Inflammatory response and early outcomes after long- versus short-incision muscle-sparing extrathoracic SSRF: a pilot observational cohort study

Although muscle-sparing extrathoracic surgical stabilization of rib fractures (SSRF) is increasingly used, exposure can be achieved through different incision strategies. Long-incision ORIF uses a wider muscle-sparing corridor, whereas short-incision ORIF (keyhole) relies on a smaller targeted access directly over the fracture site. Whether incision length affects postoperative inflammatory response and early clinical outcomes remains unclear. We compared long-incision ORIF and the keyhole approach in a pilot cohort. This single-center retrospective pilot observational cohort included patients undergoing muscle-sparing extrathoracic SSRF for ≥ 2 rib fractures. Patients were classified as long-incision ORIF (> 5 cm) or keyhole (≤ 5 cm). Patients requiring pleural entry (thoracotomy/VATS) or any prior operative intervention before SSRF were excluded. C-reactive protein (CRP) was measured preoperatively, at 24–48 h, and > 72 h postoperatively. The primary outcome was the within-patient change in CRP from the preoperative value to the first postoperative measurement obtained 24–48 h after surgery (ΔCRP24–48 h). Secondary outcomes were absolute CRP at 24–48 h and > 72 h, operative time, chest tube duration, length of stay, 30-day readmission, SSRF-related complications, and 1-month Chest Wall Injury Quality of Life Questionnaire (C-QoL). All clinical variables, perioperative CRP measurements, and C-QoL responses had been collected as part of routine clinical care and follow-up, independently of the present study, and were retrospectively extracted from the institutional clinical database. Between-group comparisons were performed using independent-samples t tests or Mann–Whitney U tests for continuous variables and chi-square or Fisher’s exact tests for categorical variables. Forty-one patients were included (long-incision ORIF, n = 28; keyhole, n = 13). Surgery was performed substantially later after injury in the keyhole group than in the long-incision ORIF group (24.2 vs. 3.9 days; p = 0.002), and the keyhole group had fewer total rib fractures, plated ribs, and plated fractures. The primary endpoint, ΔCRP24–48 h, did not differ significantly between long-incision ORIF and keyhole (126.2 vs. 86.5 mg/L; p = 0.31). Change from baseline at the later postoperative measurement also did not differ significantly (114.7 vs. 59.3 mg/L; p = 0.31). Operative time was similar (122.0 vs. 100.8 min; p = 0.207), although the median number of plated ribs was higher in the long-incision ORIF group (4.5 vs. 2; p = 0.014). One-month C-QoL was similar (38.3 vs. 37.7; p = 0.909), and no SSRF-related complications were observed (0/41; exact 95% CI, 0.0%–8.6%), but the cohort was underpowered to assess rare events. This hypothesis-generating pilot did not demonstrate a significant between-group difference in within-patient early postoperative CRP change or later change from baseline. The marked imbalance in injury-to-surgery interval and chest wall injury and construct burden precludes causal attribution of inflammatory differences to the surgical exposure strategy. These findings primarily support the design of an adequately powered, prospective, risk-adjusted study.