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A mandible fracture is a common traumatic craniofacial injury for which surgery is sometimes indicated. Post-fracture and postoperative pain are often controlled through prescribed narcotics, which have received increased attention for potential abuse. The current work identified 90-day opioid prescribing patterns following surgically treated mandible fractures. Patients who underwent open reduction and internal fixation to treat a closed mandible fracture between 2011 and 2021 were identified in the PearlDiver Mariner165 database. Exclusion criteria included: (1) patients with records active for fewer than 180 days before the injury and 90 days post-fracture, (2) age younger than 18, and (3) those with long bone fracture within 30 days of mandible fracture. Variables associated with filling an opioid prescription and utilizing excess morphine milligram equivalents (MMEs) were identified through multivariate regression. Prescribing patterns between 2011 and 2021 were analyzed using simple linear regression. A total of 15,049 patients were identified. Of these patients, opioid prescriptions were filled by 10,389 (69.0%). Greater MMEs were filled for those with greater age, prior opioid use, and history of chronic pain (P < 0.01 for all). The proportion of patients who received opioids decreased from 2011 to 2021 (73.3% versus 61.9%) during which declines were also seen for median MMEs (225.0 versus 128.4) and mean number of filled prescriptions (4.1 versus 2.8). The present work identified age and preexisting risk factors as significantly associated with excess MMEs following open reduction and internal fixation-treated mandible fracture. The decreasing proportion of patients receiving opioids along with decreasing MMEs suggests more refined practice with regard to their use., Competing Interests: J.N.G.: Editor-in-Chief of North American Spine Society Journal, Board Member North American Spine Society. M.A.: Consultant for Johnson & Johnson. The remaining authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Purpose: Prior studies characterizing surgically managed frontal sinus fractures are small, institutional studies from major trauma centers (1-5). The current study characterizes the concomitant injuries and complications following open treatment of frontal sinus fractures across the United States., Methods: Patients who underwent open treatment for a frontal sinus fracture between 2010 and 2022 were identified in a United States administrative database. Patients <18 years old and with <90 days of follow-up were excluded. Type of fracture (simple or complex), frontal sinus obliteration and concomitant fractures (facial, vertebral, extremity) were identified. 90-day surgical site infection, sinusitis, meningitis, brain abscess and cerebrospinal fluid leak were identified, as well as mucocele any time after surgery., Results: There were 1492 adult patients with open treatment of frontal sinus fractures: 654 (44%) with simple fractures and 838 (56%) with complex fractures. There were 157 (11%) patients with frontal sinus obliteration. Concomitant fractures included facial (715 patients, 48%), vertebral (55, 4%), upper extremity (40, 3%) and lower extremity (53, 4%). Within 90 days of surgery, 155 (10%) patients had a complication: surgical site infection (42, 2.8%), sinusitis (29, 1.9%), meningitis (25, 1.7%), brain abscess (23, 1.5%), and cerebrospinal fluid leak (63, 4.2%). There were 11 (0.7%) patients who developed a mucocele, and <11 (<0.7%) underwent reduction of contour deformity. On multivariate analysis, complex frontal sinus fracture and concomitant vertebral/extremity fracture were associated with increased likelihood of a complication., Conclusion: Over the last thirteen years, complication rates are low following surgically managed frontal sinus fractures. Comminuted fractures and those involving the posterior table increase the likelihood of a complication, likely due to increased injury severity. The results of the current study generally align with the published single-institution studies on complications of frontal sinus fractures treated with surgery. These findings from a large, nationwide cohort strengthen prior conclusions and increase the generalizability of reported complication rates., Competing Interests: Declarations of competing interest None., (Copyright © 2024. Published by Elsevier Ltd.)

Purpose: Direct cost comparison of nerve allograft with other techniques for repairing short digital nerve gaps are lacking. This study compares the costs of various techniques for digital nerve repair, anticipating significant cost increases for allograft implants., Methods: The State Ambulatory Surgery and Services Database for Florida, New York, and Wisconsin from 2015-2020 was used. Patients with primary repair, short autograft, conduit, and allograft were compared along total, surgical supply, operating room (OR), and anesthesia charges., Results: Among 5,009 patients were 2,967 primary nerve repairs (59.2%), 77 autografts (1.5%), 1,647 conduits (32.9%), and 318 allografts (6.3%). 2,886 patients were male (57.6%) with mean age 40.4 ± 16.3 years. Over the study period, primary repairs decreased (63.9% in 2015 to 56.3% in 2020) while allografts increased significantly (8.8% in 2018 to 12.6% in 2020).Median total charges significantly varied across procedures, with the most expensive being allograft ($35,295), followed by conduit ($25,717), autograft ($24,749), and primary repair ($18,767). On multivariable regression, allograft is significantly more expensive than autograft for total charges by $11,224 (95CI: $4,196-$18,252) and supply charges by $10,484 (95CI: $6,073-$14,896), but not for OR or anesthesia charges. Flexor tendon repair was associated with greater total, OR, and anesthesia charges but similar supply charges., Conclusions: Nerve allograft is the most expensive digital nerve repair technique most likely due to the cost of the implant. To minimize health care expenditure and ensure equitable patient access, surgeons should consider this cost along with clinical factors in choosing digital nerve repair techniques., Competing Interests: Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and received no funding for the work presented., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Introduction: Some papers suggest that wide-awake flexor tendon repair (FTR) may reduce rates of postoperative tendon gapping and rupture due to improved intraoperative testing of the repair. The current study is a nationwide cohort study comparing FTRs performed wide-awake and with traditional anesthesia., Methods: Patients undergoing zone II FTR between 2010-2022 were identified in PearlDiver. Exclusion criteria were other tendon repairs, concomitant treatment for vascular injury, fracture, dislocation or amputation, inpatient or office surgery, age <18 years and <1 year of follow-up. Patients were stratified by anesthesia technique: traditional anesthesia (general anesthesia, monitored anesthesia care, regional blocks) or wide-awake. Patients were matched based on age, sex, Elixhauser Comorbidity Index (ECI) score, geographical region, insurance coverage, number of tendon repairs and presence of concomitant nerve repair. 30-day wound complications, emergency department visits and readmissions and 1-year reoperations were identified. Total reimbursement for surgery was determined., Results: Each matched cohort included 2,563 patients. Wide-awake patients had fewer 30-day emergency department visits (2.7% vs 4.8%). There were no differences in 30-day wound complications or readmissions. There was no difference in 1-year reoperations for rupture or for stiffness. Multivariable linear regression identified wide-awake surgery to be a significantly associated with lower total reimbursement., Conclusions: Performing digital FTR using wide-awake techniques can reduce costs, but the hypothesis that wide-awake repairs may reduce rates of tendon rupture was not supported by the current study., Competing Interests: Financial Disclosure Statement: The authors have no financial conflicts of interest to disclose., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Background: Prior studies have compared perioperative opioid prescriptions between carpal tunnel release (CTR) performed wide-awake and with traditional anesthetic techniques, but the association of opioid prescriptions with surgical setting has not been fully explored. The current study assessed the association of opioid prescriptions with surgical setting (office or operating room) for wide-awake CTR., Methods: Patients with open CTR were identified in an administrative claims database (PearlDiver). Exclusion criteria included age less than 18 years, preoperative data less than 6 months, postoperative data less than 1 month, bilateral surgery, concomitant hand surgery, and traditional anesthesia (general anesthesia, sedation, or regional block). Patients were stratified by surgical setting (office or operating room) and matched by age, sex, Elixhauser Comorbidity Index, and geographic region. Prior opioid prescriptions, opioid dependence/abuse, substance use disorder, back/neck pain, generalized anxiety, and major depression were identified. Opioid prescriptions within 7 days before and 30 days after surgery were characterized., Results: Each matched cohort included 5713 patients. Compared with patients with surgery in the operating room, fewer patients with office-based surgery filled opioid prescriptions (45% vs 62%), and those prescriptions had lower morphine milligram equivalents (MMEs, median 130 vs 188). These findings were statistically significant on univariate and multivariate analysis., Conclusions: Following office-based CTR, fewer patients filled opioid prescriptions, and filled prescriptions had lower MME. This likely reflects patient and provider attitudes about pain control and opioid utilization. Further patient- and provider-level investigation may provide additional insights that could aid in efforts to reduce perioperative opioid utilization across surgical settings., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.