A Multicenter Randomized Controlled Trial on the Surgery of Fractured Ribs: The SOFRIB Trial.

Abstract

To evaluate whether surgical stabilization of rib fractures (SSRF) improves acute and patient-centered outcomes in adults with clinically significant rib fractures. Rib fractures occur in up to 40% of patients with blunt trauma and contribute substantially to morbidity and health-care cost. SSRF benefits patients with flail chest, but its role in broader injury patterns remains uncertain. SOFRIB was a multicenter, parallel-group, randomized controlled trial at nine American College of Surgeons-verified trauma centers (2014-2024). Adults (≥18 years) with ≥3 displaced rib fractures and pulmonary compromise, severe pain, or deformity were randomized (1:1) to SSRF within 5 days or standardized non-operative care. The primary outcome was intensive care unit (ICU) length of stay. Secondary outcomes included hospital length of stay (LOS), pneumonia, pulmonary function, pain scores, and quality of life (Short Form-36, Pain Impact Questionnaire-6 [PIQ-6]) . Analyses were intention to treat. Of 236 patients randomized (SSRF =114; non-operative =122), ICU LOS did not differ significantly (mean difference 1.8 days [95% CI -0.8 to 4.4]; P=0.17). SSRF was associated with longer hospital LOS (+3.3 days; P=0.01) and higher pneumonia rates (11.4% vs. 3.3%; risk ratio 3.45; P=0.02). However, SSRF improved SF-36 general health (+3.3; P=0.04), bodily pain (+4.0; P=0.02), and physical component summary (+3.3; P=0.04), each exceeding minimal clinically important difference. PIQ-6 scores indicated lower pain impact (-3.9; P=0.02). Return-to-work was more frequent with SSRF (62.5% vs. 38.7%; P=0.08). Routine SSRF did not reduce ICU stay and was associated with longer hospitalization and more pneumonia but yielded clinically meaningful quality-of-life and pain improvements. Findings support selective rather than routine SSRF.Keywords.