- Email: [email protected]
Incidence of Acute Complications Following Surgery for Syndactyly and Polydactyly: An Analysis of the National Surgical Quality Improvement Program Database from 2012 to 2014
SCIENTIFIC ARTICLE
Incidence of Acute Complications Following Surgery for Syndactyly and Polydactyly: An Analysis of the National Surgical Quality Improvement Program Database from 2012 to 2014 Thomas J. McQuillan, BA,* Jessica E. Hawkins, MSEd,* Amy L. Ladd, MD* Purpose Congenital hand differences are infrequent phenomena, and their treatment represents a relatively small fraction of cases performed by hand surgeons. Little is known about the incidence of wound complications and acute postoperative problems given the relative rarity of these procedures. This study sought to characterize the incidence of complications within 30 days of surgery for congenital hand differences. Methods The National Surgical Quality Improvement Program (NSQIP) contains prospective data regarding 30-day morbidity from 64 pediatric centers across the United States. Data from all available years (2012e2014) were queried for Current Procedural Terminology (CPT) codes pertinent to the treatment of congenital hand differences. Bivariate statistics, Fisher exact tests and Poisson 95% confidence intervals (95% CI) were used to assess the incidence of complications and examine risk factors for these outcomes. Results We identified a total of 1,656 congenital hand cases that represented 4 different CPT codes, including surgery for simple syndactyly, complex syndactyly, and polydactyly. The overall incidence of complications was 2.2% (95% CI, 1.6%e3.1%; n ¼ 37) with the most common complication being superficial surgical site infection (1.7%; 95% CI, 1.1%e2.4%) followed by related readmission (0.3%; 95% CI, 0.1%e0.7%). There was a higher incidence of complications observed in patients undergoing complex syndactyly repair (5.2% for complex syndactyly repair vs 2.3% for all others). Conclusions The rate of acute complications following procedures to correct syndactyly and polydactyly is low, the most common of which is superficial surgical site infection. The incidence of acute complications may be helpful in counseling patients and families. We suggest that further research must prioritize collecting data on long-term functional outcomes. (J Hand Surg Am. 2017;-(-):1.e1-e7. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic II. Key words Congenital, complications, NSQIP, polydactyly, syndactyly.
From the *Robert A. Chase Hand and Upper Limb Center, Stanford University Medical Center, Palo Alto, CA. Received for publication August 2, 2016; accepted in revised form May 12, 2017. This work was supported by a Stanford University MedScholars Grant to T.J.M.
Corresponding author: Thomas McQuillan, BA, Robert A. Chase Hand and Upper Limb Center, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, CA 94304; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.05.011
Ó 2017 ASSH
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Published by Elsevier, Inc. All rights reserved.
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ONGENITAL HAND DIFFERENCES and their corrective surgical treatments are relatively uncommon, with syndactyly and polydactyly being the most frequent. Estimates of the incidence of syndactyly range between 1:2,000 and 1:2,500, whereas the incidence of ulnar polydactyly ranges from 1:1,500 to 1:3,300 in Caucasian populations and 1:300 in African American populations. Radial polydactylies are rare, affecting roughly 0.08 of 100,000 live births.1 Repair of syndactyly is usually performed between 12 and 18 months of age and typically involves the use of skin flaps and grafts for soft tissue repair.2 Simple syndactyly repair may be performed without skin grafting, but extensive defatting of the web space may promote a higher rate of nerve damage and venous drainage problems.3 Complex operative reconstruction of supernumerary digits may involve soft tissue excision, corrective osteotomy, joint reconstruction, and/or muscular transfers.4 Given the relative rarity of these conditions, little is known about the rates of immediate postoperative complications such as wound infections and graft failure beyond single-institution studies.5e9 Complex procedures suggest higher complication rates, especially in the postoperative period. The American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP) provides data on 30-day outcomes of surgical care in the United States. The quality of these data regarding complications has been extensively validated10,11 for the study of immediate postoperative complications, wound infections, and surgical risk factors in the adults.12e14 The orthopedic literature has examined complication rates and risk factors in distal radius fracture surgery,15,16 and the plastic surgery literature has examined breast reconstruction.17 Lipira et al18 used data from the adult NSQIP to assess the complication rate of adult patients undergoing elective hand surgery, excluding carpal tunnel and trigger finger release, estimating an overall complication rate of 2.5% and a rate of surgical site infections (SSI) of 1.2%. The pediatric data (NSQIP-P) have recently become available and are similarly validated, as the American College of Surgeons refined variables and performed an extensive audit for data accuracy and completeness.19,20 The NSQIP-P utilizes the same systematic sampling methodology of the adult NSQIP, identifying selected cases by Current Procedural Terminology (CPT) code using a trained full-time data collector and prospectively recording over 100 different demographic, surgical profile, preoperative, laboratory, intraoperative, and postoperative variables.19
J Hand Surg Am.
For orthopedic surgery procedures, researchers have examined blood transfusions after surgery for hip dysplasia21 and early wound complications following pediatric spine surgery.22 The NSQIP-P data have been used to assess complications after cleft lip and general plastic surgery procedures in a single calendar year.23,24 Thibaudeau et al25 looked at 30-day readmission rates and complications of all pediatric upper extremity surgeries, grouping congenital hand procedures with trauma and other procedures. These procedures included percutaneous pinning of supracondylar humerus fractures, open treatment of condylar humerus fractures, and tendon sheath releases—procedures disparate in diagnosis and procedure from congenital hand differences. This study sought to report the incidence of complications specific to syndactyly or polydactyly repairs using a multi-institutional, nationwide cohort. Our hypotheses were (1) that the incidence of wound complications would be similar to that in adult hand surgery and (2) that a higher incidence of complications would exist for more complicated soft tissue and bony repairs. MATERIALS AND METHODS This retrospective cohort study was conducted using data from the NSQIP-P between the years 2012 and 2014. Over 320 variables were collected relevant to preoperative characteristics, intraoperative details, and postoperative outcomes in patients younger than age 18.26 Patient information was collected at 64 participating sites across the United States. Trained surgical reviewers assessed complications occurring in the first 30 days after surgery using chart review, telephone calls, and scheduled clinic visits. Postoperative complications in the NSQIP-P were categorized as infectious, airway-related, wound disruptions, neurological events, deep vein thrombosis, renal failure, and cardiac events; infections were further characterized as superficial, deep, or organ-space SSI, sepsis or septic shock, pneumonia, and urinary tract infections.19 Data in the NSQIP-P were deidentified and collected in aggregate; this study did not require approval from an institutional review board. The 3 years of data during the study period were merged into 1 dataset. We identified the 4 CPT codes collected by the NSQIP that were relevant to the treatment of congenital hand differences: “Repair of syndactyly web finger each web space; with skin flaps” (CPT 26560); “Repair of syndactyly web finger each web space, with skin flaps and grafts” (CPT 26561); “Repair of syndactyly each web space; complex, involving bone, nails, etc.” (CPT r
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TABLE 1.
Demographic, Provider. and Patient Characteristics With Complications (n ¼ 37)
Mean age, y (SD) Male sex
Without Complications (n ¼1,619)
Total (n ¼ 1,656)
1.75 (2.25)
2.11 (2.69)
2.10 (2.69)
24 (2%)
1023 (98%)
1047 (63%)
Race Asian
2 (3%)
68 (97%)
70 (4%)
Black or African American
9 (3%)
338 (97%)
347 (21%)
White
20 (2%)
942 (98%)
962 (58%)
Other
0 (0%)
Unknown
6 (2%)
21 (100%) 250 (98%)
21 (1%) 256 (15%)
Provider specialty Orthopedics
2 (1%)
193 (99%)
195 (12%)
Pediatric orthopedics
12 (2%)
635 (98%)
647 (39%)
Pediatric plastics
13 (3%)
465 (97%)
478 (29%)
Plastics
10 (3%)
279 (97%)
289 (17%)
Other
0 (0%)
47 (100%)
47 (3%)
Patient factors þþ
Inpatient procedure*
6 (7%)
82 (93%)
88 (5%)
Preterm birth (n ¼ 1,495)
5 (3%)
149 (97%)
154 (10%)
Congenital malformation†
18 (3%)
640 (97%)
658 (40%)
One or more other procedures‡
14 (2%)
626 (98%)
640 (39%)
2 (3%)
72 (97%)
74 (4%)
Concurrent procedure
§
*Inpatient procedure was significantly associated with complications at P < .05 with correction for False Discovery Rate. P values were calculated using Fisher exact tests for 5 patient factors only. †Classified as “Neonate < 1,500 g at time of surgery” or “Neonate > 1,500 g at time of surgery or infant/child/teenager with a history of a congenital defect at the time of surgery. ‡Other procedures are defined as additional operative procedure(s) performed by the same surgical team (ie, the same specialty/service) under the same anesthetic which has a CPT code different from that of the Principal Operative Procedure. §Concurrent procedures are defined as additional operative procedure(s) performed by a different surgical team (ie, a different specialty/service) under the same anesthetic which has a CPT code different from that of the Principal Operative Procedure.
26562); “Reconstruction of supernumerary digit, soft tissue and bone” (CPT 26587). All cases that matched these CPT codes in the NSQIP-P database during the study years were included. Patient characteristics were broken down by number (percent) and by mean (SD), and estimates were made using Poisson 95% CI. Fisher exact tests and Student’s t tests were performed for analyses assessing the differences between groups.
syndactyly web finger each web space, with skin flaps and grafts” (CPT code 26561), accounting for 32% of the procedures. The overall incidence of any complications in the cohort was 37 out of the 1,656 procedures (2.2%; 95% CI, 1.6%e3.1%) (Table 2). Five cases resulted in more than 1 complication, bringing the total number of complications to 42. The most common complication was superficial SSI (1.7%; 95% CI, 1.1%e2.4%; n ¼ 28), followed by related readmissions within 30 days (0.3%; 95% CI, 0.1%e 0.7%), deep incisional SSI (0.2%; 95% CI, 0.0%e 0.5%), and return to the operating room within 30 days (0.2%; 95% CI, 0.0%e0.5%) (Fig. 1). The procedure with the highest incidence of complications was “Repair of syndactyly each web space; complex, involving bone, nails, etc.” (CPT code 26562), which had a 3.2% (95% CI,
RESULTS From the years 2012 to 2014, the NSQIP-P contained procedural information on 1,656 pediatric hand procedures. The characteristics of this cohort are shown in Table 1. The most common congenital hand procedure was “Reconstruction of supernumerary digit, soft tissue and bone” (CPT code 26587), comprising 53% of the procedures, followed by “Repair of J Hand Surg Am.
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TABLE 2. CPT
Complications by CPT Code* n
All Complications
Wound Complications†
Unique Procedures With Any Complications
One or More Readmissions
Related Readmissions 1 (1.0%)
26560
104
4 (3.8%)
2 (1.9%)
3 (2.9%)
1 (1.0%)
26561
525
11 (2.1%)
9 (1.7%)
11 (2.1%)
8 (1.5%)
0 (0.0%)
26562
155
8 (5.2%)
5 (3.2%)
5 (3.2%)
2 (1.3%)
2 (1.3%)
26587
872
19 (2.2%)
15 (1.7%)
18 (2.1%)
9 (1.0%)
2 (0.2%)
Total
1,656
42 (2.5%)
31 (1.9%)
37 (2.2%)
20 (1.2%)
5 (0.3%)
*Percentages calculated from total number of cases per CPT code. †Wound complication ¼ Superficial SSI þ Deep SSI þ Organ infection.
FIGURE 1: Total complications for congenital hand procedures (n ¼ 1,656). FF, free flap.
1.0%e7.5%) incidence of superficial SSI and 1.3% (95% CI, 0.2%e4.7%) incidence of related readmissions (Fig. 2). There was 1 instance of a return to the operating room following complex syndactyly repair. The procedure with the least incidence of complications was “Repair of syndactyly web finger each web space, with skin flaps and grafts” (CPT code 26561) with a 2.1% (95% CI, 1.0%e3.7%) overall incidence of complications and 1.5% (95% CI, 0.7%e-3.0%) incidence of SSI. J Hand Surg Am.
The risk of related readmissions was low for all procedures, with a total of 5 admissions within 30 days among the 1,656 procedures. Several readmissions were either planned or occurred for unrelated reasons. The local NSQIP-P reviewers, through the chart review process, determined whether readmissions were related or unrelated to the index procedure. Using International Classification of Diseases, Ninth Revision, codes associated with the data, these unrelated readmissions were shown to be for various r
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FIGURE 2: Relative incidence of complications by CPT code. CPT 26560, “Repair of syndactyly web finger each web space; with skin flaps”; CPT 26561, “Repair of syndactyly web finger each web space, with skin flaps and grafts”; CPT 26562, “Repair of syndactyly each web space; complex, involving bone, nails, etc.”; CPT 26587, “Reconstruction of supernumerary digit, soft tissue and bone”; FF, free flap.
reasons, including gastrointestinal disease and dehydration, fever, otitis media, acute bronchiolitis, and fitting orthopedic devices. The most common reason for related readmissions was SSI (2 readmissions). An increased incidence of all types of complications were observed for patients undergoing syndactyly repairs involving bone compared with the other procedures (5.2% vs 2.3%; P < .05), which was statistically significant. Comparing the children with complications with those without, children with complications were more likely to be treated as inpatients in a hospital (16% vs 5%; P < .05) (Table 1). The patient-level risk factors of prematurity, presence of a congenital malformation, body mass index, or undergoing a concurrent procedure were not significantly associated with having a complication (Table 1). No patient-level risk factors (eg, inpatient status, comorbidities, prematurity) were significantly associated with the types of wound complications identified (superficial SSI and deep SSI, P ¼ .07).
hand surgeons, with the reported incidence of complications and wound infections typically limited to single institutional studies. This study utilized multiinstitutional data and aggregated over 1,600 cases from the NSQIP-P to quantify a collective experience of complication incidence following procedures for syndactyly and polydactyly. The incidence of all complications in this syndactyly and polydactyly cohort was 2.2%, with a rate of superficial and deep SSIs of 1.9%. These results compare with the incidence of complications reported by Lipira et al18 who calculated the incidence of complications and SSI at 2.5% and 1.2%, respectively, using adult NSQIP data for elective hand surgery. A higher rate of total complications (5.2%) and wound complications (3.2%) was observed in patients undergoing complex syndactyly repair (CPT 2652), which is presumably related to the greater complexity of the surgery. These rates are comparable with pediatric patients undergoing spine surgery22 (3.5%) and lower than rates of wound complications for cleft palate repair in pediatric patients (4.2%).23 Other studies have already evaluated longer-term outcomes for simple syndactyly repairs, with a recent review estimating a 5.31% chance of graft
DISCUSSION Procedures for the treatment of congenital hand differences are comparatively infrequent for general J Hand Surg Am.
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failure and a 4.76% of web creep.2 Long-term outcomes in polydactylies have cited a 19% reoperation rate for radial polydactylies27 and uncommon rates (< 5%) of neuroma formation in ulnar polydactylies.4,28 These results give further insight into the findings of Thibaudeau et al,25 who report a complication rate of 1.7% following pediatric upper extremity surgery. Several key differences exist between this study and that study, including our exclusion of 3 trauma pediatric upper extremity CPT codes. Only 13% of their total study sample (n ¼ 12,459) represented congenital hand procedures, although all of those data were analyzed as a single cohort. Because the majority of cases reported in the Thibaudeau et al25 study constitute percutaneous or open fixation of humeral fractures, these results may not be representative of the risk profile of elective congenital hand procedures. Related readmission was an infrequent complication, representing only 5 of 1,656 cases in this cohort. Given the low incidence of related readmissions, more data would be necessary to perform multivariate analysis for risk factors for readmission. This sample demonstrated significantly higher complication rates among inpatients. Other patient-level factors, such as multiple procedures, concurrent surgery under the same anesthetic, or presence of a congenital malformation, did not demonstrate higher complication rates. These findings may be explained by a selection bias; patients with multiple anomalies or other risk factors may be treated as inpatients and would not require readmission for a complication. At the discretion of NSQIP-P reviewers, readmissions were classified through an extensive chart review process, validated in the literature.10,11 The potential exists for readmissions to be coded as unrelated but may in fact be precipitated by the index procedure. This may underestimate the frequency of related readmissions using this database, which suggests a weakness of this analysis. This study has several limitations. Given the low incidence of complications, more high-quality data are needed to perform risk stratification and ensure adequate statistical power. Inpatient status, for instance, was significantly associated with total complications but not with the subgroup of SSI (P ¼ .07), although these in fact were the most common complication. Furthermore, the NSQIP-P collects information on only 4 congenital hand CPT codes, which do not represent all procedures performed by hand surgeons trained in this field. Despite the comprehensive data available on these CPT codes, considerable variation exists in surgical technique between surgeons and institutions. An additional limitation is that many J Hand Surg Am.
important outcomes for congenital hand surgery, including web creep in syndactyly, wound breakdown, or hypertrophic scar, may not be evident at 30 days. This would require prospective studies with longer follow-up periods to fully define the operative and functional outcomes of these patients.4 We provide preliminary information regarding the incidence of common complications following procedures for syndactyly and polydactyly. Using highquality data from a multicenter cohort, these results illustrate that the acute complications risk is low, the most common of which is superficial SSI. As more data become available from the NSQIP-P, further investigation of patient-level risk factors will aid in the medical evaluation of children and the counseling of their families. REFERENCES 1. Flynn J, Lovell W. Lovell and Winter’s Pediatric Orthopaedics. 7th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2014. 2. Sullivan MA, Adkinson JM. A systematic review and comparison of outcomes following simple syndactyly reconstruction with skin grafts or a dorsal metacarpal advancement flap. J Hand Surg Am. 2017;42(1):34e40.e6. 3. Oda T, Pushman AG, Chung KC. Treatment of common congenital hand conditions. Plast Reconstr Surg. 2010;126(3):121ee133e. 4. Comer GC, Ladd AL. Management of complications of congenital hand disorders. Hand Clin. 2015;31(2):361e375. 5. Cortez M, Fernandes Júnior JV, da Silva RF, et al. Surgical results from treating children with syndactyly through the collective effort system at “SOS Hand Recife” between 2005 and 2009. Rev Bras Ortop. 2014;49(4):396e400. 6. Greuse M, Coessens BC. Congenital syndactyly: defatting facilitates closure without skin graft. J Hand Surg Am. 2001;26(4):589e594. 7. Sharma RK, Tuli P, Makkar SS, Parashar A. End-of-skin grafts in syndactyly release: description of a new flap for web space resurfacing and primary closure of finger defects. Hand (N Y). 2009;4(1): 29e34. 8. Yildirim C, Sentürk S, Keklikçi K, Akmaz I. Correction of syndactyly using a dorsal separated V-Y advancement flap and a volar triangular flap in adults. Ann Plast Surg. 2011;67(4):357e363. 9. Larsen M, Nicolai JP. Long-term follow-up of surgical treatment for thumb duplication. J Hand Surg Br. 2005;30(3):276e281. 10. Dahlke AR, Merkow RP, Chung JW, et al. Comparison of postoperative complication risk prediction approaches based on factors known preoperatively to surgeons versus patients. Surgery. 2014;156(1):39e45. 11. Shiloach M, Frencher SK Jr, Steeger JE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210(1):6e16. 12. Gandaglia G, Ghani KR, Sood A, et al. Effect of minimally invasive surgery on the risk for surgical site infections: results from the National Surgical Quality Improvement Program (NSQIP) database. JAMA Surg. 2014;149(10):1039e1044. 13. Fischer JP, Wink JD, Tuggle CT, Nelson JA, Kovach SJ. Wound risk assessment in ventral hernia repair: generation and internal validation of a risk stratification system using the ACS-NSQIP. Hernia. 2014;19(1):103e111. 14. Bennett KM, Scarborough JE, Shortell CK. Predictors of 30-day postoperative stroke or death after carotid endarterectomy using the 2012 carotid endarterectomy-targeted American College of Surgeons
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National Surgical Quality Improvement Program database. J Vasc Surg. 2015;61(1):103e111. Schick CW, Koehler DM, Martin CT, et al. Risk factors for 30-day postoperative complications and mortality following open reduction internal fixation of distal radius fractures. J Hand Surg Am. 2014;39(12):2373e2380.e1. Jiang JJ, Phillips CS, Levitz SP, Benson LS. Risk factors for complications following open reduction internal fixation of distal radius fractures. J Hand Surg Am. 2014;39(12):2365e2372. Fischer JP, Nelson JA, Au A, Tuggle CT III, Serletti JM, Wu LC. Complications and morbidity following breast reconstruction—a review of 16,063 cases from the 2005e2010 NSQIP datasets. J Plast Surg Hand Surg. 2014;48(2):104e114. Lipira AB, Sood RF, Tatman PD, Davis JI, Morrison SD, Ko JH. Complications within 30 days of hand surgery: an analysis of 10,646 patients. J Hand Surg Am. 2015;40(9):1852e1859.e3. Raval MV, Dillon PW, Bruny JL, et al. Pediatric American College of Surgeons National Surgical Quality Improvement Program: feasibility of a novel, prospective assessment of surgical outcomes. J Pediatr Surg. 2011;46(1):115e121. Raval MV, Dillon PW, Bruny JL, et al. American College of Surgeons National Surgical Quality Improvement Program Pediatric: a phase 1 report. J Am Coll Surg. 2011;212(1):1e11. Sherrod BA, Baker DK, Gilbert SR. Blood transfusion incidence, risk factors, and associated complications in surgical treatment of hip
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dysplasia; 2016 [e-pub ahead of print]. J Pediatr Orthop. 2016. http:// dx.doi.org/10.1097/BPO.0000000000000804. Martin CT, Pugely AJ, Gao Y, Ilgenfritz RM, Weinstein SL. Incidence and risk factors for early wound complications after spinal arthrodesis in children: analysis of 30-day follow-up data from the ACS-NSQIP. Spine. 2014;39(18):1463e1470. Paine KM, Tahiri Y, Wes AM, et al. An assessment of 30-day complications in primary cleft lip repair: a review of the 2012 ACS NSQIP Pediatric. Cleft Palate Craniofac J. 2015;53(3):283e289. Tahiri Y, Fischer JP, Wink JD, et al. Analysis of risk factors associated with 30-day readmissions following pediatric plastic surgery: a review of 5376 procedures. Plast Reconstr Surg. 2015;135(2): 521e529. Thibaudeau S, Anari JB, Carducci N, Carrigan RB. 30-Day readmission after pediatric upper extremity surgery: analysis of the NSQIP database. J Pediatr Surg. 2016;51(8):1370e1374. American College of Surgeons. ACS NSQIP Pediatric Participant Use Data File. Available at: https://www.facs.org/quality-programs/pediatric/ program-specifics/quality-support-tools/puf. Accessed July 27, 2016. Stutz C, Mills J, Wheeler L, Ezaki M, Oishi S. Long-term outcomes following radial polydactyly reconstruction. J Hand Surg Am. 2014;39(8):1549e1552. Singer G, Thein S, Kraus T, Petnehazy T, Eberl R, Schmidt B. Ulnar polydactyly—an analysis of appearance and postoperative outcome. J Pediatr Surg. 2014;49(3):474e476.
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Incidence of Acute Complications Following Surgery for Syndactyly and Polydactyly: An Analysis of the National Surgical Quality Improvement Program Database from 2012 to 2014 Thomas J. McQuillan, BA,* Jessica E. Hawkins, MSEd,* Amy L. Ladd, MD* Purpose Congenital hand differences are infrequent phenomena, and their treatment represents a relatively small fraction of cases performed by hand surgeons. Little is known about the incidence of wound complications and acute postoperative problems given the relative rarity of these procedures. This study sought to characterize the incidence of complications within 30 days of surgery for congenital hand differences. Methods The National Surgical Quality Improvement Program (NSQIP) contains prospective data regarding 30-day morbidity from 64 pediatric centers across the United States. Data from all available years (2012e2014) were queried for Current Procedural Terminology (CPT) codes pertinent to the treatment of congenital hand differences. Bivariate statistics, Fisher exact tests and Poisson 95% confidence intervals (95% CI) were used to assess the incidence of complications and examine risk factors for these outcomes. Results We identified a total of 1,656 congenital hand cases that represented 4 different CPT codes, including surgery for simple syndactyly, complex syndactyly, and polydactyly. The overall incidence of complications was 2.2% (95% CI, 1.6%e3.1%; n ¼ 37) with the most common complication being superficial surgical site infection (1.7%; 95% CI, 1.1%e2.4%) followed by related readmission (0.3%; 95% CI, 0.1%e0.7%). There was a higher incidence of complications observed in patients undergoing complex syndactyly repair (5.2% for complex syndactyly repair vs 2.3% for all others). Conclusions The rate of acute complications following procedures to correct syndactyly and polydactyly is low, the most common of which is superficial surgical site infection. The incidence of acute complications may be helpful in counseling patients and families. We suggest that further research must prioritize collecting data on long-term functional outcomes. (J Hand Surg Am. 2017;-(-):1.e1-e7. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic II. Key words Congenital, complications, NSQIP, polydactyly, syndactyly.
From the *Robert A. Chase Hand and Upper Limb Center, Stanford University Medical Center, Palo Alto, CA. Received for publication August 2, 2016; accepted in revised form May 12, 2017. This work was supported by a Stanford University MedScholars Grant to T.J.M.
Corresponding author: Thomas McQuillan, BA, Robert A. Chase Hand and Upper Limb Center, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, CA 94304; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.05.011
Ó 2017 ASSH
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ONGENITAL HAND DIFFERENCES and their corrective surgical treatments are relatively uncommon, with syndactyly and polydactyly being the most frequent. Estimates of the incidence of syndactyly range between 1:2,000 and 1:2,500, whereas the incidence of ulnar polydactyly ranges from 1:1,500 to 1:3,300 in Caucasian populations and 1:300 in African American populations. Radial polydactylies are rare, affecting roughly 0.08 of 100,000 live births.1 Repair of syndactyly is usually performed between 12 and 18 months of age and typically involves the use of skin flaps and grafts for soft tissue repair.2 Simple syndactyly repair may be performed without skin grafting, but extensive defatting of the web space may promote a higher rate of nerve damage and venous drainage problems.3 Complex operative reconstruction of supernumerary digits may involve soft tissue excision, corrective osteotomy, joint reconstruction, and/or muscular transfers.4 Given the relative rarity of these conditions, little is known about the rates of immediate postoperative complications such as wound infections and graft failure beyond single-institution studies.5e9 Complex procedures suggest higher complication rates, especially in the postoperative period. The American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP) provides data on 30-day outcomes of surgical care in the United States. The quality of these data regarding complications has been extensively validated10,11 for the study of immediate postoperative complications, wound infections, and surgical risk factors in the adults.12e14 The orthopedic literature has examined complication rates and risk factors in distal radius fracture surgery,15,16 and the plastic surgery literature has examined breast reconstruction.17 Lipira et al18 used data from the adult NSQIP to assess the complication rate of adult patients undergoing elective hand surgery, excluding carpal tunnel and trigger finger release, estimating an overall complication rate of 2.5% and a rate of surgical site infections (SSI) of 1.2%. The pediatric data (NSQIP-P) have recently become available and are similarly validated, as the American College of Surgeons refined variables and performed an extensive audit for data accuracy and completeness.19,20 The NSQIP-P utilizes the same systematic sampling methodology of the adult NSQIP, identifying selected cases by Current Procedural Terminology (CPT) code using a trained full-time data collector and prospectively recording over 100 different demographic, surgical profile, preoperative, laboratory, intraoperative, and postoperative variables.19
J Hand Surg Am.
For orthopedic surgery procedures, researchers have examined blood transfusions after surgery for hip dysplasia21 and early wound complications following pediatric spine surgery.22 The NSQIP-P data have been used to assess complications after cleft lip and general plastic surgery procedures in a single calendar year.23,24 Thibaudeau et al25 looked at 30-day readmission rates and complications of all pediatric upper extremity surgeries, grouping congenital hand procedures with trauma and other procedures. These procedures included percutaneous pinning of supracondylar humerus fractures, open treatment of condylar humerus fractures, and tendon sheath releases—procedures disparate in diagnosis and procedure from congenital hand differences. This study sought to report the incidence of complications specific to syndactyly or polydactyly repairs using a multi-institutional, nationwide cohort. Our hypotheses were (1) that the incidence of wound complications would be similar to that in adult hand surgery and (2) that a higher incidence of complications would exist for more complicated soft tissue and bony repairs. MATERIALS AND METHODS This retrospective cohort study was conducted using data from the NSQIP-P between the years 2012 and 2014. Over 320 variables were collected relevant to preoperative characteristics, intraoperative details, and postoperative outcomes in patients younger than age 18.26 Patient information was collected at 64 participating sites across the United States. Trained surgical reviewers assessed complications occurring in the first 30 days after surgery using chart review, telephone calls, and scheduled clinic visits. Postoperative complications in the NSQIP-P were categorized as infectious, airway-related, wound disruptions, neurological events, deep vein thrombosis, renal failure, and cardiac events; infections were further characterized as superficial, deep, or organ-space SSI, sepsis or septic shock, pneumonia, and urinary tract infections.19 Data in the NSQIP-P were deidentified and collected in aggregate; this study did not require approval from an institutional review board. The 3 years of data during the study period were merged into 1 dataset. We identified the 4 CPT codes collected by the NSQIP that were relevant to the treatment of congenital hand differences: “Repair of syndactyly web finger each web space; with skin flaps” (CPT 26560); “Repair of syndactyly web finger each web space, with skin flaps and grafts” (CPT 26561); “Repair of syndactyly each web space; complex, involving bone, nails, etc.” (CPT r
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TABLE 1.
Demographic, Provider. and Patient Characteristics With Complications (n ¼ 37)
Mean age, y (SD) Male sex
Without Complications (n ¼1,619)
Total (n ¼ 1,656)
1.75 (2.25)
2.11 (2.69)
2.10 (2.69)
24 (2%)
1023 (98%)
1047 (63%)
Race Asian
2 (3%)
68 (97%)
70 (4%)
Black or African American
9 (3%)
338 (97%)
347 (21%)
White
20 (2%)
942 (98%)
962 (58%)
Other
0 (0%)
Unknown
6 (2%)
21 (100%) 250 (98%)
21 (1%) 256 (15%)
Provider specialty Orthopedics
2 (1%)
193 (99%)
195 (12%)
Pediatric orthopedics
12 (2%)
635 (98%)
647 (39%)
Pediatric plastics
13 (3%)
465 (97%)
478 (29%)
Plastics
10 (3%)
279 (97%)
289 (17%)
Other
0 (0%)
47 (100%)
47 (3%)
Patient factors þþ
Inpatient procedure*
6 (7%)
82 (93%)
88 (5%)
Preterm birth (n ¼ 1,495)
5 (3%)
149 (97%)
154 (10%)
Congenital malformation†
18 (3%)
640 (97%)
658 (40%)
One or more other procedures‡
14 (2%)
626 (98%)
640 (39%)
2 (3%)
72 (97%)
74 (4%)
Concurrent procedure
§
*Inpatient procedure was significantly associated with complications at P < .05 with correction for False Discovery Rate. P values were calculated using Fisher exact tests for 5 patient factors only. †Classified as “Neonate < 1,500 g at time of surgery” or “Neonate > 1,500 g at time of surgery or infant/child/teenager with a history of a congenital defect at the time of surgery. ‡Other procedures are defined as additional operative procedure(s) performed by the same surgical team (ie, the same specialty/service) under the same anesthetic which has a CPT code different from that of the Principal Operative Procedure. §Concurrent procedures are defined as additional operative procedure(s) performed by a different surgical team (ie, a different specialty/service) under the same anesthetic which has a CPT code different from that of the Principal Operative Procedure.
26562); “Reconstruction of supernumerary digit, soft tissue and bone” (CPT 26587). All cases that matched these CPT codes in the NSQIP-P database during the study years were included. Patient characteristics were broken down by number (percent) and by mean (SD), and estimates were made using Poisson 95% CI. Fisher exact tests and Student’s t tests were performed for analyses assessing the differences between groups.
syndactyly web finger each web space, with skin flaps and grafts” (CPT code 26561), accounting for 32% of the procedures. The overall incidence of any complications in the cohort was 37 out of the 1,656 procedures (2.2%; 95% CI, 1.6%e3.1%) (Table 2). Five cases resulted in more than 1 complication, bringing the total number of complications to 42. The most common complication was superficial SSI (1.7%; 95% CI, 1.1%e2.4%; n ¼ 28), followed by related readmissions within 30 days (0.3%; 95% CI, 0.1%e 0.7%), deep incisional SSI (0.2%; 95% CI, 0.0%e 0.5%), and return to the operating room within 30 days (0.2%; 95% CI, 0.0%e0.5%) (Fig. 1). The procedure with the highest incidence of complications was “Repair of syndactyly each web space; complex, involving bone, nails, etc.” (CPT code 26562), which had a 3.2% (95% CI,
RESULTS From the years 2012 to 2014, the NSQIP-P contained procedural information on 1,656 pediatric hand procedures. The characteristics of this cohort are shown in Table 1. The most common congenital hand procedure was “Reconstruction of supernumerary digit, soft tissue and bone” (CPT code 26587), comprising 53% of the procedures, followed by “Repair of J Hand Surg Am.
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TABLE 2. CPT
Complications by CPT Code* n
All Complications
Wound Complications†
Unique Procedures With Any Complications
One or More Readmissions
Related Readmissions 1 (1.0%)
26560
104
4 (3.8%)
2 (1.9%)
3 (2.9%)
1 (1.0%)
26561
525
11 (2.1%)
9 (1.7%)
11 (2.1%)
8 (1.5%)
0 (0.0%)
26562
155
8 (5.2%)
5 (3.2%)
5 (3.2%)
2 (1.3%)
2 (1.3%)
26587
872
19 (2.2%)
15 (1.7%)
18 (2.1%)
9 (1.0%)
2 (0.2%)
Total
1,656
42 (2.5%)
31 (1.9%)
37 (2.2%)
20 (1.2%)
5 (0.3%)
*Percentages calculated from total number of cases per CPT code. †Wound complication ¼ Superficial SSI þ Deep SSI þ Organ infection.
FIGURE 1: Total complications for congenital hand procedures (n ¼ 1,656). FF, free flap.
1.0%e7.5%) incidence of superficial SSI and 1.3% (95% CI, 0.2%e4.7%) incidence of related readmissions (Fig. 2). There was 1 instance of a return to the operating room following complex syndactyly repair. The procedure with the least incidence of complications was “Repair of syndactyly web finger each web space, with skin flaps and grafts” (CPT code 26561) with a 2.1% (95% CI, 1.0%e3.7%) overall incidence of complications and 1.5% (95% CI, 0.7%e-3.0%) incidence of SSI. J Hand Surg Am.
The risk of related readmissions was low for all procedures, with a total of 5 admissions within 30 days among the 1,656 procedures. Several readmissions were either planned or occurred for unrelated reasons. The local NSQIP-P reviewers, through the chart review process, determined whether readmissions were related or unrelated to the index procedure. Using International Classification of Diseases, Ninth Revision, codes associated with the data, these unrelated readmissions were shown to be for various r
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FIGURE 2: Relative incidence of complications by CPT code. CPT 26560, “Repair of syndactyly web finger each web space; with skin flaps”; CPT 26561, “Repair of syndactyly web finger each web space, with skin flaps and grafts”; CPT 26562, “Repair of syndactyly each web space; complex, involving bone, nails, etc.”; CPT 26587, “Reconstruction of supernumerary digit, soft tissue and bone”; FF, free flap.
reasons, including gastrointestinal disease and dehydration, fever, otitis media, acute bronchiolitis, and fitting orthopedic devices. The most common reason for related readmissions was SSI (2 readmissions). An increased incidence of all types of complications were observed for patients undergoing syndactyly repairs involving bone compared with the other procedures (5.2% vs 2.3%; P < .05), which was statistically significant. Comparing the children with complications with those without, children with complications were more likely to be treated as inpatients in a hospital (16% vs 5%; P < .05) (Table 1). The patient-level risk factors of prematurity, presence of a congenital malformation, body mass index, or undergoing a concurrent procedure were not significantly associated with having a complication (Table 1). No patient-level risk factors (eg, inpatient status, comorbidities, prematurity) were significantly associated with the types of wound complications identified (superficial SSI and deep SSI, P ¼ .07).
hand surgeons, with the reported incidence of complications and wound infections typically limited to single institutional studies. This study utilized multiinstitutional data and aggregated over 1,600 cases from the NSQIP-P to quantify a collective experience of complication incidence following procedures for syndactyly and polydactyly. The incidence of all complications in this syndactyly and polydactyly cohort was 2.2%, with a rate of superficial and deep SSIs of 1.9%. These results compare with the incidence of complications reported by Lipira et al18 who calculated the incidence of complications and SSI at 2.5% and 1.2%, respectively, using adult NSQIP data for elective hand surgery. A higher rate of total complications (5.2%) and wound complications (3.2%) was observed in patients undergoing complex syndactyly repair (CPT 2652), which is presumably related to the greater complexity of the surgery. These rates are comparable with pediatric patients undergoing spine surgery22 (3.5%) and lower than rates of wound complications for cleft palate repair in pediatric patients (4.2%).23 Other studies have already evaluated longer-term outcomes for simple syndactyly repairs, with a recent review estimating a 5.31% chance of graft
DISCUSSION Procedures for the treatment of congenital hand differences are comparatively infrequent for general J Hand Surg Am.
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failure and a 4.76% of web creep.2 Long-term outcomes in polydactylies have cited a 19% reoperation rate for radial polydactylies27 and uncommon rates (< 5%) of neuroma formation in ulnar polydactylies.4,28 These results give further insight into the findings of Thibaudeau et al,25 who report a complication rate of 1.7% following pediatric upper extremity surgery. Several key differences exist between this study and that study, including our exclusion of 3 trauma pediatric upper extremity CPT codes. Only 13% of their total study sample (n ¼ 12,459) represented congenital hand procedures, although all of those data were analyzed as a single cohort. Because the majority of cases reported in the Thibaudeau et al25 study constitute percutaneous or open fixation of humeral fractures, these results may not be representative of the risk profile of elective congenital hand procedures. Related readmission was an infrequent complication, representing only 5 of 1,656 cases in this cohort. Given the low incidence of related readmissions, more data would be necessary to perform multivariate analysis for risk factors for readmission. This sample demonstrated significantly higher complication rates among inpatients. Other patient-level factors, such as multiple procedures, concurrent surgery under the same anesthetic, or presence of a congenital malformation, did not demonstrate higher complication rates. These findings may be explained by a selection bias; patients with multiple anomalies or other risk factors may be treated as inpatients and would not require readmission for a complication. At the discretion of NSQIP-P reviewers, readmissions were classified through an extensive chart review process, validated in the literature.10,11 The potential exists for readmissions to be coded as unrelated but may in fact be precipitated by the index procedure. This may underestimate the frequency of related readmissions using this database, which suggests a weakness of this analysis. This study has several limitations. Given the low incidence of complications, more high-quality data are needed to perform risk stratification and ensure adequate statistical power. Inpatient status, for instance, was significantly associated with total complications but not with the subgroup of SSI (P ¼ .07), although these in fact were the most common complication. Furthermore, the NSQIP-P collects information on only 4 congenital hand CPT codes, which do not represent all procedures performed by hand surgeons trained in this field. Despite the comprehensive data available on these CPT codes, considerable variation exists in surgical technique between surgeons and institutions. An additional limitation is that many J Hand Surg Am.
important outcomes for congenital hand surgery, including web creep in syndactyly, wound breakdown, or hypertrophic scar, may not be evident at 30 days. This would require prospective studies with longer follow-up periods to fully define the operative and functional outcomes of these patients.4 We provide preliminary information regarding the incidence of common complications following procedures for syndactyly and polydactyly. Using highquality data from a multicenter cohort, these results illustrate that the acute complications risk is low, the most common of which is superficial SSI. As more data become available from the NSQIP-P, further investigation of patient-level risk factors will aid in the medical evaluation of children and the counseling of their families. REFERENCES 1. Flynn J, Lovell W. Lovell and Winter’s Pediatric Orthopaedics. 7th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2014. 2. Sullivan MA, Adkinson JM. A systematic review and comparison of outcomes following simple syndactyly reconstruction with skin grafts or a dorsal metacarpal advancement flap. J Hand Surg Am. 2017;42(1):34e40.e6. 3. Oda T, Pushman AG, Chung KC. Treatment of common congenital hand conditions. Plast Reconstr Surg. 2010;126(3):121ee133e. 4. Comer GC, Ladd AL. Management of complications of congenital hand disorders. Hand Clin. 2015;31(2):361e375. 5. Cortez M, Fernandes Júnior JV, da Silva RF, et al. Surgical results from treating children with syndactyly through the collective effort system at “SOS Hand Recife” between 2005 and 2009. Rev Bras Ortop. 2014;49(4):396e400. 6. Greuse M, Coessens BC. Congenital syndactyly: defatting facilitates closure without skin graft. J Hand Surg Am. 2001;26(4):589e594. 7. Sharma RK, Tuli P, Makkar SS, Parashar A. End-of-skin grafts in syndactyly release: description of a new flap for web space resurfacing and primary closure of finger defects. Hand (N Y). 2009;4(1): 29e34. 8. Yildirim C, Sentürk S, Keklikçi K, Akmaz I. Correction of syndactyly using a dorsal separated V-Y advancement flap and a volar triangular flap in adults. Ann Plast Surg. 2011;67(4):357e363. 9. Larsen M, Nicolai JP. Long-term follow-up of surgical treatment for thumb duplication. J Hand Surg Br. 2005;30(3):276e281. 10. Dahlke AR, Merkow RP, Chung JW, et al. Comparison of postoperative complication risk prediction approaches based on factors known preoperatively to surgeons versus patients. Surgery. 2014;156(1):39e45. 11. Shiloach M, Frencher SK Jr, Steeger JE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210(1):6e16. 12. Gandaglia G, Ghani KR, Sood A, et al. Effect of minimally invasive surgery on the risk for surgical site infections: results from the National Surgical Quality Improvement Program (NSQIP) database. JAMA Surg. 2014;149(10):1039e1044. 13. Fischer JP, Wink JD, Tuggle CT, Nelson JA, Kovach SJ. Wound risk assessment in ventral hernia repair: generation and internal validation of a risk stratification system using the ACS-NSQIP. Hernia. 2014;19(1):103e111. 14. Bennett KM, Scarborough JE, Shortell CK. Predictors of 30-day postoperative stroke or death after carotid endarterectomy using the 2012 carotid endarterectomy-targeted American College of Surgeons
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dysplasia; 2016 [e-pub ahead of print]. J Pediatr Orthop. 2016. http:// dx.doi.org/10.1097/BPO.0000000000000804. Martin CT, Pugely AJ, Gao Y, Ilgenfritz RM, Weinstein SL. Incidence and risk factors for early wound complications after spinal arthrodesis in children: analysis of 30-day follow-up data from the ACS-NSQIP. Spine. 2014;39(18):1463e1470. Paine KM, Tahiri Y, Wes AM, et al. An assessment of 30-day complications in primary cleft lip repair: a review of the 2012 ACS NSQIP Pediatric. Cleft Palate Craniofac J. 2015;53(3):283e289. Tahiri Y, Fischer JP, Wink JD, et al. Analysis of risk factors associated with 30-day readmissions following pediatric plastic surgery: a review of 5376 procedures. Plast Reconstr Surg. 2015;135(2): 521e529. Thibaudeau S, Anari JB, Carducci N, Carrigan RB. 30-Day readmission after pediatric upper extremity surgery: analysis of the NSQIP database. J Pediatr Surg. 2016;51(8):1370e1374. American College of Surgeons. ACS NSQIP Pediatric Participant Use Data File. Available at: https://www.facs.org/quality-programs/pediatric/ program-specifics/quality-support-tools/puf. Accessed July 27, 2016. Stutz C, Mills J, Wheeler L, Ezaki M, Oishi S. Long-term outcomes following radial polydactyly reconstruction. J Hand Surg Am. 2014;39(8):1549e1552. Singer G, Thein S, Kraus T, Petnehazy T, Eberl R, Schmidt B. Ulnar polydactyly—an analysis of appearance and postoperative outcome. J Pediatr Surg. 2014;49(3):474e476.
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