title: Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis.
abstract: OBJECTIVE
  To perform a systematic review and meta-analysis of studies comparing operative to nonoperative therapy in adult FC patients. Outcomes were duration of mechanical ventilation (DMV), intensive care unit length of stay (ICULOS), hospital length of stay (HLOS), mortality, incidence of pneumonia, and tracheostomy.
  
  
  BACKGROUND
  Flail chest (FC) results in paradoxical chest wall movement, altered respiratory mechanics, and frequent respiratory failure. Despite advances in ventilatory management, FC remains associated with significant morbidity and mortality. Operative fixation of the flail segment has been advocated as an adjunct to supportive care, but no definitive clinical trial exists to delineate the role of surgery.
  
  
  METHODS
  A comprehensive search of 5 electronic databases was performed to identify randomized controlled trials and observational studies (cohort or case-control). Pooled effect size (ES) or relative risk (RR) was calculated using a fixed or random effects model, as appropriate.
  
  
  RESULTS
  Nine studies with a total of 538 patients met inclusion criteria. Compared with control treatment, operative management of FC was associated with shorter DMV [pooled ES: -4.52 days; 95% confidence interval (CI): -5.54 to -3.50], ICULOS (-3.40 days; 95% CI: -6.01 to -0.79), HLOS (-3.82 days; 95% CI: -7.12 to -0.54), and decreased mortality (pooled RR: 0.44; 95% CI: 0.28-0.69), pneumonia (0.45; 95% CI: 0.30-0.69), and tracheostomy (0.25; 95% CI: 0.13-0.47).
  
  
  CONCLUSIONS
  As compared with nonoperative therapy, operative fixation of FC is associated with reductions in DMV, LOS, mortality, and complications associated with prolonged MV. These findings support the need for an adequately powered clinical study to further define the role of this intervention.
authors.affiliation: *Department of Surgery, Division of Acute and Critical Care Surgery †Department of Surgery, Division of Public Health Science, Washington University School of Medicine, St Louis, MO.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Leinicke
authors.forename: Leisha
authors.initials: L
authors.lastname: Elmore
authors.forename: Bradley D
authors.initials: BD
authors.lastname: Freeman
authors.forename: Graham A
authors.initials: GA
authors.lastname: Colditz
mesh_terms: D005409:Flail Chest / Q000150:complications*; D006801:Humans; D019637:Orthopedic Procedures; D016032:Randomized Controlled Trials as Topic; D012253:Rib Fractures / Q000150:complications* / Q000601:surgery*