Outcomes in Single Versus Two-Stage Surgical Stabilization of Complex Bilateral Chest Wall Injury: A Single-Center...

Surgical stabilization of rib fractures (SSRF) continues to show benefit for severe chest wall injury (CWI) with improvement in morbidity and mortality following stabilization. Complex bilateral injuries pose a clinical and technical challenge. Currently, there is no formal recommendation for an approach to repair such injuries, whether that be bilateral SSRF within the index case or staged repair. We sought to describe our institutional experience with this subset of patients, identify factors that may influence the decision to pursue single- versus two-stage procedures, and assess the potential benefit of combined bilateral SSRF during the index operation.

A retrospective, single-institution review was conducted at a Level II trauma center including patients undergoing surgical stabilization of bilateral CWI between 2018-2022. Patients were excluded if they received unilateral fixation despite having bilateral CWI or had CWI related to cardiopulmonary resuscitation. Patient/injury characteristics, operative details, and clinical outcomes, including ventilator days, length of stay data, pneumonia, and tracheostomy rates, were analyzed. Descriptive statistics were performed.

Eighteen patients met the inclusion criteria (13 one-stage and 5 two-stage). All patients had flail chest. Patient demographics, overall hospital length of stay (LOS), and post-operative LOS were similar between groups; however, the two-stage group had a higher Injury Severity Score (ISS) (26 one-stage vs 29 two-stage). Total operative time was longer for staged repairs (294 minutes vs 157 minutes for single-stage procedures). The two-stage group required more plates for stabilization (14 vs 8). Patients undergoing staged repair experienced a longer median duration of ventilator dependence (5.5 vs 3 days). Pneumonia was more frequent in the staged group, 40% (n= 2), compared with 8% (n = 1) in the single-stage procedures. Tracheostomy was performed in 40% (n=2) vs 15% (n=2) of patients in the two-stage vs single-stage groups. No inpatient mortality was reported in either cohort.

In this retrospective observational study evaluating outcomes of single and staged SSRF for complex bilateral CWI, expected differences were observed in operative time and number of plates required, both of which were higher in staged repairs. These findings likely reflect increased case complexity and resource utilization associated with staged procedures. Our observational experience highlights the need for careful patient selection and resource planning when considering staged SSRF, with the decision for surgical approach being individualized.