Preface. Hvidovre, d. 12. September, Anders Troelsen, Michael Brix, Kirill Gromov

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1 Preface The annual report from the Danish Fracture Database (DFDB) 215 is the third of its kind. It contains data based on over 4. fracture related surgeries, of which over 3. are primary surgeries registered at The purpose of DFDB is web based quality monitoring of fracture related surgery and today these efforts are joined by 2 orthopaedic departments in Denmark, covering close to 9% of the Danish population. The effort to monitor quality of fracture related surgery in Denmark is unique and important: Unique because DFDB is the fracture register with the highest national coverage in the world and important given the high number of surgeries performed each year probably making fracture surgery/traumatology one of the busiest specialties within orthopaedic surgery. Previously it has not been possible to assess nationwide quality of all fracture related surgeries. We wish to thank all the participating surgeons and departments taking part in this unique and important task. It is truly inspirational to realize the unity DFDB has brought into orthopaedic traumatology in Denmark. Also the continued support from The Danish Orthopaedic Society (DOS) and Danish Orthopaedic Trauma Society (DOT), and the possibility to present the annual report at the DOS Congress is much appreciated. The annual report is structured as previously with general data overview of registered parameters followed by department specific data, and finally the major body of the report with specific data for each anatomic region, e.g. proximal humerus, distal radius, and proximal femur. This years focus area is surgically treated clavicular fractures, a hot topic in recent years, and currently under scrutiny with new national treatment guidelines being recently published by DOT. A basic principle surrounding DFDB is that surgeons reporting to the database should get feedback concerning the quality of treatment. This is delivered via and entails surgeon specific (only to be seen by the individual surgeon), department specific (the surgeon can only see data from his/her own department), and nationwide feedback on the rate of reoperations performed. The level of detail send by can be configured by the surgeon when logged in to DFDB. It is our hope that with time this feedback from DFDB can support surgeons in making decisions about best practice in fracture related surgery. In Sweden a Fracture Register has been established too ( DFDB has engaged in cooperation with colleagues in Sweden and Norway to establish a core dataset of common parameters that will make it possible to join data and efforts across Scandinavia. Further, the efforts to become a national clinical quality monitoring database are ongoing. Finally, a platform to scan, trace and monitor orthopaedic implants has been introduced and taken in use at one department. The scanned implants are linked together with registrations in DFDB. It is a hope that the needed and important task of monitoring quality of specific implants and groups of implants can soon be undertaken in DFDB. We hope to see more departments join DFDB in the future. Hvidovre, d. 12. September, 215 Anders Troelsen, Michael Brix, Kirill Gromov

2 Table on contents About the Danish Fracture Database.1 Summary and comments 2 Data limitations 3 General overview of data.5 Department specific data 19 Focus area - Clavicle..39 Adult Proximal Humerus.44 Humeral shaft 49 Distal humerus..54 Proximal antebrachium 59 Antebrachium.64 Distal radius..69 Hand.74 Proximal femur..79 Acetabulum..84 Femur..89 Distal femur..94 Patella.99 Proximal tibia..14 Tibia shaft 19 Distal tibia 114 Malleoli 119 Foot 124 Shoulder 129 Pediatric Humerus..134 Radius/Ulna.139 Femur..144 Tibia/Fibula..149 Hand.154 Foot 158 Appendix 1 - Registered parameters...162

3 About the Danish Fracture Database Background and recent development The aim of the Danish Fracture Database is to monitor the quality of surgical fracture treatment by assessing the rate of revision surgery both in general and for each fracture type specifically. This assessment results in a potential quality improvement through focus on specific fracture types where the quality of treatment is not considered high enough. Lastly, epidemiologic research in fracture surgery will contribute to identify surgical and fracture related prognostic factors for a good or poor outcome of surgery. The use of DFDB provides each participating department the possibility to monitor own data and thus the quality of their fracture treatment. The educational level of both the surgeon and the supervisor is registered and can therefore also be monitored. During the past year, there has been a marked escalation of data entry. The number of registered surgeries has increased from approximately 28. in 214 to more than 4. in 215. Secretariat and daily operations Each participating department has a controller in daily charge of complete reporting. The daily operation is also supported by a secretariat, which was established last year at the Department of Orthopaedic Surgery, Hvidovre Hospital. The secretariat consists of an administrator, Alina Hansen, and a statistician, Thomas Kallemose. Together the developers of DFDB and the secretariat has the responsibility and right to development and changes of the registry in cooperation with the provider Procordo Aps. Steering Committee The idea behind DFDB and the registry s recent progress are attributed to Michael Brix and Anders Troelsen. Kirill Gromov contributed substantially to the registry s developmental phase. Michael, Anders and Kirill are today a part of the DFDB steering committee and are responsible for the registry s overall administration, quality monitoring, and research. In addition, each participating department is represented in the steering committee. Both DOT (Danish Orthopaedic Trauma Society) and DOS (Danish Orthopaedic Society) are represented in the steering committee. A minimum of one annual meeting is held in order to correct inexpediencies, increase the usability, and optimize the database through the members feedback. 1

4 Summary and comments In this annual report from DFDB we present a general overview of registered data as well as data for specific anatomical regions. The general overview covers basic demographics (age, gender and ASA score) for all primary surgeries as well as reoperations. Anatomical distribution of registered primary surgeries and reoperations as well as indications for reoperations are described. We describe the educational level of the primary surgeon and level of supervision for primary surgeries. Anatomical distribution for primary surgeries for all separate departments participating in the DFDB collaboration is described in the first part of the report. For definitions and specifications of the different parameters please see Appendix 1. Demographics 84% of primary procedures were due to adult fractures and 16% due to pediatric fractures. Age distribution was biphasic, with first peak at age -2 and second peak at age 6-9. More males were surgically treated for fractures when age <5, while more female were surgically treated for fractures when age >5. 76% of patients with primary surgeries had ASA score 1-2 while 78% of patients with reoperations had ASA score % of all registered patients were female. Reoperations Proximal femur (27%), malleoli (2%), and distal radius (7%) were the 3 most frequently reoperated anatomical regions in adults. Radius/ulna (47%), humerus (21%) and tibia (18%) were the 3 most frequently reoperated anatomical regions in children. Pain and discomfort due to osteosynthesis material (38%), secondary fracture dislocation (15%), and infection 13%) were the 3 most frequent indications for adult reoperations. Secondary fracture dislocation (39%), suboptimal osteosynthesis (21%), and pain and discomfort due to osteosynthesis material (22%) were the 3 most frequent indications for paediatric reoperations. Level of education 6% of all primary surgeries were performed by surgeons in training (intern- 5th year resident). Interns, 1 st year resident, 2 nd year resident, and 3 rd year residents performed more procedures under supervision than without supervision, while 4-5 th year residents, attending surgeons, and traumatologist performed more procedures without supervision than with supervision Anatomical distribution Proximal femur (35%), distal radius (15%), and malleoli (12%) were the 3 most frequent operated regions for primary adult surgical procedures. Radius/ulna (58%), humerus (22%), and tibia (9%) were the 3 most frequently operated regions for primary paediatric surgical procedures. 2

5 Data limitations There are some limitations to the data in this report. Essential limitations are: 1) Data completeness for treatment of primary fractures 2) Data completeness for reoperations Initially, after full implementation of DFDB at the orthopaedic departments in Hvidovre and Odense, an evaluation of data validity and data completeness for treatment of primary fractures and reoperations was performed (Gromov 213). Two plausible factors to limit data completeness were identified: 1) that the registry had only been implemented for few months, and 2) that both departments are large, with regularly 5-9 possible surgeons. The results of the study showed that the validity of data (the percentage of data that was correct when compared to the best external data source outside of DFDB) was 9-1% for all parameters, and most above 97%. The total degree of completeness for data entry of primary fracture treatment was 88% and for reoperations it was 77%. Thus, there was, at an early point in time after initiation of DFDB, a satisfactory degree of data validity and data completeness under the prevailing circumstances. Similar evaluations of data completeness should be performed continuously. Another limitation is lacking reoperation data performed at non-participating departments where the primary operation was performed and registered at a participating department. The extent of this phenomenon can be investigated by using data from the National Patient Registry (Landspatientregistret, LPR). For this year s report, data was not extracted from LPR with regards to knowing the true number of reoperations, why the rates of reoperations and survival curves are underestimated. However, as the number of departements participating in DFDB collaboration has risen to 2, covering close to 9% of the Danish population, such underestimation is significantly reduced. Reoperation rates and curves are presented to illustrate the potential of data analysis with the DFDB. Currently, work is ongoing to validate the primary fracture codes that are registered in the LPR, to know the validity of these codes if they are to be used as a data source for the DFDB. Furthermore, definition and validation of the reoperation codes in LPR to investigate the applicability of the LPR as a data source for the DFDB is ongoing. Fracture diagnosis in Danish National Patient Registry (NPR) have been investigated by Andersen et al. The overall validity of data was 86%. The NPR diagnosis code was correct in 94% of all cases and the NPR anatomic region was correct in 99% of all cases. In 91% of all cases the operation code was correct and the anatomic region for the operation was correct in 99% of all cases. NPR coding will be used in the future for continuous completeness monitoring of DFDB data. Data was extracted from DFDB on August 8 th 215. References Gromov K, Fristed JV, Brix M, Troelsen A. Completeness and data validity for the Danish Fracture Database. Danish medical journal. 213 Oct;6 (1):A4712. PubMed PMID:

6 Participating departments Aabenraa Aalborg Aarhus Bispebjerg Esbjerg Farsø Gentofte Herlev Hillerød Holbæk Horsens Hvidovre Kolding Køge Nykøbing Falster Odense Randers Rigshospitalet Slagelse Vejle Viborg 4

7 General overview of data The graphs in this section covers general areas such as surgery type distribution, primary indication for reoperation, and primary surgeon, which uses data from all participating departments. 4 Fracture types (41856) 84% % Adult Pediatric 4 Procedure types (38262) 9% % Primary Reoperation 5

8 4 Procedure types by fracture types (37815) Primary (33992) Reoperation (2418) Pain from osteosynthesis (145) 3 89% 2 1 Adult 95% 7% 4% Pediatric 4% 1% 12 Anatomical distribution Primary procedure Adult fractures (2918) 1 35% % 12% 2 4% 3% 1% 2% 1% Humeral shaft Proximal humerus 8% Patella Distal femur Femur Acetabulum Proximal femur Hand Distal radius Antebrachium Proximal antebrachium Distal humerus Foot Malleoli Distal tibia Tibia shaft Proximal tibia 1% 2% 1% 1% 3% 3% 1% 2% 3% % Scapula Clavicle 6

9 2 Anatomical distribution Reoperations Adult fractures (3555) % 2% 5 7% 5% 3% 1% 2% 1% 2% Proximal antebrachium Distal humerus Humeral shaft Proximal humerus Proximal femur Hand Distal radius Antebrachium 7% 2% 4% 3% 3% 4% 2% Patella Distal femur Femur Acetabulum Malleoli Distal tibia Tibia shaft Proximal tibia 5% 2% Shoulder Foot 4 Anatomical distribution Primary procedure Pediatric fracture (4985) 3 58% 2 22% 1 Humerus Radius/Ulna 4% Femur 9% Tibia/Fibula 6% Hand 1% Foot 7

10 2 Anatomical distribution Reoperation Pediatric fractures (267) % 5 21% Humerus Radius/Ulna 9% Femur 18% Tibia/Fibula 5% Hand % Foot 2 Primary indication for reoperation Adult fractures (3532) 15 38% % 9% 15% 9% 9% Infection Hematoma Bone necrosis Arthroplasty dislocation Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis Not identified preoperative fracture New fracture Neurovascular complication 1% 1% 2% % Muscle and soft-tissue revision 2% % 8

11 14 Primary indication for reoperation Pediatric fractures (263) % % 22% 4 2 5% Infection 1% 1% 5% New fracture Neurovascular complication Muscle and soft-tissue revision 1% Bone necrosis Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis 5% Not identified preoperative fracture 1% ASA-score for procedure types Adult fractures (32563) 4% Primary (297) Reoperation (3556) 36% % 4 2 4% 38% 21% 2% 1% % %

12 6 ASA-score for procedure types Pediatric fractures (525) Primary (4983) Reoperation (267) 5 98% % 2% 3% % % % % Gender (42316) 25 56% % 5 Female Male 1

13 3 Time of primary procedure Adult fractures (297) Time of day 6 Time of primary procedure Pediatric fracture (4983) Time of day 11

14 14 Surgeon level Primary procedure (3439) 12 33% % 13% 13% 14% 4 6% 2 % Intern Attending 4-5 year resident 3 year resident 2 year resident 1 year resident Traumatologist Surgeon level by procedure types Adult fractures (3252) Primary (28965) Reoperation (3555) 1 33% 8 6 2% 4 14% 13% 14% 2 % 1% Intern 17% 1 year resident 7% 4-5 year resident 3 year resident 2 year resident 44% 11% 1% Attending 7% 9% Traumatologist 12

15 25 Surgeon level by procedure types Pediatric (5246) Primary (4979) Reoperation (267) 2 35% % 16% 13% 13% 5 % % Intern 11% 1 year resident 9% 2 year resident 7% 3 year resident 14% Attending 4-5 year resident 5% 49% 1% Traumatologist 5 4 Time of primary procedure by surgeons level Adult fractures (28963) Intern (88) 1 year resident (5813) 2 year resident (3962) 3 year resident (3695) 4-5 year resident (49) Attending (9425) Traumatologist (189) Time of day 13

16 Time of primary surgery by surgeons level Pediatric fractures (4979) 8 6 Intern (15) 1 year resident (95) 2 year resident (635) 3 year resident (63) 4-5 year resident (778) Attending (1763) Traumatologist (253) Time of day 25 Level of supervision for all fracture types Primary procedure (33457) 2 58% % 5 % % 1% 2% Intern 1 year resident 2 year resident 8% Attending 4-5 year resident 3 year resident 4% Unsupervised Traumatologist 14

17 5 Level of supervision for interns and residents Adult fractures (17559) Below attending (3566) Attending or above (7596) Unsupervised (6397) % 5% 41% 35% 53% 39% 71% 1 13% 24% 26% 48%44% 8% Intern 1 year resident 2 year resident 8% 3 year resident 3% 4-5 year resident 1 Level of supervision for interns and residents Pediatric fractures (2943) Below attending (564) Attending or above (1183) Unsupervised (1196) % 5% 49% 77% 38%38% 4% 2 36%64% % Intern 13% 1 year resident 24% 2 year resident 11% 3 year resident 22% 1% 4-5 year resident 15

18 Survival for primary procedure with reoperation due to any reason as endpoint All procedures (3436) probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware All procedures (3436).98 probability days 16

19 1. Survival for primary procedure with reoperation due to any reason Adult and pediatric fractures (33989).98 probability Adult Pediatric days 5 Age distribution for gender Primary procedure (34285) Female (1954) Male (14745) 4 19% 21% 18% % 16% 1% 1% 11% 12% 11% 1% 8% 6% 8% 9% 1 5% 5% 3% 3% 2% 2% 2% Age Group 17

20 12 1 Trauma patients by anatomical distribution Adult fractures (2912) 2% No (27329) Yes (1683) % 4% 3% 2 4% 12% 6% 6% 2% Proximal antebrachium Distal humerus Humeral shaft Proximal humerus Patella Distal femur Femur Acetabulum Proximal femur Hand Distal radius Antebrachium 59% 2% 14% 7% 1% 18% 15% Malleoli Distal tibia Tibia shaft Proximal tibia 12% 12% 24% Scapula Clavicle Foot 35 3 Trauma patients by anatomical distribution Pediatric fractures (4984) 1% No (4859) Yes (125) % 5 Humerus 19% Femur Radius/Ulna 5% Tibia/Fibula 2% Hand 7% Foot 18

21 Department specific data This section provides department specific data for all 2 participating departments. The data covers anatomical distribution for primary procedure for adults and pediatric. Aabenraa 14 Anatomical distribution for Aabenraa Primary procedure Adult fractures (227) % 4 12% 15% 2 6% 4% 2% 1% 1% Proximal antebrachium Distal humerus Humeral shaft Proximal humerus 6% Distal femur Femur Proximal femur Hand Distal radius Antebrachium Foot Malleoli Distal tibia Tibia shaft Proximal tibia Patella 2% 1% 1% 2% 3% 1% 1% 5% % Scapula Clavicle 3 Anatomical distribution for Aabenraa Primary procedure Pediatric fractures (363) 25 59% % 5 Humerus Femur Radius/Ulna 5% 7% Tibia/Fibula 6% Hand 1% Foot 19

22 Aalborg 2 Anatomical distribution for Aalborg Primary procedure Adult fractures (38) % 26% 18% 5 11% 8% 3% 3% Femur Proximal femur Distal femur Tibia shaft Proximal tibia Distal tibia Malleoli 2

23 Aarhus 25 Anatomical distribution for Aarhus Primary procedure Adult fractures (33) 2 52% % 5 9% Distal radius 3% Hand Proximal femur 3% Femur Malleoli 1 Anatomical distribution for Aarhus Primary procedure Pediatric fractures (6) % 2 17% Humerus Radius/Ulna 21

24 Bispebjerg 5 Anatomical distribution for Bispebjerg Primary procedure Adult fractures (934) % 33% 16% 1 2% 1% 2% 7% Proximal antebrachium Distal humerus Humeral shaft Proximal humerus Femur Proximal femur Hand Distal radius Antebrachium 1% 6% Distal tibia Tibia shaft Proximal tibia Patella Distal femur 2% 1% 2% 4% 2% 2% 1% Foot Malleoli 5% Clavicle 2. Anatomical distribution for Bispebjerg Primary procedure Pediatric fractures (2) % 5%.5. Radius/Ulna Tibia/Fibula 22

25 Esbjerg 8 Anatomical distribution for Esbjerg Primary procedure Adult fractures (1574) 6 33% 4 2 6% Proximal antebrachium Distal humerus Humeral shaft Proximal humerus 1% 2% 3% 1% 15% 1% Patella Distal femur Femur Acetabulum Proximal femur Hand Distal radius Antebrachium Foot Malleoli Distal tibia Tibia shaft Proximal tibia % 2% 1% 1% 2% 3% 1% 14% 1% 3% % Scapula Clavicle 2 Anatomical distribution for Esbjerg Primary procedure Pediatric fractures (268) 15 52% 1 23% 5 13% Humerus Radius/Ulna 3% Femur Tibia/Fibula 6% Hand 2% Foot 23

26 Gentofte 5 Anatomical distribution for Gentofte Primary procedure Adult fractures (57) 4 72% % 1 Distal radius Hand 5 Anatomical distribution for Gentofte Primary procedure Pediatric fractures (2) % 1 Hand 24

27 Herlev 1 Anatomical distribution for Herlev Primary procedure Adult fractures (147) % 21% 2 Humeral shaft Proximal humerus Acetabulum Proximal femur Hand Distal radius Antebrachium Proximal antebrachium Distal humerus 4% 1% 2% 4% 6% 1% 1% Foot Malleoli Distal tibia Tibia shaft Proximal tibia Patella Distal femur Femur % 3% 1% 2% 3% 3% 1% 1% 1% % Scapula Clavicle 25 Anatomical distribution for Herlev Primary procedure Pediatric fractures (311) 2 65% % 5 Humerus Radius/Ulna 2% Femur 8% Tibia/Fibula % 1% Hand Foot 25

28 Hillerød 6 Anatomical distribution for Hillerød Primary procedure Adult fractures (883) % 38% 19% 1 3% 1% % 1% % Proximal antebrachium Distal humerus Humeral shaft Proximal humerus Distal femur Femur Proximal femur Hand Distal radius Antebrachium 6% Foot Malleoli Distal tibia Tibia shaft Proximal tibia Patella 2% 1% 1% 3% 3% 2% 2% 3% Clavicle 2 Anatomical distribution for Hillerød Primary procedure Pediatric fractures (234) 15 61% % 13% Humerus Radius/Ulna 2% Femur Tibia/Fibula 2% Hand 26

29 Holbæk 6 Anatomical distribution for Holbæk Primary procedure Adult fractures (891) % 1 Scapula Clavicle Foot Malleoli Distal tibia Tibia shaft Proximal tibia Patella Distal femur Femur Acetabulum Proximal femur Hand Distal radius Antebrachium Proximal antebrachium Distal humerus Humeral shaft Proximal humerus 1% 2% 1% 3% 1% 7% 2% % 2% 2% 1% 4% 2% 1% 13% 1% 2% % 2 Anatomical distribution for Holbæk Primary procedure Pediatric fractures (236) 15 59% % Humerus Femur Radius/Ulna 6% 1% Tibia/Fibula % 2% Hand Foot 27

30 Horsens 35 Anatomical distribution for Horsens Primary procedure Adult fractures (542) % 1 15% 15% 5 Clavicle Foot Malleoli Distal tibia Tibia shaft Proximal tibia Patella Distal femur Femur Acetabulum Proximal femur Hand Distal radius Antebrachium Proximal antebrachium Distal humerus Humeral shaft Proximal humerus 5% 2% 1% 1% 2% 6% % 2% 1% 1% 2% 3% 1% 3% 2% 8 Anatomical distribution for Horsens Primary procedure Pediatric fractures (15) 63% % 15% Humerus Radius/Ulna 2% Femur Tibia/Fibula 5% Hand 28

31 Hvidovre 3 Anatomical distribution for Hvidovre Primary procedure Adult fractures (4624) Clavicle Foot Malleoli Distal tibia Tibia shaft Proximal tibia Patella Distal femur Femur Acetabulum Proximal femur Hand Distal radius Antebrachium Proximal antebrachium Distal humerus Humeral shaft Proximal humerus 3% 1% 2% 4% 1% 14% 5% 37% % 2% 2% 1% 3% 4% 1% 17% 1% 2% 1 Anatomical distribution for Hvidovre Primary procedure Pediatric fractures (1384) 62% % 2 Humerus Femur Radius/Ulna 4% 5% Tibia/Fibula 4% Hand 1% Foot 29

32 Kolding 14 Anatomical distribution for Kolding Primary procedure Adult fractures (2678) % 27% 4 2 Acetabulum Proximal femur Hand Distal radius Antebrachium Proximal antebrachium Distal humerus Humeral shaft Proximal humerus 6% 2% 2% 3% 2% 9% 3% 2% 1% % Distal femur Femur Foot Malleoli Distal tibia Tibia shaft Proximal tibia Patella 4% 2% 2% 12% 1% 4% % Scapula Clavicle 4 Anatomical distribution for Kolding Primary procedure Pediatric fractures (63) 3 45% 2 31% 1 13% Humerus Femur Radius/Ulna 7% Tibia/Fibula 4% Hand 1% Foot 3

33 Køge 12 Anatomical distribution for Køge Primary procedure Adult fractures (223) % 32% 13% 2 5% 1% 2% 4% 1% Proximal antebrachium Distal humerus Humeral shaft Proximal humerus 6% Femur Acetabulum Proximal femur Hand Distal radius Antebrachium % 2% 4% 3% 1% 1% 1% Tibia shaft Proximal tibia Patella Distal femur Scapula Clavicle Foot Malleoli Distal tibia 1% 3% % 35 Anatomical distribution for Køge Primary procedure Pediatric fractures (399) % % 5 Humerus Femur Radius/Ulna 3% 1% Tibia/Fibula 5% Hand 1% Foot 31

34 Nykøbing Falster 3 Anatomical distribution for Nykøbing F Primary procedure Adult fractures (557) 25 41% % 12% 5 Acetabulum Proximal femur Hand Distal radius Antebrachium Proximal antebrachium Distal humerus Humeral shaft Proximal humerus 6% 2% 1% 3% 1% 4% Distal femur Femur Foot Malleoli Distal tibia Tibia shaft Proximal tibia Patella 3% 2% 3% 3% 3% % 1% 1% % Clavicle 6 Anatomical distribution for Nykøbing F Primary procedure Pediatric fractures (88) 5 49% % 1 Humerus Radius/Ulna 2% Femur 7% Tibia/Fibula 11% Hand 32

35 Odense 2 Anatomical distribution for Odense Primary procedure Adult fractures (3836) % 1% 1% 3% 2% 1% Proximal antebrachium Distal humerus Humeral shaft Proximal humerus 7% 29% Femur Acetabulum Proximal femur Hand Distal radius Antebrachium 5% 5% 6% 4% 2% 2% 1% Patella Distal femur Distal tibia Tibia shaft Proximal tibia 15% 4% 1% % Scapula Clavicle Foot Malleoli 4 Anatomical distribution for Odense Primary procedure Pediatric fractures (52) 3 56% 2 1 2% Humerus Femur Radius/Ulna 8% 9% Tibia/Fibula 5% Hand 1% Foot 33

36 Randers 2 Anatomical distribution for Randers Primary procedure Adult fractures (349) 15 4% 1 17% 5 13% 5% Proximal antebrachium Distal humerus Humeral shaft Proximal humerus 1% 1% 2% 1% 7% Femur Proximal femur Hand Distal radius Antebrachium 4% 1% 2% 2% 3% % Proximal tibia Patella Distal femur Distal tibia Tibia shaft Foot Malleoli % 1% Clavicle 5 Anatomical distribution for Randers Primary procedure Pediatric fractures (56) 4 61% % 4% 9% 9% Humerus Radius/Ulna Femur Tibia/Fibula Hand 34

37 Rigshospitalet 5 Anatomical distribution for Rigshospitalet Primary procedure Adult fractures (1354) % 1% 14% 1 5% 6% 4% 5% 4% 3% 3% 3% Proximal antebrachium Distal humerus Humeral shaft Proximal humerus Femur Acetabulum Proximal femur Hand Distal radius Antebrachium 7% 5% 5% 3% 4% 1% Proximal tibia Patella Distal femur Foot Malleoli Distal tibia Tibia shaft 5% 1% Scapula Clavicle 1 Anatomical distribution for Rigshospitalet Primary procedure Pediatric fractures (163) 8 44% % 17% 2 1% Humerus Radius/Ulna Femur Tibia/Fibula 4% Hand 3% Foot 35

38 Slagelse 14 Anatomical distribution for Slagelse Primary procedure Adult fractures (2851) % 19% 3% 4 12% 2 Acetabulum Proximal femur Hand Distal radius Antebrachium Proximal antebrachium Distal humerus Humeral shaft Proximal humerus % % 2% 3% 1% Distal femur Femur Foot Malleoli Distal tibia Tibia shaft Proximal tibia Patella 2% 2% 2% 3% 3% 1% % 1% 1% Clavicle 4 Anatomical distribution for Slagelse Primary procedure Pediatric fractures (519) % 5% 15% 12% Humerus Radius/Ulna 2% Femur Tibia/Fibula Hand % Foot 36

39 Vejle 14 Anatomical distribution for Vejle Primary procedure Adult fractures (235) % 31% 4 14% 16% 2 1% 1% 2% 2% Proximal antebrachium Distal humerus Proximal humerus Proximal tibia Patella Distal femur Proximal femur Hand Distal radius Antebrachium Foot Malleoli Distal tibia Tibia shaft 1% 3% 2% 1% 1% 3% 2% Clavicle 4 Anatomical distribution for Vejle Primary procedure Pediatric fractures (35) 3 86% 2 1 Radius/Ulna 9% Tibia/Fibula 6% Hand 37

40 Viborg 4 Anatomical distribution for Viborg Primary procedure Adult fractures (763) % Proximal antebrachium Distal humerus Humeral shaft Proximal humerus 1% 2% 2% 2% 2% 9% 31% Femur Proximal femur Hand Distal radius Antebrachium Foot Malleoli Distal tibia Tibia shaft Proximal tibia Patella Distal femur 2% 1% 2% 2% 2% 1% 14% 1% 2% % Scapula Clavicle 14 Anatomical distribution for Viborg Primary procedure Pediatric fractures (186) % % 15% 2 Humerus Femur Radius/Ulna 1% Tibia/Fibula 5% Hand 1% Foot 38

41 Focus area - Clavicle 12 Fracture classification for Shoulder fractures (958) 1 96% Clavicle 4% Scapula 1 Method of osteosynthesis Clavicle fractures Primary procedure (913) 92% % Plate Other 39

42 4 Indication for reoperations of Clavicle fractures (56) 3 54% 2 23% 1 9% Infection 2% New fracture 4% Suboptimal osteosynthesis 9% Secondary fracture dislocation or osteosynthesis failure Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union 6 Surgeon level for Clavicle fractures (917) 5 55% % 14% 1 6% 5% 5% 2 year resident 1 year resident Attending 4-5 year resident 3 year resident Traumatologist 4

43 8 Level of supervision for Clavicle fractures (886) 75% % % % 2 year resident 3% 4-5 year resident 3 year resident Attending 3% Traumatologist Unsupervised 2 Level of supervision for interns and residents Clavicle fractures (282) Below attending (3) Attending or above (166) Unsupervised (86) % 38% 5 76% 73% 89% 24% 1 year resident % 18% 2 year resident 9% 4% 3 year resident 6% 6% 4-5 year resident 41

44 Surgical delay for Clavicle fractures (577) % 22 % 2 % 16 % 12 % 8 % 5 % Hours (Proportion of patients operated in 24 hour intervals) 2 Time of primary Clavicle procedure Adult fractures (917) Time of day 42

45 1. Survival for primary procedure with reoperation due to any reason Clavicle fractures (917).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware Clavicle fractures (917).95 probability days 43

46 Adult Proximal Humerus 1 Method of osteosynthesis proximal humerus fractures (1136) 8 6% % 2 9% Arthroplasty Plate Other 6 Indication for reoperations of proximal humerus fractures (114) % 3% 27% 1 7% 1% 7% Infection 1% New fracture Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis 1% Arthroplasty dislocation 2% Bone necrosis Hematoma 44

47 1 Surgeon level for proximal humerus fractures (1147) 8 68% % 3% 4% 1 year resident 2 year resident 1% 4-5 year resident 3 year resident Attending 14% Traumatologist 1 Level of supervision for proximal humerus fractures (181) 8 76% % % % Intern 4-5 year resident Attending 4% Traumatologist Unsupervised 45

48 14 12 Level of supervision for interns and residents proximal humerus fractures (21) Below attending (3) Attending or above (176) Unsupervised (31) 1 76% % 4 91% 24% 2 94% % 1 year resident 6% 9% 2 year resident % % 3 year resident 5% % 4-5 year resident Surgical delay for proximal humerus fractures (794) 2 14 % 23 % 18 % 16 % 12 % 9 % 7 % Hours (Proportion of patients operated in 24 hour intervals) 46

49 1. Survival for primary procedure with reoperation due to any reason proximal humerus fractures (1147).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware proximal humerus fractures (1147).95 probability days 47

50 5 Fracture classification for proximal humerus fractures (1147) A 11B 11C 48

51 Humeral shaft 35 Method of osteosynthesis humeral shaft fractures (347) 3 75% % 5 6% Intramedullary nail(s) Plate Other 35 Indication for reoperations of humeral shaft fractures (47) % 1 19% 17% 5 4% Infection 2% 2% New fracture Neurovascular complication Muscle and soft-tissue revision 4% 4% Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union 49

52 3 Surgeon level for humeral shaft fractures (351) 25 66% % 5 % 1% Intern 2 year resident 1 year resident 3% 3% 8% 4-5 year resident 3 year resident Attending Traumatologist 35 Level of supervision for humeral shaft fractures (34) 3 78% % % 3 year resident Attending 4-5 year resident 17% 5% Traumatologist Unsupervised 5

53 3 25 Level of supervision for interns and residents humeral shaft fractures (55) Below attending (1) Attending or above (43) Unsupervised (11) % 91% 64% 32% 5 1% 1% % % Intern 9% 4% % % % % % 1 year resident 2 year resident 3 year resident 4-5 year resident Surgical delay for humeral shaft fractures (21) 8 24 % 23 % 15 % 13 % 12 % 6 % 5 % Hours (Proportion of patients operated in 24 hour intervals) 51

54 1. Survival for primary procedure with reoperation due to any reason humeral shaft fractures (351).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware humeral shaft fractures (351).95 probability days 52

55 2 Fracture classification for humeral shaft fractures (351) A 12B 12C 53

56 Distal Humerus 4 Method of osteosynthesis distal humerus fractures (462) 72% % 11% 6% External fixation Plate Screw(s) Other 6 Indication for reoperations of distal humerus fractures (85) 5 52% % Infection 2% 2% 4% New fracture Neurovascular complication Muscle and soft-tissue revision 6% 16% Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis 6% Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union 54

57 4 Surgeon level for distal humerus fractures (466) 3 58% 2 1 5% 2% 1 year resident 3 year resident 2 year resident 18% 6% Attending 4-5 year resident 11% Traumatologist 4 Level of supervision for distal humerus fractures (454) 3 68% % % % 2 year resident 3% 4-5 year resident 3 year resident Attending 8% Traumatologist Unsupervised 55

58 1 Level of supervision for interns and residents distal humerus fractures (145) Below attending (13) Attending or above (97) Unsupervised (35) % 32% 76% 2 9% 91% 1 year resident % 38% 48% 14% 7% 2 year resident 3 year resident 17% 2% 4-5 year resident Surgical delay for distal humerus fractures (392) 12 3 % 29 % 16 % 12 % 5 % 5 % 4 % Hours (Proportion of patients operated in 24 hour intervals) 56

59 1. Survival for primary procedure with reoperation due to any reason distal humerus fractures (468).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware distal humerus fractures (468).95 probability days 57

60 25 Fracture classification for distal humerus fractures (468) A 13B 13C 58

61 Proximal antebrachium 6 Method of osteosynthesis proximal antebrachium fractures (937) 5 54% % 1 6% 1% Plate Screw(s) Wire(s) Other 14 Indication for reoperations of proximal antebrachium fractures (172) 12 63% % Infection New fracture Muscle and soft-tissue revision 1% 3% 5% 12% Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis 7% Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union 59

62 6 Surgeon level for proximal antebrachium fractures (948) % 2 15% 13% 13% 16% 1 6% 3 year resident 2 year resident 1 year resident Attending 4-5 year resident Traumatologist 8 Level of supervision for proximal antebrachium fractures (927) 6 6% 4 24% 2 % 1% 1 year resident 3 year resident 2 year resident 8% 3% Attending 4-5 year resident 5% Traumatologist Unsupervised 6

63 2 Level of supervision for interns and residents proximal antebrachium fractures (54) Below attending (19) Attending or above (24) Unsupervised (191) % 52% 67% 5 38% 28% 41% 31% 37% 29% 5% 11% 4% 1 year resident 2 year resident 3 year resident 4-5 year resident 35 Surgical delay for proximal antebrachium fractures (832) 31 % 27 % 16 % 11 % 6 % 6 % 3 % Hours (Proportion of patients operated in 24 hour intervals) 61

64 1. Survival for primary procedure with reoperation due to any reason proximal antebrachium fractures (95).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware proximal antebrachium fractures (95).95 probability days 62

65 1 Fracture classification for proximal antebrachium fractures (95) A 21B 21C 63

66 Antebrachium 4 Method of osteosynthesis antebrachium fractures (386) 88% % 6% External fixation Plate Other 35 Indication for reoperations of antebrachium fractures (43) % 1 5 9% Infection 2% 7% 7% New fracture Neurovascular complication 5% Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis 16% Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union 64

67 25 Surgeon level for antebrachium fractures (41) % 36% 5 11% 12% 15% 6% % Intern Attending 4-5 year resident 3 year resident 2 year resident 1 year resident Traumatologist 3 Level of supervision for antebrachium fractures (393) 25 56% % 5 % 1% 1 year resident 3 year resident 2 year resident 7% 3% Attending 4-5 year resident 5% Traumatologist Unsupervised 65

68 1 Level of supervision for interns and residents antebrachium fractures (233) Below attending (42) Attending or above (116) Unsupervised (75) % 66% 56% 52% 31% 2 44% 33% 25% % 1% % Intern % 1 year resident 15% 2 year resident 7% 3 year resident 2% 4-5 year resident Surgical delay for antebrachium fractures (35) % 23 % 11 % 5 % 1 % 2 % 3 % Hours (Proportion of patients operated in 24 hour intervals) 66

69 1. Survival for primary procedure with reoperation due to any reason antebrachium fractures (41).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware antebrachium fractures (41).95 probability days 67

70 25 Fracture classification for antebrachium fractures (41) A 22B 22C 68

71 Distal radius 5 Method of osteosynthesis distal radius fractures (4284) 4 93% % Plate Other 14 Indication for reoperations of distal radius fractures (233) 12 48% % 16% 2 3% 3% Infection 8% 1% New fracture Neurovascular complication Muscle and soft-tissue revision 4% Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis Hematoma Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union 1% 69

72 25 Surgeon level for distal radius fractures (4366) % 17% 12% 15% 31% % Intern 4-5 year resident 3 year resident 2 year resident 1 year resident Attending 4% Traumatologist 35 Level of supervision for distal radius fractures (4265) 3 61% % 5 % 1% Intern 2 year resident 1 year resident 2% 3% Attending 4-5 year resident 3 year resident 9% 3% Unsupervised Traumatologist 7

73 1 Level of supervision for interns and residents distal radius fractures (284) Below attending (632) Attending or above (963) Unsupervised (129) % 41% 43% 82% 37% 44% 47% 2 67% 33% % Intern 13% 1 year resident 2% 2 year resident 1% 3 year resident 3% 14% 4-5 year resident Surgical delay for distal radius fractures (38) % 27 % 15 % 1 % 8 % 5 % 3 % Hours (Proportion of patients operated in 24 hour intervals) 71

74 1. Survival for primary procedure with reoperation due to any reason distal radius fractures (4376).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware distal radius fractures (4376).95 probability days 72

75 25 Fracture classification for distal radius fractures (4375) A 23B 23C 73

76 Hand 25 Method of osteosynthesis hand fractures (2352) 2 8% % 1% K-wire(s) Screw(s) Other 4 Indication for reoperations of hand fractures (8) % 31% 21% 1 8% 8% 1% Infection 1% 1% New fracture Neurovascular complication Muscle and soft-tissue revision Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis Bone necrosis Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union 2% 74

77 14 Surgeon level for hand fractures (2381) 12 44% % 13% 11% 12% 2 % Intern Attending 4-5 year resident 3 year resident 2 year resident 1 year resident 5% Traumatologist Level of supervision for hand fractures (2328) 2 69% % % 1% 1% 1 year resident 2 year resident 5% 4-5 year resident 3 year resident Attending 2% Traumatologist Unsupervised 75

78 4 Level of supervision for interns and residents hand fractures (1199) Below attending (171) Attending or above (488) Unsupervised (54) % 53% 46% 41% 45% 52% 83% 1 14% 14% 17% 83% 17% % Intern 1 year resident 2 year resident 3% 3 year resident 1% 4-5 year resident Surgical delay for hand fractures (1964) 6 36 % 25 % 13 % 1 % 7 % 5 % 3 % Hours (Proportion of patients operated in 24 hour intervals) 76

79 1. Survival for primary procedure with reoperation due to any reason hand fractures (238).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware hand fractures (238).95 probability days 77

80 14 Fracture classification for hand fractures (2381) 12 45% % 4% 4% 1. metacarpal Wrist bones 1% 1. distal phalanx 1. proximal phalanx 18% 1% 2-5 middle phalanx 2-5 proximal phalanx 2-5 metacarpal 6% 2-5 distal phalanx 78

81 Proximal femur 6 Method of osteosynthesis proximal femur fractures (1127) % 34% 14% 16% 1 4% Arthroplasty Screw(s) Intramedullary nail(s) Other Sliding hip screw(s) 6 Indication for reoperations of proximal femur fractures (953) % 18% 16% 34% 1 Infection % Bone necrosis Arthroplasty dislocation Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis Not identified preoperative fracture New fracture 4% % 3% Muscle and soft-tissue revision 5% 6% % Hematoma 79

82 6 Surgeon level for proximal femur fractures (111) % 17% 16% 13% 2% 1 1% Intern Attending 4-5 year resident 3 year resident 2 year resident 1 year resident 2% Traumatologist 6 Level of supervision for proximal femur fractures (986) 5 49% % 12% 1 % Intern 1% 2 year resident 1 year resident 4% 2% 4-5 year resident 3 year resident 4% Traumatologist Attending Unsupervised 8

83 25 Level of supervision for interns and residents proximal femur fractures (7827) Below attending (1837) Attending or above (376) Unsupervised (2914) % 47% 82% 37% 38% 47% 44% 5 44%51% 5% Intern 15% 1 year resident 25% 2 year resident 9% 3 year resident 3% 15% 4-5 year resident Surgical delay for proximal femur fractures (9631) 6 68 % 26 % 4 % 1 % % % % Hours (Proportion of patients operated in 24 hour intervals) 81

84 1. Survival for primary procedure with reoperation due to any reason proximal femur fractures (1132).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware proximal femur fractures (1132).95 probability days 82

85 6 Fracture classification for proximal femur fractures (1133) A 31B 31C 83

86 Acetabulum 3 Method of osteosynthesis acetabulum fractures (347) % 33% 5 7% External fixation Plate Screw(s) 3% Other 5 Indication for reoperations of acetabulum fractures (72) % 1 Infection 1% 1% Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis 7% 14% 1% Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union 1% Arthroplasty dislocation Bone necrosis 4% Hematoma 84

87 25 Surgeon level for acetabulum fractures (348) 2 5% % 5 1% 1 year resident 5% 3 year resident 1% 4-5 year resident Attending Traumatologist 3 Level of supervision for acetabulum fractures (348) 25 7% % 15% % % 1 year resident 4-5 year resident Attending Traumatologist Unsupervised 85

88 4 Level of supervision for interns and residents acetabulum fractures (24) Below attending (2) Attending or above (22) Unsupervised () % 1 67% 33% % 1 year resident 1% 5% % % % 3 year resident 4-5 year resident Surgical delay for acetabulum fractures (286) 8 17 % 13 % 13 % 18 % 16 % 13 % 9 % Hours (Proportion of patients operated in 24 hour intervals) 86

89 1. Survival for primary procedure with reoperation due to any reason acetabulum fractures (348).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware acetabulum fractures (348).95 probability days 87

90 5 Fracture classification for acetabulum fractures (145) % 16% 14% 14% 12% 1% 1 4% 3% 6% 3% Posterior wall Anterior wall Posterior column Anterior column Transverse Posterior column/wall Both column Ant. Column/ post hemitransverse T-type Transverse/posterior wall 88

91 Femur 6 Method of osteosynthesis femur fractures (674) 5 71% % 1 7% External fixation Intramedullary nail(s) Plate 3% Other 8 Indication for reoperations of femur fractures (141) % 27% 2 11% 11% 9% 14% Infection 1% New fracture Muscle and soft-tissue revision Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis 3% Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union Hematoma 89

92 4 Surgeon level for femur fractures (678) 3 2 2% 32% 1 15% 9% 15% 8% % Intern 3 year resident 2 year resident 1 year resident Attending 4-5 year resident Traumatologist Level of supervision for femur fractures (672) % % 1 1% 1% 2 year resident 6% 4-5 year resident 3 year resident Attending 8% Traumatologist Unsupervised 9

93 14 12 Level of supervision for interns and residents femur fractures (46) Below attending (55) Attending or above (248) Unsupervised (13) % 77% 45% 51% 4 2 % 33% 67% Intern 24% 1 year resident 56% 7% 31% 12% 2 year resident 6% 17% 3 year resident 4% 4-5 year resident Surgical delay for femur fractures (648) 4 61 % 26 % 7 % 3 % 2 % 1 % 1 % Hours (Proportion of patients operated in 24 hour intervals) 91

94 1. Survival for primary procedure with reoperation due to any reason femur fractures (678).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware femur fractures (678).95 probability days 92

95 5 Fracture classification for femur fractures (678) A 32B 32C 93

96 Distal femur 4 Method of osteosynthesis distal femur fractures (379) 82% % 6% 5% External fixation Plate Screw(s) Other 7 Indication for reoperations of distal femur fractures (13) % 2% 44% 1 9% Infection New fracture Neurovascular complication 1% 3% 5% Secondary fracture dislocation or osteosynthesis failure Suboptimal osteosynthesis Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union 94

97 25 Surgeon level for distal femur fractures (387) 2 41% % 5 6% 4% 13% 14% 2 year resident 1 year resident Attending 4-5 year resident 3 year resident Traumatologist 3 Level of supervision for distal femur fractures (38) 25 57% % 5 1% 1% 1 year resident 3% 4-5 year resident 3 year resident Attending 13% Traumatologist Unsupervised 95

98 1 Level of supervision for interns and residents distal femur fractures (171) Below attending (13) Attending or above (128) Unsupervised (3) % 63% 33% 92% 2 76% 8% 1 year resident % 24% 2 year resident % 8% 3 year resident 8% 4% 4-5 year resident Surgical delay for distal femur fractures (35) % 31 % 17 % 7 % 6 % 3 % 1 % Hours (Proportion of patients operated in 24 hour intervals) 96

99 1. Survival for primary procedure with reoperation due to any reason distal femur fractures (387).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware distal femur fractures (387).95 probability days 97

100 Fracture classification for distal femur fractures (387) A 33B 33C 98

101 Patella 4 Method of osteosynthesis patella fractures (343) 3 88% 2 1 6% Screw(s) Wire(s) 6% Other 8 Indication for reoperations of patella fractures (94) 6 6% % 18% Infection 1% New fracture 3% Suboptimal osteosynthesis 2% Secondary fracture dislocation or osteosynthesis failure Pain or discomfort from osteosynthesis Pseudarthrosis / delayed union 99

102 2 Surgeon level for patella fractures (342) % 17% 32% 5 14% 13% 6% 4-5 year resident 3 year resident 2 year resident 1 year resident Attending Traumatologist 25 Level of supervision for patella fractures (33) 2 54% % 5 11% 1% 2% 2% 1 year resident 2 year resident Attending 4-5 year resident 3 year resident 3% Traumatologist Unsupervised 1

103 1 Level of supervision for interns and residents patella fractures (212) Below attending (51) Attending or above (97) Unsupervised (64) % 72% 2 1 year resident 2 year resident 57% 35% 3% 39% 32% 15% % 3 year resident 28% 11% 17% 4-5 year resident Surgical delay for patella fractures (311) 2 42 % 32 % 13 % 5 % 4 % 2 % 3 % Hours (Proportion of patients operated in 24 hour intervals) 11

104 1. Survival for primary procedure with reoperation due to any reason patella fractures (343).95 probability days 1. Survival for primary procedure with reoperation due to any reason except pain and discomfort from surgical hardware patella fractures (343).95 probability days 12