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Mandibular fractures are rare in infants, and diagnosis can be easily missed due to the difficulty in obtaining an adequate history and the subtle signs. A high index of suspicion and detailed history taking from the caregiver are mandatory to pick up these cases.There are a plethora of management options that have been reported in dealing with such fractures. They range from conservative management to internal fixation by absorbable plates. While conservative management does not interfere with mandibular growth and teeth development, any surgical intervention can carry this risk. Nevertheless, a severely displaced fracture may need anatomical reduction and fixation to allow early nutrition.This study reports a 3-month-old male infant with a fracture in the mandibular symphysis who underwent reduction of the fracture and circummandibular fixation using immobilisation by an acrylic splint for 4 weeks. His long-term follow-up after 20 months showed adequate dentition with proper healing of the fracture site.

Charcot’s joint is a type of neuro-arthropathy, where asymmetrical damage of the involved joint happens haphazardly, without following any described pattern. We present a rare case of Charcot’s joint involving the knee joint in an adult male following spina bifida. His knee joint was successfully fused after two surgeries. Later, he sustained a fracture through the arthrodesis after a fall, which we managed surgically. The fracture through the knee arthrodesis was managed surgically by an open reduction and internal fixation, using a 14-hole broad low contact dynamic compression locking plate with bone grafting. Union was achieved at the knee arthrodesis site in 6 months. Fracture through a fused knee requires surgical management. Re-arthrodesis was done using a stable fixation. Postoperative rehabilitation should include protected weight bearing with braces and splints until a sound bony union is achieved.

Statement of problem Patients with a mandibular defect can develop mandibular deviation, resulting in a loss of or reduction in occlusal contact and ultimately loss of function. The occlusal ramp is a prosthesis used to help restore the masticatory function of such patients and is used particularly in the maxillofacial rehabilitation of patients with masticatory dysfunction resulting from mandibular deviation. The occlusal ramp is usually attached to a mandibular denture or worn as an independent device placed on the palate corresponding to the mandible that produces the offset. However, evidence of the effects of its use is sparse. Purpose The purpose of this clinical study was to investigate the effects of occlusal ramp use in functional rehabilitation. Materials and methods This study included 10 patients who had received mandibulectomies (5 men and 5 women; mean age 76.7 years, range 67 to 90 years) with deviation of the mandible. An occlusal ramp was fabricated for each participant as part of their maxillofacial prosthetic treatment. Masticatory performance was evaluated before and after the treatment by measuring glucose extraction while masticating a piece of gummy jelly. The Wilcoxon signed-rank test was used for statistical analysis (α=.05). Results The median masticatory performance score, represented as glucose concentration (mg/dL), was 82.45 before treatment and 115.45 after treatment, with an overall improvement of 33.00. Scores differed significantly before and after treatment (P=.005). Masticatory performance for each participant improved in the range of 17.7 to 103.3, highlighting the role that the occlusal ramp played in mastication, although with differing effects in each participant. Conclusions Masticatory performance in participants with mandibular deviation after a mandibulectomy was significantly improved with an occlusal ramp. This suggests the effectiveness of using occlusal ramps in maxillofacial prosthetic treatment for the recovery of masticatory function in patients with mandibular deviation.

(Background) Tranexamic acid (TXA) is widely used in hip and knee arthroplasty to reduce perioperative bleeding. Recently, its use has been expanded to arthroscopic surgery. The purpose of this study was to evaluate the efficacy of preoperative use of TXA in arthroscopic rotator cuff repair (RCR).(Methods) A cohort comprising 129 consecutive patients who underwent arthroscopic primary RCR at our institution was retrospectively investigated according to whether they received TXA (April 2018 to December 2020, TXA group, n=64) or did not receive TXA (April 2016 to March 2018, non-TXA group, n=65). TXA was administered at a dose of 1 g intravenously. Rotator cuff tears were repaired by the suture bridge technique. Videos of the arthroscopic procedures were reviewed and rated for visual clarity using a 10-point numeric rating scale. Arthroscopic procedures were divided into glenohumeral, resection of bursal tissue and acromioplasty, and RCR steps. Each step was rated separately. Age, sex, body mass index, hemoglobin level before and on days 1 and 7 after surgery, operating time, mean arterial pressure, tear size, and number of anchors used for cuff repair were compared between the two groups. (Results) There were no statistically significant differences in the patient demographic data. The operating time was significantly shorter in the TXA group than in non-TXA group (97.8 ± 21.8 min vs 116.2 ± 26.0 min). The clarity of the visual field was similar between the two groups during the glenohumeral phase but was significantly higher in the TXA group during the resection of bursal tissue and acromioplasty and RCR phases. Hemoglobin level was not significantly different between the groups on postoperative day 1 but was significantly higher in the TXA group on day 7.(Conclusion) Administration of a single intravenous dose of TXA improved visual clarity in arthroscopic RCR, decreased the total operating time, and reduced hemoglobin loss on postoperative day 7.

Background Type I open distal radius fractures treated with open reduction internal fixation (ORIF) have demonstrated minimal risk of infection. For this reason, they may not require urgent surgical treatment. The purpose of this study was to evaluate the outcomes of patients with type I open distal radius fractures treated with delayed ORIF compared with urgent ORIF. Methods We identified all Gustilo-Anderson type I open distal radius fractures that had undergone ORIF using volar plating over a 5-year period. Patients were stratified into those treated urgently within 24 hours and those scheduled for delayed surgery. Outcomes including functional scores, complications, reoperations, and radiographic measures were compared. Results Twenty-four patients (17 treated urgently and 7 treated delayed) had open type I distal radius fractures. All patients were started on empiric antibiotics at initial presentation—patients in the delayed treatment group were prescribed oral antibiotics, whereas those admitted for urgent treatment received intravenous antibiotics. There were no infections in either group and a single reoperation in each group. The mean postoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 29 (range = 0-77) and did not differ significantly between delayed (mean = 19) and urgent (mean = 38) treatment. Rate of complications and radiographic measures did not differ significantly between the groups. Conclusions Type I open distal radius fractures appear amenable to delayed outpatient ORIF provided that the wound is clean at the time of initial presentation and that antibiotics are initiated appropriately. Further prospective studies comparing delayed and urgent treatment strategies are warranted.

Study Design: A single blind randomized controlled study. Objective: The aim of this study is to evaluate the use of ultrasonography intraoperatively to assess the reduction of unilateral zygomatic complex fractures with a control group using the conventional blind digit palpation. Methods: The study comprised of a sample size of 24 patients with 21 male and 3 female patients. Patients of all age groups diagnosed with unilateral displaced zygomatic complex fracture with or without mandible fracture were included in the study. The subjects were randomized into study and control groups based on a standard protocol with a total of 24 patients. Imaging was in the form of a preoperative and postoperative 3D computed tomography scan with reconstruction of the maxilla and mandible to interpret the diagnosis for all subjects. The inter-fracture distance of the fractured infraorbital rim were measured in 3 dimensions (antero-posterior, medio-lateral and supero-inferior) and compared pre and postoperatively. Preoperative, intraoperative and postoperative ultrasonographic examination was performed and recorded on all patients at the frontozygomatic region, infraorbital rim and zygomatic buttress to assess the proximity of the fractured margins pre reduction, post reduction and post fixation of the fracture segments. Result: Statistical analytic results were significant in all 3 dimensions when measured postoperatively using computed tomography. Conclusion: Ultrasonography is an effective screening and intraoperative tool in the armamentarium of oral and maxillofacial surgery to assess zygomatic complex fractures, avoiding incisions in aesthetic areas of the maxillofacial region.

Seat belt breast deformity can result in significant aesthetic, functional and psychosocial sequelae. Although seat belt breast deformity is well documented, there is a lack of literature describing their reconstructive management. We describe the surgical management of a 63-year-old woman presenting with stage 2b seat belt breast deformity, who underwent scar revision, repositioning of the nipple–areola complex and contralateral breast reduction using Wise-pattern incisions based on superior pedicles. She made an excellent recovery with an improved aesthetic result.

Objective Tricuspid annular size reduction with annuloplasty rings represents the foundation of surgical repair of functional tricuspid regurgitation. However, the precise effect of annular size reduction on leaflet motion and geometry remains unknown. Methods Ten sheep underwent surgical implantation of a pacemaker with an epicardial lead and were paced 200-240 beats/min to achieve biventricular dysfunction and functional tricuspid regurgitation. Subsequently, sonomicrometry crystals were implanted on the right ventricle, the tricuspid annulus, and on the belly of anterior, posterior, and septal tricuspid leaflets. Double-layer polypropylene suture was placed around the tricuspid annulus and externalized to a tourniquet. Simultaneous echocardiographic, hemodynamic, and sonomicrometry data were acquired with functional tricuspid regurgitation and during 5 consecutive annular reduction steps. Annular area, tenting height, and volume, together with each leaflet strain, radial length, and angles, were calculated from crystal coordinates. Results Rapid pacing reduced both left ventricle and right ventricle function and induced functional tricuspid regurgitation (0-3+) in all animals (from 0 ± 0 to 2.4 ± 0.7, P = .002), whereas tricuspid annulus diameter increased from 2.6 ± 0.3 cm to 3.3 ± 0.3 cm (P = .001). Tricuspid annular size reduction 1 to 5 resulted in 16% ± 7%, 37% ± 11%, 55% ± 11%, 66% ± 10%, and 76% ± 8% tricuspid annulus area reduction, respectively, and successively decreased tricuspid regurgitation. Tricuspid annular size reduction 2 to 5 induced anterior and posterior leaflet restricted motion and lower diastolic motion velocities. Tricuspid annular size reduction 5 perturbed septal leaflet range of motion but preserved its angle velocities. Tricuspid annular size reduction 3-5 generated compressive strains in all leaflets. Conclusions Tricuspid annular area reduction of 55% perturbed anterior and posterior leaflet motion while maintaining normal septal leaflet movement. More extreme reduction triggered profound changes in anterior and posterior leaflet motion, suggesting that aggressive undersizing impairs leaflet kinematics.

This retrospective case series aimed to identify whether trans-articular screws, dorsal bridging plates or if a 4-corner compression plate offers better functional outcome after B2 Lis Franc injuries. Thirty-eight patients underwent surgical fixation for these injuries over five years in a Level 1 Trauma Centre. Patients were treated in 1 of 3 treatment arms: trans-articular screw, dorsal bridge plate, or 4-corner compression plate fixation. The primary outcome measures were the Manchester Oxford Foot and Ankle Questionnaire and the Euroqol- 5DL score and surgical results included postoperative complications and further surgery. Injury type, energy of mechanism, open versus closed status were not significantly different within any fixation group. We achieved 94.7% (n=36) good anatomical reduction. Finding significant improvement between plate fixation (both types) versus trans-articular screw groups treatment functional outcomes. A clinically crucial improvement in Manchester Oxford Foot & Ankle Questionnaire scores, and improved Euroqol- 5DL outcomes between 4-corner compression plate and trans-articular screw group. Overall, there was no significant difference in metalware failure, metalware removal and soft tissue complications. This study concludes that functional outcomes after Lis Franc fractures are not just dependant on the quality of anatomical reduction but are affected by fixation type. Further studies are required to provide qualitative analysis and assessment of dorsal bridge plate fixation versus 4-corner compression plate. Significantly, we have seen the 4-corner compression plate group reached the minimum clinically meaningful difference in the Manchester Oxford Foot and Ankle Questionnaire when compared to trans-articular screw fixation. Level of Clinical Evidence: 4

Background: Ever since the description of the first microvascular anastomosis, numerous alternative methods have been described to the classical approach. Tissue adhesive has shown promising result in previous studies and can be a fast and efficient alternative which still requires more studies to allow its clinical implementation. Methods: A randomized comparative experimental study was conducted on rats’ femoral arteries and an end-to-end anastomosis was performed in order to compare 2 anastomosis techniques. In one group, a simple interrupted suture was utilized, whereas in the second group a combination between fewer sutures and tissue adhesive was used. The anastomotic time, total operative time, blood flow velocity before, immediately after and 48 hours after the procedure, as well as an independent grading of the anastomosis immediately after the procedure were performed. Magnetic resonance imaging (MRI) was performed in order to assess the degree of stenosis. After euthanasia, histology and scanning electron microscopy (SEM) were performed on the vessels in order to assess possible complications. Results: A total of 24 anastomoses were performed, of which 12 with a classic technique and 12 with an adhesive technique. All the anastomoses were patent with a significant reduction of anastomotic and total operative time. The grading of the anastomoses showed better results in the classic suture group. The blood flow velocities were not statistically significant between the 2 groups. On MRI there was one stenotic anastomosis, whereas histology and SEM showed more complications on the adhesive group. Conclusion: Anastomotic times were significantly lower with a non-significant trend toward more thrombotic complications in the adhesive group. Further improvement of the glue properties and refinement of the technique will likely make it a viable alternative to interrupted suturing in the future.

Peripheral nerve blocks (PNB) have become an important modality for pain management in ankle fracture surgery. Previous studies have reported their efficacy, but concerns with rebound pain and readmissions have been cited as possible deterrents. The purpose of this study was to evaluate the effects of PNB on hospital length of stay (LOS), narcotic intake, visual analog scale (VAS) for pain, and associated complications in patients undergoing outpatient ankle open reduction internal fixation (ORIF). Adult patients undergoing ankle ORIF were matched 2:1 (no block:block) using propensity-score matching. Preoperative patient characteristics and postoperative outcomes were compared between cohorts. VAS and total narcotic intake were evaluated for each of the first 3 postoperative 8-hour shifts. Narcotic medication was converted to morphine milligram equivalents (MME). Thirty-two patients who received PNB were matched to 64 patients who did not. The PNB group had lower VAS and MME during each of the 8-hour shifts after surgery: 0 to 8 hours (VAS 1.8 vs 6.3; MME 10.6 vs 77.9; p.001), 8 to 16 hours (VAS 1.2 vs 5.9; MME 9.2 vs 28.2; p.001), 16 to 24 hours (VAS 3.7 vs 6.2; MME 13.2 vs 24.2; p = .006 and 0.019). PNB had a shorter LOS (average 16.7 hours vs 26.8 hours; p.001). There were no differences in rates of ED presentations after discharge, hospital readmissions, or complications between cohorts. Peripheral nerve blocks after ankle ORIF are associated with shorter hospital LOS, lower VAS, and reduced narcotic intake without increasing rates of ED visits, hospital readmissions, or complications.

Objective The aim of this paper is to describe a low-cost and readily accessed Manual Aspiration Reduction System (MARS) for use treating ping-pong fractures in three patients. Methods The MARS is composed of a pediatric anesthesia mask, part of a macro dripper, a 3-way stopcock, and two 60-ml syringes. Prior to its use in our patient, the system was tested on five adult volunteers to maximum negative pressure, and none reported pain during the procedure or experienced any other complication. We present three clinical cases of patients with depressed ping-pong fracture who were treated with the MARS at the bedside without anesthesia. The patients were monitored by the neonatology team throughout the procedure. Results Skull radiography revealed reduction of the fracture after the procedure performed with the MARS in all patients. The transfontanellar ultrasound and follow-up neurological examination were normal. The patient progressed favorably and was discharged from our service after 24 h. Conclusions Due to its components, the MARS is a low-cost and readily accessed system. In this case, it permitted satisfactory reduction of a ping-pong fracture in all patients. This system should greatly simplify the treatment of such fractures.

Alveolar ridge regularization involves the smoothing and minimal reduction of rough alveolar bone ridge to achieve adequate bone thickness around the implant. The effect of this procedure on peri-implant health is unclear.The purpose of this clinical study was to evaluate whether bone regularization affects the clinical and biological parameters of peri-implant health when narrow diameter implants are placed as mandibular implant overdenture retainers during initial healing and after occlusal loading.The need for mandibular ridge regularization in the anterior mandibular region was analyzed before the placement of 2 implants (2.9×10 mm, Facility; Neodent) in 21 participants provided with mandibular overdentures. Primary stability was measured by the insertion torque and implant stability quotient (ISQ). Clinical and biological evaluations measuring the plaque index, presence of calculus, probing depth, bleeding on probing index, gingival index, secondary stability (ISQ), and interleukine-1β (IL-1β) and tumor necrosis factor-α (TNF-α) concentrations in peri-implant crevicular fluid were measured during osseointegration on days 7, 15, 30, 60, and 90 and after loading on day 180 after implant placement. Multilevel mixed-effects linear regression analysis and the Kaplan-Meier test were used to analyze the data (α=.05).The ISQ values showed significant differences on days 7 (P.001) and 15 (P=.002) with higher values and on day 180 (P=.008) with a lower value compared with the baseline value in the ridge regularization group. Additionally, a significant decrease in probing depth was observed on days 60 (P=.008) and 180 (P=.027) compared with that on day 15 after implant placement. In the nonridge regularization group, significant decreases in probing depth were observed on days 30 and 180. Moreover, TNF-α levels in this group were significantly lower on days 30 (P=.001), 60, 90, and 180 (P.001) when compared with the value on day 7 (P.001). The ridge regularization group presented with significant differences in TNF-α and IL-1β levels on days 60 (P=.004) and 30 (P=.007), respectively, when compared with the values on day 7. The ISQ and probing depth in the ridge regularization group were associated with changes in TNF-α and IL-1β levels; furthermore, bone type, duration of edentulism, and mandibular bone atrophy were correlated with the clinical outcomes and TNF-α release. The implant survival rate was 67% in the nonridge regularization group and 100% in the ridge regularization group.Mandibular ridge regularization appeared to be beneficial for peri-implant healing during the early stages and after 3 months of occlusal loading in patients with an atrophic ridge, prolonged time since edentulism, and poor bone quality.

Background: It was aimed to compare conventional surgery and three-dimensional (3D) model-assisted surgery used in the treatment of calcaneal fractures. Materials & Methods: A total of 37 patients with unilateral calcaneal fractures were randomly divided into two groups as a conventional surgery group (n: 19) and a 3D model-assisted surgery group (n: 18). The preoperative, postoperative and last follow up angles of the Bohler and Gissane, calcaneal width and facet height were measured. The duration of the operation, blood loss volume, fluoroscopy usage, instrumentation time for both groups were recorded. Finally, the follow-up AOFAS scores were evaluated. A questionnaire was used to determine the perceptions of the resident doctors about the 3D model. Results: The duration of the operation, blood loss volume, fluoroscopy usage, instrumentation time for 3D model-assisted surgery group were 83.3 +/- 4.6 minutes, 83.6 +/- 4.6 ml, 6.8 +/- 1.4 times and 13.0 +/- 0.8 weeks, and as for conventional group they were 130.0 +/- 5.8 minutes, 105.1 +/- 5.6 minutes, 11.7 +/- 1.5 ml, 22.2 +/- 2.4 times and 13.3 +/- 0.8 weeks, respectively (p < 0.0001). The both groups significantly restored Bohler angle, Gissane angle, calcaneal width and calcaneal facet height after operation (p < 0.0 001). The 3D model-assisted group was significantly more succesful in restoration and protection of achieved correction of calcanel facet height (p < 0.0001). The difference was determined among the groups at the final follow-up examination with respect to the amount of change according the values achieved postop. were significant in Bohler angle (p < 0.001), calcaneal facet height (p < 0.0001) and calcaneal widht (p = 0.017). There was no significant difference between AOFAS scores of the two groups at last follow-up. Resident doctors exhibited high scores of overall satisfaction with the use of a 3D printing model. Conclusions: Compared to the conventional group, the 3D model-assisted group provide successful intervention and reduce operation, instrumentation time and the fluoroscopy usage with less blood loss. Performing 3D-assisted surgery helps the quality of reduction during the surgery and stability of internal fixation to protect achieved reduction at follow-up more succesfully. (C) 2020 Elsevier Ltd. All rights reserved., European Society of Tissue Regeneration in Orthopaedics and Traumatology (ESTROT), This paper is part of a Supplement supported by the European Society of Tissue Regeneration in Orthopaedics and Traumatology (ESTROT).

Intra-articular fibromembranous septum in the radiocarpal joint can cause wrist contracture after distal radial fracture, but the mechanism underlying the formation of the septum is unknown. This study examined the clinical outcomes in patients treated with arthroscopic excision of the septum and the factors associated with formation of the septum in patients with and without a septum.Fifty-three patients (22 with septum and 31 without septum) treated for intra-articular distal radial fracture with arthroscopy using a volar locking plate and secondary removal of the plate were included. Clinical outcomes and radiological assessments were analyzed.In patients with a septum, the range of wrist flexion and total wrist arc before the second operation were significantly more limited than in those without a septum (p 0.01 and p = 0.03, respectively). The improvement rate (improvement in wrist arc divided by the wrist arc of the healthy side) after arthroscopic excision of the septum and plate removal was greater in patients with a septum than in those without a septum (6.1% vs. 2.0%, p = 0.08). The significant factors affecting formation of the septum were the residual articular gap and the height of the midradial ridge on computed tomography images.Intra-articular fibromembranous septum after surgically treated intra-articular distal radial fracture affects limited range of motion and secondary arthroscopic excision of the septum improves the wrist range of motion. Anatomical reduction and maintenance of the articular fragment, as well as anatomical characteristics might be causes of septum formation.

Background and importance Chronic subdural hematoma (cSDH) is a common neurosurgical pathology with a projected increase in prevalence as the elderly population grows. We describe a novel implementation of the IRRAflow irrigating drainage system after burr hole evacuation of bilateral acute-on-chronic subdural hematomas that demonstrates the benefits of this system for common post-operative challenges of these surgeries. Clinical presentation An 83-year-old male presented to the emergency department with 3 weeks of progressive weakness, lethargy, and confusion following an unwitnessed fall. Physical examination was notable for pupillary asymmetry and altered mental status. Computed tomography (CT) of the head showed bilateral acute-on-chronic subdural hematomas. The patient underwent bilateral burr hole evacuation and placement of IRRAflow irrigating drains. Postoperative head CT demonstrated poor brain re-expansion with significant bilateral pneumocephalus. Marked improvement in brain re-expansion occurred with continuous irrigation and drainage, and the patient was discharged on postoperative day (POD) 3 with return to neurological baseline. He followed up on POD13 in stable condition. Conclusion This report described a patient with bilateral subdural hematomas who underwent evacuation and bilateral IRRAflow dual-lumen catheter placement. Significant postoperative pneumocephalus improved rapidly with continuous irrigation and drainage, leading to improved brain re-expansion, hematoma resolution, and excellent neurological recovery.

The aim of this study was to compare the effectiveness of Harmonic Focus+ scissors with the conventional surgical method regarding surgical blood loss and transfusion of blood products in the surgical treatment of head and neck tumours. In a retrospective study, the intraoperative blood loss, number of units of transfusion products given, operating time, and inpatient length of stay of 74 patients with squamous cell carcinoma were compared. Patients who underwent classic tumour surgery were compared with a group treated with Harmonic Focus+ scissors. A significantly lower intraoperative blood loss (496.15 ml vs 1096.0 ml, respectively; P = 0.002) and shorter operation time (436.89 minutes vs 493.13 minutes, respectively; P = 0.030) were achieved using the Harmonic Focus+ scissors when compared to the classic tumour surgery. Additionally, fewer units of blood products needed to be transfused (administration of red cell concentrates, P

Intracapsular fractures of the proximal femur are one of the most common fractures of the lower limbs. Most cases require osteosynthesis with suitable implants, and intraoperative positioning of the patient on the fracture table is a prerequisite to facilitate fracture manipulation, traction, reduction and fluoroscopy assessment. However, positioning the limbs of bilateral above-knee amputees for internal fixation of related proximal femoral fractures is a difficult task, which require customized inventory for effective limb positioning and fracture manipulation. This study reported a rare case following a crush injury of bilateral lower limb in a road traffic accident, and described some technical tips of acute femoral neck fractures in bilateral above-knee amputation. The patient was managed with immediate guillotine amputation and later secondary wound closure followed by internal fixation of the right-sided femoral neck fracture with multiple cancellous cannulated screws.

Background Indications for deltoid ligament repair in bimalleolar equivalent ankle fractures are unclear. This study compared radiographic outcomes in bimalleolar equivalent ankle fractures undergoing open reduction internal fixation (ORIF) +/− deltoid ligament repair. Methods A retrospective review of 1024 ankle fractures was performed. Bimalleolar equivalent injuries treated with ORIF +/− deltoid ligament repair were included. Radiographic assessment was performed preoperatively, and at three months postoperatively. Results One hundred and forty-seven ankle fractures met inclusion criteria with 46 undergoing deltoid ligament repairs. There was a significant decrease in medial clear space (1.93 ± 0.65 mm vs. 2.26 ± 0.64 mm, p = 0.01), and tibiofibular clear space (3.89 ± 1.20 mm vs. 4.87 ± 1.37 mm, p = 0.0001) at 3 months postoperative in the deltoid repair group compared to the no repair group. When syndesmotic fixation was performed, there were no differences between groups. Conclusion Deltoid ligament repair in bimalleolar equivalent ankle fractures resulted in reduced medial clear space, and tibiofibular clear space in the early postoperative period. These differences were small and remained within established normal limits. Level of clinical evidence Level III, retrospective cohort study.

Ameloblastomas are aggressive odontogenic entities well-known for their high tendency to recur. Clinical presentation includes lesions discovered on routine examination or radiographs, pathologies causing facial swelling, pain, cortical expansion, tooth mobility, root resorption, and paresthesia. Radiographic findings comprise large unilocular or multilocular radiolucencies with well-defined borders associated to an impacted tooth. Ameloblastomas are classified as unicystic, multicystic/solid, and peripheral. Treatment options include marsupialization, decompression, enucleation, or curettage with or without adjuvant measures such as Carnoy's solution, marginal resection, and segmental resection. Recently, Active Decompression with Distraction Sugosteogenesis (ADDS) was introduced for the conservative management of odontogenic cystic conditions. The purpose of this paper is to present two cases of a conventional ameloblastoma treated by means of ADDS. This is a novel approach whose purpose is to significantly reduce the amount of time required to decompress cystic like lesions. In these cases, ADDS proved to be a viable treatment as it demonstrated a reduction in size of the initial lesion by new osseous formation within 2 weeks of placement of the device. The cases presented in this paper demonstrate that ADDS could be a valuable treatment modality for this type of ameloblastomas, although further research is necessary to validate this philosophy.

Identify associations between preoperative radiographic measurements and clinical findings of zygomatic arch fractures and postoperative radiographic measurements. Based on those findings, propose a comprehensive treatment algorithm for the solitary zygomatic arch fracture and combined zygomatic arch-zygomatic complex fracture.Retrospective cohort study with patients referred to our department for zygomatic arch fractures between 2013 and 2018. Data analyzed included patient demographics, clinical evaluation, and radiographic information. Predictor variables were preoperative morphometric measurements: the initial latero-lateral (LL) defect was determined by the difference between the preoperative LL distances of the fractured and the healthy arches, LL distance was measured from the midsagittal plane in the cranium to the inner cortex of the most displaced arch segment, initial arch coronoid distances were measured from the medial part of the most dislocated arch fragment to the lateral aspect of the coronoid, and the anterior-posterior telescoping was measured as the distance between the 2 points in the arch that lost continuity and overlapped as a result of the fracture. The outcome was defined as the residual defect. It was calculated as the ratio between the postoperative remaining LL distance and the initial LL defect.A total of 179 cases were enrolled, all involving head residual defects. Statistical analysis was performed only on 149 medially displaced fractures. Results show that an initial LL defect larger than 3.5 mm has an 86.3% chance of remaining with a better residual defect (84.1%), P = .001. Cases with antero-posterior (AP) telescoping1.45 mm showed a 72.4% chance of remaining with a poor residual defect84% (P = .003). Arch-coronoid initial distance showed little effect on the chance of remaining with a large remining defect (P = .417, CI = 95%) CONCLUSION: Based on our results, we found that morphometric measurements can be used to predict the reduction results and can assist the clinician in choosing the optimal reduction method and thus increasing the success rate.

Background Cerebrospinal fluid (CFS) leaks are a well-known complication in spinal surgery, caused mostly by incidental durotomy (ID). Management of ID is a matter of ongoing debate. Different treatment strategies have been described ranging from no specific treatment to intraoperative suture or even complex reconstructive procedures. The role of bedrest has also been controversially discussed. The aim of this study was thus to evaluate a potential benefit of post-operative bedrest after ID. Methods ID management following lumbar spine surgery at a high-volume center between 01/2014 and 12/2017 was retrospectively assessed. Several risk factors such as type of surgery, size of dural lesion, intraoperatively chosen strategy, post-operative management (e.g. bedrest) and surgery-related complications were analyzed. Failure of the chosen strategy was defined as symptomatic CSF leakage, requiring revision surgery. Results Sufficient data was available for 135 patients with intraoperatively detected incidental durotomy. Eighty-seven patients with intraoperatively detected ID (64.4%) were additionally managed with bedrest, whereas 48 patients (35.6%) were immediately mobilized after surgery. Sixteen patients overall needed to be revised. However, patients treated with additional bedrest did not show a significant reduction of CSF fistula rate (p=0.27). The degree of laceration (>5mm) negatively affected the outcome (p=0.027). The hospital stay was significantly prolonged in patients, who were subjected to additional bedrest (p=0.001). Conclusions Postoperative CSF leakage represents a serious postoperative complication of lumbar surgery. Intraoperative dural repair plays a crucial role to avoid further neurological morbidity. Postoperative bedrest might be spared in case of watertight dural closure.

Background C2 vertebral body fractures are relatively rare fractures with no defined management protocol and outcomes. The aim of the study is to evaluate the clinical and radiological outcomes of C2 body fratecures. Methods The study was conducted at the Department of Neurosurgery, Nizam's Iinstitute of Medical Sciences, Hyderabad, India, following clearance from the Institutional Ethical Committee. The data of all patients with traumatic C2 body fracture who were managed in our department between Jan'2008 to Jan'2019 was retrieved from the database. Functional status of the patients was assessed by Neck disability index while pain was assessed by VAS at follow up after at least 6 months. Fusion and regional kyphotic angles (O-C2 and C2-C7) were assessed for radiological outcome. Results There were a total of 16 patients with isolated C2 body fractures in the defined time period. The male (n=11) : female (n=5) distribution was 2.2:1. Ten patients had road traffic accidents while the remaining 6 had history of fall from height. Only 3 patients presented with neurological deficits. Benzel Type -3 fracture pattern distribution was the most common fracture pattern (Type 1 = 1, Type 2 = 5, Type 3 = 9). Of these, 10 were operated and 6 were managed conservatively. The VAS and NDI values improved significantly in all at follow up when compared to values at presentation (p = 0.001). Time to return to work was significantly shorter in those treated with surgical intervention (mean = 2.9 + 0.87) (p = 0.001). Fusion was achieved in all the patients in both groups. Mean O-C2 angle at follow up was 21.13 + 10.1. Mean O-C2 angle was significantly decreased in non-surgical group at follow up (p = 0.039) but no significant reduction was observed in surgical group. Conclusions The management of C2 body fractures needs to be individualized, reserving surgical management for fractures requiring fragment retrival or restitution of alignment if facets were fractured.

In children, traumatic radial head dislocation (RHD) is usually associated with ulnar fracture or deformation as reported in a Monteggia injury or its Monteggia variant. Isolated traumatic RHD is extremely rare and exceptional. Traumatic RHD is frequently missed on initial radiographs, particularly if it is isolated. The management of missed RHD is challenging and remains controversial. We report a Case of chronic post-traumatic RHD in a three-year-old child treated with open reduction and reconstruction of the annular ligament. The child's elbow was stable during the follow-up, without swelling or deformity, and the elbow function was normal. The injury of the reported case does not belong to any lesion described in the Monteggia-variant classification, which might explain the reason for missing the associated dislocation. The authors recommend urgent open reduction when a chronic RHD is diagnosed and annular ligament reconstruction, particularly when the open reduction is unstable.

This article describes a 3D virtual diagnostic analysis for treatment planning an esthetically driven functional rehabilitation by using computer-aided design and computer-aided manufacturing (CAD-CAM) technology. In this protocol, a digitally planned diagnostic waxing (exocad DentalCAD) was used to visualize the proposed tooth position and the presence of areas without sufficient material thickness for the prospective additive restorations. This approach uses an additively manufactured clear resin guide to selectively reduce surfaces of a tooth erupted beyond the proposed occlusal plane. By using a 3D-printed occlusal reduction guide, the digital diagnostic waxing is accurately represented, tooth reduction controlled, and adequate occlusal clearance for the required restorative material thickness provided with a minimally invasive approach.

OBJECTIVES To determine the prevalence of ulnar head subluxation/dislocation in distal radius fracture and to discuss management, surgical outcomes, and relevant anatomy. DESIGN Retrospective review of prospectively collected data. SETTING Urban tertiary care hospitalPatients/Participants: 271 patients with displaced distal radius fractures undergoing surgical management were reviewed to determine the incidence of ulnar head subluxation or dislocation using the criteria defined by Mino et al. MAIN OUTCOMES Post-operative CT and radiographs were assessed for sigmoid notch and DRUJ reduction and fracture healing. Range of motion, functional limitation, and pain were documented at final outcome. RESULTS Of the 271 cases, there were 8 cases of pre-reduction DRUJ subluxation/dislocation, including two frank dislocations and six subluxations (2.95%). All were treated with open reduction and internal fixation of the distal radius (ORIF) with a volar locked plate. Additionally, one patient underwent ORIF of an associated distal ulnar shaft fracture and another, who had a Grade 1 open fracture over the distal ulna, underwent open TFCC repair. The remaining six patients had closed reduction of the DRUJ without further stabilizing procedures. All had stable DRUJ joints following ORIF, both intra-operatively and at final follow-up. All ulnar heads were located within the DRUJ on post-op CT; using the more sensitive radioulnar ratio there was residual ulnar head subluxation in 5/8 patients. Range of motion and functional outcome were excellent at an average of 133 weeks post-operatively. The DRUJ was stable at long-term follow-up in all patients. CONCLUSIONS Ulnar head subluxation/dislocation is an uncommon injury in the setting of distal radius fracture. When present, it can usually be treated effectively with operative stabilization of the distal radius fracture without further stabilizing procedures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE To assess the risk factors associated with deep infection after operative treatment of peritalar fracture dislocations. DESIGN A retrospective study was performed to identify patients who had operative treatment of a peritalar fracture dislocation over an 11-year period (2008-2019). SETTING Level 1 trauma center. PARTICIPANTS Patients were identified by review of all surgical billing that included open reduction of peritalar dislocation. Minimum follow-up for inclusion was 3 months or the outcome of interest. A total of 178 patients were identified and 154 patients met inclusion criteria. MAIN OUTCOME The primary outcome was deep infection, defined as return to the operating room for debridement with positive cultures. RESULTS A total of 19 (12.3%) patients developed a post-operative deep infection. The most common associated fractures were talus (47%), calcaneus (33%), and fibula (9%). The infected group was significantly older (47.2 vs 39.5 years, p=0.03). Patients undergoing operative management for peritalar fracture dislocations with current smoking were found to have significantly higher odds of postoperative deep infection (74 vs 34%, aOR=7.4, 95% CI, 2.3-24.1, p=0.001). There was a significantly higher risk of infection in patients with a Gustilo-Anderson type 3 open fractures (32 vs 12%, aOR=5.7, 95% CI, 1.6-20.3, p=0.007). The infected group had high rates of below knee amputation when compared to the group without infection (47 vs 1%, p< 0.001). CONCLUSION In our retrospective study, risk factors for infection after peritalar fracture dislocation included older age, smoking, and Gustilo-Anderson type 3 open fracture. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Summary Purpose This study aims to investigate the influence of different cranial vault suture synostoses on orbital and periorbital morphological development in Crouzon syndrome. Materials and Methods Computed tomography (CT) scans of Crouzon syndrome patients who had not undergone operation were subgrouped as follows: type I: bicoronal synostosis; type II: sagittal synostosis; type III: pansynostosis; type IV: perpendicular combinations of suture synostoses; and type V: bilateral squamosal synostosis. CT scans were measured using Materialize software. Results CT scans of 80 Crouzon syndrome patients and 72 normal controls were included. Orbital bony cavity volume was reduced in all subgroups (16-24%), including type V bilateral squamosal synostosis (16%, p=0.003), although the reduction in type II sagittal synostosis Crouzon patients failed to reach statistical significance (p=0.071). Globe volume was reduced only in type I bicoronal synostosis (9%, p=0.018), while the retrobulbar soft tissue volume decreased in type III pansynostosis group by 11% (p=0.005). Globe volume projection beyond the orbital rim was increased in all groups (p Conclusion Crouzon syndrome restricts orbital cavity volume; however, it likely does not directly affect globe growth. Severity of exorbitism varies among different suture synostosis subtypes. Concurrent bicoronal synostosis and pansynostosis restrict maxillary length, whereas it is likely that Crouzon syndrome factors intrinsically restrict the advancement of the maxilla. The influence of squamosal synostosis is limited. Therefore, subtype suture fusion individualized surgical interventions, after initial occipital expansion, likely provide additional benefits in mitigating oculo-orbital disproportion.

Management of zygomaticomaxillary complex (ZMC) fractures can be challenging. Consequently, there is a difference in treatment amongst clinicians. In the literature it remains unclear if the number of fixation points affects the quality of the anatomical reduction, stability through time, and potential complications. Therefore, the objective of this study was to assess the outcome of no fixation, one-point fixation and multiple-point fixation of ZMC fractures. MEDLINE, EMBASE and The Cochrane Central Register of Controlled Trials were searched to identify eligible studies. After screening 925 articles, 17 studies fulfilled the inclusion criteria. Based on this systematic review no clear conclusions can be drawn on how stability, repositioning, and postoperative complications are affected by the number of fixation points. Nevertheless, it can be concluded that the advantage of multiple approaches is direct visualisation, and the downside is potentially approach-related complications. This review suggests that intraoperatively assisted cone-beam computed tomography (CBCT) can help improve the quality of the repositioning and by minimising the number of fixation points, the number of postoperative complications could be further reduced.

Injury to Lisfranc's joint complex affects the longitudinal and transverse arches of the foot and can significantly alter its biomechanics. Some of the previous studies have suggested primary arthrodesis to be superior to open reduction and internal fixation for treating primarily ligamentous Lisfranc injuries. Additionally, arthrodesis is often used for treating chronic Lisfranc injuries, including those which previously underwent open reduction and internal fixation and subsequently developed arthrosis. The purpose of this study was to retrospectively evaluate the outcomes of arthrodesis at the level of Lisfranc's articulation for both acute and chronic injuries. Patients who underwent midfoot arthrodesis surgical procedures between years 2001 and 2017 were retrospectively reviewed. About 187 patients with an average age of 55.9 ± 13.2 years old and a minimum follow-up of 1 year were included in the study. Median time to return to preoperative activities was 11 weeks. Overall successful joint fusion rate was 81.4%. However, concomitantly fused joints of the midfoot and hindfoot, in addition to the tarsometatarsal joints (TMTJ), were included in the overall fusion rate. Fusion rate at the first TMTJ was 90.2% (101 out of 112), second TMTJ was 94.4% (67 out of 71), and third TMTJ was 97.8% (45 out of 46). The present study demonstrates that patients who undergo arthrodesis for both acute and chronic Lisfranc injuries typically can return to activity in under approximately 3 months postoperatively (acute patients significantly faster) with a high union rate at the TMTJs. However, the overall union rate is significantly lower when concomitant proximal midfoot and rearfoot arthrodesis procedures are performed.

Measuring bone density (BD) is a common method of determining bone quality; however, the relationship between condylar BD and the occurrence of temporomandibular joint (TMJ) disorders has not been investigated. To address this knowledge gap, we aimed to investigate condylar BD in terms of TMJ disk displacement (TMJ DD) using computed tomography (CT) and magnetic resonance imaging (MRI). We classified TMJ MRI results according to the position of the disk: normal disk position (Normal), anterior disk displacement with reduction (ADDR), and anterior disk displacement without reduction (ADDNR). After retrospectively evaluating 86 female condyles, we determined the total, cortical, and trabecular BD in the upper-joint portion of the condyle and the whole condyle using CT data. To standardize condylar BD, we calculated the BD ratios by dividing the condylar BD by the cervical axis BD. The Kruskal-Wallis test analyzed the differences in BD measurements in the TMJ DD patient groups and showed significant between-group differences in condylar BD. The total and trabecular BD was significantly higher in ADDNR condyles than in Normal or ADDR condyles (Normal = ADDRADDNR). However, there was no significant difference in the cortical BD among the three TMJ DD groups. The BD ratios showed a similar tendency with condylar BD. These results suggest that increased condylar BD - specifically total and trabecular BD - may be significantly associated with ADDNR condyles. Our findings will help clinicians determine the course of treatment for patients with disk-related TMJ disorders.

Different designs of posterior minimally invasive fixed partial dentures (MIFPDs) still require additional tooth preparation for guide planes, occlusal rest seats, and grooves and/or slots to increase retention and resistance forms. Whether a design with less tooth reduction can be successful is unclear.This in vitro study compared the long-term survival and retention after cyclic loading of a conventional MIFPD and a posterior MIFPD that was designed for less tooth reduction and improved esthetics.Previously frozen extracted human premolars and molars were embedded in polymethylmethacrylate resin blocks to simulate the loss of a first molar. The block specimens were divided into 3 groups (n=10) according to prosthesis design: control, a conventional posterior MIFPD with partial-coverage retainers; A2S, a 2-part posterior MIFPD with a semiprecision attachment; and A3, a 3-part posterior MIFPD. The prostheses were cemented onto the abutments with 4-methacryloxyethyl trimellitate anhydride/methylmethacrylate-tri-n-butylborane (4-META/MMA-TBB) resin. The specimens were subjected to 2 500 000 cyclic loading cycles with a compressive force of 50 to 800 N in a universal testing machine. After cyclic loading, the intact prosthesis was removed by using tensile force at a crosshead speed of 1 mm/min until failure. The mode of failure and bonding interface were evaluated by using stereomicroscopy and scanning electron microscopy. The retention data were analyzed by using 1-way ANOVA and the Tukey honestly significant difference (HSD) test (α=.05).No prosthesis detached during cyclic loading. The mean ±standard deviation retentive forces among the control (396.7 ±73.2 N), A2S (228.3 ±52.5 N), and A3 (529.9 ±86.2 N) groups were significantly different (P.05). The hybridized enamel layer of the abutments had a consistent thickness after immersion in 6 mol/L hydrochloric acid.The results suggest that the 2- and 3-part posterior MIFPDs should have a high long-term survival rate in the oral cavity.

Background/purpose The restoration of endodontically treated teeth (ETT) with cervical defects has been a challenge for dentists. The purpose of this study was to evaluate the effect of restorative treatment on the fracture resistance of ETT with cervical defects. Materials and methods One hundred and twenty freshly extracted human intact straight-single-root maxillary premolars were randomly divided into 6 groups. Group 1 remained untreated. Cervical defects of 4 mm-depth and 3 mm-height were created in groups 2–6. Group 3–6: root canal treatment. Group 4: direct composite resin restoration. Group 5: 2-mm full-cusp-coverage composite resin restoration. Group 6: fiber-post-supported composite resin restoration. A static fracture test was used to determine the fracture resistance of teeth under axial (n = 10) and palatal (30°) (n = 10) loading. Fracture modes were categorized as restorable and unrestorable. Results Compared with intact teeth, the axial fracture resistance of teeth with cervical defects decreased by approximately 39%, and endodontic procedures resulted in 10% more reduction. When ETT with cervical defects were restored using direct composite resin filling, the axial fracture resistance recovered to 72% of that of intact teeth, but no significant change occurred under oblique loading. After full-cusp-coverage or fiber-post-supported restoration, fracture resistance showed complete recovery to the value of intact teeth (P > 0.05). Sixty percent of fractures were unrestorable for fiber-post-supported teeth, while in the full-cusp-coverage restoration group, 80–90% of fractures were restorable. Conclusion Full-cusp-coverage restoration or fiber-post-supported restoration could improve the fracture resistance of ETT with cervical defects, whereas unrestorable fractures easily occurred in fiber-post-supported restorations.

Statement of problem Adjusting an interim screw-retained crown made of acrylic resin for maintenance of peri-implant soft tissues after immediate implant insertion requires accuracy and time. Assessments of these factors by using digital techniques are sparse. Purpose The purpose of this clinical study was to describe a technique to fabricate an acrylic resin interim crown by using the data acquired from a cone beam computed tomography (CBCT) scan. The 3D tomography files were converted to a standard tessellation language (STL) file format used to print or to mill the interim crown with a technique called digital immediate tooth restoration (DITR). Additionally, the chair time spent during the prosthetic phase was evaluated in comparison with a protocol in which a standard interim crown (SIC) was fabricated with an indirect-direct technique. Material and methods Patients who needed to replace a single nonrestorable tooth were treated from February to June 2018 with an immediately placed implant and an acrylic resin screw-retained interim prosthesis that was connected to the implant immediately after placement of the implant. The participants were divided into 2 groups according to the acrylic resin interim crown fabrication technique: group DITR and group SIC. The average time to finalize the prostheses was compared between the groups. The total chair time (TCT) taken for the adaptation of the interim crown was noted and distinguished in 3 different times corresponding to each phase of adaptation of the interim restoration of the interproximal contact areas (CT1), adaption of the postextractive alveolar bone walls (CT2), and adaption of the occlusal contacts (CT3). For each time, the number of changes (N-CT1, N-CT2, N-CT3, and TN) needed to complete each prosthetic phase was also marked and observed. Generalized linear mixed models and generalized linear models were used for data analysis. All the sites were definitively restored with a screw-retained crown after 6 months of healing, and the participants were provided with standard hygiene recall appointments for the next year. Results A total of 82 crowns at sites distributed across the mandible and the maxilla were included in the study. Thirty-five were restored with an SIC and 47 with a DITR interim crown. None of the implants were lost during the 18-month follow-up period. The analysis of the chair times registered for the adaptation of the interim crown to the implant healing abutment and to the neighboring teeth between the 2 groups showed a reduction if a DITR interim crown was used (average CT1 of 15 ±14 seconds, CT2 of 2 ±5 seconds, CT3 of 59 ±19 seconds, and TCT of 76 ±28 seconds for group DITR and average CT1 of 135 ±27 seconds, CT2 of 185 ±30 seconds, CT3 of 73 ±16 seconds, and TCT of 394 ±61 seconds for group SIC). The number of corrections to finalize the interim crown adaptations was lower for the group DITR (0.81 ±0.74 for N-CT1, 0.19 ±0.39 for N-CT2, and 2.81 ±0.74 for N-CT3) when compared with the number of corrections needed for the group SIC (4.37 ±0.81 for N-CT1, 5.57 ±0.77 for N-CT2, and 3.86 ±0.64 for N-CT3). Conclusions The data from CBCT scans led to interim acrylic resin crowns that needed fewer adjustments with the immediate implant placement and interim restoration approach, reducing chair time.

Background: Functional mitral regurgitation (FMR) is caused by left ventricular (LV) remodeling and subsequent tethering of the mitral valve (MV). If LV remodeling is irreversibly advanced, it could not be attenuated by the MV procedure alone, although the additional subvalvular procedure could induce LV reverse remodeling by forcibly reducing MV tethering. This study aimed to assess the anti-tethering effect of papillary muscle tugging approximation (PMTA) on LV reverse remodeling after mitral valve replacement (MVR) for non-ischemic FMR. Methods: The study subjects were 19 patients who underwent MVR with and without PMTA [MVR + PMTA (n = 11) and MVR alone (n = 8), respectively] for non-ischemic FMR. The tethering distance (TD) and LV end-systolic volume (ESV) at the preoperative, postoperative, and follow-up periods were assessed in terms of their correlation and time-dependent changes. The intra-LV energy efficiency was also evaluated through vector flow mapping analysis. Results: TD and ESV were comparable between both procedures preoperatively and did not change after MVR alone. In MVR + PMTA, however, a significant decrease was identified in TD and ESV at the early postoperative and follow-up periods, respectively [TD = 48, 30, and 31 mm (p < 0.001) and ESV = 159, 133, and 82 mL (p < 0.001) at the preoperative, postoperative, and follow-up periods, respectively]. Finally, at follow-up, the extent of change from the preoperative value in ESV significantly correlated with that in TD (rho = 0.81, p < 0.001 for overall; rho = 0.93, p < 0.001 for MVR + PMTA; rho = 0.86, p = 0.011 for MVR alone). The ratio of TD to ESV was also significantly correlated with systolic energy loss to LV stroke work after MVR + PMTA (rho = 0.81, p = 0.015). Conclusions: PMTA for non-ischemic FMR could induce LV reverse remodeling depending on the extent of postoperative TD reduction. A smaller TD to ESV was associated with a higher intra-LV energy efficiency after PMTA + MVR. (C) 2021 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Patients with Sjögren syndrome (SS) experience difficulties in wearing conventional dentures. After removal of all teeth, the oral rehabilitation is challenging and time consuming using conventional treatment protocols. Although implant-retained overdentures are beneficial for this specific patient group, the average total oral rehabilitation time (TORT) usually takes at least 9 months and needs to be reduced to increase patients' quality of life (QoL). In this paper, we report on a new treatment concept for immediate implant-based oral rehabilitation in a 77-year-old patient with partial edentulous SS. Because of persistent pain, discomfort, and retention problems with the conventional prosthetic devices, full clearance of the remaining mandibular dentition and immediate oral rehabilitation with an implant-retained overdenture were suggested. The treatment protocol included virtual surgical planning (VSP), combining a guided bone reduction of the mandibular alveolar process, immediate dental implant placement, and restoration using a prefabricated bar and placement of the overdenture. This method demands the use of ionizing 3D imaging optionally combined with an optical dental scan or a conventional impression. Furthermore, one needs to gain experience using VSP software. This novel treatment concept for immediate implant-based oral rehabilitation using VSP proved to be feasible and safe in a patient with SS, resulting in a significantly reduced TORT and improved QoL. Further research is needed to what extent this treatment concept could be beneficial to other patient groups, such as patients with head and neck cancer.

Background: Syndesmosis is an important soft-tissue component supporting ankle stability. It is commonly injured along with ankle fractures. Accurate reduction and fixation of syndesmosis is essential to obtain better functional results. Therefore, we aimed to find a practical method using the mortise view of the ankle to determine the optimal syndesmosis fixation angle intraoperatively. Methods: We randomly selected 200 adults (100 women and 100 men) aged 18 to 60 years. Three-dimensional anatomical models of the tibia and fibula were created. We created a best-fit plane on the articular surface of the medial malleolus and a 90° vertical plane to the medial malleolus plane. We determined two splines on the cortical borders of the tibia and fibula distant from the most superior point of the ankle joint in horizontal view. We created two spheres that fit to the predefined splines. The optimal syndesmosis fixation angle was determined measuring the angle between the line connecting the center points of the spheres and the 90° vertical plane to the medial malleolus plane. Results: We observed no statistically significant difference in optimal syndesmosis fixation angles between sex groups. The participant mean ± SD age was 47.1 ± 10.5 years. The optimal syndesmosis fixation angle in the mortise view was found to be 21° ± 4.3°. Conclusions: We determined the optimal syndesmosis fixation angle to be 21° ± 4.3° using the mortise view of the ankle. The surgeon could evaluate the whole articular surface of the ankle joint with the medial and lateral syndesmotic spaces in mortise view accurately, and at the same position syndesmosis fixation could be performed at a mean ± SD angle of 21° ± 4.3°.

Rhinoplasty is one of the most common procedures that act as a challenge for consistent outstanding results. Alar base reduction is a technique of rhinoplasty that is prescribed in many conditions. Wound closure requires using of sutures and there are several types of sutures for this purpose; however, good scar results are necessary for patients'satisfaction.To evaluate alar base resection scar results after surgical resection using different types of suturing material.This is a retrospective cohort study that was conducted at King Abdulaziz University Hospital, Riyadh, Kingdom of Saudi Arabia. The study was performed by reviewing patient's records and performing post-operative photography for patient who underwent alar base resection. The patients were divided into 2 groups, the first group of patients had the alar base wound closed with interrupted Polypropylene 6/0 and the other group wound was closed with monocryl 6/0 sutures. Visual analog scale was used to investigate basal views.The study included 80 patients divided into 2 groups, each group included 40 patients, in the first group (Polypropylene group) there were 25% males and 75% females, whereas in the second group (monocryl) there were 15% and 85% males and females, respectively. There were 85% and 82.5% unnoticeable scar reported by the first and second group, respectively; however there was no significant difference between the 2 groups (Both Polypropylene and monocryl sutures result in the same result for closing alar base wound post surgically.La rhinoplastie est l'une des principales interventions chirurgicales oú il est difficile de toujours obtenir des résultats remarquables. La réduction de la base des ailes du nez est une technique prescrite pour de nombreuses affections. Plusieurs types de sutures peuvent être utilisées pour fermer les plaies, mais de belles cicatrices s'imposent pour satisfaire les patients.Les chercheurs ont évalué les résultats des cicatrices de la base des ailes du nez après des résections chirurgicales au moyen de divers matériaux de suture.Étude de cohorte rétrospective réalisée à l'hôpital universitaire du roi Abdulaziz de Riyad, en Arabie saoudite. Les chercheurs ont examiné les dossiers des patients et photographié ceux qui avaient subi une résection de la base des ailes du nez. Les patients ont été divisés en deux groupes de 20 patients: dans le premier, les plaies de la base des ailes du nez ont été fermées par des sutures de polypropylène 6/0 et dans le deuxième, par des sutures de monocryl 6/0. Les chercheurs ont utilisé une échelle analogique visuelle pour évaluer les vues de la base des ailes du nez.L’étude se composait de 80 patients divisés en deux groupes de 40 patients. Le premier groupe (polypropylène) était composé à 25% d'hommes et à 75% de femmes, d'un âge moyen total de 32 ans, et le deuxième (monocryl), à 15 % d'hommes et à 85% de femmes. Les cicatrices n'étaient pas visibles chez 85% et 82,5% des membres du premier et du deuxième groupe, respectivement, mais la différence n'était pas significative (Les sutures de polypropylène et de monocryl donnent le même résultat clinique pour fermer les plaies de la base des ailes du nez.

After a high-speed motor vehicle collision, a man presents with a laterally dislocated ankle and pulseless foot. Dr. Michael Weaver proceeds to perform an

Scaphoid fractures, if deemed operative, can often be treated successfully by headless compression screw fixation. Unfortunately, some patients go on to develop a scaphoid fracture non-union with screw loosening, bone resorption, bone deformity and carpal malalignment. To assist surgeons in managing these difficult cases, specifically designed scaphoid fracture plates have recently been introduced. We present a case of a scaphoid fracture non-union with retained screws and bone loss that was effectively treated by volar plate fixation using a three-dimensional (3D) printed model to assist with restoration of scaphoid morphology and implant positioning. Before surgery, 3D preoperative planning using a surface registration technique and a 3D printer was performed. Referring to the 3D-printed reduced model facilitated the prediction of gaps after reduction and helped decide the implant position and screw directions. Carpal alignment parameters gradually improved by 1 year postoperatively.

Transradial (TR) approach demonstrates a significant reduction in vascular complication rates when compared with femoral approach. Nevertheless, minor kinking during this approach is not rare and in most of time can be resolved with a gentle opposite rotation maneuver. Sometimes a kinking is more severe and results in catheter entrapment in narrow radial or brachial artery. There are some documented rescue techniques described in the literature. Some of these techniques include the BP cuff technique, the femoral snare technique, the long sheath technique and the balloon retrieval technique. We report a case of a 55-years old man with stable angina pectoris who underwent coronary angiography at our hospital. During the procedure severe catheter kinking was noted. An opposite rotation maneuver failed to rescue the catheter. Then balloon rescue technique was attempted and catheter was safely extracted from radial artery . This technique can be an option during severe catheter kinking when conventional rescue maneuvers fail.

OBJECTIVES Appropriate visualization of the femoral neck is critical when performing open reduction and internal fixation (ORIF) of a femoral neck fracture. The purpose of this study was to objectively identify which surgical approach provided the most extensive visualization of the femoral neck during ORIF. Our hypothesis was that the Smith-Petersen approach with rectus release would provide the most extensive visualization. METHODS Ten cadaveric hips were utilized to compare 4 different surgical approaches to the femoral neck: Smith-Petersen (SP), Smith-Petersen with rectus release (SPwR), Watson-Jones (WJ), and Hueter approach. After surgical exposure, calibrated digital images were captured and analyzed using a computer software program to determine the percent-area visualized. Three trained investigators separately assessed each specimen to determine clinical visualization and ability of the surgeon to manually outline anatomic locations of the femoral neck: subcapital, trans-cervical, and basicervical. Data were analyzed for significant (p

OBJECTIVES To evaluate the perceived utility and associated charges of the anteroposterior (AP) radiograph during rotational ankle fracture postoperative follow-up. DESIGN Survey study with charge analysis using published data at 50 orthopaedic hospitals in the United States. SETTING Not Applicable. PARTICIPANTS Orthopaedic Trauma Association Members with an active e-mail address who were invited and interested in answering a survey. RESULTS 94% of respondents stated that they did routinely obtain an AP radiograph during rotational ankle fracture follow-up. However, 57% thought that the AP view should be eliminated from standard follow-up and only 51% found this view useful after initial treatment. CHARGE ANALYSIS The mean difference between a 2-view and 3-view ankle radiograph series was $102.00. Using this value and the assumption that each patient with a rotational ankle fracture gets 3 follow-up radiographs, there is the potential for a charge reduction of $306 per patient. Assuming over 134,000 rotational ankle fractures, a charge reduction of 41 million U.S. dollars (USD) per year is possible if the AP image is routinely removed. Actual savings are likely to be less based on agreed upon payer rates. Although less easy to quantify, there is also potential reduction of radiation exposure, radiologists' interpretation time, and data storage. CONCLUSION Routine AP radiographs should potentially be eliminated from routine postoperative ankle x-ray protocols based on this survey of experienced orthopaedic surgeons. If this specific radiograph is ordered on a case-by-case basis then significant savings may occur. LEVEL OF EVIDENCE Diagnostic Level V. See Instructions for Authors for a complete description of levels of.

Background Multiple studies have described retrograde nailing as a treatment of periprosthetic supracondylar femoral fractures (OTA/AO type 33A-C) above total knee replacements (TKR). It is often difficult to discern which TKRs will be compatible with intramedullary nailing as the femoral component design and intercondylar distance is highly variable amongst total knee designs. The goal of our study is three-fold. Review and update previous work of intercondylar distances of all currently available prostheses in the US.Review retrograde nails currently on the market and associated driving end to nail shaft diameter mismatch and opening reamer sizing.Review technical tricks for executing a retrograde femoral nail for the treatment of periprosthetic supracondylar femur fractures. Methods Data for the intercondylar distance of the femoral components, diameter of retrograde nails and reamers, and notch compatibility was gathered. Results The results were compiled and recorded. A "technical tricks" section was included which highlights reduction and fixation techniques. Conclusion This update further empowers surgeons to utilize all tools available when treating periprosthetic femur fractures and allows efficient identification of the compatibility of different TKR designs with various intramedullary nails. Level of evidence Level V. Expert Opinion. See Instructions for Authors for a complete description of levels of evidence.

Objective To determine the outcomes of pilon and tibial shaft fractures with syndesmotic injuries compared to similar fractures without syndesmotic injury. Design Retrospective Case-Control. Setting Level 1 Trauma CenterPatients/Participants: All patients over a 5-year period (2012-2017) with tibial shaft or pilon fractures with a concomitant syndesmotic injury and a control group without a syndesmotic injury matched for age, OTA/AO fracture classification and Gustilo-Anderson open fracture classification. Intervention Preoperative or intraoperative diagnosis of syndesmotic injury with reduction and fixation of both fracture and syndesmosis. Main outcome measurement Rates of deep infection, nonunion, unplanned reoperation and amputation in patients with a combined syndesmotic injury and tibial shaft/pilon fracture versus those without a syndesmotic injury. Results A total of 30 patients, including 15 tibial shaft and 15 pilon fractures were found to have associated syndesmotic injuries. The matched control group was comprised of 60 patients. The incidence of syndesmotic injury in all tibia shaft fractures was 2.3% and in all pilon fractures 3.4%.The syndesmotic injury group had more neurologic injuries (23.3% vs. 8.3% p=0.02), more vascular injuries not requiring repair (30% vs. 15%, p=0.13), and a higher rate compartment syndrome (6.7% vs. 0%, p=0.063). Segmental fibula fracture was significantly more common in patients with a syndesmotic injury (36.7% vs. 13.3%, p=0.04).Fifty percent of the syndesmotic injury group underwent an unplanned reoperation with significantly more unplanned reoperations (50% vs. 27.5%, p=0.04). The syndesmotic group had a significantly higher deep infection rate (26.7% vs. 8.3% p=0.047), and a significantly higher rate of amputation (26.7% vs. 3.3% p=0.002), while the nonunion rate was similar (17.4% vs. 16.7% p=0.85). Conclusion While syndesmotic injuries with tibial shaft or pilon fractures are rare; they are a marker of a potentially limb-threatening injury. Limbs with this combined injury are at increased risk of deep infection, unplanned reoperation and amputation. The presence of a segmental fibula fracture should raise clinical suspicion to evaluate for syndesmotic injury. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction Plating of unstable OTA/AO 44-B2 equivalent lateral malleolus (Danis-Weber B) fractures has been associated with pain, peroneal irritation, and the need for subsequent hardware removal (ROH). The purpose of this study is to retrospectively compare the rates of ROH in unstable Weber B fractures fixed with a posterior, true antiglide plate with no screws in the distal segment versus those that were fixed with a similarly placed posterior, neutralization construct that included screws in the distal fragment. Thus, evaluating the role of the distal screws in rates of ROH. Methods Skeletally mature patients that were treated for an unstable, isolated Weber B fracture at a single level-1 trauma center over a ten-year period were reviewed. Fractures treated with a single posterior plate with at least six months of follow-up were included and those fixed with a direct lateral plate were excluded. The primary outcome of this study was hardware removal defined as entire plate removal; isolated syndesmotic screw removal was not included. Results Ninety-six patients were included in the study with average age of 46 years (range 17-83) and mean length of follow-up of 24.5 months (range 6.1-140.3). There were 33 patients in the antiglide group (mean follow-up 25.5 months) and 63 in the neutralization plate group (mean follow-up 24 months, p=0.81). Fractures fixed with or without distal screws had equivalent excellent results related to bony union and alignment. However, there was a statistically significant decrease in ROH rates in the antiglide group (antiglide ROH rate 15.2%; neutralization ROH rate 38.1%; p=0.02). Relative risk of ROH with antiglide plate was 0.4 (95% CI 0.17 – 0.95; p=0.04). Conclusions Antiglide plating shows a significant risk reduction in the rate of ROH when compared to posterior based neutralization plating. A true antiglide plating construct should be considered as a safe and effective way of managing Weber B fractures with a lower relative risk of a second operation for hardware removal. Level of evidence Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To investigate patient demographics, injury characteristics, radiographic outcomes, and identify risk factors for developing post-traumatic arthritis in high energy transsyndesmotic ankle fracture dislocations, or "Logsplitter" injuries. DESIGN Retrospective cohort study. SETTING Academic level one trauma center. PATIENTS/PARTICIPANTS Twenty-seven adult patients with logsplitter injuries. INTERVENTION All patients were treated with open reduction internal fixation, with possible addition of syndesmosis screw(s) and deltoid repair. MAIN OUTCOME MEASUREMENTS Rate of post-traumatic arthritis at one year along with rate and reasons for reoperation. RESULTS Twenty-seven patients were included with mean follow up of 14.5+/-12.5 months. At one year postoperative, 14/20 patients (70%) demonstrated posttraumatic arthritis. Two patients (7.4%) went onto fusion. Reoperation rate was 51.9%. There was no significant difference in arthritis rate with the number of syndesmosis screws used, quality of reduction, or the addition of deltoid repair. CONCLUSIONS The logsplitter injury is one with devastating outcomes and high rates of arthritis; it should be considered separately from conventional ankle fractures. The role of deltoid repair remains unclear. Further study of this injury pattern is required. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Reduction using ligamentotaxis may not be effective enough to treat impacted intraarticular fragments of distal radius fractures. Articular incongruence resulting from the loss of reduction is a risk factor for postoperative osteoarthritis and worse clinical outcome. This study aimed to analyze the radiographic characterization of the impacted intraarticular fragments of distal radius fractures using two/three-dimensional computed tomography (CT). Further, we assessed the reliability and diagnostic accuracy in detecting the fragments using plain radiographs. Methods We analyzed 167 three-dimensional CT images of the intraarticular distal radius fractures and selected 12 fractures with impacted intraarticular fragments. We recorded the location, size, and displacement of the fragment using CT images. In addition, six examiners evaluated 25 fractures including those 12 fractures having the fragments using plain radiographs for detecting the fragments and their displacements. Further, we evaluated the reliability and diagnostic accuracy of the plain radiographs in the detection of the fragment. Results Fifteen impacted intraarticular fragments were found in 12 wrists. The displacement of the scaphoid facet fragment was significantly larger than that of the lunate facet fragment in CT measurement (7.0 mm and 3.6 mm). Inter and intraobserver reliability of the diagnosis for the fragment in plain radiographs were poor and fair (κ: 0.14 and κ:0.27). Diagnostic accuracy in detecting the fragment in plain radiographs generated mean sensitivity: 0.4, mean specificity: 0.73, and mean accuracy: 0.58. The mean sensitivity in detecting a lunate facet fragment was lower than that of a scaphoid facet fragment in plain radiographs (0.24 and 0.44). Conclusion Impacted intraarticular fragments were found in 7% of intraarticular distal radius fractures. We observed low reliability and sensitivity in detecting the fragment using plain radiographs. Preoperative recognition of the fragments using plain radiograph were difficult, even though the magnitude of step-off of the scaphoid facet fragment was large.

Background: The clinical and imaging features of lower tibial shaft spiral fracture concurrent with distal tibial triplane fracture are not clear. Introduction: This study was conducted to investigate these features for correct diagnosis, treatment and prevention of possible premature physeal arrest or angular deformation. Method: Patients with lower tibial shaft spiral fracture concurrent with distal tibial triplane fracture were enrolled, and the clinical, imaging, treatment and follow-up data were analyzed. Result: Five patients with lower tibial shaft spiral fracture concurrent with distal tibial triplane fracture were found including four men and one woman with an age range of 12-15 years (mean 13.6). Injury to the distal tibial epiphysis was missed in the diagnosis in plain radiography reports, but careful reevaluation confirmed distal tibial epiphysis fracture in four cases including Salter-Harris type II in three cases and type III in one case. The remaining case had no apparent distal tibial epiphysis injury in the plain radiograph. CT scan revealed that all five patients had distal tibial triplane fracture of the lateral type including two fragments in three cases and three fragments in two cases. The fracture was divided into type I(within the articular weight-bearing line) in three cases, type II (outside the articular weight-bearing line) in two cases based on the involvement of the articular surface by the fracture line. For the lower tibial fracture, one patient was treated with closed reduction and fixation with an elastic nail, three patients had internal plate fixation, and the remaining patient had cast immobilization. Followed up for 3-11 months (mean 7), all the distal tibial fractures and the triplane fractures were healed without varus or valgus deformity in the ankle. Conclusion : Distal tibial triplane fracture can be readily missed in plain radiography and should be suspected in patients with distal tibial spiral fracture which should be evaluated with a computed tomographic scan.