The Detrimental Effect of Decentralization in Digital Replantation in the United States: 15 Years of Evidence From the National Inpatient Sample

Purpose: Recent reports suggest a decrease in success rates in digital replantation in the United States. We hypothesize that this decrease may be associated with decentralization of replants away from high-volume hospitals.

Methods: All amputation injuries and digital replants captured by the National Inpatient Sample during 1998 to 2012 were identified. Procedures were characterized as occurring at high-volume hospitals (> 20 replants/y), and as being performed by high-volume surgeons (> 5 replants/y). A successful procedure was defined as one in which a replantation occurred without a subsequent revision amputation. Hospital and surgeon volume were tested for association with the year and the success of the procedure.

Results: The authors identified 101,693 amputation injuries resulting in 15,822 replants. The overall success of replants dropped from 74.5% during 2004 to 2006 to 65.7% during 2010 to 2012. The percentage of replants being performed at high-volume hospitals decreased from 15.5% during 2004 to 2006 to 8.9% during 2007 to 2009. Similarly, the percentage of replants being performed by high-volume surgeons decreased from 14.4% during 1998 to 2000 to 2.6% during 2007 to 2009. Replants performed by high-volume surgeons operating at high-volume hospitals had higher success rates than low-volume surgeons operating at low-volume hospitals (92.0% vs 72.1%). In addition, high-volume surgeons operating at high-volume hospitals attempted replantation at greater rates than low-volume surgeons operating at low-volume hospitals (21.5% vs 11.0%). Overall, an amputation injury presenting to a high-volume surgeon at a high-volume center had a 2.5 times greater likelihood of obtaining a successful replantation than an amputation injury presenting to a low-volume surgeon at a low-volume hospital.

Conclusions: These data suggest that decreased success rates of digital replantation in the United States are correlated with the decentralization of digital replantation away from high-volume hospitals.

Clinical relevance: The establishment of regional centers for replant referral may greatly increase the success of digital replantation in the United States.