Abstract
Background:
There is a wide array of indications for lower extremity amputation (LEA) and inherent variability in operative experiences between surgical residents. Significant variation in resident surgical experience performing LEAs is possible.
Objective:
To identify inter- and intra-specialty trends and variability in LEA experience in graduating orthopedic surgery, general surgery, and vascular surgery residents from 2007-2017.
Methods:
Publicly available ACGME case log data for above knee amputation, below knee amputation, and transmetatarsal/ digital amputation procedures from accredited orthopaedic surgery, general surgery, traditional (5+2) vascular surgery and integrated (0+5) vascular surgery residencies was reviewed from 2007-2017. Linear regression analysis was used to identify temporal trends, with statistical significance set at p<0.05.
Results:
From 2007-2017, the mean number of total LEA, AKA, and BKA performed by graduating orthopaedic surgery residents did not change significantly. The mean number of total LEAs logged by graduating general surgery and integrated (0+5) vascular surgery residents did not change significantly over time (p=0.98, p=0.23, respectively). The mean number of total LEAs logged by traditional (5+2) vascular surgery residents increased from 16.0 to 32.6 (p<0.01). As study year increased, graduating integrated (0+5) and traditional (5+2) vascular surgery residents logged more LEAs relative to graduating orthopaedic surgery and general surgery residents (p<0.01).
Conclusions:
There is significant variation in resident experience in LEAs between surgical specialties. Integrated vascular surgery residents logged the most LEAs, followed by traditional vascular surgery residents, orthopaedic surgery residents, and general surgery residents. Experience of orthopaedic surgery residents in LEAs has been relatively stable over time.
Level of Evidence: IV
Keywords: acgme, resident, education, amputation
Introduction
Lower extremity amputations (LEA) are a common surgical procedure in the United States, with an incidence of over 100,000 procedures occurring annually.1,2 Recent studies have demonstrated that the incidence of LEA is increasing over time; this trend is expected to increase in magnitude by 100% over the next 25-30 years.1,2 This increase is likely secondary to the growing incidence of disease processes that may be treated with LEA, including atraumatic ischemia (often secondary to peripheral artery disease), trauma, local tumors, and congenital anaomalies.2
LEA are unique procedures in that surgeons from multiple surgical specialties, including orthopaedic surgery, general surgery, and vascular surgery routinely perform amputations. At our institution, residents from orthopaedic surgery, general surgery, and vascular surgery are receive training on and perform LEAs. However, given the wide variety of indications for the procedure, as well as the inherent variability between operative experiences of surgical residents, significant variation in the level of exposure and experience of trainees performing LEAs is possible. Daniels et al.3 demonstrated significant inter- and intra-specialty variability in the number of case logs of spine surgeries between graduating orthopaedic surgery and neurosurgery residents. These findings highlight current trends in residency training, and may prove valuable in programmatic design and the practice of training surgeons well-suited to meet the increased procedural demand.
At present, a formal examination of Accreditation Council for Graduate Medical Education (ACGME) case logs comparing the number of LEA between orthopedic surgery, general surgery, and vascular surgery has not been performed. The purpose of this study is to retrospectively review ACGME case logs was for 2 specific reasons: (1) identify inter- and intra-specialty trends in the median number of resident case logs in LEA from 2007-2017; (2) evaluate for inter- and intra-specialty variability in resident case logs.
Materials and Methods
Publically available ACGME case log data for accredited orthopaedic surgery, general surgery, traditional (5+2) vascular surgery, and integrated (0+5) vascular surgery residencies was reviewed from the 2006-2007 to the 2016-2017 academic years.4 Collected data included the mean number of above knee amputations (AKA), below knee amputations (BKA), transmetatarsal and digital amputations (TM/Dig), and the mean total number of lower extremity amputations logged by graduating residents over the course of their previous five years of training. The number of LEA logged by residents in the 30th and 70th percentiles of operative volumes was collected for graduating orthopedic surgery residents. Differences between residents in the 30th and 70th percentiles of case logs were calculated and analyzed, with temporal trends identified. The total number of graduating residents and total number of ACGME accredited orthopaedic surgery, general surgery, and vascular surgery residencies were recorded for each academic year.
The ACGME assesses residency programs in orthopaedic surgery, general surgery, and vascular surgery based on the number of resident case logs in multiple defined categories.5-7 Resident case logs are coded by procedural designations based on current procedural terminology (CPT) codes. These codes may be recorded by the resident at the time of the surgery, or may be distributed to residents by a program administrator. Levels are assigned to each case based on resident responsibility throughout the case. Cases in which the resident acts as either the primary resident surgeon, or acts in a direct supervisory role to another resident are designated and logged as level 1 cases. Cases in which the resident acted in an assisting role during the surgery are designated and logged as level 2 cases.8 Level 1 and level 2 cases count equally towards fulfillment of categorical minimum case logs necessary for graduation.8 For the purposes of this study, level 1 and level 2 cases were counted as equal.
Linear regression analyses was used to identify temporal trends, with statistical significance set at p<0.05. Statistical analysis software (SAS version 9.4, SAS Institute Inc., Cary NC, USA) was utilized for statistical analysis.
This study was exempt from institutional review board (IRB) approval.
Results
From 2007-2017, the number of orthopedic surgery programs and graduating residents increased significantly, from 149 programs and 616 residents in 2007 to 156 programs and 709 residents in 2017 (p<0.01 for both) (Table 1). There was no significant change in the number of traditional vascular surgery (5+2) programs (p=0.22) and graduating residents (p=0.15) over the study period (Table 1). ACGME case log data for integrated vascular surgery (0+5) programs was available only for years 2013 to 2017. Significant increases in the number of integrated vascular surgery programs (p<0.01) and graduating residents (p<0.01) was observed over the study period (Table 1). The number of general surgery residency programs did not change significantly, while the number of graduating general surgery residents increased (p<0.01) (Table 1).
Table 1.
Trends in Demographics of ACGME Case Log Respondents, by Service and Graduating Year
| Orthopaedic Surgery | Vascular Surgery (5+2) | Vascular Surgery (0+5) | General Surgery | |||||
|---|---|---|---|---|---|---|---|---|
| Year | Programs | Residents | Programs | Residents | Programs | Residents | Programs | Residents |
| 2007 | 149 | 616 | 86 | 111 | † | † | 248 | 1004 |
| 2008 | 148 | 621 | 78 | 94 | † | † | 246 | 1020 |
| 2009 | 148 | 635 | 90 | 116 | † | † | 244 | 1044 |
| 2010 | 147 | 653 | 92 | 120 | † | † | 242 | 1040 |
| 2011 | 148 | 650 | 96 | 124 | † | † | 240 | 1060 |
| 2012 | 149 | 675 | 94 | 124 | † | † | 242 | 1092 |
| 2013 | 150 | 678 | 91 | 121 | 10 | 11 | 240 | 1098 |
| 2014 | 151 | 684 | 89 | 122 | 16 | 19 | 243 | 1105 |
| 2015 | 151 | 699 | 96 | 130 | 23 | 26 | 246 | 1142 |
| 2016 | 153 | 705 | 88 | 116 | 27 | 32 | 248 | 1172 |
| 2017 | 156 | 709 | 90 | 114 | 36 | 41 | 251 | 1211 |
| p<0.01* | p=0.002* | p=0.22 | p=0.15 | p<0.01* | p<0.01* | p=0.44 | p<0.01* | |
Year – year of resident graduation. †No data available for given year. *Statistically significant.
Over the study period, the mean number of total LEA, AKA, and BKA performed by graduating orthopaedic surgery residents did not change significantly; however, the mean number of TM/ Dig amputations decreased (p=0.04) (Table 2). The mean number of total LEA, AKA, BKA, and TM/ Dig amputations logged by traditional vascular surgery residents all increased significantly over the study period (p<0.01 for all) (Table 3; Figure 1). For integrated vascular surgery residents and general surgery residents, there was no significant change in the mean number of total LEA, AKA, BKA, and TM/ Dig amputations performed by graduating residents (Table 3; Figure 1).
Table 2.
Mean Experiences in Lower Extremity Amputation of Graduating Orthopaedic Surgery Residents, 2007-2017
| Year | AKA | BKA | TM/Dig | Total LEA |
|---|---|---|---|---|
| 2007 | 3.4 | 6.7 | 6.5 | 16.6 |
| 2008 | 3.1 | 6.5 | 5.4 | 15.0 |
| 2009 | 3.0 | 5.9 | 5.9 | 14.8 |
| 2010 | 3.0 | 5.7 | 5.7 | 14.4 |
| 2011 | 3.4 | 6.0 | 5.9 | 15.3 |
| 2012 | 3.5 | 6.5 | 6.1 | 16.1 |
| 2013 | 3.7 | 6.3 | 6.1 | 16.1 |
| 2014 | 3.0 | 5.8 | 4.9 | 13.7 |
| 2015 | 3.3 | 5.9 | 5.4 | 14.6 |
| 2016 | 3.3 | 6.4 | 5.3 | 15.0 |
| 2017 | 3.5 | 6.5 | 5.2 | 15.2 |
| Study Mean | 3.3 ± 0.24 | 6.2 ± 0.35 | 5.7 ± 0.48 | 15.2 ± 0.84 |
| p=0.34 | p=0.82 | p=0.04* | p=0.74 |
Values reported as mean or mean ±standard deviation. Year – year of resident graduation; AKA – above knee amputation; BKA – below knee amputation; TM/Dig – transmetatarsal or digital amputation; LEA – lower extremity amputation. *Statistically significant increase over study period.
Table 3.
Mean Experience in Lower Extremity Amputations of Graduating Surgical Residents, 2007-2017
| Procedure | Orthopaedic Surgery | Vascular Surgery (5+2) | Vascular Surgery (0+5) | General Surgery |
|---|---|---|---|---|
| AKA | 3.3 (3.0-3.7) | 7.7 (4.7-11.2)* | 12.9 (9.6-13.1) | 4.1 (3.9-4.4) |
| BKA | 6.2 (5.7-6.7) | 8.9 (5.1-13.4)* | 18.1 (13.4-19.8) | 5.3 (5.0-5.7) |
| TM/Digit | 5.7 (4.9-6.5)* | 7.2 (4.5-9.3)* | 18.5(16.8-21.1) | 5.3 (5.0-5.6) |
| Total | 15.2 (13.7-16.6) | 23.7 (14.8-32.6)* | 49.5 (39.8-52.8) | 14.7 (14.1-15.3) |
Mean values for 2007-2017 are shown, with range in parenthesis. Total values are inclusive of all lower extremity amputations performed by residents of respective services. AKA – above knee amputation; BKA – below knee amputation; TM/Digit – transmetatarsal or digital amputation. *Statistically significant change over study period.
Figure 1.
Mean number of total lower extremity amputations logged by specialty, 2007-2017.
A line graph depicting the temporal trends in resident experiences in LEA by respective specialty. LEA – lower extremity amputation; Ortho – orthopaedic surgery; Gen Surg – general surgery; Vasc(5+2) – traditional vascular surgery (5+2); Vasc(0+5) – integrated vascular surgery (0+5).
As study year increased, graduating integrated and traditional vascular surgery residents logged more LEAs relative to graduating orthopaedic surgery and general surgery residents (p<0.01) (Table 4). From year to year, there was no significant difference in the number of logged LEAs between graduating orthopaedic surgery and general surgery residents (p=0.84) (Table 4). The difference in the number of cases logged between graduating orthopaedic surgery residents in the 30th percentile and those in the 70th percentile decreased over the study period (p=0.03).
Table 4.
Paired Inter-Specialty Differences in Mean Lower Extremity Amputation
| Specialty Comparison | Difference between Means | 95% CI | Sig. | |
|---|---|---|---|---|
| Lower | Upper | |||
| Ortho – Vasc(0+5) | -11.44 | -12.93 | -9.93 | *** |
| Ortho – Vasc(5+2) | -2.97 | -4.16 | -1.78 | *** |
| Ortho – GS | 0.13 | -1.33 | 1.05 | |
| Vasc (0+5) - GS | 11.58 | 10.07 | 13.09 | *** |
| Vasc(0+5) – Vasc(5+2) | 8.47 | 6.96 | 9.98 | *** |
| Vasc(5+2) – GS | 3.11 | 1.92 | 4.30 | *** |
***Statistically significant, p<0.05.
Sig – significance. CI – confidence interval.
Discussion
With an incidence of over 100,000 procedures annually, and a >100% increase projected by 2050, LEA are and will likely remain a common part of a modern surgical practice.1 With vascular disease and trauma accounting for >98% of all indications for LEA, it is imperative that graduates of orthopaedic surgery, general surgery, and vascular surgery residencies be familiar with performing and caring for patients with LEA.1 With the relatively recent introduction of integrated vascular surgery residency programs, as well as restrictions regarding resident work hours and the inherent variability in operative experience between residents, there is potential for deficiency in the volume of experience in LEA over the course of a surgical residency.9-11 Iannuzzi et al.12 demonstrated the association of general surgery resident involvement with LEA cases with a multitude of adverse outcomes, major complications, and prolonged time in the operating room. The authors concluded that the presence of this risk necessitates the tracking of potential effects or changes in the training of surgical residents, as poor clinical outcomes for patients may result.12 Pugely et al.13 demonstrated increased rates of patient morbidity and longer operative times associated with orthopaedic surgery resident involvement in lower extremity trauma cases. These studies illustrate the necessity to observe and understand recent trends in the experiences of surgical residents performing LEAs.
In the United States, there is significant variation in resident experience in LEAs between surgical specialties. Integrated vascular surgery residents logged the most LEAs, followed by traditional vascular surgery residents, orthopaedic surgery residents, and general surgery residents. This data seems to be relatively consistent with current trends, as atraumatic ischemia is by far the most common for LEA in the United States, accounting for over 80% of the total number of LEA cases.2 Trauma is the second most common disease etiology, accounting for approximately 16% of LEA.2 Congenital and cancer-related diagnoses account for less than one percent of LEA each.2
Importantly, the operative experience of orthopaedic surgery residents in LEA has been stable over time. The decrease in the number of case logs between orthopaedic surgery residents in the 30th percentile versus those in the 70th percentile suggests that LEA experience is becoming more uniform between orthopaedic surgery residents on a national level over time. Similarly, the growth of integrated vascular surgery programs seems to have had little impact on LEA experience of general surgery and traditional vascular surgery residents over the study period. One possible explanation may be that the practice of integrated vascular surgery residents is simply less diverse than those of general surgery or orthopaedic surgery A residents, in that amputation for B vascular disease represents an overall greater and/or increasing proportion of practice volume relative to other specialties.
Whether or not the current levels of case volume demonstrated in this study are sufficient for competency in performing LEA is unknown. Eardley et al.14 performed a recent survey of orthopaedic surgery trainees throughout the United Kingdom. Respondents had similar case volumes in amputations relative to trainees in the present study; >75% of respondents thought of their training volume as satisfactory or greater.14 Currently, there is no defined category or minimum number of LEA that are required for graduation from AGCME-accredited orthopaedic surgery, general surgery, and vascular surgery programs.5-7 It may be worth considering there may be significant baseline post-operative morbidity and mortality in patients undergoing LEA; recent studies estimate 30 day mortality at 13-16% for patients undergoing AKA and 5-6% for patients undergoing BKA.15,16 Bosse et al. in a series of 130 patients undergoing LEA secondary to lower extremity trauma, demonstrated an overall complication rate of 33.9%.17 Wound complications, including infection, dehiscence, and failure to heal are commonplace.15,17 The potential additive effect of resident inexperience on an already morbid surgery with high rates of complications raises the question as to whether or not there should exist a minimum number of LEA cases that should be required for resident graduation. However, the data in this study is not sufficient to answer such questions, and further studies are needed.
There are several limitations to this study. First are limitations imposed by the case logs themselves. Multiple studies have raised questions about the accuracy and reliability of reporting amongst case logs of residents and fellows.18-23 Critiques include inconsistent use, incorrect, omitted, or erroneously added CPT code designations, and overall widely variable logging practices.18-23 As a group of procedures with no required minimum for graduation, case logs pertaining to LEA may be particularly susceptible to inaccuracy relative to procedures with a categorical minimum. Additional limitations include the retrospective nature of the study and the limited number of years of available data for residents of integrated vascular surgery programs. Strengths of the study include the large scale use of data obtained nationally, from a wide range of resident practices.
There is significant variation in resident experience in LEAs between surgical specialties. Integrated vascular surgery residents logged the most LEAs, followed by residents of traditional vascular surgery, orthopaedic surgery, and general surgery. The experience of orthopaedic surgery residents in LEAs has been relatively stable over the past 11 years. The growing number of cases logged by vascular surgery residents mirrors national trends in the incidence of peripheral arterial disease and LEA
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