Reconsidering rib fixation: is a complete video-assisted thoracoscopic surgery approach the future for surgical stabilization?

Severe chest trauma, particularly cases involving multiple rib fractures and/or flail chest, continues to pose a significant clinical challenge. The main objectives of treatment are pain control and stability of the thoracic wall to prevent fracture related complications. In general, treatment options include non-surgical management with analgesics, and surgical intervention to stabilize the apparent fractures. Although the latter gained popularity over the past years, surgical stabilization of rib fracture (SSRF) remains a topic of debate (1).

This debate is further elaborated by the emergence of minimally invasive surgical techniques, such as SSRF through a complete video-assisted thoracoscopic surgery (VATS) approach, offering potential benefits to conventional open fixation. A recent study by Qian et al. provides valuable insights into the safety and efficacy of SSRF via complete VATS compared to the conventional open approach (2).

Qian et al. evaluated 39 patients with severe chest trauma who underwent SSRF, where 17 patients were treated using a complete VATS approach and 22 patients undergoing open surgery (2). Of these patients, 54% (n=21/39) were diagnosed with flail chest while the remaining presented with at least three (either unilateral or bilateral) fractured ribs. These indications for surgery were in line with the consensus guidelines by the Chest Wall Injury Society (CWIS) (3). Although the CWIS-endorsed indications for SSRF differ slightly between ventilated and non-ventilated patients, surgery is generally indicated in cases of chest wall instability—such as flail chest, clinical instability, or paradoxical chest wall motion. Additional indications include the presence of three or more displaced rib fractures (defined as displacement of ≥50% of the rib width, typically involving ribs 3 through 10) accompanied by significant pulmonary physiologic compromise (e.g., elevated respiratory rate or persistent high pain scores despite adequate multimodal analgesia), or failure to wean from mechanical ventilation.

Though, it is important to note that the CWIS guidelines are predominantly based on studies utilizing an open surgical approach. Based on the findings by Qian et al., complete VATS SSRF is, compared to an open surgical approach, associated with a decrease in VAS-scores (on the seventh postoperative day) and a reduced incidence of postoperative pleural effusion (noted that it is unknown whether this translates into clinical significance) (2). These outcomes may in theory further shift the benefit-risk balance in favor of surgical intervention in selected cases.

On the contrary, complete VATS SSRF also poses additional concerns. A multinational retrospective study, including 1,224 patients in 12 trauma centers who underwent open SSRF, demonstrated hardware failure (defined as plate migration or fracture and screw migration) in up to 3% of patients (4). On top of that, there are also the patients with pseudoarthrosis, mal-union and implant- or fracture-related infections that are susceptible for hardware revision or removal. Despite Qian et al. encountered no cases requiring hardware removal, this is—if extrapolatable from the data on the open approach—of concern for memory alloy rib plates in the intrathoracic position, simply because one does not know what to expect when removing material implanted via a complete VATS approach (2). Should we for example expect pleural adhesions, increasing secondary surgical trauma? And when apparent, are they outweighed by the potential benefits of complete VATS SSRF during implantation. While the short-term results are promising, long-term follow-up studies are needed to determine whether VATS influences implant longevity and patient satisfaction.

The paper under consideration remains a proof of concept, with several aspects yet to be fully clarified. These include the already noted mid- to long-term outcomes, hardware-related complications, and the specific fracture locations that can be technically stabilized using a fully VATS-based approach, as well as the associated costs.

Another potentially hindering factor for introducing complete VATS SSRF is the specific VATS-tools needed to reduce the rib fractures and apply the rib plates (including the so-called heart-shaped reduction forceps and the detachable clip applier). Regarding the potentially associated learning curve, little is known to date. Additionally, concerns regarding prolonged single-lung ventilation in patients with bilateral lung contusions warrant further investigation, as extended ventilation may increase the risk of pulmonary complications (3).

The considered complete two-port VATS SSRF approach is applauded for its minimally invasive nature and associated benefits. However, the lack of significant differences in operation-related characteristics, including operation time, intraoperative blood loss, and ventilator days, suggests that SSRF via complete VATS and the open surgical approach are comparable regarding efficiency (2). In addition, although the statistically significant reduction in postoperative pain [as (only!) measured by visual analog scale (VAS) scores on the seventh postoperative day] highlights a potential benefit of VATS in minimizing surgical trauma, it may be questioned whether a reduction from a median VAS score from 4 to 3 translates to be clinically relevant. For example, a study by Jensen et al. suggested that a 33% decrease in pain represented a reasonable standard for a meaningful reduction from the patient’s perspective (5). In addition, based on the presented analysis, the decrease in VAS-scores cannot directly be related to the use of VATS instead of an open approach. Differences in perioperative pain management strategies, of which no mention was made, may also be attributable.

Regardless of the perceived advantages and choice of either an open or complete thoracoscopic approach to stabilize rib fractures, the addition of VATS is highly recommended, if only for careful intraoperative detection of relevant fractures that require stabilization, and identification of associated injuries, such as an entrapped lung, rupture of the diaphragm, or hemothorax that can then be drained. van Gool et al. evaluated 105 flail chest patients who underwent VATS-assisted SSRF and observed a hemothorax in most patients (76%, though a range of 25 to 2,500 mL was described with a mean of 200 mL), a diaphragm rupture in 2 patients, as well as 3 cases of an entrapped lung, highlighting the added diagnostic and therapeutic value of VATS in SSRF (6).

Pain control remains a cornerstone of rib fracture management, typically achieved through either analgesic modalities—such as epidural analgesia—or surgical stabilization of the fractures. However, emerging advances in conservative management warrant attention. One such development is percutaneous intercostal nerve cryoablation, which has demonstrated superior analgesic efficacy compared to epidural analgesia in other thoracic conditions (7). If validated in this context, its use could challenge the current rationale for surgical fixation in cases where the primary indication has been persistent pain despite the use of regular analgesics leading to respiratory complications such as pneumonia.

Qian et al. provide encouraging evidence that SSRF via complete VATS is a potential alternative to open rib fixation in selected patients with severe chest trauma (2). However, the study’s small sample size and single-center design warrant validation through larger, non-randomized, multicenter trials with longer follow-up. As minimally invasive approaches advance, their benefits—such as reduced surgical trauma and improved pain control—must be weighed against feasibility, cost, and long-term outcomes including implant related complications. Future research should therefore also focus on refining selection criteria and evaluating VATS’s impact on pulmonary related metrics and quality of life.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article has undergone external peer review.

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1119/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1119/coif). The authors have no conflicts of interest to declare.

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