Massachusetts Chapter of the American College of Surgeons

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Surgical Stabilization of Rib Fractures: Is It Time For Centers of Excellence?
Erica D. Kane MD, MPH1, Elan Jeremitsky, MD1, Fredric M. Pieracci MD, MPH, FACS3, Sarah Majercik, MD, MBA, FACS2, Andrew R. Doben, MD, FACS1
1Department of Surgery, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA; 2Division of Trauma and Surgical Critical Care, Intermountain Medical Center, Murray, UT; 3Denver Health Medical Center/University of Colorado School of Medicine, Denver, CO

INTRODUCTION
Utilization of surgical stabilization of rib fractures (SSRF) is surging nationally for severe rib injuries, including flail chest. We investigate the growth of centers performing SSRF and whether case volume impacts outcomes.

METHODS
Retrospective NTDB data on patients with SSRF (2007-2014). Cases analyzed by year, ACS trauma level, and volume of SSRF cases. Centers were stratified by tertiles: “Low volume” (LVC, <12 SSRF/year), “Medium” (MVC), and “High” (HVC, >27 SSRF/year).

RESULTS
By 2014, 637 registered trauma centers (515 LVC, 86 MVC, 36 HVC) performed 35,625 SSRF. All centers increased volume over time. MVC had the greatest increase (130%,p=0.011), followed by LVC (47%,p=0.0047) and HVC (14%,p=0.7814; A). Majority of centers performing SSRF were LVC ACS Level II, but number of MVC LII (525%, p=0.0006) increased at the steepest rate, followed by LVC Level III (410%, p=0.0072; B). Injury severity score (ISS) was significantly higher at HVC (23.13±11.28) than at MVC (21.64±11.54,p=0.0142) and LVC (20.00±11.68,p=0.0039). Overall mortality was highest at MVC (2.09%), then LVC (1.67%, p=0.1001), and lowest at HVC (1.39%,p=0.0094). Despite higher ISS, admission to HVC independently predicted decreased mortality (OR 0.931, 95%CI 0.89-0.97, p=0.002).

CONCLUSIONS
More LVC are performing SSRF compared to MVC or HVC. Despite less severely injured patients, mortality is higher at these centers. HVC have lower mortality, with more severely injured patients. Further studies are needed to determine if specialized SSRF centers will improve outcomes.


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