A bi-institutional observational study comparing short-term and long-term outcome of operative and non-operative management of clinical and radiological flail chest injuries.

Background: Operative management of chest wall injuries requiring ventilatory support has been shown to decrease the time spent on ventilator. The main purpose of this study was to investigate whether operative management reduces the need for mechanical ventilation and the impact of surgery on long-term outcome concerning pain, lung function and movement.

Methods: This is a bi-institutional prospective observational study comparing operative (Op) and non-operative (Non-Op) management of adult trauma patients with flail chest injuries. Data on the need for and LOS in intensive care (ICU), on mechanical ventilator (MV), and in hospital, and incidence of pneumonia and tracheostomy was collected. Clinical follow-up after six weeks, six months and one year concerning lung function, CT-lung volume, physical function, pain, and quality of life (QoL) was performed.

Results: There was no difference in the need for (29%) and LOS on MV and in ICU between the Op and Non-Op groups. Chest wall surgery was performed 4 days (range 2-14) post trauma and associated with a longer hospital LOS. Pneumonia was more common in the Non-Op group (37% vs. 18%, p = 0.003). Fifty patients in the Op group and 38 patients in the Non-Op group were enrolled in a follow-up where Non-Op group experienced more pain in the first six months and had a higher daily dose of oral morphine during the first six weeks post trauma. The best residual lung function and CT-lung volume was seen in patients managed with muscle-sparing surgery without thoracotomy. No considerable difference in pain, physical activity, physical function and QoL were seen between the groups after one year.

Conclusions: Operative management of flail chest injuries did not decrease the need for mechanical ventilation or the length of stay in ICU. Operating on non-ventilated patients may increase the length of hospital stay depending on day of surgery. Surgery was associated with a decreased incidence of pneumonia, less pain and subjective symptoms the first months' post-trauma despite operated patients being older and with more severe trauma, but after one year there were no significant differences between the groups. Operative technique may influence outcome and should be studied further.

Trial registration: ClinicalTrials.gov: NCT02132416, 7 May 2014.