Application of CT-based three-dimensional stereoscopic location method in surgery of rib fractures

Application of CT-based three-dimensional stereoscopic location method in surgery of rib fractures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Application of CT-based three-dimensional stereoscopic location method in surgery of rib fractures Kun Liu, Qiang Yin, Jianshuang Li, Zhiyong Dong, Jun Hao, Jiang Liu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7750501/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Jan, 2026 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose This study aimed to evaluate the efficacy of a three-dimensional stereoscopic location method utilizing the hospital's CT imaging system for rib fracture surgery. Methods We retrospectively analyzed the clinical data of 54 patients: 33 underwent three-dimensional stereoscopic localization of rib fractures, and 21 underwent traditional localization during surgery. Recorded parameters included preoperative VAS score, VAS score on third postoperative day, localization accuracy, surgical field exposure time, intraoperative blood loss, incision length, drainage volume on the first postoperative day, and postoperative hospital stay duration. Results Significant differences existed between the two groups regarding localization accuracy, surgical field exposure time, intraoperative blood loss, average incision length per plate, first postoperative day drainage volume, and postoperative hospital stay duration. Postoperative VAS scores were significantly lower than preoperative scores in both groups. However, neither the postoperative VAS scores nor the magnitude of pre-to-postoperative reduction differed significantly between groups. Conclusion CT-based three-dimensional stereoscopic location method is an effective method for rib fracture stabilization. Rib fractures Surgical stabilization Three-dimensional stereoscopic location Fracture location Figures Figure 1 Figure 2 Introduction With the advancement of transportation and construction industries, the incidence of chest trauma has risen progressively, accounting for 10–15% of all traumatic injuries [ 1 , 2 ]. Rib fractures represent one of the most common manifestations of chest trauma, occurring in over 50% of cases [ 3 , 4 ]. Rib fractures being one of the most common chest injuries (> 50%)[ 3 , 4 ]. In the past, rib fractures were primarily treated non-surgically; however, as many as 50% of patients of rib fractures, especially those with flail chest, suffer from chronic pain or thoracic deformities, and over 30% of patients experience long-term disabilities that prevent them from returning to full-time work [ 5 ]. Therefore, surgical stabilization of rib fracture (SSRF) has garnered increasing attention as a therapeutic approach [ 6 – 9 ]. Accurate preoperative location of rib fractures is critical for Surgical Stabilization of Rib Fractures (SSRF), as it effectively reduces surgical trauma and associated risks [ 10 – 12 ]. Failure to precisely identify fracture sites may necessitate extending the incision, adversely impacting postoperative recovery [ 11 , 13 ]. Historically, preoperative surface localization relied on rib computed tomography (CT) scans, three-dimensional reconstructions, and surgeon-dependent clinical judgment [ 13 – 15 ]. However, these approaches have certain limitations in accuracy, because the sites of rib fracture are often indistinctly palpable due to swelling in the soft tissues, and the change of posture affects the operator's judgment (CT scans are typically done in supine position, while surgeries are performed usually in lateral decubitus position). Currently, Preoperative ultrasound has consequently emerged as the primary modality for accurate fracture location [ 10 , 16 , 17 ]. Nevertheless, this technique remains operator-dependent, requiring specialized sonographer expertise, a significant learning curve, and immediate availability of intraoperative ultrasound equipment [ 12 , 17 , 18 ]. Therefore, we propose a novel three-dimensional stereoscopic location technique based on CT imaging to precisely identify rib fractures and guide surgical incision planning. Methods We conducted a retrospective analysis of clinical data from patients undergoing surgical stabilization of rib fractures in our department between July 2023 and September 2024. After excluding patients requiring emergency surgery or perioperative intensive care unit (ICU) management, 54 subjects were enrolled: 33 in the three-dimensional stereoscopic localization group and 21 in the conventional treatment group. All participants provided written informed consent. Preoperative variables, including gender, age, body mass index (BMI), injury mechanism, Injury Severity Score (ISS), and preoperative Visual Analogue Scale (VAS) pain scores, are presented in Table 1 . Preoperative characteristics demonstrated no statistically significant differences between the three-dimensional stereoscopic location group and the conventional treatment group. Table 1 Comparison of baseline characteristics among the tow groups [M (P25, P75), X ± S]. Variables 3D stereoscopic location group traditional group p-value Age(years old 56.58 ± 12.88 53.95 ± 9.56 0.583 Sex 0.892 Male 23 15 Female 10 6 Causes of fracture 0.377 Traffic accident 19 9 Fall injuries 13 11 Other factors 1 2 BMI 25.16 ± 2.85 23.79 ± 2.34 0.070 ISS[points, M (P25, P75) 21 (17, 24.5) 20 (16, 24.5) 0.463 Pre-op VAS score 8 (6.25, 9) 6 (5.75, 9) 0.09 Other factors include injuries caused by animals, crush injuries, and impacts from heavy objects. Preoperative Procedures All patients underwent preoperative spiral CT scans of the ribs with 3D reconstruction. In the 3D stereoscopic location group, we performed 3D measurements using our hospital's imaging system (Neusoft Imaging Diagnostic Workstation) to locate fracture sites. After the patient was positioned for surgery, these preoperative 3D data was used to guide fracture localization and mark the surgical incision. In the traditional group, preoperative surface localization relied on rib CT scans, 3D reconstructions, skeletal surface landmarks, and the surgeon's clinical experience for subjective judgment. Three-dimensional stereoscopic location method The sternal angle is the most prominent bony landmark of the chest. First, starting from the sternal angle, we measured the longitudinal distance from level of the sternal angle to the fracture site. Second, a perpendicular line was drawn from the fracture site to the body surface to determine its skin projection point. Finally, we measured the horizontal and vertical distance from the anterior or posterior midline. Intraoperative localization of the fracture sites were achieved utilizing a positioning ruler, which was developed from preoperative three-dimensional planning data. A photograph of the custom ruler is presented in Fig. 1. Surgical Approaches All patients underwent general anesthesia with either single-lumen or double-lumen endotracheal intubation selected according to clinical requirements. Patients were positioned lying on their healthy side. Fracture sites requiring fixation were identified. Incisions were planned to maximize exposure of all fracture ends, utilizing multiple small incisions when necessary. Following routine disinfection and draping, fracture sites were exposed along intermuscular planes or muscle fiber orientations to avoid muscle transection while preserving neurovascular structures. Generally, 6-hole steel plate was suitable for simple fractures. For comminuted fractures, an embracing plate was used. Fracture fragments were reduced anatomically using reduction forceps. After plates were contoured to the shape of the fractured rib, the plate was temporarily secured with plate-holding forceps. Then the plate was fixed locking screws. Thoracoscopy was performed based on preoperative findings. During thoracoscopic exploration, any thoracic organ injuries were addressed immediately. Plate length was determined by fracture morphology. A chest wall drain was placed through the incision. When thoracotomy was performed, an additional thoracic drain was inserted into the pleural cavity. Postoperatively, multimodal analgesia was administered for pain control. Perioperative antimicrobial prophylaxis was implemented. Supportive care included intravenous fluid management, therapeutic nebulization, pulmonary toileting, regular wound dressing changes. After drainage less than 50ml, the imaging examination (X-ray or CT) was reviewed and the drainage tube was removed. The procedures for three-dimensional stereoscopic localization group are shown in Fig. 2. Statistical analysis Statistical analysis was performed using SPSS 27.0 (International Business Machines Corporation). Continuous variables with normal distribution are expressed as mean ± standard deviation (mean ± SD) and compared between groups using the independent samples t-test. Non-normally distributed continuous variables are expressed as median and interquartile range (IQR) [M (P25, P75)] and compared using the Kruskal-Wallis rank-sum test. Categorical variables are presented as frequency and percentage [n (%)] and analyzed using the chi-square (χ²) test. Statistical significance was defined as P < 0.05. Results Significant differences between the two groups were observed in accuracy of location, surgical field exposure time, intraoperative blood loss, average incision length per steel plate, first postoperative day drainage, and postoperative length of stay (all p < 0.05). Both groups showed significantly lower postoperative VAS scores compared to preoperative scores (p < 0.001). However, no statistically significant differences were found between groups in either postoperative VAS scores or the magnitude of VAS score reduction (preoperative to postoperative change). (Table 2 ) Table 2 Comparison of Surgical Indicators among the Two Group. Variables 3D stereoscopic positioning group traditional group p -value Accuracy p<0.001 Inaccurate number 7 16 Accurate numbers 114 48 Pre-op VAS score 8 (6.25, 9) 6 (5.75, 9) 0.09 VAS score on the third day after surgery 4.5 (3, 5) 3 (3, 4) 0.066 The difference between pre-op and post-op VAS scores 3.5 (2.5, 5) 3 (2, 5) 0.596 Exposure time of surgical field (min) 120 (90, 150) 150 (120, 180) 0.043 Intraoperative blood loss (ml) 50 (20, 50) 100 (50, 100) p<0.001 Average incision length per steel plate (cm) 2.4 (2, 3) 3(2, 5) 0.002 First postoperative day drainage (ml) 120 (90, 150) 210(85, 260) 0.047 Postoperative length of stay (days) 10 (8, 13) 12 (9.5, 17.5) 0.047 The location was considered accurate if it is within 1.5cm. Three patients in each group did not undergo thoracoscopy, with no significant difference between groups (p = 0.054). Complications in the 3D stereoscopic positioning group included one case of pleural effusion and one wound infection. The control group had one wound infection and one screw dislodgement. No significant difference was observed in overall complication rates between groups (p > 0.05).The pleural effusion resolved after thoracentesis, and all wound infections healed with dressing changes. Discussion In this study, we innovatively applied the hospital's CT imaging system (Neusoft Image Workstation) to perform preoperative three-dimensional stereotactic localization for rib fracture surgery. Preoperatively, patients' CT images were reconstructed and measured in three dimensions using the imaging workstation, enabling precise localization of the rib fractures to guide surgical incision planning. Precise fracture localization is essential for surgical rib stabilization. While several techniques exist—including ultrasound [ 10 , 17 ], mixed reality (MR) [ 11 ], intraoperative computed tomography (CT) [ 12 ], 3D printing [ 16 , 19 , 20 ], and thoracoscopy (VATS) [ 21 – 23 ]—each presents significant limitations. These methods typically require costly specialized equipment and extended operator training. Ultrasound is limited in subscapular regions and its accuracy is compromised in patients with subcutaneous emphysema or thick adipose layers [ 17 , 18 ]. Furthermore, the pleura appears as a hyperechoic band on ultrasound, with pleural thickening further complicating fracture identification [ 24 ]. C-arm cone-beam CT exposes patients and staff to additional radiation [ 12 ]. VATS necessitates eligibility for single-lung ventilation and requires additional exploratory incisions. 3D printing introduces material costs and production delays [ 25 ]. Additionally, minimally displaced fractures may be difficult to visualize using both ultrasound and VATS. We routinely perform rib CT with 3D reconstruction on the third day post-injury. First, it can help us identify rib fractures that were not apparent on previous CT images but became worsened due to movement and breathing, thus determining which fractures require fixation [ 26 ]. Second, it assesses conservative treatment efficacy; persistent severe pain may indicate a requirement for surgical intervention. Third, Further examination was performed to exclude delayed visceral injuries and assess the patient’s physiological status and surgical risks to ensure safety of the surgery. Fourth, we determine the necessity of thoracoscopy based on the presence of hemopneumothorax or thoracic organ injury. In this study, patients were hospitalized for relatively long periods. This occurred primarily because most were involved in traffic accidents or work injuries and were not personally responsible for treatment costs. Furthermore, most patients believed extended hospitalization benefited their recovery and helped protect their rights to rest and care. Additionally, beds in our department were not under significant pressure, and patients who met discharge criteria were not compelled to leave. The post-op VAS in both groups were significantly lower than pre-op VAS, but there was no statistically significant difference in the pre-op and post-op VAS between two groups, which may be related to the usage of different perioperative analgesic drug. Because, the use of some drugs is limited to a certain extent in our hospital, and the degree of patient pain varies leaded to the the usage of different medication. Additionally, the small sample size also potentially leaded to insufficient statistical power. A significant reduction in VAS scores was observed postoperatively compared to preoperative levels within both groups. However, no statistically significant differences in VAS scores were detected between the groups preoperatively or postoperatively. This may be related to variations in perioperative analgesic regimens. The use of specific analgesics was limited to some extent in our hospital, and patient pain levels varied, leading to differing medication usage. Additionally, the small sample size potentially resulted in insufficient statistical power. The degree of obesity and female breasts had a certain impact in this method. Therefore, when measuring lateral fractures in these obesity and female patients, it is advisable to measure from the back. If measurement from the front is necessary, the soft tissue should be restored as much as possible to supine position which is consistent with the position of preoperative CT. After positioning with the locating ruler, the soft tissue was restored to the natural position of the lateral position and then marked on the skin. Since we measure the thoracic cage composed of ribs, the influence of soft tissue is limited, generally controlled within 1.5 cm. During surgery, appropriate pulling can basically meet the needs of the operation. We can speculate that if preoperative CT scans could be performed in a lateral position (with the surgical side up), consistent with the intraoperative position, the results of measurement and positioning results would be better. Measurement accuracy in this method was impacted by patient obesity and female breast anatomy. Therefore, for lateral fracture measurements in obese or female patients, measurement from the back is recommended. If anterior measurement is necessary, the soft tissue should be repositioned as closely as possible to its supine state (matching the preoperative CT position). After positioning with the locating ruler, the soft tissue was returned to its natural lateral position before skin marking. "If soft tissue mobility causes the reference point to deviate from the skin surface, simply project a perpendicular line to the bony thorax to identify the corresponding skin position. Given that the measurement target is the osseous thoracic cage, soft tissue interference is minimized, with resultant error typically controlled within 1.5 cm. Intraoperative tissue retraction proved generally sufficient. We postulate that preoperative CT imaging acquired in the lateral decubitus position (surgical side superior), congruent with the operative position, would optimize measurement and localization fidelity. Study limitations include the small sample size and retrospective design, necessitating validation via prospective randomized controlled trials. Conclusion In conclusion, this method enhances rib fracture localization accuracy, minimizes surgical incision size, reduces intraoperative blood loss, shortens operative time, and accelerates patient recovery. It eliminates the need for copying patient imaging data, requires no third-party software, and protects against privacy breaches. Simple to implement within existing hospital imaging systems, it holds significant potential for widespread clinical adoption, particularly in primary hospital. Declarations Conflict of interest None of the authors have any conflicts of interest to declare. Funding This work was supported by the Scientific Research Development Special Fund of Beijing Shunyi Hospital (No. SY 2023Y06） Ethics Statement This study has been approved by the Beijing Shunyi Hospital ethics committee approval, and a statement that informed consent to participate and publish the study has been obtained. References Demirhan R, Onan B, Oz K, Halezeroglu S. Comprehensive analysis of 4205 patients with chest trauma: a 10-year experience. Interact Cardiovasc Thorac Surg. 2009;9(3):450-453. Martin TJ, Eltorai AS, Dunn R, Varone A, Joyce MF, Kheirbek T, et al. 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Cite Share Download PDF Status: Published Journal Publication published 13 Jan, 2026 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted Editorial decision: Revision requested 12 Nov, 2025 Reviews received at journal 05 Nov, 2025 Reviewers agreed at journal 03 Nov, 2025 Reviews received at journal 22 Oct, 2025 Reviewers agreed at journal 22 Oct, 2025 Reviewers invited by journal 14 Oct, 2025 Editor assigned by journal 13 Oct, 2025 Submission checks completed at journal 06 Oct, 2025 First submitted to journal 30 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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04:44:01","extension":"jpg","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":3287217,"visible":true,"origin":"","legend":"","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7750501/v1/867699a05e9e29d5910a0524.jpg"},{"id":94625319,"identity":"89759bfb-24ba-4146-97d6-50305aba686f","added_by":"auto","created_at":"2025-10-29 04:44:01","extension":"jpg","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2231567,"visible":true,"origin":"","legend":"","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7750501/v1/43de910ee12d4ae335d4520c.jpg"},{"id":94640020,"identity":"c3790cb2-5884-4c78-b481-ec6844d12e62","added_by":"auto","created_at":"2025-10-29 07:47:52","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":921994,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-7750501/v1/9337e17618e2034c95cc8029.png"},{"id":94640100,"identity":"8765a700-1ddd-4d73-b39d-d5691fa088a8","added_by":"auto","created_at":"2025-10-29 07:48:17","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":848724,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-7750501/v1/085a2b37ac27793d1ec77431.png"},{"id":94639968,"identity":"b6f0cad0-5be0-458b-9eee-9320d4ca6199","added_by":"auto","created_at":"2025-10-29 07:47:15","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":69107,"visible":true,"origin":"","legend":"","description":"","filename":"add789ba2103488ea9f332d38d0fcdcb1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7750501/v1/b41f0fcd3fe7f2888e7cd59d.xml"},{"id":94625326,"identity":"282d94af-62a5-4ca0-9824-ef31f6241ba2","added_by":"auto","created_at":"2025-10-29 04:44:01","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":76598,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7750501/v1/401eec923c76798277d7026d.html"},{"id":94625316,"identity":"118bc98e-bd83-44b9-a6f4-7b03df9c0acd","added_by":"auto","created_at":"2025-10-29 04:44:01","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3287217,"visible":true,"origin":"","legend":"\u003cp\u003eThe positioning ruler.\u003c/p\u003e","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7750501/v1/3ed72fb6d675cbb31ca6b9ff.jpg"},{"id":94625311,"identity":"da586212-deab-453a-81d0-18115b9ad1a8","added_by":"auto","created_at":"2025-10-29 04:44:01","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2231567,"visible":true,"origin":"","legend":"\u003cp\u003eThe procedures for three-dimensional stereoscopic localization group\u003c/p\u003e\n\u003cp\u003eThree-dimensional fracture measurement at different locations. A. Anterior side; B. Lateral side; C. Posterior side.\u003cbr\u003e\nD. E. After surgical positioning, fracture sites were localized using a positioning ruler based on preoperative three-dimensional measurement data.\u003cbr\u003e\nF. The surgical incision was planned to access all fractures requiring fixation.\u003cbr\u003e\nG. Exposure of fracture sites was performed along intermuscular planes or muscle fiber directions, with careful preservation of neurovascular structures.\u003cbr\u003e\nH. Three ribs were fixed through an approximately 6 cm incision.\u003cbr\u003e\nI. Postoperative X-ray shows excellent fracture reduction and plate positioning.\u003c/p\u003e","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7750501/v1/c71a1edf5380c9ffd58a0f31.jpg"},{"id":100614672,"identity":"cd031e9b-5dd3-4ac8-b156-52d8a48a33ec","added_by":"auto","created_at":"2026-01-19 17:23:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6024978,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7750501/v1/f3564e49-3cce-40bb-b643-e39b477ba3ff.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Application of CT-based three-dimensional stereoscopic location method in surgery of rib fractures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith the advancement of transportation and construction industries, the incidence of chest trauma has risen progressively, accounting for 10\u0026ndash;15% of all traumatic injuries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Rib fractures represent one of the most common manifestations of chest trauma, occurring in over 50% of cases [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Rib fractures being one of the most common chest injuries (\u0026gt;\u0026thinsp;50%)[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In the past, rib fractures were primarily treated non-surgically; however, as many as 50% of patients of rib fractures, especially those with flail chest, suffer from chronic pain or thoracic deformities, and over 30% of patients experience long-term disabilities that prevent them from returning to full-time work [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Therefore, surgical stabilization of rib fracture (SSRF) has garnered increasing attention as a therapeutic approach [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccurate preoperative location of rib fractures is critical for Surgical Stabilization of Rib Fractures (SSRF), as it effectively reduces surgical trauma and associated risks [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Failure to precisely identify fracture sites may necessitate extending the incision, adversely impacting postoperative recovery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Historically, preoperative surface localization relied on rib computed tomography (CT) scans, three-dimensional reconstructions, and surgeon-dependent clinical judgment [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, these approaches have certain limitations in accuracy, because the sites of rib fracture are often indistinctly palpable due to swelling in the soft tissues, and the change of posture affects the operator's judgment (CT scans are typically done in supine position, while surgeries are performed usually in lateral decubitus position).\u003c/p\u003e\u003cp\u003eCurrently, Preoperative ultrasound has consequently emerged as the primary modality for accurate fracture location [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Nevertheless, this technique remains operator-dependent, requiring specialized sonographer expertise, a significant learning curve, and immediate availability of intraoperative ultrasound equipment [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTherefore, we propose a novel three-dimensional stereoscopic location technique based on CT imaging to precisely identify rib fractures and guide surgical incision planning.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a retrospective analysis of clinical data from patients undergoing surgical stabilization of rib fractures in our department between July 2023 and September 2024. After excluding patients requiring emergency surgery or perioperative intensive care unit (ICU) management, 54 subjects were enrolled: 33 in the three-dimensional stereoscopic localization group and 21 in the conventional treatment group. All participants provided written informed consent. Preoperative variables, including gender, age, body mass index (BMI), injury mechanism, Injury Severity Score (ISS), and preoperative Visual Analogue Scale (VAS) pain scores, are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Preoperative characteristics demonstrated no statistically significant differences between the three-dimensional stereoscopic location group and the conventional treatment group.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of baseline characteristics among the tow groups [M (P25, P75), X\u0026thinsp;\u0026plusmn;\u0026thinsp;S].\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3D stereoscopic location group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003etraditional group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge(years old\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56.58\u0026thinsp;\u0026plusmn;\u0026thinsp;12.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.95\u0026thinsp;\u0026plusmn;\u0026thinsp;9.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.583\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.892\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCauses of fracture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.377\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTraffic accident\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFall injuries\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25.16\u0026thinsp;\u0026plusmn;\u0026thinsp;2.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.79\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.070\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eISS[points, M (P25, P75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21 (17, 24.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (16, 24.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.463\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op VAS score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (6.25, 9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (5.75, 9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eOther factors include injuries caused by animals, crush injuries, and impacts from heavy objects.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePreoperative Procedures\u003c/h2\u003e\u003cp\u003eAll patients underwent preoperative spiral CT scans of the ribs with 3D reconstruction. In the 3D stereoscopic location group, we performed 3D measurements using our hospital's imaging system (Neusoft Imaging Diagnostic Workstation) to locate fracture sites. After the patient was positioned for surgery, these preoperative 3D data was used to guide fracture localization and mark the surgical incision. In the traditional group, preoperative surface localization relied on rib CT scans, 3D reconstructions, skeletal surface landmarks, and the surgeon's clinical experience for subjective judgment.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eThree-dimensional stereoscopic location method\u003c/h3\u003e\n\u003cp\u003eThe sternal angle is the most prominent bony landmark of the chest. First, starting from the sternal angle, we measured the longitudinal distance from level of the sternal angle to the fracture site. Second, a perpendicular line was drawn from the fracture site to the body surface to determine its skin projection point. Finally, we measured the horizontal and vertical distance from the anterior or posterior midline. Intraoperative localization of the fracture sites were achieved utilizing a positioning ruler, which was developed from preoperative three-dimensional planning data. A photograph of the custom ruler is presented in Fig.\u0026nbsp;1.\u003c/p\u003e\n\u003ch3\u003eSurgical Approaches\u003c/h3\u003e\n\u003cp\u003eAll patients underwent general anesthesia with either single-lumen or double-lumen endotracheal intubation selected according to clinical requirements. Patients were positioned lying on their healthy side. Fracture sites requiring fixation were identified. Incisions were planned to maximize exposure of all fracture ends, utilizing multiple small incisions when necessary. Following routine disinfection and draping, fracture sites were exposed along intermuscular planes or muscle fiber orientations to avoid muscle transection while preserving neurovascular structures.\u003c/p\u003e\u003cp\u003eGenerally, 6-hole steel plate was suitable for simple fractures. For comminuted fractures, an embracing plate was used. Fracture fragments were reduced anatomically using reduction forceps. After plates were contoured to the shape of the fractured rib, the plate was temporarily secured with plate-holding forceps. Then the plate was fixed locking screws. Thoracoscopy was performed based on preoperative findings. During thoracoscopic exploration, any thoracic organ injuries were addressed immediately. Plate length was determined by fracture morphology. A chest wall drain was placed through the incision. When thoracotomy was performed, an additional thoracic drain was inserted into the pleural cavity. Postoperatively, multimodal analgesia was administered for pain control. Perioperative antimicrobial prophylaxis was implemented. Supportive care included intravenous fluid management, therapeutic nebulization, pulmonary toileting, regular wound dressing changes. After drainage less than 50ml, the imaging examination (X-ray or CT) was reviewed and the drainage tube was removed.\u003c/p\u003e\u003cp\u003eThe procedures for three-dimensional stereoscopic localization group are shown in Fig.\u0026nbsp;2.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was performed using SPSS 27.0 (International Business Machines Corporation). Continuous variables with normal distribution are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) and compared between groups using the independent samples t-test. Non-normally distributed continuous variables are expressed as median and interquartile range (IQR) [M (P25, P75)] and compared using the Kruskal-Wallis rank-sum test. Categorical variables are presented as frequency and percentage [n (%)] and analyzed using the chi-square (χ\u0026sup2;) test. Statistical significance was defined as P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSignificant differences between the two groups were observed in accuracy of location, surgical field exposure time, intraoperative blood loss, average incision length per steel plate, first postoperative day drainage, and postoperative length of stay (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Both groups showed significantly lower postoperative VAS scores compared to preoperative scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, no statistically significant differences were found between groups in either postoperative VAS scores or the magnitude of VAS score reduction (preoperative to postoperative change). (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Surgical Indicators among the Two Group.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3D stereoscopic positioning group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003etraditional group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAccuracy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInaccurate number\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAccurate numbers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op VAS score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (6.25, 9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (5.75, 9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVAS score on the third day after surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.5 (3, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3, 4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.066\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe difference between pre-op and post-op VAS scores\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.5 (2.5, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (2, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.596\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExposure time of surgical field (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e120 (90, 150)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e150 (120, 180)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.043\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntraoperative blood loss (ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (20, 50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100 (50, 100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAverage incision length per steel plate (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.4 (2, 3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3(2, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFirst postoperative day drainage (ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e120 (90, 150)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e210(85, 260)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.047\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative length of stay (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (8, 13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (9.5, 17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.047\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eThe location was considered accurate if it is within 1.5cm.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThree patients in each group did not undergo thoracoscopy, with no significant difference between groups (p\u0026thinsp;=\u0026thinsp;0.054).\u003c/p\u003e\u003cp\u003eComplications in the 3D stereoscopic positioning group included one case of pleural effusion and one wound infection. The control group had one wound infection and one screw dislodgement. No significant difference was observed in overall complication rates between groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).The pleural effusion resolved after thoracentesis, and all wound infections healed with dressing changes.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we innovatively applied the hospital's CT imaging system (Neusoft Image Workstation) to perform preoperative three-dimensional stereotactic localization for rib fracture surgery. Preoperatively, patients' CT images were reconstructed and measured in three dimensions using the imaging workstation, enabling precise localization of the rib fractures to guide surgical incision planning.\u003c/p\u003e\u003cp\u003ePrecise fracture localization is essential for surgical rib stabilization. While several techniques exist\u0026mdash;including ultrasound [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], mixed reality (MR) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], intraoperative computed tomography (CT) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], 3D printing [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and thoracoscopy (VATS) [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u0026mdash;each presents significant limitations. These methods typically require costly specialized equipment and extended operator training. Ultrasound is limited in subscapular regions and its accuracy is compromised in patients with subcutaneous emphysema or thick adipose layers [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Furthermore, the pleura appears as a hyperechoic band on ultrasound, with pleural thickening further complicating fracture identification [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. C-arm cone-beam CT exposes patients and staff to additional radiation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. VATS necessitates eligibility for single-lung ventilation and requires additional exploratory incisions. 3D printing introduces material costs and production delays [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Additionally, minimally displaced fractures may be difficult to visualize using both ultrasound and VATS.\u003c/p\u003e\u003cp\u003eWe routinely perform rib CT with 3D reconstruction on the third day post-injury. First, it can help us identify rib fractures that were not apparent on previous CT images but became worsened due to movement and breathing, thus determining which fractures require fixation [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Second, it assesses conservative treatment efficacy; persistent severe pain may indicate a requirement for surgical intervention. Third, Further examination was performed to exclude delayed visceral injuries and assess the patient\u0026rsquo;s physiological status and surgical risks to ensure safety of the surgery. Fourth, we determine the necessity of thoracoscopy based on the presence of hemopneumothorax or thoracic organ injury.\u003c/p\u003e\u003cp\u003eIn this study, patients were hospitalized for relatively long periods. This occurred primarily because most were involved in traffic accidents or work injuries and were not personally responsible for treatment costs. Furthermore, most patients believed extended hospitalization benefited their recovery and helped protect their rights to rest and care. Additionally, beds in our department were not under significant pressure, and patients who met discharge criteria were not compelled to leave.\u003c/p\u003e\u003cp\u003eThe post-op VAS in both groups were significantly lower than pre-op VAS, but there was no statistically significant difference in the pre-op and post-op VAS between two groups, which may be related to the usage of different perioperative analgesic drug. Because, the use of some drugs is limited to a certain extent in our hospital, and the degree of patient pain varies leaded to the the usage of different medication. Additionally, the small sample size also potentially leaded to insufficient statistical power.\u003c/p\u003e\u003cp\u003eA significant reduction in VAS scores was observed postoperatively compared to preoperative levels within both groups. However, no statistically significant differences in VAS scores were detected between the groups preoperatively or postoperatively. This may be related to variations in perioperative analgesic regimens. The use of specific analgesics was limited to some extent in our hospital, and patient pain levels varied, leading to differing medication usage. Additionally, the small sample size potentially resulted in insufficient statistical power.\u003c/p\u003e\u003cp\u003eThe degree of obesity and female breasts had a certain impact in this method. Therefore, when measuring lateral fractures in these obesity and female patients, it is advisable to measure from the back. If measurement from the front is necessary, the soft tissue should be restored as much as possible to supine position which is consistent with the position of preoperative CT. After positioning with the locating ruler, the soft tissue was restored to the natural position of the lateral position and then marked on the skin. Since we measure the thoracic cage composed of ribs, the influence of soft tissue is limited, generally controlled within 1.5 cm. During surgery, appropriate pulling can basically meet the needs of the operation. We can speculate that if preoperative CT scans could be performed in a lateral position (with the surgical side up), consistent with the intraoperative position, the results of measurement and positioning results would be better.\u003c/p\u003e\u003cp\u003eMeasurement accuracy in this method was impacted by patient obesity and female breast anatomy. Therefore, for lateral fracture measurements in obese or female patients, measurement from the back is recommended. If anterior measurement is necessary, the soft tissue should be repositioned as closely as possible to its supine state (matching the preoperative CT position). After positioning with the locating ruler, the soft tissue was returned to its natural lateral position before skin marking. \"If soft tissue mobility causes the reference point to deviate from the skin surface, simply project a perpendicular line to the bony thorax to identify the corresponding skin position. Given that the measurement target is the osseous thoracic cage, soft tissue interference is minimized, with resultant error typically controlled within 1.5 cm. Intraoperative tissue retraction proved generally sufficient. We postulate that preoperative CT imaging acquired in the lateral decubitus position (surgical side superior), congruent with the operative position, would optimize measurement and localization fidelity.\u003c/p\u003e\u003cp\u003eStudy limitations include the small sample size and retrospective design, necessitating validation via prospective randomized controlled trials.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this method enhances rib fracture localization accuracy, minimizes surgical incision size, reduces intraoperative blood loss, shortens operative time, and accelerates patient recovery. It eliminates the need for copying patient imaging data, requires no third-party software, and protects against privacy breaches. Simple to implement within existing hospital imaging systems, it holds significant potential for widespread clinical adoption, particularly in primary hospital.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConflict of interest None of the authors have any conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003eFunding\u0026nbsp;This work was supported by the Scientific Research Development Special Fund of Beijing Shunyi Hospital (No. SY 2023Y06）\u003c/p\u003e\n\u003cp\u003eEthics Statement\u0026nbsp;This study has been approved by the Beijing Shunyi Hospital ethics committee approval, and a statement that informed consent to participate and publish the study has been obtained.\u0026nbsp;\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDemirhan R, Onan B, Oz K, Halezeroglu S. Comprehensive analysis of 4205 patients with chest trauma: a 10-year experience. 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Emerg Radiol. 2010;17(6):473-477.\u003c/li\u003e\n\u003cli\u003eZhou X, Zhang D, Xie Z, Yang Y, Chen M, Liang Z, et al. Application of 3D printing and framework internal fixation technology for high complex rib fractures. J Cardiothorac Surg. 2021;16(1):5.\u003c/li\u003e\n\u003cli\u003eZhou XT, Zhang DS, Yang Y, Zhang GL, Xie ZX, Chen MH, et al. Analysis of the advantages of 3D printing in the surgical treatment of multiple rib fractures: 5 cases report. J Cardiothorac Surg. 2019;14(1):105.\u003c/li\u003e\n\u003cli\u003eSchots JP, Vissers YL, Hulsew\u0026eacute; KW, Meesters B, Hustinx PA, Pijnenburg A, et al. Addition of Video-Assisted Thoracoscopic Surgery to the Treatment of Flail Chest. Ann Thorac Surg. 2017;103(3):940-944.\u003c/li\u003e\n\u003cli\u003eXia H, Zhu P, Li J, Zhu D, Sun Z, Deng L, et al. Thoracoscope combined with internal support system of chest wall in open reduction and internal fixation for multiple rib fractures. Exp Ther Med. 2018;16(6):4650-4654.\u003c/li\u003e\n\u003cli\u003ePieracci FM. Completely thoracoscopic surgical stabilization of rib fractures: can it be done and is it worth it?. J Thorac Dis. 2019;11(Suppl 8):S1061-S1069. \u003c/li\u003e\n\u003cli\u003eHurley ME, Keye GD, Hamilton S. Is ultrasound really helpful in the detection of rib fractures?. Injury. 2004;35(6):562-566.\u003c/li\u003e\n\u003cli\u003eLiu K, Zhang Q, Li X, Zhao C, Quan X, Zhao R, et al. Preliminary application of a multi-level 3D printing drill guide template for pedicle screw placement in severe and rigid scoliosis. Eur Spine J. 2017;26(6):1684-1689.\u003c/li\u003e\n\u003cli\u003eBauman ZM, Grams B, Yanala U, Shostrom V, Waibel B, Evans CH, et al. Rib fracture displacement worsens over time. Eur J Trauma Emerg Surg. 2021;47(6):1965-1970.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Rib fractures, Surgical stabilization, Three-dimensional stereoscopic location, Fracture location","lastPublishedDoi":"10.21203/rs.3.rs-7750501/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7750501/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eThis study aimed to evaluate the efficacy of a three-dimensional stereoscopic location method utilizing the hospital's CT imaging system for rib fracture surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively analyzed the clinical data of 54 patients: 33 underwent three-dimensional stereoscopic localization of rib fractures, and 21 underwent traditional localization during surgery. Recorded parameters included preoperative VAS score, VAS score on third postoperative day, localization accuracy, surgical field exposure time, intraoperative blood loss, incision length, drainage volume on the first postoperative day, and postoperative hospital stay duration.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eSignificant differences existed between the two groups regarding localization accuracy, surgical field exposure time, intraoperative blood loss, average incision length per plate, first postoperative day drainage volume, and postoperative hospital stay duration. Postoperative VAS scores were significantly lower than preoperative scores in both groups. However, neither the postoperative VAS scores nor the magnitude of pre-to-postoperative reduction differed significantly between groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eCT-based three-dimensional stereoscopic location method is an effective method for rib fracture stabilization.\u003c/p\u003e","manuscriptTitle":"Application of CT-based three-dimensional stereoscopic location method in surgery of rib fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 04:43:56","doi":"10.21203/rs.3.rs-7750501/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-12T11:22:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-05T10:31:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165543498281502178176613821086509479958","date":"2025-11-03T07:43:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-22T14:00:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266001870549580632525048173483722282344","date":"2025-10-22T13:41:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-14T16:45:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-13T15:27:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-06T05:38:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2025-09-30T10:22:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"c07317a0-7be7-4e00-b51c-1e229caa4ceb","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T16:48:00+00:00","versionOfRecord":{"articleIdentity":"rs-7750501","link":"https://doi.org/10.1007/s00068-025-03060-w","journal":{"identity":"european-journal-of-trauma-and-emergency-surgery","isVorOnly":false,"title":"European Journal of Trauma and Emergency Surgery"},"publishedOn":"2026-01-13 16:29:23","publishedOnDateReadable":"January 13th, 2026"},"versionCreatedAt":"2025-10-29 04:43:56","video":"","vorDoi":"10.1007/s00068-025-03060-w","vorDoiUrl":"https://doi.org/10.1007/s00068-025-03060-w","workflowStages":[]},"version":"v1","identity":"rs-7750501","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7750501","identity":"rs-7750501","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}