Xeroform Stick-Down Dressing: A Novel Treatment for Pediatric Partial-Thickness Burns.

BACKGROUND: Burns traditionally require frequent, painful dressing changes to minimize infection risk and promote wound healing. To improve care for our pediatric population, our institution adapted a skin graft donor site dressing into a "stick-down" burn dressing consisting of a one-time application of bacitracin and 3% bismuth tribromophenate/vaseline impregnated gauze (Xeroform) that adheres to the burn and peels off as new epithelialized skin forms. The goal of which is to minimize dressing change frequency and patient discomfort in a cost-effective, widely available manner. This study aimed to compare clinical outcomes of the stick-down versus traditional topical dressings. METHODS: A retrospective cohort study of pediatric patients (age <18 year) with partial-thickness burns treated at a level I pediatric trauma center for 4 years was conducted. One hundred eleven patients were included: 74 patients treated with daily silver sulfadiazene (Silvadene) dressings matched to 37 patients treated with the Xeroform stick-down dressing using 2:1 propensity score matching. Univariate analyses used Wilcoxon rank sum and Fisher exact tests. RESULTS: The cohorts had similar demographics and burn characteristics. Both groups had similar hospitalization rates (31.1% Silvadene, 32.4% Xeroform), most commonly for pain control (54.5% Silvadene, 58.3% Xeroform), with similar average daily narcotic usage (7.7 ± 12.1 morphine milliequivalents Silvadene, 5.1 ± 9.5 Xeroform; P = 0.91). The Xeroform cohort had a shorter but statistically similar hospital stay (median, 1 vs 2 days). In addition, the Xeroform cohort required significantly less dressing changes with a median of 0.5 changes compared with 12 for the Silvadene cohort ( P < 0.0001). There was no difference in time to burn reepithelialization (median, 13.0 days for Silvadene and 12.0 days for Xeroform; P = 0.20) or wound healing complications (12.5% Silvadene, 2.7% Xeroform; P = 0.15). CONCLUSIONS: The Xeroform stick-down dressing has equivalent clinical outcomes to that of standard Silvadene dressings for the treatment of pediatric partial-thickness burns with the major advantages of decreasing dressing change frequency, minimizing patient distress and pain, and streamlining clinical care.

Long-term clinical and patient-reported outcomes in free flap reconstruction of the weight-bearing heel pad and non-weight-bearing Achilles tendon regions.

BACKGROUND: The non-weight-bearing (NWB) Achilles tendon and weight-bearing (WB) heel pad regions are technically challenging to reconstruct with distinct functional and aesthetic considerations that have not been previously considered in the literature. This study is the first to characterize the long-term clinical and patient-reported outcomes of these components to better inform patients about the postreconstruction period. METHODS: A retrospective review of medical records and phone-based survey of adult patients who underwent free flap reconstruction of the heel/ankle with 6-month minimum clinical follow-up was performed. RESULTS: Forty-three patients, with 31 (72.1%) NWB and 12 (27.9%) WB defects, treated from January 1, 2000 to February 28, 2017 were included. Muscle flaps were more common than fasciocutaneous flaps (N = 36 [83.7%] vs. 7 [16.3%]). Flap survival rate was 95.3% and limb salvage rate was 93.0% at median follow-up of 12.0 months (interquartile range [IQR] 6.2, 25.5). Flap ulceration occurred more frequently in the WB region (41.7 vs. 6.5%, p = .0123). The survey response rate was 63.6%. The majority of patients complete daily tasks with no/little impairment (76.2%), walk half a mile or more (85.7%), returned to work (86.6%), and fit shoes "fair" or "well" (71.4%). Most patients were "very satisfied" with heel/ankle function (71.4%) and would "very likely" undergo the same procedure if needed (76.2%). CONCLUSIONS: Free flap reconstruction in both the NWB Achilles tendon and WB heel pad has excellent limb salvage and flap survival rates. Patients were satisfied with heel/ankle function, but additional counseling is recommended for variance in appearance and higher ulceration rates in WB defects.

Does Shorter Time to Treatment of Pediatric Femur Shaft Fractures Impact Clinical Outcomes?

BACKGROUND: Annual rankings by US News and World Report are a widely utilized metric by both health care leaders and patients. One longstanding measure is time to treatment of femur shaft fractures. Hospitals able to provide at least 80% of pediatric patients with an operating room start time within 18 hours of admission to the emergency department score better as part of the overall pediatric orthopaedic ranking. Therefore, it is important to determine whether the 18-hour treatment time for pediatric femur shaft fractures is a clinically meaningful metric. METHODS: A retrospective review of clinical outcomes of 174 pediatric patients (aged below 16 y) with isolated femur shaft fractures (Injury Severity Score=9) was conducted from 1997 to 2017 at a single level I pediatric trauma center. The 2 comparison groups were patients receiving fracture reduction within 18 hours of emergency department admission (N=87) or >18 hours (N=87). RESULTS: Patient, injury, and surgical characteristics were similar between the 2 groups. Both groups had a similar mean age (treatment <18 h=7.5 y; treatment >18 h=8.1 y). Patients who received treatment within 18 hours were more often immobilized postoperatively (70.1% vs. 53.5%; P=0.0362) and had a shorter median hospital length of stay (2 vs. 3 d; P=0.0047). There were no statistically significant differences in any outcomes including surgical site infection, time to weight-bearing (treatment <18 h mean=48.1 d vs. 52.5 d), time to complete radiographic fracture healing (treatment <18 h mean=258.9 d vs. 232.0 d), decreased range of motion, genu varus/valgus, limb length discrepancy, loss of reduction, or persistent pain. CONCLUSIONS: Treatment of pediatric femur shaft fractures within 18 hours does not impact clinical outcomes. National quality measures should therefore use evidence-based metrics to help improve the standard of care. LEVEL OF EVIDENCE: Therapeutic level III.

Post-mastectomy intensity modulated proton therapy after immediate breast reconstruction: Initial report of reconstruction outcomes and predictors of complications.

PURPOSE: To report reconstructive outcomes of patients treated with post-mastectomy intensity modulated proton therapy (IMPT) following immediate breast reconstruction (IBR). MATERIALS AND METHODS: Consecutive women with breast cancer who underwent implant-based IBR and post-mastectomy IMPT were included. Clinical characteristics, dosimetry, and acute toxicity were collected prospectively and reconstruction complications retrospectively. RESULTS: Fifty-one women were treated between 2015 and 2017. Forty-two had bilateral reconstruction with unilateral IMPT. The non-irradiated contralateral breasts served as controls. Conventional fractionation (median 50 Gy/25 fractions) was administered in 37 (73%) and hypofractionation (median 40.5 Gy/15 fractions) in 14 (27%) patients. Median mean heart, ipsilateral lung V20Gy, and CTV-IMN V95% were 0.6 Gy, 13.9%, and 97.4%. Maximal acute dermatitis grade was 1 in 32 (63%), 2 in 17 (33%), and 3 in 2 (4%) patients. Surgical site infection (hazard ratio [HR] 13.19, 95% confidence interval [CI] 1.67-104.03, p = 0.0012), and unplanned surgical intervention (HR 9.86, 95% CI 1.24-78.67, p = 0.0068) were more common in irradiated breasts. Eight of 51 irradiated breasts and 2 of 42 non-irradiated breasts had reconstruction failure (HR 3.59, 95% CI 0.78-16.41, p = 0.084). Among irradiated breasts, hypofractionation was significantly associated with reconstruction failure (HR 4.99, 95% CI 1.24-20.05, p = 0.024), as was older patient age (HR 1.14, 95% CI 1.05-1.24, p = 0.002). CONCLUSIONS: IMPT following IBR spared underlying organs and had low rates of acute toxicity. Reconstruction complications are more common in irradiated breasts, and reconstructive outcomes appear comparable with photon literature. Hypofractionation was associated with higher reconstruction failure rates. Further investigation of optimal dose-fractionation after IBR is needed.

Allograft versus autograft in cervical and lumbar spinal fusions: an examination of operative time, length of stay, surgical site infection, and blood transfusions.

BACKGROUND: Autograft harvesting for spine arthrodesis has been associated with longer operative times and increased blood loss. Allograft compared to autograft in spinal fusions has not been studied in a multicenter cohort. METHODS: Patients enrolled in the ACS-NSQIP registry between 2012 and 2013 who underwent cervical or lumbar spinal fusion with either allograft or autograft through a separate incision were included for analysis. The primary outcomes of interest were operative time, length of stay, blood transfusion, and surgical site infection (SSI). RESULTS: A total of 6790 and 6718 patients received a cervical or lumbar spinal fusion, respectively. On unadjusted analysis in both cervical and lumbar cohorts, autograft was associated with increased rates of blood transfusion (cervical: 2.9% vs. 1.0%, P<0.001; and lumbar: 21.0% vs. 15.7%, P<0.001) and increased operative time (cervical: 167 vs. 128 minutes, P<0.001; and lumbar: 226 vs. 204 minutes, P<0.001) relative to allograft. On multivariable analysis in both the cervical and lumbar cohorts, autograft was associated with increased odds of blood transfusion (cervical: OR=2.3, 95% CI: 1.0-5.1; and lumbar: OR=1.3, 95% CI: 1.1-1.6) and longer operative times (cervical: 27.8 minutes, 95% CI: 20.7-35.0; and lumbar: 25.4 minutes, 95% CI: 17.7-33.1) relative to allograft. Autograft was not associated with either length of stay or SSI. CONCLUSIONS: In a multicenter cohort of patients undergoing cervical or lumbar spinal fusion, autograft was associated with increased rates of blood transfusion and increased operative time relative to allograft.

Allegations of Failure to Obtain Informed Consent in Spinal Surgery Medical Malpractice Claims.

Importance: Predictive factors associated with increased risk of medical malpractice litigation have been identified, including severity of injury, physician sex, and error in diagnosis. However, there is a paucity of literature investigating informed consent in spinal surgery malpractice. Objective: To investigate the failure to obtain informed consent as an allegation in medical malpractice claims for patients undergoing a spinal procedure. Design, Setting, and Participants: In this retrospective cohort study, a national medicolegal database was searched for malpractice claim cases related to spinal surgery for all years available (ie, January 1, 1980, through December 31, 2015). Main Outcomes and Measures: Failure to obtain informed consent and associated medical malpractice case verdict. Results: A total of 233 patients (117 [50.4%] male and 116 [49.8%] female; 80 with no informed consent allegation and 153 who cited lack of informed consent) who underwent spinal surgery and filed a malpractice claim were studied (mean [SD] age, 47.1 [13.1] years in the total group, 45.8 [12.9] years in the control group, and 47.9 [13.3] years in the informed consent group). Median interval between year of surgery and year of verdict was 5.4 years (interquartile range, 4-7 years). The most common informed consent allegations were failure to explain risks and adverse effects of surgery (52 [30.4%]) and failure to explain alternative treatment options (17 [9.9%]). In bivariate analysis, patients in the control group were more likely to require additional surgery (45 [56.3%] vs 53 [34.6%], P = .002) and have more permanent injuries compared with the informed consent group (46 [57.5%] vs 63 [42.0%], P = .03). On multivariable regression analysis, permanent injuries were more often associated with indemnity payment after a plaintiff verdict (odds ratio [OR], 3.12; 95% CI, 1.46-6.65; P = .003) or a settlement (OR, 6.26; 95% CI, 1.06-36.70; P = .04). Informed consent allegations were significantly associated with less severe (temporary or emotional) injury (OR, 0.52; 95% CI, 0.28-0.97; P = .04). In addition, allegations of informed consent were found to be predictive of a defense verdict vs a plaintiff ruling (OR, 0.41; 95% CI, 0.17-0.98; P = .046) or settlement (OR, 0.01; 95% CI, 0.001-0.15; P < .001). Conclusions and Relevance: Lack of informed consent is an important cause of medical malpractice litigation. Although associated with a lower rate of indemnity payments, malpractice lawsuits, including informed consent allegations, still present a time, money, and reputation toll for physicians. The findings of this study can therefore help to improve preoperative discussions to protect spinal surgeons from malpractice claims and ensure that patients are better informed.

Is Patient Age Associated with Perioperative Outcomes After Surgical Resection of Benign Cranial Nerve Neoplasms?

OBJECTIVE: Previous studies have demonstrated that increasing age is associated with decreased rates of operative management and gross total resection in patients with vestibular schwannomas. METHODS: The American College of Surgeons National Surgical Quality Improvement Program data registry was used for this retrospective cohort analysis. Patients enrolled in the registry from 2007 to 2013 with a diagnosis of a benign neoplasm of a cranial nerve were included. The association between age and postoperative morbidity and mortality was evaluated by the use of multivariable logistic regression analyses. RESULTS: Of 565 patients included for analysis, the mean (median) age was 51 (53) years. Three clusters were evaluated: <50, 50-69, and ≥70 years. Mortality (0% vs. 1.03% vs. 4.55%, P = 0.012), stroke (0% vs. 0.69% vs. 6.82%, P < 0.001), and ventilator weaning failure (0.43% vs. 2.41% vs. 6.82%, P = 0.014) increased with age. Mean age was significantly greater among patients who died (70.60 vs. 50.87 years, P = 0.002) or had a stroke (68.00 vs. 50.89 years, P = 0.006), cardiac arrest (71.50 vs. 50.89 years, P = 0.038), or coma (74.00 vs. 50.96 years, P = 0.020) and those who failed ventilator weaning (62.55 vs. 50.82, P = 0.006). Age as both a continuous (odds ratio 1.10, 95% confidence interval 1.03-1.18) and categorical variable (age 70+ years odds ratio 78.88, 95% confidence interval 3.41-1825.57) was associated with an increased odds of composite morbidity. CONCLUSIONS: In patients undergoing surgery for benign cranial nerve neoplasms, increasing age is associated with increased mortality, stroke, coma, and ventilator weaning failure. Composite complication rates are significantly greater in patients ≥70 years, with a near 80-fold increased risk of complications.