Prognostic Factors for Success After Irrigation and Debridement With Modular Component Exchange for Infected Total Knee Arthroplasty.

BACKGROUND: Irrigation and debridement with modular component exchange (IDMCE) can treat prosthetic joint infection (PJI) after total knee arthroplasty (TKA). Compared to 2-stage revision, IDMCE is associated with lower morbidity but may carry higher infection recurrence rates. We aimed to identify prognostic factors associated with successful IDMCE in patients with PJI. METHODS: We identified 99 consecutive patients who underwent IDMCE following TKA PJI at a tertiary academic medical center from November 2009 through January 2016. Examined variables included age, gender, symptom duration, body mass index, Charlson comorbidity index, total protein, albumin, hemoglobin A1c, erythrocyte sedimentation rate (ESR), C-reactive protein, white blood cell count, gram stain results, final cultures, and use of long-term antibiotic suppression. Success was defined as no further operation on the ipsilateral knee. We used t tests and chi-square analyses to determine whether each preoperative factor was associated with IDMCE reoperation. RESULTS: At mean follow-up of 2.6 years, 64 patients who underwent IDMCE were defined as successful. Thirty-five patients required one or more additional procedures for recurrent infection; of these, 20 patients underwent 2-stage revision. Patients with symptom duration of less than 2 days avoided additional surgery in 88% of cases. Elevated ESR >47 mm/h was the only variable associated with reoperation (P = .005). There were no associations among the other examined variables. CONCLUSION: Using IDMCE for PJI after TKA required reoperation in 35% of cases. Elevated preoperative ESR laboratory values and duration of symptoms >2 days were associated with reoperation.

Color Match Following Free Flap Surgery in Head and Neck Reconstruction: A Colorimetric and Aesthetic Analysis.

BACKGROUND: Many options for free tissue transfer have been described for head and neck reconstruction. While functional outcomes remain paramount, aesthetic considerations like color match can be equally consequential for patient quality of life. It is important to understand differences in color match based on flap donor site for head and neck reconstruction. METHODS: A retrospective review was performed of patients who underwent head and neck reconstruction with free tissue transfer at a tertiary care academic medical center between November 2012 and November 2020. Patients with documented pictures of their reconstruction and external skin paddles were considered. Patient demographics and surgery specific factors were recorded. Objective differences in color match were obtained by calculating the International Commission on Illumination Delta E 2000 (dE2000) score. Standard univariate descriptive statistics and multivariable statistical analyses were performed. RESULTS: Lateral arm, parascapular, and medial sural artery perforator (MSAP) free tissue transfer performed favorably compared to other donor sites, whereas anterolateral thigh flaps had the highest average dE2000 scores. Differences in dE2000 scores were mitigated by post-operative radiation to the flap site and with increasing time beyond 6 months post-operatively. CONCLUSIONS: We provide an objective assessment of external skin color match in patients undergoing free tissue transfer for head and neck cancer by donor site. MSAP, lateral arm, and parascapular free flaps performed well compared to traditional donor sites. These differences are more significant at the face and mandible when compared to the neck, but diminish 6 months after surgery and with post-operative radiation to the free flap skin paddle.

The submental island flap in head and neck reconstruction: A 10-year experience examining application, oncologic safety, and role of comorbidity.

Background: We present our experience on reconstructive versatility and risk of nodal transfer with the submental island flap (SIF). We also examine the role of comorbidity as a predictor of complications. Methods: Retrospective cohort study of patients undergoing SIF over 10-year period. Comorbidity determined using Adult Comorbidity Evaluation 27 index (ACE-27). Univariable/multivariable logistic regressions performed to determine association of these characteristics and rates of major complications. Results: Fifty-eight patients underwent SIF reconstruction, 27 (45%) patients had moderate/severe comorbidity, and 24 (41%) experienced major complication. Multivariable analysis identified ACE-27 scores >2 predictive of major flap complications (OR: 17.38, 95% CI: 1.96-153.74, p = .01) and medical complications (OR: 5.8, 95% CI: 1.11-30.23, p = .037). There were no cases of pathologic nodal transfer. Conclusion: The SIF is a versatile flap and oncologically safe in carefully selected patients. The ACE-27 index is strongly predictive of major postoperative complications. Level of Evidence: 4.

Preoperative Criteria Predict Operative Time Variability Within Tympanoplasty Procedures.

OBJECTIVE: To identify preoperative patient and surgical parameters that predict operative time variability within tympanoplasty current procedural terminology (CPT) codes. STUDY DESIGN: Retrospective. SETTING: Tertiary referral center. PATIENTS: One hundred twenty eight patients who underwent tympanoplasty (CPT code 69631) or tympanoplasty with ossicular chain reconstruction (69633) by a single surgeon over 3 years. INTERVENTIONS: Procedures were preoperatively assigned a complexity modifier: Level 1 (small or posterior perforation able to be repaired via transcanal approach), Level 2 (large perforation or other factor requiring postauricular approach), or Level 3 (cholesteatoma or severe infection). MAIN OUTCOME MEASURES: Total in-room time (nonoperative time plus actual operative time). RESULTS: Consideration of preoperative parameters including surgical complexity, surgical facility, use of facial nerve monitoring, laser usage, resident involvement, revision surgery, and underlying patient characteristics (American Society of Anesthesiologists [ASA] score, body mass index [BMI]) accounted for up to 69% of surgical time variance. Across both CPT codes, surgical complexity levels accurately stratified operative times (p < 0.05). Total time was longer (by 30.0 min for 69631, 55.4 min for 69633) in Level 3 procedures compared with Level 2, while Level 1 cases were shorter (27.6, 33.9 min). Resident involvement added 25 and 32 minutes to total time (p < 0.02). Nonoperative preparation times were longer (22.1, 15.4 min) in the main hospital compared with ambulatory surgical center (p < 0.001). CONCLUSIONS: There is significant surgical time variability within tympanoplasty CPT codes, which can be accurately predicted by the preoperative assignment of complexity level modifiers and consideration of patient and surgical factors. Application of complexity modifiers can enable more efficient surgical scheduling.

A System for Characterizing Intraoperative Force Distribution During Operative Laryngoscopy.

OBJECTIVE: This study aimed to create and validate an integrated data acquisition system for gauging the force distribution between a laryngoscope and soft-tissue during trans-oral surgery. METHODS: Sixteen piezoresistive force sensors were interfaced to a laryngoscope and custom maxillary tooth guard. A protocol for calibrating the laryngoscope and maxilla sensors was developed using a motor-controlled linear stage and force measurements were validated against a digital scale. The system was initially tested during suspension laryngoscopy on three cadaver heads mounted on a cadaver head-holder. Intraoperative data was also collected from three patients undergoing head and neck tumor resection. RESULTS: Mean calibration error of the scope sensors was less than 150 g (n = 3) and mean maxilla sensor error was less than 200 g (n = 3). Peak scope mag-forces of 8.09 ± 6.61 kg and peak maxilla forces of 7.62 ± 4.57 kg were experienced during the cadaver trials. The peak scope sensor mag-force recorded during the intraoperative cases was 24.7 ± 4.53 kg, and the peak maxilla force was 22.0 ± 4.60 kg. CONCLUSION: The data acquisition system was successfully able to record intraoperative force distribution data. The usefulness of this technology in informing surgeons during trans-oral surgery should be further evaluated in patients with varying anatomic and procedural characteristics. SIGNIFICANCE: Creation of a low-cost, integrated force-sensing system allows for the characterization of retraction forces at anatomic sites including the pharynx and larynx, brain, and abdomen. Real-time force detection provides surgeons with valuable intraoperative feedback and can be used to improve deformation models at various anatomic sites.

Orbital Floor Reconstruction: A Comparison of Outcomes between Absorbable and Permanent Implant Systems.

There are distinct advantages and disadvantages between bioresorbable and permanent implants in orbital floor reconstruction. Our aim was to compare the outcomes and complications of resorbable implants and permanent implants in orbital floor fracture repair. A retrospective chart review was performed on all patients who underwent orbital floor fracture repair at a rural, tertiary care center from 2011 through 2016. Main outcome measures included improvement in diplopia, ocular motility, enophthalmos, hypoglobus, and infraorbital nerve sensation. A total of 87 patients underwent orbital floor reconstruction. After exclusion criteria were applied, 22 patients were included in the absorbable implant cohort, and 20 patients in the nonabsorbable implant cohort. All absorbable implants were composed of poly L-lactide/poly glycolide/poly D-lactide (PLL/PG/PDL), and nonabsorbable implants included both titanium/porous polyethylene (Ti/PPE) composite and titanium (Ti) mesh. Mean fracture surface area was 2.1 cm 2 (standard deviation [SD]: ± 0.9 cm 2 , range: 0.4-3.6 cm 2 ) for the absorbable implant group and 2.3 cm 2 (SD: ± 1.1 cm 2 , range: 0.6-4.4 cm 2 ) for the nonabsorbable implant group ( p = 0.58). There were no significant differences in diplopia, ocular motility, enophthalmos, hypoglobus, and infraorbital nerve sensation between absorbable and nonabsorbable implant groups. The mean follow-up time for absorbable and nonabsorbable implant groups was 622 (SD ± 313) and 578 (SD ± 151) days respectively ( p = 0.57). For moderate-size orbital floor fracture repairs, there is no difference in outcomes between absorbable implants consisting of PLL/PG/PDL and nonabsorbable implants consisting of Ti mesh or Ti/PPE combination.

Improving target localization during trans-oral surgery with use of intraoperative imaging.

PURPOSE: Trans-oral surgery provides a less invasive means for the surgical management of upper aerodigestive tract malignancies but is limited in its ability to readily assess submucosal tumor extent and location of critical structures intraoperatively. We sought to determine surgeons' baseline target localization accuracy during operative laryngoscopy with preoperative imaging alone and then assess for improvement in localization accuracy when presented with intraoperative CT imaging capturing soft tissue deformation. METHODS: Fiducial beads were placed submucosally in four cadaver heads. "Preoperative" (PO) and "intraoperative" (IO) neck CTs were acquired before and during suspension laryngoscopy using a CT-compatible laryngoscopy system. Surgeons attempted to localize submucosal fiducials beads using pins based on sequential review of PO and IO images. RESULTS: Mean total error (TE) decreased from 12.8 ± 9.9 to 10 ± 7.5 mm from PO to IO (P < 0.001), respectively. TE for base of tongue and vallecula decreased by 1.7 ± 6.7 mm (P = 0.015). Right-sided structures were most exposed by scope positioning and experienced a TE reduction of 4.8 ± 9.3 mm (P < 0.001). Task completion time decreased from PO to IO by 26% (P < 0.001). CONCLUSIONS: Intraoperative imaging significantly improves localization accuracy and task efficiency when targeting submucosal beads in cadaver heads during operative laryngoscopy.

Multi-modal Framework for Image-guided Trans-oral Surgery with Intraoperative Imaging and Deformation Modeling.

Treatment of throat cancers have improved due to minimally-invasive trans-oral approaches. Surgeons rely on preoperative imaging to guide their resection; however, large tissue deformations occur during trans-oral procedures due to placement of necessary retractors and laryngoscopes which hinders the surgeon's ability to accurately assess tumor extent and location of critical structures. We propose an image-guided framework utilizing intraoperative imaging and deformation modeling to improve surgeon accuracy and confidence. A CT-compatible laryngoscopy system previously developed was evaluated in this framework. Intraoperative images were acquired during laryngoscopy; force-sensing capabilities were enabled in the laryngoscope; and tracking of the scope and anatomic features was trialed. Tissue deformation and displacement were quantified and determined to be extensive, with values <; 4.6 cm in the tongue, <; 1.8 cm in bony structures, and <; 108.9 cm3 in airway volume change. Surgical navigation using intraoperative imaging and tracking was evaluated. Preliminary assessment of deformation modeling showed potential to supplement intraoperative imaging. Future work will involve streamlined integration of the components of this framework.