Elective Revision Research Articles

What happens after the free flap? Evaluation of aesthetic and functional elective revisions

BackgroundMicrovascular free flap reconstruction of a defect, as a single-stage procedure, does not always achieve the desired functional and esthetic result. Revisions may be necessary to achieve ideal contour, symmetry, and suspension of soft tissues, or to support dental rehabilitation. PurposeThe study purpose was to estimate the incidence and identify factors associated with elective free flap revisions.Study design, setting, sample: A retrospective cohort study of subjects who underwent free flap reconstruction was conducted to characterize the rate of elective free flap revision surgery. The study included subjects >18 years old, who underwent head and neck microvascular free flap surgery for any etiology, and both primary and secondary reconstructions, between 2014-2021. Subjects were excluded if they had incomplete records. Predictor variableThe predictor variable was composed of a set of variables, grouped into the following categories: subject demographic data, medical history, disease etiology, anatomical site, and postoperative complications. Main outcome variableThe outcome variable was time to elective revision surgery measured as months from the date of the initial operation to date of elective revision surgery. Elective revision surgery was defined as a procedure to enhance esthetics or function, which directly modifies the original surgical site, not including procedures to correct a complication, treat the original disease process, or emergencies. CovariatesNot applicable. AnalysisKaplan-Meier method was used to analyze the data, with p-value <0.05. Risk factors for elective revisions were analyzed with Cox Hazard ratio. ResultsThe sample was composed of 377 subjects that underwent free flap surgery, with a mean age of 55.9 +/- 15.9. Of these 67% were male, and 33% female, and sixty-two had an elective revision surgery (16.4%), with median follow-up period of 17 months (IQR 9-28). In the Cox regression model, only type of free flap was associated with an elective revision (p<0.05), where radial forearm had the lowest association with elective revision, and fasciocutaneous, latissimus dorsi, and scapula flaps had the highest. Conclusion and RelevanceAchieving basic wound coverage with free flaps can be a challenge, however, surgeons should prepare patients for the potential need for functional and esthetic revisions after free flap surgery to improve patient quality of life.

The experience of patients undergoing aseptic, elective revision knee joint replacement surgery: a qualitative study

BackgroundAround 6,000 revision knee replacement procedures are performed in the United Kingdom each year. Three-quarters of procedures are for aseptic, elective reasons, such as progressive osteoarthritis, prosthesis loosening/wear, or instability. Our understanding of how we can best support these patients undergoing revision knee replacement procedures is limited. This study aimed to explore patients’ experiences of having a problematic knee replacement and the impact of undergoing knee revision surgery for aseptic, elective reasons.MethodsQualitative semi structured interviews with 15 patients (8 women, 7 men; mean age 70 years: range 54–81) who had undergone revision knee surgery for a range of aseptic, elective indications in the last 12 months at an NHS Major Revision Knee Centre. Interviews were audio-recorded, transcribed, de-identified and analysed using reflexive thematic analysis.ResultsWe developed six themes: Soldiering on; The challenge of navigating the health system; I am the expert in my own knee; Shift in what I expected from surgery; I am not the person I used to be; Lingering uncertainty.ConclusionsLiving with a problematic knee replacement and undergoing knee revision surgery has significant impact on all aspects of patients’ lives. Our findings highlight the need for patients with problematic knee replacements to be supported to access care and assessment, and for long-term psychological and rehabilitation support before and after revision surgery.

Defining the tipping point for revision reverse shoulder arthroplasty

Background This study sought to characterize the tipping point values (the functional scores that patients deem dysfunctional enough to warrant surgery) for patients undergoing first revision reverse total shoulder arthroplasty (rTSA). Methods This study was a retrospective review of a prospectively collected single-institution database of patients undergoing first revision rTSA between August 2015 and December 2019. Tipping point evaluation utilized preoperative scores including the American Shoulder and Elbow Surgeons (ASES), raw and normalized Constant, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), and University of California-Los Angeles (UCLA) scores, and active range of motion including abduction, forward elevation (FE), external rotation (ER), and internal rotation score (IR) prior to elective revision rTSA. Results We included 125 revision rTSAs. Tipping points were 37.6 ASES score, 30.5 raw Constant score, 35.5 normalized Constant score, 68.1 SPADI, 3.7 SST, 13.2 UCLA score, 64° abduction, 69° FE, 23° ER, and 3.1 IR. Higher SST was found for older patients and patients with a lower body mass index. Lower abduction and FE tipping points were reported in patients undergoing revision rTSA for rotator cuff failure, unexplained pain, and implant wear. Discussion These tipping points can help surgeons counsel patients regarding when to undergo revision rTSA. Level of evidence Level III; retrospective cohort study; treatment study.

COMPARATIVE STUDY BETWEEN THE FAILURE RATES OF THE TROCHANTERIC FIXATION NAIL-ADVANCED (TFNA) AND GAMMA NAILS IN PROXIMAL FEMUR FRACTURE FIXATION

Hip fractures frequently occur in elderly patients with osteoporosis and are rapidly increasing in prevalence owing to an increase in the elderly population and social activities. We experienced several recent presentations of TFNA nails failed through proximal locking aperture which requires significant revision surgery in often highly co-morbid patient population.The study was done by retrospective data collection from 2013 to 2023 of all the hip fractures which had been fixed with Cephalomedullary nails to review and compare Gamma (2013–2017) and TFNA (2017–2023) failure rates and the timing of the failures. Infected and Elective revision to Arthroplasty cases were excluded.The results are 1034 cases had been included, 784 fixed with TFNA and 250 cases fixed Gamma nails. Out of the 784 patients fixed with TFNA, 19 fixation failed (2.45%). Out of the 250 cases fixed with Gamma nails, 15 fixation failed (6%). Mean days for fixation failure were 323 and 244 days in TFNA and Gamma nails respectively.We conclude that TFNA showed remarkable less failure rates if compared to Gamma nails. At point of launch, testing was limited and no proof of superiority of TFNA over Gamma nail. Several failures identified with proximal locking aperture in TFNA which can be related to the new design which had Substantial reduction in lateral thickness at compression screw aperture.

Closing the Loop on Revision: The Impact of Emotional Well-being on Elective Revision After Breast Reconstruction.

A diagnosis of breast cancer has a significant impact on a patient's physical and emotional health. Breast reconstruction improves quality of life and self-esteem following mastectomy. However, many patients undergo additional elective revision procedures after reconstruction. The aim of this study was to assess the relationship between perioperative emotional well-being and elective revisions in breast reconstruction. A retrospective review was performed of patients who underwent breast reconstruction with a single surgeon between January 2007 and December 2017. Revision procedures were defined as additional operations that fall outside the index reconstructive plan. Medical records were reviewed for a history of generalized anxiety disorder (GAD) and/or major depressive disorder. Multivariate analysis was performed to identify factors associated with revision. A total of 775 patients undergoing breast reconstruction were included, of whom 121 (15.6%) underwent elective revision. Overall, a history of any psychiatric history (P < .001), depression alone (P = .001%), and GAD and depression together (P = .003) were significantly associated with revision surgery. On multivariate logistic regression controlling for comorbidities and reconstruction modality, depression alone, and GAD and depression together were significantly associated with an increased likelihood of revision surgery (odds ratio, 3.20, P < .001; odds ratio, 2.63, P < .001). Perioperative emotional well-being and reconstruction modality impact the rate of secondary revision surgery. An understanding of the surgical and patient-related risk factors for revision can provide more informed patient-decision making and improve surgical planning.

Effects of Elective Revision After Breast Reconstruction On Patient-Reported Outcomes.

There has been increasing emphasis on patient-reported satisfaction as a measure of surgical outcomes. While previous research has investigated factors influencing patient satisfaction following breast reconstruction, there are few studies on how patient satisfaction is impacted by revision procedures. The purpose of this study was to investigate whether elective revisions following breast reconstruction are significantly associated with changes in patient-reported outcomes and quality of life. A retrospective review was conducted of patients who underwent immediate autologous or alloplastic breast reconstruction at a single institution from 2015-2021. Patients were included if they had completed BREAST-Q pre-operatively, post-initial reconstruction, and post-revision procedures. Patients were excluded if they received adjuvant radiation or if they had previously undergone breast reconstruction procedures. The primary outcome measures were BREAST-Q domains. Demographic, clinical, and surgical variables were also analyzed. Of the 123 patients included for analysis, 61 underwent autologous breast reconstruction and 62 underwent alloplastic reconstruction. Mean age was 49.31 ± 11.58 years and BMI was 29.55 ± 5.63 kg/m2. 48 patients underwent no revision procedures and 75 patients underwent at least one revision. Between these two groups, there were no differences in age, BMI, complication rates, socioeconomic status, or pre-operative BREAST-Q scores. Patients reported significantly higher satisfaction with outcome after their first revision compared to after initial reconstruction alone (p=0.04). Autologous reconstruction patients who had at least one revision had significantly higher Satisfaction with Outcome (p=0.02) and Satisfaction with Surgeon (p=0.05) in the 2-year follow-up period compared to patients who had no revisions. Revision procedures following autologous breast reconstruction are associated with higher patient satisfaction with outcome. Further research should explore specific factors influencing patient decision-making regarding whether to undergo revisions.

D119. Identifying Risk Factors for Elective Revisions after Breast Reconstruction

D119. Identifying Risk Factors for Elective Revisions after Breast Reconstruction

Using a Machine Learning Approach to Predict the Need for Elective Revision and Unplanned Surgery after Implant-based Breast Reconstruction.

Two-stage implant-based reconstruction after mastectomy may require secondary revision procedures to treat complications, correct defects, and improve aesthetic outcomes. Patients should be counseled on the possibility of additional procedures during the initial visit, but the likelihood of requiring another procedure is dependent on many patient- and surgeon-specific factors. This study aims to identify patient-specific factors and surgical techniques associated with higher rates of secondary procedures and offer a machine learning model to compute individualized assessments for preoperative counseling. A training set of 209 patients (406 breasts) who underwent two-stage alloplastic reconstruction was created, with 45.57% of breasts (185 of 406) requiring revisional or unplanned surgery. On multivariate analysis, hypertension, no tobacco use, and textured expander use corresponded to lower odds of additional surgery. In contrast, higher initial tissue expander volume, vertical radial incision, and larger nipple-inframammary fold distance conferred higher odds of additional surgery. The neural network model trained on clinically significant variables achieved the highest collective performance metrics, with ROC AUC of 0.74, sensitivity of 84.2, specificity of 63.6, and accuracy of 62.1. The proposed machine learning model trained on a single surgeon's data offers a precise and reliable tool to assess an individual patient's risk of secondary procedures. Machine learning models enable physicians to tailor surgical planning and empower patients to make informed decisions aligned with their lifestyle and preferences. The utilization of this technology is especially applicable to plastic surgery, where outcomes are subject to a variety of patient-specific factors and surgeon practices, including threshold to perform secondary procedures.

Elective Revision Surgery in Head and Neck Cancer Patients: A Retrospective Analysis at an Oncology Centre in Porto, Portugal.

Introduction Elective revision surgery in head and neck cancer is crucial for refining and optimizing outcomes, ensuring complete tumor removal, and enhancing both functional and aesthetic aspects, ultimately improving the overall quality of life for patients. The aim of this study is toanalyze the overall survival (OS) of head and neck cancer patients who underwent elective revision surgery with or without adjuvant treatment between 2019 and 2022, reflecting on thepractice between those years in IPO-Porto, Porto, Portugal. Methods This study included 58 patients who underwent 116 major neck surgeries. Multidisciplinary head and neck follow-up records were obtained for every patient. Overall survival and disease-specific survival (DSS) curves were calculated using the Kaplan-Meier method, and statistical significance was determined by the Log-Rank test. We did a retrospective study with an anterograde direction, evaluating the treatments that were previously done by the patients. Results The sample comprised 51 males (87.9%) and seven females (12.1%), with a mean age of 59.02±11.014 years. Head and neck pathology was mostly in the larynx (36.2%). The type of the first surgery was mainly directed to the primary tumor in 62.1% (n=36). In the other 37.9% (n=22), surgery was directed to the primary tumor in association with neck dissection. The type of the second surgery was mainly revision surgery. We found that T4 tumors (HR (hazard ratio)= 10.219, p = 0.006) and hypopharynx tumors(HR = 5.306, p =0.035)were significantly associated with inferior OS. Conclusion In our sample, we found that a T4 and a tumor located in the hypopharynxwere significantly associated with inferior OS in elective head and neck oncologic revision surgery. Disease-free survival in patients undergoing revision surgery in our sample is generally poor. In our sample, there was a statistically significant difference in overall survival between the group who underwent surgery for microscopic evidence of persistent tumor (R1) versus clinical and imagiological tumoral persistency. In our sample, the time between the first and second surgeries wasn't linked with an inferior OS. Further studies with larger populations and prospective design, with longer follow-ups can be the road to a better understanding of this issue.

PATIENT-REPORTED OUTCOME MEASURES AFTER ELECTIVE REVISION TOTAL KNEE ARTHROPLASTY IN ELDERLY PATIENTS (&gt;85 YEARS)

AbstractIntroductionRevision total knee arthroplasty (rTKA) in elderly patients (&gt;85 years) is associated with increased mortality, hospital stay and a high rate (55%) of complications. The objective was to assess PROMs in elderly patients undergoing rTKA.MethodsA retrospective cohort study of consecutive patients undergoing rTKA at an arthroplasty centre from 2001–2022 were compared to a control group (aged 50–79y) matched for gender, diagnosis &amp; surgery year. The commonest reasons for revision in elderly patients was aseptic loosening (53/100), infection (21/100) and fracture (7/100). One-year patient-reported outcome data was available for 64%.Results100 patients underwent rTKA with a mean age of 84 years (range 80–97 years, SD 3) compared to a matched control group of younger patients (mean age 69y). Preoperative function was poor, with a mean Oxford knee score (OKS) of 40/100 in elderly and 43/100 in younger patients (p=0.164).At one-year postop, mean OKS was comparable between elderly and young patients (81 and 84/100 respectively, p=0.289). The number of patients with severe pain at one year was also comparable (4% elderly and 7% young respectively, p=0.177).The improvement in OKS for elderly patients was sustained at three (82 95% CI 58–100, 14/100 known) and five years.Overall complication rate was 54%. 14% were dead at 1 year and 56% were dead at five-years.ConclusionElderly patients undergoing elective revision TKA show a mean improvement in Oxford knee score of +38 at one year. This is the same as younger patients and is sustained at three and five years.

PD12-09 OUTCOMES OF 429 PRIMARY ROBOTIC PERITONEAL FLAP GENDER AFFIRMING VAGINOPLASTY CASES

You have accessJournal of UrologyCME1 Apr 2023PD12-09 OUTCOMES OF 429 PRIMARY ROBOTIC PERITONEAL FLAP GENDER AFFIRMING VAGINOPLASTY CASES Gaines Blasdel, Charles Dubach-Reinhold, Elijah Castle, Rachel Bluebond-Langner, and Lee Zhao Gaines BlasdelGaines Blasdel More articles by this author , Charles Dubach-ReinholdCharles Dubach-Reinhold More articles by this author , Elijah CastleElijah Castle More articles by this author , Rachel Bluebond-LangnerRachel Bluebond-Langner More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003259.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Gender affirming robotic peritoneal flap vaginoplasty is a promising adaptation of established vaginoplasty techniques that has been performed since 2017. We report perioperative factors and patient reported outcomes for all consecutive cases at one center. METHODS: Records of patients undergoing primary robotic peritoneal flap gender affirming vaginoplasty with the senior authors from 9/2017-8/2022 were retrospectively reviewed. Operative time, length of stay, complications, self-report of orgasm and dilation, and date of last follow up were recorded for all patients. Clavien-Dindo grading for severity of complications were organized according to occurrence prior or after 90 days postoperatively. For outcomes with incidence greater than 5%, statistical analysis for change over years was performed using nonparametric tests. RESULTS :Primary robotic peritoneal flap gender affirming vaginoplasty was performed on 429 patients with median follow up of 369 days (interquartile range 186-607). Of these, 413 patients (96%) had 90 day or longer follow up and 16 (4%) had a Clavien-Dindo 3a or 3b complication within that period (Table 1). 245 patients had a follow up of 1 year or greater, and 9 patients (4%) had Clavien-Dindo 3a or 3b complications after 90 days in this cohort. Overall elective revision rate was 17%, with 1% revision for vaginal depth. Significant decrease in operative time was observed (p<.0001), with a mean operative time of 101 mins for cases 400-429 . Rate of dilating using the largest dilator to the deepest dot increased over these first 300 cases (p<.001) and rate of elective revision decreased (p <.001). CONCLUSIONS: Primary robotic peritoneal flap gender affirming vaginoplasty has low morbidity and complication rates with durable vaginal depth and orgasmic function at long term follow up. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e403 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gaines Blasdel More articles by this author Charles Dubach-Reinhold More articles by this author Elijah Castle More articles by this author Rachel Bluebond-Langner More articles by this author Lee Zhao More articles by this author Expand All Advertisement PDF downloadLoading ...

Outcomes of MCGR at > 3year average follow-up in severe scoliosis: who undergoes elective revision vs UPROR?

The purpose of this study was to evaluate mid-term outcomes of magnetically controlled growing rods (MCGR), evaluate factors associated with unplanned return to the operating room (UPROR) vs achieving full length. Full length was defined as achieving > 85% of the elongating portion of the rod. IRB approved retrospective single site study. 106 patients underwent MCGR between 2014 and 2020, 58 met inclusion criteria, all genders, ethnicities, and etiologies were included. Patients with < 1year follow-up or previous instrumentation were excluded. Follow-up averaged 43months. 23 patients achieved full length 13 were revised to a new MCGR and 10 to a fusion; 5 were fused due to skeletal maturity; 12 were still lengthening; 2 were being observed; 16 experienced UPROR. Major curves improved from 80° (50-114) preoperative to 40° (7-78) at most recent follow-up or prior to revision, and 24° (4-57) after fusion. Fusion patients averaged 1.3 (1-4) procedures prior to fusion and gained 75mm (38-142) in T1-S1 length. 16 patients experienced UPROR, 11 were male (p = 0.0238). All failures to elongate were male as was the rod fracture. Age was not correlated with UPROR (p = 0.318), but did correlate with implant-specific causes of UPROR. Specifically, anchor failure was associated with younger age and rod failure with older age at implantation (p = 0.013). There was no correlation between UPROR and major curve, flexibility or kyphosis. This is the largest site study evaluating mid-term outcomes in MCGR patients. At > 3.5year follow-up 47% were electively revised, 27% underwent UPROR, 26% were still lengthening, and 3% were being observed. UPROR was associated with male gender and age at implantation was associated with implant-related causes of UPROR. MCGR continues to have high complication rates, better knowledge of MCGR outcomes may improve patient education, surgical timing, and decision-making.

Clinical utility of sonication for diagnosing infection and colonization of cardiovascular implantable electronic devices.

Our study aimed to evaluate the sensitivity of the sonication tool for the microbiological diagnosis of cardiovascular implantable electronic device infections (CIEDIs). The extracted cardiac implants of 52 patients were assessed: 19 with CIEDI and 33 with elective generator replacement or revision without clinical infection. Sonication fluid culture of explanted CIEDs yielded higher numbers of microorganisms than pocket tissue or swab cultures. The sensitivity of sonication fluid culture was significantly higher than that of pocket swab and tissue culture for microbiological diagnosis of CIEDI. The microorganisms isolated most frequently via sonication of explanted CIEDs were Gram-positive cocci (70%), of which 50% was coagulase-negative Staphylococcus. Sonication fluid culture detected colonization in 36.4% of the non-infected patients. Sonication fluid culture represents a promising diagnostic strategy with increased sensitivity compared to conventional culture methods for microbiological diagnosis of cardiac devices associated with infection and colonization.

Through-and-Through Dissection of the Soft Palate for Pharyngeal Flap Inset: A "Good-Fast-Cheap" Technique for Any Etiology of Velopharyngeal Incompetence.

Objective:To determine the efficacy and resource utilization of through-and-through dissection of the soft palate for pharyngeal flap inset for velopharyngeal incompetence (VPI) of any indication.Design:Retrospective review.Setting:Tertiary care center.Patients:Thirty patients were included. Inclusion criteria were diagnosis of severe VPI based on perceptual speech assessment, confirmed by nasoendoscopy or videofluoroscopy; VPI managed surgically with modified pharyngeal flap with through-and-through dissection of the soft palate; and minimum 6 months follow-up. Patients with 22q11.2 deletion syndrome were excluded.Intervention:Modified pharyngeal flap with through-and-through dissection of the soft palate.Main Outcome Measure(s):Velopharyngeal competence and speech assessed using the Speech-Language Pathologist 3 scale.Results:The median preoperative speech score was 11 of 13 (range, 7 to 13), which improved significantly to a median postoperative score of 1 of 13 (range 0-7; P < .001). Velopharyngeal competence was restored in 25 (83%) patients, borderline competence in 3 (10%), and VPI persisted in 2 (7%) patients. Complications included 1 palatal fistula that required elective revision and 1 mild obstructive sleep apnea that did not require flap takedown. Median skin-to-skin operative time was 73.5 minutes, and median length of stay (LOS) was 50.3 hours.Conclusions:This technique allows direct visualization of flap placement and largely restores velopharyngeal competence irrespective of VPI etiology, with low complication rates. Short operative time and LOS extend the value proposition, making this technique not only efficacious but also a resource-efficient option for surgical management of severe VPI.

Venous thromboembolism after fast-track elective revision hip and knee arthroplasty – A multicentre cohort study of 2814 unselected consecutive procedures

BackgroundVenous thromboembolism (VTE) prophylaxis is much debated within total hip and knee arthroplasty (THA/TKA). Revision hip and knee arthroplasty (rTHA/rTKA) are more extensive procedures, but data on the risk of postoperative VTE is conflicting and there are no specific guidelines for thromboprophylaxis. Furthermore, data on rTHA/rTKA within a fast-track protocol is sparse. Thus, we aimed at evaluating the incidence and time course of VTE in unselected elective rTHA/rTKA within our established multicentre fast-track collaboration with in-hospital only thromboprophylaxis if length of stay (LOS) ≤ 5 days. MethodsWe used an observational study design of unselected consecutive fast-track elective major component rTHA/rTKA from 6 dedicated fast-track centres between 2010 and 2018. We obtained information on revisions through Danish hip and knee arthroplasty registers and complete (>99%) 90 days follow-up through the Danish National Patient Registry in combination with chart review. ResultsWe included 2814 procedures with median LOS 3 days [2–5] and 21% had LOS >5 days. The 90-day incidence of VTE was 0.42% (n = 12), with 8 (0.28%) DVT and 4 (0.14%) PE, after median 14 days [IQR: 11–23] with the latest on day 31. ConclusionThe 90-day incidence of VTE after elective fast-track rTHA and rTKA was about 0.4% which is comparable to the 90-day VTE incidence after primary fast-track THA, TKA and unicompartmental knee arthroplasty. Future investigations should focus on identification of high-risk patients while the surgical trauma per se may be less important.

Femoral revision for periprosthetic fracture in total hip arthroplasty

Periprosthetic fracture can create significant morbidity in the arthroplasty population. Patients with periprosthetic fracture have been shown to have worse outcomes and higher mortality than patients undergoing elective revision THA. In this review, we will focus on Vancouver B2 and B3 fractures. Both of these fracture types are associated with a loose primary prosthesis and warrant revision surgery. There are many different options for fixation choice of the femoral prosthesis, and preference has been evolving over the last 30 years. Currently, we use monoblock, tapered, fluted, titanium stems for all periprosthetic fracture revision surgeries.

Elective Revisions after Breast Reconstruction: Results from the Mastectomy Reconstruction Outcomes Consortium.

Rates of breast reconstruction following mastectomy continue to increase. The objective of this study was to determine the frequency of elective revision surgery and the number of procedures required to achieve a stable breast reconstruction 2 years after mastectomy. Women undergoing first-time breast reconstruction after mastectomy were enrolled and followed for 2 years, with completion of reconstruction occurring in 1996. Patients were classified based on the absence or presence of complications. Comparisons within cohorts were performed to determine factors associated with revisions and total procedures. Mixed-effects regression modeling identified factors associated with elective revisions and total operations. Overall, 1534 patients (76.9 percent) had no complications, among whom 40.2 percent underwent elective revisions. The average number of elective revisions differed by modality (p < 0.001), with abdominally based free autologous reconstruction patients undergoing the greatest number of elective revisions (mean, 0.7). The mean total number of procedures also differed (p < 0.001), with tissue expander/implant reconstruction patients undergoing the greatest total number of procedures (mean, 2.4). Complications occurred in 462 patients (23.1 percent), with 67.1 percent of these patients undergoing elective revisions, which was significantly higher than among patients without complications (p < 0.001). The mean number of procedures again differed by modality (p < 0.001) and followed similar trends, but with an increased mean number of revisions and procedures overall. Mixed-effects regression modeling demonstrated that patients experiencing complications had increased odds of undergoing elective revision procedures (OR, 3.2; p < 0.001). Breast reconstruction patients without complications undergo over two procedures on average to achieve satisfactory reconstruction, with 40 percent electing revisions. If a complication occurs, the number of procedures increases. Risk, II.

Discussion: Elective Revisions after Breast Reconstruction: Results from the Mastectomy Reconstruction Outcomes Consortium.

St. Louis, Mo. From the Division of Plastic and Reconstructive Surgery, Washington University School of Medicine. Received for publication March 3, 2019; accepted March 15, 2019. Disclosure:Dr. Myckatyn receives advisory board, consulting fees, and investigator-initiated research funding from RTI and Allergan. Dr. Ha has no disclosure to report. Terence M. Myckatyn, M.D., Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8238, St. Louis, Mo. 63110-1010, [email protected]

Ninety-Day Readmission in Elective Revision Lumbar Fusion Surgery in the Inpatient Setting.

Study Design:Retrospective review.Objectives:(1) Identify the 90-day rate of readmission following revision lumbar fusion, (2) identify independent risk factors associated with increased rates of readmission within 90 days, (3) and identify the hospital costs associated with revision lumbar fusion and subsequent readmission within 90 days.Methods:Utilizing 2014 data from the Nationwide Readmissions Database, patients undergoing elective revision lumbar fusion were identified. With this sample, multivariate logistic regression was utilized to identify independent predictors of readmission within 90 days. An analysis of total hospital costs was also conducted.Results:In 2014, an estimated 14 378 patients underwent elective revision lumbar fusion. The readmission rate at 90 days was 3.1% (n = 446). Diabetes with chronic complications was the only comorbidity found to carry significantly increased odds of readmission. Surgical complications such as deep venous thrombosis, surgical wound disruption, hematoma, and pneumonia (experienced during the index admission) were also independent predictors of readmission. Anterior approaches were associated with increased odds of readmission. The most common related diagnoses on readmission were hardware issues, postoperative infection, and disc herniation. Readmissions were associated with an average of $96 152 in increased hospital costs per patient compared with those not readmitted.Conclusion:Relevant patient comorbidities and surgical complications were associated with increased readmission within 90 days. Readmission within 90 days was associated with significant increases in hospital costs.

The Association Between Race/Ethnicity and Revision Following ACL Reconstruction in a Universally Insured Cohort.

There have been few large studies involving multiethnic cohorts of patients treated with anterior cruciate ligament reconstruction (ACLR), and therefore, little is known about the role that race/ethnicity may play in the differential risk of undergoing revision surgery following primary ACLR. The purpose of this study was to evaluate whether differences exist by race/ethnicity in the risk of undergoing the elective procedure of aseptic revision in a universally insured cohort of patients who had undergone ACLR. This was a retrospective cohort study conducted using our integrated health-care system's ACLR registry and including primary ACLRs from 2008 to 2015. Race/ethnicity was categorized into the following 4 groups: non-Hispanic white, black, Hispanic, and Asian. Multivariable Cox proportional-hazard models were used to evaluate the association between race/ethnicity and revision risk while adjusting for age, sex, highest educational attainment, annual household income, graft type, and geographic region in which the ACLR was performed. Of the 27,258 included patients,13,567 (49.8%) were white, 7,713 (28.3%) were Hispanic, 3,725 (13.7%) were Asian, and 2,253 (8.3%) were black. Asian patients (hazard ratio [HR] = 0.72; 95% confidence interval [CI] = 0.57 to 0.90) and Hispanic patients (HR = 0.83; 95% CI = 0.70 to 0.98) had a lower risk of undergoing revision surgery than did white patients. Within the first 3.5 years postoperatively, we did not observe a difference in revision risk when black patients were compared with white patients (HR = 0.86; 95% CI = 0.64 to 1.14); after 3.5 years postoperatively, black patients had a lower risk of undergoing revision (HR = 0.23; 95% CI = 0.08 to 0.63). In a large, universally insured ACLR cohort with equal access to care, we observed Asian, Hispanic, and black patients to have a similar or lower risk of undergoing elective revision compared with white patients. These findings emphasize the need for additional investigation into barriers to equal access to care. Because of the sensitivity and complexity of race/ethnicity with surgical outcomes, continued assessment into the reasons for the differences observed, as well as any differences in other clinical outcomes, is warranted. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.