Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients

Background. We compared the clinical efficacy of surgical stabilization and internal pneumatic stabilization in severe flail chest patients who required prolonged ventilatory support. Methods. Thirty-seven consecutive severe flail chest patients who required mechanical ventilation were enrolled in this study. All the patients received identical respiratory management, including end-tracheal intubation, mechanical ventilation, continuous epidural anesthesia, analgesia, bronchoscopic aspiration, postural drainage, and pulmonary hygiene. At 5 days after injury, surgical stabilization with Judet struts (S group, n = 18) or internal pneumatic stabilization (I group, n = 19) was randomly assigned. Most respiratory management was identical between the two groups except the surgical procedure. Statistical analysis using two-way analysis of variance and Tukey's test was used to compare the groups. Results:. Age, sex, Injury Severity Score, chest Abbreviated Injury Score, number of rib fractures, severity of lung contusion, and PaO2/FiO(2) ratio at admission were all equivalent in the two groups. The S group showed a shorter ventilatory period (10.8 +/- 3.4 days) than the I group (18.3 +/- 7.4 days) (p < 0.05), shorter intensive care unit stay (S group, 16.5 +/- 7.4 days; I group, 26.8 +/- 13.2 days; p < 0.05), and lower incidence of pneumonia (S group, 24%; 1 group, 77%; p < 0.05). Percent forced vital capacity was higher in the S group at I month and thereafter (p < 0.05). The percentage of patients who had returned to full-time employment at 6 months was significantly higher in the S group (11 of 18) than in the I group (I of 19). Conclusion:. This study proved that in severe flail chest patients, surgical stabilization using Judet struts has beneficial effects with respect to less ventilatory support, lower incidence of pneumonia, shorter trauma intensive care unit stay, and reduced medical cost than internal fixation. Moreover, surgical stabilization with Judet struts improved percent forced vital capacity from the early phase after surgical fixation. Also, patients with surgical stabilization could return to their previous employment quicker than those with internal pneumatic stabilization, even in those with the same severity of flail chest. We therefore concluded that surgical stabilization with Judet struts may be preferably applied to patients with severe flail chest who need ventilator support.