Comparison of Outcomes in Below-Knee Amputation Based on Surgeon Specialty

Abstract

Introduction/Purpose: Orthopaedic, vascular, and general surgeons all perform lower extremity amputations. Previous studies have indicated that outcomes may be related surgeon experience or skill, with a similar study indicating that general surgeons experience worst postoperative outcomes than vascular surgeons. In spite of these studies, there is a paucity of literature investigating the difference in outcomes between amputations performed by orthopaedic and vascular surgeons. This study aims to analyze the effect of surgeon specialty on 30-day complication, readmission, reoperation, and mortality rates following below-knee amputation (BKA) procedures between orthopaedic and vascular surgeons. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2010-2019 to identify 28,776 patients undergoing BKA by either orthopaedic, general, or vascular surgeons using Current Procedural Terminology (CPT) codes 27880, 27881, and 27882. Patients were stratified into groups based on surgeon specialty with 18,935 (66.4%) cases performed by vascular surgeons, 6,146 (21.6%) cases by general surgeons, and 3,429 (15.3%) cases were performed by orthopaedic surgeons. Demographics, comorbid conditions, hospital length of stay (LOS), and 30-day complications, readmission, reoperation, and mortality rates were compared between groups. Univariate and multivariate analysis were performed to examine the associations between outcomes and surgical specialty, while controlling for comorbid conditions as measured by ASA score and 5-factor modified frailty index (mFI-5) score. Results: The cohort was predominantly male (68.4%), white (61.9%), and the mean age was 63.54 (range, 18-90) years. The cohort of patients treated by vascular and general surgeons had significantly higher rates of numerous comorbidities, including mFI-5 score (p <.001) and ASA score (p <.001). When controlling for age, gender, BMI, and comorbid conditions, BKAs performed by vascular and general surgeons experienced an increased risk overall complication (General: Odds ratio [OR]=1.158, 95% confidence Interval [CI]=1.055-1.271; p=.002) (Vascular: OR=1.167, 95%CI=1.074-1.268; p<.001), readmission (General: OR=1.208; p=.011) (Vascular: OR=1.191; p=.009), and reoperation (General: OR=1.71;, p<.001) (Vascular: OR=1.975; p<.001). However, both general (OR=0.361, 95%CI=0.27-0.482; p<.001) and vascular surgeons (OR=0.367, 95%CI= 0.256-0.526; p<.001) surgeons experience decreased risk for organ/space SSI as compared to orthopaedic surgeons. Overall risk of mortality between specialties was not significantly different. Conclusion: There was no significant difference in rates of overall 30-day mortality in patients undergoing between surgical specialties when employing multivariate controls. However, patients undergoing BKA by vascular or general surgeons were found to have an increased risk of overall complication, readmission, and reoperation.