Christian Bonde

The cost of infection in severe open tibial fractures treated with a free flap

PurposeOpen tibial fractures needing soft tissue cover are challenging injuries. Infection risk is high, making treatment difficult and expensive. Delayed skin closure has been shown to increase the infection rate in several studies. We aimed at calculating the direct and indirect cost of treatment, and to determine the effect of delayed skin closure on this cost.MethodsWe reviewed all records of patients treated with a free flap in our institution for an open tibial fracture from 2002 to 2013. We calculated direct costs based on length of stay (LOS) and orthopaedic and plastic surgical procedures performed, including medications and intensive care. We analysed indirect cost in terms of absenteeism and unemployment benefits. The primary goal was to establish the extra cost incurred by an infection.ResultsWe analysed 46 injuries in 45 patients. Infection increased the LOS from 41 to 74xa0days and increased the cost of treatment from € 49,817 in uninfected fractures to € 81,155 for infected fractures. Employed patients spent 430xa0days more on unemployment benefits, than a matched cohort in the background population. Achieving skin cover within sevenxa0days of injury decreased the infection rate from 60 to 27xa0%.ConclusionsSevere open tibial fractures covered with free flaps, cause over a year of absenteeism. Infection increases direct cost of treatment over 60xa0% and roughly doubles LOS. Early soft-tissue cover and correct antibiotics have been shown to improve outcomes—underscoring the need for rapid referral to centres with an ortho-plastic set-up to handle such injuries.

Transgender Surgery in Denmark From 1994 to 2015: 20-Year Follow-Up Study

INTRODUCTIONnGender dysphoria is a mismatch between a persons biological sex and gender identity. The best treatment is believed to be hormonal therapy and gender-confirming surgery that will transition the individual toward the desired gender. Treatment in Denmark is covered by public health care, and gender-confirming surgery in Denmark is centralized at a single-center with few specialized plastic surgeons conducting top surgery (mastectomy or breast augmentation) and bottom surgery (vaginoplasty or phalloplasty and metoidioplasty).nnnAIMSnTo report the first nationwide single-center review on transsexual patients in Denmark undergoing gender-confirming surgery performed by a single surgical team and to assess whether age at time of gender-confirming surgery decreased during a 20-year period.nnnMETHODSnElectronic patient databases were used to identify patients diagnosed with gender identity disorders from January 1994 through March 2015. Patients were excluded from the study if they were pseudohermaphrodites or if their gender was not reported.nnnMAIN OUTCOME MEASURESnGender distribution, age trends, and surgeries performed for Danish patients who underwent gender-confirming surgery.nnnRESULTSnOne hundred fifty-eight patients referred for gender-confirming surgery were included. Fifty-five cases (35%) were male-to-female (MtF) and 103 (65%) were female-to-male (FtM). In total, 126 gender-confirming surgeries were performed. For FtM cases, top surgery (mastectomy) was conducted in 62 patients and bottom surgery (phalloplasty and metoidioplasty) was conducted in 17 patients. For MtF cases, 45 underwent bottom surgery (vaginoplasty), 2 of whom received breast augmentation. The FtM:MtF ratio of the referred patients was 1.9:1. The median age at the time of surgery decreased from 40 to 27 years during the 20-year period.nnnCONCLUSIONnGender-confirming surgery was performed on 65 FtM and 40 MtF cases at our hospital, and 21 transsexuals underwent surgery abroad. Mastectomy was performed in 62 FtM and bottom surgery in 17 FtM cases. Vaginoplasty was performed in 45 MtF and breast augmentation in 2 MtF cases. There was a significant decrease in age at the time of gender-confirming surgery during the course of the study period.

Amalgam Tattoo Mimicking Mucosal Melanoma: A Diagnostic Dilemma Revisited

Mucosal melanoma of the oral cavity is a rare but highly aggressive neoplasm. However, the clinicians need to be aware of the other and more frequent etiologies of intraoral pigmentation, such as amalgam tattoos. As amalgam has been extensively used for dental restorations and can cause pigmentations in the oral mucosa, this is a differential diagnosis not to be forgotten. We describe the characteristics of these two phenomena and present a case vignette illustrating the differential diagnostic issues. Other causes of intraoral pigmentation are summarized.