Evaluation of the effectiveness of various surgical techniques for early stabilization of the rib cage in comparison with conservative treatment tactics and predictors of an unfavorable outcome in patients with severe combined trauma

Abstract

The objective was to evaluate the clinical effectiveness of various surgical techniques for early stabilization of the rib cage in comparison with conservative treatment tactics. The authors attached great importance to the search for predictors of an unfavorable outcome in patients with severe combined trauma.Materials and methods. This multicenter, non-randomized, open, retro- and prospective cohort study included 65 patients with chest trauma. Pa tients were categorized into three groups depending on the technique of restoration of the disturbed thoracic skeleton. Group 1 included 19 patients with the age of 39.9 ± 2.4 years and severity of MODS-II scale 4.0 ± 0.6, ISS 24.1 ± 1.8 points. In this group, submersible constructs were used to restore sternal reconstruction. Group 2 included 24 patients aged 30.9 ± 2.4 years with MODS-II severity score of 4.3 ± 0.5, ISS 27.1 ± 1.0 points. The stabilization of the frame was carried out using the technique of fixation of the bones of the ribs and sternum with an external fixation device (AVF). Frame stabilization was performed according to the technique of fixation of rib and sternum bones with external fixation apparatus (EFA). Group 3 contained 22 patients aged 48.6 ± 2.9 years with severity of MODS-II scale 3.9 ± 0.3, ISS 24.3 ± 1.3 points and conservative treatment tactics.Results. The respiratory biomechanics parameters in groups 1 and 2 had no statistically significant differences after 24 hours of the surgical interven tion and stabilized the rib cage. The exception concerned increased CO2 accumulation and a distinct tendency to decrease lung tissue extensibility (Slang) in the group 1, which could indicate restriction of chest excursion. The analysis of correlation between clinical and laboratory parameters and lethal outcome indicated that unfavorable outcome was most closely related to prolonged prehospital time, initial severity of the condition according to SOFA and APACHE II integral scales, as well as to the development of acute kidney injury and uncompensated tissue hypoxia.Conclusion. The comparison of the three treatment methods showed that each of them has its own advantages: the technique of surgical treatment using submersible structures is characterized by the greatest aggressiveness for the victim, limits the excursion of the chest in accordance with the biomechanics of respiration, which contributes to the aggravation of tissue hypoxia, but reduces the duration of treatment and financial costs. The least expensive, but comparable in aggressiveness, is the method of hardware fixation. The most sparing for the patient, although lengthening the time of treatment and, accordingly, its cost, is the conservative method of management. Thus, the choice of surgical tactics is left to the attending physician and the patient.