title: Rate of and Risk Factors for Reoperations After Open Reduction and Internal Fixation of Midshaft Clavicle Fractures: A Population-Based Study in Ontario, Canada.
abstract: BACKGROUND
  Reoperation rates following open reduction and internal fixation (ORIF) of midshaft clavicle fractures have been described, but reported rates of nonunion, malunion, infection, and implant removal have varied. We sought to establish baseline rates of, and risk factors for, reoperations following clavicle ORIF in a large population cohort.
  
  
  METHODS
  Administrative databases were used to identify patients sixteen to sixty years of age who had undergone an ORIF of a closed, midshaft clavicle fracture from April 2002 to April 2010. The primary outcome was a reoperation within two years (isolated implant removal, irrigation and debridement [deep infection], pseudarthrosis reconstruction [nonunion], or clavicle osteotomy [malunion]). The secondary outcome was rare perioperative complications, including pneumothorax, subclavian vasculature injury, and brachial plexus injury. A multivariable logistic regression analysis was performed to determine the influence of patient and provider factors on these outcomes.
  
  
  RESULTS
  We identified 1350 patients who underwent midshaft clavicle ORIF (median age, thirty-two years [interquartile range, twenty-one to forty-four years]; 81.3% male). One in four patients (24.6%) underwent at least one clavicle reoperation. The most common procedure was isolated implant removal (18.8%), and females were at highest risk (odds ratio [OR], 1.7; p = 0.002). The median time to implant removal was twelve months. A reoperation secondary to nonunion, deep infection, and malunion occurred in 2.6%, 2.6%, and 1.1% of the patients after a median of six, five, and fourteen months, respectively. Risk factors for clavicle nonunion included female sex (OR, 2.2; p = 0.04) and a high comorbidity score (OR, 2.8; p = 0.009). For surgeons, fewer years in practice was associated with a small risk of the patient developing an infection (OR, 1.1; p < 0.001). Sixteen pneumothoraces (1.2%) were identified; however, brachial plexus and subclavian vessel injuries were each found in five or fewer patients.
  
  
  CONCLUSIONS
  Following clavicle ORIF, one in four patients underwent a reoperation. The most common procedure was implant removal, and although the rates of reoperations secondary to nonunion, malunion, and infection were low they were higher than previously reported. Pneumothoraces and neurovascular injuries were infrequent and should continue to be considered rare complications of clavicle ORIF.
  
  
  METHODS
  Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for T. Leroux: timothy.leroux@mail.utoronto.ca.
authors.forename: Timothy
authors.initials: T
authors.lastname: Leroux
authors.affiliation: Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for T. Leroux: timothy.leroux@mail.utoronto.ca.
authors.forename: David
authors.initials: D
authors.lastname: Wasserstein
authors.affiliation: Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for T. Leroux: timothy.leroux@mail.utoronto.ca.
authors.forename: Patrick
authors.initials: P
authors.lastname: Henry
authors.affiliation: Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for T. Leroux: timothy.leroux@mail.utoronto.ca.
authors.forename: Amir
authors.initials: A
authors.lastname: Khoshbin
authors.affiliation: Mount Sinai Hospital, 600 University Avenue, Toronto, ON M5G 1X5, Canada.
authors.forename: Tim
authors.initials: T
authors.lastname: Dwyer
authors.affiliation: Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada. E-mail address for C. Veillette: christian.veillette@uhn.on.ca.
authors.forename: Darrell
authors.initials: D
authors.lastname: Ogilvie-Harris
authors.affiliation: Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada. E-mail address for C. Veillette: christian.veillette@uhn.on.ca.
authors.forename: Nizar
authors.initials: N
authors.lastname: Mahomed
authors.affiliation: Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada. E-mail address for C. Veillette: christian.veillette@uhn.on.ca.
authors.forename: Christian
authors.initials: C
authors.lastname: Veillette
mesh_terms: D000293:Adolescent; D000328:Adult; D002968:Clavicle / Q000293:injuries*; D003646:Debridement; D020878:Device Removal; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods*; D050723:Fractures, Bone / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D010027:Osteotomy; D011183:Postoperative Complications / Q000453:epidemiology / Q000601:surgery*; D019736:Prostheses and Implants; D012086:Reoperation / Q000706:statistics & numerical data*; D012307:Risk Factors; D007507:Therapeutic Irrigation; D016896:Treatment Outcome