A Comparison of 30-Day Perioperative Complications for Open Operative Care of Distal Upper-Extremity Fractures Treated by Orthopedic Versus Plastic Surgeons: A Study of the National Surgical Quality Improvement (NSQIP) Database

Abstract

Purpose: To determine whether surgeon specialty affects complications after open operative care of distal upper-extremity fractures. Methods: We performed a retrospective cross-sectional study using the American College of Surgeons National Surgical Quality Improvement Database from 2005 to 2016. Patients were included if they received open operative treatment by an orthopedic or a plastic surgeon for distal radius/ulna, carpal, metacarpal, or phalangeal fracture. Univariate analysis and multivariable analysis of perioperative complications were performed to identify differences between the 2 specialties. Major complications assessed were 30-day reoperation and mortality. We also assessed transfusion, thromboembolic, surgical site infections, cardiac, pulmonary, and renal complications. Results: A total of 20,512 patients were included. Most cases performed by orthopedic surgeons (71.2%) were for distal radius/ulna fractures, whereas the majority of cases performed by plastic surgeons were for metacarpal (41.0%) and phalangeal (37.9%) fractures. No difference was identified in most perioperative complications between specialties. Plastic surgeons had a higher incidence of surgical site infections (1.2% vs 0.5%) on univariate analysis. However, when controlling for variables such as patient demographics and comorbidities in multivariable analysis, surgical specialty was not significantly associated with surgical site infection. Rather, surgery on phalangeal bones (adjusted odds ratio [aOR] ¼ 2.745; 95% confidence interval [CI], 1.559e4.833), higher wound class (wound class 3 aOR ¼ 3.630; 95% CI, 2.003e6.577), and smoking (aOR ¼ 1.970; 95% CI,1.279e3.032) were independent risk factors for surgical site infection. Plastic surgeons were found to operate on proportionally more smokers, patients with higher wound class, and phalangeal fractures (37.9% of all fracture cases) compared with orthopedic surgeons Conclusions: Orthopedic and plastic surgeons achieve equivalent outcomes from a safety perspective after open operative treatment of upper-extremity fractures in terms of mortality and 30-day reoperation, which suggests that both specialties can safely perform call-related operative upper-extremity fracture care. Plastic surgeons operated on more smokers, patients with higher wound class, and phalangeal fractures, all of which were associated with increased incidence of surgical site infection, revealing differences in practice composition from their orthopedic colleagues. Type of study/level of evidence: Therapeutic III.

Practice Patterns Among Hand Surgeons According to Primary Residency Training

“…Despite these differences in training and practice patterns, previous studies have found no difference in complication rates when comparing hand surgeons trained in orthopedic surgery or plastic surgery in the setting of upper-extremity fractures. 6 The raw complication rates calculated in this study agree with these findings. However, when taking into account the calculated morbidity and mortality rates using linear regression analysis, our study found a lower reoperation, readmission, and unplanned readmission rate in general surgery-trained hand surgeons, followed by plastics and then orthopedic surgery.…”

“…Data are queried through the use of Current Procedural Terminology (CPT) codes. 5,6 The NSQIP database was queried for all CPT codes related to the upper extremity distal to the elbow (24,000-26,999) between 2014 and 2018. Procedures that were not performed by a general, orthopedic, or plastic surgeon were excluded, as were polytraumas.…”

“…Each entry has more than 130 data points that encompass preoperative, intraoperative, and perioperative data. Data are queried through the use of Current Procedural Terminology (CPT) codes 5,6 …”

Does a Modified Frailty Index Predict 30-day Complications After Long-Bone Nonunion or Malunion Surgery?

“…The anatomic locations were grouped by CPT code into procedures of the humerus (24430 and 24435), radius or ulna (25400, 25405, 25415, and 25420), and metacarpal or phalanx (26546), as is consistent with previous studies. [25][26][27]…”

Preparation for Hand Surgery Fellowship: A Comparison of Resident Training Pathways

“…11 Completing different residency training inevitably imparts different skill sets and can affect practice patterns after graduation from training programs. 12,13 Thus, we sought to compare operative experience of graduating chief residents in orthopedic surgery, plastic surgery, and general surgery to gain an understanding of the exposure to operative hand surgery in these fields.…”