Endoscopic approach to orbital blowout fracture repair.

OBJECTIVES: Transconjunctival and subciliary approaches to orbital floor blowout fractures (OBF) have known risks of postoperative eyelid malposition. This study evaluates the endoscopic transmaxillary repair of OBFs in a cadaveric model and clinical setting. METHODS: Sixteen cadaveric and 10 clinical OBFs were repaired endoscopically. A Caldwell-Luc approach and modified sinus surgery instrumentation were used to repair each fracture. Variations in fracture pattern, instrumentation, and surgical technique were evaluated. RESULTS: Endoscopic repair was achieved in all 16 cadaveric orbits and in 9 of 10 patients. Fracture patterns were classified as either medial or lateral to the infraorbital nerve. Average clinical operating time was 1:38. Of 9 postoperative CT scans, 5 were rated as excellent, 3 as good, and 1 as poor. CONCLUSIONS: The endoscopic transmaxillary approach is a safe, viable technique for OBF repair. It offers improved visualization, anatomic fracture repair, no risk of postoperative eyelid complications, and good clinical results. EBM rating: C.     

Simulated blowout fracture of the orbit

A case of probable traumatic simulated Brown's syndrome, in which there was a false positive orbital tomogram, is presented. To our knowledge, this combination of findings has not been previously reported. The deceptive clinical signs combined with the false positive radiologic data led to the erroneous diagnosis of blowout fracture of the orbital floor and to a subsequent negative surgical exploration. Surgeons should be aware that these two infrequent findings may occur together. When there is any doubt about the diagnosis of blowout fracture of the orbital floor with muscle entrapment, conservative management may be indicated.     

Orbital blowout fracture from hydrostatic pressure

This case report describes an orbital blowout fracture due to hydrostatic pressure from a high-diving accident. Also described are the velocities encountered in this case.     

双切口双钢板治疗骨折-脱位型胫骨内髁骨折

目的 回顾性分析双切口双钢板治疗骨折-脱位型胫骨内髁骨折。方法 骨折-脱位型胫骨内髁骨折19例(AO分类：41-B3.2)，男10例，女9例，平均年龄36.0岁，平均随访11.2个月。用Rasmussen评分法评价治疗效果。结果 19例患者下肢力线全部矫正，其中优良16例，占84.2％，一般3例，占16.8％，不伴早晚期并发症。结论 用双切口双钢板治疗骨折-脱位型胫骨内髁骨折是一种可靠的手术方法，疗效佳，并发症少。     

Cyanoacrylate embolization of endoleaks after abdominal aortic aneurysm repair

Introduction: Type II endoleaks occur in up to a fifth of endoluminal repairs for abdominal aortic aneurysms and are commonly treated when aortic sac expansion can be demonstrated. Technical failure is common when catheter‐guided particulates or coil embolic agents are used. Presented here is a feasibility study using catheter‐directed N‐butyl‐2‐cyanoacrylate (Histoacryl, Braun, Tuttlingen, Germany) embolotherapy. Method: A retrospective review of the case notes of patients undergoing embolization procedures for type II endoleaks with expanding sacs was performed from this centre's cohort of endoluminal aortic repair patients under surveillance. Data on patients with type II endoleaks who were treated with either or both cyanoacrylate and coil embolization were extracted. The outcomes were then compared. Results: In total, five cases were identified, and four of these cases had both coil and glue embolization. Technical success was defined as endoleak closure proven on follow‐up computed tomographic imaging. Technical success was achieved in all four patients treated with intra‐sac cyanoacrylate. One case treated initially with coil embolization was successful. All patients had a computed tomographic scan at 3 months. One minor complication occurred that resolved without treatment. Discussion: Type II endoleaks after EVAR with expanding sacs require treatment. Percutaneous catheter‐directed cyanoacrylate embolization offers an alternative to coil or particulate embolization and, in this series, was found to be more likely to result in endoleak closure.     

Orbital blowout fracture due to true hydraulic pressure

In this report, we present an unusual case of an orbital floor fracture produced when a 56-year-old female was pushed in the face by the palm of her husband’s hand. After being pushed to the floor and held down with her face turned upwards, the woman’s husband applied pressure to her right eye region with his left palm. During this attack, she heard a cracking sound from her right orbital region, and felt dizziness, nausea, and diplopia immediately after the sound. CT scanning was undertaken, revealing a right orbital floor fracture which extended from the anterior portion of the floor to the orbital apex. A transmaxillary operation was undertaken 3 days after injury under general anesthesia. The herniated orbital tissue and fractured bone segments were reduced, and a maxillary balloon was inserted to sustain the reduced bone segments. The balloon was removed 5 weeks after the primary operation under local anesthesia. The patient’s right enophthalmos had cleared up, and CT scanning showed correct shape of the orbital floor 3 months after primary surgery. We conclude that this case of orbital floor fracture is the second reported case that supports a purely hydraulic theory.     

Endoscopic versus external repair of orbital blowout fractures.

OBJECTIVES: This study evaluates the usefulness of endoscopic repair compared to external repair in the treatment of blowout fracture (BOF) of the orbit. STUDY DESIGN AND SETTING: This retrospective study comprised 100 patients who had had surgical repair of orbital BOF since 1992. Forty-eight of the 100 had undergone endoscopic repair, 48 patients had had external repair, and four patients underwent surgery that combined the two approaches. The two basic approaches were evaluated and compared with respect to technique, results and complications. RESULTS: Endoscopically, transnasal and transantral approaches had been used for reduction and support of fractured medial and inferior walls, respectively. In the external approach, various transorbital incisions were made and the fractured wall was repaired with alloplastic or autologous materials. Complete or partial resolution of preoperative diplopia was achieved in 94% of the endoscopic group and 83% of the external group (NS). Enophthalmos was improved in 89% of the endoscopic group and 76% of the external group (NS). Though the endoscopic group had no significant complications, the external group had ectropions, significant facial scars, extrusion of inserted Medpor, and intra-orbital hematoma. CONCLUSIONS: Endoscopic repair appears to be a safe and effective technique for the treatment of BOF of the orbit.     

Subcaruncular approach for the reconstruction of blowout fractures of medial orbital walls

To obtain a wide and clean operative field for anatomic reconstruction of medial orbital blowout fractures, an alternative method called the subcaruncular approach has been performed. Between March 2008 and June 2010, this method was applied to the orbits of 41 patients with isolated pure medial orbital blowout fractures. A medial half conjunctival incision was made and extended meticulously to the subcaruncular area through preseptal plane under direct vision. Pre- and postoperative computed tomographic scans and ophthalmic examinations were performed, and clinical results were assessed. Postoperatively, computed tomographic scans revealed anatomic reduction of orbital soft tissues and the reconstructed medial orbital wall to be in proper position in all cases, and diplopia and eyeball motility limitation were resolved in most patients. There were no complications except severe chemosis in one case. We believe that this method can be a useful alternative option for the anatomic reconstruction of medial orbital blowout fractures.     

Cyanoacrylate tissue sealant impairs tissue integration of macroporous mesh in experimental hernia repair

BACKGROUND: Tissue sealants have been proposed as an alternative to permanent fixation devices in hernia repair with the aim of reducing perforation-associated complications and chronic pain. Sealants can be divided into three main categories: synthetic glues (e.g., cyanoacrylate based), biologic products (e.g., fibrin sealant), and genetically engineered polymer protein glues. The beneficial effects of fibrin sealant have been reported in both experimental and clinical hernia repair. However, data on cyanoacrylate glues for mesh sealing are limited. METHODS: In 20 Sprague-Dawley rats, two hernia defects (1.5 cm in diameter) per animal were created bilaterally in the midline of the abdominal wall. The peritoneum was spared. The lesions were left untreated for 10 days to achieve a chronic condition. Defects then were covered with TI-Mesh xl (2 x 2 cm), which was glued with Glubran-II. The time points of sacrifice were 17 days, 28 days, and 3 months. At autopsy, meshes were biomechanically tested, and histology was performed. RESULTS: Tissue integration of the meshes was impaired at all time points by impenetrable glue plaques. At application sites, the elasticity of the abdominal wall was significantly reduced because of nonresorbed, rigid glue residues. CONCLUSIONS: Mesh fixation by Glubran-II impairs tissue integration, elicits inflammation, and unfavorably alters the biomechanics of macroporous mesh and the abdominal wall.     

Endoscopic endonasal repair of blowout fractures of the orbital floor

Objectives: This study is to show the usefulness of the endoscopic endonasal approach in the surgical treatment of isolated blowout fractures of the orbital floor.Methods: Between 1997 and 2003 we operated on 65 patients complaining of diplopia due to isolated blowout fractures of the orbital floor, including 4 patients accompanied with enophthalmos. In 62 of the 65, only the endonasal approach with endoscope was used, while in the remaining 3 patients, we used the combined endonasal and transantral approach. To do the endonasal repair surgery smoothly under the endoscope, via the middle nasal meatus, septoplasty was supplemented in 13 patients and submucous conchotomy in 57. The bone fragments trapping the orbital content herniated into the maxillary sinus were carefully removed so as to keep the periorbita intact. Tampon gauzes or a balloon catheter for temporal fixation was placed in the maxillary sinus through the middle nasal meatus to support the orbital floor for 2 to 7 days. No permanent supporting material was used. Immediately following the repair and the fixation the eye traction test was respectively performed to confirm that the eyeball was freely moving.Results: Postoperatively diplopia disappeared in 50 of the 57 patients using only the endonasal approach, (87.7%) and enophthalmos improved 3 of 4 followed over 6 months.Conclusions: From this high success rate with respect especially to diplopia we conclude that the endoscopic endonasal approach is alternative to extranasal methods in view of cosmetics and the improvement of eye movement.     

Recognition and management of an orbital blowout fracture in an amateur boxer

STUDY DESIGN: Case report. OBJECTIVES: To identify key elements in the recognition and management of a patient with an orbital blowout fracture and make recommendations on diagnosis, treatment, referral, imaging, and return to sports. BACKGROUND: Orbital blowout fractures are uncommon but important injuries for physical therapists to recognize. Immediate management is essential in preventing complications. The mechanism of injury is a direct blow to the orbital rim or orbit. CASE DESCRIPTION: The patient reported to the athletic training room 15 minutes after completing a boxing match and reported that his left eye had suddenly inflated after blowing his nose. We suspected an orbital blowout fracture and referred him immediately to the emergency department where conventional radiographs were ordered. On follow-up the next day, after determining that the radiographs were normal, but still having a high index of suspicion for an orbital blowout fracture, we referred him to his primary care manager. The primary care manager ordered a computed tomography scan that revealed the fracture and referred the patient to ophthalmology. OUTCOMES: The patient was restricted from the remaining 4 weeks of the boxing season. He completed a rigorous Army physical fitness test 7 days postinjury and the Marine Corps Marathon 47 days postinjury. DISCUSSION: Orbital blowout fractures without double vision, extraocular muscle entrapment, or persistent numbness can be treated with time and protection. The patient can continue with normal fitness activities except contact or collision sports.     

Bone fracture and bone fracture repair

Fracture healing is a multistage repair process that involves complex, well-orchestrated steps initiated in response to tissue injury. The early upregulation of IL-6, osteoprotegerin (OPG), VEGF, and BMPs indicates a central role for these factors in the initiation of cartilage and periosteal woven bone formation. In both callus fracture repair and stress fracture repair, the RANKL/OPG ratio is initially reduced, but peaks earlier in stress fracture healing than callus fracture healing. Though the understanding of the biological processes and molecular signals that coordinate fracture repair has advanced, the cause of variability observed in fracture repair is poorly understood.     

钒酸盐促进大鼠内侧副韧带损伤愈合的实验研究

[目的]观察钒酸盐对大鼠内侧副韧带损伤后愈合质量的影响。[方法]选择60只成年雄性SD大鼠,随机分2组进行实验。制备右膝关节内侧副韧带断裂模型。在内侧副韧带断裂模型制备前1周至术后4周,实验组大鼠每日给予钒酸盐25 mg灌胃1次,对照组给予等量生理盐水,至术后第4周,无损伤情况下将实验组及对照组愈合处韧带取下,进行组织学检查及电镜检查。[结果]光镜下见钒酸盐组胶原纤维排列整齐,而对照组胶原纤维排列紊乱。电镜下观察见钒酸盐组韧带愈合处胶原纤维直径及排列方向均匀一致,而对照组胶原纤维直径相差较大且排列紊乱。钒酸盐组胶原纤维直径较对照组明显增粗,差异有统计学意义(P0.05)。[结论]钒酸盐可以促进韧带愈合时胶原纤维排列更为规则;同时可以增加韧带愈合后胶原纤维直径。因此,本实验可以为将来临床治疗韧带损伤提供一种新的途径及理论依据。