Do Hospital or Surgeon Volume Affect Outcomes After Surgical Management of Tibial Shaft Fractures?

Objectives: To determine whether hospital and surgeon volume are associated with outcomes after operative fixation of tibial shaft fractures.

Methods: Adults (≥18 year old) who underwent operative fixation of diaphyseal tibial fractures were identified in the New York Statewide Planning and Research Cooperative System data set from 2001 to 2015. Reoperation, nonunion, and other adverse event rates were compared across surgeon and hospital volume using multivariable Cox proportional hazards regression, adjusting for clinical and demographic factors. Low-volume providers (lowest 20%) were compared with high-volume providers (highest 20%). Low volume constituted <5 cases/year for hospitals and 1 case/year for surgeons. High volume constituted ≥40 cases/year for hospitals and ≥8 cases/year for surgeons.

Results: Nine thousand one hundred forty-seven patients were included. Relative to high-volume surgeons, low-volume surgeons experienced slightly higher rates of pneumonia [2% vs. 1%, hazard ratio (HR) 2.50, 95% confidence interval (CI) 1.38-4.53, P = 0.003], and respiratory failure (5% vs. 3%, HR 1.88, 95% CI 1.30-2.71, P = 0.001). Compared with high-volume hospitals, low-volume hospitals experienced slightly lower rates of compartment syndrome (1% vs. 3%, HR 0.45, 95% CI 0.24-0.85, P = 0.01) and fasciotomies (3% vs. 7%, HR 0.57, 95% CI 0.38-0.85, P = 0.005). The rates of all other reoperations and adverse events compared among hospitals and surgeons were not significantly different.

Conclusions: We did not detect a clinically meaningful volume-outcome relationship for either surgeons or hospitals despite the use of a robust database with rigorous statistical methodology. Of note, these findings should not be applied to rare complex injuries such as those with extensive bone loss or articular extension, which are not well represented by this study population. Therefore, we conclude that typical tibial shaft fracture, including open or closed injuries, can be safely managed in the vast majority of orthopaedic settings and that this care does not necessarily require transfer to a specialty centers. Future research into orthopaedic volume-outcome relationships could be strengthened by the use of functional outcomes (which would likely require well-organized multicenter prospective registries).

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.