Need For Revision Procedures Research Articles

Open Versus Percutaneous Fixation of Trigger Finger: Meta-Analysis of Clinical Outcomes

With variable and conflicting results to date, it remains unclear whether the percutaneous or open surgical A1 pulley release technique is superior regarding safety and efficacy. The goal of this meta-analysis was to compare the two techniques. PubMed, Cochrane, and Google Scholar (pages 1-20) were searched through August 2023. Eight randomized controlled trials met the inclusion criteria and were included in this meta-analysis. Of the eight included studies and 548 total patients, there were 278 subjects in the percutaneous release group and 270 subjects in the open release group. There was no significant difference between the two surgical techniques in postoperative rates of revision, complications, or pain. This meta-analysis found no significant difference between open and percutaneous techniques regarding the need for revision procedures, complications, or postoperative pain. Therefore, both open and percutaneous releases are appropriate. Therapeutic I.

Surgical strategies in acute subdural hematoma: a meta-analysis of decompressive craniectomy vs. craniotomy.

Acute subdural hematoma (ASDH) stands as a significant contributor to morbidity after severe traumatic brain injuries (TBI). The primary treatment approach for patients experiencing progressive neurological deficits or notable mass effects is the surgical removal of the hematoma, which can be achieved through craniotomy (CO) or decompressive craniectomy (DC). Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy. We conducted a comprehensive literature review, utilizing prominent online databases and manually searching references related to craniotomy and craniectomy for subdural hematoma evacuation up to November 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes. We included a total of 11 comparative studies in our analysis, encompassing 4269 patients, with 2979 undergoing craniotomy and 1290 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale (GCS) during their initial presentation. Following surgery, the DC group exhibited a significantly reduced rate of residual subdural (P = 0.009). Additionally, the likelihood of a poor outcome during follow-up was lower in the CO group. Likewise, the mortality rate was lower in the CO group compared to the craniectomy group (OR 0.63, 95% CI 0.41-0.98, I2 = 84%, P = 0.04). Our study found that CO was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome while DC was associated with less likelihood of residual subdural hematoma. Upon further investigation of patient characteristics who underwent into either of these interventions, it was very clear that patients in DC cohort have more serious and low pre-op characteristics than the CO group. Nonetheless, brain herniation and advanced age act as independent factor for predicting the outcome irrespective of the intervention.

Effect of hospital length of stay on functional outcomes and readmission after total shoulder arthroplasty

BackgroundTotal shoulder arthroplasty (TSA) is a common orthopedic procedure for glenohumeral osteoarthritis, rotator cuff arthropathy, and other degenerative conditions. The current standard hospital length of stay (LOS) commonly accepted following TSA is 1-2 days before discharge to home or a private facility. To evaluate the association between LOS and readmissions, revisions, and outcomes. Additionally, risk factors for increased LOS (> 24 hours) following TSA will be determined. MethodsA retrospective review identified all patients who underwent TSA between 2010 and 2019. Patients were excluded for chronic kidney disease requiring dialysis, preoperative corticosteroid use, revision TSA, undergoing a TSA for a fracture, or having no recorded outcome measures. Demographic information, operative details, medical comorbidities, length of hospital stay, complications, location of discharge, readmissions, revisions, and outcome scores were collected. Patients were categorized into two groups: discharge within 24 hours of TSA and discharge over 24 hours after TSA. ResultsPatients discharged within 24 hours had an average LOS of 0.96 ± 0.19 days, and patients discharged after 24 hours had an average LOS of 2.71 ± 1 day (P < .001). There were no significant differences in the groups with regard to race, sex, and body mass index. Patients discharged within 24 hours were younger at the time of surgery compared to patients discharged after 24 hours (66.7 ± 8.10 years and 70.1 ± 10.4 years, respectively [P = .030]). There was a significant difference in discharge location between the groups with 86.2% of patients in the under-24 hour group being discharged to home compared to only 66.0% in the over-24 hour group (P = .006). There were no significant differences between the groups with regard to postoperative complication rate, 90-day readmission rate, and need for revision procedures. There was a significant difference in the Charlson comorbidity index between the groups with those discharged within 24 hours averaging an index score of 2.78 ± 1.33 and those discharged after 24 hours averaging an index score of 4.02 ± 2.07 (P < .001). No significant differences were found between preoperative and postoperative American Shoulder and Elbow Surgeons Shoulder Survey, Single Assessment Numeric Evaluation, or Simple Shoulder Test scores between the groups. ConclusionPatients who had a hospital LOS over 24 hours following TSA were significantly older and discharged to nonhome locations at a higher rate. Patients with Charlson comorbidity index scores over 3 are more likely to have a LOS over 24 hours following TSA. Postoperative outcome measures were not affected by LOS with no significant differences in readmission rate, revision rates, and complications.

Zone I Revision Finger Amputations Performed in the Emergency Department Compared With Those Performed in the Operating Room.

Finger amputations are commonly encountered. These may be revised in the emergency department (ED) or the operating room (OR). Previous studies have demonstrated the cost-effectiveness associated with procedures performed in the ED. Patient outcomes have not been described. We retrospectively reviewed patients who presented to our level 1 trauma center with a traumatic partial or complete finger amputation through flexor tendon zone I. All were treated with revision amputation performed in either the ED or the OR between January 2012 and December 2017. A total of 172 patient charts were included. Ninety-three of the revision amputations were performed in the ED, while 79 were performed in the OR. There was no difference in age, race, sex, having a manual labor job, medical comorbidities, or mechanism of injury between the groups. Compared with procedures performed in the ED, procedures performed in the OR had a higher rate of delayed healing, a longer stay in the hospital, and a higher referral to therapy postoperatively. Length of follow-up and number of follow-up visits were not statistically different based on location of procedure. There was no difference in post-procedural infection rate or need for revision procedure between the groups. Our data support the efficacy of performing revision amputation procedures in the ED. Recorded patient complications and subsequent treatment after revision amputations performed in the ED vs the OR were comparable. Those performed in the ED potentially decrease the burden placed on the patient and the health care system. [Orthopedics. 2024;47(3):152-156.].

Autologous Fat Versus Hydroxyapatite Cement for Use in Frontal Sinus Obliteration: Systematic Review and Meta-Analysis.

Frontal sinus obliteration is a possible terminus for the management of chronic sinusitis, frontal bone trauma, cancer extirpation, or mucocele. The mucosa of the sinus is stripped and space obliterated with either autogenic, allopathic, or synthetic materials. This study aimed to compare the outcomes of autologous fat and hydroxyapatite cement (HAC) for frontal sinus obliteration. A multidatabase systematic review was conducted to collect outcomes on frontal sinus obliterations with either autologous fat or HAC. Outcomes collected included infection of the frontal sinus or obliteration material, mucocele formation, skin infection at the operative site, hematoma or seroma, cosmetic defect, donor site infection, and need for revision procedure. Prevalence of outcomes was analyzed through meta-analysis of proportions. Twenty studies were ultimately included in the meta-analysis. Sixteen studies reported outcomes for 667 patients obliterated with autologous fat, and 7 studies reported outcomes for 100 patients obliterated with HAC. Prevalence of infection of the frontal sinus or obliteration material, mucocele formation, skin infection at the operative site, hematoma or seroma, and cosmetic defect did not differ statistically between the cohorts. Donor site infection secondary to fat harvesting for fat obliteration had a prevalence of <0.01. Revision rate was 0.04 (95% confidence interval, 0.01-0.8) for fat obliteration and 0.10 (95% confidence interval, 0.00-0.33) for HAC obliteration. No statistically significant differences in the studied outcomes were detected between obliterations with autologous fat and HAC, suggesting that either is equally suitable and may be up to the surgeon's preference.

All-Inside Versus Outside-in Repair of Triangular Fibrocartilage Complex Peripheral Tears

Triangular fibrocartilage complex (TFCC) peripheral tears with persistent wrist pain can be treated with arthroscopic surgical repair owing to vascularization of the peripheral region. The safety and efficacy of all-inside repair has been shown in prior case series. The purpose of this study was to compare two methods of arthroscopic peripheral TFCC repair: all-inside vertical mattress and outside-in horizontal mattress. A 5-year retrospective review was performed on patients treated from 2016 to 2021 with wrist arthroscopy and TFCC repair for Palmer 1B tears. Patients with ulnar extrinsic ligament repair, distal radioulnar joint instability, concomitant ulnar shortening osteotomy, and extensor carpi ulnaris instability were excluded. Patient therapy and office visit records were reviewed. Outcomes including Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH); range of motion; grip strength; immobilization time; complications; and need for revision procedures were compared. Fifty-two patients were included in the study, 32 in the outside-in group and 20 in the all-inside group. The average follow-up length was 24.8 weeks, with similar range of motion and strength in both groups. The average postoperative QuickDASH score was 13 in the outside-in group and 9 in the all-inside group at 43.5 months, compared with the preoperative QuickDASH scores of 47 and 50, respectively. Mean immobilization time was longer for outside-in than for all-inside (5.25 vs 2.0 weeks, respectively). All-inside arthroscopic peripheral TFCC repair showed range of motion, grip strength, complications, revisions, and postoperative improvement in QuickDASH scores similar to those with the outside-in technique. Therapeutic IV; retrospective comparative study.

Impact on quality of life in obstructive sialadenitis predicting outcomes after sialendoscopy

PurposeSialendoscopy is a minimally invasive procedure considered a paradigm shift in the treatment of obstructive sialadenitis. However, it shows an average need for revision procedure in up to 24% of operated cases. This study analyzed whether patient-related variables could predict the need for a revision during postoperative follow-up. MethodsFrom 2012 to 2020, this prospective comparative study analyzed demographic data as well as preoperative responses to the “Manukau Salivary Symptoms Score” (MSSS) questionnaire as predictors of the need for a revision procedure due to symptoms recurrence. Results188 sialendoscopies (39.4% for stones/60.6% for stenoses) in 112 parotid (59.6%) and 76 submandibular glands (40.4%) were included in this study. Forty patients (21.3%) required a revision procedure. The variable “Impact on quality of life” in the preoperative period of patients with sialoliths showed that the likelihood of a revision procedure increases by 33.6% with each increase in the 10-point Likert scale presented in the MSSS (p = 0.010, OR = 1336, CI = 1.071 to 1.667). This finding was not influenced by the location of the sialolith in the duct (p = 0.415), size (p = 0.058) or number of stones (P = 0.476). Other demographic variables related to the patient showed no association with the need of a revision procedure. ConclusionFurther studies should be performed to exclude the influence of other variables on the results; however, special attention should be given to patients who report a greater pre-operative impact on quality of life due to sialolithiasis. Level of evidenceII.

A Retrospective Cohort Study of the Impact of Upper Lip Tie Release on Breastfeeding in Infants.

Objectives: Lingual frenotomies for the purpose of improving infant breastfeeding remain controversial, whereas maxillary frenotomies are even more so given the scant data and differing opinions on the matter. This study aimed at further elucidating the effect that maxillary frenula have on breastfeeding difficulties in infants. Methods: A retrospective chart review was performed on infants approximately aged 0-3 months who presented to a tongue tie/breastfeeding clinic from January to December of 2019. All analyzed infants had both lip and tongue ties classified by a clinician. Data on pre-frenotomy pain scores, lingual Coryllos classification, maxillary Kotlow classification, post-frenotomy complications, and breastfeeding success were captured. Results: Of the 316 infants, 224 underwent their first procedure at the tongue tie/breastfeeding clinic. Two hundred eleven out of 224 infants received a lingual frenotomy only, whereas the remaining 13 (5.8%) underwent both lingual and maxillary frenotomy procedures. Of the group of 211, 207 (98.1%) had successful feeding after 1 procedure; the remaining 4 underwent revision procedures to achieve successful feeding. All maxillary frenulum releases (n = 13) led to successful feeding without the need for revision procedures. Coryllos and Kotlow classification scores were significantly higher in the infants receiving both a maxillary and lingual frenulum release as compared with those receiving solely a lingual frenulum release. Conclusions: The majority (98.1%) of infants receiving a lingual frenulum release alone had successful feeding after only one procedure, and only 5.8% of all infants receiving any intervention required a maxillary frenulum release for successful feeding, calling into question the relative necessity of performing maxillary frenulum releases for breastfeeding difficulties.

Combination of the endoscopic septonasal flap technique and bioabsorbable steroid-eluting stents for repair of congenital choanal atresia in neonates and infants: a retrospective study

BackgroundMultiple surgical approaches have been proposed to repair the congenital choanal atresia. However, there remains no general consensus about the optimal surgical technique. This study aimed to describe and evaluate outcomes of the endoscopic septonasal flap technique combined with bioabsorbable steroid-eluting stents for repair of congenital choanal atresia in neonates and infants.MethodsClinical data of 37 neonates and infants with congenital choanal atresia who received nasal endoscopic surgery with the flap technique between January 2018 and July 2020 were analyzed retrospectively. All patients underwent the ultra‑low‑dose paranasal sinus computed tomography imaging preoperatively to confirm diagnosis and plan the surgery. In these patients, the mirrored L-shaped flap technique was performed for bilateral atresia and the cross-over L-shaped flap technique was performed for unilateral atresia. A total of 22 patients had silicone stents postoperatively and 15 patients had bioabsorbable steroid-eluting stents postoperatively. Silicone stents were removed at one month postoperatively under secondary general anesthesia, while no anesthesia was needed to remove the bioabsorbable steroid-eluting stents. Postoperative follow-up ranged from 10 months to 3 years.ResultsThe septonasal flap technique was performed in all patients. Compared with the silicone stents group, the average operative duration and the hospital length of stay in the bioabsorbable steroid-eluting stents group were decreased [(97.46 ± 15.37) min vs (83.49 ± 19.16) min t = 13.733, P < 0.001] [(12.8 ± 3.22) d vs (7.67 ± 3.91) d t = 15.082, P < 0.001], the average number of procedures was reduced [(2.04 ± 0.64) vs (1.00 ± 0.00), t = 82.689, P < 0.001], the differences were statistically significant. There were no reports of postoperative restenosis and complications in the bioabsorbable steroid-eluting stents group, and follow-up endoscopic examinations showed patency and stable nasal passages in all cases.ConclusionsThe endoscopic septonasal flap technique can effectively expose and expand the choanal bony structure for repair of congenital choanal atresia in neonates and infants. The combined use of this technique along with bioabsorbable steroid-eluting stents can help prevent the need for revision procedures and also against stent-related injuries.

Tongue Reduction for Macroglossia.

Macroglossia is a term used to describe a large tongue which protrudes outside of the mouth while in a resting position (Balaji, 2013). It is a cardinal sign in children with Beckwith-Wiedemann syndrome and can also be found in children with Down syndrome and Klippel-Trenaunay-Weber syndrome. Macroglossia can lead to airway and feeding difficulties, as well as problems with speech, drooling, and cosmesis. We present a review of tongue reduction operations performed for macroglossia over a 10-year period in Northern Ireland. We performed a retrospective review of the medical notes of those children identified to have undergone a tongue reduction procedure in the regional pediatric hospital. We reviewed the presenting symptoms and concerns, the operative technique used, postoperative outcomes, and follow up. Outcomes data included improvements in symptoms, complications, and the need for revision procedures. Six children underwent tongue reduction procedures over a 10-year period. Age range at time of surgery was between 4 months to 10 years 3 months. Five children had an underlying diagnosis of Beckwith-Wiedemann syndrome and 1 child had Down syndrome. One child underwent a second tongue reduction for mild tongue protrusion at the 5-year follow up. There were no complications in relation to tongue reduction surgery for any of the children and importantly, there were no airway complications in our series. All patients were found to have improved feeding, better tongue position in the oral cavity, reduced drooling, and better speech development following surgery. Symptomatic macroglossia requiring a tongue reduction procedure is relatively rare and these procedures are, therefore, uncommonly performed. Despite the rarity of this procedure, when it is required, it can be life saving for some infants and children, and life altering for the remainder. Improvements in airway, feeding, speech, and psychosocial wellbeing are the desired outcomes with this procedure. Throughout our 10-year series we have found it to be a relatively safe procedure but potentially anesthetically challenging. We have demonstrated both good short and long-term outcomes for these children.

Repair of Alar Defects Using the Alar Rotation Flap: Our Experience with 394 Patients.

The purpose of this study was for the authors to describe their patient selection, surgical technique, and results with the alar rotation flap for surgical defects of the nasal ala. The authors performed a retrospective analysis of all alar rotation flaps performed between June of 2006 and February of 2019. Three hundred ninety-four patients were identified, and follow-up encounters were reviewed to assess for complications and need for revision procedures. The alar rotation flap was performed on 394 patients over a 13-year period. The mean defect size was 9.3 ± 2.8 mm by 7.2 ± 2.3 mm. Three hundred nineteen patients (81 percent) were evaluated postoperatively, with a mean average duration of follow-up of 2.3 years (range, 6 days to 11.9 years). Complications included hemorrhagic crust along the incision line [n = 9 (3 percent)], flap edema [n = 7 (2 percent)], internal nasal valve dysfunction [n = 3 (1 percent)], depressed surgical scar [n = 2 (1 percent)], hematoma [n = 1 (0.5 percent)], and paresthesia [n = 1 (0.5 percent)]. The alar rotation flap is a reliable one-stage flap for small- to medium-size partial-thickness defects of the nasal ala that can produce topographic restoration with minimal risk of aesthetic or functional complication. Therapeutic, IV.

Is Diagnostic Arthroscopy at the Time of Medial Patellofemoral Ligament Reconstruction Necessary?

Background:Although medial patellofemoral ligament (MPFL) reconstruction is well described for patellar instability, the utility of arthroscopy at the time of stabilization has not been fully defined.Purpose:To determine whether diagnostic arthroscopy in conjunction with MPFL reconstruction is associated with improvement in functional outcome, pain, and stability or a decrease in perioperative complications.Study Design:Cohort study; Level of evidence, 3.Methods:Patients who underwent primary MPFL reconstruction without tibial tubercle osteotomy were reviewed (96 patients, 101 knees). Knees were divided into MPFL reconstruction without arthroscopy (n = 37), MPFL reconstruction with diagnostic arthroscopy (n = 41), and MPFL reconstruction with a targeted arthroscopic procedure (n = 23). Postoperative pain, motion, imaging, operative findings, perioperative complications, need for revision procedure, and postoperative Kujala scores were recorded.Results:Pain at 2 weeks and 3 months postoperatively was similar between groups. Significantly improved knee flexion at 2 weeks was seen after MPFL reconstruction without arthroscopy versus reconstruction with diagnostic and reconstruction with targeted arthroscopic procedures (58° vs 42° and 48°, respectively; P = .02). Significantly longer tourniquet times were seen for targeted arthroscopic procedures versus the diagnostic and no arthroscopic procedures (73 vs 57 and 58 min, respectively; P = .0002), and significantly higher Kujala scores at follow-up were recorded after MPFL reconstruction without arthroscopy versus reconstruction with diagnostic and targeted arthroscopic procedures (87.8 vs 80.2 and 70.1, respectively; P = .05; 42% response rate). There was no difference between groups in knee flexion, recurrent instability, or perioperative complications at 3 months. Diagnostic arthroscopy yielded findings not previously appreciated on magnetic resonance imaging (MRI) in 35% of patients, usually resulting in partial meniscectomy.Conclusion:Diagnostic arthroscopy with MPFL reconstruction may result in findings not previously appreciated on MRI. Postoperative pain, range of motion, and risk of complications were equal at 3 months postoperatively with or without arthroscopy. Despite higher Kujala scores in MPFL reconstruction without arthroscopy, the relationship between arthroscopy and patient-reported outcomes remains unclear. Surgeons can consider diagnostic arthroscopy but should be aware of no clear benefits in patient outcomes.

The cost-effectiveness of antibiotic-loaded bone cement versus plain bone cement following total and partial knee and hip arthroplasty

BackgroundPostoperative infection is one of the most prevalent complications following total joint arthroplasty (TJA). As such procedures become more prevalent, it is imperative that we develop new prophylactic methods to prevent the need for revision procedures. In recent years, surgeons have opted to use antibiotic-loaded bone cement (ALBC) rather than plain bone cement (PBC) in primary hip and knee replacements due to its theoretical potential of lowering infection rates. However, the cost-effectiveness of this intervention remains in question.Questions/Purposes: To determine the rate of infection and cost-effectiveness of antibiotic-loaded bone cement as compared to plain bone cement in hip and knee arthroplasty. Patients and methodsWe reviewed 4116 primary hip and knee arthroplasty cases performed between 2016 and 2018 at Morristown Medical Center in New Jersey. Data regarding demographics, complications, and any readmissions due to deep infection were collected retrospectively. During that time period there were a total of 4016 knee cases (423 ALBC, 3593 PBC) and 123 hip cases (63 ALBC, 60 PBC). The average cost for one bag of antibiotic-loaded bone cement and plain bone cement for hip and knee arthroplasty was $336.42 and $72.14, respectively. A statistical analysis was performed using Fisher's exact test; the National Healthcare Safety Network (NHSN) surgical site infection guidelines were used to distinguish between superficial and deep infections. ResultsTen patients were readmitted due to deep infection, all of whom had undergone total knee arthroplasty. Of those cases, plain bone cement was used for the index procedure in seven instances and antibiotic-loaded cement was used in three. This resulted in an infection rate of 0.19% and 0.62%, respectively, p = 0.103. There was no statistically significant difference in infection rates between the two groups. A total of 778 bags of ALBC were used in 423 knee surgeries, and 98 bags of ALBC were used in 63 hip cases. The total cost for ALBC in TKA and THA procedures was $261,734.76 (778*336.42) and $32,969.16 (98*336.42), respectively. If PBC had been used during all index procedures, it would have resulted in a total savings of $231,509.28. ConclusionsAntibiotic-loaded cement did not significantly reduce the rate of infection for either knee or hip arthroplasty. Thus, the routine use of antibiotic-loaded cement in primary hip and knee arthroplasty may be an unnecessary financial burden to the healthcare system. A larger sample size and a randomized controlled trial would help confirm our findings and would provide further information on the cost-effectiveness of ALBC cement versus PBC.Significance/Clinical Relevance: In this review of cases performed from 2016 to 2018 there was no statistically significant difference between the rate of infection and the need for revision surgeries for patients treated with ALBC versus PBC. As hospital systems continue to transition towards a bundled payment model, it becomes imperative for providers to reduce any unnecessary costs in order to increase quality and efficiency. We estimate that our hospital system could save nearly $120,000/year by using plain bone cement instead of antibiotic-loaded cement.

Comparative Analysis of Opioid Usage Following Total Ankle Arthroplasty vs Ankle Fusion

Category:Ankle, Ankle ArthritisIntroduction/Purpose:Opiate pain medication is frequently prescribed following foot and ankle surgery for post-operative pain management. Opioid abuse has now reached epidemic levels and unfortunately become an all too common occurrence following small prescriptions of opiate pain medication. Total ankle arthroplasty and ankle fusion are two commonly performed procedures for the treatment of ankle arthritis. Understanding postoperative pain medication requirements following these procedures is useful both in the counseling of patients pre-operatively as well as in assisting surgeons with the management of postoperative pain. We aim to examine patient opioid usage following total ankle arthroplasty compared to ankle fusion and assess for potential clinical factors associated with increased post-operative opioid use.Methods:Adult patients (over 18 years of age) undergoing total ankle arthroplasty or ankle fusion were identified using CPT codes (27700, 27702, 27870, 29899) to query the Pearl Diver patient record database, a private insurance database. 1127 patients undergoing total ankle arthroplasty and 2695 patients undergoing ankle fusion were identified. Demographic data including age, sex, and medical history was collected. Patients were examined for opioid usage at pre-operative, 1-month, 3-month, 6-month, and 1-year time points. Post-operative complications and need for revision procedures within 1-year were also examined. Multivariate logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) with p<0.05 considered significant.Results:The most common age group amongst ankle arthroplasty patients was 70-74 (21.9%) and 65-69 (21.6%) for fusion. Patients undergoing fusion were more likely to have DM, HTN, morbid obesity, tobacco use, CHF, CKD, and CAD, (p<0.05). Pre- operative opioid usage was significantly higher in the fusion group, 26.9% vs.18.8% (OR 1.41, CI 1.23 -1.61, p<0.01). Post-operative usage remained higher at all time points, (p<0.01). At 12 months, 8.7% of arthroplasty patients remained on opiates compared to 17.3% for fusion, (OR 1.67, CI 1.3-2.13, p<0.001). Need for revision procedures was higher in the fusion group at 1 year, 8.4% vs. 2.9%, (p<0.001). Additionally, arthroplasty patients were more likely to suffer post-operative complications including surgical site infection and DVT, OR 2.77 (CI 2.22-3.44) and OR 1.67 (CI 1.82-2.27) respectively.Conclusion:Our analysis of opiate prescription data indicates that a higher number of patients utilized opiate medication both pre-operatively and following fusion compared to arthroplasty patients at 1-month, 3-month, 6-month, and 1-year time points. Patients undergoing fusion also demonstrated worse pre-operative medical comorbidities. Additionally, patients undergoing fusion were more likely to suffer a complication including DVT and surgical site infection. This information indicates that fusion patients may require more opiate pain medication and are at increased risk for prolonged opiate use, and the potential complications of opiate use. Further analysis is indicated to determine potential risk factors for prolonged opioid use.

Principles of Orthoplastic Surgery for Lower Extremity Reconstruction: Why Is This Important?

Regardless of the antecedent etiology, lower extremity salvage and reconstruction attempts to avoid amputation, restore limb function, and improve quality of life outcomes. This goal requires a treatment team well versed in neurovascular pathology, skeletal and soft tissue reconstruction, and physical rehabilitation. A review was performed of historical milestones that lead to the development of orthoplastic extremity reconstruction, principles of current management and the evidence that supports an orthoplastic approach. Based on available evidence and expert opinion, the authors further sought to provide insight into the future of the field centered around the importance of a multidisciplinary management protocol. Historically, orthopaedic and plastic surgeons worked separately when faced with challenging reconstructive cases involving lower extremity skeletal and soft tissue reconstruction. With time, many embraced that their seemingly separate skill-sets and knowledge could be unified in a collaborative orthoplastic approach in order to offer patients the best possible chance for success. First coined by the senior author (LSL) in the early 1990s, the collaborative orthoplastic approach between orthopaedic and plastic surgeons in limb salvage for the past several decades has resulted in a unique field of reconstructive surgery. Benefits of the orthoplastic approach include decreased time to definitive skeletal stabilization/soft tissue coverage, length of hospital stay, post-operative complications, need for revision procedures and improved functional outcomes. The orthoplastic approach to lower extremity reconstruction is a collaborative model of orthopaedic and plastic surgeons working together to expedite and optimize care of patients in need of lower extremity reconstruction. The implementation of protocols, systems, and centers that foster this approach leads to improve outcomes for these patients. We encourage centers to embrace the orthoplastic approach when considering limb salvage, as the decision to amputate is irreversible.

Utilization and Economic Impact of Posterolateral Fusion and Posterior/Transforaminal Lumbar Interbody Fusion Surgeries in the United States.

Study Design:Retrospective database study.Objective:To analyze the economic and age data concerning primary and revision posterolateral fusion (PLF) and posterior/transforaminal lumbar interbody fusion (PLIF/TLIF) throughout the United States to improve value-based care and health care utilization.Methods:The National Inpatient Sample (NIS) database was queried by the International Classification of Diseases, Ninth Revision, Clinical Modification codes for patients who underwent primary or revision PLF and PLIF/TLIF between 2011 and 2014. Age and economic data included number of procedures, costs, and revision burden. The National Inpatient Sample database represents a 20% sample of discharges from US hospitals weighted to provide national estimates.Results:From 2011 to 2014, the annual number of PLF and PLIF/TLIF procedures decreased 18% and increased 23%, respectively, in the Unites States. During the same period, the number of revision PLF decreased 19%, while revision PLIF/TLIF remained relatively unchanged. The average cost of PLF was lower than the average cost of PLIF/TLIF. The aggregate national cost for PLF was more than $3 billion, while PLIF/TLIF totaled less than $2 billion. Revision burden (ratio of revision surgeries to the sum of both revision and primary surgeries) remained constant at 8.0% for PLF while it declined from 3.2% to 2.9% for PLIF/TLIF.Conclusion:This study demonstrated a steady increase in PLIF/TLIF, while PLF alone decreased. The increasing number of PLIF/TLIF procedures may account for the apparent decline of PLF procedures. There was a higher average cost for PLIF/TLIF as compared with PLF. Revision burden remained unchanged for PLF but declined for PLIF/TLIF, implying a decreased need for revision procedures following the initial PLIF/TLIF surgery.

1000 Consecutive Cases of Laser-Assisted Liposuction Utilizing the 1440nm Wavelength Nd:YAG Laser: Assessing the Safety and Efficacy.

Liposuction remains one of the most popular aesthetic surgery procedures performed today, and it has undergone continuous refinements over the past four decades. Advancements in anesthesia, improvements in instrumentation, better understanding of fluid dynamics and the addition of energy to liposuction have led to better outcomes with improved safety and efficacy. The purpose of this study is to review 1000 consecutive laser-assisted liposuction (LAL) cases utilizing the 1440nm wavelength. Emphasis was placed on complication rates and the need for revision procedures. The charts of 611 patients who underwent 1000 consecutive LAL operations were reviewed. All cases were performed either under general anesthesia or under local with sedation, and the cases were performed alone or in conjunction with other procedures. All patients went to presurgical testing and had preoperative laboratory and additional clearance by a specialist when indicated. Before and after medical photographs were obtained of all patients. All operations were done in an accredited office-based operating room. Demographic information, tumescent volume, aspirate volume, surgical time, complications and other data were reviewed. There were one minor complication and no major complications such as burns, hospitalizations or mortalities. One patient developed a small hematoma, which was likely caused by the patient self-aspirating edema fluid during the immediate post-op period. The hematoma resolved with non-surgical management. The average laser energy applied was 15,756J with an average total aspirate volume of 1256cc. Fourteen anatomic areas were treated with LAL, and 59 operations were combination cases. Energy-assisted liposuction using the 1440nm wavelength has been shown in this series to have a very low complication rate when performed alone or in combination with other aesthetic operations under local and general anesthesia. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Doing Mastoidectomy Along with Tympanic Membrane Repair Reduces the Need for Revision Procedures: A Prospective Study.

To determine the role of cortical mastoidectomy on the results of tympanoplsty in tubotympanic type of chronic suppurative otitis media. A prospective, observational, interventional study was conducted from a period of October 2006-October 2008. This included 40 patients of either sex in the age group of 15-45years having tubotympanic type of CSOM. Tympanoplasty with mastoidectomy was done in all the patients and they were followed up for graft acceptance and hearing impairment for 5years to see the long term results. Per-operatively, the antrum was involved in 17, aditus in 11 and middle ear in 8 patients. Incus was necrosed in 10 cases and malleus and incus were absent in a single case. Mucoid discharge was found in the middle ear in 12 out of 40 patients. Mucoid discharge ears had antral mucosal hypertrophy in 100%, blocked aditus in 75% and middle ear mucosal hypertrophy in 58% cases; ossicular necrosis in 75% cases. 90% of the cases had graft accepted. In dry ears, graft take up rate was 89% and in ears with mucoid discharge it was 92%. Average air-bone-gap reduced to 13.90dB as compared to average air-bone-gap (Av. AB Gap1) preoperatively of 38.62dB. After 5years, 83.5% patients had >10dB improvement in hearing. We recommend opening of the mastoid if on inspection of middle ear one finds mucoid type of discharge.

Intraoperative Imaging Changes Management in Orbital Fracture Repair

Intraoperative imaging is gaining widespread use in the management of facial fracture repair. The aim of this study was to determine whether intraoperative imaging changes the management of orbital fracture repair. A retrospective case series was performed of all cases of orbital fracture repair from 2008 to 2015 in which the intraoperative O-arm was used at Regions Hospital (St Paul, MN), a level I trauma center. The primary outcome variable was a change in management, ranging from orbital plate repositioning to proceeding with orbital floor exploration. The study sample was composed of 101 patients with a mean age of 40±15years. Approximately 75% (76 of 101) of patients were male and 25% (25 of 101) were female. All cases were secondary to assault, motor vehicle accident, fall, or gunshot wounds. Use of the O-arm resulted in a change in management in 44% (44 of 101) of cases. In 48% (21 of 44) of these cases in which intraoperative imaging resulted in a change in management, the orbital plate was repositioned to optimize repair. In 16% (7 of 44) of these cases, the orbital plate was exchanged for a different size or type of plate. In 7% (3 of 44) of these cases, the orbital plate was reshaped by bending to improve contour for the repair. In another 7% (3 of 44) of these cases, the orbital plate was reshaped by trimming the plate to optimize the length or width of the plate for repair. In 7% of these cases, the orbital floor required exploration based on intraoperative imaging. In 5% of these cases, the orbital floor was found to be adequately reduced after zygoma reduction based on intraoperative imaging and did not require exploration. Use of intraoperative imaging allows the surgeon to make real-time changes in operative management ranging from orbital plate repositioning to deciding whether to proceed with orbital floor exploration. This not only allows for immediate optimization of repair but also could decrease the need for revision procedures, thus decreasing patient morbidity and improving patient outcomes.

Venous Bridge Arterial Grafting for Thumb Replantation.

The purpose of this study is to describe a novel technique using an interposition vein graft for thumb replantation in these severe avulsion injuries. From 2002 to 2012, 8 patients underwent interposition venous bridge grafting from the dorsal radial artery at the anatomic snuffbox to the ulnar digital artery of the thumb. All patients had a traumatic thumb amputation with a severe injury to the ulnar digital artery. The technique began with bony stabilization; the radial artery at the anatomic snuffbox is exposed, vein graft harvested, and microsurgical end-to-side (proximally) and end-to-end (distally) anastomoses are carried out. The average time to the operating room was 7.4 hours and time to reperfusion was 9.5 hours. At 3.1 years of follow-up, all 8 thumbs remained viable, without any need for revision procedures. The only complication was a metacarpal shaft nonunion treated successfully with iliac crest bone grafting. At last follow-up, all patients reported no or mild pain, with an average metacarpophalangeal (MCP) range of motion of 46.5°, and intact but diminished 2-point discrimination. All patients were able to return to work full-time. Due to the challenging nature of thumb avulsion injuries and the pronated position of the thumb, novel salvage alternatives are important. We describe a technique when no proximal vessels are available, using a vein to bridge the dorsal radial artery to the ulnar digital artery of the thumb. This novel arterial reconstruction has shown promise in thumb replantation associated with severe avulsion injuries.