Comparative Effectiveness Analysis of Complex Lower Extremity Reconstruction: Outcomes and Costs for Biologically Based, Local Tissue Rearrangement, and Free Flap Reconstruction.

BACKGROUND: Various surgical techniques exist for lower extremity reconstruction, but limited high-quality data exist to inform treatment strategies. Using multi-institutional data and rigorous matching, the authors evaluated the effectiveness and cost of three common surgical reconstructive modalities. METHODS: All adult subjects with lower extremity wounds who received bilayer wound matrix, local tissue rearrangement, or free flap reconstruction were retrospectively reviewed (from 2010 to 2017). Cohorts' comorbidities and wound characteristics were balanced. Graft success at 180 days was the primary outcome; readmissions, reoperations, and costs were secondary outcomes. RESULTS: Five hundred one subjects (166 matrix, 190 rearrangement, and 145 free flap patients) were evaluated. Matched subjects (n = 312; 104/group) were analyzed. Reconstruction success at 180 days for matrix, local tissue rearrangement, and free flaps was 69.2 percent, 91.3 percent, and 93.3 percent (p < 0.001), and total costs per subject were $34,877, $35,220, and $53,492 (p < 0.001), respectively. Median length of stay was at least 2 days longer for free flaps (p < 0.0001). Readmissions and reoperations were greater for free flaps. Local tissue rearrangement, if achievable, provided success at low cost. Free flaps were effective with large, traumatic wounds but at higher costs and longer length of stay. Matrices successfully treated older, obese patients without exposed bone. CONCLUSIONS: Lower extremity reconstruction can be performed effectively using multiple modalities with varying degrees of success and costs. Local tissue rearrangement and free flaps demonstrate success rates greater than 90 percent. Bilayer wound matrix-based reconstruction effectively treats a distinct patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Comparative Effectiveness of Retromuscular and Intraperitoneal Repair: What Is the Value of Posterior Sheath Reconstruction?

BACKGROUND: The authors hypothesize that posterior sheath reconstruction to achieve retromuscular mesh placement provides outcomes comparable to traditional retromuscular mesh placement and superior to intraperitoneal repair. METHODS: Patients were divided into three groups: (1) retromuscular mesh placement with repaired posterior sheath defects, (2) retromuscular repair with an intact posterior sheath, and (3) intraperitoneal repair. Primary outcomes included recurrence, surgical-site occurrences, and cost. RESULTS: Overall, 179 patients were included. Posterior sheath defects were repaired primarily with absorbable suture or biological mesh. Recurrence rates differed significantly between standard retromuscular repair and intraperitoneal repair groups (p < 0.009), trended toward significance between repaired posterior sheath and intraperitoneal repair groups (p < 0.058), and showed no difference between repaired posterior sheath and standard retromuscular repair (p < 0.608). Retromuscular repair was clinically protective and cost-effective. CONCLUSIONS: This analysis of posterior sheath reconstruction suggests outcomes comparable to traditional retromuscular repair and a trend toward superiority compared with intraperitoneal repair. Achieving retromuscular closure appears to demonstrate clinical and cost efficacy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Antibiotic Use in Primary Palatoplasty: A Survey of Practice Patterns, Assessment of Efficacy, and Proposed Guidelines for Use.

BACKGROUND: The literature provides no guidelines for antibiotic use in palatoplasty. The authors sought to ascertain practice patterns; review a large, single-surgeon experience, and propose guidelines for antibiotic use in primary palatoplasty. METHODS: A six-question survey was e-mailed to all surgeons of the American Cleft Palate-Craniofacial Association. A retrospective study was also conducted of the senior author's 10-year primary palatoplasty series, and two groups were studied. Group 1 received no antibiotics. Group 2 received preoperative and/or postoperative antibiotics. RESULTS: Three hundred twelve of 1115 surgeons (28 percent) responded to the survey. Eighty-five percent administered prophylactic antibiotics, including 26 percent who used a single preoperative dose. A further 23 percent gave 24 hours of postoperative therapy; 12 percent used 25 to 72 hours, 16 percent used 4 to 5 days, and 12 percent used 6 to 10 days. Five percent of surgeons administered penicillin, 64 percent administered a first-generation cephalosporin, 13 percent administered ampicillin/sulbactam, and 8 percent gave clindamycin. The authors reviewed 311 patients; 173 receive antibiotics and 138 did not. Delayed healing and fistula rates did not differ between groups: 16.8 percent versus 15.2 percent (p = 0.71) and 2.9 percent versus 1.4 percent (p = 0.47), respectively. A single patient treated without antibiotics developed a postoperative bacteremia. This case did not meet the Centers for Disease Control definition of a surgical site infection, but the patient developed a palatal fistula. CONCLUSIONS: Antibiotic use in primary palatoplasty varies widely. The authors' data support a clinician's choice to forego antibiotic use; however, given the significance of palatal fistulae and the single case of postoperative streptococcal bacteremia, the study group recommends a single preoperative dose of ampicillin/sulbactam. Current evidence cannot justify the use of protracted antibiotic regimens. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Radiographic assessment of ligamentous injuries in distal radius fractures after open reduction and internal fixation.

OBJECTIVES: Concomitant ligamentous injury in distal radius fractures (DRF) may explain continued pain following surgery. The purpose of this study was to compare radiographic measurements assessing scaphoid translation in DRF after reduction, to measurements performed on normal radiographs. This may allow noninvasive evaluation of radiocarpal ligamentous integrity. METHODS: Fifty postoperative radiographs were evaluated. The distance between the ulnar border of the radial styloid and the radial border of the scaphoid was measured midway between the styloid tip and scaphoid base, and then divided by scaphoid width at the same level. The measured ratios were compared to previously established normal data, established radiographic measurements of fracture reduction, fracture characteristics and fixation methods. RESULTS: Radiographic scaphoid position measurements differed significantly from normals (p = 0.0001). Fracture characteristics, surgical difficulty, and technique were not associated with scaphoid position. CONCLUSIONS: Despite accurate surgical reduction, abnormal positioning of the scaphoid may persist. This may reflect ligamentous injury, which generates suboptimal clinical results. Identifying and addressing ligamentous injury during surgery may prevent the development of instability and improve outcome after DRF.