REVIEW ARTICLE
Operative Treatment of Rib Fractures in Flail
Chest Injuries: A Meta-analysis and
Cost-Effectiveness Analysis
Eric Swart, MD,* Joseph Laratta, MD,† Gerard Slobogean, MD,‡ and Samir Mehta, MD§
Objectives: 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 require-
ments 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.
Methods: 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.
Results: 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.
Conclusions: Surgical fixation of rib fractures sustained from flail
chest injuries decreased ICU time, mortality, pulmonary complica-
tions, and hospital LOS and resulted in improved health care–related
outcomes and was a cost-effective intervention. These results were
Accepted for publication November 4, 2016.
From the *Department of Orthopaedic Surgery, University of Massachusetts,
Worcester, MA; †Department of Orthopaedic Surgery, Columbia Univer-
sity 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.
The authors report no conflict of interest.
Presented at the Annual Meeting of the Orthopaedic Trauma Association,
October 6–8, 2016, National Harbor, MD.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.jorthotrauma.com).
Reprints: Eric Swart, MD, Department of Orthopaedic Surgery, University of
Massachusetts, Worcester, MA 01605 (e-mail: ericswartmd@gmail.com).
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DOI: 10.1097/BOT.0000000000000750
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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.
Key Words: rib fracture fixation, flail chest, cost-effectiveness
Level of Evidence: Economic Level III. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2017;31:64–70)
INTRODUCTION
Rib fractures are common injuries occurring in 10% of
all patients admitted after blunt chest trauma.1 The most
severe manifestation of rib fractures is a flail chest, defined
as at least 3 or 4 consecutive ribs broken in at least 2 places,2
which is found in approximately 7% of patients with rib
fractures.3 These severe injuries are clinically relevant to
the multiple-injured patient as they affect respiratory mechan-
ics, increasing the work of breathing and making it difficult
for patients to effectively ventilate on their own because of
paradoxical motion of the chest wall.4
Historically, flail chests have been treated primarily
with supportive care consisting of pain control and ventilatory
support as needed.5 However, this often requires prolonged
intubation or even tracheostomy, 5 with the accompanied
medical complications and additional resource utilization
associated with intensive care and prolonged mechanical
ventilation. In addition, these supportive care interven-
tions are associated with high levels of long-term
morbidity. 6
Operative management of rib fractures with open
reduction and internal fixation (ORIF) as a primary strategy
has gained relevance, with the aim of restoring the mechanical
integrity of the chest wall and reducing the duration and intensity
of respiratory support required.2,4,7,8 This has been investigated
by randomized trials and some early meta-analyses9–11
suggesting promising results, although several additional
high-quality studies have recently been published since
some of the more recent meta-analyses.12–16 Preliminary
economic evaluations have also been conducted evaluating
the feasibility of primary early fixation,17 although they
were limited in quality by a narrow scope of data used
without formal sensitivity analysis.
The purpose of this study was to construct an economic
model based on rigorous meta-analysis using the most recent
J Orthop Trauma  Volume 31, Number 2, February 2017
J Orthop Trauma  Volume 31, Number 2, February 2017
high-quality literature available to evaluate both the economic
and medical benefits of early fixation of rib fractures in severe
chest trauma. Our hypothesis was that the additional cost and
operative complications of surgical fixation may be offset by
the decreased medical complications and resource utilization
of prolonged intensive care and ventilator support required by
nonoperative treatment.
MATERIALS AND METHODS
Study Design
This was a 2-part study in which we initially conducted
a meta-analysis of the existing literature and then used the
results of that meta-analysis to populate an economic model
and cost-effectiveness analysis.
Source of Funding
No external funding was used for this study.
Literature Search and Study Identification
A comprehensive search of the literature was performed
based on the Preferred Reporting Items for Systematic
Reviews and Meta-analyses (PRISMA) guidelines on June
1, 2016. The databases used included PubMed, EMBASE,
MEDLINE, and Scopus. Our goal of the search was to
identify studies comparing nonoperative and operative man-
agement of rib fractures—specifically flail chest injuries.
All published articles were retrieved without a search con-
straint on publication date. The key words “flail chest,”
“rib fracture,” “internal fixation,” and “osteosynthesis”
were used (see Table, Supplemental Digital Content 1,
http://links.lww.com/BOT/A831). A manual search of refer-
ence lists of included studies and previous reviews was also
performed to find additional suitable citations.
Study Selection and Data Extraction
All potentially relevant publications retrieved from the
4 databases were combined and evaluated. The evaluation
was performed independently by 2 authors (E.S. and J.L.).
Titles were screened for relevance to rib fracture manage-
ment. Subsequently, the abstracts of selected articles were
screened to retrieve studies comparing the operative and
nonoperative treatment of flail chest. During the title and
abstract screening, if insufficient data were present, the
citation was assessed by full-text review. Full-text review
was performed on the selected abstracts focused on outcomes
related to clinical efficacy and cost-effectiveness.
The final inclusion criteria included the following: (1)
study comparing nonoperative and operative treatment
groups, (2) participants 18 years of age or older with an
acute diagnosis of flail chest. No studies were excluded on the
basis of the types of outcome measures used or study design.
Two independent investigators (J.L. and E.S.) extracted
information using standardized extraction forms. The extracted
data included the following: ventilator days, intensive care unit
(ICU) length of stay (LOS), hospital LOS, mortality rate,
pneumonia rate, and tracheostomy rate (Table 1).
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Rib Fracture Fixation Cost-Effectiveness
Statistical Methods of Meta-analysis
Meta-analysis was performed using Review Manager 5.0
(http://tech.cochrane.org/revman). The weighted mean differ-
ence and 95% confidence interval (CI) were calculated for
continuous variables, and the weighted risk ratio and 95% CI
were calculated for dichotomous variables. If the standard error
was not reported in a study, it was imputed using the methods
described by Ma et al.34 Statistical significance was set at P ,
0.05. Heterogeneity was calculated using the I2 statistic,35 with
random-effects models used when the heterogeneity was
greater than 50%. These values were all recalculated using only
data available from level 1 prospective trials as well.
Cost-Effectiveness Analysis Model Design
A cost-effectiveness analysis was conducted based on
the guidelines by the Panel on Cost-Effectiveness in Health
and Medicine.36 As there are no reliable data about long-term
indirect costs (return to work, etc.), costs were taken solely
from a payer perspective, with only costs incurred during
index hospitalization or subsequent revision operations mod-
eled. For health utility gains, a lifetime time duration was
used, assuming an average age of 46 years (based on the
average age of patients included in the studies), with a life
expectancy of 80 years (based on US life tables37). For cost-
effectiveness calculations, we used a limit of $100,000 per
quality-adjusted life year (QALY) as a cutoff for incremental
cost-effectiveness ratio (ICER), based on studies suggesting
that this is a reasonable contemporary threshold.38
A model was developed to evaluate the clinical and
economic outcomes of 2 different treatment strategies:
operative ORIF or nonoperative management with supportive
ventilation and pain management. For each treatment strat-
egy, the incidence of complications including mortality,
pneumonia, tracheostomy, and reoperation were modeled,
as well as increased ICU and hospital LOS (Fig. 1 and
Table 2). We assumed that all major costs and health events
occurred during index hospitalization; that is, that costs and
health utility states were equal for all survivors after initial
hospitalization. The only exception to this was when revision
surgery was required in the ORIF group after discharge, in
which case the cost of that procedure was included.
Cost of rib fracture fixation was challenging to estimate,
given that this is a relatively novel procedure, is not frequently
performed, and is variably coded/billed. To overcome this, we
obtained estimates of the variable procedure costs (which include
implants, supplies, and supporting staff salary in the operating
room) from 3 different level 1 trauma centers where these
procedures are regularly performed. Average variable costs
ranged from $13,500 per case to $22,000 per case, and an
average between all 3 institutions of $17,100 was used. This was
combined with an average physician reimbursement of $4000
published in other studies,17 for an average procedure cost of
$21,100, with the cost ranging from $17,500 to $26,000 in sen-
sitivity analysis. Cost of revision ORIF for complication was
assumed to be 150% of the primary operation. Other costs ana-
lyzed included those of treatment of pneumonia and tracheos-
tomy, as well as the additional cost associated with ICU or
hospital LOS and were determined by literature review.17,39–46
www.jorthotrauma.com | 65
Swart et al J Orthop Trauma  Volume 31, Number 2, February 2017

TABLE 1. Results of Literature Review and Meta-analysis

No. Patients Ventilator Time, d ICU LOS, d
ORIF Non-Op ORIF Non-Op
Study LoE ORIF Non-Op Avg SD Avg SD Avg SD Avg
Ahmed et al18 3 26 38 3.9 4.3 15.0 6.4 9.0 3.9 21.0
Althausen et al19 3 22 28 4.1 4.7 9.7 7.4 7.3 4.2 9.7
Balci et al20 3 27 37 3.1 1.8 7.2 5.8
de Moya et al21 3 16 32 7.0 8.0 6.0 10.0 9.0 8.0 7.0
DeFreest et al22 3 41 45 9.3 10.7 5.8 11.2 14.0 11.0 8.0
Doben et al16 3 10 11 8.2 6.9 18.0 11.9 12.5 6.2 15.3
Granetzny et al23 1 20 20 2.0 4.9 12.0 8.8 9.6 4.4 14.6
Granhed et al13 3 60 153 2.7 2.8 9.0 3.2
Jayle et al12 3 10 10 3.1 5.2 5.9 9.4 9.0 4.3 12.3
Karev et al24 3 40 93 2.3 0.6 6.3 1.2
Kim et al25 3 18 45
Majercik et al26 3 38 57 6.0 3.0 7.0 6.0 3.0 1.0 5.0
Marasco et al14 1 23 23 6.3 3.5 7.5 5.4 13.5 3.0 18.7
Nirula et al27 3 30 30 6.5 1.3 11.2 2.6 12.1 1.2 14.1
Tanaka et al28 1 18 19 10.8 3.4 18.3 7.4 16.5 7.4 26.8
Teng et al29 3 32 28 14.0 3.9 20.0 7.4 8.7 3.5 15.2
Voggenreiter et al30 3 20 22 18.8 20.3 27.2 27.8
Wada et al31 3 84 336
Xu et al32 3 17 15 10.5 3.7 13.7 4.4 15.9 5.0 19.6
Zhang et al33 3 24 15 12.0 2.6 7.0 2.5 24.5 2.4 21.5
Heterogeneity (I2), % 83 91
Meta-analysis effect size (SD) 4.57 (60.59) 3.25 (61.29)
Effect size using only level 1 studies 6.03 (62.74) 6.84 (62.48)
ICU LOS, d Hospital LOS, d Mortality Pneumonia Tracheostomy
Non-Op ORIF Non-Op Op Non-Op Op Non-Op Op Non-Op
Study SD Avg SD Avg SD Inc Inc Inc Inc Inc Inc
Ahmed et al18 5.3 0.08 0.29 0.15 0.50 0.12 0.37
Althausen et al19 6.1 11.9 6.5 19.0 8.8 0.05 0.25 0.14 0.39
Balci et al20 18.3 7.6 19.3 6.9 0.11 0.27 0.00 0.19
de Moya et al21 10.0 18.0 12.0 16.0 11.0 0.31 0.38
DeFreest et al22 10.0 28.3 17.0 13.0 9.0 0.02 0.11 0.27 0.22 0.24 0.18
Doben et al16 9.8 21.6 9.6 28.5 14.1 0.00
Granetzny et al23 7.3 11.7 6.8 23.1 10.4 0.10 0.15 0.10 0.50
Granhed et al13 0.03 0.00
Jayle et al12 8.5 21.7 7.8 32.3 19.3 0.40 0.30
Karev et al24 0.23 0.46 0.15 0.34
Kim et al25 0.06 0.22
Majercik et al26 3.5 0.24 0.39 0.05 0.23
Marasco et al14 4.1 0.00 0.04 0.48 0.74 0.39 0.70
Nirula et al27 2.7 18.8 1.8 21.1 3.9
Tanaka et al28 13.2 0.22 0.89 0.28 0.79
Teng et al29 6.1 17.1 5.4 22.4 8.8 0.13 0.43
Voggenreiter et al30 0.15 0.36 0.25 0.32
Wada et al31 33.0 10.5 42.0 17.5 0.04 0.02 0.12 0.20
Xu et al32 5.0 0.00 0.07 0.59 0.93 0.12 0.40
Zhang et al33 3.9 38.0 5.3 60.0 15.4 0.00 0.13 0.67 0.47 0.50 0.47
Heterogeneity (I2), % 91 89 0 55 42
Meta-analysis effect size (SD) 3.25 (61.29) 4.84 (61.98) RR 0.44 (60.09) RR 0.59 (60.10) RR 0.52 (60.07)
Effect size using only level 1 studies 6.84 (62.48) 3.01 (60.73) RR 0.56 (60.57) RR 0.39 (60.09) RR 0.46 (60.11)
Avg, average value; Inc, incidence rate; LoE, level of evidence; Non-Op, patients treated nonoperatively with standard of care; RR, risk ratio.

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J Orthop Trauma  Volume 31, Number 2, February 2017 Rib Fracture Fixation Cost-Effectiveness

FIGURE 1. For patients suffering a flail

chest injury, after the initial decision
between operative fixation (ORIF) and
standard care (mechanical ventilation),
they are modeled to have medical com-
plications (mortality, pneumonia, or tra-
cheostomy) based on the values given in
Table 2. Some patients undergoing ORIF
are also modeled to have surgical com-
plications after discharge requiring revi-
sion surgery (eg, removal of hardware).

The following baseline parameters were obtained using
the weighted average across all included studies in the meta-
analysis: age of the base case (46 years old), incidence of
pneumonia (47%), incidence of tracheostomy (37%), and
surgical revision rate (5%). As there have been substantial
improvements in intensive management over the past 10
years, baseline mortality rate was based solely using data
from the 2 “modern” level 1 studies (Marasco et al,14 and
Granetzny et al23) of 9.3%. Reduction in ICU stay, hospital
stay, mortality, pneumonia, and tracheostomy from operative
treatment were obtained from the meta-analysis.
The gains in QALYs arose from increased survivor-
ship during initial hospitalization. As noted above, we
assumed that all survivors had a life expectancy of 80 years.
Although there is some literature to suggest that there may
be some long-term functional benefits of ORIF,12,23,28 we
assumed equal posthospitalization health states between
nonoperative and operative patients (a utility of 1.0), so as
not to bias the model in favor of ORIF. Patients who had
a postsurgical complication or revision were modeled to
have a disutility of 0.3.17
Sensitivity Analysis
To test the stability of conclusions on input variable
uncertainty, probabilistic sensitivity analysis was conducted.
All input parameters were allowed to randomly vary within

TABLE 2. Input Values Used to Calculate the Cost-Effectiveness of ORIF of Rib Fractures in Flail Chest Injuries
Value
Description Base Case Low High Reference
Costs, $
Rib fracture ORIF 21,100 17,500 26,000 14
24 h in the ICU 2000 1200 2500 37–43
24 h in the hospital (non-ICU) 700 400 800 36,42
Pneumonia 3679 2000 4000 14
Tracheostomy 400 200 1000 14
Clinical outcome probabilities
Average reduction in time in ICU after ORIF, d 3.25 0.66 5.83 *
Average reduction in total hospital LOS, d 4.84 0.88 8.80 *
Baseline mortality rate with conservative care, % 0.09 0.04 0.46 *
Baseline rate of pneumonia with conservative care, % 0.47 0.25 0.93 *
Baseline tracheostomy rate with conservative care, % 0.43 0.19 0.79 *
Reduction in mortality with ORIF, RR 0.44 0.30 0.65 *
Reduction in rate of pneumonia with ORIF, RR 0.59 0.52 0.81 *
Reduction in rate of tracheostomy with ORIF, RR 0.52 0.40 0.69 *
Complication rate of ORIF requiring revision, % 0.05 0.00 0.50 *
Age of base case 46 *
Life expectancy 80 34
*Based on internal meta-analysis.
RR, risk ratio.

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Swart et al
FIGURE 2. Flow diagram presenting the
systematic review process used in this
study.
their 95% CIs, and a Monte Carlo simulation was used to
estimate the probability of a given strategy being preferred
over a range of ICERs. In addition, one-way sensitivity
analysis was performed on all the variables listed in Table 2
within their 95% CIs to identify edge cases.
Finally, results of the meta-analysis and economic
model were re-examined using only data from level 1
prospective randomized trials, to see if our conclusions would
vary.
RESULTS
Systematic Review and Meta-analysis
The initial literature search returned 451 studies,
and after review, a total of 20 studies met inclusion
criteria12–14,16,18–21,23–33 (Fig. 2). Data for ventilator time,
ICU LOS, hospital LOS, mortality rate, pneumonia rate, tra-
cheostomy rate, and reoperation rate were extracted, and the
data synthesized to generate a mean effect size with 95% CI
(Table 1). All the variables measured showed improvement in
the operative group which was statistically significant (P ,
0.05). Full forest plots and funnel plots for each variable are
also given in Supplemental Digital Content 2 (see Appendix,
http://links.lww.com/BOT/A832). Analysis was repeated using
only data from level 1 prospective randomized control trials
(also shown in Table 1).
Cost-Effectiveness Analysis
For the base case (using data from all available studies),
nonoperative management had an average total cost of $8629
and an average of 30.84 QALY. ORIF had an average cost
of $23,682 and 32.60 QALY, giving it an ICER of
$8577/QALY.
Using only data from level 1 studies, nonoperative
management had an average total cost of $11,700 and an
average of 30.84 QALY. ORIF had an average cost
of $23,314 and 32.20 QALY, giving it an ICER of
$8348/QALY.
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J Orthop Trauma  Volume 31, Number 2, February 2017
Sensitivity Analyses
When all the variables listed in Table 2 were varied
through their 95% CIs, ORIF remained the most cost-
effective strategy, with ICER never exceeding $16,000/QALY.
The model was most sensitive to revision rate, but even
with complication/revision rates as high as 50%, ORIF still
had an ICER of $18,000/QALY, well under the threshold for
cost-effectiveness.
Results of probabilistic sensitivity analysis showed that
ORIF is the preferred strategy (cost effective in over 50%
of simulations) when the societal willingness to pay (ICER
threshold) is greater than $8500/QALY (Fig. 3). For ICER
thresholds greater than $25,000/QALY, ORIF was the
preferred strategy in virtually all simulations.
Repeating the meta-analysis and cost-effectiveness
using only data from level 1 prospective randomized trials
did not affect conclusions of the probabilistic sensitivity
analysis (see Appendix, Supplemental Digital Content 3,
http://links.lww.com/BOT/A833).
DISCUSSION
Flail chest injuries from high-energy blunt trauma can
be devastating, life altering events with extremely high
morbidity and mortality rates. In addition, these injuries
require extensive resource utilization due to the intensive
level of care demanded by traditional conservative manage-
ment strategies. In that context, surgical intervention that
improves clinical outcomes and reduces overall demand of
care is appealing.
The results of this meta-analysis and economic simu-
lation are encouraging: the literature-reported data show
a universal decrease in complications (morbidity, pneumonia,
and tracheostomy requirements) with some of the increased
cost of surgery offset by decreased length of stay in both
the ICU and the hospital overall. These results are robust
over an extremely wide range of input values, making a
compelling case for more aggressive surgical management of
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J Orthop Trauma  Volume 31, Number 2, February 2017
FIGURE 3. Results of probabilistic sensi-
tivity analysis. Curves show the percent
chance of either ORIF (blue) or standard
care (red) being cost effective for a given
willingness to pay (ICER). Editor’s Note:
A color image accompanies the online
version of this article.
these injuries. Of note, the results of the analysis using only
level 1 studies were comparable with other similar recent
meta-analyses,11 further increasing the confidence in results.
Furthermore, we assumed equal clinical outcomes and costs
in all survivors, although several studies have suggested that
nonoperative treatment of flail chest may be associated with
impaired pulmonary function12,23,28 and long-term decreased
quality of life.6,15 If anything, this may underestimate the
benefit of surgical treatment.
Historically, nonoperative management of the flail chest
has been the standard of care. The choice of nonoperative
management may have resulted from the knowledge gap
regarding fracture fixation strategies and techniques by those
managing the chest wall injuries in these patients (eg,
intensivists). As rib fracture fixation has gained popularity
and fixation techniques and implants have been refined,
clinical outcomes are encouraging. The results of this analysis
suggest that patients could substantially benefit from surgical
management of rib fractures if complications can be limited
through a more intimate coordination between general/
thoracic surgeons and orthopaedic surgeons. The economic
benefits are sensitive to complication rate, suggesting that
optimum outcomes would be achieved when these procedures
are performed by surgeons with expertise in each individual
step, also supporting a multidisciplinary approach.
One of the major limitations of this study is the
retrospective, comparative nature of many of the studies used
in the analysis. Most studies were retrospective in nature, the
outcomes reporting were heterogeneous, and the criteria for
operative intervention variably defined. However, testing with
broad sensitivity analysis demonstrated that the results were
robust, and retesting with only prospective randomized data
did not affect conclusions, suggesting that these observed
effects are clinically meaningful and not due to the bias that
retrospective studies potentially contain. In fact, assuming
a similar overall effect size, a study reporting the opposite
results of our analysis would have to have over 300 patients to
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Rib Fracture Fixation Cost-Effectiveness
reverse the central conclusions of this study (in terms of
mortality rate, pneumonia, and tracheostomy reduction).
Obtaining accurate cost estimates of this infrequent
operation is also challenging and a potential source of
uncertainty, which we have attempted to mitigate by pooling
between data across 3 busy level 1 trauma centers. In
addition, ORIF of rib fractures for flail chest is a relatively
uncommon operation in most trauma centers; the literature
used in this analysis represents results from centers that are
relatively experienced in this procedure, and it remains to be
demonstrated how reproducible these benefits will be with
broader adoption of these techniques. Finally, it is important
to note that this analysis only concerns acute fixation of rib
fractures resulting in flail chest, and these results should not
be generalized to fixation of single isolated rib fractures
without pulmonary compromise or to established nonunions.
The results of this meta-analysis and cost-effectiveness
analysis show that acute ORIF of rib fractures in patients with
flail chest injuries results in reduced mortality and medical
complications in conjunction with being a cost-effective
intervention. In a hospital with surgeons comfortable with
thoracic exposures and with principles and techniques of rigid
internal fixation, strong consideration should be given to
operative intervention in these patients by a multidisciplinary
effort.
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