Modified Frailty Index Identifies Increased Risk of Postoperative Complications in Geriatric Patients After Open Reduction Internal Fixation for Distal Radius and Ulna Fractures: Analysis of 5654 Geriatric Patients, From the 2005 to 2017 the National Surgical Quality Improvement Project Database.

BACKGROUND: Open reduction internal fixation (ORIF) of distal radius and ulnar fractures (DRUFs) is one of the most common fracture surgeries for hand surgeons. Few studies have evaluated how frailty contributes to outcomes in geriatric hand surgery patients. This study hypothesizes that geriatric patients scoring higher on the modified Frailty Index 5 (mFI-5) are at greater risk of postoperative complications following DRUF fixation. METHODS: The American College of Surgeons National Surgical Quality Improvement Project database was reviewed for ORIF for DRUFs from 2005 to 2017. Statistically significant differences for demographics, comorbidities, mFI-5, and postoperative complications between geriatric and nongeriatric patients were evaluated with multivariate logistic regression analysis. RESULTS: A total of 17,097 ORIF for DRUFs were collected by the National Surgical Quality Improvement Project 2005-2017, with 5654 patients older than 64 years (33.2%). Average age for geriatric patients undergoing ORIF for DRUFs was 73.7 years. Within geriatric patients, an mFI-5 score >2 confers 1.6-times increased risk of returning to the operating room following ORIF for DRUF (adjusted odds ratio, 1.6; P = 0.02), whereas an increase in mFI-5 score >2 confers a 3.2-times increased risk of deep vein thrombosis among geriatrics (adjusted odds ratio, 3.2 P < 048). CONCLUSION: Frailty among geriatric patients confers increased risk of deep vein thrombosis postoperatively. Geriatric patients with higher frailty scores carry a significantly increased risk of returning to the operating room within 30 days. Hand surgeons can use the mFI-5 to screen geriatric patients with DRUF patients to guide perioperative decision-making.

Sensorimotor Outcomes of Upper Extremity End-to-Side Nerve Transfers: A Meta-analysis.

BACKGROUND: End-to-side nerve transfer (ETSNT) for treatment of peripheral nerve injuries is controversial given the myriad anatomic locations, injury types, and indications. Efficacy of ETSNT remains debated. We hypothesized differences in age, sex, transfer location, and time to surgery influence outcomes. METHODS: We performed a search of the PubMed database for ETSNT in the upper extremity from 1988 to 2018. Age, sex, transfer location, time to surgery, donor and recipient axons, and strength and sensation outcomes as measured by Medical Research Council scale were extracted from articles. Meaningful recovery was classified as Medical Research Council Grade 3 or greater. Association between meaningful recovery and younger (<25) and older (≥25) patients, injury mechanism, sex, transfer location, donor axons, and recipient axons were calculated using a χ 2 or Fisher exact test. A logistic mixed effect model was used with time to surgery, age (categorical), transfer location, and injury type as a fixed effect, and a random paper effect was included to account for correlation among patients from the same paper. RESULTS: One hundred fifteen patients from 11 studies were included. Neither age (continuous variable, P = 0.68) nor time to surgery ( P = 0.28) affected meaningful recovery. Injury mechanism, sex, and younger age (<25 vs ≥25 years) were not associated with meaningful recovery. Within the brachial plexus ETSNT demonstrated median M4 ± 1 postoperative strength, with trunks/cords as the primary axon donor ( P = 0.03). The musculocutaneous nerve demonstrated promising but variable results in 31 patients with median strength M3 ± 4. Digital nerves consistently demonstrated meaningful sensory recovery as both donor and recipient axons (15 of 15, 100%). Logistic regression analysis demonstrated that odds of meaningful recovery after ETSNT are significantly greater for transfers within the brachial plexus compared with the distal arm (odds ratio, 41.9; 95% CI, 1.1-1586.7, P = 0.04), but location does not significantly affect meaningful recovery ( P = 0.22). CONCLUSIONS: Patients undergoing ETSNT for digital nerve injury demonstrated meaningful recovery. End-to-side nerve transfer seems to be more efficacious when performed within the brachial plexus. This study did not find sex, injury mechanism, or time to surgery to significantly affect meaningful recovery. Additional study is needed to better evaluate the effectiveness of ETSNT in the upper extremity.

Should We Consider Preparing Patients for Future Face Transplant when Managing Complex Facial Trauma?

With advancements in microsurgical technique and experience, face transplantation is becoming a clinical reality and acceptable procedure. Preparation of the maxillofacial skeleton and initial soft-tissue coverage for face transplant candidates is essential for optimizing the ultimate outcome by providing immediate coverage of vital structures, functionality, and a stable skeletal framework. We present our experience of preparing such a patient who underwent a successful face transplant, with an excellent outcome. A 24-year-old man sustained a self-inflicted ballistic injury to his face. Composite tissue deficits included significant soft-tissue loss in the central lower and midface, comminuted fractures of midface, and large bone gaps of the maxilla and mandible. He underwent open reduction internal fixation of bilateral LeFort III, zygomaticomaxillary complex, and complex maxillary and mandibular fractures with titanium plates and a free anterolateral thigh perforator flap to the midface with concomitant pedicled left supraclavicular artery fasciocutaneous flap to the lower face. He subsequently underwent a second free anterolateral thigh perforator for the exposed mandibular hardware due to partial necrosis of the supraclavicular artery fasciocutaneous flap. The patient achieved stable bone reconstruction and soft-tissue coverage and was discharged home. He was placed on the waiting list for a face transplant by another center in the country and eventually underwent a successful face transplant. We believe that the preparation of the patient with complex craniomaxillofacial trauma for face transplant should be considered when the extent of injury exceeds conventional reconstructive limits. Our approach provides the best opportunity for an optimal face transplant outcome while minimizing flap donor site morbidity.

Geriatric Patients Carry Increased Risk for Deep Venous Thrombosis and Pulmonary Embolism in Reduction Mammaplasty: An Analysis of 1897 Geriatric Patients Among 25,909 Cases From 2005 to 2017 National Surgical Quality Improvement Project Databases.

INTRODUCTION: Reduction mammaplasty is one of the most common plastic surgery procedures performed. No study has evaluated whether geriatric patients are at greater risk for developing postoperative complications relative to nongeriatric patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database was reviewed for reduction mammaplasty procedures from 2005 to 2017. Hypothesis testing for demographics, comorbidities, and postoperative complications between geriatric and nongeriatric patients was performed. Statistically significant differences were then evaluated with multivariate logistic regression analysis. RESULTS: A total of 25,909 reduction mammaplasties were collected by NSQIP from 2005 to 2017, with 1897 patients older than 64 years (8% of all cases). The average age for geriatric breast reduction patients was 69 years versus 41.5 years for nongeriatric patients. Rates of comorbidities including diabetes, smoking status, dyspnea status, and hypertension medication were statistically different between the groups. Rates of deep venous thrombosis (DVT) and pulmonary embolism (PE) were significantly higher in geriatric versus nongeriatric patients, respectively (0.32 vs 0.06, P < 0.001 and 0.37 vs 0.09, P < 0.001). Multivariate analysis demonstrated geriatric patients had a 4.2 and 3.9 times higher risk of developing a DVT and PE than nongeriatric patients (C.I. 1.5-11.6, P = 0.006 and C.I. 1.6-9.8, P = 0.004). DISCUSSION: This study represents the largest evaluation of geriatric reduction mammaplasties in the United States. Although rare, geriatric age confers a 4 times increased risk for developing DVT and PE relative to nongeriatric patients all while adjusting for preoperative risk factors in reduction mammaplasty. Plastic surgeons should consider counseling their geriatric patients regarding these increased risks.

Global Burden of Craniofacial Disorders: Where Should Volunteering Plastic Surgeons and Governments Focus Their Care?

PURPOSE: Approximately 11% of the global burden of disease is surgically treatable. When located within the head, face, and neck region, plastic surgeons are particularly trained to treat these conditions. The purpose of this study was to describe the etiology, disability, and barriers to receiving care for diseases of the head, face, mouth, and neck region across 4 low-and-middle-income countries. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) instrument is a cluster randomized, cross-sectional, national survey administered in Nepal, Rwanda, Sierra Leone, and Uganda from 2011 to 2014. The survey identifies demographic characteristics, etiology, disease timing, proportion seeking/receiving care, barriers to care, and disability. RESULTS: Across the 4 countries, 1413 diseases of head, face, mouth, and neck region were identified. Masses (22.13%) and trauma (32.8%) were the most common etiology. Nepal reported the largest proportion of masses (40.22%) and Rwanda reported the largest amount of trauma (52.65%) (P < 0.001). Rwanda had the highest proportion of individuals seeking (89.6%) and receiving care (83.63%) while Sierra Leone reported the fewest (60% versus 47.77%, P < 0.001). In our multi-variate analysis literacy and chronic conditions were predictors for receiving care while diseases causing the greatest disability predicted not receiving care (ORa .58 and .48 versus 1.31 P < 0.001). CONCLUSIONS: The global volunteering plastic surgeon should be prepared to treat chronic craniofacial conditions. Furthermore, governments should address structural barriers, such as health illiteracy and lack of access to local plastic surgery care by supporting local training efforts.

Rethinking burns for low & middle-income countries: Differing patterns of burn epidemiology, care seeking behavior, and outcomes across four countries.

PURPOSE: Low-and middle-income (LMIC) countries account for 90% of all reported burns, nevertheless there is a paucity of providers to treat burns. Current studies on burns in LMICs have not evaluated the gap between care seeking and receiving. This study explores this gap across socioeconomically similar populations in a multi-country population based assessment to inform burn care strategies. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) instrument is a cross sectional national, cluster random sampling survey administered in Nepal, Rwanda, Sierra Leone, and Uganda from 2011 to 2014. The survey identifies burn etiology, demographics, timing, disability, and barriers to receiving care. RESULTS: Among 13,763 individuals surveyed, 896 burns were identified. Rwanda had the highest proportion of individuals seeking and receiving care (91.6% vs 88.5%) while Sierra Leone reported the fewest (79.3% vs 70.3%). Rwanda reported the largest disability while Nepal reported the highest proportion with no disability (47.5% vs 76.2%). Lack of money, healthcare providers, and rural living reduce the odds of receiving care by 68% and 85% respectively. CONCLUSIONS: Despite similar country socioeconomic characteristics there was significant variability in burn demographics, timing, and disability. Nevertheless, being geographically and economically disadvantaged predict lack of access to burn care.