Abstract
Purpose
The purpose of this study was to evaluate whether fellowship training affected trends and complications of operative clavicle fracture treatment in newly trained orthopedic surgeons.
Methods
The American Board of Orthopedic Surgery (ABOS) database was utilized to identify cases of open treatment of clavicle fractures submitted by ABOS Part-II Board Certification candidates. From 2005 to 2017, 3148 candidates performed at least one open clavicle fracture treatment. Overall, 6919 cases were included; 3516 of these had over 6 weeks of follow-up. Candidates were divided by fellowship type into 5 groups: Trauma, Sports Medicine, Hand and Upper Extremity or Shoulder, multiple, and other or no fellowship(s). Group differences were analyzed with ANOVA and Bonferroni post hoc analysis. Complications, reoperations, nonunion rates, and readmissions between groups were evaluated with Chi-squared test and logistic regression analyses.
Results
Case volume during the study period was significantly higher after 2007. Trauma candidates performed significantly more operations for clavicle fracture per candidate while candidates with other or no fellowship(s) performed significantly fewer operations per candidate. Patients treated by Trauma candidates were significantly older, had significantly fewer early surgical complications and significantly more early medical complications. Nonunion rates were not significantly different between groups.
Conclusion
Candidates treated clavicle fractures surgically more often in 2007 and beyond. Trauma candidates treated older patients, had fewer early surgical complications, and had more medical complications. Reoperation, readmission and nonunion rates were not significantly different between groups.
Keywords: American Board of Orthopedic Surgery, ABOS, Fellowship, Exam subspecialty, Complications, Clavicle fracture
1. Introduction
Clavicle fractures account for up to 10% of all fractures in adults.1,2 Nonoperative treatment of clavicle fractures has historically been the treatment of choice, with low nonunion rates in early literature. However, emerging literature on the treatment of displaced clavicle fractures has reported a higher nonunion rate for nonoperative treatment (up to 20%), with higher union rates with operative fixation.2 Advantages of operative treatment for displaced clavicle fractures include a lower nonunion rate, superior functional scores, improved patient-reported outcomes, and higher patient satisfaction in the short-term compared to nonoperative treatment.1,3, 4, 5, 6 The recent literature in support of operative fixation for displaced clavicle fractures may influence residency and fellowship training and potentially impact trends regarding the treatment of these fractures. However, this topic has received little attention in the literature.
There is an increasing trend towards subspecialization within orthopedic surgery and completion of a fellowship among recent orthopedic trainees.7 The percentage of fellowship-trained applicants to the American Board of Orthopedic Surgeons (ABOS) Part-II examination increased to 90% in 2013.7 Additionally, 78% of procedures submitted to the ABOS from 2003 to 2013 were performed within an applicant’s area of fellowship training. There is evidence to suggest that subspecialization improves clinical outcomes.8 However, the effect of subspecialty training and subspecialization on the treatment and outcomes of clavicle fractures has not been well evaluated.
The purpose of this study was to compare trends and early complication rates among fellowship-trained orthopedic trauma surgeons as compared to all other candidates performing operative fixation of clavicle fractures. We hypothesized that graduates of an orthopedic trauma fellowship program would treat clavicle fractures surgically more often than their peers and have fewer complications.
2. Methods
2.1. Data collection
A proposal was submitted and approved by the ABOS for access to the shoulder case data submitted by ABOS Part-II candidates. Candidates submit all operative cases performed over a 6-month period to the ABOS in preparation for the Part-II Orthopedic Board Certification oral examination and this usually occurs during their first and second years in practice. The ABOS database contained candidate information such as ID, exam subspecialty, fellowship(s) completed, and region of practice. Each case submitted included a case ID, year of surgery, patient age, patient gender, follow-up (weeks), International Classification of Diseases (ICD) codes, Current Procedural Terminology (CPT) codes as well as complication type (medical or surgical) and whether a reoperation and readmission occurred. No information in the ABOS database can be used to identify candidate surgeons or patients. This study was considered exempt by our Institutional Review Board (IRB).
Information on all cases with a CPT code of 23515 (open treatment of clavicular fracture, with or without internal fixation) was included in the study. A total of 3148 candidates performed at least one case between 2005 and 2017. The candidates in this study performed 6919 open treatments of clavicle fractures; 3516 of these cases had a minimum of 6 weeks of follow-up. Candidates self-reported complications according to type: surgical, medical, reoperation, or readmission as well as incidence of nonunion. Early surgical complications were further categorized as nerve palsy/injury, implant-related, wound-related, loss of reduction, and infection. The following early complication rates were calculated: surgical, medical, reoperation, and readmission. Surgical and medical complications were collected throughout the study period (2005–2017), but reoperation and readmission were added to the ABOS dataset in 2013, so they were only collected from 2013 to 2017. Based on the relatively short-term follow-up available in the data, all surgical complications were considered early complications. Nonunion rates were calculated for each group throughout the study period. Candidates were divided into five groups consisting of candidates that completed a (1) Trauma Fellowship, (2) Sports Medicine Fellowship, (3) Hand and Upper Extremity or Shoulder Fellowship, (4) multiple fellowships, or (5) other or no fellowships. Data from Trauma Fellowship candidates was compared to the other four groups.
2.2. Statistical analysis
Descriptive statistics were calculated for the number of candidates, number of cases, cases per candidate, patient gender, and patient age. Significant differences between candidate groups and exam year were evaluated. When a significant main effect was found, Bonferroni post hoc tests were calculated to discern specific differences. Complications were evaluated with Chi-squared tests to determine if differences existed between trauma and all other candidates. Logistic regression analyses were used to assess the association between complication rates and candidate groups with patient age and gender as covariates. Robust, clustered standard errors were specified to account for the correlation between cases that were operated on by the same candidate surgeon. Stata/MP 15.1 (StataCorp LLC, College Station, Texas) was used for all analyses and statistical significance was set at P < .05.
3. Results
Four hundred and two candidates (12.8%) completed a trauma fellowship (Table 1). There were 2746 other candidates that treated at least one case in this series. This included 1109 candidates (35.2%) who completed a Sports Medicine fellowship, 495 candidates (15.7%) who completed a Hand and Upper Extremity or Shoulder fellowship, 182 candidates (5.8%) who completed multiple fellowships and 960 candidates (30.5%) that completed other or no fellowship.
Table 1.
Candidate and patient characteristics.
| Trauma | Sports | Upper/Shoulder | Multiple Fellowships | Others or No Fellowship | p | |
|---|---|---|---|---|---|---|
| Candidates, n (%) | 402 (12.8%) | 1109 (35.2%) | 495 (15.7%) | 182 (5.8%) | 960 (30.5%) | NA |
| Cases, n (%) | 1413 (20.4%) | 2338 (33.8%) | 1125 (16.3%) | 395 (5.7%) | 1648 (23.8%) | NA |
| Cases per candidate, μ±SD | 3.5 ± 3.2 ∗ | 2.1 ± 1.5 | 2.3 ± 1.8 | 2.2 ± 1.4 | 1.7 ± 1.2 ∗∗ | <0.001 |
| Male patients, n (%) | 1114 (78.8%) | 1826 (78.1%) | 882 (78.4%) | 314 (79.5%) | 1301 (79.0%) | 0.949 |
| Patient age, μ±SD | 36.7 ± 15.5^ | 34.3 ± 15.6 | 35.9 ± 15.7 | 34.1 ± 15.6 | 32.1 ± 15.5^^ | <0.001 |
| Follow-up weeks, μ±SD | 7.5 ± 5.6# | 8.1 ± 5.7 | 8.2 ± 5.8 | 8.5 ± 6.0 | 7.9 ± 5.7 | 0.005 |
| Cases with more than 6 weeks follow-up | ||||||
| Cases, n (%) | 682 (19.4%) | 1205 (34.3%) | 601 (17.1%) | 209 (5.9%) | 819 (23.3%) | NA |
| Follow-up weeks, μ±SD | 12.2 ± 4.2 | 12.5 ± 4.3 | 12.6 ± 4.3 | 12.9 ± 4.6 | 12.4 ± 4.6 | 0.242 |
Cases/candidate ∗significantly higher all comparisons.
∗∗ significantly lower all comparisons.
Patient age ^significantly higher than sports, multi & Other/No; ^^ significantly lower than trauma, sports Upper/Shoulder.
Follow-up weeks # trauma significantly lower than sports, upper/shoulder & Multi.
The average age of patients in this study was 34.5 ± 15.6 years and 78.6% were male. Patient age was significantly higher (P < .001) in the trauma fellowship group (36.7 ± 15.5) as compared to the other study groups. Candidates who completed other or no fellowship had significantly lower patient age (32.1 ± 15.5, P < .001). No significant difference in patient gender was seen between the groups (P = 0.949). The average follow-up for all cases in the study was 8.0 weeks (range 0–48). The average follow-up in the trauma fellowship group was significantly lower than the Sports Medicine fellowship group, Hand and Upper Extremity or Shoulder fellowship group, multiple fellowships group, or other/no fellowship group (P = .005).
The number of open treatment of clavicle fracture cases reported by ABOS candidates varied overall but averaged 532.2 per year (Fig. 1). Each candidate treated an average of 2.19 ± 1.9 clavicle fracture cases over the course of the study. ABOS candidates performed significantly fewer clavicle fracture cases in 2005 and 2006 compared to the other years in the study period (P < .05). The trauma group performed significantly more clavicle fracture cases per candidate (3.5 ± 3.2), while the candidates with other or no fellowship performed significantly less clavicle fracture cases per candidate (1.7 ± 1.2, P < .001). Yearly averages of clavicle fracture cases per candidate were significantly higher in the trauma group for 9 of the 13 years reported in this study (Fig. 2).
Fig. 1.
Total number of CPT-23515 cases and candidates per year.
Fig. 2.
Yearly trends showing the average number of cases per candidate.
The self-reported complication rates are summarized by group in Table 2. Overall, the early surgical complication rate was 11.9%. Additionally, surgical complications were categorized by type and frequency (Table 2). The trauma group had a significantly lower overall rate of surgical complications (9.5%, P = .016) as well as in the nerve palsy/injury (2.1%, P = .04) and wound-related (0.5%, P = .012) complication subtypes. The overall rate of nonunion/malunion/delayed union was 1.3% for the full cohort and when only analyzing with greater than 6 weeks follow-up, the rate was 2.3%. These rates of nonunion/malunion/delayed union did not differ between groups.
Table 2.
Multiple Type and frequency of complications.
| Complication | Trauma | Sports | Upper/Shoulder | Multiple Fellowships | Others or No Fellowship | p |
|---|---|---|---|---|---|---|
| Cases 2005–2017 | n = 1413 | n = 2338 | n = 1125 | n = 395 | n = 1648 | |
| Surgical: All surgical, n (%) Nerve palsy/injury, n (%) Implant related, n (%) Wound related, n (%) Loss of reduction, n (%) Infection, n (%) |
134 (9.5%) 29 (2.1%) 30 (2.1%) 7 (0.5%) 5 (0.4%) 16 (1.1%) |
304 (13.0%) 77 (3.3%) 55 (2.4%) 37 (1.6%) 12 (0.5%) 34 (1.5%) |
142 (12.6%) 43 (3.8%) 25 (2.2%) 11 (1.0%) 9 (0.8%) 21 (1.9%) |
53 (13.4%) 11 (2.8%) 9 (2.3%) 9 (2.3%) 6 (1.5%) 5 (1.3%) |
191 (11.6%) 39 (2.4%) 46 (2.8%) 21 (1.3%) 10 (0.6%) 30 (1.8%) |
0.016 0.040 0.783 0.012 0.092 0.475 |
| Medical: All medical, n (%) Unspecified, n (%) Anemia, n (%) DVT, n (%) |
43 (3.0%) 16 (1.1%) 6 (0.4%) 6 (0.4%) |
22 (0.9%) 10 (0.4%) 0 (0%) 2 (0.1%) |
13 (1.2%) 7 (0.6%) 0 (0%) 0 (0%) |
4 (1.0%) 2 (0.5%) 2 (0.5%) 1 (0.3%) |
17 (1.0%) 11 (0.7%) 1 (0.1%) 0 (0%) |
<0.001 0.144 0.001 0.008 |
|
Cases 2013–2017 |
n = 874 |
n = 1181 |
n = 670 |
n = 235 |
n = 696 |
|
| Reoperation, n (%) | 17 (2.0%) | 31 (2.6%) | 17 (2.5%) | 7 (3.0%) | 17 (2.4%) | 0.847 |
| Readmission, n (%) |
12 (1.4%) |
15 (1.3%) |
12 (1.8%) |
4 (1.7%) |
12 (1.7%) |
0.878 |
|
Nonunion, malunion, or delayed union |
Trauma |
Sports |
Upper/Shoulder |
Multiple Fellowships |
Others or No Fellowship |
p |
| All cases | 11 (0.8%) | 33 (1.4%) | 16 (1.4%) | 9 (2.3%) | 19 (1.2%) | 0.154 |
| Cases with >6w follow-up | 10 (1.5%) | 30 (2.5%) | 15 (2.5%) | 8 (3.8%) | 17 (2.1%) | 0.308 |
Medical complications occurred in 1.4% of all cases with the trauma group reporting a significantly higher rate of medical complications than other groups (3.0%, P < .001). Reoperation and readmission rates were not significantly different by candidate groups and averaged 2.4% for reoperation and 1.5% for readmission.
Logistic regression was utilized to evaluate each of the complication rates along with covariates such as patient age and gender. Risk ratios (RR) were calculated with the trauma group being the reference group [RR = 1.0]. Patients with a medical complication had a 76% greater risk of also having a surgical complication (P = .027). The other groups had a significantly higher rate of surgical complications and greater risk than the trauma group (Table 3). Additionally, with each additional year of patient age, the risk of a surgical complication increased by 1% (P < .001). The risk of a medical complication increased by 4% for each additional year of patient age (P < .001).
Table 3.
Multiple fellowships compared.
| Variable | Surgical Complication Risk Ratio [95% CI] (p) |
Medical Complication Risk Ratio [95% CI] (p) |
|---|---|---|
| Age (y) | 1.01 [1.01–1.02] (<0.001) | 1.04 [1.03–1.05] (<0.001) |
| Male gender | 0.81 [0.68–0.96] (0.014) | 0.70 [0.45–1.09] (0.112) |
| Medical complication | 1.76 [1.07–2.92] (0.027) | NA |
| Trauma Fellowship | 1.0 - Reference group | 1.0 - Reference group |
| Sports Med Fellowship | 1.49 [1.20–1.85] (<0.001) | 0.32 [0.19–0.54] (<0.001) |
| Hand/Shoulder | 1.41 [1.10–1.81] (0.007) | 0.37 [0.20–0.67] (0.002) |
| Multiple Fellowships | 1.55 [1.10–2.19] (0.011) | 0.34 [0.12–0.98] (0.046) |
| Other/No Fellowship | 1.35 [1.06–1.70] (0.013) | 0.38 [0.21–0.67] (0.001) |
| Constant |
0.07 [0.06–0.10] (<0.001) |
0.01 [0.004–0.02] (<0.001) |
|
Reoperation Risk Ratio [95% CI] (p) |
Readmission Risk Ratio [95% CI] (p) |
|
| Age (y) | 1.00 [0.99–1.02] (0.915) | 1.00 [0.99–1.03] (0.290) |
| Male gender | 0.96 [0.57–1.63] (0.885) | 0.96 [0.49–1.88] (0.902) |
| Surgical complication | 59.8 [31.4–113] (<0.001) | 18.6 [9.8–35.3] (<0.001) |
| Medical complication | 2.85 [1.02–7.97] (0.045) | 36.2 [16.0–81.6] (<0.001) |
| Trauma Fellowship | 1.0 - Reference group | 1.0 - Reference group |
| Sports Med Fellowship | 0.98 [0.51–1.88] (0.949) | 1.13 [0.48–2.71] (0.776) |
| Hand/Shoulder | 0.94 [0.45–1.96] (0.867) | 1.58 [0.63–3.97] (0.328) |
| Multiple Fellowships | 0.99 [0.38–2.61] (0.985) | 1.36 [0.37–4.98] (0.643) |
| Other/No Fellowship | 0.91 [0.43–1.91] (0.799) | 1.40 [0.54–3.64] (0.490) |
| Constant | 0.003 [0.002–0.01] (<0.001) | 0.002 [0.001–0.01] (<0.001) |
Analysis of reoperation and readmission data comprised a subset of cases from 2013 to 2017, since the ABOS started requiring reporting in 2013. The risk of reoperation was 59 times more likely to occur in cases with a surgical complication (P < .001) (Table 3). Cases that had a medical complication had a 2-fold increase in risk (P = .045) of undergoing a reoperation. In patients with medical complications that required reoperation, 5 out of 6 also had a surgical complication. Age, gender, and candidate group were not significant factors in reoperation rates. Similar to reoperation, the risk of readmission was significantly higher in cases that had a surgical (RR = 18.6, P < .001) or medical (RR = 36.2, P < .001) complications. No significant difference in readmission risk was found between candidate groups.
4. Discussion
The purpose of this study was to compare trends and early complication rates in open treatment of clavicle fracture cases performed by ABOS Part-II trauma fellowship candidates and all other ABOS candidates between 2005 and 2017. The trauma fellowship group performed significantly more clavicle fracture cases per candidate. A recent study of ABOS Part II candidates showed that between 2003 and 2013, graduates of fellowship training programs are more likely to perform procedures within their area of fellowship training.7 Based on the information from ABOS database, it is not clear why the trauma group has a higher average number of cases per candidate. Possible explanations may include that the trauma group was referred more operative fractures, this group cared for more polytrauma patients that needed open clavicle fracture treatment or that once a group is trained to perform a procedure then that training is used more often.
The overall early self-reported surgical complication rate in this study was 11.9%. There is large variability in the complication rates of operative treatment for clavicle fractures in the literature. In a randomized controlled trial from 2007, the Canadian Orthopedic Trauma Society reported a 37% complication rate among operatively treated fractures, with most complications being implant-related.1 In a meta-analysis, McKee et al. demonstrated a 29% overall complication rate in 212 operatively treated clavicle fractures.6 A systematic review of complications with plate fixation for clavicle fractures noted a prevalence of neurovascular complications ranging from 0 to 38%, and all were transient. Wound and deep infections were reported below 10% in their included studies.9
The reported surgical complication rate in our study is likely lower than reported studies due to shorter follow-up. A follow-up period of at least one year would allow adequate time to observe for nonunion, malunion, implant failure, or symptomatic hardware requiring reoperation. Additionally, the ABOS dataset does not distinguish timing from injury to operative fixation (whether for acute fracture, early conversion from nonoperative treatment, or symptomatic nonunion), or type of implant used (i.e. plate fixation, intramedullary nail, etc.). These factors affect complication rates after operative treatment.10,11
When comparing fellowship training, trauma candidates had significantly lower early self-reported surgical complication rates than other groups (9.5%, P = .016) and treated significantly more cases per candidate (3.5 ± 3.2, P < .001). There is a growing body of evidence demonstrating the impact of specialization and surgeon experience on operative outcomes.12 A systematic review of various surgical specialties demonstrates that high-volume surgeons experienced better outcomes than low-volume surgeons across a variety of surgical fields.13 A study evaluating bariatric surgeons demonstrated technical skills assessment predicts clinical outcomes, complication rates, and patient mortality.14 Studies evaluating ABOS candidates demonstrated similar correlations in complication rates and specialization. A recent study of almost 30,000 carpal tunnel releases showed that fellowship training among ABOS candidates improved outcomes and decreased complication rates for open and endoscopic carpal tunnel release.15 Another study of ABOS candidates performing distal clavicle excision from 2004 to 2013 showed a lower reported complication rate for sports-medicine fellowship-trained candidates compared to all other candidates.16 When specifically evaluating operative fixation of clavicle fractures, Leroux et al. found that fewer years in practice was associated with a small but significant risk of developing an infection.17
In our study, the overall self-reported early medical complication rate was 1.4%. This study showed a significant difference in medical complications between the trauma group and other groups (3.0%, P < .001). Several factors may contribute to this. When comparing the average patient age between the two groups, the trauma fellowship group patients were significantly older. While older patients may have a higher risk of sustaining medical complications, this mean age differences between these groups may not be big enough to be clinically significant. A recent review of the Swedish Fracture Register showed that the mean age of clavicle fractures undergoing operative treatment was 36 ± 15 years.18 A second potential explanation is that specialists in any field see and treat more “complicated” patients or patients with more comorbidities, which may lead to increased medical complication rates. A third potential explanation, referenced earlier, is that clavicle fracture operations among the trauma group may include an increased proportion of polytrauma patients with associated injuries that might contribute to a higher medical complication rate. However, these are all assumptions, as it is difficult to analyze potential factors contributing to medical complication rates from the information captured in the ABOS database.
The overall self-reported early reoperation and readmission rates were 2.4% and 1.5%, respectively. There were no significant differences in either rate between the groups in this study. The early reoperations included in this study were dominated by cases with a surgical complication. The risk of readmission was significantly higher in patients with a surgical or medical complication. Cases with a medical complication had a 2-fold increased risk of undergoing a reoperation (P = .045). Longer follow-up in this study is required to know the true reoperation and readmission rates. In an analysis of risk factors for complications after operative treatment of displaced midshaft clavicle fractures, Shin et al. reported that 12% of patients required reoperation, most commonly from implant-related complications.19 At a Level 1 Trauma Center between 2010 and 2012, five of fifty-six operatively treated clavicle fractures required reoperation (8.9%): two for nonunion, two for traumatic re-fracture, and one for pain.20 A database review of 1350 operatively treated mid-shaft clavicle fractures reported a 24.6% reoperation rate.17 The majority of reoperations were for implant removal (18.8%, median time of twelve months), while 5.8% of patients underwent reoperation for nonunion, malunion, or infection. A more recent study demonstrated a symptomatic hardware removal rate of 23%.11
There are multiple limitations to this study, including those inherent to registries. Firstly, the data in this study is self-reported by ABOS candidates which may cause discrepancies in data logging and the threshold to report certain complications, such as pain and stiffness. Secondly, the database also does not include information relating to injury chronology, medical history, comorbidities, fracture location/pattern, implant choice, reason for reoperation, or reason for readmission. Thirdly, while one of the goals of this study was to evaluate early complication rates, the short length of follow-up does not account for adverse events that fall outside this follow-up period. Additionally, although the study looked at complication rates and rates of surgery, there is no specific outcome data to compare performance amongst the groups. Lastly, this study reported on trends in recently trained orthopedic surgeons in the United States and may not apply to more experienced surgeons or surgeons internationally.
5. Conclusion
During this study, candidates treated clavicle fractures surgically more often overall and on average. Trauma candidates performed surgery at a higher average rate, had significantly fewer early surgical complications, but had more early medical complications. There was no difference in reoperation or readmission rates between groups. The risk of reoperation was higher for both groups if the patient had a surgical or medical complication.
Authorship contributions
Mufaddal M Gombera, M.D.: conception and design, writing the manuscript, critical revision of the manuscript, supervision. Brent J. Morris, M.D.: conception and design, writing the manuscript, critical revision of the manuscript. Hussein A. Elkousy, M.D.: conception and design, writing the manuscript, critical revision of the manuscript. Mitzi S. Laughlin, Ph.D.: conception and design, data collection, analysis and interpretation of data, writing the manuscript, critical revision of the manuscript, statistical expertise, administrative, technical, or material support, supervisison. Emily A. Vidal, B.S.: analysis and interpretation of data, writing the manuscript, critical revision of the manuscript, administrative, technical, or material support. Mark R. Brinker, M.D.: conception and design, critical revision of the manuscript, supervision.
Conflicts of interest and source of funding
No direct funding was received for this study. Dr. Brinker reports personal fees from Zimmer Biomet that do not pertain to the submitted work. Dr. Morris reports royalties from Elsevier, personal fees from DJ Orthopedics, personal fees and non-financial support from Wright Medical Group N.V. and Tournier Inc. that do not pertain to the submitted work. The Fondren Orthopedic Research Institute (FORI) supports part of the study team (MSL and EAV).
Acknowledgements
The authors would like to thank the American Board of Orthopedic Surgery for providing the data.
References
- 1.Canadian Orthopaedic Trauma Society Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: a multicenter, randomized clinical trial. J Bone Joint Surg. 2007;89(1):1–10. doi: 10.2106/JBJS.F.00020. [DOI] [PubMed] [Google Scholar]
- 2.Wiesel B., Nagda S., Mehta S., Churchill R. Management of midshaft clavicle fractures in adults. J Am Acad Orthop Surg. 2018;26(22):e468–e476. doi: 10.5435/JAAOS-D-17-00442. [DOI] [PubMed] [Google Scholar]
- 3.Hill J.M., Mcguire M.H., Crosby L.A., Hill J.M., McGuire M.H. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. 1997;79(4):3. doi: 10.1302/0301-620x.79b4.7529. [DOI] [PubMed] [Google Scholar]
- 4.Nowak J., Holgersson M., Larsson S. Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop. 2005;76(4):496–502. doi: 10.1080/17453670510041475. [DOI] [PubMed] [Google Scholar]
- 5.Mckee MD, Pedersen EM, Jones C, et al. Deficits Following Nonoperative Treatment of Displaced Midshaft Clavicular Fractures. VO LU M E.:6. [DOI] [PubMed]
- 6.McKee R.C., Whelan D.B., Schemitsch E.H., McKee M.D. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. The Journal of Bone and Joint Surgery-American. 2012;94(8):675–684. doi: 10.2106/JBJS.J.01364. [DOI] [PubMed] [Google Scholar]
- 7.Horst P.K., Choo K., Bharucha N., Vail T.P. Graduates of orthopaedic residency training are increasingly subspecialized: a review of the American board of orthopaedic surgery Part II database. J Bone Joint Surg. 2015;97(10):869–875. doi: 10.2106/JBJS.N.00995. [DOI] [PubMed] [Google Scholar]
- 8.Katz J.N., Losina E., Barrett J. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States medicare population∗. The J. Bone Joint Surg.-Am. 2001;83(11):1622–1629. doi: 10.2106/00004623-200111000-00002. [DOI] [PubMed] [Google Scholar]
- 9.Wijdicks F.-J.G., Van der Meijden O.A.J., Millett P.J., Verleisdonk E.J.M.M., Houwert R.M. Systematic review of the complications of plate fixation of clavicle fractures. Arch Orthop Trauma Surg. 2012;132(5):617–625. doi: 10.1007/s00402-011-1456-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.McKnight B., Heckmann N., Hill J.R. Surgical management of midshaft clavicle nonunions is associated with a higher rate of short-term complications compared with acute fractures. J Shoulder Elbow Surg. 2016;25(9):1412–1417. doi: 10.1016/j.jse.2016.01.028. [DOI] [PubMed] [Google Scholar]
- 11.Asadollahi S., Hau R.C., Page R.S., Richardson M., Edwards E.R. Complications associated with operative fixation of acute midshaft clavicle fractures. Injury. 2016;47(6):1248–1252. doi: 10.1016/j.injury.2016.02.005. [DOI] [PubMed] [Google Scholar]
- 12.Malangoni M.A., Biester T.W., Jones A.T., Klingensmith M.E., Lewis F.R. Operative experience of surgery residents: trends and challenges. J Surg Educ. 2013;70(6):783–788. doi: 10.1016/j.jsurg.2013.09.015. [DOI] [PubMed] [Google Scholar]
- 13.Halm E.A., Lee C., Chassin M.R. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med. 2002;137(6):511. doi: 10.7326/0003-4819-137-6-200209170-00012. [DOI] [PubMed] [Google Scholar]
- 14.Birkmeyer J.D., Finks J.F., O’Reilly A. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369(15):1434–1442. doi: 10.1056/NEJMsa1300625. [DOI] [PubMed] [Google Scholar]
- 15.Mathen S., Nosrati N., Merrell G. Decreased rate of complications in carpal tunnel release with Hand fellowship training. Journal of Hand and Microsurgery. 2018;10(1):26–28. doi: 10.1055/s-0037-1618913. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Amirtharaj M.J., Wang D., McGraw M.H. Trends in the surgical management of acromioclavicular joint arthritis among board-eligible US orthopaedic surgeons. Arthrosc J Arthrosc Relat Surg. 2018;34(6):1799–1805. doi: 10.1016/j.arthro.2018.01.024. [DOI] [PubMed] [Google Scholar]
- 17.Leroux T., Wasserstein D., Henry P. Rate of and risk factors for reoperations after open reduction and internal fixation of midshaft clavicle fractures: a population-based study in ontario, Canada. The Journal of Bone and Joint Surgery-American. 2014;96(13):1119–1125. doi: 10.2106/JBJS.M.00607. [DOI] [PubMed] [Google Scholar]
- 18.Kihlström C., Möller M., Lönn K., Wolf O. Clavicle fractures: epidemiology, classification and treatment of 2 422 fractures in the Swedish Fracture Register; an observational study. BMC Muscoskel Disord. 2017;18(1) doi: 10.1186/s12891-017-1444-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Shin S.-J., Do N.-H., Jang K.-Y. Risk factors for postoperative complications of displaced clavicular midshaft fractures. J Trauma Inj Infect Crit Care. 2012;72(4):1046–1050. doi: 10.1097/TA.0b013e31823efe8a. [DOI] [PubMed] [Google Scholar]
- 20.Persico F., Lorenz E., Seligson D. Complications of operative treatment of clavicle fractures in a Level I Trauma Center. Eur J Orthop Surg Traumatol. 2014;24(6):839–844. doi: 10.1007/s00590-013-1273-3. [DOI] [PubMed] [Google Scholar]