ORIGINAL ARTICLE Early Surgical Stabilization of Flail Chest With Locked Plate Fixation Peter L. Althausen, MD, MBA,* Steven Shannon, BS,† Chad Watts, BS,† Kenneth Thomas, MD,* Martin A. Bain, MD, FACS,‡ Daniel Coll, P-AC, MHS,§ Timothy J. O’Mara, MD,* and Timothy J. Bray, MD* Objectives: To compare the results of surgical stabilization with locked plating to nonoperative care of flail chest injuries. Design: Retrospective case–control study. Setting: Level II trauma center. Patients/Participants: From January 2005 to January 2010, 22 patients with flail chest treated with locked plate fixation were compared with a matched cohort of 28 nonoperatively managed patients at our institution. Intervention: Open reduction internal fixation of rib fractures with 2.7-mm locking reconstruction plates. Main Outcome Measurements: Demographic data, such as age, sex, injury severity score, number of fractures, and lung contusion severity, were recorded. Intensive care unit data concerning length of stay (LOS), tracheostomy, and ventilator days were noted. Operative data, such as time to OR, operative time, and estimated blood loss, were recorded. Hospital data, including total hospital LOS, need for reintubation, and home oxygen requirements, were documented. Results: Average follow-up period of operatively managed patients was 17.84 6 4.51 months, with a range of 13–22 months. No case of hardware failure, hardware prominence, wound infection, or non- union was reported. Operatively treated patients had shorter intensive care unit stays (7.59 vs. 9.68 days, P = 0.018), decreased ventilator requirements (4.14 vs. 9.68 days, P = 0.007), shorter hospital LOS (11.9 vs. 19.0 days, P = 0.006), fewer tracheostomies (4.55% vs. 39.29%, P = 0.042), less pneumonia (4.55% vs. 25%, P = 0.047), less need for reintubation (4.55% vs. 17.86%, P = 0.34), and decreased home oxygen requirements (4.55% vs. 17.86%, P = 0.034). Conclusions: This study demonstrates the potential benefits of surgical stabilization of flail chest with locked plate fixation. When compared with case-matched controls, operatively managed patients demonstrated improved clinical outcomes. Locked plate fixation seems to be safe as no complications associated with hardware failure, plate prominence, wound infection, or nonunion were noted. Key Words: flail chest, rib fractures, ORIF, surgical stabilization (J Orthop Trauma 2011;25:641–648) INTRODUCTION Flail chest is an important clinical finding that occurs in approximately 10% of patients with chest trauma. 1 Its presence alone carries an associated mortality rate of 10%–15%. 1 The therapeutic approach to the management of flail chest has become a matter of recent controversy. 2,3 The standard of care has been selected ventilatory support and tracheostomy when indicated. 4,5 Continuous epidural anesthesia is beneficial and has been shown to reduce both intensive care unit (ICU) and total hospital length of stay (LOS). 6 Nonoperative treatment algorithms can be complicated by prolonged ventilatory support, posttraumatic pneumonia, empyema, respiratory insufficiency, and chronic pain from fracture nonunion. 2,7,8 Long-term disability is reported in over one-third of these patients. 8–11 These outcomes have resulted in substantial hospital and societal costs. Over the past 30 years, the benefits of surgical stabilization have been reported in several small cases series. 12–16 These reports suggest that the pulmonary improve- ment resulting from open reduction internal fixation shortens the duration of intubation, decreases ICU LOS, lowers the incidence of pneumonia, improves pulmonary function testing, restores chest wall continuity, and allows patients to return to work more quickly. 12–16 A recent case–control study by Nirula et al 17 demonstrated a trend toward fewer total ventilator days and no difference in total hospital or ICU LOS. Tanaka et al 4 compared 18 patients treated with surgical stabilization with 19 patients treated with internal pneumatic stabilization and found statistically shorter ventilator times and ICU stays, as well as a lower incidence of pneumonia and reduced hospital costs. Similar results were reported by Granetzny et al, 18 who demonstrated statistically fewer ventilator, ICU, and hospital days in addition to fewer cases of chest infection in operatively managed patients. Despite these encouraging results, some studies have reported plate OTA Highlight Paper Accepted for publication May 13, 2011. From the *Reno Orthopaedic Clinic, Reno, NV; †University of Nevada Medical School, Reno, NV; ‡Western Surgical Group, Reno, NV; and §Renown Regional Medical Center, Reno, NV. Presented in part at the Annual Meeting of the Orthopaedic Trauma Association, 2010, Baltimore, MD. No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Reprints: Peter L. Althausen, MD, MBA, Reno Orthopaedic Clinic, 555 North Arlington Avenue, Reno, NV 89503 (e-mail: palthausen@sbcglobal.net). Copyright Ó 2011 by Lippincott Williams & Wilkins J Orthop Trauma  Volume 25, Number 11, November 2011 www.jorthotrauma.com | 641