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Upper extremity nerve reconstruction: does specialty training affect treatment strategy utilization?
Jonathan L Jeger, MD
1, Pooja Dhupati, MPH
2; Shelley S. Noland, MD
1(1)Mayo Clinic, Phoenix, AZ, (2)University of Arizona College of Medicine Phoenix, Phoenix, AZ
IntroductionBoth plastic and orthopedic surgeons have adopted nerve transfers (NTs) for treatment of upper extremity nerve injuries. There is a gap in the literature regarding differences in NT utilization rates and outcomes between these surgical disciplines. This study aims to analyze upper extremity nerve reconstructions (UENR) with and without NT performed by plastic and orthopedic surgeons.
Methods We identified patients undergoing UENR procedures performed by plastic or orthopedic surgeons in the NSQIP database (2014-2022). NT utilization trends were analyzed using Current Procedural Terminology codes. UENR cases were further subdivided into cases with and without NT. Descriptive statistics analyzed patient demographics, morbidities and indications by International Classification of Diseases code. Fisher's exact test, Chi-square test, and Wilcoxon rank sum test assessed associations (p<0.05). A subgroup analysis of NT cases was performed based on level of injury.
Results521 UENR cases were included. 74% of cases were performed by orthopedic surgeons (N=383) and 26% by plastic surgeons (N=138). Orthopedic surgeons performed NTs in 33 out of 383 cases (8.6%) while plastic surgeons performed NTs in 24 out of 138 cases (17%). Plastic surgeons were more likely to utilize NTs in UENR compared to orthopedic surgeons (Odds Ratio=2.23, p=0.005). Patients undergoing NT by either type of surgeon had higher estimated preoperative morbidity compared to patients undergoing reconstruction without NT (p<0.001). Cases involving NTs performed by either specialty had longer operative times compared to cases without NTs (p<0.001). Amongst cases performed by plastic surgeons, there were more postoperative complications in cases with NTs (3 complications in 24 cases, 13%) than in cases without NTs (4 complications in 114 cases, 3.5%) (p=0.039). All complications in the NT group were minor (Clavien-Dindo class I). There was no difference in overall complication rates between the specialties. The most common indication for NT was ulnar nerve injury for both orthopedic (85%) and plastic surgeons (67%).
ConclusionsPlastic and orthopedic surgeons have adopted NTs as part of their armamentarium for upper extremity nerve injuries. The most common indication for NT is ulnar nerve injury and cases with higher preoperative morbidity were more likely to be treated with NTs. Although orthopedic surgeons perform more UENR overall, plastic surgeons have a higher NT utilization rate. This may reflect discrepancies in training between the 2 specialties, including in the amount of microsurgical training residents are exposed to. This finding may help guide training objectives for aspiring hand surgeons.
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