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Numerous studies on the mechanisms of ankle injury deal with injuries to the syndesmosis and anterior ligamentous structures but a previous sectioning study also describes the important role of the posterior talofibular ligament (PTaFL) in the ankle's resistance to external rotation of the foot. It was hypothesized that failure level external rotation of the foot would lead to injury of the PTaFL. Ten ankles were tested by externally rotating the foot until gross injury. Two different frequencies of rotation were used in this study, 0.5 Hz and 2 Hz. The mean failure torque of the ankles was 69.5 [+ or -] 11.7 Nm with a mean failure angle of 40.7 [+ or -] 7.3[degrees]. No effects of rotation frequency or flexion angle were noted. The most commonly injured structure was the PTaFL. Visible damage to the syndesmosis only occurred in combination with fibular fracture in these experiments. The constraint of the subtalar joint in the current study may have affected the mechanics of the foot and led to the resultant strain in the PTaFL. In the real world, talus rotations may be affected by athletic footwear that may influence the location and potential for an ankle injury 'under external rotation of the foot. [DOI: 10.1115/1.4002025] Keywords: posterior talofibular ligament, anterior deltoid ligament, ankle sprain, external rotation, sports injury

Background: Historical concerns over bone resorption and malunion of the osteocutaneous radial forearm free flap (OCRFFF) limited its widespread adoption for head and neck reconstruction, despite lack of outcomes data evaluating this notion. Methods: A retrospective cohort study was performed including patients 18 years or older who underwent reconstruction of the mandible using an OCRFFF. Linear modeling and logistic regression were used to evaluate the change in bone volume and union over time. Results: One hundred and twenty‐one patients were included in the study. A mixed effects linear model incorporating age, sex, treatment type, and number of bone segments did not demonstrate a significant loss of bone volume over time. A logistic regression model identified lack of adjuvant treatment and time to be significantly associated with complete union. Conclusion: This study supports that the OCRFFF is a stable form of osseus reconstruction for defects of the head and neck. [ABSTRACT FROM AUTHOR]

Background: While quality of life (QOL), psychosocial health, and adverse treatment outcomes have been studied in head and neck cancer (HNC) patients, decision regret is an important and understudied complication that can negatively impact future health care decision making. Methods: Data collected using a HNC patient registry with questionnaires administered at initial consultation visits plus 3 and 6 months after treatment completion was retrospectively analyzed. A visual analog anxiety scale and the University of Washington Quality of Life were given at clinic visits. Decision regret was determined using a validated scale. Demographic and clinical variables were collected retrospectively and at baseline. Results: Patients with higher anxiety and lower self‐reported QOL had higher concurrent regret at 3‐month (n = 140) and at 6‐month (n = 82) post‐treatment. Later disease stage at presentation, nonprimary surgical treatment, and lower health literacy were associated with greater regret. Conclusions: Decision regret was highest in HNC patients with high anxiety, low QOL, and more advanced disease. [ABSTRACT FROM AUTHOR]

Objective: To reproduce a published study comparing outcomes of patients who underwent microvascular reconstruction by plastic surgeons and otolaryngologists and to examine how case selection and methodology using the National Surgical Quality Improvement Program (NSQIP) data set can affect results and conclusions. Study Design: Cross-sectional analysis of US national database. Setting: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2005 to 2017. Subjects and Methods: A recently published study that used the NSQIP database to compare outcomes after head and neck free tissue transfer between plastic surgeons and otolaryngologists was reproduced. Different approaches to case selection and statistical analysis were evaluated and their effects on statistical significance and study conclusions were compared. Results: When all cases of free tissue transfer, captured in NSQIP between 2005 and 2017, were compared between plastic surgery and otolaryngology, plastic surgery patients appeared to have lower rates of complications and length of stay. However, a more in-depth analysis demonstrated that these results were confounded by older and sicker otolaryngology patients. A second analysis of the same NSQIP data, limited to only head and neck oncologic reconstructions, demonstrated that otolaryngology patients had fewer complications on univariate and multivariable analysis. Conclusion: We demonstrated how case selection and analysis can significantly affect results. It is incumbent upon researchers who use NSQIP and other publicly available data sets to fully detail their methodology to allow other researchers to reproduce and evaluate their work and for the journal editorial process to carefully evaluate the methodology and conclusions of their contributing authors. [ABSTRACT FROM AUTHOR]

What is Known and Objective: Prescription drug stewardship is critical. Autopopulation(AP) of medication quantities may influence prescriber behaviour. We investigate the impact of AP removal(APR) on opioid prescribing. Methods: Inpatient and emergency department(ED) discharges with opioid pain medications 2 years before and after APR were identified. Milligrams of morphine equivalents(MMEs) prescribed were recorded. Group comparisons were performed using Mann‐Whitney U tests. Spearman's rho was used to analyse correlations between pain level and quantity of prescribed opioids. Mann‐Kendall tests assessed trends in prescription patterns. Generalized estimating equations assessed trends in total quantity of prescribed MME. Results and Discussion: A total of 53 608 patient encounters were included for analysis. In surgical patients, there were no trends in the frequency of prescriptions below, at or above the AP quantity pre‐APR. Post‐APR, there was a decrease in the percentage of prescriptions written for the AP quantity(τ = −.493, P =.001) and an increase in prescriptions for <30 tablets(τ =.468,P =.001). In non‐operative patients, the pre‐APR period was associated with a lower percentage of prescriptions >30 tablets and a greater percentage of prescriptions for <30 tablets. Interestingly, APR reversed this trend in prescriptions for >30 tablets and resulted in an increase in larger prescriptions. Multivariate analysis of the total prescribed quantity of MME found no significant trend across months for inpatients prior to and after APR (0.997, P =.065 and 1.003, P =.142; respectively). The ED model found a monthly downward trend in amount of prescribed MME prior to and after APR (0.986, P <.001 and 0.990, P <.001; respectively). In the inpatient setting, pain was positively correlated to discharge MME (ρ =.028, P <.001); with those reporting the highest pain receiving the greatest amount of opioids both pre‐ and post‐APR. Interestingly, in the ED, this finding was negatively correlated (ρ = −.086, P <.001); with those reporting the lowest pain receiving the greatest amount of opioids both pre‐ and post‐APR. What is New and Conclusions: AP removal may have unintended consequences, such as increased prescriptions for greater quantities. To drive down prescription amounts, lower anchor values may be of more utility than APR. The poor correlation of pain values with prescribed medications warrants further investigation. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: To develop a "word cloud"-based visual letter of recommendation (VLOR) and to evaluate its efficiency in discerning applicant quality compared to narrative letters of recommendation (NLORs).Study Design: Cross-sectional cohort study.Methods: NLORs for 48 otolaryngology residency applicants interviewed from the 2016 application cycle were identified and mined for descriptive terms to generate a word cloud, referred to as a VLOR. Eight individuals reviewed and rated a total of 187 blinded NLORs and 48 VLORs on a four-point scale (negative to exceptional). Median VLOR and NLOR scores and the time to review for each candidate were compared using the Wilcoxon signed rank test.Results: It took significantly more time to review the NLORs in comparison to the VLORs (67 seconds, interquartile range [IQR]: 41-98 seconds vs. 17 seconds, IQR: 11-26 seconds, P < .001). There was no significant difference between median scores for VLORs and NLORs (P = .136). Review time and score correlated positively for VLORs and was statistically significant (ρ = 0.459, P = .001), indicating that more time spent reviewing equates to higher scores. The same relationship appeared with NLORs, but was not statistically significant (ρ = 0.276, P = .058).Conclusions: VLORs are a novel and efficient additive tool for screening candidates for otolaryngology residency interview slots. Their scores do not significantly vary from NLOR scores and are significantly faster to evaluate.Level Of Evidence: 2b Laryngoscope, 129:2026-2030, 2019. [ABSTRACT FROM AUTHOR]

Background: If conservative management of CSF leak is unsuccessful, surgical repair is indicated for the prevention of severe complications such as meningitis. This study investigated the influence of surgical timing on clinical and economic outcomes.Methods: Retrospective review of the National Inpatient Sample (2012) and the Nationwide Inpatient Sample (2002-2011) for nonelective admissions with a principal diagnosis of CSF rhinorrhea treated with surgical repair of the meninges. Demographics and outcomes of patients undergoing meningeal repair for CSF rhinorrhea were analyzed. Cases were classified into four groups based on timing of surgical intervention: 1) performed on the day of admission (day 0), 2) performed between days 1 and 3, 3) performed between days 4 and 7, and 4) performed between days 8 and 14.Results: A total of 1,088 emergent admissions were analyzed. On average, patients underwent surgical repair between the second and fourth day of admission. Lowest rates of meningitis were in patients treated on the day of admission (6.1%); those treated at 2 weeks had a 34.7% incidence. Multivariate analysis controlling for comorbidity burden, gender, and surgical timing found the highest odds of meningitis in patients treated with surgical repair during the second week of admission compared to repair on the day of admission (OR 8.2, P < .001). Length of stay (LOS) and hospital costs increased as time to repair increased.Conclusion: Multiple factors influence outcomes in patients with CSF rhinorrhea. Early surgical repair was significantly associated with decreased rates of meningitis, LOS, and hospital costs. Expedient treatment of patients admitted for CSF rhinorrhea may prove to be both a cost- and morbidity-saving measure.Level Of Evidence: 2C Laryngoscope, 129:539-543, 2019. [ABSTRACT FROM AUTHOR]