You are here

  • Home
  • Archive
  • Volume 8, Issue 1
  • Surgical subspecialization is associated with higher rate of rib fracture stabilization: a retrospective database analysis

Article Text

Article menu

Download PDFPDF

Original research
Surgical subspecialization is associated with higher rate of rib fracture stabilization: a retrospective database analysis
  1. Avanti Badrinathan1,
  2. Anuja L Sarode1,
  3. Christine E Alvarado1,
  4. Jillian Sinopoli2,
  5. Jonathan D Rice2,
  6. Philip A Linden2,
  7. Matthew L Moorman3,
  8. Christopher W Towe2
  1. 1Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
  2. 2Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
  3. 3Division of Trauma and Acute Care Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
  1. Correspondence to Dr Christopher W Towe; christopher.towe{at}uhhospitals.org

Abstract

Background Surgical stabilization of rib fractures (SSRF) is performed on only a small subset of patients who meet guideline-recommended indications for surgery. Although previous studies show that provider specialization was associated with SSRF procedural competency, little is known about the impact of provider specialization on SSRF performance frequency. We hypothesize that provider specialization would impact performance of SSRF.

Methods The Premier Hospital Database was used to identify adult patients with rib fractures from 2015 and 2019. The outcome of interest was performance of SSRF, defined using International Classification of Diseases—10th Revision Procedure Coding System coding. Patients were categorized as receiving their procedures from a thoracic, general surgeon, or orthopedic surgeon. Patients with missing or other provider types were excluded. Multivariate modeling was performed to evaluate the effect of surgical specialization on outcomes of SSRF. Given a priori assumptions that trauma centers may have different practice patterns, a subgroup analysis was performed excluding patients with ‘trauma center’ admissions.

Results Among 39 733 patients admitted with rib fractures, 2865 (7.2%) received SSRF. Trauma center admission represented a minority (1034, 36%) of SSRF procedures relative to other admission types (1831, 64%, p=0.15). In a multivariable analysis, thoracic (OR 6.94, 95% CI 5.94–8.11) and orthopedic provider (OR 2.60, 95% CI 2.16–3.14) types were significantly more likely to perform SSRF. In further analyses of trauma center admissions versus non-trauma center admissions, this pattern of SSRF performance was found at non-trauma centers.

Conclusion The majority of SSRF procedures in the USA are being performed by general surgeons and at non-trauma centers. ‘Subspecialty’ providers in orthopedics and thoracic surgery are performing fewer total SSRF interventions, but are more likely to perform SSRF, especially at non-trauma centers. Provider specialization as a barrier to SSRF may be related to competence in the SSRF procedures and requires further study.

Type Therapeutic/care management.

Level of evidence IV

  • rib fractures
  • Practice Patterns, Physicians'

Data availability statement

Data may be obtained from a third party and are not publicly available. This retrospective study used the 2015–2019 iterations of the Premier Hospital Database (PHD; Premier, Charlotte, North Carolina, USA), which is a large US-based hospital database containing information on inpatient discharges from geographically diverse, non-profit, non-governmental and community and teaching hospitals as well as health systems from rural and urban areas, encompassing nearly 121 million inpatient admissions. These data may be obtained from Premier.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/tsaco-2022-000994

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Surgical stabilization of rib fractures (SSRF) is inconsistently used despite guidelines. Previous studies show that provider specialty is associated with confidence and competency with the procedure.

    WHAT THIS STUDY ADDS

    • Only a minority of patients with rib fracture undergoing SSRF are seen at trauma centers. Thoracic and orthopedic providers are more likely to perform SSRF procedures at non-trauma facilities.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Provider specialization has a significant impact on how often SSRF is being performed. This may demonstrate a barrier to utilization of existing guidelines and offer an area of improvement in resources and training.

    Background

    Although most patients with rib fractures are managed without surgery, surgical stabilization of rib fractures (SSRF) is appropriate for a select subset of patients.1 2 As studies have demonstrated benefit to SSRF, it has been performed more frequently and with broader indications than previously.3–5 However, SSRF utilization remains far below what is expected given the clinical evidence, even in patients with flail chest.6–8

    One potential reason for below-expected use of SSRF may be linked to the specialization of providers who perform SSRF. Previous studies have shown that a minority of surveyed academic surgeons have either assisted on or performed an SSRF procedure, including only 33% of trauma surgeons, who considered themselves competent to perform SSRF.9 Conversely, a majority of thoracic surgeons surveyed responded that they had performed rib fracture repair and an overwhelming majority (91%) stated that they felt competent with SSRF procedures. Provider specialty has not been directly studied with regard to frequency of SSRF performance.

    The aim of this study is to elucidate the patient, provider, and hospital-associated factors that affect the frequency of SSRF performance, using a nationally representative database encompassing both trauma centers and non-trauma facilities. We hypothesize that the frequency of SSRF performance is significantly impacted by provider specialization and that this impact may differ based on hospital characteristics.

    Methods

    This retrospective study used the 2015–2019 iterations of the Premier Hospital Database (PHD), which is a large US-based hospital database containing information on inpatient discharges from geographically diverse, non-profit, non-governmental and community and teaching hospitals as well as health systems from rural and urban areas, encompassing nearly 121 million inpatient admissions.10 The PHD was queried to identify adult inpatients over the age of 18 years with rib fractures.

    Patients with rib fractures were identified using International Classification of Diseases—10th Revision (ICD-10) diagnosis codes. Patients were excluded if they were not inpatient admissions, if they did not have a known discharge status, or if they were seen by an unknown provider specialty (figure 1). Rib fractures were stratified into three categories: single rib fractures, multi-rib (non-flail) fractures, and flail chest. Patient demographic and clinical factors, such as age, gender, comorbidity scores, and hospital were also obtained from the database. Elixhauser Comorbidity Indices were calculated using ICD-10 coding. Abbreviated Injury Scale (AIS) scores were also calculated using ICD-10 coding using ICDPIC software refined for R.11 12 Maximum overall AIS was defined as the maximum AIS found over the six body regions encompassing AIS scoring.11 12

    Figure 1
    Figure 1

    CONSORT flow diagram of study design. CONSORT, Consolidated Standards of Reporting Trials; SSRF, surgical stabilization of rib fractures.

    The primary outcome was the performance of SSRF procedures. SSRF procedure was categorized by ICD-10 PCS coding. Procedures were categorized by provider type as reported by Premier into general surgery, thoracic surgery, orthopedic surgery, and trauma surgery. For the purpose of analysis, general surgery and trauma surgery categories were combined, given that non-trauma centers were analyzed.

    Descriptive analysis was performed to examine the overall demographics of the study population relative to performance of SSRF. Categorical and binary variables were compared using χ2 testing. Continuous variables were reported as median with IQR and compared using the Wilcoxon rank-sum test. Multivariate modeling was also performed to determine demographic and clinical factors associated with SSRF. Variables for multivariable regression were included if considered clinically salient, such as age or trauma center status. Given a priori assumptions that trauma centers may have different practice patterns, a subgroup analysis was performed on trauma center admissions and non-trauma center admissions separately. In addition, patients with other ‘non-chest’ injuries, as determined by AIS scoring, may also be impacted by differing practice patterns. As such, a second subgroup analysis was performed for patients with isolated chest injuries, excluding patients with AIS score >1 in any non-chest region.

    All analyses were performed using STATA SE/V.14 (StataCorp, College Station, Texas, USA). Results are presented as OR with 95% CIs. Findings were considered significant if p≤0.05. P values were not corrected for multiple hypothesis testing.

    Results

    A total of 39 733 patients were admitted with rib fractures, a minority of whom (14 837, 37.34%) were admitted to trauma centers. Among all patients with rib fractures, 2865 patients (7.21%) received SSRF (table 1). A majority of patients undergoing SSRF had multi-rib, non-flail injuries (54.14%, p<0.001). Patients undergoing SSRF were of similar age (median 57, IQR 46–67) to those who did not undergo SSRF (median 57, IQR 38–72, p=0.426) and had a similar number of Elixhauser comorbidities (2, IQR 1–3 vs. 2, IQR-1–3). SSRF was performed more often in white race, non-Hispanic patients compared with non-white race (61.99% vs. 56.02%, p<0.001). Patients undergoing SSRF had greater maximum AIS score in the chest region (4, IQR 2–4 vs. 1, IQR 1–2, p<0.001) and in their overall maximum AIS score (4 vs. 2, p<0.001). SSRF was more common at teaching centers (68.48% vs. 31.52%, p<0.001), but was not associated with trauma center admission (1034 of 2865, 36.09% vs. 13 803 of 36 868, 37.4%, p=0.151).

    View this table:
    Table 1

    Demographics of all patients with rib fractures based on their receipt of SSRF

    Although most patients with rib fractures received care by a general surgeon, there were notable differences in SSRF performance by provider type. In multivariable analysis, SSRF performance was strongly associated with orthopedic (OR 2.60, 95% CI 2.16–3.14, p<0.001) and thoracic surgery provider types (OR 6.94, 95% CI 5.94–8.11, p<0.001) (table 2). Patients with flail chest were also more likely to undergo SSRF (OR 25.14, 95% CI 20.74–30.47, p<0.001). Hospital location in the southern USA (OR 0.87, 95% CI 0.78–97, p<0.001) and western USA (OR 1.37, 95% CI 1.20–1.56, p<0.001) was also associated with differences in SSRF performance. Trauma center designation was not associated with any difference in SSRF performance (OR 1.06, 95% CI 0.97–1.16, p<0.001).

    View this table:
    Table 2

    Multivariable analysis of factors associated with SSRF performance for all 39 733 identified patients with rib fractures

    Trauma center subgroups

    A total of 14 837 patients (37.3%, 14 837 of 39 733) were admitted to trauma centers. At trauma centers, thoracic surgery (OR 2.46, 95% CI 0.77–7.82, p=0.125) and orthopedic surgery specializations (OR 0.57, 95% CI 0.73–4.59, p=0.605) were not associated with a difference in performance of SSRF in comparison with general surgeons. Fracture pattern and geographic region were also associated with SSRF, with decreased odds of SSRF performance in the southern and northeastern USA at non-trauma centers and at southern US trauma centers (table 3).

    View this table:
    Table 3

    Multivariable analysis of SSRF performance among 14 837 patients with rib fractures at trauma center locations vs. 24 896 patients at non-trauma centers

    At non-trauma facilities, orthopedic (OR 5.92, 95% CI 4.62–7.59, p<0.001) and thoracic surgeons (OR 20.98, 95% CI 16.15–27.05, p<0.001) were more likely to perform SSRF (table 3). Similar to trauma centers, fracture pattern and geographic region were also associated with SSRF.

    Isolated chest injuries

    A total of 20 949 (52.7%) patients were admitted with isolated chest injuries (defined as AIS score ≤1 for non-chest regions). Of these, a minority (6533 of 20 949, 31.18%) were admitted to trauma centers. Similar to the full cohort, orthopedic (OR 5.67, 95% CI 4.38–7.35) and thoracic providers (OR 19.67, 95% CI 15.04–25.73, p<0.001) were more likely to perform SSRF in patients who were not admitted to trauma centers. At trauma centers, there was no significant association between provider type and SSRF performance (table 4).

    View this table:
    Table 4

    Multivariable analysis of SSRF performance of 20 949 patients with isolated chest injury, defined as AIS score ≤1 for non-chest areas

    Discussion

    This study used a large nationally representative database to identify factors associated with performance of SSRF among patients admitted with rib fractures. In our analysis, we found that provider specialization, facility characteristics, and fracture type were all strongly associated with performance of SSRF. The majority of SSRF admissions were at non-trauma center locations. At these locations, thoracic surgery provider type was strikingly associated with SSRF. In non-trauma center locations, there were also notable regional differences in care, with SSRF less likely to be performed in the south and northeast. We think that this is the first study of provider type associations with SSRF performance in such a large population, encompassing both trauma and non-trauma centers.

    The primary outcome of interest in this study was performance of SSRF based on provider type. A minority of patients in this study (7.2%) underwent SSRF procedures, which was similar to the results of previous studies.1 2 Although general surgeons and trauma surgeons were the most common provider type, other surgical specialties were more likely to perform SSRF. This was especially notable at non-trauma facilities, where specialty providers were significantly more likely to perform SSRF. Mayberry et al demonstrated that trauma surgeons self-reported decreased confidence and competence in performing SSRF procedures.9 Our finding may corroborate that trauma providers may not be performing SSRF due to unfamiliarity with the procedure, especially at community hospitals.8 In comparison, Mayberry et al demonstrated that thoracic surgeons were the only provider specialization in which a majority reported having assisted or performed rib fracture repair, which may be why they were found to be more likely to perform SSRF.9

    The results of this study also highlight the association of hospital location characteristics with the performance of SSRF. Previous studies of hospital characteristics indicated that nearly half of patients with rib fracture present to non-trauma center facilities.13–15 In comparison, approximately two-thirds of patients in this study presented to non-trauma center facility, with only 36.1% of patients undergoing SSRF being admitted to a trauma center. Though Tignanelli et al demonstrated an increased likelihood of SSRF at level I trauma centers using the National Trauma Databank (NTDB), our results demonstrate that this may only be a minority of patients undergoing SSRF.6 This finding may suggest that a majority of SSRF patients are not captured in studies of the ACS-TQIP Database or NTDB, which only encompass US trauma centers. In addition, the geographical location of hospitals was also demonstrated to play a role in the frequency of SSRF intervention. Both trauma centers and non-trauma centers in the southern region of the USA were found to be less likely to perform SSRF. This result reflects findings of previous studies which show that the southern USA had the slowest rate of increase in SSRF usage during the study period.1 Conversely, trauma centers in the western USA were more likely to perform SSRF. A potential reason for these differences is in the regionalization of providers, with providers trained in one region remaining in that region for practice, leading to a lack of exposure to SSRF from providers in other regions who may be more familiar with the procedure. Similar geographical differences in practice pattern have been demonstrated in other aspects of surgery.16 17 Further studies regarding geographical differences in SSRF acceptance may help further delineate the cause of these regional differences.

    In addition, this study demonstrated the striking differences in SSRF performance based on fracture type. Mayberry et al demonstrated that a minority of surgeons (44%) accepted flail chest as an indication for intervention, suggesting low utilization, even with the publication of randomized trials supporting the use.9 18 19 We found that patients with flail chest were overwhelmingly likely to undergo SSRF (OR 900.22, 95% CI 398.45–2033.88, p<0.001) at both trauma and non-trauma centers, suggesting a possible increased adherence to current guidelines for this injury pattern by providers. Furthermore, multi-rib, non-flail injuries demonstrated decreased likelihood of SSRF performance compared with flail chest, suggesting some possible adherence to NONFLAIL guidance.1 A subgroup analysis was performed of patients with isolated chest injury as defined by AIS scoring to exclude possible confounding factors that may influence surgical candidacy. Results from this analysis were consistent with the analysis of the full cohort, with increased performance of SSRF by more specialized providers at non-trauma center facilities. Chest region AIS did not show any significant association in either the trauma center group or the non-trauma center group, suggesting that other factors played a role when SSRF was performed in these patients. However, patients with flail chest were overwhelmingly likely to undergo SSRF, regardless of presenting center.

    There are several limitations to this retrospective study. The study relies on an administrative database and the fracture patterns and the indications for surgery are not adjudicated. The accuracy of individual entries cannot be verified by the study team. As such, race and ethnicity data cannot be verified and may be misclassified or misidentified. This study cannot therefore assess whether surgery was ‘appropriate’ among the patients in the study as this is a complex clinical decision. We think that the impact of potential inaccuracies on the findings should be limited by the large cohort of patients analyzed in this study. Additionally, rib fractures in this study were characterized using ICD-10 diagnosis codes. Inaccuracies in ICD-10 coding could potentially lead to mischaracterization of a patient’s injuries, leading to incorrect inclusion or exclusion from the study population. The impact of this potential source of error should, however, be minimized by the large patient cohort. Lastly, the designation of provider specialization is provided by the database, and may be inaccurate. The differentiation of general versus trauma surgeon may, for example, be arbitrary, especially at non-trauma centers. Nonetheless, we think it is unlikely that thoracic surgeon specialty and general/trauma surgeons could be miscategorized given the requirement for board certification of thoracic surgeons.

    SSRF is underused, despite the presence of multiple evidence-based practice guidelines supporting its usage. Provider specialization is significantly associated with the frequency of SSRF procedures performed. Though thoracic and orthopedic surgeons make up a small fraction of providers performing SSRF, they are significantly more likely to perform them than their general surgery and trauma surgery counterparts. This difference in frequency may indicate barriers to utilization of SSRF among certain provider types, including sufficient training and institutional resources.

    Data availability statement

    Data may be obtained from a third party and are not publicly available. This retrospective study used the 2015–2019 iterations of the Premier Hospital Database (PHD; Premier, Charlotte, North Carolina, USA), which is a large US-based hospital database containing information on inpatient discharges from geographically diverse, non-profit, non-governmental and community and teaching hospitals as well as health systems from rural and urban areas, encompassing nearly 121 million inpatient admissions. These data may be obtained from Premier.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study was considered exempt by the local institutional review board (IRB# EM-17-06).

    References

    1. ↵
      1. Pieracci FM,
      2. Leasia K,
      3. Bauman Z,
      4. Eriksson EA,
      5. Lottenberg L,
      6. Majercik S,
      7. Powell L,
      8. Sarani B,
      9. Semon G,
      10. Thomas B, et al
      . A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, NONFLAIL fracture patterns (chest wall injury Society NONFLAIL). J Trauma Acute Care Surg 2020;88:249–57. doi:10.1097/TA.0000000000002559
      OpenUrl
    2. ↵
      1. Kasotakis G,
      2. Hasenboehler EA,
      3. Streib EW,
      4. Patel N,
      5. Patel MB,
      6. Alarcon L,
      7. Bosarge PL,
      8. Love J,
      9. Haut ER,
      10. Como JJ
      . Operative fixation of rib fractures after blunt trauma: a practice management guideline from the eastern association for the surgery of trauma. J Trauma Acute Care Surg 2017;82:618–26. doi:10.1097/TA.0000000000001350
      OpenUrlPubMed
    3. ↵
      1. Kane ED,
      2. Jeremitsky E,
      3. Pieracci FM,
      4. Majercik S,
      5. Doben AR
      . Quantifying and exploring the recent national increase in surgical stabilization of rib fractures. J Trauma Acute Care Surg 2017;83:1047–52. doi:10.1097/TA.0000000000001648
      OpenUrlPubMed
    4. ↵
      1. Kane ED,
      2. Jeremitsky E,
      3. Bittner KR,
      4. Kartiko S,
      5. Doben AR
      . Surgical stabilization of rib fractures: a single institution experience. J Am Coll Surg 2018;226:961–6. doi:10.1016/j.jamcollsurg.2017.11.008
      OpenUrlPubMed
    5. ↵
      1. Zhang Q,
      2. Song L,
      3. Ning S,
      4. Xie H,
      5. Li N,
      6. Wang Y
      . Recent advances in rib fracture fixation. J Thorac Dis 2019;11:S1070–7. doi:10.21037/jtd.2019.04.99
      OpenUrl
    6. ↵
      1. Tignanelli CJ,
      2. Rix A,
      3. Napolitano LM,
      4. Hemmila MR,
      5. Ma S,
      6. Kummerfeld E
      . Association between adherence to evidence-based practices for treatment of patients with traumatic rib fractures and mortality rates among US trauma centers. JAMA Netw Open 2020;3:e201316. doi:10.1001/jamanetworkopen.2020.1316
    7. ↵
      1. Pieracci FM,
      2. Agarwal S,
      3. Doben A,
      4. Shiroff A,
      5. Lottenberg L,
      6. Whitbeck SA,
      7. White TW
      . Indications for surgical stabilization of rib fractures in patients without flail chest: surveyed opinions of members of the chest wall injury Society. Int Orthop 2018;42:401–8. doi:10.1007/s00264-017-3612-1
      OpenUrl
    8. ↵
      1. Pieracci FM,
      2. Majercik S,
      3. Ali-Osman F,
      4. Ang D,
      5. Doben A,
      6. Edwards JG,
      7. French B,
      8. Gasparri M,
      9. Marasco S,
      10. Minshall C, et al
      . Consensus statement: surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury 2017;48:307–21. doi:10.1016/j.injury.2016.11.026
      OpenUrl
    9. ↵
      1. Mayberry JC,
      2. Ham LB,
      3. Schipper PH,
      4. Ellis TJ,
      5. Mullins RJ
      . Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair. J Trauma 2009;66:875–9. doi:10.1097/TA.0b013e318190c3d3
      OpenUrlCrossRefPubMed
    10. ↵
      1. Premier Applied Sciences®
      . Premier healthcare database white paper: data that informs and performs, march 2, 2020. Premier Inc, 2020.
    11. ↵
      1. Clark DE,
      2. Osler TM,
      3. Hahn DR
      . ICDPIC: stata module to provide methods for translating international classification of diseases (ninth revision) diagnosis codes into standard injury categories and/or scores statistical software components S457028, boston college department of economics. 2010.
    12. ↵
      1. Clark DE,
      2. Black AW,
      3. Skavdahl DH,
      4. Hallagan LD
      . Open-Access programs for injury categorization using ICD-9 or ICD-10. Inj Epidemiol 2018;5:11.:11. doi:10.1186/s40621-018-0149-8
      OpenUrl
    13. ↵
      1. Choi J,
      2. Kaghazchi A,
      3. Dickerson KL,
      4. Tennakoon L,
      5. Spain DA,
      6. Forrester JD
      . Heterogeneity in managing rib fractures across non-trauma and level I, II, and III trauma centers. Am J Surg 2021;222:849–54. doi:10.1016/j.amjsurg.2021.02.013
      OpenUrl
    14. ↵
      1. Ferre AC,
      2. Towe CW,
      3. Bachman KC,
      4. Ho VP
      . Should rib fracture patients be treated at high acuity trauma hospitals? J Surg Res 2021;266:328–35. doi:10.1016/j.jss.2021.02.040
      OpenUrlPubMed
    15. ↵
      1. Rockne WY,
      2. Grigorian A,
      3. Christian A,
      4. Nahmias J,
      5. Lekawa M,
      6. Dolich M,
      7. Chin T,
      8. Schubl SD
      . No difference in mortality between level I and level II trauma centers performing surgical stabilization of rib fracture. Am J Surg 2021;221:1076–81. doi:10.1016/j.amjsurg.2020.09.033
      OpenUrl
    16. ↵
      1. Reames BN,
      2. Shubeck SP,
      3. Birkmeyer JD
      . Strategies for reducing regional variation in the use of surgery: a systematic review. Ann Surg 2014;259:616–27. doi:10.1097/SLA.0000000000000248
      OpenUrlCrossRefPubMed
    17. ↵
      1. Becher RD,
      2. Jin L,
      3. Warren JL,
      4. Gill TM,
      5. DeWane MP,
      6. Davis KA,
      7. Zhang Y
      . Geographic variation in the utilization of and mortality after emergency general surgery operations in the northeastern and southeastern United States. Ann Surg 2022;275:340–7. doi:10.1097/SLA.0000000000003939
      OpenUrl
    18. ↵
      1. Tanaka H,
      2. Yukioka T,
      3. Yamaguti Y,
      4. Shimizu S,
      5. Goto H,
      6. Matsuda H,
      7. Shimazaki S
      . Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002;52:727–32; doi:10.1097/00005373-200204000-00020
      OpenUrlCrossRefPubMedWeb of Science
    19. ↵
      1. Pieracci FM,
      2. Lin Y,
      3. Rodil M,
      4. Synder M,
      5. Herbert B,
      6. Tran DK,
      7. Stoval RT,
      8. Johnson JL,
      9. Biffl WL,
      10. Barnett CC, et al
      . A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg 2016;80:187–94. doi:10.1097/TA.0000000000000925
      OpenUrlCrossRefPubMed

    Footnotes

    • Presented at This work was presented as an oral presentation at the 2022 Chest Wall Injury Summit, April 28–30, Park City, Utah, USA. This work has not been previously published.

    • Contributors All authors were involved in the conception or design of this work. AB, ALS and CWT collected data and performed statistical analysis. AB and CWT created figures and tables. All authors drafted and revised the abstract; drafted the article; and edited and critically reviewed the final article. CWT acts as guarantor for the work and controlled the decision to publish.

    • Funding This study was partially funded by an unrestricted educational grant from Zimmer Biomet.

    • Competing interests CWT is a consultant for Atricure, Zimmer Biomet, Sig Medical and Medtronic, but these relationships have not influenced this work in any way.

    • Provenance and peer review Not commissioned; internally peer reviewed.

    • © Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.