INCREASING VALUE: CAN MIDSHAFT CLAVICLE FRACTURES BE SURGICALLY TREATED AS AN OUTPATIENT?
Authors: Lowe Jermonte , Akoto Alex , Duggan Patrick , Wells Lawrence W 
Published: March 2019

Purpose In the US, ambulatory surgical centers (ASCs) are an increasingly popular approach to lowering costs by managing patients in an outpatient setting. There is also a trend towards operative management of clavicle fractures, one of the most commonly fractured bones in children. Here, we evaluate the safety and success of open reduction and internal fixation (ORIF) of the clavicle, still an understudied procedure in the pediatric population. Furthermore, we appraise the feasibility of performing clavicle ORIF at ASCs, with an eye toward improving the value of an increasingly commonplace operation. Methods We reviewed the records of 82 consecutive pediatric patients who underwent clavicle ORIF from 2011 to 2015. 6 patients had proximal third fractures and were excluded. Data from the remaining 76 patients were analyzed. Patients discharged the day of surgery were defined as feasible for ASC management. Other factors relevant to the feasibility of ASC management were examined including: length of admission, surgical admission directly from the emergency department (ED), complications, patient controlled analgesia (PCA) use, and recovery. Results The 76 patients had a mean age of 15.3 ± 2.0 years. 29 (38.2%) were discharged the day of surgery, and 73 (96.1%) were discharged after one night or less. 13 (17.1%) patients received PCA. 21 (27.6%) patients were admitted for surgery directly from the ED. 17 (22.4%) experienced postoperative complications, including anesthesia/parasthesia near the operative site, constipation, 5 cases of hardware problems, and 1 nonunion. In 54 patients for whom active range of motion was described at final follow-up (mean time to follow-up 17.0 ± 12.0 weeks), 49 (90.7%) regained full range of motion, including all 40 patients followed 8 or more weeks postoperatively. 2 patients successfully underwent ORIF at an ASC without incident. Univariate analysis revealed that PCA use (p=0.024) was positively correlated with day of surgery discharge. Both univariate (p=0.025) and multivariate analysis (p=0.019) revealed a negative correlation between admission directly from the ED and day of surgery discharge. Conclusion Given the lack of serious complications, and the strong clinical outcomes seen in our large patient group, our data suggest that clavicle fixation is a safe and effective procedure in the pediatric population. Furthermore, over a third of patients were discharged the same day, suggesting that a significant proportion of our patients could have been managed in an ASC. Importantly, ED admission is a strong negative predictor of day of surgery discharge, and thus feasibility for ASC management. The increasingly operative management of clavicle fractures, a common injury, constitutes a unique opportunity to improve value. Future studies should explore how delays in surgical treatment, analgesic regimens like PCA, and other factors may affect length of postoperative stay, which in turn may further define a subpopulation well-suited for ASC management.