Incidence and Reimbursement Trends for Facial Fracture Repair in the Elderly: A Medicare Analysis.

OBJECTIVES: The aim was to describe incidence and reimbursement trends of surgical repair of facial fractures among the Medicare population. METHODS: The annual procedure data from the Centers for Medicare and Medicaid Service National Part B Data File from 2000 to 2019 were queried. RESULTS: The total number of surgically corrected facial fractures increased from 10,148 in 2000 to 19,631 in 2019 in a linear pattern (r = 0.924). Specifically, nasal bone/septum fracture repairs increased the most by 200.6% (n = 4682 to n = 14,075), whereas operations for TMJ dislocations, malar/zygoma fractures, and alveolar ridge/mandibular fractures decreased by 27.9%, 12.3%, and 3.2%, respectively, between 2000 and 2019. Correspondingly, the total Medicare reimbursement rose from $2,574,317 in 2000 to $4,129,448 in 2019 (r = 0.895). However, the mean reimbursement for all procedures decreased from $376.63 to $210.35 (44.1% fall) over the same time after adjusting for inflation, with this trend holding for individual fracture types as well. CONCLUSIONS: Given the population's increasing age, there has been a significant increase in the number of surgical repairs of facial fractures in Medicare patients between 2000 and 2019. However, this is largely driven by an increase in nasal bone/septum closed reductions, with stagnant and, in some cases, declining incidence among other fracture repairs. The reason is unclear and may be related to an increase in nonoperative management or poor outcomes. Nevertheless, like other subfields within otolaryngology and medicine at large, payments have lagged far behind, which may play some role. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:659-665, 2024.

Frailty, Age, ASA Classification, and BMI on Postoperative Morbidity in Mandibular Fracture ORIF.

OBJECTIVE: To assess how traditional, simple markers of health independently affect postoperative morbidity of mandibular fracture open reduction-internal fixations (ORIFs). STUDY DESIGN: Cohort study. SETTING: National Surgical Quality Improvement Project (NSQIP) Database. METHODS: The 2005 to 2017 NSQIP database was queried for patients who underwent mandibular ORIF. To control for the severity of the trauma, an additional "concurrent surgery" variable was created. A modified 5-item frailty index was calculated based on the following: presurgery-dependent functional status, chronic hypertension, diabetes mellitus, history of chronic obstructive pulmonary disease, and history of congestive heart failure. RESULTS: Among 1806 patients with mandibular ORIFs (mean age 34.8 ± 15.4 years), modified frailty index (mFI) was associated with 30-day medical complications (p < .001), reoperation (p < .001), and readmission (p = .005) on univariate analysis. Increased age was associated with prolonged hospitalization (p < .001) and medical complications (p < .001). The increased American Society of Anesthesiologists (ASA) score was associated with all endpoints (p ≤ .003), while increased body mass index (BMI) was associated with none. On multivariate analysis, only increased ASA was associated with any adverse event (reference: ASA 1; ASA 2, odds ratio [OR]: 2.17 [95% confidence interval, CI: 2.17-3.71], p = .004; ASA 3-4, OR: 3.63 [95% CI: 1.91-6.91], p < .001). Similarly, mFI and BMI were not independently associated with prolonged hospitalization (≥2 days) (p ≥ .015), but 65+ age (reference: 18-49; OR: 2.33 [95% CI: 1.40-3.86], p = .001) and ASA 3 to 4 groups (reference: ASA 1; OR: 3.26 [95% CI: 2.06-5.14], p < .001) were. CONCLUSION: ASA status and age are more useful modalities than mFI or BMI in predicting poor postoperative morbidity in mandibular ORIF. These simple metrics can assist with managing surgeons' expectations for mandibular ORIF patients.

Autologous costochondral graft harvest in children.

INTRODUCTION: Autologous costochondral grafting is a commonly employed technique in pediatric otolaryngology for reconstructing a cartilaginous or bony structure, such as the trachea, larynx, nose or mandible by harvesting rib cartilage or bone from the same patient. Complications include infection, pneumothorax, hematoma, scarring, and pleural leak, and the literature regarding these complication rates in pediatric patients undergoing this procedure is sparse. The objective of this study was to determine the donor site complication rate associated with rib graft harvest procedures performed by pediatric otolaryngologists in infants and children and to compare this to established complication rates reported in adults. METHODS: A retrospective cohort study was performed, examing the charts of 33 patients who underwent airway, mandible, nose, or external ear reconstruction by means of autologous rib grafting between 2010 and 2018 at an urban tertiary medical center in Boston, Massachusetts. All patients were under the age of 18 years old and had undergone rib harvest and subsequent airway, mandible, nose, or external ear reconstruction by two pediatric otolaryngologists. RESULTS: Of these, 20 were female and 13 were male, with a mean age of 2.5 years at date of surgery. No patients were excluded. A total of 41 costochondral graft harvests from a total of 36 incision sites were included. Pooled donor site complication incidences were 1 intraoperative pleural leak (2.8%) and 1 incision site infection (2.8%). Drains were not utilized postoperatively; there were no incidences of postoperative hematoma or seroma. No outside specialty consults were necessary to manage these. There were 2 instances of hypertrophic scarring, both developing in patients who underwent skin excisions for skin graft harvest or scar excision from the same incision used for graft harvest (5.6%). CONCLUSIONS AND RELEVANCE: Autologous rib grafting amounts to a simple, extrapleural chest wall procedure, which may be safely performed in children by pediatric otolaryngologists with acceptably low complication rates.