Setting and Outcomes in Finger Replantation following Pediatric Traumatic Amputations: National Study of 3,090 Patients
Neill Yun Li, MD; Justin E Kleiner, BS; Andrew Paul Harris, MD; Avi D Goodman, MD; Julia A. Katarincic, MD
Brown University, Providence, RI
INTRODUCTION: Setting and outcomes of pediatric digit replantations following traumatic amputations have not been described through a national pediatric database. We sought to determine hospital characteristics, length of stay, cost, and in-hospital complications associated with replantation and amputation procedures along with risk factors for subsequent revision procedures.
MATERIALS&METHODS: The Kid's Inpatient Database (KID) from the Healthcare Cost and Utilization Project (HCUP) for 2000 to 2012 were queried for traumatic amputations of the thumb or finger (ICD-9: 885.0, 886.0). Subjects were then separated into replantation (ICD-9-CM: 84.21, 84.22) and revision amputation (ICD-9-CM: 84.01, 84.02) groups. Those who underwent replantation were further divided into revision amputation (ICD-CM: 84.01, 84.02) and/or microvascular revision (ICD-9-CM: 39.3, 39.4). Age, sex, digit(s), cost, length of stay, and hospital characteristics were extracted. In-hospital complications (wound dehiscence, infection, thrombosis, cardiac, respiratory, urinary) were defined with ICD-9 codes. Fisher's exact tests and multivariable regressions were used with p values < 0.05 determined to be significant a priori.
RESULTS: From 2000 to 2012, traumatic digit amputations occurred in 3,090 pediatric patients with 1,950 (63.1%) patients undergoing revision amputation and 1,140 (36.9%) undergoing replantation. Multivariable regression demonstrated no variation in replantation rates by year (p = 0.17). Public hospitals were less likely to perform replantations than private hospitals (OR = 0.556, 95% CI: 0.327-0.945, p<0.05). No difference was seen between urban teaching and urban non-teaching hospitals performing replantations. Replantation did vary significantly by hospital location where rural hospitals performed a lower rate of replantations than urban hospitals (OR=0.436, 95% CI: 0.268-0.71, p<0.01). Mean replantation charges ($40,468, 95%CI: $36,096.18-$44839.82), length of stay (4.81 days, 95%CI: 4.44-5.18days), and in-hospital complication rates (13.26%, 95%CI: 10.79% - 15.7%) were significantly greater than amputation ($25,185, 95%CI: $22,793.64 - $27,576.36; 2.76 days 95% CI: 2.51 - 3.01days; 3.22%, 95% CI: 2.04% - 4.40%) (p < 0.001). Following replantation, 237 (20.8%) underwent revision amputation, 209 (18.3%) with vascular revision, and 388 (34%) required vascular revision and/or amputation. Multivariable regression demonstrated that older patients, males, and recent treatments were significantly associated with increased rate of revision following replantation (p < 0.05).
CONCLUSIONS: Older patients, males, and recent treatment were at greater risk for revision procedures without significant influence from hospital setting. Total charges, length of stay, and complication rates were significantly greater with replantation than with revision amputation. Appropriate patient selection, resources, and experience to pursue such procedures must be taken into account to provide optimum outcomes for pediatric replantations.
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