Oral rehabilitation and associated quality of life following mandibular reconstruction with free fibula flap: a cross-sectional study.

Introduction: Mandibular reconstruction with the free fibula flap (FFF) has become a standardized procedure. The situation is different with oral rehabilitation, so the purpose of this study was to investigate the frequency of implant placement and prosthetic restoration. Additionally, the patients' situation, motivation, and treatment course were structurally assessed. Materials and methods: All cases between January 2013 and December 2018 that underwent mandibular reconstruction in our department with a free fibula flap and gave written informed consent to participate were interviewed with two structured questionnaires about their restoration and quality of life. Additionally, medical records, general information, status of implants and therapy, and metric analyses of the inserted implants were performed. Results: In total 59 patients were enrolled and analyzed in this monocentric study. Overall, oral rehabilitation was achieved in 23.7% at the time of investigation. In detail, implants were inserted in 37.3% of patients and showed an 83.3% survival of dental implants. Of these implanted patients, dental implants were successfully restored with a prosthetic restoration in 63.6. Within this subgroup, satisfaction with the postoperative aesthetic and functional result was 79.9% and with the oral rehabilitation process was 68.2%. Satisfaction with the implant-borne prosthesis was 87.5%, with non-oral-squamous-cell-carcinoma patients being statistically significantly more content with the handling (p=0.046) and care (p=0.031) of the prosthesis. Discussion: Despite the well-reconstructed bony structures, there is a need to increase the effort of achieving oral rehabilitation, especially looking at the patient's persistent motivation for the procedure.

Comparison of three-dimensional imaging of the nose using three different 3D-photography systems: an observational study.

BACKGROUND: New 3D technologies for superficial soft tissue changes, especially in plastic and reconstructive surgical procedures, can improve the planning and documentation of facial surgeries. The purpose of this study was to compare and determine the applicability and feasibility of three different 3D-photography systems in clinical practice imaging the nose. METHODS: A total of 16 healthy non-operated noses were included in this prospective study. A plaster model of each nose was produced, digitized, and converted to a .stl mesh (= ground truth model). Three-dimensional images of each nose were then taken using Artec Space Spider (gold standard), Planmeca ProFace®, and the Bellus3D Dental Pro application. All resulting .stl files were aligned to the ground truth model using MeshLab software, and the root mean square error (RMSE), mean surface distance (MSD), and Hausdorff distance (HD) were calculated. RESULTS: The Artec Space Spider 3D-photography system showed significantly better results compared to the two other systems in regard to RMSE, MSD, and HD (each p < 0.001). There was no significant difference between Planmeca ProFace® and Bellus3D Dental Pro in terms of RMSE, MSD, and HD. Overall, all three camera systems showed a clinically acceptable deviation to the reference model (range: -1.23-1.57 mm). CONCLUSIONS: The three evaluated 3D-photography systems were suitable for nose imaging in the clinical routine. While Artec Space Spider showed the highest accuracy, the Bellus3D Dental Pro app may be the most feasible option for everyday clinical use due to its portability, ease of use, and low cost. This study presents three different systems, allowing readers to extrapolate to other systems when planning to introduce 3D photography in the clinical routine.

Perioperative anticoagulation in head and neck free flap reconstructions: Experience of an anticoagulative scheme and its modification.

OBJECTIVES: Microvascular anastomoses in microvascular reconstructions induce rheological changes in the anastomosed vessels and are usually counteracted by anticoagulative medication. There is no regimen commonly agreed on. This study provides an easy to use anticoagulative regimen. PATIENTS AND METHODS: Consecutive cases of either anticoagulative regimen between 2013 and 2018 that underwent microvascular reconstruction in the head and neck area were included in this retrospective study, resulting in 400 cases in total. Two different anticoagulative regimens were applied to 200 patients in each group: (a) intraoperatively administered unfractionated 5000 I.U. high molecular weight heparin (HMWH) and postoperatively low molecular weight heparin (LMWH, Enoxaparin) 1 mg/kg/body weight postoperatively and (b) intraoperatively LMWH 0.5 mg/kg/body weight as well as 12 h later and 1 mg/kg/body weight postoperatively. RESULTS: The LMWH cohort showed fewer overall thromboembolic (8.5% vs. 11%; p = .40) and peripheral thrombotic events (1% vs. 3.5%; p = .18) and lung embolisms (3% vs. 4%; p = .59). The number of thromboses at the site of the anastomosis was equally distributed. In regard to flap-specific complications, LMWH was associated with a positive effect, in particular with respect to total flap losses (5% vs. 7%; p = .40) and wound-healing disorders (14.5% vs. 20%; p = .145). CONCLUSION: Findings indicate that intra- and postoperatively administered LMWH as the only anticoagulative medication seems reliable in our clinical routine of head and neck free flap reconstructions.

Extended orbital exenteration, epithetic restoration, and patient supply: A cross-sectional study of a historic cohort.

BACKGROUND: The aim of this study was to investigate the clinical course and to redefine an optimized algorithm for OE cases until epithetic restoration. METHODS: Indication, defect type according to Kesting, reconstructive technique, incidence of postoperative complications and peri-implantitis, patients' quality of life, timing of periorbital implant insertion, incidence of and interval to implant loss, and time until epithetic restoration were analyzed in 43 patients. RESULTS: A significant correlation was detected between wound dehiscence and defect type. Out of 24 patients, 7 were implanted secondarily with a median time interval of 399 days (270-2015) after OE. Eleven out of 83 placed implants were lost in 8 patients with a median time interval of 586 days (264-4485) after insertion. The majority of epithesis carriers had no or few restrictions in their quality of life. CONCLUSIONS: We recommend our modified treatment algorithm to further improve and shorten the clinical course.

Face the Future-Artificial Intelligence in Oral and Maxillofacial Surgery.

Artificial intelligence (AI) has emerged as a versatile health-technology tool revolutionizing medical services through the implementation of predictive, preventative, individualized, and participatory approaches. AI encompasses different computational concepts such as machine learning, deep learning techniques, and neural networks. AI also presents a broad platform for improving preoperative planning, intraoperative workflow, and postoperative patient outcomes in the field of oral and maxillofacial surgery (OMFS). The purpose of this review is to present a comprehensive summary of the existing scientific knowledge. The authors thoroughly reviewed English-language PubMed/MEDLINE and Embase papers from their establishment to 1 December 2022. The search terms were (1) "OMFS" OR "oral and maxillofacial" OR "oral and maxillofacial surgery" OR "oral surgery" AND (2) "AI" OR "artificial intelligence". The search format was tailored to each database's syntax. To find pertinent material, each retrieved article and systematic review's reference list was thoroughly examined. According to the literature, AI is already being used in certain areas of OMFS, such as radiographic image quality improvement, diagnosis of cysts and tumors, and localization of cephalometric landmarks. Through additional research, it may be possible to provide practitioners in numerous disciplines with additional assistance to enhance preoperative planning, intraoperative screening, and postoperative monitoring. Overall, AI carries promising potential to advance the field of OMFS and generate novel solution possibilities for persisting clinical challenges. Herein, this review provides a comprehensive summary of AI in OMFS and sheds light on future research efforts. Further, the advanced analysis of complex medical imaging data can support surgeons in preoperative assessments, virtual surgical simulations, and individualized treatment strategies. AI also assists surgeons during intraoperative decision-making by offering immediate feedback and guidance to enhance surgical accuracy and reduce complication rates, for instance by predicting the risk of bleeding.

The COVID-19 pandemic and its possible impact on the treatment of odontogenic and intraoral abscesses.

Most odontogenic and intraoral abscesses can be treated on an outpatient basis with local anesthesia. However, severe disease progression may require an incision under general anesthesia (GA) with postoperative inpatient treatment. This study aimed to evaluate the first "COVID-19 year" in Germany and compare the first "COVID-19 year" with the two previous years. All consecutive cases with odontogenic or intraoral abscesses treated in an outpatient or inpatient setting between 2018 and 2021 were included in this study. Data were collected, including the type of anesthesia, length of hospital stay, and healthcare costs. Despite the lower total number of abscess treatments in the first year of COVID-19 (n = 298 patients) than that in the two previous years (n = 663 patients), the number of advanced abscesses requiring intervention under GA was significantly higher (p < 0.001). This increased burden of care was also reflected in increased healthcare costs. The measures taken against the COVID-19 pandemic had an impact on the course of other diseases, for example, odontogenic and intraoral abscesses. The results showed an emerging conflict in patient care during the pandemic crisis that should be considered in possible future pandemics.

Comparison of a high-definition three-dimensional digital camera system with a conventional state-of-the-art operation microscope for microsurgical anastomoses.

Since its clinical implementation, microvascular surgery has depended on the continuous improvement of magnification tools. One of the more recent developments is a high-definition three-dimensional (3D) digital system (exoscope), which provides an alternative to the state-of-the-art operating microscopes. This study aimed to evaluate the advantages and disadvantages of this technology and compare it with its predecessor. The study included 14 surgeons with varying levels of experience, none of which had used a 3D optical system previously. Six of these surgeons performed five arterial and five venous anastomoses in the chicken thigh model with both the VITOM 3D exoscope-guided system and the Pentero operating microscope. These anastomoses were then evaluated for their quality and anastomosis time. The participants and the other eight surgeons, who had used the digital 3D camera system for microsurgical training exercises and vascular sutures, answered a questionnaire. The anastomosis time and number of complications were lower with the conventional microscope. Participants rated the image quality with the conventional microscope as higher, whereas the field of view and ergonomics were favorable in the digital 3D camera system. Exoscopes are optics suitable for performing simple microvascular procedures and are superior to classical microscopes ergonomically. Thus far, they are inferior to classical microscopes in terms of image quality and 3D imaging.

The impact of passive alveolar molding vs. nasoalveolar molding on cleft width and other parameters of maxillary growth in unilateral cleft lip palate.

OBJECTIVE: Passive alveolar molding (PAM) and nasoalveolar molding (NAM) are established presurgical infant orthodontic (PSIO) therapies for cleft lip palate (CLP) patients. PAM guides maxillary growth with a modified Hotz appliance, while NAM also uses extraoral taping and includes nasal stents. The effects of these techniques on alveolar arch growth have rarely been compared. MATERIAL AND METHODS: We retrospectively compared 3D-scanned maxillary models obtained before and after PSIO from infants with unilateral, non-syndromic CLP treated with PAM (n = 16) versus NAM (n = 13). Nine anatomical points were set digitally by four raters and transversal/sagittal distances and rotations of the maxilla were measured. RESULTS: Both appliances reduced the anterior cleft, but NAM percentage wise more. NAM decreased the anterior and medial transversal width compared to PAM, which led to no change. With both appliances, the posterior width increased. The alveolar arch length of the great and small segments and the sagittal length of the maxilla increased with PAM but only partially with NAM. However, NAM induced a significant greater medial rotation of the larger and smaller segment compared to PAM with respect to the lateral angle. CONCLUSIONS: NAM and PAM presented some significant differences regarding maxillary growth. While NAM reduced the anterior cleft and effectively rotated the segments medially, PAM allowed more transversal and sagittal growth. CLINICAL RELEVANCE: The results of this study should be taken into consideration when to decide whether to use PAM or NAM, since they show a different outcome within the first few months. Further studies are necessary regarding long-term differences.

Effect of segmental versus marginal mandibular resection on local and lymph node recurrences in oral squamous cell carcinoma: is tumorous bone infiltration or location and resulting soft tissue recurrences a long-term problem?

PURPOSE: Oral squamous cell carcinomas (OSCCs) adjacent to the mandible or with clinically suspected bone infiltration are surgically treated either with marginal or segmental resections. This retrospective study compared both resections regarding local recurrence and lymph node recurrence or secondary lymph node metastases. METHODS: All consecutive primary OSCC cases between January 2007 and December 2015 that underwent mandibular marginal or segmental resection were included. Rates of local and lymph node recurrences or secondary metastases and possible risk factors such as tumor localization according to Urken's classification were recorded. RESULTS: In total, 180 patients with 85 marginal (group I) and 95 segmental (group II) mandibular resections were analyzed. The local recurrence rates were comparable between the groups (28.2% vs. 27.4%; p = 0.897). Lymph node recurrences or secondary metastases were higher in group I (9.4% (n = 8) vs. 6.2% (n = 6); p = 0.001). Tumor localization appears to affect the outcomes. Significantly fewer local and lymph node recurrences/metastases were found for Urken's classification SB and S calculated by two-proportion z-test (p = 0.014 and 0.056, respectively). Local recurrences mostly emerged from soft tissues, which should be resected more radically than the bones. CONCLUSION: While bone infiltration appears technically well controllable from an oncologic point of view, local recurrences and lymph node recurrences/metastases remain an issue. Regular clinical aftercare with imaging is crucial to detect recurrences.

Mandibular reconstructions with free fibula flap using standardized partially adjustable cutting guides or CAD/CAM technique: a three- and two-dimensional comparison.

Background: Mandibular reconstruction with the fibula free flap (FFF) is performed freehand, CAD/CAM-assisted, or by using partially adjustable resection/reconstruction aids. The two latter options represent the contemporary reconstructive solutions of the recent decade. The purpose of this study was to compare both auxiliary techniques with regard to feasibility, accuracy, and operative parameters. Methods and materials: The first twenty consecutively operated patients requiring a mandibular reconstruction (within angle-to-angle) with the FFF using the partially adjustable resection aids between January 2017 and December 2019 at our department were included. Additionally, matching CAD/CAM FFF cases were used as control group in this cross-sectional study. Medical records and general information (sex, age, indication for surgery, extent of resection, number of segments, duration of surgery, and ischemia time) were analyzed. In addition, the pre- and postoperative Digital Imaging and Communications in Medicine data of the mandibles were converted to standard tessellation language (.stl) files. Conventional measurements - six horizontal distances (A-F) and temporo-mandibular joint (TMJ) spaces - and the root mean square error (RMSE) for three-dimensional analysis were measured and calculated. Results: In total, 40 patients were enrolled (20:20). Overall operation time, ischemia time, and the interval between ischemia time start until end of operation showed no significant differences. No significant difference between the two groups were revealed in conventional measurements of distances (A-D) and TMJ spaces. The Δ differences for the distance F (between the mandibular foramina) and the right medial joint space were significantly lower in the ReconGuide group. The RMSE analysis of the two groups showed no significant difference (p=0.925), with an overall median RMSE of 3.1 mm (2.2-3.7) in the CAD/CAM and 2.9 mm (2.2-3.8) in the ReconGuide groups. Conclusions: The reconstructive surgeon can achieve comparable postoperative results regardless of technique, which may favor the ReconGuide use in mandibular angle-to-angle reconstruction over the CAD/CAM technique because of less preoperative planning time and lower costs per case.

Infantile human labial glands: Distribution of aquaporins and claudins in the context of paracellular and transcellular pathways.

Human labial glands consist of saliva-secreting cells which are formed by serous and predominantly mucous glandular cells. The following excretory duct system converts the isotonic saliva into a hypotonic fluid. Liquids are transported across the membrane of epithelial cells by paracellular or transcellular mode of action. We studied aquaporins (AQP) and tight junction proteins in the endpieces and duct system of human labial glands of 3-5-month-old infants for the first time. AQP1, AQP3, and AQP5 represent the transcellular transport; tight junction proteins like claudin-1, - 3, - 4, and - 7 regulate the permeability of the paracellular pathway. Specimens of 28 infants were included in this study and analyzed histologically. AQP1 was present in myoepithelial cells and in endothelial cells of small blood vessels. AQP3 showed basolateral plasmamembrane localization in glandular endpieces. AQP5 was localized at the apical cytomembrane in serous and mucous glandular cells and at the lateral membrane in serous cells. Ducts remained unstained with the antibody to AQP1, AQP3, and AQP5. Claudin-1, - 3, - 4, and - 7 were expressed mainly in the lateral plasmamembrane of serous glandular cells. In the ducts, claudin-1, - 4, and - 7 were detected at the basal cell layer, claudin-7 also at the lateral cytomembrane. Our findings provide new insights into the localization of epithelial barrier components necessary for regulating saliva-modification in infantile labial glands.

Conditioning of microvascular venous flaps in rats.

Venous-only perfusion flaps have not been used widely because of the associated high failure rate. Tissue conditioning offers a broad scope of techniques that can be applied pre-, peri-, or postoperatively to promote the adaptation of the affected tissue to any subsequent stress. This study aimed to assess the survival rates associated with a pure venous perfusion flap and investigate whether the timing of the vascular conditioning can affect free flap survival. Forty-four rats were included in the experiment. Group I underwent veno-arterial anastomoses with epigastric graft with pure venous perfusion without tissue conditioning. Groups II and III were pretreated for 7 or 14 days with ischemic conditioning. These groups were compared with a control group (group IV) of conventionally perfused flaps. After the initial surgery, all flaps were assessed clinically, photometrically, and by indocyanine green videoangiography. The flap success rates were 0% in group I, 49.97% ± 24.34% in group II, and 64.95% ± 20.36% in group III. The control group showed an overall survival of 89.3% ± 6.51%. With suitable conditioning, pure venous blood supply can provide adequate perfusion in the rat epigastric flap model. The timing of vascular conditioning appears to be critical for flap survival.

Imaging of traumatic mandibular fractures in young adults using CT-like MRI: a feasibility study.

OBJECTIVES: To assess and compare the diagnostic performance of CT-like images based on a three- dimensional (3D) T1-weighted spoiled gradient-echo sequence (3D T1 GRE) with CT in patients with acute traumatic fractures of the mandible. MATERIALS AND METHODS: Subjects with acute mandibular fractures diagnosed on conventional CT were prospectively recruited and received an additional 3 T MRI with a CT-like 3D T1 GRE sequence. The images were assessed by two radiologists with regard to fracture localization, degree of dislocation, and number of fragments. Bone to soft tissue contrast, diagnostic confidence, artifacts, and overall image quality were rated using a five-point Likert-scale. Agreement of measurements was assessed using an independent t-test. RESULTS: Fourteen subjects and 22 fracture sites were included (26 ± 3.9 years; 4 females, 10 males). All traumatic fractures were accurately detected on CT-like MRI (n = 22, κ 1.00 (95% CI 1.00-1.00)). There was no statistically significant difference in the assessment of the fracture dislocation (axial mean difference (MD) 0.06 mm, p = 0.93, coronal MD, 0.08 mm, p = 0.89 and sagittal MD, 0.04 mm, p = 0.96). The agreement for the fracture classification as well as the inter- and intra-rater agreement was excellent (range κ 0.92-0.98 (95% CI 0.96-0.99)). CONCLUSION: Assessment of mandibular fractures was feasible and accurate using CT-like MRI based on a 3D T1 GRE sequence and is comparable to conventional CT. CLINICAL RELEVANCE: For the assessment of acute mandibular fractures, CT-like MRI might become a useful alternative to CT in order to reduce radiation exposure particularly in young patients.

Blood flow analyses by intraoperative transit-time flow measurements of free flaps for head and neck reconstructions: A prospective single-center study.

BACKGROUND: The behavior of blood flow changes within free flaps following microvascular anastomosis is not well described in the literature. The aim of this study was to determine the immediate blood flow behavior of different free flaps as reference values for various clinical applications. METHODS: Intraoperative transit-time flow measurements were performed on patients receiving free flap transfer in the head and neck area comprising radial forearm flaps (RFF), peroneal artery perforator flaps (PAP), anterolateral thigh flaps (ALT), vastus lateralis flaps (VLF), parascapular flaps (PSF), latissimus dorsi flaps (LDF), fibula free flaps (FFF), deep circumflex iliac artery flaps (DCIA), and scapular flaps (SF). In accordance with a structured protocol, measurements took place at the pedicle directly before flap harvesting and at the recipient vessels 1 h after flap transfer. Heart rate, transplant weight, and other patient characteristics were recorded and analyzed. RESULTS: A total of 129 were enrolled, comprising 66 RFF, 8 ALT, 6 PAP, 11 VLF, 3 PSF, 2 LDF, 24 FFF, 7 DCIA, and 2 SF. In most of the transplant groups, arterial perfusion increased after anastomosis at the recipient site. The arterial pulsatility index developed indirectly proportionally to arterial blood flow, whereas venous blood drainage did not show any statistically significant changes. Muscle flaps had the highest arterial perfusion before flap transfer. Composite transplants with hard and soft tissue presented the greatest increase in arterial perfusion. The lowest arterial blood flow after anastomosis was measured in PAP and RFF. In contrast, RFF and PAP presented the highest arterial perfusion per 100 g transplant weight. CONCLUSIONS: Arterial perfusion changed, whereas venous blood flow did not show any statistically significant variations in any transplant group. Perfusion of free flaps does not only depend on the recipient vessel and the recipient bed, but also on flap-specific anatomy and physiology.

Delphi survey of intercontinental experts to identify areas of consensus on the use of indocyanine green angiography for tissue perfusion assessment during plastic and reconstructive surgery.

BACKGROUND: In recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery. METHODS: A two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement. RESULTS: Consensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20-60 seconds preassessment) and best camera angle (61-90o) and target-to-tissue distance (20-30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments. CONCLUSION: ICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool.

Superficial Temporal Artery and Vein as Alternative Recipient Vessels for Intraoral Reconstruction With Free Flaps to Avoid the Cervical Approach With the Resulting Need for Double Flap Transfer in Previously Treated Necks.

Background: Microvascular reconstruction remains challenging in previously operated and irradiated patients, especially when double flaps seem to be the only solution due to osteoradionecrosis. An alternative reconstructive option could be microvascular anastomosis to the temporal vessels to avoid the obligatory cervical incision. Methods and Materials: All consecutive cases between January 2013 and 2020 that underwent either mandibular resection and reconstruction with a free fibula flap (FFF) and another soft tissue flap (group I) or pure intraoral resection and reconstruction with an FFF or radial forearm flap (RFF) with temporal microvascular anastomosis (group II) were included. Patients' general information, indication and extent of surgery, time of ischemia, time of total surgery, and duration of hospital stay as well as incidence of complications were retrospectively recorded and analyzed. Results: Seventeen (group I) and 11 (group II) cases were included. In group I, FFF was combined with RFF (n = 9), anterolateral thigh flap (ALT, n = 7), or latissimus dorsi flap (n = 1). Group II consisted of six FFFs and five RFFs. Operation time and hospitalization duration were significantly shorter in group II (p < 0.001 and p = 0.025), whereas ischemic time of FFF was significantly shorter in group I (p = 0.002). All patients in group I required a tracheostomy, while only four cases in group II did (p = 0.004). The complication rate regarding hematoma removal, revision of anastomosis, flap loss, delirium, sepsis, pleural effusion, pneumonia, and pulmonary artery embolism showed no significant differences between the two groups. Conclusions: The superficial temporal vessels served as versatile recipient vessels for intraoral mandibular and soft tissue reconstruction and led to reduced operation time, hospitalization duration, and indication for a primary tracheostomy. Thus, this approach may help to avoid cervical incision for reconstruction in irradiated patients.

Results of a Clinical Scoring System Regarding Symptoms and Surgical Treatment of Isolated Unilateral Zygomatico-Orbital Fractures: A Single-Centre Retrospective Analysis of 461 Cases.

Systematic assessment of computed tomography (CT) scans and clinical symptoms is necessary to quickly indicate the correct treatment of zygomatico-orbital (ZMO) fractures. For this purpose, a clinical scoring system (=Clinical Score) was developed and correlated with CT scans to analyse its validity. Every operated, isolated, and unilateral ZMO fracture between January 2012 and December 2016 was screened retrospectively, including patient and treatment data. All available CT scans were analysed, and the grade of dislocation was measured for each case and plane. Four hundred and sixty-one cases were included and showed a median surgery time of 66.0 min (5.0−361.0) and a median postoperative hospital stay of three days (0−25). The distribution of gender, aetiologies and age groups was significantly different (each p = 0.001), and the aetiology had a significant influence on the Clinical Score (p = 0.038). The degree of dislocation in the coronary and sagittal planes correlated significantly with the Clinical Score with regard to the orbital involvement (p < 0.001, ρ = 0.566; p < 0.001, ρ = 0.609). The simple, quick, and easy-to-apply Clinical Score showed a significant correlation with the most important planes in CT scans as well as with the clinical course. It may facilitate fast risk stratification of the patient. However, the validity of the proposed score in determining indications must now be evaluated in a prospective setting, including both operated and non-operated fractures.

Preoperative Peroneal Artery Perforator Mapping Using Indocyanine Green Angiography: A Prospective Clinical Trial.

BACKGROUND: Perforator imaging is a prerequisite in preoperative planning of the peroneal perforator flap and the fibula skin island. Although reports indicate that indocyanine green angiography assessment method might be advantageous over conventional ultrasound-based techniques (i.e., Doppler and color duplex), in practice, clear evidence is lacking. Thus, a comparative assessment of the utility of indocyanine green angiography and ultrasound-based techniques in the identification of suitable lower leg skin perforators was performed. METHODS: A prospective clinical cohort study with a series of 12 consecutive patients was conducted to assess indocyanine green angiography, Doppler ultrasound, and color duplex ultrasound techniques for preoperative perforator detection in the lower leg before free fibula flap harvest. Anatomical dissection served as a reference. Parameters measured were perforator spatial distance to the reference (precision), operative time expenditure, and ease of device usage for assessment/outcomes. RESULTS: This study included 12 patients, with a total of 27 perforators. Exhibition of technique sensitivity and positive predictive values were as follows: indocyanine green angiography, 93 percent and 100 percent; Doppler ultrasound, 82 percent and 82 percent; and color duplex ultrasound, 89 percent and 86 percent, respectively. With regard to the indocyanine green angiography technique, the distance to the actual perforator location was significantly shorter, which aided detection and lesser time expenditure during operation. CONCLUSIONS: The indocyanine green angiography technique proved to have high precision, sensitivity, positive predictive value, and easy-to-use capabilities because of its exceptional spatial and temporal information, compared to the conventional, ultrasound-based techniques. Therefore, indocyanine green angiography is superior for preoperative perforator imaging of the lateral lower leg. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Oral bacteria in infective endocarditis requiring surgery: a retrospective analysis of 134 patients.

OBJECTIVES: It has been reported that bacteria associated with infective endocarditis originate from the oral cavity in 26-45% of cases. However, little is known on the counts and species of periodontal microbiota in infected heart valves. The aim of this study was to identify these aspects of periodontal microbiota in infective endocarditis and to potentially initiate a dental extraction concept for periodontally compromised teeth concerning patients requiring heart valve surgery. MATERIALS AND METHODS: The retrospective study group consisted of tissue samples from infected heart valves of 683 patients who had undergone heart valve surgery. Before patients had undergone cardiac surgery, the following laboratory tests confirmed the occurrence of endocarditis in all patients: blood cultures, echocardiography, electrocardiography, chest X-ray, and electrophoresis of the serum proteins. The specimens were aseptically obtained and deep frozen immediately following surgery. Microbiological diagnosis included proof of germs (dichotomous), species of germs, and source of germs (oral versus other). RESULTS: Microbiota was detected in 134 (31.2%) out of 430 enrolled patients. Oral cavity was supposed to be the source in 10.4% of cases, whereas microbiota of the skin (57.5%) and gastrointestinal tract (GIT, 24.6%) were detected considerably more frequently. Moreover, periodontal bacteria belonged mostly to the Streptococci species and the yellow complex. None of the detected bacteria belonged to the red complex. CONCLUSION: Most frequently, the skin and GIT represented the site of origin of the microbiota. Nevertheless, the oral cavity represented the source of IE in up to 10%. Consequently, it needs to be emphasized that a good level of oral hygiene is strongly recommended in all patients undergoing heart valve surgery in order to reduce the bacterial load in the oral cavity, thereby minimizing the hematogenous spread of oral microbiota. The prerequisites for conservative dental treatment versus radical tooth extraction must always be based on the patient's cooperation, and the clinical intraoral status on a sense of proportion in view of the overall clinical situation due to the underlying cardiac disease. CLINICAL RELEVANCE: The oral cavity is a source of oral microbiota on infected heart valves. Patients requiring heart valve surgery should always undergo a critical evaluation of dental treatment affecting periodontally compromised teeth, favoring a systematic, conservative-leaning recall.