Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures. A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research. From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P < 0.00001, I2 = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I2 = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I2 = 57%) was significantly lower. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment. GRADE showed this meta-analysis to have very low to low confidence. Meta-analysis of large-scale trials showed that surgical stabilization of multiple rib fractures shortened the duration of mechanical ventilation and reduced the incidence of pneumonia but lacked clear evidence for improvement of mortality compared to conservative treatment. Trial sequential analysis suggested the need for more cases, and GRADE highlighted low certainty, emphasizing the necessity for further targeted RCTs, especially in mechanically ventilated patients. Systematic review registration: UMIN Clinical Trials Registry UMIN000049365.

中文翻译：

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对比较胸部创伤伴多发性肋骨骨折的非手术和手术治疗的随机对照试验的荟萃分析和试验序贯分析


创伤性肋骨骨折的手术治疗以获得更好的结果仍在争论中。在过去十年中，肋骨骨折的手术稳定率急剧增加。本研究旨在对随机对照试验 （RCT） 进行系统评价和荟萃分析，以评估手术治疗与保守治疗相比对成年创伤性多发性肋骨骨折患者的有效性和安全性。根据系统评价和荟萃分析指南的首选报告项目进行系统文献评价。我们检索了MEDLINE、Scopus和Cochrane对照试验中心注册库（Cochrane Central Register of Controlled Trials），并使用Cochrane偏倚风险2（Risk-of-Bias 2）工具来评价方法学质量。计算具有 95% 置信区间 （CI） 的相对风险结局： 全因死亡率、肺炎发生率和机械通气天数。采用建议分级评估、开发和评价 （GRADE） 方法评估证据的总体质量，并进行试验序贯分析以确定对进一步研究的意义。从 719 条记录中，我们纳入了 9 项 RCT，招募了 862 名患者。将患者分为手术组 （接受手术稳定胸壁损伤，n = 423） 或对照组 （n = 439）。两组之间的全因死亡率无显著差异（RR = 0.53;95% CI 0.21 至 1.38，P = 0.35，I2 = 11%）。然而，在手术组中，机械通气持续时间（平均差 -4.62;95% CI -7.64 至 -1.60，P < 0.00001，I2 = 94%）和重症监护病房住院时间（平均差 -3.05;95% CI -5.87 至 -0.22;P < 0.00001，I2 = 96%）显著缩短，肺炎发生率 （RR = 0.57;95% CI 0.35 至 0.92;P = 0.02，I2 = 57%） 显著降低。死亡率的试验序贯分析表明样本量不足，无法做出明确判断。GRADE 显示该荟萃分析的可信度为极低至低。大规模试验的荟萃分析表明，手术稳定多发性肋骨骨折可缩短机械通气的持续时间并降低肺炎的发生率，但与保守治疗相比，缺乏改善死亡率的明确证据。试验序贯分析表明需要更多病例，而 GRADE 强调低质量，强调进一步靶向 RCT 的必要性，尤其是在机械通气患者中。系统综述注册： UMIN 临床试验注册中心 UMIN000049365。