Genetic insights into the social organization of Neanderthals.

Genomic analyses of Neanderthals have previously provided insights into their population history and relationship to modern humans1-8, but the social organization of Neanderthal communities remains poorly understood. Here we present genetic data for 13 Neanderthals from two Middle Palaeolithic sites in the Altai Mountains of southern Siberia: 11 from Chagyrskaya Cave9,10 and 2 from Okladnikov Cave11-making this one of the largest genetic studies of a Neanderthal population to date. We used hybridization capture to obtain genome-wide nuclear data, as well as mitochondrial and Y-chromosome sequences. Some Chagyrskaya individuals were closely related, including a father-daughter pair and a pair of second-degree relatives, indicating that at least some of the individuals lived at the same time. Up to one-third of these individuals' genomes had long segments of homozygosity, suggesting that the Chagyrskaya Neanderthals were part of a small community. In addition, the Y-chromosome diversity is an order of magnitude lower than the mitochondrial diversity, a pattern that we found is best explained by female migration between communities. Thus, the genetic data presented here provide a detailed documentation of the social organization of an isolated Neanderthal community at the easternmost extent of their known range.

Pleistocene sediment DNA reveals hominin and faunal turnovers at Denisova Cave.

Denisova Cave in southern Siberia is the type locality of the Denisovans, an archaic hominin group who were related to Neanderthals1-4. The dozen hominin remains recovered from the deposits also include Neanderthals5,6 and the child of a Neanderthal and a Denisovan7, which suggests that Denisova Cave was a contact zone between these archaic hominins. However, uncertainties persist about the order in which these groups appeared at the site, the timing and environmental context of hominin occupation, and the association of particular hominin groups with archaeological assemblages5,8-11. Here we report the analysis of DNA from 728 sediment samples that were collected in a grid-like manner from layers dating to the Pleistocene epoch. We retrieved ancient faunal and hominin mitochondrial (mt)DNA from 685 and 175 samples, respectively. The earliest evidence for hominin mtDNA is of Denisovans, and is associated with early Middle Palaeolithic stone tools that were deposited approximately 250,000 to 170,000 years ago; Neanderthal mtDNA first appears towards the end of this period. We detect a turnover in the mtDNA of Denisovans that coincides with changes in the composition of faunal mtDNA, and evidence that Denisovans and Neanderthals occupied the site repeatedly-possibly until, or after, the onset of the Initial Upper Palaeolithic at least 45,000 years ago, when modern human mtDNA is first recorded in the sediments.

Initial Upper Palaeolithic humans in Europe had recent Neanderthal ancestry.

Modern humans appeared in Europe by at least 45,000 years ago1-5, but the extent of their interactions with Neanderthals, who disappeared by about 40,000 years ago6, and their relationship to the broader expansion of modern humans outside Africa are poorly understood. Here we present genome-wide data from three individuals dated to between 45,930 and 42,580 years ago from Bacho Kiro Cave, Bulgaria1,2. They are the earliest Late Pleistocene modern humans known to have been recovered in Europe so far, and were found in association with an Initial Upper Palaeolithic artefact assemblage. Unlike two previously studied individuals of similar ages from Romania7 and Siberia8 who did not contribute detectably to later populations, these individuals are more closely related to present-day and ancient populations in East Asia and the Americas than to later west Eurasian populations. This indicates that they belonged to a modern human migration into Europe that was not previously known from the genetic record, and provides evidence that there was at least some continuity between the earliest modern humans in Europe and later people in Eurasia. Moreover, we find that all three individuals had Neanderthal ancestors a few generations back in their family history, confirming that the first European modern humans mixed with Neanderthals and suggesting that such mixing could have been common.

14th century Yersinia pestis genomes support emergence of pestis secunda within Europe.

Pestis secunda (1356-1366 CE) is the first of a series of plague outbreaks in Europe that followed the Black Death (1346-1353 CE). Collectively this period is called the Second Pandemic. From a genomic perspective, the majority of post-Black Death strains of Yersinia pestis thus far identified in Europe display diversity accumulated over a period of centuries that form a terminal sub-branch of the Y. pestis phylogeny. It has been debated if these strains arose from local evolution of Y. pestis or if the disease was repeatedly reintroduced from an external source. Plague lineages descended from the pestis secunda, however, are thought to have persisted in non-human reservoirs outside Europe, where they eventually gave rise to the Third Pandemic (19th and 20th centuries). Resolution of competing hypotheses on the origins of the many post-Black Death outbreaks has been hindered in part by the low representation of Y. pestis genomes in archaeological specimens, especially for the pestis secunda. Here we report on five individuals from Germany that were infected with lineages of plague associated with the pestis secunda. For the two genomes of high coverage, one groups within the known diversity of genotypes associated with the pestis secunda, while the second carries an ancestral genotype that places it earlier. Through consideration of historical sources that explore first documentation of the pandemic in today's Central Germany, we argue that these data provide robust evidence to support a post-Black Death evolution of the pathogen within Europe rather than a re-introduction from outside. Additionally, we demonstrate retrievability of Y. pestis DNA in post-cranial remains and highlight the importance of hypothesis-free pathogen screening approaches in evaluations of archaeological samples.

Microstratigraphic preservation of ancient faunal and hominin DNA in Pleistocene cave sediments.

Ancient DNA recovered from Pleistocene sediments represents a rich resource for the study of past hominin and environmental diversity. However, little is known about how DNA is preserved in sediments and the extent to which it may be translocated between archaeological strata. Here, we investigate DNA preservation in 47 blocks of resin-impregnated archaeological sediment collected over the last four decades for micromorphological analyses at 13 prehistoric sites in Europe, Asia, Africa, and North America and show that such blocks can preserve DNA of hominins and other mammals. Extensive microsampling of sediment blocks from Denisova Cave in the Altai Mountains reveals that the taxonomic composition of mammalian DNA differs drastically at the millimeter-scale and that DNA is concentrated in small particles, especially in fragments of bone and feces (coprolites), suggesting that these are substantial sources of DNA in sediments. Three microsamples taken in close proximity in one of the blocks yielded Neanderthal DNA from at least two male individuals closely related to Denisova 5, a Neanderthal toe bone previously recovered from the same layer. Our work indicates that DNA can remain stably localized in sediments over time and provides a means of linking genetic information to the archaeological and ecological records on a microstratigraphic scale.

The genome of the offspring of a Neanderthal mother and a Denisovan father.

Neanderthals and Denisovans are extinct groups of hominins that separated from each other more than 390,000 years ago1,2. Here we present the genome of 'Denisova 11', a bone fragment from Denisova Cave (Russia)3 and show that it comes from an individual who had a Neanderthal mother and a Denisovan father. The father, whose genome bears traces of Neanderthal ancestry, came from a population related to a later Denisovan found in the cave4-6. The mother came from a population more closely related to Neanderthals who lived later in Europe2,7 than to an earlier Neanderthal found in Denisova Cave8, suggesting that migrations of Neanderthals between eastern and western Eurasia occurred sometime after 120,000 years ago. The finding of a first-generation Neanderthal-Denisovan offspring among the small number of archaic specimens sequenced to date suggests that mixing between Late Pleistocene hominin groups was common when they met.

Reconstructing the genetic history of late Neanderthals.

Although it has previously been shown that Neanderthals contributed DNA to modern humans, not much is known about the genetic diversity of Neanderthals or the relationship between late Neanderthal populations at the time at which their last interactions with early modern humans occurred and before they eventually disappeared. Our ability to retrieve DNA from a larger number of Neanderthal individuals has been limited by poor preservation of endogenous DNA and contamination of Neanderthal skeletal remains by large amounts of microbial and present-day human DNA. Here we use hypochlorite treatment of as little as 9 mg of bone or tooth powder to generate between 1- and 2.7-fold genomic coverage of five Neanderthals who lived around 39,000 to 47,000 years ago (that is, late Neanderthals), thereby doubling the number of Neanderthals for which genome sequences are available. Genetic similarity among late Neanderthals is well predicted by their geographical location, and comparison to the genome of an older Neanderthal from the Caucasus indicates that a population turnover is likely to have occurred, either in the Caucasus or throughout Europe, towards the end of Neanderthal history. We find that the bulk of Neanderthal gene flow into early modern humans originated from one or more source populations that diverged from the Neanderthals that were studied here at least 70,000 years ago, but after they split from a previously sequenced Neanderthal from Siberia around 150,000 years ago. Although four of the Neanderthals studied here post-date the putative arrival of early modern humans into Europe, we do not detect any recent gene flow from early modern humans in their ancestry.

From Esthetic Medicine to Optimizing Reconstructive Outcome: A Feasibility Trial on Secondary Refinement of Fasciocutaneous Anterolateral Thigh Flaps with Cryolipolysis.

BACKGROUND: Free adipocutaneous anterolateral thigh (ALT) flaps have evolved as workhorse flaps to reconstruct complex, multicompound defects. While coverage is safely achieved, flaps may remain bulky. As a standard of care, flaps are refined with liposuction, partial excision, or combination of both. Cryolipolysis is widely used for fat reduction in esthetic medicine. This pilot comparative study analyses whether cryolipolysis may serve as a safe alternative method to effectively reduce volume in fasciocutaneous flaps. Moreover, patients' satisfaction with the procedure is evaluated. METHODS: In this single-center, retrospective, interventional comparative cohort study, 10 patients with free subfascial ALT flaps for distal extremity reconstruction underwent cryolipolysis (60 minutes, -9°C). Circumference of the extremities and subcutaneous fat thickness were determined before (T1) and 12 weeks (T2) after cryolipolysis. Patient satisfaction was evaluated with a questionnaire of Likert's scale questions. Duration of hospital stay, intervention time, costs, and possible complications were analyzed and compared with surgical flap contouring (n = 12). RESULTS: All patients undergoing cryolipolysis were male, with a median age of 52 years without arterial disease-like state or deep vein thrombosis (DVT). At T2, a significant reduction of circumference of 1.8 ± 0.9 cm (p < 0.001) and subcutaneous fat layer of 7.7 ± 3.0 mm (p < 0.0001) was recorded. Overall, 90% of the patients were satisfied with the result. Cryolipolysis was well tolerated. One patient developed a second-degree frostbite which healed without further intervention. Cryolipolysis proofed to be as safe as surgical flap contouring. Hospital stay was significantly shorter (p < 0.01) and personal resources were spared when flap contouring was performed with cryolipolysis. CONCLUSION: This is a novel application of evolving body-contouring cryolipolysis from esthetic medicine into optimizing outcomes in reconstructive surgery. Cryolipolysis has been shown to be relatively safe and effective to reduce ALT's volume with high patients' satisfaction. This successful pilot study encourages further investigation with a prospective randomized control trial.

Nuclear DNA sequences from the Middle Pleistocene Sima de los Huesos hominins.

A unique assemblage of 28 hominin individuals, found in Sima de los Huesos in the Sierra de Atapuerca in Spain, has recently been dated to approximately 430,000 years ago. An interesting question is how these Middle Pleistocene hominins were related to those who lived in the Late Pleistocene epoch, in particular to Neanderthals in western Eurasia and to Denisovans, a sister group of Neanderthals so far known only from southern Siberia. While the Sima de los Huesos hominins share some derived morphological features with Neanderthals, the mitochondrial genome retrieved from one individual from Sima de los Huesos is more closely related to the mitochondrial DNA of Denisovans than to that of Neanderthals. However, since the mitochondrial DNA does not reveal the full picture of relationships among populations, we have investigated DNA preservation in several individuals found at Sima de los Huesos. Here we recover nuclear DNA sequences from two specimens, which show that the Sima de los Huesos hominins were related to Neanderthals rather than to Denisovans, indicating that the population divergence between Neanderthals and Denisovans predates 430,000 years ago. A mitochondrial DNA recovered from one of the specimens shares the previously described relationship to Denisovan mitochondrial DNAs, suggesting, among other possibilities, that the mitochondrial DNA gene pool of Neanderthals turned over later in their history.

A genetic analysis of the Gibraltar Neanderthals.

The Forbes' Quarry and Devil's Tower partial crania from Gibraltar are among the first Neanderthal remains ever found. Here, we show that small amounts of ancient DNA are preserved in the petrous bones of the 2 individuals despite unfavorable climatic conditions. However, the endogenous Neanderthal DNA is present among an overwhelming excess of recent human DNA. Using improved DNA library construction methods that enrich for DNA fragments carrying deaminated cytosine residues, we were able to sequence 70 and 0.4 megabase pairs (Mbp) nuclear DNA of the Forbes' Quarry and Devil's Tower specimens, respectively, as well as large parts of the mitochondrial genome of the Forbes' Quarry individual. We confirm that the Forbes' Quarry individual was a female and the Devil's Tower individual a male. We also show that the Forbes' Quarry individual is genetically more similar to the ∼120,000-y-old Neanderthals from Scladina Cave in Belgium (Scladina I-4A) and Hohlenstein-Stadel Cave in Germany, as well as to a ∼60,000- to 70,000-y-old Neanderthal from Russia (Mezmaiskaya 1), than to a ∼49,000-y-old Neanderthal from El Sidrón (El Sidrón 1253) in northern Spain and other younger Neanderthals from Europe and western Asia. This suggests that the Forbes' Quarry fossil predates the latter Neanderthals. The preservation of archaic human DNA in the warm coastal climate of Gibraltar, close to the shores of Africa, raises hopes for the future recovery of archaic human DNA from regions in which climatic conditions are less than optimal for DNA preservation.

A single-center retrospective comparison of Duplex ultrasonography versus audible Doppler regarding anterolateral thigh perforator flap harvest and operative times.

INTRODUCTION: We reported on the superiority of preoperative Duplex mapping ("Duplex") over audible Dopplers ("Doppler") in anterolateral thigh perforator (ALT) free flaps for upper extremity reconstruction. To corroborate our findings on a larger cohort, we conducted this present study focusing on surgical efficiency and patient safety. METHODS: 150 consecutive ALT free flaps were divided into 65 cases of preoperative Duplex versus 85 Doppler controls. We first compared patient demographics, operative details, and defect and flap characteristics. We then assessed group differences in the number and course of perforators pursued intraoperatively, flap harvest and operative times, and donor-site complications. Additionally, the impact of the training level of the primary microsurgeon was evaluated. RESULTS: Cases and controls were comparable regarding age (p = .48), sex (p = .81), ASA class (p = .48), and BMI (p = .90). Duplex was associated with an increased likelihood of raising flaps on one single dominant perforator of purely septal course and significant reductions of flap harvest (68 ± 10 min, p < .0001) and operative times (74 ± 16 min, p < .0001), regardless of the experience of the primary microsurgeon. There were strong negative linear correlations between preoperative Duplex and both the flap harvest and operative times (p < .0001). Additionally, while there was no effect on the emergency take-back rate (OR = 1.3, p = .60), revisions were significantly less likely among duplexed patients (OR = 0.15, p = .04). CONCLUSIONS: Preoperative Duplex is associated with a significant reduction in ALT free flap harvest and overall operative times, as well as donor-site revisions as opposed to Doppler planning, regardless of the training level of the primary microsurgeon.

A Retrospective Comparative Functional and Aesthetic Outcome Study of Muscle versus Cutaneous Free Flaps for Distal Upper Extremity Reconstruction.

BACKGROUND: Function and cosmesis are crucial in upper extremity reconstruction. Yet, there persists a lack of outcome evaluations, particularly regarding differences between free flap types. METHODS: In a single-center retrospective analysis, outcomes were compared between patients with cutaneous or muscle free flaps for distal upper extremity reconstruction between 2008 and 2018. The Disabilities of Arm, Shoulder and Hand -Score, Michigan-Hand (MHQ), and Short Form 36 Health Survey (SF-36) Questionnaires were assessed, motor function was quantified, and self-reported measures of cosmesis were compared, including the Vancouver Scar-Scale (VSS), MHQ aesthetics-subscale (MAS), and Moscona's cosmetic validation-score (CVS). RESULTS: One-hundred forty-one cases were identified, with a shift toward cutaneous flaps over the study period. Muscle flaps were used for larger defects (251 vs. 142 cm2, p = 0.008). Losses, thromboses, and donor-site complications were equally distributed. Partial necroses were more frequent in muscle flaps (11 vs. 1%, p = 0.015). Seventy patients with 53 cutaneous versus 17 muscle flaps were reexamined. There was no difference in the timing of flap coverage (after 16 vs. 15 days, p = 0.79), number of preceding (2 vs. 1.7, p = 0.95), or subsequent operations (19/53 vs. 5/17, p = 0.77). Patients with cutaneous flaps showed higher grip strength (25 vs. 17 kg, p = 0.046) and reported better hand function (MHQ: 58 vs. 47, p = 0.044) and general health (SF-36: 70 vs. 61, p = 0.040), as well as more favorable appearance (MAS: 71 vs. 57, p = 0.044, CVS: 77 vs. 72, p = 0.048), and scar burden (VSS: 0 vs. 3, p < 0.001). CONCLUSION: Cutaneous flaps yielded better motor function, self-perceived cosmesis, patient satisfaction, and quality of life in our cohort of distal upper extremity reconstructions.

Comparison of pedicled versus free flaps for reconstruction of extensive deep sternal wound defects following cardiac surgery: A retrospective study.

BACKGROUND: Myocutaneous pedicled flaps are the method of choice for sternal reconstruction after deep sternal wound infection (DSWI) following cardiac surgery. We set out to investigate whether free flaps provide a superior alternative for particularly extended sternal defects. METHODS: Between October 2008 and February 2020, 86 patients with DSWI underwent sternal reconstruction with myocutaneous flaps at our institution. Patients were retrospectively grouped into pedicled (A; n = 42) and free flaps (B, n = 44). The objective was to compare operative details, outcome variables, surgical as well as medical complication rates between both groups, retrospectively. Binary logistic regression analysis was applied to determine the effect of increasing defect size on flap necrosis. RESULTS: Rates of partial flap necrosis (>5% of the skin island) were significant higher in pedicled flaps (n = 14), when compared to free flaps (n = 4) (OR: 5.0; 33 vs. 9%; p = .008). Increasing defect size was a significant risk factor for the incidence of partial flap necrosis of pedicled flaps (p = .012), resulting in a significant higher rate of additional surgeries (p = .036). Binary regression model revealed that the relative likelihood of pedicled flap necrosis increased by 2.7% with every extra square-centimeter of defect size. CONCLUSION: To avoid an increased risk of partial flap necrosis, free flaps expand the limits of extensive sternal defect reconstruction with encouragingly low complication rates and proved to be a superior alternative to pedicled flaps in selected patients.

A comparative study of preoperative color-coded Duplex ultrasonography versus handheld audible Dopplers in ALT flap planning.

INTRODUCTION: The anterior lateral thigh (ALT) flap's vascular variability can lead to complications. Thus, the accuracy of numerous planning modalities has been studied. The clinical relevance of competing mapping methods, however, remains unknown. Therefore, we compared the impact of color-coded Duplex ultrasonography and handheld audible Dopplers on surgical efficacy and flap safety. PATIENTS AND METHODS: Forty-four ALT flaps were included in this comparative retrospective monocentric study. Twelve patients received Duplex scans and 32 flaps were designed using Dopplers only. Patient, defect, and flap characteristics of both groups were analyzed. The effect of either planning method on the primary outcome variables - flap harvest and operative times (HT, OT), course of perforator dissection, incidence of flap loss, emergent re-explorations, and donor-site revisions - was then assessed. RESULTS: Patient, defect, and flap characteristics were comparable between both groups, including flap size (Doppler: 134 ± 73 cm2 , Duplex: 131 ± 65 cm2 , p = .90). There was no flap loss. Emergent re-explorations (Doppler: 4/32, Duplex: 1/12, p = .70) and donor-site revisions (Doppler: 2/32, Duplex: 1/12, p = .81) were equally distributed. Duplex rendered septal perforator dissection 10 times more likely (Chi-Square = 8.9, p = .003, OR = 9.7), reaching 50% (n = 6/12), as opposed to only 9% in the Doppler cohort (n = 3/32). This allowed for highly significant HT and OT reductions of 89 minutes, respectively (p < .01): from 255 and 383 min (Doppler) to 166 and 294 min (Duplex). CONCLUSIONS: Preoperative Duplex significantly reduces harvest and operative times of ALT flaps.

Single-stranded DNA library preparation from highly degraded DNA using T4 DNA ligase.

DNA library preparation for high-throughput sequencing of genomic DNA usually involves ligation of adapters to double-stranded DNA fragments. However, for highly degraded DNA, especially ancient DNA, library preparation has been found to be more efficient if each of the two DNA strands are converted into library molecules separately. We present a new method for single-stranded library preparation, ssDNA2.0, which is based on single-stranded DNA ligation with T4 DNA ligase utilizing a splinter oligonucleotide with a stretch of random bases hybridized to a 3΄ biotinylated donor oligonucleotide. A thorough evaluation of this ligation scheme shows that single-stranded DNA can be ligated to adapter oligonucleotides in higher concentration than with CircLigase (an RNA ligase that was previously chosen for end-to-end ligation in single-stranded library preparation) and that biases in ligation can be minimized when choosing splinters with 7 or 8 random nucleotides. We show that ssDNA2.0 tolerates higher quantities of input DNA than CircLigase-based library preparation, is less costly and better compatible with automation. We also provide an in-depth comparison of library preparation methods on degraded DNA from various sources. Most strikingly, we find that single-stranded library preparation increases library yields from tissues stored in formalin for many years by several orders of magnitude.

Continuous Video-Rate Laser Speckle Imaging for Intra- and Postoperative Cutaneous Perfusion Imaging of Free Flaps.

BACKGROUND: Success of free tissue transfer depends on standardized intraoperative flap design, microsurgical technique, and postoperative monitoring. We sought to investigate whether laser speckle imaging (LSI) is suitable for optimization of intraoperative flap design and postoperative monitoring of free flaps with skin paddles. METHODS: Skin perfusion was assessed with LSI in 27 free flaps after dissection at the donor site, after anastomosis at the recipient site, after inset and on postoperative days (POD) 1, 5, and 10. Skin perfusion of the whole flap (ROI [region of interest]-1) and the area over the pedicle (ROI-2) were compared between patients with and without postoperative complications (POC+ and POC - , respectively). A receiver operating characteristic (ROC) analysis was performed to determine the optimal cutoff for perfusion during LSI-guided microsurgery. RESULTS: In flaps without or only minor POC, intraoperatively measured perfusion over ROI-2 was significantly higher compared with ROI-1, whereas no significant differences were found for flaps with major POC. Perfusion of ROI-1 and 2 intraoperatively and on POD 1 was significantly lower in the POC+ compared with the POC- group (p < 0.05). ROC analysis yielded a threshold of 107 perfusion units (PU) at ROI-2 with an area under the curve (AUC) of > 0.8 for identification of flaps with major POC. CONCLUSION: LSI is an easy to use, noninvasive technique for identification of malperfused areas in free flaps, thus allowing for intraoperative decision-making on flap dimensions and postoperative monitoring. LSI therefore is a valuable tool for perfusion assessment with a high potential to become an established part of microsurgical practice.

Socioeconomic Status Affects Postoperative Time to Union in Pediatric Patients with a Surgically Treated Fracture.

Fractures account for 10% to 25% of all pediatric injuries, and surgical treatment is common. In such cases, postoperative healing can be affected by a number of factors, including those related to socioeconomic status (SES). The purpose of this study was to investigate the relationship between time to fracture union and SES, which was measured with use of the median household income (MHI) and Child Opportunity Index (COI). Methods: A retrospective review was conducted of pediatric patients with a long-bone fracture that had been surgically treated at a Level-I pediatric trauma center between January 2010 and June 2020. Demographic and relevant medical data were collected. Patients were sorted into union and nonunion groups. The ZIP code of each patient was collected and the MHI and COI of that ZIP code were identified. Income brackets were created in increments of $10,000 ranging from $20,000 to $100,000, with an additional category of >$100,000, and patients were sorted into these groups according to MHI. Comparisons among the income groups and among the union status groups were conducted for each of the collected variables. A multiple regression analysis was utilized to determine the independent effect of each variable on time to union. Results: A total of 395 patients were included in the final sample, of whom 51% identified as Hispanic. Patients in the union group had a higher mean COI and MHI. Nonunion occurred in only 8 patients. Patients who achieved fracture union in ≤4 months had a significantly higher mean COI and MHI. When controlling for other demographic variables, the time to union increased by a mean of 9.6 days for every $10,000 decrease in MHI and increased by a mean of 6.8 days for every 10-unit decrease in the COI. Conclusions: The present study is the first, to our knowledge, to investigate the relationship between SES and time to fracture union in pediatric patients. When controlling for other demographic factors, we found a significant relationship between SES and time to union in pediatric patients with a surgically treated fracture. Further investigations of the relationship between SES and time to union in pediatric patients are needed to determine potential mechanisms for this relationship. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Postoperative monitoring of free muscle flaps using perforator-based adipocutaneous skin paddles: economy, quality of care and aesthetics]. / Postoperatives Monitoring freier Muskellappenplastiken mittels perforatorbasierten adipokutanen Monitorinseln: Ökonomie, Versorgungsqualität und Ästhetik.

INTRODUCTION: Besides fasciocutaneous workhorse flaps, free muscle flaps for the reconstruction of large soft tissue defects are well-established standard microsurgical procedures. Random-pattern adipocutaneous skin paddles are often included for postoperative perfusion monitoring of the muscle flap. At our institution, both conventional broad-based and perforator-based adipocutaneous skin paddles are used. While conventional skin paddles have to be removed during a second operation, perforator-based skin paddles can be removed at the bedside by ligature. The present study aims to compare economic aspects, quality of care and aesthetic results of perforator-based versus conventional adipocutaneous skin paddles after free muscle flap transfer. METHODS: 102 patients treated between August 2014 and July 2016 were identified and included in a retrospective data analysis. Patients with perforator-based skin paddles (group A) were compared with a population of patients with conventional skin paddles (group B). Patient characteristics, procedural characteristics, economic data and aesthetic results were compared between both groups. RESULTS: Perforator-based skin paddles were raised in 72 patients (group A, 71 %), and conventional skin paddles were raised in the remaining 30 patients (group B, 29 %). Patient, defect, and flap characteristics were comparable in both groups. Operating times tended to be shorter in group B. Skin paddle removal was performed significantly earlier in group A (p < 0.01). Both overall and post-reconstructive length of hospital stay were significantly shorter in group A (p = 0.03; p < 0.01). Also, personnel and material resources were saved and more satisfactory aesthetic results were achieved in group A. CONCLUSION: Perforator-based monitor islands can help avoid secondary operations that would otherwise be necessary to remove monitoring skin paddles. Thus, the inpatient length of stay can be reduced while sparing material and human resources.

The 8-item Modified Frailty Index Is an Effective Risk Assessment Tool in Anterior Cervical Decompression and Fusion.

STUDY DESIGN: Case-control study; Level of evidence, 3. OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is one of the most common procedures for cervical diseases often with reliable outcomes. However, morbidity rates can be as high as 19.3% so appropriate patient selection and risk stratification is imperative. Our modified frailty index (MFI) predicts postoperative complications after other orthopaedic procedures. We hypothesized that this index would predict complications in a large cohort of ACDF patients. METHODS: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, including patients who underwent ACDF from 2015-2020. An 8-item MFI score was calculated for each patient. We recorded 30-days postoperative complications, readmission, and reoperation rates, adjusting for baseline features using standard multivariate regression. This project was approved of by the University of Texas Health Science Center Institutional Review Board and an IRB exception was granted. RESULTS: We identified 17 662 ACDF cases. Patients with MFI of 5 or greater had a 37.53 times increased odds of incurring postoperative complications compared to patients with MFI of 0 (P < .001) even when age, sex, race, and ethnicity were controlled for. Specifically, life-threatening Clavien-Dindo IV complications, as well as wound, cardiac, renal, and pulmonary complications were significantly increased in patients with an MFI of 5 or greater. Also, as MFI increased from 1-2 to 3-4 to 5 or greater, the odds of readmission increased from 1.36 to 2.31 to 5.42 times (P < .001) and odds of reoperation from 1.19 (P = .185) to 2.3 to 6.54 times (P < .001). Frailty was still associated with increased complications, readmission, and reoperation after controlling for demographic data, including age, as well as operative time and length of stay. CONCLUSION: Frailty is highly predictive of postoperative complications, readmission, and reoperation following ACDF. Employing a simple frailty evaluation can guide surgical decision-making and patient counseling for cervical disease.

Use of Clindamycin for Necrotizing Soft Tissue Infection Decreases Amputation Rate.

OBJECTIVE: To identify the impact of clindamycin use on mortality and amputation rates in patients with necrotizing fasciitis. DESIGN: Retrospective review. SETTING: Level 1 trauma center, single-center study. PATIENTS/PARTICIPANTS: All patients from 2008 to 2019 with a diagnosis of necrotizing fasciitis. One hundred ninety patients were included in statistical analysis. INTERVENTION: Use of clindamycin in the initial antibiotic regimen in the treatment of necrotizing soft tissue infection. MAIN OUTCOME MEASUREMENTS: Amputation and mortality rates. RESULTS: Patients who received clindamycin had 2.92 times reduced odds of having an amputation when compared with their counterparts, even when American Society of Anesthesiologist scores, comorbidities, smoking, drug use, alcohol consumption, race, ethnicity, sex, and age were controlled for and regardless of other antibiotics started (P = 0.015). There was no significant difference in mortality rate between those patients who did and did not receive clindamycin as part of their initial antibiotic regimen (8.3% vs. 11.6%, respectively; P = 0.453). CONCLUSION: The use of clindamycin in the initial antibiotic regimen for treatment of NSTI was shown to significantly decrease rates of amputation but not mortality. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.