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

BACKGROUND: Patients with multiple rib fractures and flail chest often also experience subsequent respiratory failure requiring mechanical ventilation. The benefits of surgical stabilization of rib fractures (SSRF) for this critically patient population remains controversial. This study aimed to evaluate whether early SSRF facilitates ventilator liberation and reduces complications in patients who develop respiratory failure requiring mechanical ventilation within 24 hours of admission. METHODS: This retrospective cohort study analyzed 59 patients with three or more rib fractures or radiographically confirmed flail segments accompanied by respiratory failure requiring mechanical ventilation within 24 hours of admission at Tianjin Hospital from January 2018 to December 2025. Patients were divided into a surgical group (SSRF; n=30) and nonsurgical group (n=29). The primary outcome was the duration of mechanical ventilation. Secondary outcomes included intensive care unit (ICU) length of stay, ventilator-free days at 28 days (VFD-28), pneumonia, tracheostomy, in-hospital mortality, and surgical complications. Statistical analyses included Kaplan-Meier curve analysis and Cox proportional hazards regression. RESULTS: The baseline characteristics did not differ between the two groups (all P>0.05). The surgical group, as compared to the nonsurgical group, had a significantly shorter median duration of mechanical ventilation {6.0 [interquartile range (IQR): 4.25-8.78] vs. 17.0 (IQR: 15.0-21.0) days; P<0.001}, a shorter median ICU stay [18.0 (IQR: 14.25-21.0) vs. 26.0 (IQR: 20.0-36.0) days; 0.003], and more median VFD-28 [22.0 (IQR: 19.23-23.75) vs. 10.0 (IQR 0-12.0) days; P<0.001]. Moreover, the surgical group had 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%; P=0.03). Multivariable Cox regression confirmed SSRF to be an independent protective factor for successful liberation from mechanical ventilation [hazard ratio (HR): 4.633, 95% confidence interval (CI): 2.158-9.944; P<0.001]. The surgical site infection rate was 3.3% (1/30), and there were no hardware-related complications. CONCLUSIONS: Early SSRF in patients receiving mechanical ventilation due to 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 in this high-risk subgroup but remain to be validated in prospective multicenter studies.