A Retrospective Review of Differences in Complication Rates between Dorsal Percutaneous and Mini-Open Surgical Fixation of Scaphoid Fractures

Abstract Objective We retrospectively reviewed the complications of 80 cases of scaphoid screw fixation in acute fractures and early nonunions comparing dorsal percutaneous and mini-open approaches. Methods We performed a chart review of all patients who underwent surgical fixation of a scaphoid fracture or a nascent nonunion using a dorsal percutaneous or dorsal mini-open technique by a single surgeon. We collected data on patient demographics, including age and smoking status, time to surgery, fracture type, union, and the major and minor complications that occurred in each group. Fisher's exact tests were used to compare the complication rates between the groups. Results We identified 80 patients who underwent surgical fixation. Of these, 44 underwent percutaneous fixation and 36 underwent mini-open fixation. All fractures went on to heal. There was a total of five complications identified. There were no major complications in the percutaneous group, but one major complication in the mini-open group (a delayed union that eventually healed at 6 months). There were two minor complications in each group. There was no statistically significant difference in total, major, or minor complication rates between the groups. Conclusions This study suggests that a dorsal percutaneous surgical technique for scaphoid fracture repair does not affect the complication rate despite prior literature to the contrary. Both techniques analyzed produce excellent rates of union with very low complication rates. Surgeon-specific technique rather than operative approach or exposure may be responsible for previously reported complication rates in the fixation of scaphoid fractures. Level of Evidence This is a level III, therapeutic study.

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Nonunion Rates in Hind- and Midfoot Arthrodesis in Current, Ex-, and Nonsmokers

Foot & Ankle International ◽

10.1177/1071100720971269 ◽

2020 ◽

pp. 107110072097126

Author(s):

Jack Allport ◽

Jayasree Ramaskandhan ◽

Malik S. Siddique

Keyword(s):

Risk Factor ◽

Cohort Study ◽

Relative Risk ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Smoking Status ◽

Time Frame ◽

Modifiable Risk Factor ◽

Level Of Evidence ◽

Significant Difference

Background: Nonunion rates in hind or midfoot arthrodesis have been reported as high as 41%. The most notable and readily modifiable risk factor that has been identified is smoking. In 2018, 14.4% of the UK population were active smokers. We examined the effect of smoking status on union rates for a large cohort of patients undergoing hind- or midfoot arthrodesis. Methods: In total, 381 consecutive primary joint arthrodeses were identified from a single surgeon’s logbook (analysis performed on a per joint basis, with a triple fusion reported as 3 separate joints). Patients were divided based on self-reported smoking status. Primary outcome was clinical union. Delayed union, infection, and the need for ultrasound bone stimulation were secondary outcomes. Results: Smoking prevalence was 14.0%, and 32.2% were ex-smokers. Groups were comparable for sex, diabetes, and body mass index. Smokers were younger and had fewer comorbidities. Nonunion rates were higher in smokers (relative risk, 5.81; 95% CI, 2.54-13.29; P < .001) with no statistically significant difference between ex-smokers and nonsmokers. Smokers had higher rates of infection ( P = .05) and bone stimulator use ( P < .001). Among smokers, there was a trend toward slower union with heavier smoking ( P = .004). Conclusion: This large retrospective cohort study confirmed previous evidence that smoking has a considerable negative effect on union in arthrodesis. The 5.81 relative risk in a modifiable risk factor is extremely high. Arthrodesis surgery should be undertaken with extreme caution in smokers. Our study shows that after cessation of smoking, the risk returns to normal, but we were unable to quantify the time frame. Level of Evidence: Level III, retrospective cohort study.

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Day case locked anterior plating for distal radial fractures is safe with uninterrupted antithrombotic therapy

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193420966231 ◽

2020 ◽

pp. 175319342096623

Author(s):

James A. Morris ◽

Max Little ◽

Thomas Ashdown ◽

Oliver T. Clough ◽

Timothy Packer ◽

...

Keyword(s):

Wound Dehiscence ◽

Complication Rates ◽

Day Case ◽

Antithrombotic Treatment ◽

Distal Radial Fractures ◽

Level Of Evidence ◽

Excessive Bleeding ◽

Superficial Wound ◽

Surgical Fixation ◽

Anterior Plating

We undertook a matched prospective cohort study over a 4-year period to examine the safety of continuing the administration of regular antithrombotic treatment with warfarin, clopidogrel or aspirin during day case surgical fixation of distal radial fractures. One hundred and one patients were identified and consented to participate in this study. There was only one reported complication: a superficial wound infection treated with antibiotics. No episodes of excessive bleeding were noted intraoperatively. All patients were discharged home on the day of surgery and there were no episodes of readmission, significant bleeding, haematoma requiring intervention, compartment syndrome or wound dehiscence. Complication rates were comparable with those of the matched cohort of patients undergoing the same procedure but who were not taking antithrombotic medications. Level of evidence: IV

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Factors Associated with Scaphoid Nonunion following Early Open Reduction and Internal Fixation

Journal of Wrist Surgery ◽

10.1055/s-0039-3402769 ◽

2020 ◽

Vol 09 (02) ◽

pp. 141-149

Author(s):

Pooja Prabhakar ◽

Lauren Wessel ◽

Joseph Nguyen ◽

Jeffrey Stepan ◽

Michelle Carlson ◽

...

Keyword(s):

Internal Fixation ◽

Open Reduction ◽

Scaphoid Fracture ◽

Receiver Operating Curve ◽

Scaphoid Nonunion ◽

Retrospective Case ◽

Level Of Evidence ◽

Fracture Location ◽

Scaphoid Fractures ◽

Time From Injury

Abstract Background Nonunion after open reduction and internal fixation (ORIF) of scaphoid fractures is reported in 5 to 30% of cases; however, predictors of nonunion are not clearly defined. Objective The purpose of this study is to determine fracture characteristics and surgical factors which may influence progression to nonunion after scaphoid fracture ORIF. Patients and Methods We performed a retrospective case–control study of scaphoid fractures treated by early ORIF between 2003 and 2017. Inclusion criteria were surgical fixation within 6 months from date of injury and postoperative CT with minimum clinical follow-up of 6 months to evaluate healing. Forty-eight patients were included in this study. Nonunion cases were matched by age, sex, and fracture location to patients who progressed to fracture union in the 1:2 ratio. Results This series of 48 patients matched 16 nonunion cases with 32 cases that progressed to union. Fracture location was proximal pole in 15% (7/48) and waist in 85% (41/48). Multivariate regression demonstrated that shorter length of time from injury to initial ORIF and smaller percent of proximal fracture fragment volume were significantly associated with scaphoid nonunion after ORIF (63 vs. 27 days and 34 vs. 40%, respectively). Receiver operating curve analysis revealed that fracture volume below 38% and time from injury to surgery greater than 31 days were associated with nonunion. Conclusion Increased likelihood for nonunion was found when the fracture was treated greater than 31 days from injury and when fracture volume was less than 38% of the entire scaphoid. Level of Evidence This is a Level III, therapeutic study.

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Absence of Association between Preoperative Estimated Glomerular Filtration Rates and Postoperative Outcomes following Elective Gastrointestinal Surgeries: A Prospective Cohort Study

Anesthesiology Research and Practice ◽

10.1155/2018/5710641 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7

Author(s):

Sivesh K. Kamarajah ◽

Behrad Barmayehvar ◽

Mustafa Sowida ◽

Amirul Adlan ◽

Christina Reihill ◽

...

Keyword(s):

Risk Stratification ◽

Glomerular Filtration ◽

Elective Surgery ◽

Gastrointestinal Surgery ◽

Major Complication ◽

Postoperative Outcomes ◽

Queen Elizabeth Hospital ◽

Complication Rates ◽

Significant Difference ◽

The Impact

Background. Preoperative risk stratification and optimising care of patients undergoing elective surgery are important to reduce the risk of postoperative outcomes. Renal dysfunction is becoming increasingly prevalent, but its impact on patients undergoing elective gastrointestinal surgery is unknown although much evidence is available for cardiac surgery. This study aimed to investigate the impact of preoperative estimated glomerular filtration rate (eGFR) and postoperative outcomes in patients undergoing elective gastrointestinal surgeries. Methods. This prospective study included consecutive adult patients undergoing elective gastrointestinal surgeries attending preassessment screening (PAS) clinics at the Queen Elizabeth Hospital Birmingham (QEHB) between July and August 2016. Primary outcome measure was 30-day overall complication rates and secondary outcomes were grade of complications, 30-day readmission rates, and postoperative care setting. Results. This study included 370 patients, of which 11% (41/370) had eGFR of <60 ml/min/1.73 m2. Patients with eGFR < 60 ml/min/1.73 m2 were more likely to have ASA grade 3/4 (p<0.001) and >2 comorbidities (p<0.001). Overall complication rates were 15% (54/370), with no significant difference in overall (p=0.644) and major complication rates (p=0.831) between both groups. In adjusted models, only surgery grade was predictive of overall complications. Preoperative eGFR did not impact on overall complications (HR: 0.89, 95% CI: 0.45–1.54; p=0.2). Conclusions. Preoperative eGFR does not appear to impact on postoperative complications in patients undergoing elective gastrointestinal surgeries, even when stratified by surgery grade. These findings will help preassessment clinics in risk stratification and optimisation of perioperative care of patients.

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Safety of Outpatient Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis

Neurosurgery ◽

10.1093/neuros/nyy636 ◽

2019 ◽

Vol 86 (1) ◽

pp. 30-45 ◽

Cited By ~ 7

Author(s):

Ketan Yerneni ◽

John F Burke ◽

Pranathi Chunduru ◽

Annette M Molinaro ◽

K Daniel Riew ◽

...

Keyword(s):

Safety Profile ◽

Meta Analysis ◽

Anterior Cervical Discectomy ◽

Complication Rates ◽

Outpatient Basis ◽

Level Of Evidence ◽

Cervical Discectomy ◽

Significant Difference ◽

Level I ◽

High Level

ABSTRACT BACKGROUND Anterior cervical discectomy and fusion (ACDF) is being increasingly offered on an outpatient basis. However, the safety profile of outpatient ACDF remains poorly defined. OBJECTIVE To review the medical literature on the safety of outpatient ACDF. METHODS We systematically reviewed the literature for articles published before April 1, 2018, describing outpatient ACDF and associated complications, including incidence of reoperation, stroke, thrombolytic events, dysphagia, hematoma, and mortality. A random-effects analysis was performed comparing complications between the inpatient and outpatient groups. RESULTS We identified 21 articles that satisfied the selection criteria, of which 15 were comparative studies. Most of the existing studies were retrospective, with a lack of level I or II studies on this topic. We found no statistically significant difference between inpatient and outpatient ACDF in overall complications, incidence of stroke, thrombolytic events, dysphagia, and hematoma development. However, patients undergoing outpatient ACDF had lower reported reoperation rates (P < .001), mortality (P < .001), and hospitalization duration (P < .001). CONCLUSION Our meta-analysis indicates that there is a lack of high level of evidence studies regarding the safety of outpatient ACDF. However, the existing literature suggests that outpatient ACDF can be safe, with low complication rates comparable to inpatient ACDF in well-selected patients. Patients with advanced age and comorbidities such as obesity and significant myelopathy are likely not suitable for outpatient ACDF. Spine surgeons must carefully evaluate each patient to decide whether outpatient ACDF is a safe option. Higher quality, large prospective randomized control trials are needed to accurately demonstrate the safety profile of outpatient ACDF.

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Reliability of clinical tests for prediction of occult scaphoid fractures and cost benefit analysis of a dedicated scaphoid pathway

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193420979465 ◽

2020 ◽

pp. 175319342097946

Author(s):

Preetham Kodumuri ◽

Andrew McDonough ◽

Victoria Lyle ◽

Zaf Naqui ◽

Lindsay Muir

Keyword(s):

Outcome Measure ◽

Cost Benefit Analysis ◽

Scaphoid Fracture ◽

Cost Benefit ◽

Clinical Suspicion ◽

Secondary Outcome ◽

Secondary Outcome Measure ◽

Post Injury ◽

Level Of Evidence ◽

Scaphoid Fractures

We reviewed the outcomes of our dedicated clinic for suspected scaphoid fractures. The primary outcome measure was to test the reliability of accurately diagnosing an occult scaphoid fracture with a combination of anatomical snuff box, scaphoid tubercle, longitudinal compression tenderness, ulnar deviation and the pinch test. Cost savings of the new patient pathway was our secondary outcome measure. Between December 2016 and March 2020, 922 patients were recruited at a mean of 12 days post-injury. Sixty-five per cent ( n = 602) with a low clinical suspicion were discharged and 35% ( n = 320) with a high clinical suspicion had same day MRI scan. Fifty-eight scaphoid fractures were diagnosed and treated with no nonunions reported. Anatomical snuff box tenderness was the most sensitive test (90%). A combination of five tests better excluded an occult fracture (80% accuracy). The dedicated scaphoid clinic pathway resulted in 350 fewer follow-up visits and an overall saving of £59,666. Level of evidence: III

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Audit of Complications in an Otolaryngology Led Skull-Base Surgical Practice

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1676793 ◽

2018 ◽

Vol 80 (06) ◽

pp. 586-592

Author(s):

Uma Patnaik ◽

Smriti Panda ◽

Alok Thakar

Keyword(s):

Skull Base ◽

Surgical Complications ◽

Skull Base Surgery ◽

Major Complication ◽

Anterior Skull Base ◽

Complication Rates ◽

Permanent Disability ◽

Lateral Skull Base ◽

Significant Difference ◽

Surgical Complexity

Objective This study was aimed to classify and study complications of surgery of the cranial base, primarily from an otorhinolaryngology perspective. Design This study was designed with consecutive cohort of skull base surgical cases. Setting Tertiary referral academic center. Participants Patients having skull-base surgery at a otorhinolaryngology based skull-base unit, from 2002 to 2015. Main Outcome Measures Enumeration of complications is the main outcome of this study. Surgical procedures, categorized for complexity as per a unified system, are applicable to endoscopic and open procedures. Complications were categorized as per the British Association of Otolaryngologists coding of surgical complications. Complication classified as major if life-threatening, causing permanent disability, or compromising the result of surgery. Results A total of 342 patients (n = 342) were operated; 13 patients' records were excluded due to < 6 months posttreatment follow-up. The study group constituted 204 anterior skull-base (endoscopic, 120; open/external, 84) and 125 lateral skull-base procedures. Complication rates noted to increase in both groups with increasing complexity of surgical intervention. Anterior skull-base surgery (total complications, 11%; major, 3%; death, 0.5%) noted to have significantly less surgical complications than lateral skull-base surgery (total complications, 33%; major, 15%; death, 1.6%; p < 0.001). Among the anterior procedures no significant difference noted among endoscopic and external approaches when compared across similar surgical complexity. Conclusion Despite improvement in surgical and perioperative care, the overall major complication rate in a contemporary otolaryngology led, primarily extradural, skull-base practice is noted at 8%. Perioperative mortality, though rare, was encountered in 1%. A standard method for categorization of surgical complexity and the grade of complications as reported here is recommended.

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A Meta-Analysis of Complication Rates Among Different SMAS Facelift Techniques

Aesthetic Surgery Journal ◽

10.1093/asj/sjz045 ◽

2019 ◽

Vol 39 (9) ◽

pp. 927-942 ◽

Cited By ~ 15

Author(s):

Andrew A Jacono ◽

A Sean Alemi ◽

Joseph L Russell

Keyword(s):

Facial Nerve ◽

Nerve Injury ◽

Meta Analysis ◽

Complication Rates ◽

Level Of Evidence ◽

Facial Nerve Injury ◽

Significant Difference ◽

Meta Analyses ◽

Smas Flap

AbstractBackgroundSub-superficial musculo-aponeurotic system (SMAS) rhytidectomy techniques are considered to have a higher complication profile, especially for facial nerve injury, compared with less invasive SMAS techniques. This results in surgeons avoiding sub-SMAS dissection.ObjectivesThe authors sought to aggregate and summarize data on complications among different SMAS facelift techniques.MethodsA broad systematic search was performed. All included studies: (1) described a SMAS facelifting technique categorized as SMAS plication, SMASectomy/imbrication, SMAS flap, high lateral SMAS flap, deep plane, and composite; and (2) reported the number of postoperative complications in participants. Meta-analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsA total 183 studies were included. High lateral SMAS (1.85%) and composite rhytidectomy (1.52%) had the highest rates of temporary nerve injury and were the only techniques to show a statistically significant difference compared with SMAS plication (odds ratio [OR] = 2.71 and 2.22, respectively, P < 0.05). Risk of permanent injury did not differ among techniques. An increase in major hematoma was found for the deep plane (1.22%, OR = 1.67, P < 0.05) and SMAS imbrication (1.92%, OR = 2.65, P < 0.01). Skin necrosis was higher with the SMAS flap (1.57%, OR = 2.29, P < 0.01).ConclusionsThere are statistically significant differences in complication rates between SMAS facelifting techniques for temporary facial nerve injury, hematoma, seroma, necrosis, and infection. Technique should be selected based on quality of results and not the complication profile.Level of Evidence: 2

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Prepectoral Direct-to-Implant Breast Reconstruction: Early Outcomes and Analysis of Postoperative Pain

Aesthetic Surgery Journal Open Forum ◽

10.1093/asjof/ojz006 ◽

2019 ◽

Vol 1 (1) ◽

Cited By ~ 1

Author(s):

Rafi Fredman ◽

Cindy Wu ◽

Mihaela Rapolti ◽

Daniel Luckett ◽

Jason Fine ◽

...

Keyword(s):

Postoperative Pain ◽

Breast Reconstruction ◽

Statistical Significance ◽

Complication Rates ◽

Level Of Evidence ◽

Trade Offs ◽

Technological Advances ◽

Significant Difference ◽

Aesthetic Results ◽

Postmastectomy Radiation Therapy

Abstract Background Direct-to-implant (DTI) breast reconstruction provides high-quality aesthetic results in appropriate candidates. Most commonly, implants are placed in the subpectoral space which can lead to pain and breast animation. Surgical and technological advances have allowed for successful prepectoral implant placement which may eliminate these trade-offs. Objectives Here we present early outcomes from 153 reconstructions in 94 patients who underwent prepectoral DTI. We sought to determine whether these patients have less postoperative pain and narcotic use than subpectoral implant or expander placement. Methods A retrospective review was performed for all prepectoral DTI reconstructions at our institution from 2015 to 2016. Data were collected on postoperative pain and narcotic use while in hospital. Results The average follow-up time was 8.5 months (range, 3–17 months) and the overall complication rate was 27% (n = 41) with the most common complications being skin necrosis (9%, n = 13) and infection (7%, n = 11). No statistically significant difference in complications was found in patients who underwent postmastectomy radiation therapy. Patients who underwent prepectoral DTI reconstruction did not have a statistically significant difference in postoperative pain and narcotic use while in-hospital compared with other techniques. Conclusion Prepectoral DTI reconstruction provides good results with similar complication rates to subpectoral techniques. Prepectoral DTI eliminates the problem of breast animation. Although our series did not reach statistical significance in pain scores or requirement for postoperative narcotics, we believe that it is an important preliminary result and with larger numbers we anticipate a more definitive conclusion. Level of Evidence: 4

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Pediatric Scaphoid Nonunions: A Case Series, Review of the Literature, and Evidence-Based Guidelines

Journal of Wrist Surgery ◽

10.1055/s-0039-3401035 ◽

2019 ◽

Vol 09 (01) ◽

pp. 002-012 ◽

Cited By ~ 1

Author(s):

Kerstin Oestreich ◽

Tatiana Umata Yoko Jacomel ◽

Sami Hassan ◽

Maxim David Horwitz ◽

Tommy Roger Lindau

Keyword(s):

Nonoperative Management ◽

Pediatric Population ◽

Scaphoid Fracture ◽

Case Series ◽

Fracture Site ◽

X Rays ◽

Review Of The Literature ◽

Level Of Evidence ◽

Scaphoid Fractures ◽

Magnetic Resonance Imaging Mri

Abstract Background Scaphoid fractures represent less than 3% of hand and wrist fractures in the pediatric population. Nonunions are very rare. We present a case series (n = 18) of nonunions in skeletally immature children and adolescents. We further present a review of the literature on pediatric scaphoid nonunions. Materials and Methods We reviewed the literature by searching the main databases on pediatric scaphoid nonunions, but to identify factors that lead to nonunion, we also searched for databases on scaphoid fractures. Seventy articles were found for the period between 1961 and 2019, all with level 4/5 evidence. Results The nonunion rate of pediatric scaphoid fractures in the literature is on average 1.5%, occurring mostly as a result of missed or underdiagnosed injuries, similar to our presented case series. Half (n = 9) of the injuries in our case series were missed initial injuries, leading to scaphoid nonunions and half developed nonunions after initial treatment. We found excellent outcomes and with surgical and nonoperative management, with few complications. Not surprisingly, the duration of immobilization is longer with nonoperative management. Conclusions Based on the literature, we recommend a period of nonoperative management before surgery in undisplaced nonunions. In displaced nonunions, open reduction and internal fixation ± bone grafting is necessary. In pediatric scaphoid fractures, similar to adult cases, we identified that suspicious scaphoid fractures should be considered for initial immobilization, and repeat X-rays and early magnetic resonance imaging (MRI) or computed tomography (CT) scans should be considered at follow-up. Immobilization time and type of plaster should be appropriate in relation to the fracture site, similar to the adult scaphoid fracture. Level of Evidence This is a Level IV study.

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