Abstract
Background
Multiple rib fractures cause substantial morbidity through severe pain, impaired ventilation, and pulmonary complications. While open rib fixation is well established, thoracoscopic fixation may reduce soft-tissue trauma and enhance recovery, but comparative evidence remains unclear. This systematic review and meta-analysis aimed to compare thoracoscopic versus open fixation for multiple rib fractures in terms of effectiveness and safety outcomes.
Methods
We conducted a systematic literature search across PubMed, Scopus and Web of Science to retrieve comparative studies comparing thoracoscopic fixation versus traditional open fixation for multiple rib fractures regarding pain, perioperative outcomes and safety outcomes. Risk of bias of included studies was assessed using the ROBINS-I tool. A meta-analysis was conducted using a random-effects model in R (version 4.5.0).
Results
Nine comparative studies were identified (total participants = 751). Meta-analysis revealed that thoracoscopic fixation was associated with improved postoperative pain compared with open fixation. Pain was significantly lower with thoracoscopy on postoperative day (POD) 1 (SMD= −1.12, 95% CI −1.64 to −0.61) and POD7 (SMD= −1.90, 95% CI −3.08 to −0.73), while POD3 was not significant (SMD= −1.49, 95% CI −3.52–0.54). Thoracoscopy reduced incision length (MD= −4.19 cm) and blood loss (MD= −18.56 mL) and shortened hospital stay (MD= −2.05 days), with no difference in operative time (MD= 9.66 min). Pleural effusion was less frequent (OR 0.32, 95% CI 0.10–1.00) on thoracoscopic fixation.
Conclusion
There may be clinically significant benefits of thoracoscopic rib fixation over open fixation for multiple rib fractures. These benefits may include less early postoperative pain, smaller incisions, less blood loss, shorter hospital stays, and no increase in operative time. Overall complication rates were similar, but thoracoscopic fixation was associated with fewer pleural effusions. Due to significant heterogeneity and the predominance of observational studies, there is a need for more rigorous prospective trials.
Introduction
Rib fractures are common after blunt thoracic trauma and can impose substantial morbidity when fractures are multiple, displaced, or associated with flail chest. Severe pain and chest wall instability restrict ventilation and impair cough, promoting atelectasis, secretion retention, and pneumonia, complications that can precipitate respiratory failure and prolong intensive care unit (ICU) and hospital stay [1]. Most uncomplicated fractures are treated nonoperatively with multimodal analgesia, pulmonary hygiene, and pleural drainage when indicated. However, selected patients with marked displacement or chest wall instability may not regain adequate respiratory mechanics with supportive care alone, motivating increased use of surgical stabilization of rib fractures (SSRF) to restore thoracic mechanics and reduce pulmonary complications [1], [2], [3].
Modern evidence supporting SSRF initially emerged from flail chest populations. In a landmark randomized trial, Tanaka and colleagues reported benefits with operative stabilization over internal pneumatic stabilization, including fewer pulmonary complications and reduced ventilator dependence [4]. Subsequent randomized evidence also suggested improved resource utilization and reduced need for downstream supportive interventions after operative fixation in traumatic flail chest [5]. Systematic reviews and meta-analyses have generally reinforced these signals, associating SSRF with fewer pneumonias, shorter durations of mechanical ventilation, and shorter ICU length of stay in appropriately selected cohorts, while highlighting ongoing uncertainty regarding generalizability beyond classic flail chest [6].
Traditional SSRF is usually performed through open reduction and internal fixation (ORIF) with sizable incisions and soft-tissue dissection to expose fracture sites for reduction and plating. Although open approaches provide direct visualization, they may increase muscle injury and postoperative pain, concerns that become more pronounced when fractures are posterior, subscapular, or distributed across multiple ribs and regions [1]. These limitations have accelerated development of less invasive strategies, including minimally invasive plate osteosynthesis concepts adapted to rib fixation [7].
Thoracoscopic and thoracoscopy-assisted approaches represent a further step toward minimizing exposure while enhancing visualization. Thoracoscopy can facilitate evaluation and treatment of concomitant intrathoracic pathology (e.g., hemothorax or retained clot), help localize fracture sites from within the pleural cavity, and support more precise incision planning with potentially reduced muscle dissection [1], [8]. Thoracoscopic-assisted rib plating (TARP) has been described as a pragmatic hybrid strategy that uses thoracoscopic guidance to enable limited-access fixation; early experience emphasized feasibility and potential recovery advantages in selected patients, including older individuals who may be more sensitive to the morbidity of open exposure [8]. Contemporary position statements now explicitly recognize minimally invasive and intrathoracic approaches as part of the expanding SSRF toolkit, while noting that the strength of comparative evidence varies by technique and setting [3], [9].
Despite a strong rationale, it remains uncertain whether thoracoscopic techniques consistently outperform traditional open ORIF across diverse injury patterns. Proposed benefits include smaller incisions, less muscle disruption, reduced postoperative pain, earlier mobilization, and improved pulmonary mechanics, factors that could reduce pulmonary complications and length of stay. Potential tradeoffs include specialized equipment requirements, longer operative times during the learning curve, and technique-specific risks related to reduction accuracy or implant positioning when operating through limited working corridors [10], [11]. Reports on ultra-minimally invasive SSRF also note that limited incisions may require extension when exposure or reduction is inadequate, potentially diminishing intended advantages [9], [12].
Given the increasing adoption of thoracoscopic and thoracoscopy-assisted SSRF, a focused comparative synthesis is warranted. Thus, we conducted this meta-analysis comparing thoracoscopic techniques with traditional open ORIF to clarify whether minimally invasive visualization and access translate into measurable improvements in clinically important outcomes. Such evidence is essential for aligning practice with guideline frameworks.