Thirty-Day Outcomes of Upper Extremity Replantation and Revascularization Procedures: An Analysis of the National Surgical Quality Improvement Program Database
Olachi O. Oleru, B.S.1, Marc El Beaino, M.D.1, M.Sc, Bradley C. Wham, M.D.1, Karan Dua, M.D.1, Gregory S. Penny, M.D.1, Alexander Rompala, B.A.1, Neil V. Shah, M.D., M.S.1, Suhail Kamrudin K. Mithani, MD2, Charles Ekstein, M.D.1 and Steven M. Koehler, M.D.1, (1)State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY, (2)Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
Introduction: Over the past half-century, upper extremity replantation and revascularization has advanced through improved instrumentation and microsurgical techniques. Studies show high survival rates and excellent functional and aesthetic results. We hypothesized that upper extremity replantation and revascularization procedures may be performed safely with low rates of 30-day adverse outcomes when examined across a nationally-representative cohort of heterogeneous patients and institutions.
Methods: Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we identified patients who underwent upper extremity replantation or revascularization procedures between 2008 and 2016. Patients were identified using Current Procedural Terminology (CPT) codes corresponding to digit (index, middle, ring, little), thumb, hand, forearm, and arm replantation, and blood vessel repair of the hand/upper extremity. Complications, reoperations, and unplanned readmissions were queried from the database. Rates of 30-day postoperative complications were determined, and total reoperation rate (along with procedures performed) and unplanned readmissions related to the index procedure were identified.
Results: This study included a total of 326 patients undergoing replantation and revascularization procedures of the upper extremity. The patients had a mean age of 51 years (18 to 89 years) and were 61.7% male and 38.3% female. 65.1% were white, 16.0% were black, and 18.8% were other. Replantation procedures included digit (non-thumb) replantation (3.7%), thumb replantation (3.1%), and hand replantation (0.3%). Revascularization procedures included upper extremity blood vessel repair with vein graft (65.5%) and direct blood vessel repair of the hand and fingers (27.4%). The 30-day complications included intraoperative transfusions (8.0%), failure to wean off the ventilator for greater than 48 hours (2.1%), deep venous thrombosis (1.5%), pulmonary embolism (1.2%), and pneumonia (1.2%) (Figure 1). The reoperation rate was 5.5%, with incision and drainage occurring most frequently (0.6%). The readmission rate was 3.7%, most commonly for pulmonary embolism (0.6%).
Conclusions: The most common complication for upper extremity replantation is intraoperative transfusions. This is unsurprising considering the 52% rate of transfusions during leech therapy for replantation previously reported by Rizis et al., Plast Recon Surg 2011. Upper extremity replantation with blood vessel repair can be performed with suitable rates of complications in the 30-day postoperative period. These rates are consistent with published data from single-center series and reports from several centers.
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