Effect of Surgeon and Hospital Volume on Complications After Operative Tarsal Fracture Repair

OBJECTIVE:To determine whether increased surgeon and hospital volume is associated with lower rates of complications after tarsal fractures. DESIGN:Retrospective cohort study of the State Inpatient Databases. SETTING:Two hundred ninety-nine hospitals in Florida (2005–2012) and New York (2006–2008). PATIENTS/PARTICIPANTS:Four thousand one hundred thirty-two tarsal fractures that underwent fixation by 1223 surgeons. INTERVENTION:Surgical repair of tarsal fractures. MAIN OUTCOME MEASUREMENTS:Composite of readmission for infection requiring operative treatment, wound dehiscence, nonunion, avascular necrosis, or amputation within 2 years of the index procedure. RESULTS:The mean age was 44 (±15) years, a majority were men (70%) and white (69%), and the mean number of Charlson comorbidities was 0.21 (±0.58). Multivariable logistic regression demonstrated a reduction in the likelihood of complications by 9% for each 5 additional surgeries performed by the operating surgeon [odds ratio (OR), 0.91 per 5 surgeries; 95% confidence interval (CI), 0.82–0.99]. Other factors associated with complications included increased age (OR, 1.23 per 10 years; 95% CI, 1.10–1.36), male sex (OR, 1.56; 95% CI, 1.12–2.17), open fractures (OR, 2.84; 95% CI, 1.92–4.19), number of Charlson comorbidities (OR, 1.23; 95% CI, 1.02–1.48), income quartile (OR, 1.48; 95% CI, 1.00–2.17), uninsured (OR, 2.47; 95% CI, 1.39–4.39), and other government program insurance (OR, 1.52; 95% CI, 1.06–2.18). CONCLUSIONS:We observed a significant inverse relationship between surgeon volume and complication rates when controlling for patient and injury characteristics. In contrast to previous research, a volume–outcome relationship was not observed at the hospital level. These results suggest that such complex injuries should be triaged to the most experienced providers. LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.