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A multicenter evaluation of the optimal timing of surgical stabilization of rib fractures

Pieracci, Fredric, M., MD, MPH; Coleman, Julia, MD, MPH; Ali-Osman, Francis, MD; Mangram, Alicia, MD; Majercik, Sarah, MD, MBA; White, Thomas, W., MD; Jeremitsky, Elan, MD; Doben, Andrew, R., MD

Journal of Trauma and Acute Care Surgery: January 2018 - Volume 84 - Issue 1 - p 1–10
doi: 10.1097/TA.0000000000001729
AAST 2017 Plenary Paper
Editor's Choice

BACKGROUND The optimal timing of surgical stabilization of rib fractures (SSRF) remains debated. We hypothesized that (1) demographic, radiologic, and clinical variables are associated with time to surgery and (2) shorter time to SSRF improves acute outcomes.

METHODS Prospectively collected SSRF databases from four trauma centers were merged and analyzed (2006–2016). The independent variable was days from hospital admission to SSRF (early [<1 day], mid [1–2 days], and late [3–10 days]). Outcomes included length of operation, number of ribs repaired, prolonged (>24 hours) mechanical ventilation, pneumonia, tracheostomy, length of stay, and mortality. Multivariable logistic regression was used to control for significant differences in covariates between groups.

RESULTS Five hundred fifty-one patients were analyzed. The median time to SSRF was 1 day (range, 0–10); 207 (37.6%) patients were in the early group, 168 (30.5%) in the midgroup, and 186 (31.9%) in the late group. There was a significant shift toward earlier SSRF over the study period. Time to SSRF was significantly associated with study center (p < 0.01), year of surgery (p < 0.01), age (p = 0.02), mechanism of injury (p = 0.04), and body mass index (p = 0.02). Injury severity was not associated with time to surgery. Despite repairing the same median number of ribs (4; range, 1–13), median length of surgery was 68 minutes longer for the late as compared to the early group (p < 0.01). After controlling for the aforementioned significant covariates, each additional hospital day before SSRF was independently associated with a 31% increased likelihood of pneumonia (p < 0.01), a 27% increased likelihood of prolonged mechanical ventilation (p < 0.01), and a 26% increased likelihood of tracheostomy (p < 0.01).

CONCLUSION Surgical stabilization of rib fractures within 1 day of admission is associated with certain demographic and physiologic variables. After controlling for confounding factors, early SSRF was accomplished using less operative time, and was associated with favorable outcomes. When indicated and feasible, SSRF should occur as early as possible.

Level of evidence Therapy, level III.

From the Denver Health Medical Center (F.M.P., J.C.), Denver, Colorado; Honor Health (F.A.-O., A.M.), Pheonix, Arizona; Intermountain Medical Center (S.M., T.W.W.), Salt Lake City, Utah; and Baystate Medical Center (E.J., A.R.D.), Springfield, Massachusetts

Submitted: July 3, 2017, Revised: September 11, 2017, Accepted: October 11, 2017, Published online: October 25, 2017.

Plenary presentation at the 76th Annual Meeting of the American Associate for the Surgery of Trauma and Clinical Congress of Acute Care Surgery Congress, September 13–16, 2017, Baltimore, MD.

Address for reprints: Fredric M. Pieracci, MD, Trauma Medical Director, Denver Health Medical Center, Associate Professor of Surgery, University of Colorado School of Medicine, 777 Bannock St, MC0206, Denver, CO 80206; email:

© 2018 Lippincott Williams & Wilkins, Inc.