Abstract
BACKGROUND: Rib fractures are frequently encountered in trauma care and are particularly hazardous for functionally dependent patients, leading to increased morbidity and mortality rates. Surgical stabilization of rib fractures (SSRF) improves outcomes in selected populations; however, its role in functionally dependent individuals remains underexplored. METHODS: A retrospective cohort analysis was conducted using the American College of Surgeons-Trauma Quality Improvement Program dataset from 2020 to 2022. Patients with three or more rib fractures and AIS (Abbreviated Injury Scale) greater than 3 for the rib and thoracic wall, along with documented functional dependency, were included. Propensity score matching (3:1) was applied to reduce the selection bias between patients receiving SSRF and those managed conservatively. The main outcomes of interest were in-hospital mortality, acute respiratory distress syndrome, unplanned intensive care unit (ICU) admission, unplanned intubation, and ventilator-associated pneumonia (VAP). A subgroup analysis compared early (≤ 72 h) versus late SSRF. RESULTS: Among 18,643 eligible patients, 359 (1.9%) underwent SSRF. Before matching, patients with SSRF had higher Injury Severity Scores (ISS), ICU admissions, and complication rates. After matching (294 SSRF vs. 883 conservative patients), SSRF was associated with significantly lower mortality (4.8% vs. 8.7%, p = 0.038) despite higher rates of unplanned ICU admission (11.2% vs. 7.0%, p = 0.031), unplanned intubation (10.2% vs. 6.1%, p = 0.026), and VAP (3.1% vs. 0.6%, p = 0.002). In the subgroup analysis, early SSRF led to fewer ventilator days (p = 0.013), and shorter ICU (p < 0.001), and hospital length of stays (LOS, p < 0.001), with no difference in mortality compared with late SSRF. However, the late SSRF group still had significantly lower in-hospital mortality compared to the conservative treatment group (3.8% vs. 10.9%, p = 0.023). CONCLUSION: SSRF in functionally dependent trauma patients with multiple rib fractures and significant chest wall injury (AIS ≥ 3) is associated with a significant reduction in in-hospital mortality compared to conservative management, despite a higher incidence of complications and prolonged ICU LOS. Early SSRF further improves clinical outcomes by decreasing ventilator duration and overall hospital LOS. These findings support the consideration of SSRF-particularly when performed early-as a beneficial strategy for managing rib fractures in functionally dependent patients. Even when performed at a later stage, SSRF still offers advantages over conservative treatment in reducing mortality. prospective studies are warranted to validate these results and establish clear patient selection criteria.