eReply: In patients with acute flail chest does surgical rib fixation improve outcomes in terms of morbidity and mortality?

We welcome and agree with the comments by John Edwards [1] on the evidence for rib fixation for acute flail chest [2]. The series published by Jayle et al. [3] is described by the authors as 'a matched case-control study that prospectively included patients with multiple trauma and blunt chest injury' that were treated over a one-year period. They matched patients in a 1:1 ratio to a control group that did not undergo rib fixation at the unit. Similarly Pieracci et al. [4] evaluated a prospective controlled series of patients who were treated with/without rib fixation.

We also looked at the series by Wu et al. [5]. The data here are difficult to interpret and do not provide the best evidence looking at the role of rib fixation for acute flail chest. This study although large (n = 164), excluded patients for a whole host of reasons including if they were female. The study grouped together a very heterogenous population where patients had either: (i) multiple rib fracture >3; (ii) frame fracture dislocation 50% or higher; (iii) serious chest wall deformity or chest cavity active bleeding; (iv) if the patients had flail chest. They then used random grouping if the patient agreed into which group they were placed, with no methods provided for the process of randomization.

We keenly await the results of the ongoing five prospective trials (https://clinicaltrials.gov), including the Sheffield Multiple Rib Fractures Study: (SMuRFS) that is on its way to provide better evidence for the role of rib fixation.

Conflict of interest: none declared.

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