for the operative manage- most displaced ribs was performed by placing the Stracos ment approach and has led surgeons to consider expand- plates. The remaining broken ribs were fixed with wire to ing its indications. the ribs repaired with the plate. Once the reduction was We report our experience of the ICU management of considered satisfactory, two anterior and posterior endo- thoracic trauma patients after SRFF referred to Tenon thoracic tubes were placed. After closing, the tubes were hospital, a University teaching hospital and referral tho- put under suction at − 20 cmH20. racic center in Paris, France. The aim of this retrospective The characteristics of the surgical procedure were col - cohort study was to describe the characteristics of the lected: surgical approach, duration of surgery, perio- patients, the surgical procedure, and the in-hospital out- perative transfusion and fluid intake, duration of lung comes, and to identify factors associated with the occur- exclusion and type of regional analgesia technique. rence of postoperative complications. Postoperative period Methods All patients received the same enhanced recovery after Admission surgery protocol from our center (detailed in the Addi- From November 2013 to December 2016, all the con- tional file  2), including early mobilization, early oral secutive patients admitted to the ICU of Tenon hospital feeding, daily respiratory physical therapy, and pain con- for the perioperative management of chest trauma were trol. Pain control was provided by multimodal analgesia eligible. Written informed consent was not required including regional analgesia: all patients received a para- because of the retrospective nature of the investigation, vertebral catheter, except if the trauma involved more which was approved by the Institutional Review Board than 6 levels or if the trauma was bilateral in which case of the French learned society for respiratory medicine - an epidural catheter was placed. Société de Pneumologie de Langue Française (CEPRO Postoperative respiratory failure was defined as a fail - 2019-010). Demographics and medical history were col- ure of extubation within the first postoperative 24  h, or lected from the computerized medical records, Respira- as the need for HFNO, NIV or invasive ventilation. Post- tory failure was defined as the need for high flow nasal operative hemodynamic failure was defined as the need oxygen (HFNO), non-invasive ventilation (NIV), or intu- for the administration of vasoactive drugs. Postopera- bation with invasive ventilation. The TTSS was calcu - tive acute renal failure was defined as the need for renal lated on ICU admission, including the age of patients, the replacement therapy. Postoperative pneumonia was PaO2/FiO2 ratio, the number of fractured ribs, and the defined by a clinical suspicion of pneumonia associated F éray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 3 of 9 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] 26 [18–34] ISS, median [IQR 25–75] 21 [16–28] TTSS, median [IQR 25–75] 11 [9–12] Comorbidity Charlson score, median [IQR 25–75] 0 [0–1] Smoking, n (%) 17 (40) Cause of thoracic trauma, n (%) Road traffic accident 20 (48) Domestic fall 17 (40) Time from trauma to ICU admission (days), median [IQR 25–75] 3.0 [2–5.8] Number of broken ribs, median [IQR 25–75] 7 [5–8.8] Flail chest, n (%) 39 (93) (1) Pulmonary contusion, n (%) 27 (67) 1 lobe 16 (40) 2 lobes 7 (17) > 2 lobes 4 (10) (1) Pleural involvement, n (%) 34 (85) Isolated pleural effusion 3 (7) Pneumothorax/Hemopneumothorax unilateral 29 (72) Pneumothorax/Hemopneumothorax bilateral 1 (2) Tension pneumothorax 1 (2) (2) Associated intra-thoracic fractures, n (%) 20 (51) Sternum 3 (8) Clavicle 5 (13) Scapula 9 (23) Vertebrae 3 (8) Extra-thoracic injury, n (%) 17 (40) Head and neck injury, n 2 (Specific intervention needed), n (0) Face, n 4 (Surgery needed), n (2) Extremities, n 5 (Surgery needed), n (3) Abdomen, n 3 (Specific intervention needed), n (1) Spine, n 3 (Surgical or radiological procedures needed), n (2) Preoperative respiratory status, n (%) Respiratory failure * 12 (29) Invasive ventilation 6 (14) Non-invasive ventilation 6 (14) High flow nasal oxygen therapy 1 (2) SAPS II, Simplified Acute Physiologic Score; ISS, Injury Severity Score; ICU, intensive care unit; TTSS, Thoracic Trauma Severity Score *NIV was used for hypoxemic and hypercapnic patients, while HFNO was administered to hypoxemic patients without hypercapnia. Without rapid clinical or biological improvement, patients received invasive mechanical ventilation (1) (2) Date available for 40 patients and 39 patients Féray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 4 of 9 Fig. 1 Diagram of the patient’s course with a microbiological documentation. Lengths of ICU Mann–Whitney test, according to their parametric dis- and hospital stay and respective vital status at discharge tribution. Categorical variables were compared by a chi2 were reported. 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 Statistical analysis measured the crude associations between variables of The primary endpoint was the rate of occurrence of post - interest and postoperative complications, using Odds operative complications, defined as at least one postop - Ratio (OR) and their corresponding 95% confidence erative event among acute respiratory, hemodynamic interval (95% CI). The multivariable analysis was per - or renal failure, postoperative pneumonia, surgical site formed by a step-by-step logistic regression model, inte- infection or ICU death. The secondary endpoints were grating the selected variables in univariate analysis with a the factors associated with the occurrence of postopera- p-value < 0.1, and respecting the ratio of 1–10 events per tive complications. Continuous variables are expressed variable. The area under the receiver operating character - as median and interquartile [25–75], and categorical istic (ROC) curve [33] was used to assess the discrimina- variables as numbers (percentage). Continuous vari- tion of the model. Statistics were performed using Stata/ ables were compared using the Student’s t-test or the tm 13.1 software (StataCorp, College Station, Texas, USA). F éray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 5 of 9 Fig. 2 Distribution of the TTSS Table 2 Operative characteristics Variable Value Time from trauma to surgery (days), median [IQR 25–75] 4 [2–6] Table 3 Main postoperative outcomes Red blood cells transfusion, n (%) 6 (14) Variable Value (1) Vasopressor support (norepinephrine), n (%) 11 (27) (2) Crystalloid fluid administration (ml/kg/h) 7.21 [4.4–10.4] Ventilatory support Ventilation Duration of postoperative mechanical ventilation 0 [0–1.0] (days), median [IQR 25–75] Selective intubation, n (%) 42 (100) (3) Early extubation 35 (83) Ventilation difficulties, n (%) 13 (31) (4) NIV or nasal high flow nasal oxygen (HFNO) 2 Duration of surgery (hours), median [IQR 25–75] 2.33 [2.0–3.0] Reintubation 3 Postoperative analgesia, n (%) 40 (95) Late extubation (no extubation possible within the 7 (17) Paravertebral catheter 31 (77) first 24 h) Epidural catheter 9 (23) Postoperative organ failure, n (%) None 2 (5) Postoperative respiratory failure 12 (28) (1) (2) (3) (4) Data available for 40 patients , 20 patients , 31 patients , and 35 patients Postoperative hemodynamic failure* 6 (14) Postoperative renal failure 1 (2) Postoperative infectious events** Results Postoperative pneumonia, n (%) 11 (26) During the study period, 42 patients were referred to Ventilator associated pneumonia 8 our ICU from the trauma centers of Paris area (either Emergency Departments or ICUs), for the perioperative Surgical site infection, n (%) 0 management of chest trauma after a median duration of ICU stay 3.0  days [2.0–5.75]. The patient course is described in Death 2 (4) Fig.  1. The patients were 58-year old [46.5–77] with few Length of stay (days), median [IQR 25–75] 6.5 [4.0–9.0] comorbidities (Table  1). On preoperative assessment, 12 Hospital stay patients (29%) had acute respiratory failure, 6 of them Death 0 required NIV and 6 required invasive ventilation. The Length of stay (days), median [IQR 25–75] 11.5 [9.0–16.0] mean duration of ventilation (invasive and non inva- NIV, Non-invasive ventilation sive) before surgery was 1 day [1–4]. The TTSS was 11.0 *One patient had an acute coronary syndrome (ST+) [9–12] (Fig.  2), with 7 broken ribs [5–8.75]. Pulmonary **The numbers of postoperative pneumonia are 3 and 8 in non-mechanically ventilated and mechanically ventilated patients, respectively Féray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 6 of 9 Table 4 Factors associated with postoperative complications Variable No postoperative Postoperative OR [CI 95%] p complication, n = 24 complication, n = 18 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 (%) 1 (4) 5 (28) 8.85 [0.79–99.31] 0.03 Number of red blood cells, median IQR [25–75] 0 [0–0] 0 [0–2] 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 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 nasal oxygen (HFNO), non-invasive ventilation (NIV ), or intubation with invasive ventilation Main postoperative outcomes contusion was frequent (27/40, 67%). A flail chest was Main postoperative outcomes are summarized in Table 3. present in 39 patients (93%). The remaining three patients Extubation was performed in the operative room or had 5 broken ribs (n = 2), and 8 broken ribs associated within the first 24  h after surgery in most patients with a sternal fracture (n = 1). Associated extra thoracic (n = 35; 83%). Among those latter, 2 required NIV and injuries are described in the Appendix (Additional file  1: 3 required reintubation due to hypercapnic respiratory Table S2). failure (Additional file  3: Fig.  S1). Seven patients (17%) SRFF was performed 4 days [2–6] after the trauma. The could not be extubated within the first 24  h after sur - characteristics of intraoperative anesthesia are detailed gery (Additional file  4: Fig. S2). Six of them were hypox- in Table 2. Intraoperative ventilation difficulties occurred emic with ventilator-associated pneumonia and one had in 13 patients. A thoracic paravertebral catheter was difficulty coughing. Eleven patients (26%) developed a inserted at the end of the surgical procedure in most patients (n = 31; 77%). F éray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 7 of 9 Discussion In this observational retrospective cohort study, we describe the characteristics, the management and the outcomes of 42 patients referred to the ICU of a refer- ral thoracic center for surgical rib fracture fixation after a severe chest trauma, using the titanium plate of the Stra- cos system. Our cohort is original, as it included different patients than those described in previous randomized controlled trials [14–16] (Additional file  1: Table  S3). This was a selected population of patients transferred from trauma center with only isolated chest trauma. Our patients had more domestic accidents, were older, and had no respira- Fig. 3 Diagnostic performance of TTSS and SAPSII without age for tory failure in two third of the cases. predicting postoperative complications Postoperative complications occurred in 18 patients (43%) including two ICU deaths. This high rate of post - operative complications may question the role of surgery postoperative pneumonia, 8 of whom were mechani- in such a selected population, particularly in old patients cally ventilated, and 5 patients (12%) developed a postop- with severe trauma. The formalized experts French erative ARDS. Two patients had a tracheotomy. The ICU guidelines published in 2015 and 2017 recommend sur- and hospital lengths of stay were 6.5  days [4.0–9.0] and gical rib fixation «in mechanically ventilated patients if 11.5 days [9.0–16.0], respectively. Two patients (4%) died the respiratory condition does not allow weaning from in the ICU. mechanical ventilation within 36  hours of admission», on the basis of three small size randomized clinical trials, Factors associated with postoperative complications two of which no longer reflect current practices [14–16]. A postoperative complication occurred in 18 patients These results are confirmed by more recent retrospec - (43%). Factors associated with the occurrence of post- tive series, where operative rib fixation has the poten - operative complications are detailed in Table  4. Comor- tial to reduce ventilator days and ICU stay in selected bidities (diabetes and ischemic heart disease), high patients with severe traumatic flail chest requiring TTSS, bilateral fractures, other chest trauma (clavicle, mechanical ventilation [22]. sternum, scapula or vertebrae fractures), initial clini- The radiological severity (flail chest) of the chest cal severity (initial respiratory failure, tracheal intuba- trauma may out weight  the clinical and respiratory sta- tion with mechanical ventilation, SAPSII score) and the tus of the patient in the surgical decision. However, the need for intraoperative transfusion (transfusion, number benefit of SRFF in non-ventilated patients remains to of units) were associated with the occurrence of postop- be determined. In a recent case–control series involv- erative complications. In multivariable analysis, the TTSS ing non-mechanically ventilated patients with flail chest, (OR = 1.89; IC95% 1.12–3.17; p = 0.016) and the SAP- the patients who were treated non-surgically had better SII without age (OR = 1.17; IC95% 1.02–1.34; p = 0.024) outcomes than their counterparts, with shorter dura- were independently associated with the occurrence of tion of mechanical ventilation, lower rate of post-oper- postoperative complications, with good discrimina- ative pneumonia and shorter ICU and hospital lengths tion (area under the ROC curve 0.88) and calibration of stay [21]. One of the main expected benefits of sur - (Hosmer Lemeshow test 0.696) (Fig.  3). The ISS score gery is to decrease the duration of mechanical ventila- was not associated with the occurrence of postoperative tion and reduce the associated morbidity. By restoring complications. parietal rigidity, better wall mobility should be achieved, facilitating the restoration of proper ventilation. How- Long‑term outcomes (planned post‑hospitalization visits) ever, this hypothesis has not been confirmed in any At one month, data were available for 37 patients (92%). controlled trial, and large variations in the duration of All were alive, and 8 patients had chronic neurological mechanical ventilation have been reported [15–17]. In pain assessed by DNA4 questionnaire. Treatment with the most recent series by Marasco et  al. [15] the dura- pregabalin was started. At one year, data were available tion of mechanical ventilation was similar in the surgical for 26 patients (65%) and all were alive. group (6.3  days ± 3.4), as compared with the conserva- tive group (7.5  days ± 5.4). Several hypotheses may explain the lack of benefits of surgery on the duration of Féray et al. Journal of Cardiothoracic Surgery (2023) 18:37 Page 8 of 9 mechanical ventilation. First, the chest wall mobility res- [20] reported a decreased ICU and hospital lengths of toration and the expected better pulmonary compliance stay in operated patients, as compared with non-oper- could be insufficient, due to the rigidity  of the material ated patients (3  days vs. 7  days). Ali-Osman et  al. [32] used. In our series, the titanium claw plates were used. suggested an improved pulmonary function among oper- These clips simplify the fixation of screwless plates but ated patients despite an increased hospital length of stay. there is no evidence that they may  reduce the risk of Altogether, the benefits of surgery seem to exist when intercostal neurovascular damage. Second, the surgical performed early after trauma in young patients with res- procedure itself may be more deleterious than beneficial. piratory failure despite effective analgesia. In patients The complications associated with selective intubation without respiratory failure or in older patients, surgical [23, 24], one-lung ventilation, lateral decubitus position- treatment is probably more controversial. ning [25, 26] and the consequence of perioperative fluid administration and transfusion must be weighed against Limitation of the study the expected advantages of surgery. A muscle-sparing The main limitations of our study are related to its ret - approach, less invasive than posterolateral thoracotomy, rospective and single center nature, as well as its sample could be considered as suggested in a recent series [27]. size. The initial medical management of patients was not Data from the literature on other postoperative respira- protocolized, since they were taken care of in a trauma tory outcomes are unclear. The incidence of ARDS is not center before being referred to our hospital. Our popula- known but it increases with the number of fractured ribs tion was selected for receiving SRFF in an expert center, [28]. Its incidence has decreased since the introduction which makes the results less generalizable. The impact of protective ventilation [29]. Postoperative pneumo- of the surgery on long-term respiratory function and nia is not clearly defined in the literature and its inci - chronic pain was not evaluated. dence varies from 10 to 48% [15, 17]. In our series, only To summarize, we describe a cohort of 42 thoracic the episodes with high clinical suspicion of pneumonia trauma patients with flail chest who received SRFF with and microbiological documentation were considered, titanium plates in an expert thoracic center. The TTSS accounting for an overall incidence of postoperative and SAPSII score without age were independently asso- pneumonia of 26%. A reduction in the length of stay is ciated with postoperative complications that occurred in also expected with the surgical treatment, but results are 43% of cases. Conversely, the ISS score was not associ- conflicting [15, 16, 20, 30]. The most recent randomized ated with such complications. controlled study conducted in the United Kingdom with Further trials will help to provide answers about the the length of stay as the primary end point, reported a benefit of the surgery in non-mechanically ventilated significantly shorter length of stay in surgical patients, as patients with isolated chest trauma. compared with their counterparts (14.5 days vs. 30 days) [30]. The length of stay was longer than in other series Supplementary Information [20, 21, 31, 32]. The online version contains supplementary material available at https:// doi. The optimal time for surgery is also important, as org/ 10. 1186/ s13019- 023- 02121-8. delayed surgery may result in pathological bone con- solidation. Recent case–control studies [18–20] have Additional file 1: Table S1. Thoracic Trauma Severity Score. Table S2. Summary of characteristics and outcomes of patients treated with rib reported a shorter duration of post-operative mechanical fixation in different recent series. Table S3. Descriptive table of associated ventilation in patients operated within the first 4–5 days extra thoracic lesions. after trauma. In our series, surgery was performed after a Additional file 2: Protocol for enhanced rehabilitation after surgery. median time of 4 days. Additional file 3: Figure S1. Post-operative outcomes in early extubated The three existing randomized controlled trials do not patients (first 24 hours after surgery) allow determining whether a surgical approach can ben- Additional file 4: Figure S2. Post-operative outcomes in late extubated efit in non-intubated and old patients, as in our series. patients (beyond the first day of surgery). There are several retrospective series with similar popu - lation. Farquhar et  al. [21] reported an increased length Acknowledgements of stay in operated patients (7.4 ± 6.7 days), as compared The authors wish to thank all the participants who contributed to the conduct of the study in Tenon hospital. with non-operated patients (3.7 ± 6.0  days), but surgery was performed a week after trauma. Wijffels et  al. [31] Author contributions reported a lower rate of postoperative pneumonia and 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 and CQ revised a shorter hospital length of stay in operated patients, at the manuscript. 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Journal

Journal of Cardiothoracic Surgery – Springer Journals

Published: Jan 18, 2023

Keywords: Thoracic trauma; Flail chest; Surgical rib fracture fixation; Complication; TTSS score

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