Abstract
IMPORTANCE: Replantation and revascularization are among the most technically challenging surgical procedures and have varying success rates. Methods to assess surgeon skill for this complex undertaking are lacking. OBJECTIVE: To examine whether a surgeon proficiency score is associated with clinical outcomes across multiple institutions. DESIGN, SETTING, AND PARTICIPANTS: This multicenter retrospective cohort study analyzed all digit replantation and revascularization after traumatic amputations for adult patients from January 1, 2000, to August 31, 2022, at 8 medical institutions in the United States, India, and Singapore. Data were collected and analyzed from February to October 2024. EXPOSURE: Surgeon proficiency (range, 1.0 to 7.5; higher score indicates greater proficiency) and procedure difficulty (range, -1.0 to 7.5; higher score indicates greater difficulty) scores. Each surgeon's procedures were sorted chronologically, then divided in half. Proficiency scores were calculated for each surgeon based on the difficulty and outcomes of their early procedures and validated using outcomes from their later procedures. Difficulty scores were calculated based on patient and injury characteristics. MAIN OUTCOMES AND MEASURES: The outcome of interest was procedure success, defined as digit survival at 1 month after the operation. RESULTS: Of 653 digits that were replanted or revascularized by 65 surgeons, 458 (70.1%) were successful. Mean (SD) patient age was 41.0 (15.7) years, and 571 patients (87%) were male. Difficulty scores ranged from 1.0 to 7.5, with a mean of 2.7, and were significantly higher in failed procedures than in successful procedures (mean [SD], 3.2 [1.4] vs 2.5 [1.2]; P < .001). Proficiency scores ranged from -0.37 to 4.14, with a mean of 1.40. For each 1-point increase in proficiency score, a surgeon's future success rate increased by 7.5% (95% CI, 5.5%-8.1%; P < .001). After adjusting for surgeon experience, difficulty score, and additional patient- and injury-level characteristics using mixed-effects logistic regression, greater surgeon proficiency score and lower difficulty score were associated with greater likelihood of individual procedure success (surgeon proficiency: odds ratio [OR], 1.46; 95% CI, 1.02 to 2.10; P = .04; difficulty: OR, 0.70; 95% CI, 0.57 to 0.86; P = .001). CONCLUSIONS AND RELEVANCE: This multi-institutional cohort study of patients who underwent digit replantation or revascularization found that surgeon proficiency score was associated with 1-month success. These findings suggest that national trauma referral networks should incorporate difficulty and proficiency scoring tools when coordinating patient transfers after traumatic digit amputation. Centers with high replant volume or those who are geographically well-positioned to become replant centers should aim to recruit and improve reimbursement for surgeons with high proficiency scores. Meanwhile, surgeons with low proficiency scores should seek out additional training to improve their skills.