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

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] = 2.745; 95% confidence interval [CI], 1.559-4.833), higher wound class (wound class 3 aOR = 3.630; 95% CI, 2.003-6.577), and smoking (aOR = 1.970; 95% CI, 1.279-3.032) 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.