Outpatient Prescription Opioid Use following Discharge after Deep Inferior Epigastric Perforator Breast Reconstruction with and without an Educational Intervention.

BACKGROUND: There is limited evidence for appropriate postoperative opioid prescribing in autologous breast reconstruction. We sought to describe postoperative outpatient prescription opioid use following discharge after deep inferior epigastric perforator (DIEP) breast reconstruction with and without an educational video. METHODS: Patients undergoing DIEP reconstruction were given a 28-day postoperative pain and medication logbook from August 2022 to June 2023. Our practice implemented an educational video upon discharge on proper opioid consumption. Descriptive statistics on patient characteristics, intraoperative and postoperative opioid consumption, and outpatient prescription opioid use after discharge were compared between the two cohorts. RESULTS: A total of 53 logbooks were completed with 20 patients in the no video cohort and 33 in the video cohort. On average, the days to cessation of opiates was longer in the no video cohort (8.2 vs. 5.1 days, p = 0.003). The average number of oxycodone 5 mg equivalents consumed following discharge was 13.8 in the no video cohort and 7.8 in the video cohort, which was statistically significant (p = 0.01). Overall, the percentage of opioids prescribed that were consumed in the video cohort was 28.3% versus 67.1% in the no video cohort. CONCLUSION: For patients discharging home after DIEP reconstruction, we recommend a prescription for 12 oxycodone 5 mg tablets. With the use of an educational video regarding proper opioid consumption, we were able to reduce the total outpatient opioid use to 5 oxycodone 5 mg tablets following hospital discharge.

Associations with Discharge to Post-Acute Care Facilities Among Patients Undergoing Open Reduction Internal Fixation of Distal Radius Fractures.

Introduction: Distal radius fractures are a common injury of the hand and wrist that often require intensive rehabilitation. We sought to identify risk factors associated with discharge to a post-acute care facility following distal radius fracture repair. Methods: The 2011 to 2016 National Surgical Quality Improvement Program® (NSQIP) database was queried for all Current Procedural Terminology (CPT) codes that corresponded with open distal radius fracture repair. Patients with concomitant traumatic injuries were excluded. Patient demographics, comorbidities, perioperative factors, laboratory data, and surgical details were collected. Our primary outcome was to determine postoperative discharge destination: home versus a post-acute care facility, and to identify factors that predict discharge to post-acute care facility. Secondary outcomes included unplanned readmission, reoperation, and complications. Results: Between 2011 and 2016, a total of 12,001 patients underwent open distal radius fracture repair and had complete information for their discharge. Of these analyzed patients, 3.24% (n = 389) were discharged to rehabilitation facilities. The following factors were identified on multivariate analysis to have an association with discharge to a post-acute care facility: 65 years or older, White race, underweight, using steroids preoperatively, American Society of Anesthesiologists (ASA) classification > 2, admitted from a nursing home or already hospitalized, anemic, undergoing bilateral surgery, wound classification other than clean, and complications prior to discharge. Conclusion: Factors identified by our study to have associations with discharge to post-acute care facilities following distal radius fracture repair can help in appropriate patient counseling and triage from the hospital to home versus a post-acute care facility.

Introduction: Les fractures du radius distal sont des blessures courantes de la main et du poignet qui exigent souvent une réadaptation intensive. Les chercheurs ont voulu déterminer les facteurs de risque associés au congé dans un établissement de soins post-aigus après la réparation d'une fracture du radius distal. Méthodologie: Les chercheurs ont fouillé la base de données 2011-2016 des NSQIP pour extraire tous les codes CPT (terminologie procédurale actuelle) qui correspondaient aux réparations des fractures ouvertes du radius distal. Les patients atteints d'autres blessures traumatiques ont été exclus. Les chercheurs ont colligé les caractéristiques démographiques des patients, leurs maladies sous-jacentes, les facteurs périopératoires, les données de laboratoire et l'information chirurgicale. Le résultat primaire consistait à déterminer la destination du congé postopératoire, soit le domicile ou l'établissement de soins postaigus, et à établir quels facteurs permettent de prédire un congé dans un établissement de soins postaigus. Les résultats secondaires incluaient des réadmissions non planifiées, la reprise de l'opération et les complications. Résultats: Entre 2011 et 2016, un total de 12 001 patients ont subi la réparation d'une fracture ouverte du radius distal et reçu de l'information complète lors de leur congé. De ce nombre, 3,24% (n = 389) ont obtenu leur congé dans des établissements de réadaptation. L'analyse multivariée a établi que les facteurs suivants étaient associés à un congé dans un établissement de soins postaigus : un âge de 65 ans ou plus, la race blanche, l'insuffisance pondérale, la prise de stéroïdes après l'opération, une classification d'ASA supérieure à 2, l'admission à partir d'un centre de soins de longue durée ou le fait d'être déjà hospitalisé, l'anémie, la chirurgie bilatérale, une classification des plaies autres que propre et des complications avant le congé. Conclusion: La présente étude a déterminé que certains facteurs associés au congé dans un établissement de soins postaigus après une réparation du radius distal peuvent contribuer à des conseils appropriés aux patients et à un triage de l'hôpital vers le domicile plutôt que vers un autre établissement.

Association between blood markers and the progression of osseointegration in percutaneous prostheses patients-A pilot study.

Patients implanted with osseointegrated (OI) prosthetic systems have reported vastly improved upper and lower extremity prosthetic function compared with their previous experience with socket-suspension systems. However, OI systems have been associated with superficial and deep-bone infections and implant loosening due, in part, to a failure of the osseointegration process. Although monitoring the osseointegration using circulating biomarkers has clinical relevance for understanding the progression of osseointegration with these devices, it has yet to be established. Ten patients were enrolled in this study. Blood samples were collected at pre-selected times, starting before implantation surgery, and continuing to 12 months after the second surgery. Bone formation markers, bone resorption markers, and circulating amino acids were measured from blood samples. A linear mixed model was generated for each marker, incorporating patient ID and age with the normalized marker value as the response variable. Post hoc comparisons were made between 1 week before Stage 1 Surgery and all subsequent time points for each marker, followed by multiple testing corrections. Serial radiographic imaging of the residual limb containing the implant was obtained during follow-up, and the cortical index (CI) was calculated for the bone at the porous region of the device. Two markers of bone formation, specifically bone-specific alkaline phosphatase (Bone-ALP) and amino-terminal propeptide of type I procollagen (PINP), exhibited significant increases when compared with the baseline levels of unloaded residual bone prior to the initial surgery, and they subsequently returned to their baseline levels by the 12-month mark. Patients who experienced clinically robust osseointegration experienced increased cortical bone thickness at the porous coated region of the device. A medium correlation was observed between Bone-ALP and the porous CI values up to PoS2-M1 (p = .056), while no correlation was observed for PINP. An increase in bone formation markers and the lack of change observed in bone resorption markers likely reflect increased cortical bone formation induced by the end-loading design of the Utah OI device used in this study. A more extensive study is required to validate the correlation observed between Bone-ALP and porous CI values.

The Effect of Body Mass Index on Free Flap Breast Reconstruction.

BACKGROUND: Literature addressing the risks associated with increasing body mass index (BMI) for patients undergoing free flap breast reconstruction is limited. Often, an arbitrary BMI cutoff (i.e., BMI of 30 kg/m2) is used to determine candidacy for a free flap without substantial backing evidence. This study utilized a national multi-institutional database to analyze outcomes of free flap breast reconstruction and stratified complications by BMI class. METHODS: Using the 2010 to 2020 National Surgical Quality Improvement Program database, patients who underwent free flap breast reconstruction were identified. Patients were divided into six cohorts based on the World Health Organization BMI classes. Cohorts were compared by basic demographics and complications. A multivariate regression model was created to control for age, diabetes, bilateral reconstruction, American Society of Anesthesiologists class, and operative time. RESULTS: Surgical complications increased with each BMI class, with the highest rates occurring in class I, II, and III obesity, respectively. In a multivariable regression model, the risk for any complication was significant for class II and III obesity (odds ratio [OR]: 1.23, p < 0.004; OR: 1.45, p < 0.001, respectively). Diabetes, bilateral reconstruction, and operative time were independently associated with an increased risk of any complication (OR: 1.44, 1.14, 1.14, respectively, p < 0.001). CONCLUSION: This study suggests that the risks of postoperative complications following free flap breast reconstruction are highest for patients with a BMI greater than or equal to 35 kg/m2, having nearly 1.5 times higher likelihood of postoperative complications. Stratifying these risks by weight class can help guide preoperative counseling with patients and help physicians determine candidacy for free flap breast reconstruction.

Outcomes after tissue expander exchange to implant in two-stage prepectoral breast reconstruction with and without acellular dermal matrix: A retrospective cohort study.

As prepectoral implant placement becomes widely adopted, recent studies investigating the use of acellular dermal matrix (ADM) during tissue expander placement have demonstrated no major benefit with regard to postoperative outcomes. We sought to evaluate second-stage outcomes 1 year after tissue expander exchange to implant with and without ADM. Consecutive patients who underwent prepectoral tissue expander-based breast reconstruction with and without ADM were identified. Patients were followed up for 1 year after tissue expander exchange to implant. Second-stage outcomes of interest including implant rippling, capsular contracture, implant explantation, additional revision surgeries, and patient-reported outcomes were collected and compared. Sixty-eight breasts in the ADM cohort and sixty-one breasts in the no ADM cohort underwent tissue expander exchange to implant. Second-stage outcomes of interest were similar between the ADM and no ADM cohorts with no statistically significant differences identified regarding incidences of implant rippling (24.6% vs. 12.1%, p = 0.08), capsular contracture (4.5% vs. 3.3%, p = 1.00), and explantation (6.6% vs. 1.7%, p = 0.67) between the two cohorts. BREAST-Q scores were similar between the two cohorts with the exception of physical wellbeing and satisfaction in terms of implant rippling, as can be seen, which improved in the no ADM cohort (p = 0.04). Our study reports no major benefit for the inclusion of ADM with respect to implant rippling, capsular contracture, explantation, need for additional revision surgeries, and patient-reported satisfaction in prepectoral second-stage implant-based breast reconstruction.

A Comparison of Postoperative Outcomes between Unilateral and Bilateral Palatoplasty: Analysis of 2015-2020 Pediatric NSQIP Data.

OBJECTIVE: We sought to identify differences in 30-day medical and surgical complications in unilateral versus bilateral palatoplasty. DESIGN: The NSQIP-P 2015-2020 database was queried to identify cleft palate repairs using CPT codes. Cases were stratified as unilateral (Veau III) and bilateral (Veau IV) using ICD-9 and -10 codes. SETTING: A nationally representative random sample. PATIENTS/PARTICIPANTS: A total of 3791 cases were identified with 2608 undergoing unilateral repair and 1183 undergoing bilateral repair. MAIN OUTCOMES/MEASURES: The postoperative outcomes of interest included surgical complications (surgical site infections, wound dehiscence), medical complications (pneumonia, urinary tract infection, seizure, cardiac arrest, bleeding/transfusions, systemic sepsis, unplanned intubation), readmission, and reoperation. RESULTS: The bilateral cohort was older (696 days versus 619 days, P < .001) and had longer operative times (157.3 min versus 144.5 min, P < .001). The unilateral cohort had more comorbidities including developmental delay, structural CNS abnormalities, need for nutritional support, and bleeding disorders. The bilateral cohort had statistically significant higher occurrences of wound dehiscence (2.1% versus. 1.2%, P = .03) and readmission (3.2% versus 1.7%, P = .01). On multivariate analysis, bilateral cleft repair (OR: 1.83, CI: 1.176-2.840, P = .007) and ASA class 4 (OR: 13.1, CI 2.288- 62.586, P = .002) were associated with greater odds of readmission. CONCLUSION: Patients who underwent bilateral cleft repair had a higher proportion of 30-day postoperative complications and a two-fold increased odds of readmission. While palatoplasty is generally regarded as a safe procedure in the pediatric population, identifying factors related to an increased risk of early postoperative complications can help surgical teams better manage high-risk individuals.

An Evaluation of Early Complications after Prepectoral Tissue Expander Placement in First-Stage Breast Reconstruction with and without Acellular Dermal Matrix.

PURPOSE: Prepectoral breast reconstruction has become popularized with the concurrent use of acellular dermal matrix (ADM). We sought to compare three-month postoperative complication rates and explantation rates for first stage, tissue expander based prepectoral breast reconstruction with and without the use of ADM. METHODS: A single institution retrospective chart review was performed to identify consecutive patients undergoing prepectoral tissue-expander based breast reconstruction from August 2020 to January 2022. Chi-squared tests were used to compare demographic categorical variables and multiple variable regression models were used to identify variables associated with three-month postoperative outcomes. RESULTS: We enrolled 124 consecutive patients. Fifty-five patients (98 breasts) were included in the no-ADM cohort and 69 patients (98 breasts) were included in the ADM cohort. There were no statistically significant differences between ADM and no-ADM cohort in regard to 90-day postoperative outcomes. On multivariable analysis, there were no independent associations between seroma, hematoma, wound dehiscence, mastectomy skin flap necrosis, infection, unplanned return to the OR, or explanation in the ADM or no ADM groups after controlling for age, BMI, history of diabetes, tobacco use, neoadjuvant chemotherapy, and postoperative radiotherapy. CONCLUSION: Our results reveal no significant differences in odds of postoperative complications, unplanned return to the OR, or explantation between ADM and no-ADM cohorts. More studies are needed to evaluate the safety of prepectoral, tissue expander placement without ADM.

Serum procalcitonin level is independently associated with mechanical ventilation and case-fatality in hospitalized COVID-19-positive US veterans-A potential marker for disease severity.

The Coronavirus-19 disease (COVID-19) has claimed over 6.8 million lives since first being reported in late 2019. The virus that causes COVID-19 disease is highly contagious and spreads rapidly. To date, there are no approved prognostic tools that could predict why some patients develop severe or fatal disease outcomes. Early COVID-19 studies found an association between procalcitonin (PCT) and hospitalization or duration of mechanical ventilation and death but were limited by the cohort sizes. Therefore, this study was designed to confirm the associations of PCT with COVID-19 disease severity outcomes in a large cohort. For this retrospective data analysis study, 27,154 COVID-19-positive US veterans with post-infection PCT laboratory test data and their disease severity outcomes were accessed using the VA electronic healthcare data. Cox regression models were used to test the association between serum PCT levels and disease outcomes while controlling for demographics and relevant confounding variables. The models demonstrated increasing disease severity (ventilation and death) with increasing PCT levels. For PCT serum levels above 0.20 ng/ml, the unadjusted risk increased nearly 2.3-fold for mechanical ventilation (hazard ratio, HR, 2.26, 95%CI: 2.11-2.42) and in-hospital death (HR, 2.28, 95%CI: 2.16-2.41). Even when adjusted for demographics, diabetes, pneumonia, antibiotic use, white blood cell count, and serum C-reactive protein levels, the risks remained relatively high for mechanical ventilation (HR, 1.80, 95%CI: 1.67-1.94) and death (HR, 1.76, 95%CI: 1.66-1.87). These data suggest that higher PCT levels have independent associations with ventilation and in-hospital death in veterans with COVID-19 disease, validating previous findings. The data suggested that serum PCT level may be a promising prognostic tool for COVID-19 severity assessment and should be further evaluated in a prospective clinical trial.

A Comparison of Postoperative Outcomes Between Immediate, Delayed Immediate, and Delayed Autologous Free Flap Breast Reconstruction: Analysis of 2010-2020 NSQIP Data.

BACKGROUND: While many factors influence decisions related to the timing between mastectomy and flap-based breast reconstruction, there is limited literature comparing postoperative complications between immediate (IBR), delayed immediate (DIBR), and delayed (DBR) reconstruction modalities. Using the National Surgical Quality Improvement Program (NSQIP), we sought to compare postoperative complication rates of each timing modality. METHODS: The NSQIP 2010-2020 database was queried for patients who underwent free flap breast reconstruction. Cases were categorized to include mastectomy performed concurrently with a free flap reconstruction, removal of a tissue expander with free flap reconstruction, and free flap reconstruction alone which are defined as IBR, DIBR, and DBR, respectively. The frequency of postoperative outcomes including surgical site infection (SSI), wound dehiscence, intraoperative transfusion, deep venous thrombosis (DVT), and return to operating room (OR) was assessed. Overall complication rates, hospital length of stay (LOS), and operative time were analyzed. Multivariable regression analysis controlling for age, race, BMI, diabetes, hypertension, ASA class, and laterality was performed. RESULTS: A total of 7,907 cases that underwent IBR, DIBR (n = 976), and DBR reconstruction (n = 6,713) were identified. No statistical difference in occurrence of SSIs, wound dehiscence, or DVT was identified. DIBR (9%) and DBR (11.9%) were associated with less occurrences of reoperation than IBR (13.2%, p < 0.001). Univariate and multivariate regression analysis demonstrated that DIBR and DBR were associated with a lower odds of complications and shorter operation time versus IBR. No statistically significant differences between DIBR and DBR in surgical complications, LOS, and operative time were identified. CONCLUSION: Awareness of overall complication rates associated with each reconstructive timing modality can be used to help guide physicians when discussing reconstructive options. Our data suggests that DIBR and DBR are associated with less overall complications than IBR. Physicians should continue to consider patients' unique circumstances when deciding upon which timing modality is appropriate.

Masseter-to-facial nerve transfer for facial nerve reanimation.

Smooth symmetric facial muscle function is important for social interactions. When lesions of the facial nerve occur, achieving complete restoration of balanced and spontaneous facial function can be challenging. In this video, the authors demonstrate the surgical details and long-term follow-up of a masseter-to-facial nerve transfer in a 3-year-old girl who had insidious onset of a left facial palsy due to a facial nerve schwannoma. After resection, she underwent distal nerve repair with a masseter-to-zygomatic branch transfer. She demonstrated decreased lagophthalmos and good activation and excursion on the left side with near symmetry to the right side, but lacked left frontalis function. The video can be found here: https://stream.cadmore.media/r10.3171/2022.9.FOCVID22107.

Analysis of Readmissions and Reoperations in Pediatric Microvascular Reconstruction.

BACKGROUND: Free tissue transfer is utilized as a reconstructive option for various anatomic defects. While it has long been performed in adults, reconstructive surgeons have used free tissue transfer to a lesser degree in children. As such, there are few analyses of factors associated with complications in free tissue transfer within this population. The aim of this study is to assess factors associated with readmission and reoperation in pediatric free flap patients utilizing the pediatric National Surgical Quality Improvement Program database. METHODS: Pediatric patients who underwent microvascular reconstruction between 2015 and 2020 were included. Patients were identified by five microvascular reconstruction Current Procedural Terminology codes and were then stratified by flap site (head and neck, extremities, trunk) and defect etiology (congenital, trauma, infection, neoplasm). Multivariate logistic regression was performed to identify factors associated with readmissions and reoperations. RESULTS: The study cohort consisted of 258 patients. The average age was 10.0 ± 4.7 years and the majority of patients were male (n = 149, 57.8%), were of white race (n = 164, 63.6%), and had a normal body mass index. Twenty-two patients (8.5%) experienced an unplanned readmission within 30 days of the initial operation, most commonly for wound disruption (31.8% of readmissions). The overall rate of unplanned reoperation within 30 days was 11.6% (n = 30) for all patients, with an average of 8.9 ± 7.5 days to reoperation. On multivariate regression analysis, each hour increase in operative time was associated with an increased odds of reoperation (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.12, 1.45) and readmission (OR: 1.16; 95% CI: 1.02, 1.34). CONCLUSION: In pediatric patients undergoing free tissue transfer, higher readmission and reoperation risk was associated with longer operative duration. Overall, free tissue transfer is safe in the pediatric population with relatively low rates of readmission and reoperation.

The BREASTrial Stage III: Acellular Dermal Matrix Breast Reconstruction Outcomes from 3 Months to 2 Years Postoperatively.

BACKGROUND: The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial (BREASTrial) is a blinded, randomized trial comparing the outcomes of tissue expander breast reconstruction using AlloDerm or DermaMatrix. In this final stage of the trial, outcomes 3 months to 2 years after definitive reconstruction are reported along with patient satisfaction data. METHODS: A randomized trial was conducted to compare complication rates between groups of patients who underwent reconstruction with AlloDerm and DermaMatrix. Regression models were used to analyze the impact of matrix type, age, chemotherapy, radiation therapy, and reconstructive type on complication rates. Premastectomy and postmastectomy questionnaires were used to assess patient satisfaction and were also analyzed using regression models. RESULTS: Of the 128 patients (199 breasts) who were randomized in the trial, 108 patients (167 breasts) were available for analysis in stage III. There was no difference in the overall complication rates between the AlloDerm and DermaMatrix groups (6% versus 13.2%; P = 0.3) or the severity of those complications ( P = 0.7). Obesity was a positive predictor for complications, regardless of reconstruction group ( P = 0.02). Patient satisfaction was positive overall and did not grossly vary between AlloDerm and DermaMatrix groups. CONCLUSIONS: Findings from the BREASTrial conclude that AlloDerm and DermaMatrix exhibit similar histologic and clinical outcomes. Patient satisfaction is also similar between matrices. Obesity is a predictor of complications, and acellular dermal matrices should be used with caution in these patients. As the largest head-to-head trial comparing two acellular dermal matrices, the BREASTrial contributes to the fund of knowledge regarding acellular dermal matrix supplementation in breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A Nationwide Analysis Evaluating the Safety of Using Acellular Dermal Matrix with Tissue Expander-Based Breast Reconstruction.

Background In March 2021, the United States Food and Drug Administration (FDA) safety communication cautioned against the use of acellular dermal matrix (ADM) products in breast reconstruction and reiterated that the FDA does not approve ADM use in breast surgery. This study aims to assess the safety of ADM use in breast reconstruction. Methods Women who underwent ADM and non-ADM assisted tissue expander (TE)-based breast reconstruction were identified using the National Surgical Quality Improvement Program database (2012-2019). Trends of ADM use over time, and 30-day outcomes of surgical site infection (SSI), dehiscence, and unplanned reoperation were assessed. Results Of the 49,049 TE-based breast reconstructive cases, 42.4% were ADM assisted and 57.6% non-ADM assisted. From 2012 to 2019, the use of ADM increased from 26.1 to 55.6% (relative risk [RR] =1.10; p < 0.01). Higher rates of SSI (3.9 vs. 3.4%; p = 0.003) and reoperation (7.4 vs. 6.0%; p < 0.001) were seen in the ADM cohort. There was no significant difference seen in dehiscence rates (0.7 vs. 0.7%; p = 0.73). The most common reoperation within 30 days for the ADM group (17.6%) was removal of TE without insertion of implant (current procedural terminology: 11,971). ADM-assisted breast reconstruction was associated with increased relative risk of SSI by 10% (RR = 1.10, confidence interval [CI]: 1.01-1.21; p = 0.03) and reoperation by 15% (RR = 1.15, CI: 1.08-1.23; p < 0.001). Conclusions ADM-assisted breast reconstruction more than doubled from 2012 to 2019. There are statistically higher complication rates of SSI (0.5%) and reoperation (1.4%) with ADM use in TE-based breast reconstruction, suggesting that reconstruction without ADM is safe when comparing immediate postoperative outcomes.

Comparison of Human, Porcine, and Bovine Acellular Dermal Matrix in Prepectoral Breast Reconstruction: A Scoping Review.

OBJECTIVE: The aim of the study is to determine rates of overall complications and failure of prepectoral breast reconstruction between various types of acellular dermal matrices (ADMs). BACKGROUND: Implant-based breast reconstruction is the most common reconstructive technique after mastectomy in the United States. Traditionally, the reconstruction has been performed in the subpectoral plane; however, there has been an emerging interest in prepectoral reconstruction using ADM. Human (hADM), porcine (pADM), and bovine (bADM) ADMs are available for use, but little is known about the benefits and complication profiles of each for prepectoral breast reconstruction. METHODS: Studies examining complications after the use of ADM for prepectoral breast reconstruction were identified using MEDLINE, Embase, the Cochrane Library, LILACS, and the Web of Science from January 2010 to August 2021. Titles and abstracts of 1838 studies were screened, followed by full-text screening of 355 articles. Thirty-three studies were found to meet inclusion criteria. RESULTS: From the 33 studies, 6046 prepectoral reconstructions were examined. Implant loss was comparable across the different types of ADM (pADM, 4.0%; hADM, 4.0%; bADM, 3.7%). Bovine ADM had the highest rate of capsular contracture (6.1%), infection (9.0%), skin flap necrosis (8.3%), dehiscence (5.4%), and hematoma (6.1%) when compared with both hADM and pADM. Human ADM had the highest rate of postoperative seroma (5.3%), followed by pADM (4.6%) and bADM (4.5%). CONCLUSIONS: Among the prepectoral breast reconstruction studies using hADM, pADM, or bADM included in our analysis, complication profiles were similar. Bovine ADM had the highest proportion of breast complications in the following categories: capsular contracture, infection rate, skin flap necrosis, dehiscence, and hematoma. Implant loss was comparable across the cohorts. Overall, prepectoral breast reconstruction using ADM leads to relatively low complication rates with the highest rates within the bADM cohort.

Meshed Acellular Dermal Matrix for Two-Staged Prepectoral Breast Reconstruction: An Institutional Experience.

The introduction of acellular dermal matrix (ADM) to breast reconstruction has allowed surgeons to reexplore the prepectoral implant placement technique in postmastectomy breast reconstruction. Our institution adopted a novel approach using meshed ADM to lessen the financial burden of increased ADM utilization with the prepectoral breast reconstruction. This is a retrospective, single-center review of two-stage prepectoral breast reconstruction using meshed human-derived ADM for anterior prosthesis coverage. Patient demographics, oncologic data, perioperative characteristics, and complications were examined and reported as means with standard deviations. Cost-saving with the meshed technique was evaluated. Forty-eight patients (72 breasts) with a mean age of 48.5 ± 15.0 years (range 26-70 years) were included in the study. The mean follow-up time was 13.2 ± 4.4 months (range 4.1-25.8 months). Nineteen breasts (24.6%) experienced complications, with seromas being the most common complication (12.5%, n = 9). Expander removal and reoperation occurred at a rate of 8.3 and 9.7%, respectively. The average time to drain removal was 18.8 ± 6.6 days (range 8-32 days). Meshed ADM provided an average cost savings of $6,601 for unilateral and $13,202 for bilateral reconstructions. Our study found that human-derived meshed ADM can be safely used in two-staged prepectoral tissue expander-based breast reconstruction and can result in significant cost savings.

Free Vascularized Fibula Salvage of Failed CPH in Pediatric Sarcoma Patients.

Background: Due to extended life expectancy and recent improvements in surgical techniques, limb salvage has replaced amputation as the gold standard and is now performed in 90-95% of upper extremity malignancies. However, many of these salvage procedures are associated with significant postsurgical complications. In particular, the clavicula pro humero (CPH) procedure is associated with high rates of nonunion. We present our experience with upper extremity salvage using the free vascularized fibular flap (VFF) after failure or nonunion of the original CPH procedure in the pediatric population. Methods: Five patients under the age of 18 diagnosed with upper extremity sarcoma who underwent tumor resection with immediate CPH reconstruction complicated with nonunion, and subsequent revision with free VFF were included. Data on patient demographics, oncologic characteristics, surgical procedures, intraoperative details, postoperative complications, and time to graft union were recorded. Results: Five patients (average age = 8.4 years; range = 5-10 years at surgery date) underwent secondary limb salvage procedure with free VFF reconstruction following failed CPH reconstruction for proximal humeral osteosarcoma (n = 4) or Ewing sarcoma (n = 1). The mean follow-up was 3.7 years. Complications occurred in five patients (100%), with three patients requiring reoperation (60%). Four patients achieved graft union (average union time = 3.7 months) and successful limb reconstruction. Four patients were alive with no local recurrence of the disease. One patient did not achieve union and was lost to follow-up. Conclusion: Primary bone tumors in the pediatric population require wide surgical resection, and reconstruction often has high complication rates that can warrant further procedures. A free VFF is a viable option for upper extremity salvage after previously failed reconstructions because it provides vascularized tissue to a scarred tissue bed and allows for the replacement or augmentation of large bony defects.

Hospitalization, mechanical ventilation, and case-fatality outcomes in US veterans with COVID-19 disease between years 2020-2021.

PURPOSE: Although veterans represent a significant proportion (7%) of the USA population, the COVID-19 disease impact within this group has been underreported. To bridge this gap, this study was undertaken. METHOD: A total of 419,559 veterans, who tested positive for COVID-19 disease in the Veterans Affairs hospital system from March 1st, 2020 to December 31st, 2021 with 60-days follow-up, was included in this retrospective review. Primary outcome measures included age-adjusted incidences and relative incidences of COVID-19 hospitalization, mechanical ventilation, and case-fatality outcomes. RESULTS: Of this veteran cohort with COVID-19 disease, predominately 85.7% were male, 59.1% were White veterans, 27.5% were ages 50-64, and 40.5% were obese. Although Black veterans were at 63% higher relative risk (RR) for hospitalization incidences, they had a similar risk RR for in-hospital deaths compared to the White-veteran referent. Asian, American Indian/Alaska Native races, advanced age ≥65, and the underweight were at high RR for mechanical ventilator and/or in-hospital deaths compared to respective referent groups. Veterans who are ≥85 years old had a nearly 5-fold higher incidence of death compared respective referent group. The monthly outcomes for hospitalization, ventilation, and case-fatality data showed decreasing trends with time. CONCLUSION: An increased incidence of death was associated with age ≥65 years and underweight veterans compared to the referent group. Age-adjusted data, however, did not show any increased incidence of death in Black veterans compared to White veterans. RATINGS OF THE QUALITY OF THE EVIDENCE: 3 (Case-control studies; retrospective cohort study).

Characteristics of Nonelderly Adult Health Care Persistent Super Utilizers in Utah.

In the United States, the top 1% and top 5% of health care spenders account for 23% and 50% of total health care spending, respectively. These high spenders have been coined the term super utilizers (SU). The aim of this study was to identify the characteristics associated with these patients to aid in developing public health interventions aimed at transitioning patients out of the SU category and thus ultimately helping to control health care costs. The authors utilized the Utah All-Payer Claims Database and Utah Population Database from 2013 to 2015 to identify demographics, comorbid conditions, health care utilization, and cost characteristics of persistent super utilizers (PSU) (≥3 hospitalizations per year for 3 years) of health care compared with persistent nonsuper utilizers (PNSU) (<3 hospitalizations per year for 3 years). Multivariable logistic regression was utilized to identify the characteristics associated with PSU versus PNSU. Higher outpatient/Emergency Department/noninpatient (eg, visits with imaging and Centers for Medicare & Medicaid Services preventive visits) health care utilization and spending, and prevalence of comorbid disease and psychosocial conditions were associated with PSU. In multivariable analysis, factors such as heart disease, chronic kidney disease (CKD), diabetes, alcohol abuse, and depression were statistically significantly associated with higher odds of PSU, with the most noteworthy being CKD (odds ratio [OR] 6.85, 95% confidence interval [95% CI] 5.84-8.02; P < 0.001), alcohol abuse (OR 5.90, 95% CI 4.49-7.69; P < 0.001), and heart diseases (OR 4.41, 95% CI 3.74-5.18; P < 0.001). The annual health care cost of a PSU is about 11.5 times greater than a PNSU ($54,776 vs. $4801; P < 0.001).

Impact of Chemotherapy and Radiation Therapy on Inflammatory Response, Neovascularization, and Capsule Formation of Acellular Dermal Matrix in Breast Reconstruction: Analysis of the BREASTrial Biopsy Specimens.

BACKGROUND: The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial is a single-center, blinded, prospective, randomized, controlled trial established to compare outcomes using two popular types of acellular dermal matrices, AlloDerm and DermaMatrix, in tissue expander breast reconstruction. This study used the acellular dermal matrix biopsy specimens from the trial to evaluate how adjuvant therapy influences inflammation, neovascularization, and capsule formation of the acellular dermal matrix. METHODS: Punch biopsy specimens were taken at the time of expander exchange and were analyzed by a blinded pathologist. The inflammatory response was quantified by the number of fibroblasts, giant cells, and lymphocytes. Neovascularization and capsule formation were similarly quantified by the number of new capillaries and capsule presence and thickness, respectively. RESULTS: Histology specimens were collected from 109 patients (170 breasts). In the absence of adjuvant therapy, there was no significant difference between AlloDerm and DermaMatrix in terms of inflammation, neovascularization, or capsule thickness. Both acellular dermal matrices showed a significant decrease in inflammation and neovascularization with adjuvant therapy. When chemotherapy and radiation therapy were used, the decrease in inflammation was greatest for the group reconstructed with DermaMatrix (p < 0.039). CONCLUSIONS: Adjuvant therapy influences the inflammatory response, neovascularization, and capsule formation in both acellular dermal matrices. Adjuvant therapy has a protective effect on the inflammatory response toward both acellular dermal matrices in breast reconstruction. In the setting of chemotherapy and radiation therapy, DermaMatrix produced the greatest reduction in inflammation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Transverse Rectus Abdominis Muscle Flow-Through to Free Fibula Flap for Lumbar Spinal Reconstruction in a Pediatric Patient: A Case Report.

CASE: A 7-week-old girl presented with a recurrent primitive myxoid mesenchymal tumor of infancy requiring extensive resection of lower back musculature, L3-S2 vertebral bodies, and left L5 nerve root. Reconstruction consisted of transverse rectus abdominis muscle (TRAM) flow-through to free fibular flap to reconstruct the bony defect and fill the soft-tissue void. One-year postoperative imaging revealed a well-incorporated fibula graft. At the 30-month follow-up, the patient can bear weight on the autograft while sitting upright, allowing for efficient ambulation with a wheelchair. CONCLUSION: TRAM flow-through to free fibular flap is an efficacious reconstructive method for a multilevel vertebral spinal defect in a pediatric patient.