Rib fixation: becoming popular but does it benefit patients?

A paper by Monash University researchers and surgeons at the Alfred Hospital has cast doubt on the growing practice of rib fixation in some patients with chest injuries.

Fractured ribs are a common injury in trauma patients. At worst, what’s termed ‘flail chest’ – when ribs become detached from the rest of the ribcage – is associated with life-threatening injuries and a significant mortality.

Surgeon Professor Silvana Marasco was first author on a paper published in the international journal Injury that examined long-term quality of life in patients who underwent rib fixation. Rib fixation, which uses a minimally invasive operation to insert and screw on contoured titanium plates to ribs, is relatively new.

The study retrospectively examined data from 67 patients with rib fixations from among the 1482 major trauma patients admitted to the Alfred Hospital with rib fractures from January 2012 to April 2015.

It compared these patients with others who had not had the surgery but couldn’t demonstrate any benefit of rib fixation to quality of life 24 months after injury.

“We really didn’t find any real differences between the two groups at six, twelve or twenty-four months,” Prof. Marasco said. “The patients with rib fixation weren’t worse off though,” she said.

The rib-fixation patients were, however, older and had more severe injuries, including a higher incidence of flail chest injury compared to the other group. “It was appropriate that we were cherry-picking the worst patients for rib fixation and not just applying this new operation to every patient.”

Traditionally patients with flail chest have been treated with analgesics and put on a ventilator until their ribs started to stick and they could breathe on their own.

The paper follows a similar ground-breaking study Prof. Marasco published in 2013 when fib fixation had only been used at The Alfred for a few years. That study demonstrated that the surgery led to earlier discharge from intensive care, less ventilation and benefits for hospital cost savings, but that the patients were not perceiving that they felt any better a few months later.

“It was quite a new operation then and everyone was getting very excited about rib fixation and perhaps expanding the indications a little too quickly,” Prof. Marasco said.

The only group proven to benefit from rib fixation in randomised control trials is ventilator-dependent flail chest patients, she said.

“But all around the world people are fixing patients with multiple fractured ribs who aren’t on a ventilator, don’t have a flail chest or just have one displaced rib and there’s never been any level one evidence to prove there’s a benefit to these groups of patients.

“I think this (latest) paper is very important. I’m hoping it will put the brakes on a bit and make people think about the patients they’re operating on and whether they’re doing the right thing by taking them to theatre,” she said.

A number of new ways of managing the pain patients experience in the first few days after a bad rib injury, including anaesthetic techniques and localised pain blocks, have been developed over the past five to 10 years which were helping keep patients off ventilators, she said.

A randomised control trial being conducted at The Alfred and other centres around Australia is now looking at the practice prospectively.

Prof. Marasco, who is a cardiothoracic surgeon and Deputy Director of the Alfred Hospital cardiothoracic unit, is a keen researcher outside surgery. She conducted a PhD on rib fixation and gained a Master of Bioethics, both at Monash University. The Central Clinical School awarded her a clinical adjunct professorship in 2017 for her research efforts.

Senior author on the paper was Professor Michael Bailey.

Marasco SF, Martin K, Niggemeyer L, Summerhayes R , Fitzgerald M, Bailey M. Impact of rib fixation on quality of life after major trauma with multiple rib fractures. Injury. 2018 Nov 3. pii: S0020-1383(18)30653-3. doi: 10.1016/j.injury.2018.11.005. [Epub ahead of print]