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Operative Treatment of Rib Fractures in Flail

Chest Injuries: A Meta-analysis and
Cost-Effectiveness Analysis
Eric Swart, MD,* Joseph Laratta, MD,† Gerard Slobogean, MD,‡ and Samir Mehta, MD§

sensitive to overall complication rates, and operations should be

Objectives: Flail chest is a common injury sustained by patients conducted by surgeons or combined surgical teams comfortable with
who experience high-energy blunt chest trauma and results in severe both thoracic anatomy and exposures as well as with the principles
respiratory compromise because of altered mechanics of respiration. and techniques of internal fixation.
There has been increased interest in operative fixation of these
injuries with the intention of restoring the mechanical integrity of the Key Words: rib fracture fixation, flail chest, cost-effectiveness
chest wall, and several studies have shown that ventilation require- Level of Evidence: Economic Level III. See Instructions for
ments and pulmonary complications may be decreased with Authors for a complete description of levels of evidence.
operative intervention. The purpose of this study was to evaluate
fixation of rib fractures in flail chest injuries using cost-effectiveness (J Orthop Trauma 2017;31:64–70)
analysis, supported by systematic review and meta-analysis.
Methods: This was a 2-part study in which we initially conducted INTRODUCTION
a systematic literature review and meta-analysis on outcomes after Rib fractures are common injuries occurring in 10% of
operative fixation of flail chest injuries, evaluating intensive care unit all patients admitted after blunt chest trauma.1 The most
(ICU) stay, hospital length of stay (LOS), mortality, pneumonia, and severe manifestation of rib fractures is a flail chest, defined
need for tracheostomy. The results were then applied to a decision- as at least 3 or 4 consecutive ribs broken in at least 2 places,2
analysis model comparing the costs and outcomes of operative which is found in approximately 7% of patients with rib
fixation versus nonoperative treatment. The validity of the results fractures.3 These severe injuries are clinically relevant to
was tested using probabilistic sensitivity analysis. the multiple-injured patient as they affect respiratory mechan-
Results: Operative treatment decreased mortality, pneumonia, and ics, increasing the work of breathing and making it difficult
tracheotomy (risk ratios of 0.44, 0.59, and 0.52, respectively), as well for patients to effectively ventilate on their own because of
as time in ICU and total LOS (3.3 and 4.8 days, respectively). paradoxical motion of the chest wall.4
Operative fixation was associated with higher costs than nonoperative Historically, flail chests have been treated primarily
treatment ($23,682 vs. $8629 per case, respectively) and superior with supportive care consisting of pain control and ventilatory
outcomes (32.60 quality-adjusted life year (QALY) vs. 30.84 QALY), support as needed.5 However, this often requires prolonged
giving it an incremental cost-effectiveness ratio of $8577/QALY. intubation or even tracheostomy, 5 with the accompanied
medical complications and additional resource utilization
Conclusions: Surgical fixation of rib fractures sustained from flail associated with intensive care and prolonged mechanical
chest injuries decreased ICU time, mortality, pulmonary complica- ventilation. In addition, these supportive care interven-
tions, and hospital LOS and resulted in improved health care–related tions are associated with high levels of long-term
outcomes and was a cost-effective intervention. These results were morbidity. 6
Operative management of rib fractures with open
Accepted for publication November 4, 2016. reduction and internal fixation (ORIF) as a primary strategy
From the *Department of Orthopaedic Surgery, University of Massachusetts, has gained relevance, with the aim of restoring the mechanical
Worcester, MA; †Department of Orthopaedic Surgery, Columbia Univer-
sity Medical Center, New York, NY; ‡Department of Orthopaedic Surgery, integrity of the chest wall and reducing the duration and intensity
University of Maryland School of Medicine R Adams Cowley Shock of respiratory support required.2,4,7,8 This has been investigated
Trauma Center, Baltimore, MD; and §Department of Orthopaedic Surgery, by randomized trials and some early meta-analyses9–11
University of Pennsylvania Medical Center, Philadelphia, PA. suggesting promising results, although several additional
The authors report no conflict of interest. high-quality studies have recently been published since
Presented at the Annual Meeting of the Orthopaedic Trauma Association,
October 6–8, 2016, National Harbor, MD. some of the more recent meta-analyses.12–16 Preliminary
Supplemental digital content is available for this article. Direct URL citations economic evaluations have also been conducted evaluating
appear in the printed text and are provided in the HTML and PDF versions the feasibility of primary early fixation,17 although they
of this article on the journal’s Web site ( were limited in quality by a narrow scope of data used
Reprints: Eric Swart, MD, Department of Orthopaedic Surgery, University of
Massachusetts, Worcester, MA 01605 (e-mail:
without formal sensitivity analysis.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. The purpose of this study was to construct an economic
DOI: 10.1097/BOT.0000000000000750 model based on rigorous meta-analysis using the most recent

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J Orthop Trauma  Volume 31, Number 2, February 2017 Rib Fracture Fixation Cost-Effectiveness

high-quality literature available to evaluate both the economic Statistical Methods of Meta-analysis
and medical benefits of early fixation of rib fractures in severe Meta-analysis was performed using Review Manager 5.0
chest trauma. Our hypothesis was that the additional cost and ( The weighted mean differ-
operative complications of surgical fixation may be offset by ence and 95% confidence interval (CI) were calculated for
the decreased medical complications and resource utilization continuous variables, and the weighted risk ratio and 95% CI
of prolonged intensive care and ventilator support required by were calculated for dichotomous variables. If the standard error
nonoperative treatment. was not reported in a study, it was imputed using the methods
described by Ma et al.34 Statistical significance was set at P ,
0.05. Heterogeneity was calculated using the I2 statistic,35 with
MATERIALS AND METHODS random-effects models used when the heterogeneity was
greater than 50%. These values were all recalculated using only
Study Design data available from level 1 prospective trials as well.
This was a 2-part study in which we initially conducted
a meta-analysis of the existing literature and then used the
results of that meta-analysis to populate an economic model Cost-Effectiveness Analysis Model Design
and cost-effectiveness analysis. A cost-effectiveness analysis was conducted based on
the guidelines by the Panel on Cost-Effectiveness in Health
Source of Funding and Medicine.36 As there are no reliable data about long-term
indirect costs (return to work, etc.), costs were taken solely
No external funding was used for this study.
from a payer perspective, with only costs incurred during
index hospitalization or subsequent revision operations mod-
Literature Search and Study Identification eled. For health utility gains, a lifetime time duration was
A comprehensive search of the literature was performed used, assuming an average age of 46 years (based on the
based on the Preferred Reporting Items for Systematic average age of patients included in the studies), with a life
Reviews and Meta-analyses (PRISMA) guidelines on June expectancy of 80 years (based on US life tables37). For cost-
1, 2016. The databases used included PubMed, EMBASE, effectiveness calculations, we used a limit of $100,000 per
MEDLINE, and Scopus. Our goal of the search was to quality-adjusted life year (QALY) as a cutoff for incremental
identify studies comparing nonoperative and operative man- cost-effectiveness ratio (ICER), based on studies suggesting
agement of rib fractures—specifically flail chest injuries. that this is a reasonable contemporary threshold.38
All published articles were retrieved without a search con- A model was developed to evaluate the clinical and
straint on publication date. The key words “flail chest,” economic outcomes of 2 different treatment strategies:
“rib fracture,” “internal fixation,” and “osteosynthesis” operative ORIF or nonoperative management with supportive
were used (see Table, Supplemental Digital Content 1, ventilation and pain management. For each treatment strat- A manual search of refer- egy, the incidence of complications including mortality,
ence lists of included studies and previous reviews was also pneumonia, tracheostomy, and reoperation were modeled,
performed to find additional suitable citations. as well as increased ICU and hospital LOS (Fig. 1 and
Table 2). We assumed that all major costs and health events
Study Selection and Data Extraction occurred during index hospitalization; that is, that costs and
All potentially relevant publications retrieved from the health utility states were equal for all survivors after initial
4 databases were combined and evaluated. The evaluation hospitalization. The only exception to this was when revision
was performed independently by 2 authors (E.S. and J.L.). surgery was required in the ORIF group after discharge, in
Titles were screened for relevance to rib fracture manage- which case the cost of that procedure was included.
ment. Subsequently, the abstracts of selected articles were Cost of rib fracture fixation was challenging to estimate,
screened to retrieve studies comparing the operative and given that this is a relatively novel procedure, is not frequently
nonoperative treatment of flail chest. During the title and performed, and is variably coded/billed. To overcome this, we
abstract screening, if insufficient data were present, the obtained estimates of the variable procedure costs (which include
citation was assessed by full-text review. Full-text review implants, supplies, and supporting staff salary in the operating
was performed on the selected abstracts focused on outcomes room) from 3 different level 1 trauma centers where these
related to clinical efficacy and cost-effectiveness. procedures are regularly performed. Average variable costs
The final inclusion criteria included the following: (1) ranged from $13,500 per case to $22,000 per case, and an
study comparing nonoperative and operative treatment average between all 3 institutions of $17,100 was used. This was
groups, (2) participants 18 years of age or older with an combined with an average physician reimbursement of $4000
acute diagnosis of flail chest. No studies were excluded on the published in other studies,17 for an average procedure cost of
basis of the types of outcome measures used or study design. $21,100, with the cost ranging from $17,500 to $26,000 in sen-
Two independent investigators (J.L. and E.S.) extracted sitivity analysis. Cost of revision ORIF for complication was
information using standardized extraction forms. The extracted assumed to be 150% of the primary operation. Other costs ana-
data included the following: ventilator days, intensive care unit lyzed included those of treatment of pneumonia and tracheos-
(ICU) length of stay (LOS), hospital LOS, mortality rate, tomy, as well as the additional cost associated with ICU or
pneumonia rate, and tracheostomy rate (Table 1). hospital LOS and were determined by literature review.17,39–46

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Swart et al J Orthop Trauma  Volume 31, Number 2, February 2017

TABLE 1. Results of Literature Review and Meta-analysis

No. Patients Ventilator Time, d ICU LOS, d
Study LoE ORIF Non-Op Avg SD Avg SD Avg SD Avg
Ahmed et al18 3 26 38 3.9 4.3 15.0 6.4 9.0 3.9 21.0
Althausen et al19 3 22 28 4.1 4.7 9.7 7.4 7.3 4.2 9.7
Balci et al20 3 27 37 3.1 1.8 7.2 5.8
de Moya et al21 3 16 32 7.0 8.0 6.0 10.0 9.0 8.0 7.0
DeFreest et al22 3 41 45 9.3 10.7 5.8 11.2 14.0 11.0 8.0
Doben et al16 3 10 11 8.2 6.9 18.0 11.9 12.5 6.2 15.3
Granetzny et al23 1 20 20 2.0 4.9 12.0 8.8 9.6 4.4 14.6
Granhed et al13 3 60 153 2.7 2.8 9.0 3.2
Jayle et al12 3 10 10 3.1 5.2 5.9 9.4 9.0 4.3 12.3
Karev et al24 3 40 93 2.3 0.6 6.3 1.2
Kim et al25 3 18 45
Majercik et al26 3 38 57 6.0 3.0 7.0 6.0 3.0 1.0 5.0
Marasco et al14 1 23 23 6.3 3.5 7.5 5.4 13.5 3.0 18.7
Nirula et al27 3 30 30 6.5 1.3 11.2 2.6 12.1 1.2 14.1
Tanaka et al28 1 18 19 10.8 3.4 18.3 7.4 16.5 7.4 26.8
Teng et al29 3 32 28 14.0 3.9 20.0 7.4 8.7 3.5 15.2
Voggenreiter et al30 3 20 22 18.8 20.3 27.2 27.8
Wada et al31 3 84 336
Xu et al32 3 17 15 10.5 3.7 13.7 4.4 15.9 5.0 19.6
Zhang et al33 3 24 15 12.0 2.6 7.0 2.5 24.5 2.4 21.5
Heterogeneity (I2), % 83 91
Meta-analysis effect size (SD) 4.57 (60.59) 3.25 (61.29)
Effect size using only level 1 studies 6.03 (62.74) 6.84 (62.48)
ICU LOS, d Hospital LOS, d Mortality Pneumonia Tracheostomy
Non-Op ORIF Non-Op Op Non-Op Op Non-Op Op Non-Op
Study SD Avg SD Avg SD Inc Inc Inc Inc Inc Inc
Ahmed et al18 5.3 0.08 0.29 0.15 0.50 0.12 0.37
Althausen et al19 6.1 11.9 6.5 19.0 8.8 0.05 0.25 0.14 0.39
Balci et al20 18.3 7.6 19.3 6.9 0.11 0.27 0.00 0.19
de Moya et al21 10.0 18.0 12.0 16.0 11.0 0.31 0.38
DeFreest et al22 10.0 28.3 17.0 13.0 9.0 0.02 0.11 0.27 0.22 0.24 0.18
Doben et al16 9.8 21.6 9.6 28.5 14.1 0.00
Granetzny et al23 7.3 11.7 6.8 23.1 10.4 0.10 0.15 0.10 0.50
Granhed et al13 0.03 0.00
Jayle et al12 8.5 21.7 7.8 32.3 19.3 0.40 0.30
Karev et al24 0.23 0.46 0.15 0.34
Kim et al25 0.06 0.22
Majercik et al26 3.5 0.24 0.39 0.05 0.23
Marasco et al14 4.1 0.00 0.04 0.48 0.74 0.39 0.70
Nirula et al27 2.7 18.8 1.8 21.1 3.9
Tanaka et al28 13.2 0.22 0.89 0.28 0.79
Teng et al29 6.1 17.1 5.4 22.4 8.8 0.13 0.43
Voggenreiter et al30 0.15 0.36 0.25 0.32
Wada et al31 33.0 10.5 42.0 17.5 0.04 0.02 0.12 0.20
Xu et al32 5.0 0.00 0.07 0.59 0.93 0.12 0.40
Zhang et al33 3.9 38.0 5.3 60.0 15.4 0.00 0.13 0.67 0.47 0.50 0.47
Heterogeneity (I2), % 91 89 0 55 42
Meta-analysis effect size (SD) 3.25 (61.29) 4.84 (61.98) RR 0.44 (60.09) RR 0.59 (60.10) RR 0.52 (60.07)
Effect size using only level 1 studies 6.84 (62.48) 3.01 (60.73) RR 0.56 (60.57) RR 0.39 (60.09) RR 0.46 (60.11)
Avg, average value; Inc, incidence rate; LoE, level of evidence; Non-Op, patients treated nonoperatively with standard of care; RR, risk ratio.

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J Orthop Trauma  Volume 31, Number 2, February 2017 Rib Fracture Fixation Cost-Effectiveness

FIGURE 1. For patients suffering a flail

chest injury, after the initial decision
between operative fixation (ORIF) and
standard care (mechanical ventilation),
they are modeled to have medical com-
plications (mortality, pneumonia, or tra-
cheostomy) based on the values given in
Table 2. Some patients undergoing ORIF
are also modeled to have surgical com-
plications after discharge requiring revi-
sion surgery (eg, removal of hardware).

The following baseline parameters were obtained using assumed that all survivors had a life expectancy of 80 years.
the weighted average across all included studies in the meta- Although there is some literature to suggest that there may
analysis: age of the base case (46 years old), incidence of be some long-term functional benefits of ORIF,12,23,28 we
pneumonia (47%), incidence of tracheostomy (37%), and assumed equal posthospitalization health states between
surgical revision rate (5%). As there have been substantial nonoperative and operative patients (a utility of 1.0), so as
improvements in intensive management over the past 10 not to bias the model in favor of ORIF. Patients who had
years, baseline mortality rate was based solely using data a postsurgical complication or revision were modeled to
from the 2 “modern” level 1 studies (Marasco et al,14 and have a disutility of 0.3.17
Granetzny et al23) of 9.3%. Reduction in ICU stay, hospital
stay, mortality, pneumonia, and tracheostomy from operative Sensitivity Analysis
treatment were obtained from the meta-analysis. To test the stability of conclusions on input variable
The gains in QALYs arose from increased survivor- uncertainty, probabilistic sensitivity analysis was conducted.
ship during initial hospitalization. As noted above, we All input parameters were allowed to randomly vary within

TABLE 2. Input Values Used to Calculate the Cost-Effectiveness of ORIF of Rib Fractures in Flail Chest Injuries
Description Base Case Low High Reference
Costs, $
Rib fracture ORIF 21,100 17,500 26,000 14
24 h in the ICU 2000 1200 2500 37–43
24 h in the hospital (non-ICU) 700 400 800 36,42
Pneumonia 3679 2000 4000 14
Tracheostomy 400 200 1000 14
Clinical outcome probabilities
Average reduction in time in ICU after ORIF, d 3.25 0.66 5.83 *
Average reduction in total hospital LOS, d 4.84 0.88 8.80 *
Baseline mortality rate with conservative care, % 0.09 0.04 0.46 *
Baseline rate of pneumonia with conservative care, % 0.47 0.25 0.93 *
Baseline tracheostomy rate with conservative care, % 0.43 0.19 0.79 *
Reduction in mortality with ORIF, RR 0.44 0.30 0.65 *
Reduction in rate of pneumonia with ORIF, RR 0.59 0.52 0.81 *
Reduction in rate of tracheostomy with ORIF, RR 0.52 0.40 0.69 *
Complication rate of ORIF requiring revision, % 0.05 0.00 0.50 *
Age of base case 46 *
Life expectancy 80 34
*Based on internal meta-analysis.
RR, risk ratio.

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Swart et al J Orthop Trauma  Volume 31, Number 2, February 2017

FIGURE 2. Flow diagram presenting the

systematic review process used in this

their 95% CIs, and a Monte Carlo simulation was used to Sensitivity Analyses
estimate the probability of a given strategy being preferred When all the variables listed in Table 2 were varied
over a range of ICERs. In addition, one-way sensitivity through their 95% CIs, ORIF remained the most cost-
analysis was performed on all the variables listed in Table 2 effective strategy, with ICER never exceeding $16,000/QALY.
within their 95% CIs to identify edge cases. The model was most sensitive to revision rate, but even
Finally, results of the meta-analysis and economic with complication/revision rates as high as 50%, ORIF still
model were re-examined using only data from level 1 had an ICER of $18,000/QALY, well under the threshold for
prospective randomized trials, to see if our conclusions would cost-effectiveness.
vary. Results of probabilistic sensitivity analysis showed that
ORIF is the preferred strategy (cost effective in over 50%
of simulations) when the societal willingness to pay (ICER
RESULTS threshold) is greater than $8500/QALY (Fig. 3). For ICER
Systematic Review and Meta-analysis thresholds greater than $25,000/QALY, ORIF was the
The initial literature search returned 451 studies, preferred strategy in virtually all simulations.
and after review, a total of 20 studies met inclusion Repeating the meta-analysis and cost-effectiveness
criteria12–14,16,18–21,23–33 (Fig. 2). Data for ventilator time, using only data from level 1 prospective randomized trials
ICU LOS, hospital LOS, mortality rate, pneumonia rate, tra- did not affect conclusions of the probabilistic sensitivity
cheostomy rate, and reoperation rate were extracted, and the analysis (see Appendix, Supplemental Digital Content 3,
data synthesized to generate a mean effect size with 95% CI
(Table 1). All the variables measured showed improvement in
the operative group which was statistically significant (P ,
0.05). Full forest plots and funnel plots for each variable are DISCUSSION
also given in Supplemental Digital Content 2 (see Appendix, Flail chest injuries from high-energy blunt trauma can Analysis was repeated using be devastating, life altering events with extremely high
only data from level 1 prospective randomized control trials morbidity and mortality rates. In addition, these injuries
(also shown in Table 1). require extensive resource utilization due to the intensive
level of care demanded by traditional conservative manage-
Cost-Effectiveness Analysis ment strategies. In that context, surgical intervention that
For the base case (using data from all available studies), improves clinical outcomes and reduces overall demand of
nonoperative management had an average total cost of $8629 care is appealing.
and an average of 30.84 QALY. ORIF had an average cost The results of this meta-analysis and economic simu-
of $23,682 and 32.60 QALY, giving it an ICER of lation are encouraging: the literature-reported data show
$8577/QALY. a universal decrease in complications (morbidity, pneumonia,
Using only data from level 1 studies, nonoperative and tracheostomy requirements) with some of the increased
management had an average total cost of $11,700 and an cost of surgery offset by decreased length of stay in both
average of 30.84 QALY. ORIF had an average cost the ICU and the hospital overall. These results are robust
of $23,314 and 32.20 QALY, giving it an ICER of over an extremely wide range of input values, making a
$8348/QALY. compelling case for more aggressive surgical management of

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J Orthop Trauma  Volume 31, Number 2, February 2017 Rib Fracture Fixation Cost-Effectiveness

FIGURE 3. Results of probabilistic sensi-

tivity analysis. Curves show the percent
chance of either ORIF (blue) or standard
care (red) being cost effective for a given
willingness to pay (ICER). Editor’s Note:
A color image accompanies the online
version of this article.

these injuries. Of note, the results of the analysis using only reverse the central conclusions of this study (in terms of
level 1 studies were comparable with other similar recent mortality rate, pneumonia, and tracheostomy reduction).
meta-analyses,11 further increasing the confidence in results. Obtaining accurate cost estimates of this infrequent
Furthermore, we assumed equal clinical outcomes and costs operation is also challenging and a potential source of
in all survivors, although several studies have suggested that uncertainty, which we have attempted to mitigate by pooling
nonoperative treatment of flail chest may be associated with between data across 3 busy level 1 trauma centers. In
impaired pulmonary function12,23,28 and long-term decreased addition, ORIF of rib fractures for flail chest is a relatively
quality of life.6,15 If anything, this may underestimate the uncommon operation in most trauma centers; the literature
benefit of surgical treatment. used in this analysis represents results from centers that are
Historically, nonoperative management of the flail chest relatively experienced in this procedure, and it remains to be
has been the standard of care. The choice of nonoperative demonstrated how reproducible these benefits will be with
management may have resulted from the knowledge gap broader adoption of these techniques. Finally, it is important
regarding fracture fixation strategies and techniques by those to note that this analysis only concerns acute fixation of rib
managing the chest wall injuries in these patients (eg, fractures resulting in flail chest, and these results should not
intensivists). As rib fracture fixation has gained popularity be generalized to fixation of single isolated rib fractures
and fixation techniques and implants have been refined, without pulmonary compromise or to established nonunions.
clinical outcomes are encouraging. The results of this analysis The results of this meta-analysis and cost-effectiveness
suggest that patients could substantially benefit from surgical analysis show that acute ORIF of rib fractures in patients with
management of rib fractures if complications can be limited flail chest injuries results in reduced mortality and medical
through a more intimate coordination between general/ complications in conjunction with being a cost-effective
thoracic surgeons and orthopaedic surgeons. The economic intervention. In a hospital with surgeons comfortable with
benefits are sensitive to complication rate, suggesting that thoracic exposures and with principles and techniques of rigid
optimum outcomes would be achieved when these procedures internal fixation, strong consideration should be given to
are performed by surgeons with expertise in each individual operative intervention in these patients by a multidisciplinary
step, also supporting a multidisciplinary approach. effort.
One of the major limitations of this study is the
retrospective, comparative nature of many of the studies used
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