Surgeon volume and risk of deep surgical site infection following open reduction and internal fixation of closed ankle fracture

Increasing evidences have shown that surgeon volume was associated with postoperative complications or outcomes in a variety of orthopaedics surgeries, but few were focused on ankle fractures. This study aimed to investigate the deep surgical site infection (DSSI) in association with the surgeon volume following open reduction and internal fixation (ORIF) of ankle fractures. This was a retrospective analysis of the prospectively collected data on patients who underwent ORIF for acute closed ankle fractures between October 2014 and June 2020. Surgeon volume was defined as the number of ORIF procedures performed within 12 months preceding the index operation. The receiver operating characteristic (ROC) curve was constructed to determine the optimal cut‐off value, whereby surgeon volume was dichotomized as high or low. The outcome was DSSI within 1 year postoperatively. Multivariate logistics analysis was performed to examine the DSSI in association with surgeon volume and multiple sensitivity/subgroup analyses were performed to refine the findings. Among 1562 patients, 33 (2.1%) developed a DSSI. The optimal cut‐off value was 7/year. Low‐volume (<7/year) was significantly associated with a 5.0‐fold increased risk of DSSI (95%CI, 2.2‐11.3; P < .001). Sensitivity/subgroup analyses restricted to patients aged <65 years, with or without concurrent fractures, with unimalleolar fractures, bi‐ or trimalleolar fractures, receiving ORIF within 14 days and those operated by ≥10‐year experience surgeons showed the consistently significant results (ORs, 2.7‐6.8, all P < .05). The surgeon volume of <7 cases/year is associated with an increased risk of DSSI. It is more feasible that patients with complex fractures or conditions (eg, bi‐ and trimalleolar or presence of concurrent fractures) are preferentially directed to high‐volume and experienced surgeons.