Impact of Patient Demographics, Surgeon Volume, and Hospital Type on Distal Radius Fracture Surgery Outcomes: A Population-Based Study

Abstract

Purpose

This study aimed to evaluate the impact of patient demographics, surgeon volume, and hospital type on composite outcomes, infection, and revision following surgery for acute, isolated distal radius fractures (DRFs).

Materials and Methods

This population-based study examined Ontario administrative health data from 2010 to 2020, identifying 13,389 adults who underwent surgical fixation for acute, isolated DRFs. Patients with open fractures, other associated injuries, neurovascular injuries, prior surgery on the same limb, or any other factors that could worsen prognosis were excluded. Covariates included were time to surgery, patient demographics (age, biological sex, comorbidities, rural residence, income quintile), surgeon factors (volume, fixation type), fracture type (intra-articular vs. extra-articular), and hospital type (teaching vs. non-teaching). The primary outcome was a composite measure of complications, including infection, revision surgery, and hardware removal. Secondary outcomes included postoperative infection and revision procedures. Time-to-event Cox proportional multivariable models were applied to estimate hazard ratios (HRs) with 95% confidence intervals (CIs), adjusting for covariates.

Results

A total of 13,389 patients were included in the analysis. Higher surgeon volume was associated with improved outcomes: Every additional five DRF surgeries performed in the prior year reduced the risk of composite complications by 4% (HR 0.96, 95% CI 0.94–0.98; p < 0.001) and the risk of revision surgery by 10% (HR 0.90, 95% CI 0.86–0.93; p < 0.001).

Rural residence was associated with a 44% higher risk of postoperative infection (HR 1.43, 95% CI 1.08–1.89; p = 0.01). Increased comorbidity burden, measured by the Johns Hopkins score, was consistently associated with worse outcomes: Each one-point increase corresponded to a 6.4% higher likelihood of composite complications (HR 1.06, 95% CI 1.05–1.08; p < 0.001).

Female sex was protective across outcomes, reducing the risk of infection by 25% (HR 0.75, 95% CI 0.59–0.96; p = 0.02) and revision surgery by 19% (HR 0.81, 95% CI 0.68–0.98; p = 0.02). Older age was associated with a modest but consistent protective effect, reducing the risk of composite complications by 1% per year of age (HR 0.99, 95% CI 0.98–0.99; p < 0.001).

Conclusion

Surgeon volume independently reduced complications and revisions after DRF surgery, while rural residence and higher comorbidity burden markedly increased infection risk. The protective effects of female sex and older age highlight the importance of nuanced risk assessment. Strategies to expand access to high-volume surgeons and targeted perioperative care may improve outcomes and reduce disparities in fracture management.

Level of Evidence

Level III.

Keywords

radius - surgery - outcomes - complications

• References

• 1 Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin 2012; 28 (02) 113-125
• 2 Aryee JNA, Frias GC, Haddad DK. et al. Understanding variations in the management of displaced distal radius fractures with satisfactory reduction. Hand (N Y) 2025; 20: 762-769
• 3 DeGeorge Jr BR, Van Houten HK, Mwangi R, Sangaralingham LR, Larson AN, Kakar S. Outcomes and complications in the management of distal radial fractures in the elderly. J Bone Joint Surg Am 2020; 102 (01) 37-44
• 4 Tuaño KR, Fisher MH, Lee N. et al. Analysis of postoperative distal radius fracture outcomes in the setting of osteopenia and osteoporosis for patients with comorbid conditions. J Hand Surg Glob Online 2023; 5 (05) 601-605
• 5 Liu K, Grigor EJM, Antflek D, Ho G, Baltzer HL, Paul R. Time to surgical management of distal radius fractures: Effects on health care utilization and functional outcomes. Can J Surg 2024; 67 (04) E286-E294
• 6 Ruangsomboon P, Bagouri E, Pincus D, Paterson JM, Ravi B. Association of surgeon volume with complications following direct anterior approach (DAA) total hip arthroplasty: a population-based study. Acta Orthop 2024; 95: 505-511
• 7 Harkin W, Berreta RS, Williams T. et al. The effect of surgeon volume on complications after total shoulder arthroplasty: A nationwide assessment. J Shoulder Elbow Surg 2024; 34: 1112-1119
• 8 Johns Hopkins Medicine. The Johns Hopkins ACG Case Mix System. Version 6.0 Release Notes (Vol. PC (DOS/WIN/NT) and Unix Version 6.0–April 2003). 2003. Baltimore: Johns Hopkins Bloomberg School of Public Health.
• 9 Kralj B. Rurality Index Score - Measuring Rurality - RIO2008_BASIC: Methodology and Results. Published online 2008. Accessed October 1, 2025 at: https://www.oma.org/siteassets/oma/media/pagetree/about-oma/expert--advice/2008rio-fulltechnicalpaper.pdf
• 10 Ontario.ca. Classification of hospitals. Accessed January 28, 2025 at: http://www.ontario.ca/page/classification-hospitals
• 11 Liang Z, Zhang W, Deng Y. et al. Impact of surgeon volume on the risk of complications following volar locking plating of unstable distal radius fracture. Medicine (Baltimore) 2024; 103 (48) e40660
• 12 Mosenthal WP, Boyajian HH, Ham SA, Conti Mica MA. Treatment trends, complications, and effects of comorbidities on distal radius fractures. Hand (N Y) 2019; 14 (04) 534-539
• 13 Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am 2011; 93 (23) 2146-2153
• 14 Constantine RS, Le ELH, Gehring MB, Ohmes L, Iorio ML. Risk factors for infection after distal radius fracture fixation: analysis of impact on cost of care. J Hand Surg Glob Online 2022; 4 (03) 123-127
• 15 Vasara H, Stenroos A, Tarkiainen P. et al. Incidence and risk factors of adverse events after distal radius fracture fixation with volar locking plates: retrospective analysis of 2,790 cases. Acta Orthop 2024; 95: 645-653
• 16 Li Y, Zhou Y, Zhang X, Tian D, Zhang B. Incidence of complications and secondary procedure following distal radius fractures treated by volar locking plate (VLP). J Orthop Surg Res 2019; 14 (01) 295