Maxillofacial trauma scoring systems

The changing complexity of maxillofacial fractures in recent years has created a situation where classical systems of classification of maxillofacial injuries fall short of defining trauma particularly that observed with high-velocity collisions where more than one region of the maxillofacial skeleton is affected. Trauma scoring systems designed specifically for the maxillofacial region are aimed to provide a more accurate assessment of the injury, its prognosis, the possible treatment outcomes, economics, length of hospital stay, and triage. The evolution and logic of such systems along with their merits and demerits are discussed. The author also proposes a new system to aid users in quickly and methodically choosing the system best suited to their needs without having to study a plethora of literature available in order to isolate their choice.     

Local vanadium release from a calcium sulfate carrier accelerates fracture healing

This study evaluated the efficacy of using calcium sulfate (CaSO₄) as a carrier for intramedullary delivery of an organic vanadium salt, vanadyl acetylacetonate (VAC) after femoral fracture. VAC can act as an insulin‐mimetic and can be used to accelerate fracture healing in rats. A heterogenous mixture of VAC and CaSO₄ was delivered to the fracture site of BB Wistar rats, and mechanical testing, histomorphometry, micro‐computed tomography (micro‐CT) were performed to measure healing. At 4 weeks after fracture, maximum torque to failure, effective shear modulus, and effective shear stress were all significantly higher (p < 0.05) in rats treated with 0.25 mg/kg VAC–CaSO₄ as compared to carrier control rats. Histomorphometry found a 71% increase in percent cartilage matrix (p < 0.05) and a 64% decrease in percent mineralized tissue (p < 0.05) at 2 weeks after fracture in rats treated with 0.25 mg/kg of VAC–CaSO₄. Micro‐CT analyses at 4 weeks found a more organized callus structure and higher trending maximum connected z‐ray. fraction for VAC–CaSO₄ groups. Evaluation of radiographs and serial histological sections at 12 weeks did not show any evidence of ectopic bone formation. As compared to previous studies, CaSO₄ was an effective carrier for reducing the dose of VAC required to accelerate femoral fracture healing in rats. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:727–734, 2014.     

不同内固定方式对老年股骨粗隆间骨折全身情况的影响

目的探讨动力髋螺钉(DHS)、股骨近端防旋髓内钉(PFNA)及Inter Tan内固定对老年股骨粗隆间骨折全身情况的影响。方法笔者自2012-01—2013-12共诊治老年股骨粗隆间骨折189例,根据内固定方式分为DHS、PFNA、Inter Tan 3组,分别比较3组术中情况(麻醉方式、手术时间、失血量)、白细胞计数、血红蛋白、氧分压(PO2)、并发症、死亡率等。结果 3组麻醉方式、手术时间比较差异均无统计学意义(P0.05);Inter Tan组显性、隐性失血量及输血量均较DHS组和PFNA组多,差异有统计学意义(P0.05);3组术前白细胞计数差异不明显,术后均有不同程度升高,Inter Tan组术后1、3、5 d白细胞计数水平较其他2组明显升高,术后3 d差异有统计学意义(P0.05);3组术前血红蛋白水平差异不明显,术后均有不同程度下降,3组术后1、3 d血红蛋白水平差异均有统计学意义(P0.05);3组术前PO2差异无统计学意义,术后均有不同程度下降,术后1、3、5 d Inter Tan组下降最明显,其次为PFNA组,DHS组最高,差异有统计学意义(P0.05);术前谷丙转氨酶3组间差异无统计学意义(P0.05),3组术后1、3 d差异有统计学意义(P0.05);DHS组住院期间并发症6例,PFNA组8例,Inter Tan组14例,3组比较差异均无统计学意义(P0.05)。结论髓内及髓外固定均可对机体产生一定影响,髓内固定中的Inter Tan对失血量、白细胞计数、血红蛋白、PO2影响最大,但3种内固定方式对于总体结局(死亡及并发症)的影响差异不大。     

Effect of finish line design on stress distribution in bilayer and monolithic zirconia crowns: a three‐dimensional finite element analysis study

This study evaluated the influence of different finish line designs and abutment materials on the stress distribution of bilayer and monolithic zirconia crowns using three‐dimensional finite element analysis (FEA). Three‐dimensional models of two types of zirconia premolars – a yttria‐stabilized zirconia framework with veneering ceramic and a monolithic zirconia ceramic – were used in the analysis. Cylindrical models with the finish line design of the crown abutments were prepared with three types of margin curvature radius (CR): CR = 0 (CR0; shoulder margin), CR = 0.5 (CR0.5; rounded shoulder margin), and CR = 1.0 (CR1.0; deep chamfer margin). Two abutment materials (dentin and brass) were analyzed. In the FEA model, 1 N was loaded perpendicular to the occlusal surface at the center of the crown, and linear static analysis was performed. For all crowns, stress was localized to the occlusal loading area as well as to the axial walls of the proximal region. The lowest maximum principal stress values were observed when the dentin abutment with CR0.5 was used under a monolithic zirconia crown. These results suggest that the rounded shoulder margin and deep chamfer margin, in combination with a monolithic zirconia crown, potentially have optimal geometry to minimize occlusal stress.     

The effect of delay to surgery on morbidity,mortality and length of stay following periprosthetic fracture around the hip

With the increasing prevalence of total hip arthroplasty and the increasing longevity of patients with implants in situ, periprosthetic fractures of the proximal femur are seen with greater frequency. They represent a challenging surgical problem, requiring combined arthroplasty and trauma skills in a potentially compromised surgical bed. We present data from the 82 consecutive patients with periprosthetic fractures around the hip presenting to two NHS Foundation Trusts in the period January 2009 to February 2014.Inpatient mortality across all sites was 11.0%. This increased to 17.1% at 1 year. There was no association between delay to surgery and either inpatient or 1 year mortality. Mean delay to surgery was 4.1 days in those without inpatient mortality, 5.2 days in those with (p = 0.3075). Mean delay to surgery was 4.5 days in those with 1 year mortality, 4.16 days in those without (p = 0.6203). The number of post-operative complications was not significantly positively correlated with increasing delay to surgery (Pearson correlation coefficient −0.04437).It would appear that a delay to order necessary equipment and obtain relevant surgical expertise for the treatment of these complex fractures is safe and not associated with increased mortality or post-operative complications.     

The mandibular symphysis as a starting point for the occlusal-level reconstruction of panfacial fractures with bicondylar fractures and interruption of the maxillary and mandibular arches: Report of two cases

Panfacial fractures represent a challenge, even for experienced maxillofacial surgeons, because all references for reconstructing the facial skeleton are missing. Logical reconstructive sequencing based on a clear understanding of the correlation between projection and the widths and lengths of facial subunits should enable the surgeon to achieve correct realignment of the bony framework of the face and to prevent late deformity and functional impairment. Reconstruction is particularly challenging in patients presenting with concomitant fractures at the Le Fort I level and affecting the palate, condyles, and mandibular symphysis. In cases without bony loss and sufficient dentition, we believe that accurate fixation of the mandibular symphysis can represent the starting point of a reconstructive sequence that allows successful reconstruction at the Le Fort I level. Two patients were treated in our department by reconstruction starting in the occlusal area through repair of the mandibular symphysis. Both patients considered the postoperative facial shape and profile to be satisfactory and comparable to the pre-injury situation.     

A systematic literature review of tibial plateau fractures: What classifications are used and how reliable and useful are they?

IntroductionClassification systems such as the Schatzker and AO/OTA have been proposed for standardised assessment of tibial plateau fractures and to guide clinical decision making. However, there has been no comprehensive literature review of all classification systems for tibial plateau fractures, including assessment of their reliability. The aim of this systematic review was to identify and appraise previously established classification systems for tibial plateau fractures and determine their reliability for fracture classification.MethodsSix databases were searched from inception until October 2016. Classification systems for tibial plateau fractures were identified. No restriction was placed on imaging modality (plain film X-ray, CT, MRI). Data synthesis was performed to identify common features of the systems, their prevalence within the literature and studies of intra and inter-rater reliability of fracture classification using Kappa coefficient (κ).ResultsThirty-eight classification systems were identified, five of which were a sub-classification of a single fracture type from a previous tool. The Schatzker and AO/OTA classification systems were the most commonly reported. Of the tools identified only five have been tested for inter and intra-observer reliability (Schatzker, AO/OTA, Duparc, Hohl and Luo). Reliability of more simplistic classification systems, such as that by Luo et al. (three-column) was typically high (intra-κ = 0.67–0.81, inter-κ = 0.71–0.87), but with the disadvantage of providing less information on fracture patterns and morphology. Intra and inter-observer reliability using plain film X-ray was frequently moderate (κ = 0.40–0.60), with 2D and 3D CT typically improving reliability of classification. Only 11 of the 32 complete classification systems identified association of fracture classification with clinical outcome.DiscussionFrequently used systems for classification of tibial plateau fractures display moderate intra and inter-observer reliability. More sophisticated imaging modalities such as 2D and 3D CT typically improve reliability estimates. Using fracture classification based on imaging findings to predict clinical outcome was not a commonly reported goal of newly developed systems. More detailed assessment of fracture patterns and morphology, in conjunction with information on surgical fixation, may be desirable for predicting outcomes and to guide clinical decision making.     

(iii) Principles of acetabular fractures

Acetabular fractures are rare, significant injuries involving the articular surface of the acetabulum. They are typically associated with a high-energy mechanism of injury, though fragility type fractures are now increasingly seen. Associated injuries to another organ system are seen in half of all cases. Radiographic assessment is performed using antero-posterior pelvic radiographs and Judet views, as well as computerized tomography (CT). Classification is based on the column theory and describes fracture anatomy in relation to the anterior and posterior columns. Non-operative treatment is indicated when there is less than 2 mm of articular displacement or when patient factors (such as associated injuries/co-morbidities) or soft tissue injury are incompatible with surgery. Open reduction and internal fixation is indicated in displaced fractures, total hip arthroplasty being used in unreconstructable injuries. Operative treatment involves difficult exposures and technically demanding reduction and fixation techniques. Significant associated injuries include neurovascular injury, bleeding, open fracture wounds, soft tissue injury, hip dislocation and femoral fractures. Late complications include post-traumatic osteoarthritis, avascular necrosis and heterotopic ossification. The goals of treatment should be to give the patient a congruent, functional hip whilst minimizing the complications from both the injury and surgery. Poor results are more likely if the reduction is non-anatomical.     

A case-controlled,retrospective, comparative study on the use of biodegradable synthetic polyurethane foam versus polyvinyl acetate sponge after nasal fracture reduction

One of the most frequently used packing materials in closed reduction of a nasal bone fracture is the hydroxylated polyvinyl acetate sponge (PVAS; Merocel^®); however this may cause synechia, epistaxis, and pain. Synthetic polyurethane foam (SPF; Nasopore^® Forte) has recently been used in septoplasty to prevent synechia or restenosis and haematoma formation. The purpose of this study was to compare the effects of PVAS and SPF on postoperative appearance and discomfort following the reduction of nasal bone fractures. We retrospectively reviewed all patient questionnaires and medical histories, and clinical photographs and computed tomography scans obtained before and after surgery. Outcomes were assessed using the Global Aesthetic Improvement Scale (GAIS) score and visual analogue scale (VAS) scores, which were used to assess discomfort during the 6-month follow-up period. Postoperatively, there was no statistically significant difference in the GAIS for the two packing materials (P > 0.05). Postoperative epistaxis was observed at a significantly lower rate in the SPF group than in the PVAS group, whereas anterior rhinorrhea and posterior nasal drip occurred at significantly higher rates following removal of packing in the SPF group (P < 0.05). The results of this study suggest that synthetic dissolvable polyurethane may be a reliable alternative material for nasal packing and postoperative management following the reduction of nasal bone fractures.