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journal homepage: www.JournalofSurgicalResearch.com

A Randomized Controlled Trial of Surgical Rib

Fixation in Polytrauma Patients With Flail Chest

Tao Liu, PhD,a Peng Liu, MD,b Jiajun Chen, PhD,a Jie Xie, PhD,a
Fan Yang, PhD,a and Yiliu Liao, PhDa,*
a
Trauma Center, Department of Emergency and Trauma Surgery, Tongji Hospital, Tongji Medical College of
Huazhong University of Science and Technology, Wuhan, China
b
Department of Emergency Surgery, Wuhan Pu’ai Hospital, Tongji Medical College of Huazhong University of
Science and Technology, Wuhan, China

article info abstract

Article history: Background: Flail chest (FC) is known to account for high mortality and morbidity and is
Received 13 June 2018 typically treated with conservative care. Operative fixation of FC has been advocated as an
Received in revised form alternative treatment choice. This prospective randomized controlled trial aims to
19 February 2019 compare surgical and nonsurgical management of FC in patients with severe polytrauma.
Accepted 3 April 2019 Methods: Severe polytrauma patients with FC admitted between January 2015 and July 2017
Available online 14 May 2019 to our trauma center were investigated. The enrolled patients were randomly assigned to
the surgical or nonsurgical group. Basic characteristics of injury and clinical outcomes
Keywords: were compared.
Rib fractures Results: Fifty patients entered final analysis, with 25 patients in each group. Operative rib
Flail chest fixation was associated with shorter duration of mechanical ventilation (7 d [interquartile
Severe polytrauma range {IQR} 6-10] versus 9 d [IQR 7-12], P ¼ 0.012), shorter ICU stay (10 d [IQR 7-12] versus 12 d
Operative rib fixation [IQR 9-15], P ¼ 0.032), lower risk of adult respiratory distress syndrome (28% versus 60%,
P ¼ 0.045), pneumonia (48% versus 80%, P ¼ 0.038), and thoracic deformity (8% versus 36%,
P ¼ 0.037) and less pain while coughing (pain score 6 [IQR 3-8] versus 8 [IQR 4-9], P ¼ 0.029)
and deep breathing (pain score 5 [IQR 3-9] versus 7 [IQR 3-9], P ¼ 0.038). Subgroup analysis
was conducted by presence of pulmonary contusion. Shorter time on the ventilator use and
ICU stay associated with rib surgery was not observed in patients with pulmonary
contusion.
Conclusions: This study reveals that surgical rib fixation may provide some critical care
benefits for severe polytrauma patients with FC, including less medical resource use and
lower risk of complications. Further studies should be designed to optimally identify pa-
tients who are most likely to benefit from this surgery.
ª 2019 Elsevier Inc. All rights reserved.

Background without major complications. However, more severe in-

stances of these injuries will result in a mechanically unstable
Rib fractures are present in approximately one-fourth of pa- chest walld“flail chest (FC),” which is defined as three or more
tients with blunt chest trauma, and most patients can heal consecutive rib fractures in multiple locations, creating a flail

* Corresponding author. Department of Emergency and Trauma Surgery, Tongji Medical College of Huazhong University of Science and
Technology, Wuhan 430030, China. Tel./fax: þ86 027 83665306.
E-mail address: yiliu.liao@hotmail.com (Y. Liao).
0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jss.2019.04.005
224 j o u r n a l o f s u r g i c a l r e s e a r c h  o c t o b e r 2 0 1 9 ( 2 4 2 ) 2 2 3 e2 3 0
segment. FC, characterized by asynchronous chest wall
movement and paradoxical respiratory mechanics, is associ-
ated with high mortality (up to 35%). In addition, FC increases
short-term complications, such as adult respiratory distress
syndrome (ARDS) and pneumonia and long-term complica-
tions, such as chronic pain and thoracic deformity.1
Intermittent positive pressure ventilation (internal pneu-
matic splint) is one of the most important nonsurgical treat-
ments of FC.2 However, prolonged mechanical ventilation
(MV) can, in turn, increase the risk of pneumonia and the
resultant sepsis, which are the two lethal comorbidities.3
Open reduction and internal fixation (ORIF) of ribs has been
shown to restore chest wall integrity and respiratory mecha-
nism, which allows for good pain control and early weaning
from MV.4-8 However, some factors (e.g., unified indications
and controversial efficacy) still make this approach under-
used. In addition, whether patients with multisystem trauma
will benefit from this approach also needs to be addressed.
Therefore, we conducted this randomized controlled trial
study to investigate the effect of different treatment practices
(nonsurgical versus surgical) of FC on the clinical outcomes in
patients with severe polytrauma.
Patients and methods
A prospective randomized trial was conducted on patients
with polytrauma with injury severity score (ISS) of 16 or more
who were admitted to our trauma center from January 2015 to
July 2017. Patients were consecutively recruited in this study if
FC was identified. Exclusion criteria included age <18 y, death
within 48 h, cervical spinal cord injury with paralysis, severe
head injury (abbreviated injury score [AIS] of head >3 and
Glasgow Coma Scale [GCS] < 8), uncorrected coagulopathy,
and pre-existing cardiac or pulmonary conditions. Patients
were randomized either to surgical or conservative treatment
for FC by using random numbers balanced with block size of
10. Basic clinical characteristics regarding age, sex, injury
mechanism, AIS of chest, ISS, and GCS were collected. More
detailed information about injury characteristics and in-
terventions was also recorded. In addition, arterial blood-gas
analyses were performed for all the patients. Main outcomes
including in-hospital mortality, incidence of complications
(pneumonia, ARDS and sepsis), and resources utility (MV days
[MVDs], ICU length of stay [ILOS], and hospital length of stay
[HLOS]) were recorded for comparison between the surgically
managed and nonsurgically managed group. Pneumonia was
defined as a new infiltrate on chest X-ray, positive sputum
culture, and signs of systemic infection such as leukocytosis
or fever. According to the Berlin definition, ARDS was defined
as an acute hypoxemic respiratory distress syndrome, not
fully explained by cardiac failure occurring within 1 wk of a
known clinical insult, or new or worsening respiratory
symptoms, with bilateral opacities on chest X-ray.9 Sepsis was
defined by the new standard of sepsis-3.10 Pain at rest, cough,
and deep breathing were assessed based on a widely used
scale, where 0 is no pain and 10 is the worst pain imagin-
able.11,12 Pain scoring was completed at enrollment and a
week after enrollment. We also examined the rate of reintu-
bation and tracheostomy. Patients were assessed for thoracic
deformity 3 mo after discharge. Thoracic deformity was
identified with 3-dimensional computed tomography.13
The whole rescue chain for enrolled patients, from emer-
gent treatment to definitive therapy, was taken charge by a
same group of traumatic surgeons. Rib ORIF was performed as
early as possible if the patient could tolerate it. Decision for the
surgery was made by a multiple disciplinary team composed by
traumatic surgeons, anesthetists, radiographers, and nurses.
Ribs differ from long bones in many ways, impacting their
operative management.14 The preferred surgical implant in
this study was a U-plate because it is well adapted for the
unique features of ribs.15 First, ribs have a thin cortical layer.
The locking screws in the middle combined with the claws on
the sides anchor the plate to the cortices of the bone, providing
a stable and durable construct. Second, ribs have changing
curvature and angulations along the length. The U-plate is
flexible enough to be contoured appropriately to sit flush
against the rib and fracture segment.16 Only fractures occur-
ring in ribs 4-9 were fixed because these ribs provide the main
stabilization for chest wall. Stabilizing these ribs can result in
the greatest pain relief and improvement in pulmonary func-
tion. Anterior and lateral rib fractures were preferentially fixed
over posterior rib fractures because of more reliable fixation
and easier access.17 Displaced rib fractures should be consid-
ered a priority for surgical fixation. If more than one displaced
fracture existed per rib, all fractures were fixed.
Routine management for all the patients in this study
included pain control, external fixation by chest splint or
bandage, pulmonary physiotherapy, fibrobronchoscopic
drainage, and antibiotics administration. Intubation, thor-
acostomy, or MV was also performed if needed. Oral
(nonsteroidal anti-inflammatory drugs) and infusion (fenta-
nyl) pain medications were used to control the pain. If
hemothorax developed, a pleural drainage catheter was
routinely placed. Systemic antibiotics were only used in the
perioperative period and when pneumonia or sepsis was
defined. There was no need for ongoing antibiotic adminis-
tration, even if a thoracostomy tube remained in place.
Sample size estimation was performed using values of
MVDs from patients with FC treated at our trauma center over
the 3 y before this study. Assuming an alpha of 0.05, power of
0.8, and a standard deviation of 110 h, to detect a difference in
MV duration of 72 h (3 d), 21 patients per group were required
to be enrolled.
The Ethical Committee of Tongji Hospital affiliated with
Huazhong University of Science and Technology, Wuhan,
China, approved the research. Written informed consent was
obtained from all patients. This randomized trial was not
registered.
Statistical analysis
Considering the small sample size in this study, nonpara-
metric tests were used. Continuous data were compared using
the Wilcoxon rank-sum test and reported as medians with
interquartile range. Fisher’s exact test was used for categorical
variables, where values were small and reported as numbers
(%). A two-tailed P value < 0.05 was considered statistically
significant.
 l i u e t a l  s u r g i c a l r i b fi x a t i o n f o r p o l y t r a u m a 225

state (median ISS >25, median AIS of chest ¼ 3) but good

Fig. 1 e Flowchart for patients’ inclusion process. (Color
version of figure is available online.)
Results
Of 1918 consecutive severe polytrauma patients during the
period of study, there were a total of 106 cases intercurrent
with FC. Fifty-three patients met the inclusion criteria and
received allocated intervention. One patient assigned to the
operative group did not receive surgery because of the rapid
deterioration of a cerebral hemorrhage. Two patients (one in
each group) were lost to follow-up. Eventually, each group
consisted of 25 patients. Figure 1 describes the patients’ in-
clusion process. The most common injury mechanism was
motor vehicle collision (31/50), followed by fall (16/50) and
blunt force (3/50). There was no difference in injury mecha-
nism between the surgical and nonsurgical groups (data not
shown). In addition, no apparent differences were found in
average age, sex distribution, and average number of frac-
tured ribs in flail segment. Patients between the two groups
had similar injury severity, characterized by severe traumatic
consciousness (median GCS ¼ 12). Furthermore, levels of PH,
PaO2/FiO2, and lactate revealed that patients from the two
groups are with similar baseline physiology state. Table 1
provides a summary of clinical demographics mentioned
previously.
As is shown in Table 2, pulmonary contusion (PC) was the
most common concomitant injury of chest trauma, followed
by hemothorax, pneumothorax, and sternal fracture. Injuries
and operations in other body regions were also recorded.
Factually, no difference in concomitant injuries was found
between the patients from the two groups. Taken together,
disparity in the prognosis of polytrauma patients with FC in
our study could not be attributed to the injury characteristics
alone. All the ORIF operations in this study were performed
within 72 h after arrival at our trauma center, nearly half of
which (10/21) were done emergently.
Mortality of patients in surgical and nonsurgical group was
16% and 8%, respectively, without significant difference.
Operative management was associated with lower incidence
of pneumonia (48% versus 80%, P ¼ 0.038) and ARDS (28%
versus 60%, P ¼ 0.045). As shown in Table 3, all aspects of pain
intensity at baseline (admission) could be considered equal
between the two groups. However, pain while coughing (6
versus 8, P ¼ 0.029) and deep breathing (5 versus 7, P ¼ 0.038)
improved markedly in the surgical group a week later. There
were no significant differences in pain at rest (5 versus 5,
P ¼ 0.99), rate of sepsis (8% versus 16%, P ¼ 0.67), reintubation
(4% versus 0%, P ¼ 0.99), and tracheostomy (40% versus 28%,
P ¼ 0.55) between the two groups. Most patients (72% versus
80%, P ¼ 0.39) in both groups needed the intervention of MV
(Table 3). Patients with hemothorax and pneumothorax in
both groups had good therapeutic outcomes after thoracic
drainage, so thoracoscopic surgeries were not performed.

Table 1 e Group demographics.

Demographics Surgical group Nonsurgical group P value
No. of patients 25 25
Age 42 (25-58) 39 (24-56) 0.39
Sex, M/F 21/4 20/5 0.99
No. of ribs in flail segment 6 (4-9) 5 (3-7) 0.81
Injury severity
AIS of chest 3 (2-4) 3 (2-4) 0.99
ISS 29 (22-36) 27 (20-36) 0.78
GCS 12 (10-14) 12 (10-13) 0.99
Injury mechanism
Motor vehicle collision 17 14 0.99
Fall from height 7 9 0.99
Crush 1 2 0.99
Blood-gas analysis
PaO2/FiO2 254.1 (198.4-317.8) 234.4 (176.6-302.2) 0.73
Lactate (mmol/L) 2.3 (1.4-2.8) 2.1 (1.1-2.7) 0.89
PH 7.38 (7.35-7.42) 7.39 (7.34-7.44) 0.99

AAAM, AIS-2005 of Association for the Advancement of Automotive Medicine.

All continuous values were reported as median (IQR).
226 j o u r n a l o f s u r g i c a l r e s e a r c h  o c t o b e r 2 0 1 9 ( 2 4 2 ) 2 2 3 e2 3 0
Table 2 e Injury characteristics and interventions.
Surgical group (n ¼ 25)
Chest injuries, n (%)
Pulmonary contusion
Hemothorax
Pneumothorax
Sternal fracture
Other injuries, n (%)
Head injuries
Abdominal injuries
Spinal injuries
Pelvic injuries
Limb injuries
Other operations, n
Laparotomy
ORIF of the spine
ORIF of the limb
ORIF of the pelvic
Timing of rib fixation after inclusion (h), median (IQR)
To further evaluate the effect of rib surgery on medical
resources utilization, we conducted a subgroup analysis by PC
with 16 patients in the surgical group and 18 cases in the
nonsurgical group. We found that patients with concurrent PC
had poor outcomes, characterized by a notable increase in
MVDs, ILOS, and HLOS. Compared with nonsurgical treat-
ment, surgical management of FC in patients with multiple
trauma was associated with reduction in MVDs (7 d versus 9 d,
P ¼ 0.012) and ILOS (10 d versus 12 d, P ¼ 0.032). However, these
benefits lost their statistical significance in the presence of PC.
In contrast, patients without PC seemed to gain greater ben-
efits from ORIF. For HLOS, no improvements were found in
surgical group, regardless of whether PC existed or not. Con-
crete data of clinical outcomes are listed in Table 3.
Two representative cases receiving ORIF are illustrated in
Figures 2 and 3, respectively. One case was that of severe PC,
and the other suffered diaphragmatic hernia.
Discussion
Although nonsurgical treatment is still the overwhelming
choice for FC, there are an increasing number of studies
demonstrating the benefits of surgical intervention, including
two meta-analyses.18,19 Similar results are seen in our study.
Rib interfixation for multiple trauma patients with FC is
associated with lower risk of pneumonia, ARDS, and chest
deformity, in addition to better pain control and shorter
duration of MV and ILOS.
Prolonged MV in patients with chest trauma results in high
rates of pneumonia, lung injury, sepsis, ICU stay, and death.20
Thus, shortening MV time to prevent ventilator-associated
complications becomes the primary concern. Consistently,
our study indicates lower pneumonia incidence and shorter
ILOS in patients with rib fixation treatment, who have earlier
weaning of MV. Unexpectedly, HLOS was not significantly
Nonsurgical group (n ¼ 25) P value
16 (64) 18 (72) 0.76
12 (48) 10 (40) 0.78
9 (36) 11 (44) 0.77
2 (8) 2 (8) 0.99
13 (52) 16 (64) 0.57
6 (24) 4 (16) 0.73
7 (28) 10 (40) 0.55
5 (20) 3 (12) 0.70
11 (44) 14 (56) 0.57
2 3
1 2
7 6
2 2
37 (21-55)
affected for these patients. It deserves notice that some sub-
jective factors such as bed availability and insurance status
may confound this variable.
Pain from the chest wall itself can result in hypoventilation
and ineffective coughing with resultant atelectasis and bron-
chial plugging.21 This decreased air exchange can eventually
cause pain-related respiratory failure. Therefore, controlling
pain to ameliorate ventilation by allowing for coughing and
deep breathing is key in the management of rib fractures,
particularly for FC.22 It was reported that the rate of death
decreased by 40%, with adequate pain control.23 Epidural
analgesia is recommended by a newly issued practice man-
agement guideline from the Eastern Association for the Sur-
gery of Trauma (EAST) to control the pain in patients with blunt
thoracic trauma.24 This technique is not used in this study
because of possible presence of contraindications for patients
with severe polytrauma including shock, coagulopathy, and
spine injury.24 Whether epidural catheter use will improve
many of the outcome measures in the nonoperative patient
cohort and reduce or eliminate some of the benefits seen with
surgical rib fixation needs our further investigation. In fact,
multimodal analgesia using different classes of analgesics
(combination of opioids and nonsteroidal anti-inflammatory
drugs in this study) is also recommended in the guideline to
improve analgesia and patient outcomes.24 Early mobilization
of the chest wall is also an effective way to alleviate pain. Over
the years, various methods have been used to stabilize the
chest wall. External fixation with a chest strap or chest shield is
a common nonsurgical approach. However, external fixation
inevitably restricts chest wall movement, which may lead to
feelings of chest tightness, pain, and hypoventilation.25 Inter-
nal fixation can provide better stability for the injured seg-
ments of the chest wall than external fixation. Without stable
fixation of severely fractured and displaced ribs, excessive
movement at the fracture site may ultimately result in
persistent chronic pain, rib nonunion, and chest deformity.26
 l i u e t a l  s u r g i c a l r i b fi x a t i o n f o r p o l y t r a u m a 227

Table 3 e Clinical outcomes.

Outcomes Surgical group (n ¼ 25) Nonsurgical group (n ¼ 25) P value
MVDs, median (IQR)
Overall 7 (6-10) 9 (7-12) 0.012
With PC 9 (7-13) 10 (7-16) 0.063
Without PC 5 (3-8) 8 (5-12) 0.015
ILOS, median (IQR)
Overall 10 (7-12) 12 (9-15) 0.032
With PC 11 (8-15) 11 (7-16) 0.28
Without PC 8 (6-11) 11 (7-14) 0.019
HLOS, median (IQR)
Overall 21 (17-25) 22 (17-26) 0.44
With PC 25 (20-28) 23 (19-27) 0.071
Without PC 17 (14-20) 18 (15-22) 0.056
In-hospital mortality, n (%) 4 (16%) 2 (8%) 0.67
Pneumonia, n (%) 12 (48%) 20 (80%) 0.038
ARDS, n (%) 7 (28%) 15 (60%) 0.045
Sepsis, n (%) 2 (8%) 4 (16%) 0.67
Reintubation, n (%) 1 (4%) 0 (0) 0.99
Tracheostomy, n (%) 10 (40%) 7 (28%) 0.55
MV required, n (%) 18 (72%) 20 (80%) 0.74
Thoracic deformity, n (%) 2 (8%) 9 (36%) 0.037
Pain at admission, median (IQR)
Rest 6 (4-7) 7 (4-8) 0.78
Coughing 8 (3-9) 8 (4-9) 0.44
Deep breathing 8 (4-9) 7 (3-9) 0.51
Pain after a week, median (IQR)
Rest 5 (3-7) 5 (2-7) 0.99
Coughing 6 (3-8) 8 (4-9) 0.029
Deep breathing 5 (3-9) 7 (3-9) 0.038

Taken together, it can partly explain the findings in this study
that patients receiving ORIF have less pain (particularly when
they are coughing or deep breathing) and lower incidence of
ARDS and chest wall deformity.
PC is an important concern for patients with FC, as it is
thought to result in poor outcomes. Therefore, the potential
role of surgical management in this subset of patients was
specifically investigated in this study. The results revealed
that PC was indeed closely related to prolonged MVDs, ILOS,
and HLOS. More importantly, PC partly offsets the outcome
improvement that rib ORIF brought. A study of over 400 pa-
tients also found no benefit of rib ORIF in patients with severe
PC.27 Althausen et al.7 reported similar findings. The suggested
reason is that patients with FC complicated by PC are liable to
require long-term MV because of a combination of paren-
chymal pathology and altered respiratory mechanics, such
that potential improvement in respiratory mechanics due to
operative fixation is not sufficient to affect ventilator wean-
ing.28 However, it is worth noting that there is currently no
clear definition and classification for PC: whether radiology
imaging or more objective tests such as bronchoalveolar
lavage are better for diagnosis is unknown.29
The spectrum of operative techniques for rib interfixation
includes rigid devices such as plates,30 struts,31 and
intramedullary nails32 and less rigid Kirschner wires19 and
sutures. These surgical approaches differ in terms of their
efficacy and safety, and the optimal approach has not been
determined. We choose one specific type of fixation
devicedU-plate in this study for three reasons. First, our
group has used this device for a long time and mastered it
well, which may decrease the risk of the operation. Second,
using one specific device and technique may eliminate the
confounding factor originated from the operation itself.
Third, U-plate has some unique benefits in fixing rib, which
are mentioned previously. The type of fixation, in fact, ap-
pears to be less important because consistent benefits have
been seen across a heterogeneous group of surgical im-
plants.18 Moreover, as with any surgical procedure, operative
fixation of rib fractures has the risk of complications such as
wound infection, hardware failure or migration, malunion/
nonunion of the fracture site, osteomyelitis, and empy-
ema.18 Perhaps due to the small sample size of the present
study, no complications were observed. In fact, there are a
series of pitfalls in the whole procedure of rib ORIF, from
localization of fractures, positioning, and exposure, to
reduction, stabilization, and postoperative care.33 Use of a
standard protocol and operative strategy may reduce the
morbidity rate in the future.
228 j o u r n a l o f s u r g i c a l r e s e a r c h  o c t o b e r 2 0 1 9 ( 2 4 2 ) 2 2 3 e2 3 0

Fig. 2 e (A) Anteroposterior chest radiograph demonstrating multiple fractures of ribs 4-9 on the right side. (B and C) Chest
CT results revealed right-sided displaced rib fractures and pulmonary contusion. (White arrow: the right lung and heart
were severely displaced from their normal positions). (D) Fractured and displaced rib (black arrow). (E) Photograph
demonstrating rib fixation with the claw-shaped plates in place. (F) Postoperative chest X-ray demonstrating the rib
fixations of the fifth to ninth ribs on the right side. (Color version of figure is available online.)

Currently, there are no absolute indications for rib ORIF.
Surgical intervention should be considered when relative in-
dications exist, including pain refractory to medical manage-
ment, respiratory failure due to chest wall instability,
respiratory failure despite external fixation, chest wall defor-
mity with visibly distracted rib fractures, impaired pulmonary
function tests, and paradoxical breathing.34 These situations
are liable to occur in patients with severe FC, so these patients
may benefit from ORIF. However, regarding patients with
multiple injuries, their conditions may become more critical
and complex because they are commonly accompanied by
unstable cardiopulmonary status, shock, and hemodynamic

Fig. 3 e Thoracotomy for diaphragmatic hernia and internal fixation of multiple rib fractures. (A) Chest X-ray demonstrating
diaphragmatic hernia and left-sided multiple rib fractures. (Red arrow: trachea displaced to the right side. White arrow: the
stomach in the thoracic cavity). (B) Ruptured diaphragm (arrow). (C) Internal fixation of rib fractures in multiple sites by
using the claw-shaped plates. (D) Postoperative rib fixation. (Color version of figure is available online.)
 l i u e t a l  s u r g i c a l r i b fi x a t i o n f o r p o l y t r a u m a
instability. Systemic conditions should be evaluated repeat-
edly before the operation. Time to surgical stabilization varies
in the literature from 24 h or less to more than 8 days after
admission.17 Although there is no specific time firmly rec-
ommended, it is consistently considered that if the patient
can withstand operation, the earlier that the operation is
performed, the better. Theoretically, early surgical interven-
tion provides the most benefit to patients with FC, as it allows
avoidance of prolonged MV and associated complications. In
contrast, later surgical intervention might result in dis-
appearing benefit and increasing procedural risks.18
Certain limitations of this study are worth noting. First,
sample size is relatively small and likely underpowered to
detect many clinically relevant endpoint differences. Some
subgroup analyses (e.g., geriatric population) are also not
appropriate to be carried out. We have tried to make a subgroup
analysis for elderly patients (>60 y old), which has less buffer to
tolerate multiple rib fractures and may potentially benefit
more from rib fixation; however, the sample size is too small to
perform statistical analysis (three patients for each group). We
will investigate this subset in future studies with more cases
included. Second, several important clinical problems have not
been clarified in this study, which include whether patients
with severe traumatic brain injury benefit from operative rib
fixation and what the minimum amount of chest wall stability
is necessary to obtain the observed benefits of surgery. Third,
there is a lack of data on respiratory function tests of the pa-
tients, which will reveal the lung function more objectively.
Conclusions
In this prospectively designed study, we aimed to demonstrate
the effect of rib interfixation on severe poly-trauma patients
with combined FC. Our findings in the present study suggest
that operative management in the case of FC might not reduce
mortality but could provide some important positive clinical
outcomes such as MVDs, ILOS, incidence of ARDS and pneu-
monia, pain while coughing and deep breathing, and chest wall
deformity. Although this analysis is very encouraging in sup-
port of operative fixation of FC, a future, thoughtfully designed
study with a larger sample size will standardize other facets of
this procedure. Appropriate patient selection, standard pro-
tocol, and operative strategy may minimize the risks and
maximize the benefits of this procedure.
Acknowledgment
Authors’ contributions: Y.L. was responsible for study concept
and design along with article review. T.L. contributed to
drafting and revision of the article. J.C. and P.L. were respon-
sible for data collection. J.X. and F.Y. performed statistical
analysis of data.
Disclosure
None of the authors have any conflict of interest to declare
about this article.
229
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