Is it safe to assist proximal humeral nailing to residents? An analysis of 1134 cases

Intramedullary nailing is a common procedure for the treatment of proximal humeral fractures. In practical resident training this standardized operation plays an important role in the introduction to osteosynthesis. Our aim was to investigate whether assisting this operation to residents influences the surgical complication rate both in-house and on re-admission.

All 1134 patients who received a proximal humeral Targon PH nail (Aesculap) for proximal humeral fractures were included between 2000 and 2013. Several age groups (≤60 years, 61-70 years, 71-80 years, 80-90 years, and over 90 years) were analyzed separately. Complications including screw/nail protrusion, displacement, infection, humeral head necrosis, nonunion, stiffness, hematoma, impingement, screw loosening, implant failure, dislocation were recorded. 803 (70.7%) of the patients were female. Mean patient age was 71.7 years (standard deviation: 14.0 years). For detection of significantly different complication frequencies between operations performed by residents or attending physicians, we used the χ² test in cases with all expected values greater than five, otherwise we used the two-sided Fisher's exact test.

Supervised residents performed 204 operations. Overall complication rate was 12.6% (95% CI: 10.7-14.5%). The complication rate of the attending operations was 13.2% while it was 9.8% for resident operations. The difference was not significant. No statistically significant relation between age group and complication rate was found. In all patients older than 80 years the complication rate was higher when operated by residents compared to those operated by consultants, whereas in younger patients it was lower. Whereas the difference was not significant in patients younger than 60 and older than 80, we found significantly less complications in the group of patients between 61 and 80 years of age. On the other hand patients between 81 and 90 years displayed a 1.46 fold higher risk after training operations. No significant differences in the frequency of the different complications were found.

We conclude that proximal humeral nailing is an operation suitable for teaching purposes. However, patients between 81 and 90 years of age seem to be at an increased risk for complications if operated by a resident.