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 (615) years, a majority were men (70%) and white (69%), and the mean number of Charlson comorbidities was 0.21 (60.58). 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.