Early surgical stabilization of rib fractures in patients with mechanical ventilation-dependent respiratory failure secondary to severe chest wall injury: a retrospective cohort study

Introduction

Background

Among trauma cases, 20–25% involve chest trauma, with the most common type of injury being rib fracture (1-3). Multiple rib fractures or flail chest substantially increase the risk of mortality (4). In patients with these injuries, severe pain and instability of the chest walls compromise airway clearance and limit ventilation, causing hypoxemia, carbon dioxide retention, and atelectasis. In critical situations, mechanical ventilation procedures are necessary to ensure patient survival (5,6). Surgical stabilization of rib fractures (SSRF) is a recommended intervention in patients with flail chest or multiple rib fractures and is supported by international guidelines due to its proven effectiveness (7,8).

Rationale and knowledge gap

A common clinically important issue is the development of respiratory failure requiring invasive mechanical ventilation before surgical assessment can be completed (9). There is limited clinical evidence regarding the efficacy of SSRF in patients already on mechanical ventilation at the time of admission. Some studies suggest that surgery shortens intensive care unit (ICU) length of stay without significantly reducing ventilation duration (10), whereas others report higher rates of successful liberation from ventilation after SSRF (11). In a recent multicenter randomized clinical trial by Dehghan et al., the number of ventilator-free days at 28 days (VFD-28) was 2.8 days higher in the subgroup of patients intubated at the time of surgery than in nonoperatively managed patients (12). The uncertainty in effectiveness has contributed to therapeutic nihilism, with a significant portion of surgeons remaining reluctant to operate on ventilator-dependent patients due to a perceived elevated perioperative risk.

Objective

This study was conducted to determine whether early SSRF provides clinical benefit in patients who develop respiratory failure requiring mechanical ventilation within 24 hours of admission—a high-risk subgroup that has not been specifically examined. Administration of SSRF was compared with nonoperative management in terms the duration of ventilator liberation and related complications. The findings may better inform clinical decision-making in this critical population. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0910/rc).

Methods

Study design and participants

We retrospectively reviewed the medical records of patients with three or more rib fractures or radiographically confirmed flail segments (RCFS) accompanied by respiratory failure requiring mechanical ventilation within 24 hours of admission to Tianjin Hospital from January 2018 to December 2025. The inclusion criteria were as follows: (I) age ≥18 years; (II) three or more rib fractures or RCFS on chest computed tomography (CT) with three-dimensional reconstruction; (III) respiratory failure requiring invasive mechanical ventilation within 24 hours of admission; and (IV) chest Abbreviated Injury Scale (AIS) ≥3 as the leading injury. Meanwhile, the exclusion criteria were as follows: (I) death or discharge against medical advice within 24 hours of admission; (II) severe traumatic brain injury (head AIS ≥3); (III) high cervical spinal cord injury (C5 vertebra or above) that could directly impair diaphragmatic function via injury to the phrenic motor neurons (C3–C5 vertebrae) and thereby cause ventilator dependency unrelated to chest wall injury; (IV) significant nonthoracic injuries, defined as an AIS ≥3 in a body region other than the chest (head/face, abdomen/pelvis, spine, extremities, or external); and (V) pre-existing severe pulmonary disease, defined as Global Initiative for Chronic Obstructive Lung Disease stage 3–4 chronic obstructive pulmonary disease, home oxygen dependency, advanced interstitial lung disease (diffusing capacity of the lung for carbon monoxide <40%), or prior lung transplantation. For consistency, we used RCFS as the inclusion criterion; moreover, because all patients were already on positive-pressure ventilation at presentation, clinical assessment of paradoxical chest wall motion was unreliable. The screening and inclusion process is described in the “Study population and screening” section.

Based on the type of treatment, we divided patients into surgical (SSRF) and nonsurgical groups. Each of the surgical patients had been subjected to SSRF and mechanical ventilation.

Surgical technique

Surgical decision pathway

All SSRF procedures in this study were performed by a single dedicated thoracic surgical team led by Dr. Wang Dongbin, ensuring technical consistency. The decision to perform SSRF was made by a multidisciplinary team, which included experts in thoracic surgery, intensive care medicine, and anesthesiology. Patients who met the inclusion criteria (i.e., three or more rib fractures or RCFSs with respiratory failure requiring mechanical ventilation) were recommended for SSRF, but the final decision was determined by (I) patient and family preference; (II) age and comorbidity-related surgical risk; and (III) economic considerations.

SSRF was practiced in endotracheal intubation under general anesthesia in the lateral decubitus position. The position of incisions was selected according to the three-dimensional CT reconstruction of the ribs (5–8 cm along fracture end lines). The ends of rib fractures were exposed via muscle-sparing techniques, the periosteum was debrided (with neurovascular injury and penetration of pleura being avoided), and fractures were reduced. Surgeons’ decisions regarding plate and screw systems or intramedullary splints were determined according to fracture patterns. Closed thoracic drainage tubes were placed postoperatively.

Nonsurgical management

Nonoperative care comprised lung-protective mechanical ventilation, multimodal analgesia (nonsteroidal anti-inflammatory drugs with opioids on demand), elastic thoracic stabilization belts (chest binders) applied around the lower and mid chest as a supportive adjunct to limit paradoxical motion and provide modest analgesia—with careful tension adjustment to avoid restricting lung expansion—and aggressive pulmonary toilet. Both the surgical and nonsurgical groups were managed by the same multidisciplinary team under uniform institutional protocols for lung-protective ventilation, analgesia, and sedation (guided by the Numerical Rating Scale and the Critical-Care Pain Observation Tool), daily sedation interruption with spontaneous breathing trials, ventilator-associated pneumonia prevention bundles, tracheostomy indications, enteral nutrition initiation, and ventilator liberation criteria. The only systematic difference between groups was whether SSRF was performed.

Data measures and outcome measures

Demographic data, injury mechanism, AIS, Injury Severity Score (ISS), arterial blood gas parameters, comorbidities, and chest wall injury characteristics (number of fractured ribs, number of flail segments, bilaterality, pneumothorax, hemothorax, and Modified RibScore) were recorded. The primary outcome was the duration of mechanical ventilation (days from intubation to successful extubation). The secondary outcomes were the following: (I) postoperative ventilation duration (surgical group only); (II) VFD-28; (III) ICU length of stay; (IV) incidence of pneumonia (defined by new infiltrates on chest radiography plus fever or leukocytosis); (V) tracheostomy rate; (VI) in-hospital mortality; and (VII) for the surgical group, time from admission to SSRF and surgical complications (wound infection, hardware-related issues, reoperation, and perioperative bleeding requiring intervention). Total hospital length of stay was not used as a primary quality measure because of its susceptibility to influence from nonclinical factors (13).

Statistical analysis

Data were analyzed with SPSS 26.0 (IBM Corp., Armonk, NY, USA). The Shapiro-Wilk test was used to test continuous variables for the normality of distribution. Normally distributed data are expressed as the mean and standard deviation and were compared between groups via the independent samples t-test. Nonnormally distributed data are expressed as the median and interquartile range and were compared between groups via the Mann-Whitney U test. Categorical variables are expressed as frequencies (percentages) and were compared between groups via the χ² or Fisher’s Exact test.

Kaplan-Meier survival analysis was used to generate cumulative ventilator liberation curves, and differences between groups were assessed via the log-rank test. Cox proportional hazards regression was conducted to identify the factors associated with ventilation duration. Variables with P<0.05 in the univariate analysis were subsequently entered into the multivariate model. A two-sided P<0.05 was considered statistically significant (Figure 1).

Figure 1 Kaplan-Meier curves for the cumulative ventilator liberation probability over time for the surgical and nonsurgical groups. Log-rank P<0.001. Numbers in parentheses represent the number of patients remaining on ventilation at each time point. d, day; Non-op, non-operative; SSRF, surgical stabilization of rib fractures.

Ethics statement

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This retrospective cohort study was reviewed and approved by the Ethics Committee of Tianjin Hospital (Approval No. 2026041; approved on February 4, 2026). Given the retrospective nature of the analysis, the requirement for written informed consent was waived.

Results

Baseline characteristics

Study population and screening

Of the 5,468 patients admitted with rib fractures during the study period, 78 patients met the initial anatomical and physiological criteria (≥3 rib fractures or flail segment plus mechanical ventilation within 24 hours). Meanwhile, 19 patients were excluded: 4 due to death or discharge against medical advice within 24 hours, 5 due severe traumatic brain injury (head AIS ≥3), 2 due to high cervical spinal cord injury (C5 vertebra or above), 5 due to significant nonthoracic injuries (nonchest AIS ≥3), 2 due to pre-existing severe lung disease, and 1 due to an age <18 years. The final cohort comprised 59 patients: 30 in the surgical (SSRF) group and 29 in the nonsurgical group. All 59 patients had RCFS, and no nonflail patients were included. The patient selection process is shown in Figure 2.

Figure 2 Flowchart of patient selection in the study. AIS, Abbreviated Injury Scale; AMA, against medical advice; ICU, intensive care unit; LOS, length of stay; MV, mechanical ventilation; SCI, spinal cord injury; SSRF, surgical stabilization of rib fractures; TBI, traumatic brain injury; VFD, ventilator-free days.

As shown in Table 1, the two groups were balanced in age, sex, injury mechanism, AIS/ISS scores, arterial blood gas parameters, and comorbidities (all P>0.05). The median PaO₂:FiO₂ ratio did not differ significantly between groups [nonsurgical: 156.5, interquartile range (IQR) 135.75–170.25; surgical: 145.0, IQR 121.75–161.50; P=0.22]. Notably, the surgical group, as compared to the nonsurgical group, had numerically more severe chest-wall injuries (median 10 vs. 8; P=0.002) and a higher median Modified RibScore (4 vs. 3; P=0.003).

Primary outcome

The duration of mechanical ventilation was significantly higher in the nonsurgical group (median 17.0 days, IQR 15.0–21.0 days; P<0.001) than in the surgical group (median 6.0 days, IQR 4.25–8.78 days). In the surgical group, the median time from admission to SSRF was 2.85 days (IQR 1.07–3.75 days; range 0.60–20.70 days); 1 patient underwent SSRF within 24 hours, 14 within 24–72 hours, 11 between 3 and 7 days, and 4 after 7 days. The median postoperative ventilation duration was 3.0 days (IQR 2.0–5.0 days). Sensitivity analysis via a Cox proportional hazards model was conducted with time to SSRF entered as a time-varying covariate and yielded results consistent with those of the principal analysis.

Secondary outcomes

Table 2 provides a summary of the secondary outcomes. The surgical group, as compared with the nonsurgical group, had a shorter median length of ICU stay (surgical: 18.0 days, IQR 14.25–21.0 days; nonsurgical: 26.0 days, IQR 20.0–36.0 days; 0.003) and a higher median VFD-28 (surgical: 22.0 days, IQR 19.23–23.75 days; nonsurgical: 10.0 days, IQR 0–12.0 days; P<0.001), as well as a lower incidence of pneumonia (13.3% vs. 48.3%; P=0.009), tracheostomy (26.7% vs. 58.6%; P=0.03) and in-hospital mortality (0% vs. 20.7%). Total hospital length of stay was not included as a quality outcome (13).

Surgical complications

Among the 30 patients who underwent SSRF, the surgical site infection rate was 3.3% (1/30; superficial wound infection treated successfully with local wound care and oral antibiotics). No hardware-related complications, reoperations, perioperative bleeding requiring intervention, deep infections, or perioperative deaths occurred. The overall complication rate was 3.3% (1/30), and all events had a Clavien-Dindo grade ≤II.

Predictors of successful liberation from mechanical ventilation

According to univariate Cox regression, the factors significantly associated with time to successful liberation from mechanical ventilation were SSRF [hazard ratio (HR) 4.828, 95% confidence interval (CI): 2.640–8.830; P<0.001], pneumonia (HR 0.350, 95% CI: 0.182–0.674; P=0.002), and tracheostomy (HR 0.251, 95% CI: 0.134–0.470; P<0.001) (Table 3).

Multivariate analysis (Table 4) validated SSRF as an independent protective factor of liberation from mechanical ventilation (HR 4.633, 95% CI: 2.158–9.944; P<0.001). Other independent predictors of successful ventilator liberation were tracheostomy (HR 0.304, 95% CI: 0.131–0.706; P=0.006) and shorter ICU length of stay (HR 0.940, 95% CI: 0.908–0.973; P<0.001).

Discussion

Principal findings

This study examined a cohort of patients with severe chest wall injury requiring mechanical ventilation within 24 hours of admission. In the multivariate analysis, the group treated with early SSRF, as compared with the nonsurgical group, had a median 11-day reduction in the duration of mechanical ventilation, a 12-day increase in VFD-28, and a 5.25-fold higher rate of successful ventilator liberation. SSRF was also associated with significantly lower rates of pneumonia, tracheostomy, and in-hospital mortality. Notably, the surgical group had numerically more severe chest-wall injuries (higher number of rib fractures and Modified RibScore) yet experienced better outcomes, an observation that rules out selection bias as an explanation for the benefit of SSRF. These findings suggest that ventilator-dependent patients with chest wall trauma can still benefit from surgical intervention.

Strengths and limitations

Strengths of this study include the focus on a clinically important high-risk subgroup that is underrepresented in the literature, the strict inclusion criteria (chest AIS as leading injury), and the use of time-to-event analysis with Cox regression, which is well-suited to examining ventilation duration data.

However, several limitations should also be noted. First, as we employed a retrospective, single-center design with a single dedicated surgical team, the external validity of the findings is unclear. Second, the sample size was modest (N=59), and propensity-score matching was not performed due to this limited sample size. Third, although we adjusted for confounders in multivariate Cox regression and conducted a sensitivity analysis using time to SSRF as a time-varying covariate, residual selection bias inherent to the retrospective design cannot be excluded. Fourth, the primary outcome included preoperative ventilator time in the surgical group, which may underestimate the postoperative benefit, and examining postoperative ventilation duration separately and including VFD-28 in the sensitivity analysis could mitigate this bias. Fifth, standardized quantitative pulmonary contusion volume was not available in the retrospective imaging records. Sixth, long-term functional outcomes beyond the index hospitalization were not assessed. Future prospective multicenter trials with standardized SSRF protocols and long-term follow-up are warranted.

Comparison to similar research

Studies on the use of SSRF for flail chest have produced conflicting results. In the study by Marasco et al., SSRF was associated with a small reduction in ICU stay, but there was no significant change in ventilation duration (9); meanwhile, Tanaka et al. reported benefits in both ICU stay and ventilation duration (11,14). The most relevant and recent evidence was generated by the multicenter randomized clinical trial by Dehghan et al. (12), in which patients intubated at the time of SSRF had a median 2.8-day increase in VFD-28 as compared with patients who received no surgical care. Our cohort exhibited a considerably larger between-group VFD-28 difference (12 days), likely because we focused on a more severely affected subgroup consisting entirely of patients with RCFS requiring mechanical ventilation within 24 hours of admission. The World Society of Emergency Surgery and Chest Wall Injury Society position paper (8), the timing study by Lagazzi et al. (15), and the early-SSRF multicenter randomized controlled trial by Wang et al. (16) also provide evidence supporting the efficacy of early SSRF in patients with severe chest wall injury. Finally, our approach, which is similar to that of Tanaka et al. (11), aims to stabilize all unstable ribs whenever feasible, whereas that of Marasco et al. fixes only one fracture site per rib in segmental fractures; however, selective fixation may yield less clinical benefit, which may partly explain the discrepancy in findings between our own and Marasco et al.’s study (9).

Interpretation of findings

Our findings may be attributable to a number of different mechanisms that are particular to mechanically ventilated patients. To begin, in patients with flail chest who are ventilator-dependent, paradoxical chest wall motion causes substantial patient-ventilator asynchrony and necessitates deep sedation and protracted paralysis. SSRF reestablishes continuity of the chest wall, eliminating paradoxical movement and enabling improved synchrony with the ventilator. This may explain why the surgical group in our study had a shorter time to postoperative liberation from ventilation (a median of 3 days after surgery).

Moreover, high-risk patients with rib fractures are mechanically ventilated, thereby exposing them to the risk of developing ventilator-associated pneumonia due to immobility, poor cough, and inability to clear respiratory secretions. SSRF stabilizes the fracture pieces, thus eliminating the grinding of the bone-on-bone contact that produces serious pain during coughing. This enables patients to complete pulmonary toilet and reduces the amount of sedation, thus abolishing the cycle of immobility and infection. The significantly reduced pneumonia rate in the surgical group compared with the nonsurgical group (13.3% vs. 48.3%) supports this view.

Finally, mechanical ventilation requires extended tracheostomy tube placement. SSRF decreases the period of invasive ventilation and surgical airways by decreasing time to liberation from ventilation. The lower rate of tracheostomy in the surgical group than in the nonsurgical group (26.7% vs. 58.6%) was likely a factor that contributed to the lack of mortality in the surgery group, as tracheostomy increases the risk of bleeding, infection, and stenosis of the airways.

Conclusions

Early SSRF in mechanically ventilated patients with severe chest wall injury significantly reduced the duration of mechanical ventilation, ICU stay, pneumonia, tracheostomy, and in-hospital mortality while maintaining a low complication rate. Our findings support the consideration of SSRF for this high-risk subgroup; however, further prospective multicenter trials are needed to confirm these results.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0910/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0910/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0910/prf

Funding: This research was supported by the Tianjin Natural Science Foundation under the project “Research and Development of a Tied Absorbable Internal Fixation System for Rib Fractures” (No. 24JCZDJC01170, to D.W., H.X., P.Z., Y.Z., Z.S., Y.L., G.D.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0910/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This retrospective cohort study was reviewed and approved by the Ethics Committee of Tianjin Hospital (approval No. 2026041; approved on February 4, 2026). Given the retrospective nature of the analysis, the requirement for written informed consent was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: J. Gray)