Treatment-center variations in open versus closed reduction for nonelderly femoral neck fractures

Abstract Objective: To determine if variation in the practice of open vs closed reduction of femoral neck fractures (FNFs) for nonelderly adults at the aggregate treatment center level can be explained by patient and fracture characteristics. Methods: Design: Multicenter retrospective cohort. Setting: Twenty-five North American Level 1 Trauma Centers. Patient Selection Criteria: Skeletally mature patients between the ages of 18 and 60 years with operative repair of FNFs. Outcome Measures and Comparisons: The propensity for treatment with open vs closed reduction was estimated given patient and fracture characteristics from all patients included in the study. Predicted probabilities of open reduction were averaged for each treatment center and used to assess variation in each centers' proportion of open reductions. Logistic models of treatment approach were fit with and without indicator variables for treatment centers to test the impact of exclusion of treatment center using a likelihood ratio test. Results: The sample included 818 patients with a mean age of 43.9 (SD 11.3), 56.7% of patients were male, and 37.0% presented with a Pauwels angle >50°. Open reduction was performed more frequently for 225/352 (63.9%) displaced FNFs compared with 131/466 (28.1%) nondisplaced FNFs ( P < 0.001). A likelihood ratio test showed significant deterioration of model fit with exclusion of treatment center for both groups ( P < 0.001). Conclusions: The decision to perform an open vs closed reduction differed significantly compared with that which would have been predicted based on patient characteristics and case-mix at several treatment centers. This suggests that external factors beyond case-mix may bias operative decision making at a treatment center level. Level of Evidence: Level III Therapeutic.