Enhanced bone formation by strontium modified calcium sulfate hemihydrate in ovariectomized rat critical-size calvarial defects.

The development of a new generation of biomaterials with high osteogenic ability for treatment of osteoporotic fractures is being intensively investigated. The objective of this paper was to investigate new bone formation in an ovariectomized rat (OVX rat) calvarial model of critical size bone defects filled with Sr-containing α-calcium sulfate hemihydrate (SrCSH) cement compared to an α-calcium sulfate hemihydrate (α-CSH) cement and empty defect. X-ray diffraction analysis verified the partial substitution of Sr2+ for Ca2+ did not change the phase composition of α-CSH. Scanning electron microscopy showed that Sr-substituted α-CSH significantly increased the surface roughness. The effects of Sr substitution on the biological properties of SrCSH cement were evaluated by adhesion, proliferation, alkaline phosphatase (ALP) activity of osteoblast-like cells MC3T3-E1. The results showed that SrCSHs enhanced MC3T3-E1 cell proliferation, differentiation, and ALP activity. Furthermore, SrCSH cement was used to repair critical-sized OVX rat calvarial defects. The in vivo results revealed that SrCSH had good osteogenic capability and stimulated new blood vessel formation in a critical sized OVX calvarial defect within 12 weeks, suggesting that SrCSH cement has more potential for application in bone tissue regeneration.

A QI Initiative to Reduce Hospitalization for Children With Isolated Skull Fractures.

BACKGROUND AND OBJECTIVE: Although children with isolated skull fractures rarely require acute interventions, most are hospitalized. Our aim was to safely decrease the hospitalization rate for children with isolated skull fractures. METHODS: We designed and executed this multifaceted quality improvement (QI) initiative between January 2008 and July 2015 to reduce hospitalization rates for children ≤21 years old with isolated skull fractures at a single tertiary care pediatric institution. We defined an isolated skull fracture as a skull fracture without intracranial injury. The QI intervention consisted of 2 steps: (1) development and implementation of an evidence-based guideline, and (2) dissemination of a provider survey designed to reinforce guideline awareness and adherence. Our primary outcome was hospitalization rate and our balancing measure was hospital readmission within 72 hours. We used standard statistical process control methodology to assess change over time. To assess for secular trends, we examined admission rates for children with an isolated skull fracture in the Pediatric Health Information System administrative database. RESULTS: We identified 321 children with an isolated skull fracture with a median age of 11 months (interquartile range 5-16 months). The baseline admission rate was 71% (179/249, 95% confidence interval, 66%-77%) and decreased to 46% (34/72, 95% confidence interval, 35%-60%) after implementation of our QI initiative. No child was readmitted after discharge. The admission rate in our secular trend control group remained unchanged at 78%. CONCLUSIONS: We safely reduced the hospitalization rate for children with isolated skull fractures without an increase in the readmissions.

Local versus general anesthesia for the management of nasal bone fractures: a systematic review and meta-analysis.

PURPOSE: The aim of this study was to answer the following question: in patients with nasal bone fractures (NBFs), does closed reduction under local anesthesia (LA) produce comparable outcomes as closed reduction under general anesthesia (GA)? MATERIALS AND METHODS: A systematic review with meta-analysis and a comprehensive electronic search without date and language restrictions was performed in August 2014. The inclusion criteria were studies in humans, including randomized or quasi-randomized controlled trials (RCTs), controlled clinical trials (CCTs), and retrospective studies whose aim was comparing clinical outcomes between LA and GA for closed reduction of NBFs. RESULTS: Eight publications were included: 3 RCTs, 2 CCTs, and 3 retrospective studies. Three studies showed a low risk of bias, and 5 studies showed a moderate risk of bias. There was no statistical difference between LA and GA for closed reduction of NBFs with regard to patient satisfaction with anesthesia, patient satisfaction with function of the nose, need for subsequent retreatment (septoplasty, septorhinoplasty, or rhinoplasty with refracture), and a patient's chosen treatment for a refracture of the nose. There was a statistical difference between LA and GA for closed reduction of NBFs with regard to patient satisfaction with the appearance of the nose. CONCLUSION: Regardless of the cost and risks associated with GA, the results of the meta-analysis showed that GA provides better patient satisfaction with anesthesia, appearance and function of the nose, and preference of treatment for a refracture of the nose. In addition, the meta-analysis showed that GA decreased the number of subsequent corrective surgeries (septoplasty, septorhinoplasty, and rhinoplasty) required.

Efficiently engineered cell sheet using a complex of polyethylenimine-alginate nanocomposites plus bone morphogenetic protein 2 gene to promote new bone formation.

Regeneration of large bone defects is a common clinical problem. Recently, stem cell sheet has been an emerging strategy in bone tissue engineering. To enhance the osteogenic potential of stem cell sheet, we fabricated bone morphogenetic protein 2 (BMP-2) gene-engineered cell sheet using a complex of polyethylenimine-alginate (PEI-al) nanocomposites plus human BMP-2 complementary(c)DNA plasmid, and studied its osteogenesis in vitro and in vivo. PEI-al nanocomposites carrying BMP-2 gene could efficiently transfect bone marrow mesenchymal stem cells. The cell sheet was made by culturing the cells in medium containing vitamin C for 10 days. Assays on the cell culture showed that the genetically engineered cells released the BMP-2 for at least 14 days. The expression of osteogenesis-related gene was increased, which demonstrated that released BMP-2 could effectively induce the cell sheet osteogenic differentiation in vitro. To further test the osteogenic potential of the cell sheet in vivo, enhanced green fluorescent protein or BMP-2-producing cell sheets were treated on the cranial bone defects. The results indicated that the BMP-2-producing cell sheet group was more efficient than other groups in promoting bone formation in the defect area. Our results suggested that PEI-al nanocomposites efficiently deliver the BMP-2 gene to bone marrow mesenchymal stem cells and that BMP-2 gene-engineered cell sheet is an effective way for promoting bone regeneration.

Effects of laser and ozone therapies on bone healing in the calvarial defects.

This study aims to analyze the effect of the low-level laser therapy (LLLT) and ozone therapy on the bone healing of critical size defect (CSD) in rat calvaria. A total of 30 Wistar male rats were used. A 5-mm-diameter trephine bur was used to create CSD on the right side of the parietal bone of each rat calvarium. Once the bone was excised, a synthetic biphasic calcium phosphate graft material was implanted to all the bone defect sites. The animals were randomly divided into 3 groups as follows: the control group (n = 10), which received no LLLT or ozone therapy; the LLLT group (n = 10), which received only LLLT (120 seconds, 3 times a week for 2 weeks); and the ozone therapy group (n = 10) (120 seconds, 3 times a week for 2 weeks). After 1 month, all the rats were killed, and the sections were examined to evaluate the presence of inflammatory infiltrate, connective tissue, and new bone formation areas. Histomorphometric analyses showed that in the LLLT and ozone groups, the new bone areas were significantly higher than in the control group (P < 0.05). In the LLLT group, higher new bone areas were found than in the ozone group (P < 0.05). This study demonstrated that both ozone and laser therapies had a positive effect on bone formation in rat calvarial defect, compared with the control group; however, ozone therapy was more effective than LLLT (808 nm; 0.1 W; 4 J/cm(2); 0.028 cm(2), continuous wave mode).

Manipulation of nasal fractures with local anaesthetic: a 'how to do it' with online video tutorial.

Nasal fractures are the most common facial fractures and displaced fractures may cause considerable cosmetic concern. Traditionally, displaced nasal fractures have been manipulated under general anaesthesia (GA) performed within 2 weeks of the injury. Despite evidence for the benefit of local anaesthesia (LA), nasal fractures are still most commonly reduced under GA. We have presented a method of reduction of simple nasal fractures under LA in an outpatient setting. This has the advantage of being painless, simple to attempt and cost-effective. If reduction is inadequate then a general anaesthetic reduction is still possible. A recent comprehensive systematic review of all the available evidence did not show any significant difference (in terms of cosmesis, pain or nasal obstruction) between using LA and GA methods and highlighted the evidence base to support LA. We describe our method of assessment and treatment of displaced nasal fractures and provide an online tutorial (http://sciencestage.com/v/22194/local-anaesthetic-nasal-fracture-reduction.html). It is important to keep in mind that any concerns should be referred to an otolaryngology specialist for further management and that practitioners attempting this technique should first receive training from an otolaryngologist.

Manipulation of nasal fractures under local anaesthetic: a convenient method for the Emergency Department and ENT clinic.

BACKGROUND: Nasal fractures are the commonest facial fracture. They can cause morbidity in terms of nasal obstruction and cosmesis. They can be treated by simple external digital manipulation, provided they are seen and assessed in a timely fashion. This manipulation is commonly done under general anaesthetic (GA), which utilises precious resources and may cause delays in treatment. SUMMARY OF EVIDENCE FOR PROPOSED METHOD: A recent comprehensive systematic review has shown local anaesthetic (LA) to be comparable to GA in terms of cosmesis, airway patency and patient acceptability. The experience for the patient is akin to that of a dental filling, and can be made more painless with the use of topical anaesthesia. PROPOSED METHOD: In the current age of evidence-based medicine and drive for cost-effective management decisions, it is thought that LA manipulation may offer a superior option to GA. A simple method for manipulation under LA is presented that can be done in the Emergency Department.

Reduction of nasal bone fractures: a comparative study of general, local, and topical anesthesia techniques.

UNLABELLED: The aim of the current study of nasal bone fracture reduction carried out under topical, local, and general anesthesia was to suggest a proper treatment of patients with nose fractures. METHOD: The patient candidates for close nasal bone reduction (CNR) were divided into 3 groups: topical anesthesia (TA), local anesthesia (LA), and general anesthesia (GA), and CNR was performed. After reduction, pain scores and satisfaction and failure rates after 2 and 30 days were noted. All the patients were followed up for at least 1 month. RESULTS: The mean pain scores (TA = 2.35, LA = 2.47, and GA = 1.9) showed no significant difference among these 3 groups (P > 0.05). The percentages of the patients' satisfaction in the groups were as follows: TA = 84.6%, LA = 83.8%, and GA = 91.7%. These values had no statistical difference (P > 0.05). There was no significant difference among the failure rates on the second day and after 1 month of follow-up (after 2 d, TA = 10%, LA = 18%, and GA = 14%, and after 1 month, TA = 2%, LA = 7%, and GA = 5%). CONCLUSIONS: If the selection of patients is done properly, CNR under TA/LA will have considerable success in comparison with GA. Topical anesthesia is suggested in simple nasal fracture with unilateral depression or minimal displacement.

Nasal fracture reduction: local versus general anaesthesia.

OBJECTIVE: To investigate the outcomes from nasal fracture reduction performed under local anaesthesia (LA) and general anaesthesia (GA). METHOD: A randomised multi-centred prospective trial and cohort analysis. Patients were randomised into two groups, 74 (53%) underwent closed reduction under LA, 65 (47%) patients underwent closed reduction under GA. MAIN OUTCOME MEASURES: Pain scores and patient toleration of local or general nasal manipulation was noted. RESULTS: The pain score ranged from 0 (no pain) to 10 (unbearable pain). The mean pain score in the LA group was 3, compared to 2 in the GA group. LA manipulation was tolerated equally well as GA manipulation by 85% of the patients in each group. The number of patients requiring a septorhinoplasty was compared between LA 19/74 (26%), and GA 21/65 (32%). This failed to demonstrate a significant difference with a p value of 0.50. The absolute risk difference was 5% with a 95% confidence interval of (20% to -10%). CONCLUSION: This trial clearly shows LA to be as effective as GA in the first line management of nasal fractures. The degree of septal displacement and presence of nasal tip deviation were associated with persistent nasal deformity following nasal fracture reduction.

Porous silk fibroin 3-D scaffolds for delivery of bone morphogenetic protein-2 in vitro and in vivo.

Bone morphogenetic protein-2 (BMP-2) plays a key role in osteogenesis. Biomaterials used for the sustained delivery of BMP-2 in vivo have shown therapeutic benefits. In the present study, BMP-2 was loaded in porous silk fibroin scaffolds derived from silkworm cocoons (2.4 +/- 0.14 microg per scaffold). The release profile of BMP-2 under dynamic culture conditions (spinner flasks) showed that after 1 week in culture 25% of the initial BMP-2 was retained adsorbed to the scaffold; up to 4 weeks no additional BMP-2 was released. BMP-2 induced human bone marrow stromal cells (hMSCs) to undergo osteogenic differentiation when the seeded scaffolds were cultured in medium supplemented with osteogenic stimulants for 4 weeks, based on elevated alkaline phosphatase activity, calcium deposition, and transcript levels for bone sialoprotein, osteopontin, osteocalcin, BMP-2, and cbfa-1. Micro-computed tomography revealed densely deposited mineral at the center of the scaffolds. In contrast, hMSCs cultured in control scaffolds (no BMP-2) exhibited limited osteogenesis. When implanted in critical sized cranial defects in mice, scaffolds loaded with BMP-2 and seeded with hMSCs resulted in significant bone ingrowth. These results were qualitatively similar to scaffolds loaded with BMP-2 but no hMSCs or with BMP-2 and hMSCs but not pregrown into bone-like tissue. Bone-related outcomes were improved when compared with the scaffold controls implanted without BMP-2. These studies illustrate the potential use of slow degrading silk fibroin 3-D scaffolds loaded with BMP-2, in combination with hMSCs, in osteogenesis studies in vitro and in vivo, and provide a new range of material properties for these applications.

Reduction of nasal fractures under local anaesthesia: an acceptable practice?

Nasal fractures are among the most common bony injuries and are among the most frequent reasons for referral to Otorhinolaryngology departments resulting in significant pressure on clinical resources. We present our experience of a Nasal Fracture Clinic dedicated to the assessment of nasal injuries. A prospective study has been undertaken using questionnaires regarding patient satisfaction and acceptability of manipulation under a local anaesthetic (LA). During our three-month study period 91 new patients with nasal injuries were seen; 43 patients were diagnosed to have a displaced nasal fracture requiring reduction. Reduction of the nasal fracture under LA was performed in 37 patients. We found that manipulation under LA was preferred by 94% of patients over the age of 14 years. We achieved a high patient satisfaction rate (80% after three months). The discomfort associated with reduction under LA did not exceed that of a minor dental procedure. No significant complications were encountered during the study period. We conclude that reduction of nasal fractures under LA is a safe and attractive alternative to reduction under a general anaesthetic (GA) and frees-up valuable clinical resources.

Nasal fractures--the details.

Due to the nose's prominent location and functional and cosmetic importance, nasal fractures present a challenge to the facial plastic surgeon to restore all things to normal. Although little groundbreaking news has been reported recently in the literature on nasal fractures, there is ample literature already in print on virtually every topic concerning nasal fractures. This article concentrates on the details of actually managing nasal fractures, with comments on present-day coding of posttraumatic septorhinoplasty.

Nasal manipulation with intravenous sedation. Is it an acceptable and effective treatment?

Local anaesthesia is increasingly being used for nasal manipulation. Doubt remains over the discomfort associated with this procedure. We studied in a prospective manner, the acceptability and effectiveness of nasal manipulation with intravenous sedation and local anaesthesia, in a case series of thirty-five patients. Patients used linear analogue scales to assess outcome and pain associated with the procedure. More than half of the patients (60%) returned pain scores of only 1 out of 10. Thirty-two patients (90%) found the procedure less painful than receiving a tooth filling from the dentist, while thirty-four patients (97%) said they would undergo the same procedure again if they re-fractured their nose. The effectiveness of the treatment as assessed by an independent observer revealed that 90% of patients had achieved a significant reduction in their deformity (P = 1.27 x 10(-9).

Efficacy of external fixation following nasal manipulation under local anaesthesia.

Nasal fractures are one of the commonest reasons for patients being referred to ENT departments, but few studies have been published about the management of this condition. In particular, the efficacy of external splintage following manipulation has not been assessed. This was a prospective randomized study, which examined the results of manipulation under local anaesthetic and the benefit to be gained from external fixation with Plaster of Paris (POP) following this procedure. Accurate measurements of the degree of deviation of the nose pre- and post-manipulation were obtained using a camera mounted on a specially designed frame. Thirty-three out of 241 consecutive patients seen at a research clinic over the course of 12 months were included in the study. The mean deviation of the nasal bridge at presentation was 4.12 mm. Manipulation under local anaesthetic significantly improved the degree of deviation (mean 2.47 mm, P = 0.0011, 90% CI, 1-2 mm). Randomization of the patients, following manipulation, into POP/none-POP groups showed that external splintage of the nose appeared to be of little practical benefit.

Manipulation of the fractured nose using topical local anaesthesia.

Simple fracture of the nasal bone can be reduced under local or general anaesthesia. A combination of topical anaesthetic (EMLA cream) and cocainization of the nasal mucosa was used successfully in manipulation of fractured nasal bones in twelve patients without discomfort.