Free Fibula Flap for Extremity Oncologic Defects: Factors Influencing Union and Functional Outcomes.

BACKGROUND: The goal of this study was to evaluate outcomes after vascularized bone flap (VBF) reconstruction of oncologic bony extremity defects. A secondary goal was to compare union rates based on various insetting methods, including onlay, intermedullary, and intercalary. METHODS: The authors conducted a retrospective review of consecutive patients who received an extremity reconstruction with a fibula flap after oncologic resection between 2001 and 2019. RESULTS: The authors identified a total of 60 fibular VBFs in 55 patients (67% lower extremity, 33% upper extremity). The overall union rate was 91.7% (55 of 60). For lower extremity reconstructions, the mean time to full weightbearing was 16 months (range, 4 to 44 months). Fibula VBFs were onlay in 65% of cases, intercalary in 23%, and intramedullary in 12%. Forty-three percent of patients required a reoperation as a result of a surgical complication. Immediate femur reconstruction subgroup analysis demonstrated that onlay fibula flap orientation was associated with a significantly increased risk for any complication (odds ratio, 6.3; 95% CI, 1.4 to 28.7; P = 0.03) as well as an increased risk for requiring conversion to endoprostheses because of nonunion (OR, 12.1; 90% CI, 1.03 to 143.5; P = 0.03) compared with intramedullary placement. CONCLUSIONS: The free vascularized fibula flap is a reliable option for functional reconstruction of any long bone extremity defect, but complications in these complex procedures are not uncommon. In patients with immediate femur reconstructions, intramedullary fibula placement was associated with significantly lower complication and lower metallic implant conversion rates and a trend toward a more rapid early union compared with onlay VBF. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Incidence of Readmission Following Pediatric Hand Surgery: An Analysis of 6600 Patients.

Background: Quality in surgical outcomes is frequently assessed by the 30-day readmission rate. There are limited data available in the published literature regarding readmission rates following pediatric hand surgery. This study aims to identify factors associated with an increased risk of readmission following hand surgery in a pediatric population. Methods: The 2012-2017 National Surgical Quality Improvement Project - Pediatric (NSQIP-P) databases were queried for pediatric patients who underwent procedures with hand-specific current procedural terminology (CPT) codes. The primary outcome was readmission. Results: A total of 6600 pediatric patients were identified and included in the analysis. There were 45 patients who were readmitted in the study cohort, giving an overall readmission rate of 0.68%. The median time to readmission was 12 (IQR 5-20) days. On univariate analysis, factors associated with readmission included younger age, smaller size, prematurity, higher American Society of Anesthesiologists (ASA) class, inpatient admission at index operation, and longer anesthesia and operative times. Complex syndactyly repair was also associated with higher readmission rates. On multivariate analysis, ASA class 3 or 4 and inpatient surgery remained significant predictors of readmission. Conclusions: Overall, pediatric hand surgery is associated with a very low risk of 30-day readmission. Higher ASA class and inpatient surgery increase patients' risk for readmission. In particular, complex syndactyly repair is associated with a higher risk of readmission than other hand procedures. This information is useful in surgical planning and preoperative counseling of parents.

Impact of Cardiac Risk Factors in the Postsurgical Outcomes of Patients With Cleft Lip.

ABSTRACT: Congenital cardiac comorbidities represent a potentially elevated risk for complications in patients undergoing cleft lip repair. National databases, such as the National Surgical Quality Improvement Program Pediatric (NSQIP-P) allow for analysis of large national datasets to assess these risks and potential complications. The aim of this study is to assess the risk of complications in patients undergoing cleft lip repair with congenital cardiac co-morbidities using the NSQIP-P.The 2012 to 2014 NSQIP-P databases were queried for patients undergoing cleft lip repair. Data abstracted for analysis included demographic, clinical, and outcomes data. Patients with cleft lip were stratified based on the presence or absence of congenital cardiac comorbidities. Univariate analysis and step-wise, forward logistic regression were performed to compare these groups.Nationally, between 2012 and 2014, 2126 patients underwent cleft lip repair, 227 with cardiac disease, and 1899 without cardiac disease. Weights were similar between the groups at the time of surgery, though patients with cardiac comorbidities were older. Postoperatively, cardiac disease patients were more likely to experience an adverse event. Specifically, they were more likely to experience reintubation, reoperation, longer length of stay, and death. Rates of surgical site infection and dehiscence were not different between the groups.This study demonstrates that cleft lip repair in patients with congenital heart defects is safe. However, patients undergoing cleft lip repair with comorbid congenital cardiac disease were more likely to experience adverse events. Cardiac patients require special preoperative evaluation before repair of their cleft lip, but do not appear to experience worse wound-related outcomes.

Ulnar Artery Aneurysm as a Late Sequela of Marfan Syndrome.

Marfan syndrome (MFS) is a connective tissue disorder caused by mutations of the FBN1 gene encoding fibrillin-1, which leads to overexpression of transforming growth factor-ß, increased hyaluronan deposition, and matrix metalloproteinase activity in the media of the aorta and other muscular arteries. Marfan syndrome patients present with connective tissue laxity and aneurysmal changes to muscular arteries. Successful medical and surgical intervention has prolonged the life expectancy of MFS patients, which can allow atypical presentations of the syndrome to manifest. We present a case of a 49-year-old man with MFS who developed an ulnar artery aneurysm that was treated by excision and vein grafting.

Cervical Spine Injuries in Pediatric Maxillofacial Trauma: An Under-Recognized Problem.

Pediatric cervical spine injuries (CSI) are uncommon events, but can be devastating injuries. Facial fractures have been associated with injuries to the cervical spine in children, but may be deemed isolated facial fractures and bypass the standard trauma pathway. The objective of this study is to describe the mechanisms, associated injuries and outcomes of pediatric cervical spine injuries in patients with known maxillofacial trauma at a level 1 trauma center. An analysis was performed of all patients under the age of 18 with maxillofacial trauma admissions to a single level 1 trauma center, from 2006 to 2015. Patients were stratified based on the presence or absence of a cervical spine injury. Data was abstracted to include demographic, mechanism and clinical outcomes data. There were 1274 patients who were admitted with maxillofacial trauma during the study period. Of these, 72 (5.7%) experienced a cervical spine injury. Factors associated with cervical spine injuries include older age and penetrating mechanism. Cervical spine injuries were associated with concomitant traumatic brain injuries and skull fractures. Patients with spine injuries were more like to experience a longer length of stay and death. On multivariate analysis, only increased age predicted CSI. Our database demonstrated a 5.7% incidence of pediatric cervical spine injuries in patients with maxillofacial trauma. This incidence is higher than previously published reports of smaller cohorts. Clinicians must take care to stabilize the cervical spine in any patient with facial fractures, especially during work up and diagnostic maneuvers performed before spinal injuries are ruled out.

Impact of Cardiac Risk Factors in the Postsurgical Outcomes of Patients With Cleft Palate: Analysis of the 2012-2014 NSQIP Database.

OBJECTIVE: To assess the risk of complication in patients undergoing cleft palate repair with congenital cardiac comorbidities in a large, national cohort. DESIGN: Retrospective review. PATIENTS/SETTING: Using the 2012-2014 National Surgical Quality Improvement Program (NSQIP) Pediatric database, patients undergoing cleft palate repair were selected for analysis. Patients with cleft palate repairs were stratified based on the presence or absence congenital cardiac comorbidities. Univariate and stepwise forward logistic regression were conducted. MAIN OUTCOME MEASURES: It is hypothesized that risk of postoperative adverse events in patients with congenital cardiac comorbidities is higher than in patients without cardiac disease. RESULTS: Nationally, between 2012 and 2014, 3240 patients underwent cleft palate repair, 422 (13.0%) with cardiac disease, and 2818 (87.0%) without cardiac disease. Patients with cardiac disease were smaller (10.5 [6.6] kg vs 11.6 [8.6] kg, P < .01) and more likely to be premature (4.6% vs 13.0%, P < .01) compared to those without cardiac disease. Postoperatively, patients with cardiac conditions were more likely to experience an adverse event (8.8% vs 4.2%, P < .01). Specifically, they were more likely to experience reintubation (1.7% vs 0.4%, P < .01), reoperation (2.1% vs 0.6%, P < .01), and longer length of stay (2.7 [7.0] vs 1.6 [2.8] days, P < .01). Rates of surgical site infection and dehiscence were not different. CONCLUSIONS: Cleft palate repair in patients with concurrent congenital cardiac defects is a safe procedure but carries elevated risk in the postoperative period as demonstrated in this analysis of the NSQIP-Pediatric database. Technical risks are equivalent. Additional anesthesia and surgical awareness of these potential complications is essential to minimize perianesthesia risks.

Use of REBOA to stabilize in-hospital iatrogenic intra-abdominal hemorrhage.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become an increasingly popular alternative to emergency thoracotomy and aortic cross-clamping in patients with exsanguinating hemorrhage.1 This new capability is increasingly being used in non-trauma situations.2 3 This report demonstrates another novel use of REBOA for iatrogenic intra-abdominal hemorrhage. An 83-year-old man with multiple medical comorbidities and a history of chronic mesenteric ischemia was admitted to our institution for an elective mesenteric revascularization. Revascularization was unsuccessful, despite attempts to cross the lesion. Postprocedure, the patient developed a right groin hematoma, and CT on postprocedure day 0 demonstrated a femoral artery pseudoaneurysm and subintimal contrast at the level of the celiac artery, representing an iatrogenic dissection. The following day, he complained of dizziness. Physical examination revealed a blood pressure of 68/35 mm Hg, heart rate of 100 beats per minute, and a distended abdomen. Because the surgical intensive care unit (SICU) was full, he was transferred to the neurotrauma intesive care unit (NTICU) and intubated for hemodynamic instability. A chest X-ray revealed a prior thoracic endovascular aortic repair (figure 1), but no intrathoracic hemorrhage or pathology. Bedside ultrasonography revealed intra-abdominal fluid. Laboratory workup showed hemoglobin of 6.1 g/dL, from 10.9 the previous day. The patient was given two units of packed red blood cells, without response. The intensive care unit (ICU) team initiated norepinephrine, with minimal improvement despite increasing doses. Figure 1Chest X-ray with catheter in zone 1. Arrows mark the proximal and distal markers of the resuscitative endovascular balloon occlusion of the aorta. WHAT WOULD YOU DO?: Transfuse two units of packed red blood cells and observe.Proceed to the operating room (OR) for exploratory laparotomy.Endovascular balloon occlusion of the aorta (zone 1).

Is There a Higher Risk of Mother-to-child Transmission of HIV Among Pregnant Women With Perinatal HIV Infection?

Cases of mother-to-child-transmission in the Surveillance Monitoring of ART Toxicities Study of Pediatric HIV/AIDS Cohort Study were identified from 2007 to 2015. Among 2123 births, 9 infants were HIV infected, giving a mother-to-child-transmission rate of 0.5% (95% confidence interval: 0.3%-1.0%). Mothers with perinatal HIV infections had a higher mother-to-child-transmission rate (1.1%; 95% confidence interval: 0.3%-4.3%) than mothers without perinatal HIV infections (0.4%; 95% confidence interval: 0.2%-1.0%), associated with a greater likelihood of detectable viral load at delivery.

Preoperative Glycosylated Hemoglobin and Postoperative Glucose Together Predict Major Complications after Abdominal Surgery.

BACKGROUND: Glycosylated hemoglobin (HbA1c) is diagnostic of and a measure of the quality of control of diabetes mellitus. Both HbA1c and perioperative hyperglycemia have been targeted as modifiable risk factors for postoperative complications. The HbA1c percent cutoff that best predicts major complications has not been defined. STUDY DESIGN: A prospective study of all abdominal operations from a single institution from 2007 to 2010 was performed. All patients with HbA1c within 3 months before surgery were included. The primary end point was major complication, using the Clavien-Dindo complication system, within 30 days of surgery. Stepwise, multivariate analysis was performed including clinically relevant variables chosen a priori. RESULTS: Among 438 patients who had a measured HbA1c, 96 (21.9%) experienced a major complication. On multivariate analysis, HbA1c ≥ 6.5% (odds ratio = 1.95; 95% CI, 1.17-3.24; p = 0.01) was found to be the most significant predictor of major complications. Glyosylated hemoglobin and glucose were strongly correlated (correlation coefficient 0.414, p < 0.01). Predicted probabilities demonstrated that both HbA1c and glucose together contributed to major complications; and HbA1c impacted the ability to achieve optimal perioperative glucose control. Patients with a BMI >30 kg/m(2), history of coronary artery disease, and nonwhite race were more likely to have a HbA1c ≥ 6.5%. CONCLUSIONS: Elevated HbA1c ≥ 6.5% and perioperative hyperglycemia were associated with an increased rate of major complications after abdominal surgery. Elevated peak postoperative glucose levels were correlated with elevated HbA1c and were independently associated with major complications. More liberal HbA1c testing should be considered in high-risk patients before elective surgery. Safe, feasible, and effective strategies to reduce both HbA1c and perioperative hyperglycemia need to be developed to optimize patient outcomes.

External validation of the ventral hernia risk score for prediction of surgical site infections.

BACKGROUND: Previously, we reported that the Ventral Hernia Risk Score (VHRS) was more accurate in a Veterans Affairs (VA) population in predicting surgical site infection (SSI) after open ventral hernia repair (VHR) compared with other models such as the Ventral Hernia Working Group (VHWG) model. The VHRS was developed using single-center data and stratifies SSI risk into five groups based on concomitant hernia repair, skin flaps created, American Society of Anesthesiologists (ASA) score ≥3, body mass index ≥40 kg/m(2), and incision class 4. The purpose of this study was to validate the VHRS for other hospitals. METHODS: A prospective database of all open VHRs performed at three institutions from 2009-2011 was utilized. All 436 patients with a follow-up of at least 1 mo were included. The U.S. Centers for Disease Control and Prevention (CDC) definition of SSI was utilized. Each patient was assigned a VHRS, VHWG, and CDC incision classification. Receiver-operating characteristic curves were used to assess predictive accuracy, and the areas under the curve (AUCs) were compared for the three risk-stratification systems. RESULTS: The median follow-up was 20 mos (range 1-49 mos). During this time, 111 patients (25.5%) developed a SSI. The AUC of the VHRS (0.73; 95% confidence interval [CI] 0.67-0.78) was greater than that of the VHWG (0.66; 95% CI 0.60-0.72; p<0.01) and the CDC incision class (0.68; 95% CI 0.61-0.74; p<0.05). CONCLUSIONS: The VHRS provides a novel, internally and externally validated score for a patient's likelihood of developing a SSI after open VHR. Elevating skin flaps, ASA score ≥3, concomitant procedures, morbid obesity, and incision class all independently predicted SSI. It remains to be determined if pre-operative patient selection and risk reduction, surgical techniques, and post-operative management can improve outcomes in the highest-risk patients. The VHRS provides a starting point for key stakeholders to discuss the management of ventral hernias.

Development and validation of a risk stratification score for ventral incisional hernia after abdominal surgery: hernia expectation rates in intra-abdominal surgery (the HERNIA Project).

BACKGROUND: Ventral incisional hernias (VIH) develop in up to 20% of patients after abdominal surgery. No widely applicable preoperative risk-assessment tool exists. We aimed to develop and validate a risk-assessment tool to predict VIH after abdominal surgery. STUDY DESIGN: A prospective study of all patients undergoing abdominal surgery was conducted at a single institution from 2008 to 2010. Variables were defined in accordance with the National Surgical Quality Improvement Project, and VIH was determined through clinical and radiographic evaluation. A multivariate Cox proportional hazard model was built from a development cohort (2008 to 2009) to identify predictors of VIH. The HERNIAscore was created by converting the hazards ratios (HR) to points. The predictive accuracy was assessed on the validation cohort (2010) using a receiver operator characteristic curve and calculating the area under the curve (AUC). RESULTS: Of 625 patients followed for a median of 41 months (range 0.3 to 64 months), 93 (13.9%) developed a VIH. The training cohort (n = 428, VIH = 70, 16.4%) identified 4 independent predictors: laparotomy (HR 4.77, 95% CI 2.61 to 8.70) or hand-assisted laparoscopy (HAL, HR 4.00, 95% CI 2.08 to 7.70), COPD (HR 2.35; 95% CI 1.44 to 3.83), and BMI ≥ 25 kg/m(2) (HR1.74; 95% CI 1.04 to 2.91). Factors that were not predictive included age, sex, American Society of Anesthesiologists (ASA) score, albumin, immunosuppression, previous surgery, and suture material or technique. The predictive score had an AUC = 0.77 (95% CI 0.68 to 0.86) using the validation cohort (n = 197, VIH = 23, 11.6%). Using the HERNIAscore: HERNIAscore = 4(∗)Laparotomy+3(∗)HAL+1(∗)COPD+1(∗) BMI ≥ 25, 3 classes stratified the risk of VIH: class I (0 to 3 points),5.2%; class II (4 to 5 points),19.6%; and class III (6 points), 55.0%. CONCLUSIONS: The HERNIAscore accurately identifies patients at increased risk for VIH. Although external validation is needed, this provides a starting point to counsel patients and guide clinical decisions. Increasing the use of laparoscopy, weight-loss programs, community smoking prevention programs, and incisional reinforcement may help reduce rates of VIH.