Gender-Based Frailty in Multiple Orthopedic Fractures.

The 5-factor modified frailty index (mFI-5) has been used as a prognostic tool to identify patients at higher risk for complications and mortality but has not been used to assess the relationship between frailty and extent of injury following ground-level falls. The aim of this study was to determine if mFI-5 is associated with increased risk for combined femur-humerus fractures compared to isolated femur fractures in geriatric patients. A retrospective analysis of 2017-2018 American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) data identified 190 836 patients with femur fractures and 5054 patients with combined femur-humerus fractures. In multivariate analysis, gender was the only statistically significant predictor for risk of combined vs isolated fractures (OR 1.69, 95% CI [1.65, 1.74], P < .001). While outcome data for the mFI-5 repeatedly shows increased risk for adverse events, this tool may over-estimate the disease specific risk factors rather than the overall frailty state of the patient and diminish its predictive power.

Age-Related Outcomes in Le Fort Fractures.

This study aims to provide patient characteristics and short-term clinical outcomes of Le Fort fractures. Using the National Surgical Quality Improvement Program database from 2016 to 2019, cases involving Le Fort fractures on initial encounters were reviewed. 130 cases from 3293 facial fractures were identified. 70 cases were diagnosed with type I, 41 with type II, and 19 with type III. The male-to-female ratio was 4.9:1. Compared to geriatric patients (>65 years old), Le Fort fractures were more common among patients between the ages of 18 and 65 (P < .003). 5.4% of patients had in-hospital complications, including sepsis, superficial-deep incisional surgical site infection, and wound disruption. Two patients (1.5%) were readmitted, while three (2.3%) underwent reoperation. Type I fractures in adult males are the most common presentation. Overall complication rates for surgical repairs are low.

Combined Upper-Lower Extremities Fractures in the Elderly.

Age-related bone loss is believed to increase the risk of traumatic fragility fractures in both men and women. We aimed to determine the risk factors associated with simultaneous fractures in the upper-lower extremities. This retrospective study utilized the ACS-TQIP database from 2017 to 2019 to identify patients with respective fractures caused by ground-level falls. A total of 403,263 patients with femur fractures and 7,575 patients with combined upper-lower extremities (humerus-femur) fractures were identified. Patients had higher odds of combined upper-lower extremities fractures with increasing age: 18-64 (OR 1.05, P < .001); 65-74 (OR 1.72, P < .001); and 75-89 (OR 1.90, P < .001) while adjusting for other statistically significant risk factors. Advanced age increases the risk of traumatic combined upper-lower extremities fractures. Prevention strategies should be emphasized to reduce the burden of simultaneous injury in the upper-lower extremities.

Le Fort Fractures: A Collective Review.

Le Fort fractures constitute a pattern of complex facial injury that occurs secondary to blunt facial trauma.  The most common mechanisms of injury for these fractures, which are frequently associated with drug and alcohol use, include motor vehicle collisions, assault, and falls. A thorough search of the world's literature following PRISMA guidelines was conducted through PubMed and EBSCO databases. Search terms included "Le Fort fracture", "facial", "craniofacial", and "intracranial."  Articles were selected based on relevance and examined regarding etiology, epidemiology, diagnosis, treatment, complications, and outcomes in adults. The analyzed studies were published between 1980 and 2016. Initial data search yielded 186 results. The search was narrowed to exclude articles lacking in specificity for Le Fort fractures.  Fifty-one articles were selected, the majority of which were large case studies, and collectively reported that Le Fort fractures are most commonly due to high-velocity MVC and that the severity of fracture type sustained occurred with increasing frequency.  It was also found that there is a general lack of published Level I, Level II, and Level III studies regarding Le Fort fracture management, surgical management, and outcomes. The limitation of this study, similar to all PRISMA-guided review articles, is the dependence on previously published research and availability of references as outlined in our methodology. While mortality rates for Le Fort fractures are low, these complex injuries seldom occur in isolation and are associated with other severe injuries to the head and neck. Quick and accurate diagnosis of Le Fort fractures and associated injuries is crucial to the successful management of blunt head trauma.

Biological vs. mechanical aortic root replacement.

OBJECTIVES: Although age and co-existing coronary disease are major determining factors when deciding valve choice (mechanical vs. biological) in simple aortic valve replacement, no studies have documented selection criterion for biological (BIO) vs. mechanical (MECH) aortic root prosthesis. METHODS: Two hundred and twenty-one consecutive patients underwent elective aortic root replacement with either BIO (homograft, n=111, Freestyle, n=25) or MECH composite grafts (n=85). Median age in BIO was 53 years and in MECH 54 years (P=NS). Groups were similar in gender, NYHA class and ejection fraction (BIO, EF=59% vs. MECH, EF=55%), but the need for concomitant coronary artery bypass grafting (CABG) did differ between groups (MECH=35% vs. BIO=17%, P=0.003). Mean follow-up was 42+/-28 months for mortality and 39+/-28 months for morbidity. RESULTS: Full root replacement was performed in 213 patients (96%) and hemi-root in eight (4%). The most common underlying etiologies were annulo-aortic ectasia (n=82, 37%), calcified-degenerative (n=73, 33%) and bicuspid/congenital aortic valve disease (n=39, 18%). Operative mortality was 1.5% for BIO and 2.4% for MECH (P=0.5). By univariate analysis there was a trend towards greater 5-year survival in BIO (92.4% vs. 88.2%, P=0.068). By multivariate analysis, increasing age (HR=2.4, P=0.003), previous valve replacement (HR=4.7, P=0.024), concomitant CABG (HR=3.7, P=0.032), and perioperative stroke (HR=9.9, P=0.0005) were all independent predictors of late death. The 5-year freedom from valve-related complications was similar in both groups (BIO=93% vs. MECH=86%, P=0.5). CONCLUSIONS: Elective aortic root replacement is an exceedingly safe operation. At mean follow-up of 4 years, there is no meaningful difference in early or mid term valve-related results between BIO and MECH aortic root replacement. Continued evaluation for late valve-related complications in this cohort will be necessary to determine the advantages, if any, of one prosthesis over the other.

Management of mild aortic stenosis during coronary artery bypass surgery: an update, 1992-2001.

BACKGROUND: "Prophylactic" aortic valve replacement (AVR) in patients with asymptomatic, mild-to-moderate aortic stenosis (AS) at the time of CABG is controversial. In 1994, we reported our initial experience involving 44 patients and have now updated our series in an attempt to further evaluate outcomes. METHODS: Between January 1992 and July 2001, 100 consecutive patients underwent reoperative AVR following previous CABG. Forty patients had their initial surgery at the Brigham & Women's Hospital (BWH) and 60 patients had their coronary surgery elsewhere. None of the 40 BWH patients had a mean valve gradient greater than 25 mmHg at the time of CABG. RESULTS: The mean time interval from CABG to AVR for the entire group was 9.0 years (range: 1.4-21 years). Overall operative mortality (OM) was 7% including 5 deaths (10.2%) among 49 patients requiring additional CABG at the time of AVR and 2 deaths (3.9%) among 51 patients without additional coronary artery intervention. This OM rate was a notable decrease from our earlier report of 18.2% (P = 0.07). Furthermore, operative mortality decreased progressively from 15.4% in 1992-1993 to 0% in 2000-2001 (P = NS). CONCLUSION: The OM of reoperative AVR following CABG has fallen in recent years. Given the relevance of newer techniques and approaches, it may be reasonable to adopt an expectant management approach in patients with asymptomatic mild-to-moderate AS (i.e., mean systolic gradient less than 25 mmHg) at the time of CABG.