Educational assessment of intrathoracic and extrathoracic surgical stabilization of rib fractures.

Background: Surgical stabilization of rib fractures (SSRF) is being done with increased frequency and new advances. Intrathoracic SSRF is a new less invasive approach compared to the traditional extrathoracic plating procedure. Educational assessment can be done through descriptive analysis of learning curves with operation time used as a proxy measurement for learning. The objective of this level 3 observational cohort study is to assess the learning curve of introducing the intrathoracic method of plating at a large academic medical institution.

Methods: Intrathoracic surgical stabilization of rib fractures was introduced at a tertiary trauma center in March of 2019. All patients that received SSRF beginning 11/2017 were included. Patients with abbreviated injury scale score of the head, abdomen, extremity, or face greater than three and days from injury to SSRF greater than 4 were excluded. Operation time was determined from time of incision to completion of skin closure. Time per fracture and time per plate were calculated using total operation time. Learning curves and CUSUM graphs for individual surgeons that had completed in more than 3 SSRF cases were generated using and trended for statistical significance.

Results: After exclusions, there were 38 patients with extrathoracic SSRF between November 2017-September 2021 and 24 patients with intrathoracic plating between March 2019-Sept. 2021. There were 5 fellows and 6 residents that performed extrathoracic SSRF. Four fellows and 2 residents performed intrathoracic SSRF. Graphs of time per fracture and time per plate over time produced learning curves without an inflection point for extrathoracic or intrathoracic SSRF in any of the following categories: all surgeries (Figs. 1 and 2), academic year (July to June), individual attending surgeons, fellows, or residents.

Conclusion: There was no discernible inflection point on the generated learning curves. Time per plate and time per fracture did not decrease as surgeons gained more experience. Introducing intrathoracic SSRF in a large academic hospital may not need to account for a learning curve adjustment period.