Patient reported and clinical outcomes of robotic-arm assisted unicondylar knee arthroplasty: Minimum two year follow-up.

BACKGROUND: Unicompartmental knee arthroplasty (UKA) originated in the 1950's. There have been many enhancements to the implants and the technique, improving the precision and accuracy of this challenging operation. Specifically for Robotic Arm Interactive Orthopedic System (Rio; Mako Stryker, Fort Lauderdale, FL), there are many studies reporting clinical outcomes, but our search offered nothing regarding patient reported outcomes using validated surveys. METHODS: Patients with onlay tibial components presenting for routine follow-up of robotic-arm assisted UKA performed between May 2009 and September 2013 were invited to participate. Four joints had simultaneous patella femoral resurfacing. Knee Injury and Osteoarthritis Outcomes Score (KOOS) and the 2011 Knee Society Scores were collected. Radiographic evidence of osteoarthritis in the non-operative knee compartments was documented. RESULTS: Eighty-one patients presented for follow-up and consented to participate. Mean follow up was 54 months. Mean patient reported KOOS activities of daily living and pain scores were each 90. Knee Society 2011 mean objective score was 96 and mean function score 81. There was one revision to total knee at 40 months post-op for pain after injury. Seventy-seven percent reported their knee always felt "Normal", 20% sometimes, and only 3% reported that it never felt normal. CONCLUSION: Literature on UKA failure rates suggests that UKA may be a less forgiving procedure than total knee arthroplasty. Robotic-arm assisted surgery is reported to improve the accuracy of implant placement. Based on our prospectively collected positive patient outcomes, the authors have achieved good results from performing robotic-arm assisted UKA on select patients.

Bone health measured using quantitative ultrasonography in adult males with muscular dystrophy.

OBJECTIVES: To compare muscle and bone health markers in adult males (aged 20-59 yrs) with and without muscular dystrophy (MD). METHODS: Participants included 11 Fascioscapulohumeral (FSH), 11 Becker's (Be), 9 limb girdle (LG), 11 Duchenne (DMD), and 14 non-dystrophic controls (CTRL). Physical activity was assessed using Bone (BPAQ) and disability specific (PASIPD) questionnaires. Bone QUS provided T- and Z scores from the Distal Radius (DR) and Mid-shaft tibia (MST). Tibialis anterior cross sectional area (TAACSA) was measured using B-mode ultrasound. Grip strength was measured in all but DMD. RESULTS: Physical activity was lower in DMD, FSH and BeMD than CTRL (P<0.05), and lower in DMD than other MDs (P<0.01). T and Z scores were lower in DMD and Be than CTRL (DR, P<0.05); and lower in DMD than CTRL, LG, and FSH (MST, P<0.01). TAACSA and grip strength was 35-59% and 50-58% smaller in MD than CTRL, respectively (P<0.01). Within MD, BPAQ correlated with bone QUS measures (r=0.42-0.38, P<0.01). PASIPD correlated with grip strength (r=0.65, P<0.01) and TAACSA (r=0.46, P<0.01). CONCLUSION: Muscle size, strength, and bone health was lower in adult males with MD compared to adult males without MD, the extent of this is partially determined by physical activity.

Gastrocnemius medialis muscle architecture and physiological cross sectional area in adult males with Duchenne muscular dystrophy.

OBJECTIVES: To describe muscle size and architecture of the gastrocnemius medialis (GM) muscle in eleven adult males with Duchenne Muscular Dystrophy (DMD, age 24.5±5.4 years), and a control group of eleven males without DMD (CTRL, age 22.1±0.9 years). METHODS: GM anatomical cross sectional area (ACSA), volume (VOL), physiological cross sectional area (PCSA), fascicle length (Lf) and pennation angle (θ) were assessed using B-Mode Ultrasonography. GM ACSA was measured at 25, 50 and 75% of muscle length (Lm), from which VOL was calculated. At 50% of Lm, sagittal plane images were analysed to determine GM Lf and θ. GM PCSA was calculated as: VOL/Lf. The ratio of Lf and Lm was also calculated. RESULTS: GM ACSA at 50% Lm, VOL and PCSA were smaller in DMD males compared to CTRL males by 36, 47 and 43%, respectively (P<0.01). There were no differences in Lf and θ. GM Lm was 29% shorter in DMD compared to CTRL. Lf/Lm was 29% longer in DMD (P<0.01). CONCLUSIONS: Unlike previous data in children with DMD, our results show significant atrophy in adult males with DMD, and no change in Lf or θ. The shorter Lm may have implications for joint flexibility.

Covalent IR820-PEG-diamine nanoconjugates for theranostic applications in cancer.

Near-infrared dyes can be used as theranostic agents in cancer management, based on their optical imaging and localized hyperthermia capabilities. However, their clinical translatability is limited by issues such as photobleaching, short circulation times, and nonspecific biodistribution. Nanoconjugate formulations of cyanine dyes, such as IR820, may be able to overcome some of these limitations. We covalently conjugated IR820 with 6 kDa polyethylene glycol (PEG)-diamine to create a nanoconjugate (IRPDcov) with potential for in vivo applications. The conjugation process resulted in nearly spherical, uniformly distributed nanoparticles of approximately 150 nm diameter and zeta potential -0.4±0.3 mV. The IRPDcov formulation retained the ability to fluoresce and to cause hyperthermia-mediated cell-growth inhibition, with enhanced internalization and significantly enhanced cytotoxic hyperthermia effects in cancer cells compared with free dye. Additionally, IRPDcov demonstrated a significantly longer (P<0.05) plasma half-life, elimination half-life, and area under the curve (AUC) value compared with IR820, indicating larger overall exposure to the theranostic agent in mice. The IRPDcov conjugate had different organ localization than did free IR820, with potential reduced accumulation in the kidneys and significantly lower (P<0.05) accumulation in the lungs. Some potential advantages of IR820-PEG-diamine nanoconjugates may include passive targeting of tumor tissue through the enhanced permeability and retention effect, prolonged circulation times resulting in increased windows for combined diagnosis and therapy, and further opportunities for functionalization, targeting, and customization. The conjugation of PEG-diamine with a near-infrared dye provides a multifunctional delivery vector whose localization can be monitored with noninvasive techniques and that may also serve for guided hyperthermia cancer treatments.

High-dose rifapentine with moxifloxacin for pulmonary tuberculosis.

BACKGROUND: Tuberculosis regimens that are shorter and simpler than the current 6-month daily regimen are needed. METHODS: We randomly assigned patients with newly diagnosed, smear-positive, drug-sensitive tuberculosis to one of three regimens: a control regimen that included 2 months of ethambutol, isoniazid, rifampicin, and pyrazinamide administered daily followed by 4 months of daily isoniazid and rifampicin; a 4-month regimen in which the isoniazid in the control regimen was replaced by moxifloxacin administered daily for 2 months followed by moxifloxacin and 900 mg of rifapentine administered twice weekly for 2 months; or a 6-month regimen in which isoniazid was replaced by daily moxifloxacin for 2 months followed by one weekly dose of both moxifloxacin and 1200 mg of rifapentine for 4 months. Sputum specimens were examined on microscopy and after culture at regular intervals. The primary end point was a composite treatment failure and relapse, with noninferiority based on a margin of 6 percentage points and 90% confidence intervals. RESULTS: We enrolled a total of 827 patients from South Africa, Zimbabwe, Botswana, and Zambia; 28% of patients were coinfected with the human immunodefiency virus. In the per-protocol analysis, the proportion of patients with an unfavorable response was 4.9% in the control group, 3.2% in the 6-month group (adjusted difference from control, -1.8 percentage points; 90% confidence interval [CI], -6.1 to 2.4), and 18.2% in the 4-month group (adjusted difference from control, 13.6 percentage points; 90% CI, 8.1 to 19.1). In the modified intention-to-treat analysis these proportions were 14.4% in the control group, 13.7% in the 6-month group (adjusted difference from control, 0.4 percentage points; 90% CI, -4.7 to 5.6), and 26.9% in the 4-month group (adjusted difference from control, 13.1 percentage points; 90% CI, 6.8 to 19.4). CONCLUSIONS: The 6-month regimen that included weekly administration of high-dose rifapentine and moxifloxacin was as effective as the control regimen. The 4-month regimen was not noninferior to the control regimen. (Funded by the European and Developing Countries Clinical Trials Partnership and the Wellcome Trust; RIFAQUIN Current Controlled Trials number, ISRCTN44153044.).

Chemotherapy-induced changes in cardiac capillary permeability measured by fluorescent multiple indicator dilution.

Anthracyclines cause severe irreversible cardiac toxicity. The study of changes in cardiac permeability with chemotherapy could enhance the understanding of mechanisms behind cardiac damage, and provide useful information to evaluate anthracycline cardiotoxicity. Thirty-six rats (12 Sprague-Dawley, 12 Wistar, 12 Fischer-344) were randomly assigned to control (n = 21) or doxorubicin (n = 15), and injected i.p. with a cumulative dose of 18 mg/kg doxorubicin in saline (vehicle) or vehicle alone over 12 days. Echocardiography was performed at baseline and on day 11. An isolated heart experiment was done on day 12 to obtain perfused heart pressure values, and to measure cardiac capillary permeability using a Texas Red/sodium fluorescein multiple indicator dilution method. Control animals had significantly lower average permeability-surface-area-products (0.035 ± 0.013 cm(3)/s) than doxorubicin animals (0.066 ± 0.023 cm(3)/s), PSP ± SD, p < 0.001. These permeability changes correlated with significant functional changes. There was a significant decline in cardiac function with a deleterious effect of chemotherapy on fractional shortening (p < 0.001), left ventricular developed pressure (p < 0.001), contractility (p < 0.001), and relaxation (p = 0.02). Based on our results, cardiac capillary permeability changes can be detected after in vivo chemotherapy treatment using our fluorescent multiple indicator dilution technique, and may provide valuable information in evaluating cardiotoxicity of novel drugs.

Environmental controls on the activity of aquifer microbial communities in the 300 area of the Hanford site.

Aquifer microbes in the 300 Area of the Hanford Site in southeastern Washington State, USA, are located in an oligotrophic environment and are periodically exposed to U(VI) concentrations that can range up to 10 µM in small sediment fractures. Assays of (3)H-leucine incorporation indicated that both sediment-associated and planktonic microbes were metabolically active, and that organic C was growth-limiting in the sediments. Although bacteria suspended in native groundwater retained high activity when exposed to 100 µM U(VI), they were inhibited by U(VI) <1 µM in synthetic groundwater that lacked added bicarbonate. Chemical speciation modeling suggested that positively charged species and particularly (UO2)3(OH)5 (+) rose in concentration as more U(VI) was added to synthetic groundwater, but that carbonate complexes dominated U(VI) speciation in natural groundwater. U toxicity was relieved when increasing amounts of bicarbonate were added to synthetic groundwater containing 4.5 µM U(VI). Pertechnetate, an oxyanion that is another contaminant of concern at the Hanford Site, was not toxic to groundwater microbes at concentrations up to 125 µM.

Nanoplexes for cell imaging and hyperthermia: in vitro studies.

Novel IR820-polyethylene glycol-diamine nanoplexes (IR820-PDNCs) have potential multifunctional imaging-hyperthermia applications in cancer. Nanoplexes were formulated by ionic interaction and characterized in vitro for their imaging and hyperthermia capabilities. The resulting nanoplexes were approximately 50 nm diameter, with a zeta potential of 2.0 +/- 0.9 mV, and able to generate heat upon exposure to 808 nm laser. Cytotoxicity studies in SKOV-3, MES-SA and Dx5 cancer cell lines demonstrate comparable cytotoxicity of IR820-PDNCs versus free IR820 after 24 hours. The nanoplexes are able to produce hyperthermic cell growth inhibition in all three cancer cell lines after excitation with laser. The level of cell growth inhibition caused by hyperthermia is significantly higher for IR820-PDNCs compared to IR820 in MES-SA and Dx5 cells. Fluorescent microscope images after 2.5-hour exposure to 5 microM IR820-PDNCs or 5 microM free IR820 show increased uptake for IR820-PDNCs compared to free IR820, especially for SKOV-3 and Dx5 cancer cells. This formulation can potentially be used in multifunctional cancer theranostics.

Comparative study of the optical and heat generation properties of IR820 and indocyanine green.

AbstractNear-infrared (NIR) fluorophores are the focus of extensive research for combined molecular imaging and hyperthermia. In this study, we showed that the cyanine dye IR820 has optical and thermal generation properties similar to those of indocyanine green (ICG) but with improved in vitro and in vivo stability. The fluorescent emission of IR820 has a lower quantum yield than ICG but less dependence of the emission peak location on concentration. IR820 demonstrated degradation half-times approximately double those of ICG under all temperature and light conditions in aqueous solution. In hyperthermia applications, IR820 generated lower peak temperatures than ICG (4-9%) after 3-minute laser exposure. However, there was no significant difference in hyperthermia cytotoxicity, with both dyes causing significant cell growth inhibition at concentrations ≥ 5 µM. Fluorescent images of cells with 10 µM IR820 were similar to ICG images. In rats, IR820 resulted in a significantly more intense fluorescence signal and significantly higher organ dye content than for ICG 24 hours after intravenous dye administration (p < .05). Our study shows that IR820 is a feasible agent in experimental models of imaging and hyperthermia and could be an alternative to ICG when greater stability, longer image collection times, or more predictable peak locations are desirable.

Vaccination with Mage-b DNA induces CD8 T-cell responses at young but not old age in mice with metastatic breast cancer.

BACKGROUND: Elderly individuals react less efficiently to vaccines than do adults, mainly because of T-cell unresponsiveness. In this study, we analysed whether tumour-associated antigen (TAA)-specific CD8 T-cell responses could be induced by vaccination in old mice with metastatic breast cancer. METHODS: The effect of pcDNA-3.1- and Listeria-based vaccines, expressing TAA Mage-b, on Mage-b-specific immune responses was tested in spleens and draining lymph nodes (LNs) of mild (4TO7cg) and aggressive (4T1) syngeneic metastatic mouse breast tumour models at young (3 months) and old (20 months) age. RESULTS: Interferon gamma and interleukin-2 levels increased significantly in draining LNs and spleens of Mage-b-vaccinated mice compared with those in control groups at young but not old age in both mouse tumour models. A significant increase was observed in the number of IFNgamma-producing Mage-b-specific CD8 T cells after Mage-b vaccination in the 4T1 model at young but not old age. This correlated with a reduced protective effect of Mage-b vaccination against metastatic breast cancer at old compared with young age. CONCLUSIONS: The absence of CD8 T-cell responses after Mage-b vaccination and the accompanying reduced protection against metastatic breast cancer in old compared with young mice point towards the need for tailoring cancer vaccination to older age.

Antigen receptor V-segment usage in mucosal T cells.

In the accepted model of lymphocyte intestinal homing, naïve T cells recirculate via organized lymphoid tissues, whilst induced effector/memory cells home to the intestinal mucosa. In order to assess the T-cell-receptor repertoire in the intestine and gut-associated lymphoid tissue (GALT), spectratyping was performed on the proximal and the distal intestine, spleen and mesenteric lymph node tissue from six PVG rats. The products were analysed with an automated sequencer and statistical analyses were performed with hierarchical cluster analysis. This demonstrated the presence of a restricted T-cell repertoire in the small intestine compared with that in the mesenteric lymph nodes and the spleen. It also demonstrated marked differences in repertoire between individual, fully inbred rats maintained under apparently identical conditions in the same cage and fed identical diets. In addition, this work demonstrated marked differences between repertoires in the proximal and the distal intestine. Such marked differences are likely to reflect the end result of increasing divergence over time produced by relatively subtle effects of environment and antigenic load. Equally, marked differences in repertoire between small intestinal segments within individual rats indicate selective recruitment or retention of specific clones, presumably antigen-driven.

A reassessment of the mating system characteristics of the army ant Eciton burchellii.

In a recent study, Denny et al. (2004a) showed that queens of the army ant, Eciton burchellii, mate with multiple males and presented estimates suggesting that they mate with more males than queens of any other ant species so far investigated. They also inferred that data were consistent with queens being inseminated repeatedly throughout their life, which would be exceptional among the social Hymenoptera and contradictory to predictions from kin selection theory. In the present study, we reanalyze these data using new software and supplement them with similar microsatellite data from other colonies of the same species. Mating frequencies in E. burchellii are indeed very high (mean observed and effective queen-mating frequencies of 12.9 each) but considerably lower than the previous estimates. We show that the number of patrilines represented in the first worker offspring of a young queen is lower than in older queens but suggest that this may be due to initial sperm clumping in the queen's sperm storage organ, rather than to repeated inseminations. Moreover, we found no evidence for repeated mating by genotyping sequential worker generations produced by a single old queen, showing that she did not obtain new inseminations despite ample opportunities for mating.

The prevalence of stress urinary incontinence in patients with cystic fibrosis: an under-recognized problem.

OBJECTIVE: To identify the prevalence of stress urinary and fecal incontinence in patients with cystic fibrosis (CF) and investigate any correlation between CF severity and the incidence and degree of incontinence. PATIENTS AND METHODS: An initial postal questionnaire was used to identify patients with an incontinence problem, followed by a detailed interview-administered questionnaire assessing the type of incontinence and the impact of the incontinence on patients and the management of their CF. The correlation between CF severity and the incidence and severity of incontinence was also analysed. All patients aged 5-18 years attending the CF service at The Respiratory and Urology departments of a University Teaching Hospital were invited to participate. There was no therapeutic intervention. RESULTS: Stress urinary incontinence was present in 31% of girls and 2.2% of boys, with fecal incontinence in four girls. The youngest patient with incontinence was 9 years old. Of the patients, 78% found their incontinence a problem and 44% had hidden the problem from parents and carers. There was no correlation between incontinence and the severity of CF as measured by the forced expiratory volume in 1s. CONCLUSIONS: Urinary incontinence is common in girls with CF and in many cases it is a hidden problem. These patients need to be identified so they can receive appropriate management, instead of suffering in silence.

Exceptionally high levels of multiple mating in an army ant.

Most species of social insects have singly mated queens, although there are notable exceptions. Competing hypotheses have been proposed to explain the evolution of high levels of multiple mating, but this issue is far from resolved. Here we use microsatellites to investigate mating frequency in the army ant Eciton burchellii and show that queens mate with an exceptionally large number of males, eclipsing all but one other social insect species for which data are available. In addition we present evidence that suggests that mating is serial, continuing throughout the lifetime of the queen. This is the first demonstration of serial mating among social hymenoptera. We propose that high paternity within colonies is most likely to have evolved to increase genetic diversity and to counter high pathogen and parasite loads.

Mandibular distraction osteogenesis in very young patients to correct airway obstruction.

The purpose of this study was to measure changes in the airway cross-sectional area of pediatric patients with micrognathia and obstructive airway symptoms after treatment by mandibular distraction. The measurements obtained were correlated with the clinical outcomes.Ten patients, ranging in age from 3 months to 8 years, underwent measurement and distraction. Eight patients were under 30 months of age. Six were diagnosed with Pierre Robin sequence, two with Treacher Collins syndrome, and two with Nager syndrome. All patients had retrognathia of greater than 8 mm and obstructive airway symptoms while awake that had resulted in tracheostomy (3), repeated apnea monitor triggering (5), or abnormal sleep study (2). Cephalometric analysis was performed pretreatment and posttreatment by distraction. The effective airway space was defined with the following boundaries: a horizontal line from the tip of the odontoid to the velum, the uvula tip to the tongue base along the shortest line, the tongue base down to the base of the epiglottis, and the horizontal line to the posterior pharynx. These lines were traced for each cephalogram, the outline was digitized, and the area was calculated by computer. An analysis of the square area change was done by paired t test. The range of distraction was 8 to 22 mm; the mean effective airway increase was 67.5 percent, with a range of 26 to 120 percent. Measurable airway increase occurred in all patients who underwent distraction, and all patients showed clinical improvement. Six patients with Pierre Robin sequence became asymptomatic, with normal sleep, feeding, and weight gain. Two patients with Nager syndrome and tracheostomies were decannulated and were asymptomatic postdistraction. One patient with Treacher Collins syndrome without tracheostomy became asymptomatic after mandibular distraction; one patient failed to distract because of premature consolidation and continued to require a cannula. Mandibular distraction seems to provide a consistent change in tongue base position that improves obstructive airway symptoms by increasing measured effective airway space. The potential for mandibular distraction exceeds the simple correction of malocclusion also by eliminating soft-tissue obstruction of the micrognathic airway. Airway improvement is independent of the syndrome diagnosed. Mandibular distraction osteogenesis may be useful to avoid or decannulate existing tracheostomy in infants with micrognathia.

Synchronous bladder reconstruction and antegrade continence enema.

PURPOSE: We assess the long-term outcome of synchronous bladder reconstruction and antegrade continence enema in a large series of patients. MATERIALS AND METHODS: We retrospectively reviewed records of the last 50 consecutive patients treated at 1 unit in Southampton and 1 in Denver. RESULTS: A total of 46 patients were available for analysis, including 24 from Southampton and 22 from Denver. Median patient age at operation was 12 years (range 4 to 30), median followup was 44 months (range 7 to 100), and 80% of patients had neuropathy and anorectal malformation. A variety of bladder reconstructive procedures were performed and 58% of patients underwent a simultaneous Mitrofanoff procedure. Fecal and urinary continence was achieved in 76% of patients but the rate of revision surgery was high. The most common complication was stomal stenosis (17%). Secondary procedures consisted of refashioning urethral length, closure of the bladder neck, bladder augmentation and conduit revision. CONCLUSIONS: It is now possible to produce double continence in some patients with synchronous combined surgery, a goal that was not achievable without colostomy before the development of the antegrade continence enema in 1990. However, the surgery is demanding with high revision rates and we emphasize that it should only be performed in patients who are highly motivated and have reasonable dexterity and intelligence. This careful patient selection is confirmed by the fact that surgery was performed on 2 to 3 patients a year at each unit. This surgery should only be performed at facilities which can provide long-term patient followup.

Congenital megaprepuce: an emerging condition--how to recognize and treat it.

OBJECTIVE: To highlight the clinical presentation, pathological anatomy and surgical management of an emerging condition, the congenital megaprepuce (CM). PATIENTS AND METHODS: All patients with CM treated at Southampton between 1994 and 1998 were reviewed retrospectively; 20 patients underwent surgery (mean age at operation 16 months, range 6-43). Surgical correction developed over this period and variations on a basic technique are now used, depending on the precise pathological anatomy. These techniques are described and illustrated. Cosmetic and functional success, and parental satisfaction, were assessed by a review of the case-notes. RESULTS: After a follow-up of >/= 6 months, the cosmetic and functional outcome was very successful, with the parents of 19 of the 20 patients satisfied. Five patients underwent re-operation, all requiring excision of redundant penile skin. CONCLUSIONS: CM is a striking condition which cannot be easily missed or hidden; we propose that it is a newly emerging and distinct condition which should not be confused with a buried, concealed, webbed, trapped or micropenis. Early surgical correction is recommended and circumcision should be avoided.

Efficacy of preoperative decontamination of the oral cavity.

This two-part study consisted of: (1) a survey to assess current practice patterns, and (2) an experiment designed to assess the results of varying intraoral preparations. A 48 percent response rate was obtained from the survey of the 318 active members of the American Society of Maxillofacial Surgeons. This survey demonstrated that significant controversy continues regarding the efficacy of preoperative decontamination of the oral cavity. This prospective, randomized experimental study of 30 patients (saline, 10; povidone-iodine, 10; no preparation, 10) demonstrates a significant and sustained reduction of both anaerobic and aerobic bacteria after intraoral preparation with povidone-iodine solution but not saline. The patient's age, use of preoperative intravenous cephalosporin, and type and length of procedure did not influence the postoperative bacterial counts. Although none of the patients in this study developed an infection, recommendations are provided for standardized preoperative treatment of the oral cavity.

Role of three-dimensional computed tomography in the assessment of nasoorbitoethmoidal fractures.

Successful management of nasoorbitoethmoidal (NOE) fractures requires early diagnosis and accurate determination of the extent of injury. Although the anatomic complexity of the NOE region merits a clear interpretation of the spatial relationships associated with each injury, the role of three-dimensional (3D) computed tomography (CT) in the assessment of these fractures remains unclear. To clarify the diagnostic value of 3D CT, this retrospective analysis compares statistically the accuracy of two-dimensional (2D) CT against 3D CT in the detection of NOE fracture line tracts in 21 consecutive patients with surgically confirmed NOE fractures. Accuracy of radiographic findings of both modalities were compared with intraoperative findings serving as the "gold standard" for detecting fracture lines in NOE fractures. This statistical analysis indicates that combining 3D CT and 2D CT produces a higher diagnostic yield in the evaluation of NOE fractures than using either modality alone. Although 2D CT was significantly superior (p < 0.05) for inspection of the medial orbital wall, 3D CT offered significantly greater diagnostic accuracy (p < 0.05) along the medial maxillary buttress, particularly at the piriform aperture. 3D CT clarified spatially several unusual NOE injuries that were indiscernible with 2D CT alone. We recommend the combination of 3D CT with 2D CT for serious NOE injuries, particularly those involving displacement of the NOE complex or associated with other major midfacial fractures.