Swart Eric, Laratta Joseph, Slobogean Gerard, Mehta Samir
*Department of Orthopaedic Surgery, University of Massachusetts, Worcester, MA; †Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY; ‡Department of Orthopaedic Surgery, University of Maryland School of Medicine R Adams Cowley Shock Trauma Center, Baltimore, MD; and §Department of Orthopaedic Surgery, University of Pennsylvania Medical Center, Philadelphia, PA.
J Orthop Trauma. 2017 Feb;31(2):64-70. doi: 10.1097/BOT.0000000000000750.
Flail chest is a common injury sustained by patients who experience high-energy blunt chest trauma and results in severe respiratory compromise because of altered mechanics of respiration. There has been increased interest in operative fixation of these injuries with the intention of restoring the mechanical integrity of the chest wall, and several studies have shown that ventilation requirements and pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate fixation of rib fractures in flail chest injuries using cost-effectiveness analysis, supported by systematic review and meta-analysis.
This was a 2-part study in which we initially conducted a systematic literature review and meta-analysis on outcomes after operative fixation of flail chest injuries, evaluating intensive care unit (ICU) stay, hospital length of stay (LOS), mortality, pneumonia, and need for tracheostomy. The results were then applied to a decision-analysis model comparing the costs and outcomes of operative fixation versus nonoperative treatment. The validity of the results was tested using probabilistic sensitivity analysis.
Operative treatment decreased mortality, pneumonia, and tracheotomy (risk ratios of 0.44, 0.59, and 0.52, respectively), as well as time in ICU and total LOS (3.3 and 4.8 days, respectively). Operative fixation was associated with higher costs than nonoperative treatment ($23,682 vs. $8629 per case, respectively) and superior outcomes (32.60 quality-adjusted life year (QALY) vs. 30.84 QALY), giving it an incremental cost-effectiveness ratio of $8577/QALY.
Surgical fixation of rib fractures sustained from flail chest injuries decreased ICU time, mortality, pulmonary complications, and hospital LOS and resulted in improved health care-related outcomes and was a cost-effective intervention. These results were sensitive to overall complication rates, and operations should be conducted by surgeons or combined surgical teams comfortable with both thoracic anatomy and exposures as well as with the principles and techniques of internal fixation.
Economic Level III. See Instructions for Authors for a complete description of levels of evidence.
连枷胸是经历高能钝性胸部创伤的患者常见的损伤，由于呼吸力学改变导致严重的呼吸功能不全。人们对通过手术固定这些损伤以恢复胸壁的机械完整性越来越感兴趣，多项研究表明手术干预可降低通气需求和肺部并发症。本研究的目的是通过成本效益分析评估连枷胸损伤中肋骨骨折的固定情况，并辅以系统评价和荟萃分析。
这是一项分为两部分的研究，我们首先对连枷胸损伤手术固定后的结局进行了系统的文献综述和荟萃分析，评估重症监护病房（ICU）住院时间、住院时间（LOS）、死亡率、肺炎以及气管切开术的需求。然后将结果应用于决策分析模型，比较手术固定与非手术治疗的成本和结局。使用概率敏感性分析测试结果的有效性。
手术治疗降低了死亡率、肺炎和气管切开术的发生率（风险比分别为0.44、0.59和0.52），以及ICU住院时间和总住院时间（分别为3.3天和4.8天）。手术固定与比非手术治疗更高的成本相关（分别为每例23,682美元和8629美元），但结局更好（32.60质量调整生命年（QALY）对30.84 QALY），使其增量成本效益比为8577美元/QALY。
连枷胸损伤所致肋骨骨折的手术固定减少了ICU时间、死亡率、肺部并发症和住院时间，并改善了与医疗保健相关的结局，是一种具有成本效益的干预措施。这些结果对总体并发症发生率敏感，手术应由熟悉胸部解剖结构和暴露以及内固定原则和技术的外科医生或联合手术团队进行。
经济水平III。有关证据水平的完整描述，请参阅作者指南。
