Is Higher Surgeon Volume Associated With Lower Complication and Revision Risk After Distal Radius Fracture Surgery? A...

Surgeon case volume has been linked with outcomes across many orthopaedic procedures, but its influence on distal radius fracture fixation remains uncertain.

(1) For distal radius fracture surgery, at what surgeon annual case volume does the risk of complications plateau? (2) For distal radius fracture surgery, at what surgeon annual case volume does the risk of revision surgery plateau?

A retrospective, population-based study was performed using administrative health databases in Ontario, Canada, accessed through the Institute for Clinical Evaluative Sciences, an independent, nonprofit research institute that houses linkable, individual-level health administrative data for Ontario's publicly funded healthcare system. Between 2010 and 2020, a total of 27,945 adult patients (≥ 18 years of age) underwent surgical fixation for acute isolated distal radius fracture. After applying prespecified inclusion and exclusion criteria, including exclusion of patients with open fractures, polytrauma, compartment syndrome, neurovascular injury, emergent presentations, incomplete administrative records, or prior distal radius surgery, a final cohort of 13,389 patients (48% of the initial cohort) was included (71% [9533] females; mean ± SD age 56 ± 15 years). Surgeon annual case volume, defined as the number of distal radius fracture fixations performed in the preceding year, was the primary exposure. The primary outcome was a composite of complications, including postoperative complications or revision surgery up to 10 years after the index procedure; revision surgery was also analyzed separately. Cox proportional hazards models were adjusted for demographics, comorbidities, fracture type (intraarticular versus extraarticular), fixation method, and hospital type (teaching versus nonteaching). Restricted cubic spline models were used to assess nonlinearity and identify potential volume thresholds.

Surgeons performing < 5 distal radius fracture fixations annually had the highest hazards of both composite complications and revision surgery. Complication hazards declined with increasing surgeon volume and stabilized after approximately 20 procedures per year; consistent with this threshold, surgeons performing 20 to 24 procedures annually demonstrated a 37% lower hazard of complications compared with surgeons performing < 5 procedures per year (HR 0.63 [95% confidence interval (CI) 0.49 to 0.81]; p = 0.004). Revision surgery hazards likewise declined with increasing surgeon volume but plateaued at a lower threshold of approximately 10 procedures per year; surgeons performing 10 to 14 procedures annually had a 56% lower hazard of revision surgery compared with surgeons performing < 5 procedures per year (HR 0.44 [95% CI 0.33 to 0.60]; p < 0.001).

Surgeons who perform distal radius fracture fixation infrequently may benefit from focused strategies to support maintenance of procedural proficiency including continuing professional development and enhanced surgical training. At a systems level, the lower risk of complications observed among surgeons performing at least 20 procedures per year have implications for training programs, ongoing competence frameworks, and health-system planning, particularly in settings where referral options may be limited.

Level III, prognostic study.