June 2018 #PRSJournalClub Wrap-Up: “Disappearing Digits: Analysis of National Trends in Amputation and Replantation in the United States”

by Geoffrey E. Hespe, MD (@GeoffreyHespeMD)
Plastic Surgery Resident, University of Michigan


Once again we have had very engaging #PRSJournalClub on Facebook this June where we discussed a recent article by Drs. Patrick L. Reavey (@DrPatrickReavey), John T. Strantix (@JTStranix), Horatiu Muresan, Marc Soares and Vishnal Thanik entitled “Disappearing Digits: Analysis of National Trends in Amputation and Replantation in the United States.

The full discussion can be found on the PRS Facebook page (https://www.facebook.com/PRSjournal/).

You are able to read the article for free here at the PRS Website.

The article was first discussed by the current Resident Ambassadors to the PRS Editorial Board Francesco Egro (@francescoegro), Nikki Phillips (@drnikkiphillips) and Ira Savetsky (@irasavetskymd) with special guest Scott D. Lifchez.

Listen to their podcast discussion below:

In a #PRSHotTopic video, Editor-in-Chief Dr. Rod J. Rohrich discusses this article and important points from these authors work. The short video can be found here:

The authors in this paper investigate a surprising trend in hand surgery in which there appears to be a decrease in the number of finger replantations occurring in the United States despite significant improvements in microsurgical techniques and no change in the number of finger amputations. The authors use three different national databases, the National Electronic Injury Surveillance System, the Bureau of Labor Statistics: Illness, Injuries and Fatalities, and Health Care Cost and Utilization Project: National Inpatient Sample, in order to investigate this trend. Each database is different and allows the authors to examine different aspects of this question.

The National Electronic Injury Surveillance System is used to estimate national totals for all injuries that present to hospital emergency rooms and is managed by the U.S. Consumer Product Safety Commission. Using this database, the authors were able to examine the number of finger amputations per year during the study period as well as gather baseline characteristics. Finger amputations were further segregate their data into major amputations (single- and multi-digit amputations) and minor amputations (partial and fingertip amputations).

The Bureau of Labor Statistics: Illness, Injuries, and Fatalities database is used to gather job-related injuries in order to estimate national averages. Here the authors were able to determine the incidence rate per 10,000 workers.

Finally, the Health Care Cost and Utilization Project: National Inpatient Sample is used to determine national averages for specific diseases and procedures and collects its data from US hospital admissions for all-payers. The authors used this database to determine rate of replantation ICD procedure codes. Specifically they looked at replantations, primary amputations and revascularizations. Although all categories of data were not 100% complete they were able to get a good sense regarding mechanism, baseline characteristics and primary payer.

Using the National Electronic Injury Surveillance System, the authors were able to show that fingertip amputations were the most common injury seen during the study period and this occurred in male patients 80.8% of the time and adults in 73%. The majority of these injuries occurred at home. Most importantly, this data demonstrated that over the study period there was no change in the frequency of amputations (p=0.097).Interestingly, they did see a decrease in the rate of major amputations (single- and multi-digit amputations; p=0.009) when compared to minor amputations. The authors, were able to support their findings regarding fingertip amputations comprising the majority of injuries using the Bureau of Labor Statistics. Of significance, using this database the authors found that over the study period of 2000 to 2010 there was a 41% drop in finger amputations at the workplace.

Finally, the authors used the National Inpatient Sample to examine replantation rates from 2000 to 2010. Similar to the National Electronic Injury Surveillance System, they found that most patients undergoing replantation were male and adults. Not surprisingly, the majority of these replant procedures were performed at large (77.8%) and teaching institutions (82.5%). Medium size hospitals performed more amputations (49.3%) which makes sense as they may not have the experience or resources to perform technically challenging replantations. To address the authors main question in this paper, was there decrease in the number of replantations over the study period, they found that replantations were performed 5.6% less each year for a total decrease of 46% (p=0.0002). When looking at which institutions were performing these procedures most institutions only performed one a year where there was a small group of institutions (2.2 to 8.1%) which performed more than 10 a year.

In summary, in this interesting paper by Reavey et al. they were able to demonstrate using three different national databases that over the study period of 2000 to 2010 although there was no change in the number of patients sustained finger amputation, there was a significant decline in the number of amputations. The authors clearly state the limitations of their study, which include missing data, the inability to perform direct comparison between the databases, and deficiencies of each database. In their discussion, the authors propose that the decrease in replantations is not solely due to the decrease in work-related digital amputations because they observed a decrease in replantation in all patients (men, women and children). The authors suggest that this may rather be due to an overall “decrease in enthusiasm” by surgeons to perform replantation. In addition, since few institutions perform high volumes of replantation, most surgeons may just not feel comfortable performing replantation in the first place. They conclude by discussing the importance of regional transplant centers to allow patients with finger amputations to have the best chance for replantation as well as the importance of trainees gaining exposure to replantation during training so they can be prepared when going into practice.

We had another exciting #PRSJournalClub discussion regarding this article on Facebook which occurred on June 24th. As always, practicing plastic surgeons and residents incited a great question and answer session allowing us to dive deeper into this paper. I have provided a summary of the top Q/A’s below for your viewing.  We are excited to continue this great resource.

Looking forward to seeing you at the next #PRSJournalClub!

Geoff

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