Missed connections: National trends in the utilization of regenerative peripheral nerve interface surgery for major extremity amputation.

Abstract

Phantom-limb pain and symptomatic neuromas are common complications of amputation that highlight the need for preventive therapies. We analyzed national trends in the utilization of regenerative peripheral nerve interface (RPNI) surgery during major extremity amputation. The National Inpatient Sample from 2016-2022 was analyzed using ICD-10 procedure codes to identify patients undergoing amputations of the upper extremity or lower extremity through the lower leg. Concomitant RPNI surgery was identified by procedural codes for peripheral nerve supplementation. Among 468,850 patients who underwent major extremity amputation, 1030 (0.22%) received RPNI surgery in the same admission. The upper arm and forearm comprised 1.8% of amputations but were over three times more likely to receive concurrent RPNI surgery than lower leg amputations (OR 3.25 [2.53-4.12]). The highest income quartile was associated with greater chance of receiving RPNI surgery relative to the lowest-income quartile (OR: 1.58 [1.28-1.94]). Black patients were less likely than White patients (OR: 0.80 [0.66-0.97]), and privately insured patients were more likely than those under Medicare (OR 1.65 [1.37-1.98]) to receive RPNI surgery. RPNI surgery was performed almost exclusively at urban teaching hospitals (98.0% vs. 72.5% of amputation alone, p < 0.001). RPNI surgery was associated with increased total cost (+$16,059, p = 0.033); however, no change in length of stay was observed after multivariate adjustment. Despite its potential to prevent post-amputation pain and neuroma formation, RPNI surgery remains underused nationwide. Demographic and hospital level disparities underscore systemic inequities in preventive surgical care for post-amputation pain.