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Complications following Upper Extremity Amputation or Replantation: A Review of 14,481 Cases
Arjun Sebastian, MD1; Rajaie Hazboun, BA1; Amy Wagie, BA2, Elizabeth Habermann, PhD2; Sanjeev Kakar, MD1
1Department of Orthopedics, Mayo Clinic, Rochester, MN; 2Department of Health Sciences Research, Mayo Clinic, Rochester, MN

Background: Severe traumatic injuries to the upper extremity often require treatment with surgical amputation. Replantation can be successfully employed in select cases for limb and digit salvage. While the epidemiology and economics of upper extremity replantation and amputation surgery have been defined in the literature, the causes of injury, incidence of complications, and risk factors for complications are not well understood.

Methods: The Nationwide Inpatient Sample was used to identify 14,481 patients who underwent either amputation or replantation for upper extremity injuries between 2002 and 2011. ICD-9 procedure codes were used to separate patients into groups that underwent amputation or replantation. Data was collected regarding patient demographics, comorbidities, hospitalization characteristics, and postoperative complications. Univariate testing and multivariable logistic regression analysis was performed to identify predictors of complications.

Results: Of the 14,481 patients, 12,502 (86.3%) underwent upper extremity amputation and 1979 (13.7%) underwent replantation. The mean age of the cohort was 44.1 years with 86.5% of the patients being male. The most frequent causes of injury were machinery accidents (58.2%), motor vehicle accidents (10.7%), and crush injuries (9.0%). In the replantation group, 106 (5.4%) suffered a complication related to the reattached extremity or part. In the amputation group, 83 (0.7%) suffered a complication related to the amputation stump. Predictors of complications following amputation or replantation were identified in univariate analysis including demographics, comorbidities, and admission characteristics. Independent risk factors for complications following replantation included peripheral vascular disease (OR 8.89, p < .001), recent weight loss (OR 8.51, p = .028), iatrogenic injuries (OR 5.29, p = .003), and admission to a trauma center (OR 3.67, p = .003). Independent risk factors for complications following amputation included discharge against medical advice (OR 7.10, p = .017), Medicare or Medicaid as a secondary payer (OR 5.28, p = .007), pulmonary circulation disorders (OR 4.79, p = .032), and renal failure (OR 3.50, p = .022). Of note, upper quartile hospital charges (OR .394, p = .021) and weekend admissions (OR .411, p = .009) were protective.

Discussion: Complications are significantly more frequent following replantation in comparison to amputation. In this cohort, patients with peripheral vascular disease were at significantly increased risk for complications following replantation. The importance of postoperative amputation care is highlighted by the increased complication rate in patients with unanticipated discharges. Further studies are needed to identify why certain payer status and admission characteristics were predictive of and protective against complications.

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