School of Medicine Publications and Presentations

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Background: Surgical stabilization of rib fractures (SSRF) has gained increasing interest over the past decade, yet few candidates who could benefit from SSRF undergo operative management. We conducted an international survey of institutional SSRF guidelines comparing congruence between practice and contemporary evidence. We hypothesized that few guidelines reflect comprehensive evidence to facilitate standardized patient selection, operation, and post-operative management.

Methods: A request for institutional rib fracture guidelines was distributed from the Chest Wall Injury Society. SSRF-specific guideline contents were extracted using a priori-designed extraction sheets and compared against 28 SSRF evidence-based recommendations outlined by a panel of 14 international experts. Fisher's exact test compared the proportion of strong and weak evidence-based recommendations specified within a majority of institutional guidelines to evaluate whether strength of evidence is associated with implementation.

Results: A total of 36 institutions from three countries submitted institutional rib fracture management guidelines, among which 30 had SSRF-specific guidance. Twenty-eight guidelines (93%) listed at least one injury pattern criteria as an indication for SSRF, while 22 (73%) listed pain and 21 (70%) listed impaired respiratory function as other indications. Quantitative pain and respiratory function impairment thresholds that warrant SSRF varied across institutions. Few guidelines specified non-acute indications for SSRF or perioperative considerations. Seven guidelines (23%) detailed post-operative management but recommended timing and interval for follow-up varied. Overall, only three of the 28 evidence-based SSRF recommendations were specified within a majority of institutional practice guidelines. There was no statistically significant association (p = 0.99) between the strength of recommendation and implementation within institutional guidelines.

Conclusions: Institutional SSRF guidelines do not reflect the totality of evidence available in contemporary literature. Guidelines are especially important for emerging interventions to ensure standardized care delivery and minimize low-value care. Consensus effort is needed to facilitate adoption and dissemination of evidence-based SSRF practices.

Level of evidence: Level VI, Therapeutic/Care Management.


This is a non-final version of an article published in final form in

Choi, J., Badrinathan, A., Shine, R., Benz, C., Toia, A., Whitbeck, S., Kryskow, M., White, T., & Kirsch, J. (2022). Challenges in Closing the Gap between Evidence and Practice: International Survey of Institutional Surgical Stabilization of Rib Fractures Guidelines. The journal of trauma and acute care surgery, 10.1097/TA.0000000000003785. Advance online publication.

Publication Title

The Journal of Trauma and Acute Care Surgery



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Mentor/PI Department


Available for download on Saturday, September 23, 2023

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