Flail chest (FC) results in paradoxical chest wall movement, altered
respiratory mechanics, and frequently 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.
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,
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.
Nine studies with a total of 538 patients met inclusion criteria.
Compared to control treatment, operative management of FC was associated
with shorter DMV (pooled ES −4.52; days, 95% confidence interval [CI]
−5.54, −3.50), ICULOS (−3.40 days; 95% CI
−6.01,−0.79), HLOS (−3.82 days; 95% CI
−7.12,−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).
As compared to 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