Platelet-Rich Plasma Lysate Enhances the Osteogenic Differentiation of Adipose-Derived Stem Cells.

ABSTRACT: Adipose-derived stem cells (ADSCs) have become an accepted source of cells in bone tissue engineering. This study aimed to investigate whether platelet-rich plasma (PRP) lysate can replace traditional fetal bovine serum as a culture medium with the enhanced proliferation and osteogenic potential of ADSCs. We divided the experiment into 5 groups where the ADSCs were cultured in an osteogenic medium containing 2.5%, 5%, 7.5%, and 10% PRP lysate with 10% fetal bovine serum as the control group. The cell proliferation, alkaline phosphatase (ALP) activity, ALP stain, alizarin red stain, osteocalcin (OCN) protein expression, and osteogenic-specific gene expression were analyzed and compared among these groups. The outcome showed that all PRP lysate-treated groups had good ALP stain and ALP activity performance. Better alizarin red stains were found in the 2.5%, 5%, and 7.5% PRP lysate groups. The 2.5% and 5% PRP lysate groups showed superior results in OCN quantitative polymerase chain reaction, whereas the 5% and 7.5% PRP lysate groups showed higher OCN protein expressions. Early RUNX2 (Runt-related transcription factor 2 () genes were the most expressed in the 5% PRP lysate group, followed by the 2.5% PRP lysate group, and then the 7.5% PRP lysate group. Thus, we concluded that 5% PRP lysate seemed to provide the optimal effect on enhancing the osteogenic potential of ADSCs. Platelet-rich plasma lysate-treated ADSCs were considered to be a good cell source for application in treating nonunion or bone defects in the future.

The Comparison of Functional Outcomes in Patients With Unilateral or Bilateral Intracapsular Mandibular Condylar Fractures After Closed or Open Treatment: A 10-Year Retrospective Study.

BACKGROUND: The treatment strategies for mandibular condylar head fractures, also known as intracapsular condylar fractures (ICFs), have not been concluded. We humbly present our treatment outcomes and share our experience in our department. AIMS AND OBJECTIVES: The aim of this study was to compare the functional outcomes between closed reduction (CR) and open reduction and internal fixation (ORIF) for management of unilateral or bilateral ICFs. MATERIALS AND METHODS: This 10-year retrospective cohort study included 71 patients with 102 ICFs who were treated in our department from May 2007 to August 2017. Nine patients mixed with extracapsular fractures were excluded; thus, 62 patients with 93 ICFs were included. All patients received treatment by the senior surgeon in Chang Gung Memorial Hospital, Linkou Branch, Taiwan. The patient's basic data, fracture morphologies, associated injuries, managements, complications, and maximal mouth opening (MMO) measurement at 1, 3, 6, and 12 months postoperative were reviewed for analysis. RESULTS: Among the 93 fractures, 31 (50%) were bilateral and 31 were unilateral (50%). Based on He's classification, 45 (48%) had type A fracture, 13 (14%) had type B, 5 (5%) had type C, 20 (22%) had type M, and 10 (11%) had no displacement. Maximal mouth opening of 37 mm in unilateral cases after 6 months was significantly higher than the 33-mm MMO in bilateral cases. In addition, the MMO in the ORIF group was significantly higher than that of the CR group in 3 months postoperative. Univariate (odds ratio, 4.92; P = 0.01) and multivariate (odds ratio, 4.76; P = 0.027) analyses revealed CR as an independent risk factor for trismus development compared with ORIF. Malocclusion was observed in 5 patients in both CR and ORIF groups. In addition, 1 patient developed temporomandibular joint osteoarthritis in the CR group. No surgical-related temporary or permanent facial nerve palsy was observed. CONCLUSIONS: Open reduction and internal fixation for condylar head fracture provided better recovery in MMO than CR, and the MMO recovery was less in bilateral condylar head fracture than unilateral condylar head fracture. Open reduction and internal fixation in ICFs have a lower risk for trismus development and should be the treatment of choice in selected cases.

Application of Orthognathic Surgery Principles and Techniques in the Management of Craniomaxillofacial Trauma.

BACKGROUND: Posttraumatic secondary deformities of facial skeleton may occur because of nonmanagement or ill management of primary injuries, whereas some unexpectedly occur even after dedicated management attempts. Orthognathic surgery (OGS) principles and techniques can be used as an efficient tool to correct posttraumatic craniomaxillofacial deformities or skeletal developmental deformities during trauma management. AIM AND OBJECTIVES: The aims of this study were to describe the different types of posttraumatic secondary deformity and address how to use the principles of orthognathic techniques to correct them. MATERIALS AND METHODS: Patients with orthognathic surgical osteotomies during primary or secondary management of facial trauma (referred to as trauma-OGS) during the period of 2010 to 2018 were retrospectively reviewed. Variables pertaining to patients and surgery were collected, including trauma diagnosis, etiology, duration between trauma/primary surgery and secondary presentation, suggested reason for secondary deformity, intervention undertaken to address, and the surgical outcome. RESULTS: Twenty-seven patients were eligible and extensively reviewed. Etiological categorization of trauma-OGS could be done into posttraumatic deformities (18) and developmental deformities (9). The former group was further categorized as OGS done as primary procedure (8) that included immobile Le Fort fractures and delayed initial treatment, and OGS done as secondary procedure (10) that included complex fractures and condylar fractures. The developmental deformity group was categorized into OGS done simultaneously during trauma management (5) or done as a secondary procedure after trauma management (4). CONCLUSIONS: Application of principles and techniques of OGS in indicated primary or secondary management of facial trauma patients should always be considered. The categorization of scenarios presented in this article relating facial trauma and OGS may further help to understand the application.

Facial Fracture Patterns and Severity of Associated Injuries After Motorcycle Accidents.

BACKGROUND: Motorcycle injuries remain a significant cause of motor vehicle-related morbidity and mortality in Taiwan. Besides, the facial region is a commonly fractured site under motorcycle accidents. To date, there are no trauma mechanism-based studies of facial fractures. AIM AND OBJECTIVES: This study aims to determine the facial fracture patterns, the severity of head trauma, and associated injuries by different motorcycle-related trauma mechanisms enabling a greater understanding of its distribution and magnitude. METHODS: This is a retrospective descriptive analysis conducted over a 2-year period at Linkou Chang Gung Memorial Hospital. We focused on the population of maxillofacial injury caused by motorcycle accidents. We divided the patient cohort into 3 main trauma mechanisms: single-motorcycle collision (SM group), motorcycle-to-motorcycle collision (MM group), motorcycle-to-vehicle collision (MV group). Data, including demographics, age, fracture patterns of facial bones, and other associated injuries, were collected. RESULTS: A total of 881 cases were identified that involved facial fractures. Most patients were male (71%), young adult (mean age, 32.49 years), and the most common fracture region is the midfacial fracture (79.5%, 700 victims). Among the 3 groups, the MM group was less likely to sustain severe injuries by trauma score system, less head injury and mortality rate. The MV group and SM group have similar mortality rates but different fracture pattern tendencies. Lower facial fractures were more likely in the MV group, but midface fractures in the SM group. Associated injuries were higher in the MV group. CONCLUSIONS: Our study presents the different trends of fracture patterns and injury under 3 main mechanisms of motorcycle casualties. We document all these data in the hope of providing insights into trauma doctors dealing with motorcycle accidents.

Comparison of the Effectiveness Between Conventional and Modified Cinch Suture Techniques in LeFort I Osteotomy: A Systematic Review and Meta-Analysis of Randomized Control Trials.

BACKGROUND: LeFort I osteotomy changes the morphology of the nose. The cinch suture has been proven to prevent the increase in nasal base and alar width. Different types of cinch sutures have been proposed. However, their effectiveness is unclear. AIM AND OBJECTIVES: The aim of this study was to compare the surgical outcomes between conventional and modified cinch techniques through a systematic review and meta-analysis of randomized control trials (RCTs). MATERIAL AND METHODS: We performed systematic search from Embase, PubMed, and the Cochrane Library according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement up to March 2021. The surgical techniques of different cinch sutures were reviewed, and the outcomes of nasal alar width and alar base width were compared between modified and conventional methods. RESULTS: A total of 4 eligible RCTs were included in this meta-analysis. Pooled data showed no significant difference in alar base width change between modified and conventional methods (mean difference, -0.37; 95% confidence interval, -1.32 to 0.57; P = 0.44). Pooled data of 3 studies also showed no significant difference in nasal alar width change (mean difference, -0.11; 95% confidence interval, -1.18 to 0.95; P = 0.83). CONCLUSION: Based on the current data pooled from the available RCTs, no significant difference was found between the conventional cinch technique and the modified technique.

Aesthetic Outcome of Primary Rhinoplasty of Saddle Nose Deformity in Naso-Orbital Ethmoidal Fractures in Asian Patients.

BACKGROUND: Saddle nose deformity following naso-orbital ethmoidal (NOE) fractures remain a challenging problem for the reconstructive surgeon. Early reduction and internal fixation allow for fracture stabilization but is unable to address the problem of the depressed nasal dorsum, especially after soft tissue shrinkage. The aim of this study is to evaluate the outcome of primary rhinoplasty in patients with NOE fractures. MATERIALS AND METHODS: From 2016 to 2019, 9 patients presented to our department with NOE fractures complicated by saddle nose deformity underwent primary nasal reconstruction at the time of their fracture fixation. Life size (1:1) frontal and lateral postoperative photographs were taken. Three objective measurements were made, including the nasofrontal angle, tip projection, and radix projection. These measurements were compared between normal persons (group 1), preoperative patients (group 2), and postoperative patients (group 3). Nose aesthetic assessment was carried out via a panel assessment using a Visual Analog Scale of 5. Patient satisfaction was further assessed subjectively by the patient themselves using the Visual Analog Scale. RESULTS: When comparing group 3 to 2, a significant reduction in the nasofrontal angles was found with an accompanying increase in the radix and tip projection ( P <0.05). No statistical significance between normal persons and postprimary rhinoplasty patients was noted between groups 1 and 3. Average patient satisfaction scored 3.86±1.07 compared with 3.63±0.84 by laypersons and 4±0.77 by specialists' panel. CONCLUSION: Primary nasal reconstruction may be an alternative method for achieving optimum results following NOE fractures preventing the development of secondary saddle nose deformity with a shortened nose which may potentially be more difficult to correct.

Le Fort Fractures With Maxillary Immobility: Classification and the Moment Concept to Rationalize Optimal Surgical Treatment.

BACKGROUND: Le Fort fractures with maxillary immobility are an uncommon presentation of facial trauma often associated with the disturbance of occlusion. Historically, cases involving high Le Fort fractures require a coronal extensive approach to mobilize the maxilla for occlusion restoration. Here, we review our institutional series of immobile Le Fort fractures and present their treatment approach, outcomes, classification, and then rationalize our treatment with a concept philosophy. MATERIALS AND METHODS: We treated 12 consecutive patients with unilateral and bilateral immobile Le Fort fractures from 2010 to 2017. The mean age was 27.1 years. Ten patients had a unilateral greenstick Le Fort III fracture. Five patients also had associated mandible fractures. Intraoperative occlusions could only be restored after Le Fort I osteotomy was performed on the side of the immobile Le Fort fracture. The mean follow-up period was 1.6 years. RESULTS: All patients presented good long-term occlusion restoration. There were no cases of nonunion or significant complications. None of the patients complained of any malar or periorbital cosmetic issues during follow-up sessions. CONCLUSIONS: We presented an institutional series and classification of unusual Le Fort fractures with maxillary immobility, including a previously unreported fracture configuration of greenstick unilateral Le Fort III fractures combined with complete contralateral Le Fort I fracture. Based on our moment concept to rationalize treatment, as well as a systematic review of published literature, we advocate the judicious use of Le Fort I osteotomy to efficiently and safely treat these unusual fractures.

Functional Outcomes of Surgical Management of Mandibular Condylar Head Fractures.

BACKGROUND: Various procedures have been described for the management of mandibular condylar head fracture, but a standard treatment is not yet conclusive. This report describes our experience with osteosynthesis of condylar head fracture at Linkou Chang Gung Memorial Hospital. METHODS: Sixteen patients with unilateral or bilateral mandibular condylar head fractures diagnosed by computed tomography and treated by open reduction and internal fixation between August 2014 and September 2016 were retrospectively reviewed. A preauricular approach was consistently used for internal fixation with 2 microplates and 4 screws after anatomic reduction. Occlusion, maximum mouth opening (MMO), radiographic outcome, and complications were recorded. RESULTS: Mean ± SD patient age was 29.5 ± 11.4 years, and mean ± SD procedure time was 264.3 ± 83.1 minutes. Mean ± SD postoperative MMO was 23.5 ± 10.2 mm at 1 month, 34.1 ± 8.6 mm at 3 months, 39.1 ± 5.7 mm at 6 months, and 40.0 ± 6.8 at 1 year. Early recovery of MMO of greater than 30 mm was achieved by 13 patients at 3 months after open reduction and internal fixation. There were no major complications. CONCLUSIONS: Microplate fixation from the posterior aspect of the mandibular condylar head via the preauricular approach was safe for patients with mandibular condylar head fractures.

Preparation and Characterization of Surface Heat Sintered Nanohydroxyapatite and Nanowhitlockite Embedded Poly (Lactic-co-glycolic Acid) Microsphere Bone Graft Scaffolds: In Vitro and in Vivo Studies.

In the context of using bone graft materials to restore and improve the function of damaged bone tissues, macroporous biodegradable composite bone graft scaffolds have osteoinductive properties that allow them to provide a suitable environment for bone regeneration. Hydroxyapatite (HAP) and whitlockite (WLKT) are the two major components of hard tissues such as bone and teeth. Because of their biocompatibility and osteoinductivity, we synthesized HAP (nHAP) and WLKT nanoparticles (nWLKT) by using the chemical precipitation method. The nanoparticles were separately incorporated within poly (lactic-co-glycolic acid) (PLGA) microspheres. Following this, the composite microspheres were converted to macroporous bone grafts with sufficient mechanical strength in pin or screw shape through surface sintering. We characterized physico-chemical and mechanical properties of the nanoparticles and composites. The biocompatibility of the grafts was further tested through in vitro cell adhesion and proliferation studies using rabbit bone marrow stem cells. The ability to promote osteogenic differentiation was tested through alkaline phosphate activity and immunofluorescence staining of bone marker proteins. For in vivo study, the bone pins were implanted in tibia bone defects in rabbits to compare the bone regeneration ability though H&E, Masson's trichrome and immunohistochemical staining. The results revealed similar physico-chemical characteristics and cellular response of PLGA/nHAP and PLGA/nWLKT scaffolds but the latter is associated with higher osteogenic potential towards BMSCs, pointing out the possibility to use this ceramic nanoparticle to prepare a sintered composite microsphere scaffold for potential bone grafts and tissue engineered implants.

Functional and Aesthetic Outcome of Extensive Orbital Floor and Medial Wall Fracture via Navigation and Endoscope-assisted Reconstruction.

BACKGROUND AND PURPOSE: Extensive orbital floor and medial wall fractures compared with isolated orbital wall fractures are more likely to require surgical correction because of a higher possibility of complications like diplopia, enophthalmos, or numbness. The unique and complex contours of the orbital anatomy limit the intraoperative view of the intraorbital anatomy, and complex orbital fractures involving the buttress of the transition zone area all make orbital reconstruction surgery more challenging. The aim of this study was to describe our experience with surgical approaches using navigation- and endoscope-assisted guidance for extensive orbital floor and medial wall fracture reconstruction. PATIENTS AND METHODS: A retrospective study was conducted on consecutive 17 patients from 2015 to 2017 presenting with unilateral extensive orbital floor and medial wall fractures at the Chang Gung Memorial Hospital, Linkou Branch. The fractures were treated surgically with a preformed mesh plate and layered Medpor (Porex Surgical Inc, Atlanta, Ga) through navigation and endoscopy. The preoperative and postoperative functional and aesthetic outcomes were described. RESULTS: All extensive orbital floor and medial wall fractures were successfully reconstructed. Of the 17 patients, 11 experienced diplopia preoperatively, and for 2 of the 11 patients, diplopia improved immediately after surgery. In the remaining 9 patients, diplopia still persisted after surgery; however, diplopia recovered after an average of 3.44 months (range, 1-9 months). Average enophthalmos among the 10 patients, evaluated by postoperative follow-up computed tomography scan, improved from 2.99 to 0.68 mm. There were no major complications during follow-up, and all patients were satisfied with their final appearance and function. CONCLUSIONS: On the basis of the results, our surgical approach using preformed titanium mesh plates and Medpor under the assistance of navigation and endoscopy can be a safe, accurate, and effective method for the management of extensive orbital floor and medial wall fractures and clearly optimizes functional and aesthetic outcomes.

The Correlation of Age and Patterns of Maxillofacial Bone Fractures and Severity of Associated Injuries Caused by Motorcycle Accidents.

BACKGROUND: Every year, there are significant numbers of motorcycle accident casualties in Taiwan. These accidents are the leading cause of maxillofacial trauma. Age should be an important factor of maxillofacial fracture patterns yet there is limited literature on the topic. Therefore, this study aims to evaluate the correlation of age with maxillofacial fracture in motorcycle accidents. METHODS: This is a retrospective descriptive analysis conducted over 2-year period at Linkou Chang Gung Memorial Hospital. We focused on the population of maxillofacial injury caused by motorcycle accidents. Data, including demographics, age, fracture patterns of facial bones, and other associated injuries, were collected. RESULTS: Among 881 admissions, there were 179 patients in the minor group, 644 patients in the adult group, and 58 patients in the geriatric group. With patterns of maxillofacial fracture, midface fracture was the most common type. The minor group had higher incidence of mandibular fracture. The geriatric group sustained more midface fracture. Associated injuries, such as severe head injuries and c-spine injury, were more likely to occur with the old age victims. The overall mortality rate was 3.1%. CONCLUSIONS: Our study presents the different trends of fracture patterns in different age groups, which is associated with different types of treatment required. We summarized all these data in the hope of providing further assistance to trauma doctor dealing with motorcycle accidents.

Simultaneous Surgical Correction of Skeletal Class III Dentofacial Deformity During Acute Management of Facial Fractures: Patient Selection and Surgical Technique.

BACKGROUND: Mandibular prognathism is a common dentofacial deformity in Asia. Treatment of such condition may vary from orthodontic camouflage to surgical orthodontics with orthognathic surgery depending on the severity of the condition. Because of the prominent position of the mandible, fractures involving different locations of the mandible commonly occur in maxillofacial trauma. Anatomical reduction of maxillofacial fractures and restoration of the pretraumatic occlusion are the primary goals of acute management of facial fractures. In patients with dentofacial deformity, simultaneous surgical correction of their malocclusion and improvement of their facial aesthetics while providing open treatment to the maxillofacial fractures are rarely reported in the literature. PATIENTS AND METHODS: We reported 3 cases with combined open reduction and internal fixation and surgery-first orthognathic surgery principles to correct class III malocclusion with mandibular prognathism during acute management of maxillofacial fractures. Computer-assisted surgical simulation was used in surgical planning and fabrication of surgical splint. RESULTS: Two patients underwent mandibular osteotomies in addition to open reduction and internal fixation of maxillofacial fractures. One patient had both maxillary and mandibular osteotomies during facial fracture repair. Class I occlusion with satisfactory facial profile was achieved in all 3 cases. CONCLUSIONS: Careful patient selection with presurgical planning using computer-assisted surgical simulation is essential in achieving successful outcomes in correcting dentofacial deformities while managing maxillofacial fractures. This combined technique is a viable option in the surgical management of facial fractures in patients with dentofacial deformities.

The Outcome Analysis of Traumatic Facial Nerve Palsy Treated With Systemic Steroid Therapy.

PURPOSE: Although facial nerve palsy is uncommon after a blunt craniofacial injury, it will result in functional and aesthetic disability if full recovery is not achieved. Currently, the management is still controversial and mainly through systemic steroid therapy or surgical decompression. However, current studies mainly focus on the surgical intervention, and only a few of these studies discuss the details of the steroid treatments. Thus, the purpose of this study is to analyze possible prognosis factors of systemic steroid in managing traumatic facial nerve palsy after a blunt craniofacial injury retrospectively. METHODS: During the period from May 2005 to April 2015 at Chang Gung Memorial Hospital, a total of 26 patients who suffered from post-traumatic facial nerve palsy receiving steroid therapy were enrolled in the study. All the patient's charts were reviewed, recorded, and analyzed including the general data, temporal bone fracture type, hospital courses, trauma-related data from emergency room records, and initial and final facial nerve palsy grading. The facial nerve palsy was graded using the House-Brackmann (HB) system; the final HB grade I was set as full recovery. RESULTS: The outcome showed steroid therapy onset within 24 hours (odds ratio [OR] = 10.111; 95% confidence interval [CI] = 1.597-64.005; P = 0.014) and steroid therapeutic duration for longer than 14 days (OR = 11.571; 95% CI = 1.172-114.262; P = 0.036) possessed a significantly better recovery rate. CONCLUSION: This study recommends to apply steroids within 24 hours once post-traumatic facial palsy occurs and the therapy should persist longer than 14 days.

Bone Regeneration Using Adipose-Derived Stem Cells in Injectable Thermo-Gelling Hydrogel Scaffold Containing Platelet-Rich Plasma and Biphasic Calcium Phosphate.

For bone regeneration, a biocompatible thermo-gelling hydrogel, hyaluronic acid-g-chitosan-g-poly(N-isopropylacrylamide) (HA-CPN) was used as a three-dimensional organic gel matrix for entrapping rabbit adipose-derived stem cells (rASCs). Biphasic calcium phosphate (BCP) ceramic microparticles were embedded within the gel matrix as a mineralized bone matrix, which was further fortified with platelet-rich plasma (PRP) with osteo-inductive properties. In vitro culture of rASCs in HA-CPN and HA-CPN/PRP/BCP was compared for cell proliferation and osteogenic differentiation. Overall, HA-CPN/PRP/BCP was a better injectable cell carrier for osteogenesis of rASCs with increased cell proliferation rate and alkaline phosphatase activity, enhanced calcium deposition and mineralization of extracellular matrix, and up-regulated expression of genetic markers of osteogenesis. By implanting HA-CPN/PRP/BCP/rASCs constructs in rabbit critical size calvarial bone defects, new bone formation at the defect site was successfully demonstrated from computed tomography, and histological and immunohistochemical analysis. Taken together, by combining PRP and BCP as the osteo-inductive and osteo-conductive factor with HA-CPN, we successfully demonstrated the thermo-gelling composite hydrogel scaffold could promote the osteogenesis of rASCs for bone tissue engineering applications.

Evaluation of the stromal vascular fraction of adipose tissue as the basis for a stem cell-based tissue-engineered vascular graft.

OBJECTIVE: One of the rate-limiting barriers within the field of vascular tissue engineering is the lengthy fabrication time associated with expanding appropriate cell types in culture. One particularly attractive cell type for this purpose is the adipose-derived mesenchymal stem cell (AD-MSC), which is abundant and easily harvested from liposuction procedures. Even this cell type has its drawbacks, however, including the required culture period for expansion, which could pose risks of cellular transformation or contamination. Eliminating culture entirely would be ideal to avoid these concerns. In this study, we used the raw population of cells obtained after digestion of human liposuction aspirates, known as the stromal vascular fraction (SVF), as an abundant, culture-free cell source for tissue-engineered vascular grafts (TEVGs). METHODS: SVF cells and donor-paired cultured AD-MSCs were first assessed for their abilities to differentiate into vascular smooth muscle cells (SMCs) after angiotensin II stimulation and to secrete factors (eg, conditioned media) that promote SMC migration. Next, both cell types were incorporated into TEVG scaffolds, implanted as an aortic graft in a Lewis rat model, and assessed for their patency and composition. RESULTS: In general, the human SVF cells were able to perform the same functions as AD-MSCs isolated from the same donor by culture expansion. Specifically, cells within the SVF performed two important functions; namely, they were able to differentiate into SMCs (SVF calponin expression: 16.4% ± 7.7% vs AD-MSC: 19.9%% ± 1.7%) and could secrete promigratory factors (SVF migration rate relative to control: 3.1 ± 0.3 vs AD-MSC: 2.5 ± 0.5). The SVF cells were also capable of being seeded within biodegradable, elastomeric, porous scaffolds that, when implanted in vivo for 8 weeks, generated patent TEVGs (SVF: 83% patency vs AD-MSC: 100% patency) populated with primary vascular components (eg, SMCs, endothelial cells, collagen, and elastin). CONCLUSIONS: Human adipose tissue can be used as a culture-free cell source to create TEVGs, laying the groundwork for the rapid production of cell-seeded grafts.

Endoscopic-Assisted Removal of a Rare Mucocele Complicating From Alloplastic Medial Orbital Fracture Reconstruction.

Orbital wall fracture reconstruction is usually recommended to prevent subsequent functional and esthetic complications. Mucocele development following such injuries or its management is recognized but rare sequelae. When they occur, they represent a diagnostic and management dilemma. The authors described a patient with orbital and ethmoidal mucocele. A 62-year-old female patient presented with progressive left exophthalmos 1 year following titanium mesh reconstruction of a medial orbital wall fracture. Computed tomography and magnetic resonance imaging demonstrated an encysted lesion encasing the mesh plate in the left orbit and extending into the ethmoidal sinus. The patient is treated surgically through endoscopic-assisted approach with complete removal of the lesion and lacrimal duct stenting. The patient improved immediately after surgery.

Risk Factors Analysis for the Outcome of Indirect Traumatic Optic Neuropathy With Steroid Pulse Therapy.

BACKGROUND: Although recent evidence suggests a controversy effect of steroids in the management of indirect traumatic optic neuropathy (TON), steroid pulse therapy remains one of the reasonable treatments for patients with indirect TON. It is thought that microcirculatory spasms, edema, and nerve cell necrosis can be prevented or reduced by large doses of steroids. The aim of this study is to analyze the predisposing factors for the recovery of patients with indirect TON who were treated with steroid pulse therapy. MATERIALS AND METHODS: In tracing the 2008 to 2014 data from the Trauma Center of Chang Gung Memorial Hospital, 20 consecutive cases of indirect TON were identified retrospectively. Twenty cases showed no light perception (NLP) under initial ophthalmologic examination. They all received steroid pulse therapy with methylprednisolone in IV form after examination by ophthalmologists, and they did not receive optic nerve decompression. The general data, fracture pattern from images, hospital courses, trauma-related data from ER record, and the initial and final visual data from ophthalmologic records are reviewed. The odds ratio (OR) and 95% confidence intervals (CI) are calculated. Fisher exact test is used for 2 variables to test differences between proportions. Nonparametric statistics are applied to compare the mean values of the data. RESULTS: The results show that for female patients (OR, 3.400; 95% CI, 1.628-7.101; P = 0.049), the administration of methylprednisolone in less than 24 hours from the injury (OR, 3.429; 0.297-39.637), lateral force fracture pattern (OR, 3.500; 0.313-39.153), age of 40 years or younger (OR, 2.333; 0.197-27.567), and pure facial trauma (OR, 3.667; 0.273-49.288) are the predisposing factors for improvement of visual acuity. Patients with orbital blowout fractures (OR, 9.800; 95% CI, 0.899-106.845; P = 0.070), initial free extraocular movement (EOM) (OR, 6.667; 0.809-54.597; P = 0.145), initial intraoptic pressure (IOP) greater than 25 mmHg (OR, 8.000; 0.598-106.936), and higher triage grade (OR, 3.000; 0.447-20.153) are at risk of showing no improvement. CONCLUSIONS: From this study, we might suggest to apply steroid pulse therapy on those patients without contraindication, with an incurring injury less than 24 hours previously. Factors such as sex, age, lateral force fracture pattern, and pure facial trauma revealed a better outcome for improvement of visual acuity. Orbital blowout fractures, initial free EOM, initial IOP greater than 25 mmHg, and higher triage grade suggested poor improvement of visual acuity.

Aesthetic and Functional Outcome of Zygomatic Fractures Fixation Comparison With Resorbable Versus Titanium Plates.

OBJECTIVE: The study compares resorbable versus titanium fixation systems for their aesthetic and functional outcome in the treatment of zygomatic fractures. METHODS: Twenty-seven patients who required operative reduction and internal fixation for zygomatic fractures were studied in the period from April 2007 to March 2008. Fourteen patients who had fixation with resorbable plate/screws (group A) were compared with 13 patients fixed with titanium plates/screws (group B). The aesthetic outcome was evaluated by an overall self-satisfaction score at 2, 4, and 6 weeks and then at 6 months and 1 year postoperative interval, and the degree of displacement from computed tomographic facial bones were compared preoperatively and 1 year postoperatively. The functional outcome was evaluated by a self-satisfaction scoring system and maximum mouth opening during the same time intervals. RESULTS: The outcome showed that the 2 groups were matched in age, sex ratio, fracture severity, total displacement with 5 sutures, and aesthetic scores preoperatively (P > 0.05). The subjective evaluation by patients for functional satisfaction and overall satisfaction all showed lower satisfaction of absorbable group when compared to titanium group within a postoperative 4-week period, but the satisfaction was similar for both groups after 4 weeks. There was no significant difference between the 2 groups at each measured time period. Postoperative total displacement and aesthetic score demonstrated great improvement in fracture reduction and long-term stability in both groups. CONCLUSION: There is no significant difference in the outcome between resorbable and titanium plates/screws in fixation of zygomatic fractures. These findings together with the advantages of biodegradable fixation validate its use in fixing these fractures with minimal morbidity.

The radiographic and functional outcome of bilateral mandibular condylar head fractures: a comparison between open and closed treatment.

UNLABELLED: Bilateral mandibular condylar fractures accounts for 24% to 33% of condylar fractures but the indications of open reduction of bilateral condylar fracture are still controversial. It is generally accepted that displaced subcondylar fractures are indicated for open reduction, but the proper treatment of condylar head fractures are still variable. This retrospective study compares the radiographical and functional outcomes of bilateral condylar head fractures between open and closed reduction groups. MATERIALS AND METHODS: From February 1994 to June 2012, a total of 85 patients with bilateral condylar head fractures were retrospectively reviewed. Among this group, 41 cases underwent open reductions while the other 44 cases had closed reductions. Only adult patients with adequate follow-up and complete radiographic study were included in this study: consisting of 20 patients in the open group and 18 patients in the closed group.The subjective symptoms including temporomandibular joints (TMJ) symptoms, complications or adverse sequelae, and functional results, such as maximal mouth opening, were recorded. The outcome of patient's satisfaction was individually assessed by an independent reviewer. The computed tomographic results after treatment were evaluated between both groups. RESULTS: The mean follow-up period was 25.5±13.3 months. The open reduction group had better postoperative chewing functions, less malocclusion rates, less degree of TMJ pain (p=0.046), better radiographic outcome (p=0.036), and an overall satisfaction rate (p=0.039).There were 4 cases of failure in the closed reduction group. Subsequent open reduction (n=2) and redo closed reduction with intermaxillary fixation (n=2) were performed. Eleven patients in the close reduction group presented persistent malocclusion through objective evaluation. The subsequent treatment included further orthognathic surgery (n=1) and orthodontic treatment (n=7). Three of the patients refused further treatment. CONCLUSIONS: Open reduction for bilateral condylar head fractures presented an overall better functional and radiographic outcome, with higher patient satisfaction if condylar fracture segments were still feasible for rigid fixation.

Increasing the success of reverse sural flap from proximal part of posterior calf for traumatic foot and ankle reconstruction: patient selection and surgical refinement.

In this report, we present our experience on the use of the reverse sural flap for traumatic foot and ankle reconstruction. The patient selection and surgical refinement are discussed. From 2007 to 2010, 11 consecutive patients underwent modified reverse sural flap at the Chang Gung Memorial Hospital. The defects were located at the ankle (three cases), foot (two cases), and heel (six cases). Particular attention was paid to precise patient selection and surgical refinements. Patient selection was based on the lower limb vascular status by palpable distal pedal pulses and ankle brachial index ranging from 0.9 to 1.2. Surgical techniques were refined as precisely locating the perforators of peroneal artery, placing the skin paddle in upper third of leg for a distal region coverage, designing a 7-cm-wide adipofascial pedicle with a 2 cm skin paddle on it, preserving the mesentery structure of sural nerve and concomitant artery with or without including gastrocnemius muscles cuff, no tunneling when inset this flap and supercharging with lesser saphenous vein whenever needed. All the flaps survived completely. Only one patient required immediate anastomosis of lesser saphenous vein to local vein around defect in order to relieve the venous congestion during operation. Patients felt diminished but adequate recovery of sense of touch and temperature at the flap. Following the precise patient selection and surgical refinements, the modified reverse sural flap seemed to be a reliable and effective local flap for reconstruction of the soft tissue defects on ankle and foot.