Surgeon Volume as Indicator of Outcomes after Free Flap Extremity Reconstruction

This study evaluated and described the contribution of surgeon volume to outcomes after extremity free flap reconstruction.

Using the National Inpatient Sample for 1998 to 2001, 1850 patients underwent an extremity free flap reconstruction procedure (ICD-9-CM code 83.82). One hundred sixty-nine surgeons were identified in the data sets with a unique surgeon identification number. Surgeons were categorized in terms of annual free flap volume as low-volume (≤ 10 procedures), medium-volume (11 to 30), and high-volume (> 30). Primary outcome variables included in-hospital mortality, length of stay, hospital charges, postoperative flap loss, hemorrhage, and other local wound complications.

Extremity free flaps were performed annually by high-volume surgeons in 55.6% of patients, by medium-volume surgeons in 28.6% of patients, and by low-volume surgeons in 15.8% of patients. Of the 169 surgeons studied, 14.2% were high-volume surgeons, 20.7% were medium-volume, and 65.1% low-volume. The overall in-hospital mortality rate was 0.80%. Observed mortality by surgeon volume was 0.37% for high-volume surgeons, 0.74% for medium-volume, and 2.38% for low-volume surgeons (p < 0.01). The postoperative flap loss rate was 0.03% for high-volume surgeons, 0.74% for medium-volume, and 2.29% for low-volume surgeons (p < 0.001). All complications, such as wound hematoma/infection/disruption and postoperative hemorrhage, were decreased by approximately 80% in the high-volume group, with flap loss being the most significant with a 98.7% decrease in the high-volume surgeon group (p < 0.001). Mean length of stay was diminished by 15% in the high-volume group, compared to the low-volume group (p < 0.001), and mean hospital cost was 13% lower in the high-volume group than in the low-volume (p < 0.01).

High-volume surgeons do more than 50% of extremity free flap grafts in the United States. However, the number of low-volume surgeons is nearly five times greater than that of high-volume surgeons performing this challenging procedure. An individual surgeon must perform a critical number of cases per year in order to maintain low complication rates and improved outcomes.