BoneTape: A novel osteosynthetic device for the stabilization of zygomatic fractures.

BACKGROUND: The study aims to assess the safety and effectiveness of BoneTape™, a new resorbable bone fixation device, using a zygomatic fracture model in rabbits. METHODS: The study followed BoneTape™ samples and control (sham) groups over 2-, 6-, and 12-week periods post-zygomaticomaxillary (ZM) osteotomy and zygomaticofrontal (ZF) disarticulation. The osteotomized segments were analyzed for bone healing, inflammatory response, and tissue healing. µCT imaging and histological analysis were used to examine the axial alignment, offset, and quality of new bone formation. RESULTS: BoneTape™ samples demonstrated enhanced maintenance of the initial intraoperative positioning, reduced axial offset, and better alignment when compared with the control group, enabling stable bone healing under physiological loading conditions. Complete union was observed at 12-weeks in both groups. The BoneTape™ group experienced minimal immune and tissue reactions, classically associated with wound healing, and showed an increased number of giant cells at 6 and 12-weeks. CONCLUSION: BoneTape™ represents a promising advancement in osteosynthesis, demonstrating efficacy in maintaining stable zygomatic reconstruction and eliciting minimal immune response in a rabbit model. This study introduces BoneTape™ as a disruptive solution specifically designed for clinical application in cranio-maxillofacial fracture fixation, with the potential to eliminate the use of over-engineered solutions while offering benefits such as ease of application and fewer biologically disruptive steps.

Management of frontal sinus fractures requiring surgical intervention: An analysis of a case series.

<b><br>Introduction:</b> Isolated frontal bone fractures constitute 5-15% of traumatic facial fractures cases, with frontal sinus fractures categorized into anterior wall, posterior wall, or complex fractures. The approach is tailored to fracture type and bone fragment displacement. This paper presents the summary of surgical management in patients with isolated and complex fractures of the anterior wall of the frontal sinus.</br> <b><br>Material and Methods:</b> Five patients with different frontal sinus fractures were treated surgically. The same management protocol - diagnosis and surgical intervention was implemented in all cases The retrospective analysis included fracture assessment, surgical approach, and long-term outcomes evaluation.</br> <b><br>Results:</b> The most common cause of fractures was falls, while two complex fractures involved the anterior and posterior walls. External approach, bone fragment removal, endoscopy, and external stabilization were employed in all cases. One patent required delayed revision surgery due to retaining metallic foreign body. Follow-up radiological examinations showed proper healing and cosmetic outcomes were satisfactory in all of the cases.</br> <b><br>Conclusion:</b> Surgical management of isolated fractures of the frontal sinus anterior wall, involving bone fragment removal, realignment, and endoscopy, yielded satisfactory functional and cosmetic outcomes without internal or external stabilization. Long-term monitoring and symptom assessment are crucial, especially in cases with penetrating injuries and foreign body risk.</br>.

Maxillofacial trauma and its management presenting at a tertiary care hospital in Lahore during Covid-19 pandemic.

Objectives: The objective of this study was to assess the patterns of maxillofacial injuries, aetiology and their management during the pandemic of Covid-19 in a tertiary care hospital in Lahore, Pakistan. METHODS: This is a single center, prospective cross-sectional study. Patients from all age groups who presented at the Emergency room of Jinnah Hospital Lahore and managed by the Oral and Maxillofacial Surgery Department during 1st December 2020 till 31st January 2021 were included. Data were analyzed using IBM SPSS for Windows, Version 20.0. RESULTS: Total 202 patient were analyzed, 161 (79.7%) were male and 41 (20.3%) were females. Male to female ratio was 4:1. About fifty three percent of patients belonged to the age group 15-35 years. The most common cause was road traffic accidents (RTA), followed by fall. Eighty-three (41.1%) had only soft tissue injuries without any bony fracture and 119 (58.9%) had facial bones fractures. Zygomatic bone fracture was most common (53.8%) followed by mandible fracture (31.1%). Sixty-one out of 119 patients with fractures were treated with Open Reduction Internal Fixation (ORIF). Three patients had complete loss of vision because of facial trauma. Only 56 (28%) patients were managed under General Anaesthesia. CONCLUSIONS: During the initial pandemic era, a large majority of patients presenting with maxillofacial injuries were young male adults. The most common cause of maxillofacial trauma was RTAs. Soft tissue injuries were predominant followed by facial bone fractures and zygomatic bone was more frequent among the fracture cases. Covid-19 pandemic increased the difficulties faced in the management of maxillofacial trauma patients.

Naso-Orbital-Ethmoid Fracture Repair Techniques: A Systematic Review.

PURPOSE: Naso-orbital-ethmoid (NOE) complex fractures present a challenge to repair. The classification system used to categorize the fracture type was established in 1991 based off the medial canthal tendon attachment. The primary objective was to systematically review the literature outlining repair techniques for NOE fracture after the adoption of the Markowitz classification system. METHODS: A systematic search was performed in PubMed, Embase, and Web of Science to identify peer-reviewed research. Eligible studies were peer-reviewed articles reporting on operative techniques used to repair NOE fractures in adult patients after 1991. Two investigators independently reviewed all articles and extracted data. Level of evidence was assessed by Oxford Center for Evidence-based Medicine guidelines. RESULTS: This review identified 16 articles that met inclusion/exclusion criteria representing 517 patients. One article outlined a closed reduction technique with transnasal wiring. The remaining articles discussed open approaches with various exposure techniques, most common being the coronal incision. Miniplates and screws were most often implemented for rigid fixation as well as transnasal wiring to repair disrupted medial canthal tendon and canthal bearing bone in Type 2 and 3 NOE fractures. Ten of the studies included in this review had a level of evidence of 4. CONCLUSIONS: NOE fractures present a complex fracture pattern and challenge to repair. New exposure techniques and multidisciplinary approaches have been described. However, fixation techniques have remained relatively consistent through the years. Surgeon preference and comfort with performing the specific techniques leads to the best patient outcomes. With the low level of evidence referenced, more robust research is needed to evaluate these techniques.

How I do it: single-staged emergency neurosurgical management of frontal penetrating craniocerebral injury with depressed skull fracture.

CONTEXT: Penetrating craniocerebral injury associated with depressed skull fracture is an infrequent yet timely neurosurgical emergency. Such injury frequently occurs in the frontal region during traffic accident or stone throw in the civilian setting. As military neurosurgeons, we present our experience in the surgical debridement and reconstruction of this peculiar type of traumatic brain injury. METHODS: The patient lies supine, the head in neutral position heal by a Mayfield head clamp. The first step is the debridement of the frontal wound. Then, the depressed skull fracture is operated on using a tailored coronal approach through Merkel dissection plane, in order to keep a free pericranial flap. The bone flap is cut around the depressed skull fracture. Neuronavigation allows to locate the frontal sinus depending on whether it has been breached and thus requires cranialization. Brain and dura mater debridement and plasty are performed. Cranioplasty is performed using either native bone fragments fixed with bone plates or tailored titanium plate if they are too damaged. CONCLUSION: Performing wounded skin closure first and then a tailored coronal approach with free pericranial flap and a craniotomy encompassing the depressed skull fracture allows to treat frontal penetrating craniocerebral injury in an easy-to-reproduce manner.

Traumatic Head Injuries from Ceiling Fans at a Pediatric Level I Trauma Center in the United States.

BACKGROUND/OBJECTIVE: Several studies describe traumatic head injuries caused by ceiling fans in Australia, the Middle East, and Malaysia. Some injuries required neurosurgical intervention, especially those caused by metallic ceiling fans. This study describes traumatic head injuries caused by ceiling fans at a single pediatric level 1 trauma center in the Southern USA. METHODS: Medical records were retrospectively reviewed for patients under 18 years of age who presented with a traumatic injury to the head from a ceiling fan from January 1, 2008, through December 31, 2021. The cohort of patients meeting all inclusion criteria was identified by querying multiple free-text fields derived from the electronic medical record, followed by a manual record review. RESULTS: Of 60 children treated for traumatic head injury from a ceiling fan, the median age was 5.7 years and 53% were female. Laceration was the most common injury (80%), followed by scalp swelling/hematoma (20%), contusion (8%), and skull fracture (7%). Two patients (3%) with intracranial hemorrhage and fracture underwent neurosurgery. One neurosurgical case involved a metal ceiling fan and the other involved an outdoor ceiling fan. Nearly half of the injuries involved bunk or loft beds (47%) and young children were often injured while being lifted up by a caregiver (18%). CONCLUSION: Although most pediatric traumatic head injuries from ceiling fans resulted in minor injuries, our center saw a similar proportion of cases with skull fractures to what has been reported in Australia (5%). The effects of fan construction and blade material on the severity of head injury may warrant further study. Understanding the most common mechanisms for these injuries may guide injury prevention efforts.

A Method for Precise Reduction of Facial Bone Fractures Using Intraoperative Ultrasound With a Solid Gel Pad as a Coupling Medium.

This study introduces a method to overcome technical challenges in using intraoperative ultrasound for the closed reduction of nasal bone and zygomatic arch fractures. The curvature of the face makes it difficult to apply an ultrasound probe to the facial area. We used a solid gel pad as a coupling medium during surgery to improve the scanning of facial bone fractures. The results show that the fracture sites observed on preoperative computed tomography scans can be easily visualized using intraoperative ultrasound, and real-time manipulation confirms successful reduction. The solid gel pad is light, malleable, easy to use, and provides accurate images. Overall, the use of ultrasound with a solid gel pad enhances the accuracy of closed reduction in facial bone fracture surgeries, confirming fracture patterns and ensuring precise reduction.

Utility of CT or X-ray in the management of adult nasal fracture.

PURPOSE: The primary objective of this study is to evaluate the use of imaging in the management of nasal fracture in adults and determine if imaging is beneficial to clinical decision making when planning for surgery. A secondary objective of this study is to compare surgical rates for nasal fracture between pediatric and adult populations. METHODS: This is a retrospective case-control study of 357 patients seen at University Hospitals Cleveland Medical Center from January 2015 through January 2020 with a diagnosis of nasal fracture. An odds ratio was calculated to determine likelihood of surgical intervention between patients who had imaging of the nasal bones and patients who did not. RESULTS: 82 % of patients had either CT or X-ray imaging. The odds ratio of patients who had surgery after CT or X-ray imaging compared to patients who had surgery without prior imaging was 0.092 (95 % CI: 0.0448-0.1898, p-value <0.0001). A total of 54 (15 %) adult patients had surgery, in comparison to 50 % of pediatric patients with diagnosis of nasal fracture. 202 (57 %) of patients did not follow up after initial diagnosis by radiology. CONCLUSION: The statistical analysis suggests that while CT and X-ray are frequently obtained in the setting of nasal fracture, patients without imaging are more likely to have surgery (p < 0.05) than patients with imaging. This indicates that imaging is likely unnecessary for surgical planning. Most adults do not pursue surgery, and surgical rates for adults with nasal fracture are much lower than those of pediatric patients with nasal fracture.

Time-to-operation delays and in-hospital complications in operative facial trauma: A national analysis.

BACKGROUND: Management of facial fractures is variable. Understanding how time to operative management impacts outcomes can help standardize practice. METHODS: Retrospective analysis of the ACS Trauma Quality Improvement Program (TQIP) database between 2016 and 2019. Adult patients with operative facial fractures were isolated by ICD-10 procedure codes, and further stratified by fracture location, including the mandible, orbit, maxilla, zygoma, and frontal bone. Multivariable logistic regression was conducted to predict in-hospital complications (both surgical and systemic complications) adjusting for time-to-operation, comorbidities, fracture location, AIS, and demographics. RESULTS: 1678 patients with operative facial fractures were identified. The median time-to-operation was 2 days (IQR 1.0-2.0 days). Most patients only had one operative fracture (95 %) and orbital fracture was the most common (44 %). The overall complication rate was higher for those operated after 2 days compared to those operated between 1 and 2 days and within 24 h (2.8 % vs 0.6 % vs 0.7 %; p < 0.001). Patients who were operated on after 48 h exhibited an increased risk of any complication (OR 4.72, 95 % CI 1.49-16.6, p = 0.010) on multivariable models. CONCLUSION: Delays in the management of facial fractures are associated with more in-hospital complications. However, the incidence of short-term postoperative complications remains low. Injury characteristics are the primary predictor of delays in operation, however Hispanic patients independently experienced delays in care.

Surgical Treatment of Complex Craniofacial Fractures.

OBJECTIVE: Severe craniofacial fractures may present different needs in treating intracranial lesions over facial injuries. This paper examines the results of our strategy, consisting of a single-stage combined neurosurgical-maxillofacial treatment. METHODS: A retrospective review was conducted of 33 consecutive patients with complex fractures of the anterior cranial fossa and facial skeleton, who required elective surgery for craniofacial reconstruction. Patients who required emergency surgery for intracranial clots or penetrating wounds were excluded. In all cases, all or almost all the anterior skull-base was injured with compound fractures of the frontal sinus, the orbital roofs, the lamina cribrosa, and the planum sphenoidale. In all cases, the prioritization of treatment was carefully discussed, and surgical timing and strategy were agreed. RESULTS: There was 1 dead. Olfactory injuries were always found intraoperatively. There were no mucoceles, CSF-leak recurrences, cranial infections, or neurologic worsening. The functional and neurologic results were highly satisfactory. CONCLUSIONS: The one-stage surgical treatment of complex craniofacial fractures has numerous advantages, including the possibility of reducing facial fractures without the risk of CSF leaks. It also eliminates the need for repeated procedures in fragile patients, and the need to dismantle the facial reconstruction if the skull base repair is performed later. The main issue is the surgical timing, considering that the maxillofacial surgeon usually favors early facial repair, whereas the neurosurgeon generally prefers delayed manipulation of the contused frontal lobes. A timeframe of 10-14 days after trauma may be a good compromise for safe procedures with excellent neurologic and functional outcomes.

Predictors of Middle Meningeal Artery-Related Vascular Diseases Associated with Blunt Head Trauma.

OBJECTIVE: Traumatic middle meningeal artery (MMA)-middle meningeal vein (MMV) fistula (MMA-MMV fistula) and MMA pseudoaneurysm are the 2 main MMA-related vascular diseases occurring after blunt head trauma. These are rare but known causes of delayed intracranial hemorrhage. This study investigated predictors that may aid in the diagnosis of these diseases. METHODS: In our department, screening digital subtraction angiography (DSA) is performed for patients with blunt head trauma accompanied by intracranial hemorrhage and skull or facial bone fracture. This study included 87 patients who underwent screening DSA without craniotomy from January 2019 to June 2023. The patients' clinical characteristics were retrospectively collected from the database. Statistical analysis was performed to examine the associations of various evaluation items with MMA-related vascular diseases. RESULTS: The first DSA examination revealed 34 MMA-MMV fistulas and 1 MMA pseudoaneurysm. The second follow-up DSA examination revealed 13 MMA-MMV fistulas and four MMA pseudoaneurysms. Temporal/parietal bone fracture (odds ratio, 5.33; P = 0.0005; 95% confidence interval, 1.95-14.60) was significantly associated with MMA-related vascular diseases. Endovascular treatments were performed in 9 patients. All procedures were successfully completed without complications; no delayed bleeding was observed. CONCLUSIONS: Temporal/parietal bone fracture in patients with blunt head trauma is a likely predictor of MMA-related vascular diseases. When initial head computed tomography reveals this pathology, we recommend careful imaging follow-up (e.g., DSA) and treatment as needed, while considering the possibility of MMA-related vascular diseases.

Perfecting the Outcome of Nasal Bone Fracture in the Pediatric Population With a Navigation System.

BACKGROUND: The trend of using navigation systems for treating facial bone fractures is increasing. Nevertheless, any detailed recommendation on using a navigation system to treat nasal bone fracture has never been discussed. Plastic surgeons are prone to do closed reduction of nasal bone fractures with remnant posttraumatic edema in the pediatric population. This study hypothesized that the navigation system benefits this population's treatment of nasal bone fractures. METHODS: The authors evaluated the medical records, plain x-ray, and facial computed tomography scans of 44 pediatric patients (below the age of 18) with nasal bone fractures treated with a closed reduction from May 2021 to December 2022. Preoperative and postoperative computed tomography scan were used to assess the outcome. RESULTS: The average age for 44 pediatric nasal bone fracture patients was 10. Fifteen were female, while males were 29. All cases were successfully corrected clinically and radiologically without noticeable complications. CONCLUSIONS: Using navigation systems to correct nasal bone fractures provides additional benefits for the pediatric population. This technique is especially useful if the fracture is located at the junction between the nasal bone and nasal process of the maxilla and is combined with concurrent old nasal bone fractures.

Caring for the Patient with Otolaryngologic Trauma Is a Complex Matter.

In an Austrian study of 14,654 patients with 35,129 injuries treated at a single Department of Cranio-Maxillofacial and Oral Surgery over a 15-year period, the following was seen.1 Older people were more prone to soft tissue lesions with a rising risk of 2.1% per year older, equal in men and women. Younger patients were at higher risk of dentoalveolar trauma with an increase of 4.4% per year younger, and this was 19.6% higher for women. The risk of sustaining facial bone fractures increased each year by 4.6% and was 66.4% times higher in men. A total of 2550 patients (17.4%) suffered 3834 concomitant injuries of other body parts.

Treatment Outcomes With Conservative Management of Frontal Sinus Outflow Tract Fractures.

OBJECTIVE: Historically, early surgical management of frontal sinus outflow tract (FSOT) fractures has been standard practice. There has been a paradigm shift toward nonsurgical or delayed management. Unfortunately, clinical indications and treatment outcomes for this approach are poorly understood. This study evaluates radiologic indicators, as well as sinus reaeration and complication rates for FSOT injuries treated nonsurgically. STUDY DESIGN: A retrospective cohort study of FSOT injuries between 2005 and 2019. SETTING: Academic, tertiary care medical center. METHODS: Radiographic fracture patterns of the frontal ostia (FO) and frontal recess (FR) were recorded as either patent, disrupted, or obstructed. Sinus reaeration, surgical rescue, and complication rates were documented. Patients with follow-up imaging >42 days were included. Patients undergoing immediate surgical intervention were excluded. RESULTS: One hundred patients were identified and 44 met the criteria (88 sinuses). Among nonobstructed FSOT injuries (ie, patent or disrupted), reaeration occurred in 91% of the FO and 98% of FR injuries. Two sinuses required surgical rescue including 1 Draf IIB (1%), and 1 obliteration (1%). Two sinuses had complications including 1 mucocele (1%) and 1 cerebrospinal fluid leak (1%). FO and FR fracture patterns had no identifiable correlation with long-term reaeration rates or the need for surgical intervention. CONCLUSION: Among nonobstructive injuries to the FSOT, average reaeration rates in observed patients were high (91%-98%). Rescue surgery (2%) and complication rates (2%) were low, suggesting that nonsurgical management of nonobstructed FSOT is a viable strategy. No radiographic features were clearly identified to be predictive of sinus reaeration.

Kimura disease of naso-orbito-ethmoid region and review of surgical approaches to naso-orbito-ethmoid region.

SummaryA man in 30s had complaints of glabellar and upper nasal swelling for 8 years. It was insidious in onset and gradually progressive causing epiphora and restriction of nasal visual field. Fine-needle aspiration cytology and biopsy revealed features which were suggestive of Kimura's disease (KD). CT scans showed a well-defined subcutaneous swelling in the naso-orbito-ethmoid (NOE) region. KD presents as lymphoglandular swelling; however, NOE region is an uncommon site of occurrence. A thyroid-shaped tumour was excised by H-shaped incision approach to the NOE region.

Comparing the Efficacy of Postoperative Antibiotic Regimens in the Treatment of Maxillofacial Fractures: A Prospective Study.

AIM: The present study was designed to investigate the difference in the effectiveness of a 3 day postoperative course and a single perioperative dose of antibiotics on the incidence of postoperative infection in the management of maxillofacial trauma patients. MATERIALS AND METHODS: About 183 maxillofacial trauma patients requiring open reduction and internal fixation (ORIF) under general anesthesia were divided based on the type of fracture sustained, i.e., mandibular fractures, Le Fort fractures, and zygomaticomaxillary complex fractures. Patients from each fracture type were randomized into two groups, A and B. All patients were administered amoxicillin/clavulanate 1.2 grams intravenously 8 hours from the time of admission till the patient was taken up for surgery. Once the patients were taken up for surgery, a perioperative dose was administered. No antibiotics beyond this point were given to patients in Group A. Patients in Group B were administered the same antibiotic for 3 postoperative days additionally. Outcomes in terms of purulent discharge from the surgical site, an abscess or any other sign of infection, and wound dehiscence requiring reopening of the surgical site were considered. Patients were reviewed at 1 week, 2 weeks, 1 month, 2 months, and 3 months. RESULTS: No statistically significant difference was found between the two groups across all three fracture types in terms of postoperative outcomes. However, increased numbers of complications were noted in the patients treated with an intra-oral approach in each fracture type irrespective of group. All complications were managed with local measures. CONCLUSION: A single perioperative dose of antibiotics is effective in minimizing postoperative complications following ORIF of maxillofacial fractures and there is no significant benefit in prolonging the course of antibiotics postoperatively with the need for further studies to be conducted considering comminuted, complex fractures and old fractures. CLINICAL SIGNIFICANCE: In maxillofacial trauma, fractures frequently communicate with contaminated indigenous flora on the skin surface, oral cavities, or sinus cavities. Surgery is frequently performed using an approach across a contaminated area, even in closed fractures. Postoperative infections can be significantly decreased by using antibiotics in surgical procedures to treat facial fractures.

The Management of Posttraumatic Nasal Deformities.

Nasal bone fractures are the most common fractures of the facial skeleton and are often accompanied by bony, cartilaginous, and soft tissue injuries. These injuries are often complex, and when untreated or inadequately treated, can lead to posttraumatic nasal deformity. The most common deformities are the crooked nose and the saddle nose. Both deformities may result in significant cosmetic and functional concerns. The treatment of these deformities can be complex, requiring careful evaluation of the nose and thoughtful planning to correct the cosmetic deformity and restore functional integrity. The rhinoplasty surgeon will benefit from having a large repertoire of techniques to achieve these repairs. In this article, we discuss the options and concepts for the management of nasal bone fractures as well as complicated posttraumatic nasal deformity. Level of evidence is not available.

Management of Mid-Facial Fracture Complicated by Pseudoaneurysm of Posterior Superior Alveolar Artery.

Facial fractures, particularly mid-facial fractures, can result in various complications, such as functional and esthetic problems. Prompt reconstruction of the fractured bones is crucial for restoring normal anatomy and function and preventing complications. However, such procedures can be complex and carry the risk of potential complications. The authors report the case of a 27-year-old man who underwent open reduction and internal fixation of the left zygomatic complex fracture and reconstruction of the left inferior orbital wall. During the surgery, heavy bleeding from the posterior superior alveolar artery due to a broken bone near the pterygomaxillary region caused a prolonged surgery time and the development of a pseudoaneurysm. The pseudoaneurysm was eventually treated with superselective transcatheter embolization using 25% N-Butyl cyanoacrylate glue. This case highlights the challenges in the management of mid-facial fractures and the potential complications that can arise during surgery, particularly when dealing with the pterygomaxillary region.

Management of Complications and Secondary Deformity After Fractures of the Midface, Orbit, and Upper Third of the Maxillofacial Skeleton.

Craniomaxillofacial trauma is a challenging entity to manage effectively and often necessitates serial evaluation and treatment. A multidisciplinary team is best served to evaluate and treat these complex injury patterns with the use of necessary adjuncts, such as neuronavigation, intraoperative imaging, custom implant use, and virtual surgical planning. Complications of facial trauma can present at a spectrum of time points and manifest in a variety of manners and as such patients should be observed closely and longitudinally. Although not all complications and secondary deformities can be avoided, this article highlights some common pitfalls and our unique management strategies.

Pediatric Cranial Vault and Skull Base Fractures.

Cranial vault and skull base fractures in children are distinctly different from those seen in adults. Pediatric skull fractures have the benefit of greater capacity to remodel; however, the developing pediatric brain and craniofacial skeleton present unique challenges to diagnosis, natural history, and management. This article discusses the role of surgical treatment of these fractures, its indications, and techniques.