DISCUSSION
Rib fracture, as the most prevalent type of thoracic trauma, exhibits distinct global epidemiological patterns, with East Asia and high-income North America identified as key high-incidence regions. In terms of absolute case numbers, China currently bears the highest global disease burden. Projections indicate that the worldwide burden of rib fractures will continue to rise through 2030[12], accounting for approximately 10% of all chest trauma-related hospitalizations[13,14]. Historically, rib fractures have been classified by complexity into simple, multiple, and flail chest injuries, with severity varying substantially across categories. While most injuries can be managed successfully through either nonoperative or surgical treatment, optimal therapeutic strategies depend on fracture characteristics and associated clinical complications[15]. Conservative approaches, such as chest wall strapping, rib traction, and ventilator support, are often associated with several drawbacks including a high incidence of complications, prolonged treatment duration, significant pain, and delayed healing. In contrast, a growing body of evidence demonstrates that surgical stabilization for multiple rib fractures, particularly in flail chest, can significantly alleviate pain, improve ventilation, reduce dependence on mechanical ventilation and the incidence of pulmonary complications, and decrease hospital length of stay, mortality, and disability rates[16-18].
Traditional ORIF for rib fractures presents notable disadvantages, such as extensive incisions, substantial tissue trauma, prolonged postoperative recovery, and a high rate of complications[9]. With continuous advancements in thoracoscopic techniques, their application in the emergency management of thoracic trauma has become increasingly widespread. Compared to conventional open surgery, thoracoscopy offers two major advantages: (1) Although imaging modalities like CT three-dimensional reconstruction and ultrasound can localize fracture sites preoperatively, intraoperative displacement may still occur. Thoracoscopic visualization enables precise intraoperative localization of rib fractures, facilitating optimal incision planning and minimizing incision length; (2) It provides superior capability for exploring and managing associated intrathoracic injuries, including hemothorax, lung lacerations, diaphragmatic rupture, and intercostal artery injury[8]. Thoracoscopy enables genuine muscle‑sparing surgery by avoiding transection of major chest wall muscles or forceful retraction of the scapula, thereby largely preserving shoulder girdle function. Furthermore, the panoramic intrathoracic view allows not only fracture fixation but also comprehensive assessment of pulmonary contusion and management of active bleeding or organized hemothorax. More importantly, the reduced muscular trauma leads to significantly less postoperative pain, which encourages early and effective coughing and consequently markedly lowers the risk of pulmonary complications such as pneumonia[19]. Recently, Huang et al. conducted a comparative clinical study on this topic, further highlighting the clinical benefits of total thoracoscopic surgery[20].
A variety of rib-fixation systems, including claw-shaped plates, screw-and-plate constructs, and intramedullary devices, have been introduced worldwide, each with inherent advantages and limitations[21-23]. In the present study, the Complete Thoracoscopy group was treated with a TiNi shape-memory alloy claw that has gained increasing clinical acceptance[10,24]. The device obviates the need for drilling or cable-tying, thereby simplifying instrumentation. Manufactured from nickel-titanium alloy, it offers superior biocompatibility, corrosion resistance, and MRI compatibility, while eliciting minimal immune response. Its temperature-dependent memory property allows intra-operative deformation under cold saline and automatic restoration to its pre-set configuration at body temperature, generating continuous, dynamic compression across the fracture site. In contrast to conventional rigid plates, the TiNi-claw incorporates a reversed-arch design that increases its transverse diameter, creating a “neurovascular window” that protects the intercostal bundle. Consequently, fixation forces are redirected to the lateral cortical surface of the rib, reducing the risk of chronic post-operative chest-wall pain[10].
In a case-control study, Wang et al. demonstrated significant differences between thoracoscopic and conventional open surgical treatment for rib fractures[25]. The thoracoscopic approach was associated with a lower incidence of postoperative complications, along with favorable outcomes in terms of operative time, intraoperative blood loss, and incision length. Patients reported markedly reduced postoperative pain and significantly improved quality of life. While completely thoracoscopic rib fracture fixation was shown to be a safe, feasible, and minimally invasive method for mid-and posterior rib fractures covered by the scapula and thick dorsal muscles, the incidence of postoperative fracture malalignment was noted to be higher than anticipated[26]. In another retrospective analysis, Qian et al. evaluated outcomes of complete thoracoscopic surgery for multiple rib fractures or flail chest accompanied by severe thoracic trauma[27]. Their results indicated no statistically significant differences (P > 0.05) between groups in operative time, intraoperative blood loss, chest tube drainage volume, postoperative ventilator days, ICU length of stay, or total hospital stay. Although the overall postoperative complication rate did not differ significantly (P = 0.358), the incidence of pleural effusion was lower in the thoracoscopic group compared with the open surgery group (P = 0.025). Moreover, VAS pain scores on postoperative day 7 were significantly lower in the thoracoscopic group (P = 0.014). Thoracoscopically assisted rib fracture fixation represents a hybrid technique that combines conventional open surgical exposure with thoracoscopic visualization. While maintaining an external incision for fracture reduction and fixation, the procedure utilizes intra-thoracic endoscopic guidance, particularly advantageous in complex fractures and cases requiring simultaneous management of intrathoracic injuries. This approach enhances intraoperative visualization during fixation, facilitates hematoma evacuation, and may potentially reduce perioperative complications[28]. A prospective study reported that the thoracoscopically assisted group had shorter ventilator use (3.19 ± 3.37 days vs. 8.05 ± 8.23 days, P = 0.002) and a significantly lower incidence of pneumonia (38.1% vs. 75.0%, P = 0.005). Hospital stay was also notably shorter in the intervention group (17.76 ± 8.38 days vs. 24.13 ± 9.80 days, P = 0.011). These findings suggest that rib fixation combined with video-assisted thoracoscopic surgery (VATS) in severe blunt thoracic trauma with acute respiratory failure can shorten ventilator dependence, reduce pneumonia rates, and decrease overall hospitalization time[29].
In our retrospective analysis, we moved beyond the traditional open surgical approach for rib fractures and focused specifically on comparing complete thoracoscopy vs. thoracoscopy-assisted surgery in the treatment of multiple rib fractures in non-flail chest. Baseline demographic and clinical characteristics showed no significant differences between the two groups, confirming comparability. No statistically significant differences were observed in key perioperative indicators, including the number of fractured ribs fixed intraoperatively, postoperative chest-tube drainage volume, time to drain removal, and length of hospital stay. Furthermore, the incidence of common postoperative complications, such as pulmonary infection, pleural effusion, atelectasis, and surgical site infection, did not differ significantly between the two groups. It is noteworthy, however, that while the difference in the incidence of surgical site infection between the two groups did not reach statistical significance, not a single case of surgical site infection was observed in the Complete Thoracoscopy group. This observation, albeit derived from a limited sample, suggests a potential clinical trend favoring the complete thoracoscopic approach. The absence of surgical site infection in this cohort may partially reflect the inherent advantages of a minimally invasive technique, which typically involves smaller incisions, reduced tissue trauma, and potentially lower risk of wound complications, thereby contributing to enhanced postoperative recovery. This is also consistent with the finding in our study that the Complete Thoracoscopy group had significantly shorter skin incisions, implying reduced chest-wall trauma. Pre-operative VAS scores were identical; however, values on post-operative days 3 and 7 were lower in both groups relative to baseline, confirming that surgical stabilization abbreviates the painful period. Importantly, VAS scores at both time-points were significantly lower in the Complete Thoracoscopy group, an effect attributed to limited muscular and neural injury. Operative time was marginally longer in the Complete Thoracoscopy group, a predictable consequence of the learning curve associated with the adoption of a novel, fully endoscopic technique. We anticipate that accumulated experience will shorten operative times to, or even below, those required for the hybrid approach. At 3-month follow-up, no implant failure, respiratory dysfunction, or chest-wall deformity was encountered. Patients in the Complete Thoracoscopy group reported less frequent residual pain and hypo-aesthesia, reflecting the clinical benefits of minimized surgical trauma. Collectively, these data indicate that complete thoracoscopic SSRF with TiNi-claws reduces surgical insult, preserves shoulder-girdle function, and attenuates early and intermediate pain and dysesthesia compared with the thoracoscopy-assisted technique. Furthermore, with the deepening integration of medicine and engineering, a growing number of novel materials and technologies are being translated into preliminary clinical studies and applications for the internal fixation of rib fractures[30,31]. Concurrently, the continued maturation of artificial intelligence and 3D printing technologies holds significant promise for improving surgical outcomes for patients with rib fractures[32].
Several limitations of this study should be acknowledged. First, as a single-center investigation with a relatively small sample size, the statistical analyses may be subject to bias. Beyond that, the choice between complete thoracoscopy and thoracoscopy-assisted surgery was based on surgeon assessment, fracture pattern, and patient characteristics and preferences, rather than random allocation. This introduces a potential selection bias. Specifically, the complete thoracoscopy cohort included a higher proportion of younger patients, who may possess inherently better recovery potential and different pain perceptions. Although we ensured baseline comparability between the two groups, residual confounding from unmeasured factors (e.g., preoperative fitness, psychosocial factors) cannot be ruled out. Consequently, the observed advantages of complete thoracoscopy in VAS scores and patient satisfaction should be interpreted with caution, as they may be partially attributable to these baseline demographic and motivational differences rather than the surgical approach alone. Future prospective, randomized trials involving larger, multicenter cohorts are warranted to definitively isolate the effect of the surgical technique and validate our findings. Additionally, the follow-up period was limited, with clinical outcomes assessed only at three months postoperatively. Consequently, the long-term effectiveness of the two surgical approaches could not be evaluated. Future studies should incorporate extended follow-up durations to address this gap.
In conclusion, both complete thoracoscopic and thoracoscopy-assisted mini- incision approaches demonstrate satisfactory surgical outcomes for the treatment of multiple rib fractures. The complete thoracoscopic technique is associated with minimized surgical trauma, reduced postoperative pain, and improved clinical effectiveness in the short term, supporting its broader clinical application.