Bony Displacement Research Articles

Minimal Detectable Bone Fracture Gaps in CT Images and Digital Three-Dimensional (3D) Radii Models.

Knowledge of the minimal detectable bone fracture gap is essential in three-dimensional (3D) models, particularly in pre-operative planning of osteosynthesis to avoid overlooking gaps. In this study, defined incisions and bony displacements ranging from 100 to 400 µm were created in diaphyseal radii in 20 paired forearm specimens and verified with light microscopy. The specimens were scanned utilizing different computed tomography (CT) technologies/scanners, specimen positionings, scan protocols, image segmentations, and processing protocols. Inter- and intra-operator variabilities were reported as coefficient kappa. In CT images, fracture gaps of 100 µm and bone lamellae of 300 µm and 400 µm width were identified at a rate of 80 to 100%, respectively, independent of the investigated settings. In contrast, only 400µm incisions and bony displacements were visible in digital 3D models, with detection rates dependent on CT technology, image segmentation, and post-processing algorithm. 3D bone models based on state-of-the-art CT imaging can reliably visualize clinically relevant bone fracture gap sizes. However, verification of fractures to be surgically addressed should be verified with the original CT image series.

Prognosis of teeth in mandibular fracture lines.

Teeth in a jaw fracture line, because of the presence of the periodontal ligament, may communicate with the oral cavity. There are no guidelines for the management of teeth in mandibular fracture lines. The aim of this study was to investigate the factors related to dental problems with teeth involved in mandibular fracture lines and to determine the best treatment option. This retrospective study was based on the medical and radiographic records of patients with mandibular fractures. The relationships among the patient's age, gender, smoking history, amount of bony displacement, surgery, trauma-surgery period, apical involvement, tooth mobility, and periodontal status were investigated. Group comparisons were performed using the chi-squared test, Fisher's exact test, and Mann-Whitney U-test. A total of 238 patients (247 fracture lines) with mandibular fractures including a tooth in the line of the fracture were examined. Post-operative dental complications occurred in 42 cases (17.0%). Extraction of related teeth occurred in 34 cases (80.9%) compared to eight cases (19.0%) related to root canal therapy. This study defined "dental problem" as "a case with a tooth extracted or endodontically treated after trauma." The variables associated with an increased risk of dental problems were the amount of bony displacement (p<.01), tooth mobility (p<.01), and pre-existing marginal alveolar bone loss (p=.027). The prognosis of teeth in mandibular fracture lines was related to tooth mobility, periodontal state, and the amount of bony displacement.

VRT in Traumatic Maxillo-Facial Injuries; Is it of an Added Value Compared to Axial and Reconstructed CT Images?

Abstract Background: Maxillo-facial fractures are very frequently seen as a result of increased incidence of road traffic accidents and aggressive fights. Due to new advances in multi-slice computed tomography and 3D VRT reconstructed images, accurateness of detection of occult fractures and outcome of maxilla-facial traumas has noticeably improved. Aim of Study: This study was conducted aiming at the description of different forms of maxillo-facial injuries, imaging criteria of different fractures of the maxilla and facial bones as well as the benefit of utilizing 3D VRT computed tomography with image reconstruction compared to axial CT images. Patients and Methods: Prospective study of 100 patients, coming to the Emergency Department with trauma and clinical evidence suggestive of maxillo-facial injuries. Multi-slice CT was done to all patients with coronal and sagittal as well as VRT reconstruction. All studies were assessed for presence of maxillo-facial fractures with detection of the types and extent of these fractures as well as associated soft tissue injuries. The findings missed or confirmed by the VRT image compared to those found by the axial images were assessed. Results: We detected that maxillo-facial fractures were more common in males (90%) than in females (10%). Road traffic accidents came first regarding the cause of these injuries followed by physical attack and fall from a height. The age group most affected was ranging from 18-35 years in 37% of the cases. Commonest fractures were seen at the maxillary sinuses (in 43% of the cases) followed by the nasal bones, zygomatic arches, mandible and orbital bony boundaries. Associated soft tissue injuries were very common. The extension of the complex fractures, occult fractures and bony displacements were more precisely assessed. VRT was superior to axial image in detection of fractures with others missed compared to the findings by the axial CT images. Conclusion: Multi-slice computed tomography offers excellent resolution needed for proper assessment of facial bones' difficult anatomy hence helping in the accurate assess-ment of facial bones' fractures needed for proper planning for surgery with VRT images adding more data compared to the axial and reconstructed images.

Periorbital Entrapment in a Minimally Displaced Medial Wall Fracture

I experienced periorbital entrapment in a minimally displaced medial wall fracture. An 18-year male was hit in the left eye by a fist. He had decreased horizontal ocular motility with pain. Exophthalmometry of both eyes were same. Computed tomography (CT) demonstrated a minimally displaced medial wall fracture with herniation of orbital fat. Decreased horizontal ocular motility and pain persisted until the fifth post-trauma day. On exploration, entrapped soft tissue was found and dissected from the fractured site, but the bony displacement was minimal. After release, the forced duction test became normal and postoperative CT demonstrated reduced herniated orbital fat. In cases of a minimally displaced medial orbital wall fracture, if the patient feels pain while gazing horizontally, precise inspection of the CT scan is needed. If the pain persists for several days, despite the absence of diplopia, periorbital entrapment should be suspected and exploration can be considered.

Risk factors for hypesthesia after repair of facial fractures

The aim of this study was to investigate the incidence of hypesthesia in patients with facial bone fractures and to identify the relationships between posttraumatic hypesthesia and risk factors, including general and fracture-related characteristics. A total of 437 patients who underwent surgery for facial bone fractures were included. Clinical neurosensory testing was performed at different time points (immediately after trauma and 1 week, 1 month, and 6 months after surgery). The results of these assessments were compared with regard to characteristics and fracture sites. The hypesthesia incidences were highest in the mandible (19.1%), maxilla (18.3%), and orbit (8.5%). Sensation was recovered by 97.3% of all patients by 6 months after surgery. Risk factors for hypesthesia were direct nerve injury (P = .002), distance (≤10 mm) between the fracture and nerve foramen (P = .002), the amount of bony displacement (P = .035), and age (P = .004). There were significant differences among the fracture sites. Posttraumatic hypesthesia increased temporarily after surgery, but most patients recovered by 6 months postoperatively. Recovery from postoperative hypesthesia was related to the fracture site and pattern. Cases in which the patient did not recover involved direct nerve injury.

Three-Dimensional Computed Tomography Analysis of Stability Following Two- and Three-Point Fixation With Biodegradable Plates Among Patients With Zygomatic Fracture.

Open reduction followed by internal fixation has been regarded as the most effective technique for the surgical repair of zygomatic fractures. However, the ideal number and locations of internal fixation points to maintain stable reduction remain controversial. Using 3-dimensional computed tomography, we aimed to compare the stability of 2-point and 3-point fixation among patients who had undergone surgical repair of zygomatic bone fractures. The study included 22 patients (17 men, 5 women) with unilateral zygomatic bone fractures who had undergone open reduction with 2-point or three-point fixation using biodegradable materials (11 patients in each group). The authors measured the lateral projection and height of the zygoma at 2 landmark points (zygomaticofacial foramen and frontozygomatic suture). In each group, bony displacement was analyzed between the preoperative and immediate postoperative phases, and between the preoperative and follow-up phases. Differences in stability between the 2 groups were analyzed by comparing values between the immediate postoperative and follow-up phases. The 2-point group exhibited a lower rate of complex fractures at the frontozygomatic suture than the 3-point group (18.2%, 63.6%, respectively). In both groups, the authors observed significant differences in the lateral projection of the zygomaticofacial foramen between the preoperative and immediate postoperative phases, and between the preoperative and follow-up phases. No significant differences in stability were observed between the groups. Our findings demonstrated that 2-point fixation of the zygoma with biodegradable materials is as stable as 3-point fixation. It could be initially considered when open reduction of frontozygomatic suture was not essential.

Accuracy of soft tissue prediction in surgery-first treatment concept in orthognathic surgery: A prospective study

PurposeThe purpose of this study was to provide a quantitative accuracy assessment of soft tissue predictions generated by a computer-aided maxillofacial planning system in patients undergoing orthognathic surgery following the “surgery-first” treatment. Materials and methodsFor this study, we looked at 16 patients with open bite dentofacial-dysmorphosis who underwent orthognathic surgery. Surgeries were planned using conventional sketches and the newly developed computer-assisted SOTIRIOS planning software (developed by the authors). Validation procedures were performed in the following steps: (1) Standardized registration of the pre- and postoperative CT volumes; (2) Automated adjustment of the bone-related preoperative planning to the actual postoperative bony displacement; (3) Simulation of soft tissue changes according to the definitive bony movements; and (4) Calculation of soft tissue differences between the predicted and the actual 6-month postoperative results by distance mapping. ResultsThe program produced a clinically satisfactory 3D soft tissue prediction, with a mean error of 1.46 mm ± 1.53 mm. The program was suitable for use in virtual surgical planning without technical assistance. ConclusionThis study shows that the program is quite accurate, enabling the surgeon to predict the outcome of the soft tissue. This has the potential to promote the routine application of the surgery-first approach in patients suffering from open bite.

A concealed central giant cell granuloma and its combined orthodontic and surgical management

Abstract: Central giant cell granulomas (CGCGs) can be aggressive lesions that lead to bony expansion, tooth displacement and root resorption. Often noticed by a patient when small to moderate in size, we present a case of large CGCG that was undetected in a 13-year-old due to ongoing fixed orthodontic treatment. Subsequently, her fixed appliance was vital in maintaining the rigid fixation of her teeth during surgical management and postoperative healing. CPD/Clinical Relevance: An orthodontist is in an ideal position to identify oral medical conditions, especially rapidly growing ones, due to their more regular contact with patients.

Interfraction movement and clinical outcome of immobilization for thoracic irradiation: A randomized controlled trial

AbstractObjectiveTo evaluate the impact of immobilization on set‐up errors and clinical outcomes in patients receiving radiation therapy to the thorax.MethodsPatients receiving curative intent radiation therapy to the lung and esophagus were randomized to no immobilization (control) or immobilization (chest jig or vacuum bag), and treatment verification images were acquired within 3 days of commencing treatment and then weekly. The primary outcome was the proportion of patients having a deviation &gt;5 mm from the isocenter. Assessment was carried out blinded to immobilization assignment.ResultsOf the 77 patients, 75 patients were allocated to either immobilization or control. No statistical difference in the proportion of patients with bony displacements &gt;5 mm from the isocenter were observed (P = 0.5), as was the case for both systematic and random errors between the groups. There was an increased risk of local failure in the immobilized control group (HR 1.46, 95% CI 0.78–2.71, P = 0.23) based on a competing risk analysis. The median overall survival was 18.4 months and 27.0 months in the control and immobilized groups, respectively (HR 0.73, 95% CI 0.51–1.04, P = 0.08).ConclusionsThe results failed to show benefit with immobilization in reducing set‐up errors, local control, and overall survival.

Functional and radiological outcome of proximal femoral locking compression plates in the treatment of unstable trochanteric fractures

Introduction Intertrochanteric femoral fracture is extracapsular fracture of the proximal femur between the greater and lesser trochanters. They represent about 50% of all hip fractures. Considerable complications such as pulmonary embolism, deep venous thrombosis, and pneumonia are frequently seen with these fractures mainly due to prolonged immobilization and specifically in elderly patients. These fractures can be categorized into stable and unstable according to the bony construct displacement after a fracture. Approximately 35–40% will be classified as unstable three-part and four-part fractures; unstable fractures are difficult to manage with dynamic hip screw alone and are technically much more challenging and the treatment is more controversial. Patients and methods During the period from 1 July 2016 till 1 February 2017, 44 patients with unstable trochanteric fractures AO A2 and A3 who were admitted in the Causality Department in Kasralainy Hospital, Cairo University were randomly selected in our study to be treated by fixation with proximal femoral locking compression plate according to the standardized protocol. Results Patient demographics: 28 women and 16 men were included with a mean age of 61.75 years (SD 8.7); eight patients were diabetic; four patients were hypertensive, and three were cardiac. The total hospital stay was a mean of 8.95 days, mean preoperative period was 4.44 days, and the mean postoperative period was a mean of 4.73 days (SD 1.16).The mean operative time was 106 min; the mean blood loss intraoperative was 308 ml; postoperative infection was three (6.8%) cases; and all of them resolved with a single session of debridement. One case of deep venous thrombosis (DVT) was treated by conservative measures and four cases of varus malunion with no functional deficit. The mean time for fracture union was 17.9 weeks and the mean time till weight-bearing was 12 weeks. Mean harris hip score (HHS) at 6 months was 62.3 which is fair and 81.2 at 12 months which is good. Conclusion Proximal femoral locking compression plate was an effective treatment for unstable trochanteric fracture in terms of time to full weight-bearing. It can be used in these fractures with good functional outcomes and low complication rates. Level of Evidence: Level II randomized, prospective trial.

Simulation of three surgical techniques combined with two different bone-borne forces for surgically assisted rapid palatal expansion of the maxillofacial complex: a finite element analysis

Surgically assisted rapid palatal expansion (SARPE) is a common treatment to correct transverse maxillary deficiencies. Finite element analysis was simulated for six designs of SARPE based on a computed tomography scan of a human skull: median osteotomy with palatal (type A) or alveolar ridge (type B) bone-borne force, additional lateral osteotomy with palatal (type C) or alveolar ridge (type D) bone-borne force, and additional pterygomaxillary separation with palatal (type E) or alveolar ridge (type F) bone-borne force. The transverse expansion was about 1.0mm. The distribution of von Mises stress and the displacement were evaluated. The largest stress distribution was after types A and B, followed by types C and D, and finally types E and F. Displacement increased simultaneously. Palatal bone-borne forces (types A, C, and E) led to higher stress distributions in the midface and maxilla, but to a more parallel expansion compared with alveolar ridge-borne forces (types B, D, and F). The largest bony displacements at the midpalatal suture were anterior in all models. Increased weakening of the bony pillar of the facial skeleton and the use of palatal bone-borne forces leads to a decrease in stress distribution in the midface and to a more parallel transverse expansion of the maxilla.

Influence of setback and advancement osseous genioplasty on facial outcome: A computer-simulated study.

The aim of this virtual study was to investigate the influence of angular deviation and displacement distance on the overlying soft tissue during chin genioplasty. Computed tomography data from 21 patients were read using ProPlan CMF software. Twelve simulated genioplasties were performed per patient with variable osteotomy angles and displacement distances. Soft-tissue deformations and cephalometric analysis were compared. Changes in anterior and inferior soft-tissue of the chin along with resultant lower facial third area were determined. Maximum average changes in soft-tissue were obtained anterior after 10-mm advancement about 4.19 SD 0.84mm and inferior about-1.55 SD 0.96mm. After 10-mm setback anterior -4.63 SD 0.56mm and inferior 0.75 SD 1.16 mm were deviations found. The anterior soft tissue showed a statistically significant change with bony displacement in both directions independent of osteotomy angle (p<0.001) and only after a 10-mm advancement with an angle of-5° significant differences at inferior soft-tissue were noted (p=0.0055). The average area of the total lower third of the face was 24,807.80 SD 4,091.72mm(2) and up to 62.75% was influenced. Advanced genioplasty leads to greater changes in the overlying soft tissue, whereas the affected area is larger after setback displacement. The ratio between soft and hard tissue movements largely depends on the displacement distance.

An anthropometric and three-dimensional computed tomographic evaluation of two-point fixation of zygomatic complex fractures.

BackgroundMaintaining stability and restoring the aesthetic appearance are the fundamental goals when managing zygomatic fractures. We aimed to evaluate the stability and anthropometric outcomes of zygomatic fracture patients who underwent two-point fixation involving the infraorbital rim and zygomaticomaxillary buttress via the transconjunctival and gingivobuccal approaches without any skin incisions.MethodsWe examined 15 zygomatic fracture patients who underwent two-point fixation during a 3-year period. Stability was evaluated using three-dimensional facial bone computed tomography. Superoinferior and anteroposterior displacement of the zygoma was quantified. The aesthetic appearance of the periorbital region was evaluated using indirect anthropometry with standardized clinical photographs. The ratios between the eye fissure height and width, and lower iris coverage ratio were used to evaluate aesthetical changes. The bony displacement and aesthetic ratios were analyzed using Wilcoxon or Friedman tests. The correlation between the preoperative zygoma position and anthropometric values was analyzed.ResultsThe positions of the zygoma were similar to those on the contralateral side at the long-term follow-up. The preoperative anthropometric measurements on the fractured side differed from those on the contralateral side, although these values were close to the normal values at the long-term follow-up. Furthermore, we noted that the anteroposterior displacement strongly positively correlated with the lower iris coverage rate (Spearman's coefficient= 0.678, P=0.005).ConclusionsTwo-point fixation of zygomatic fractures achieved stable outcomes on long-term follow-up, and also appeared to be reliable in restoring the aesthetic appearance of the periorbital region.

Acute Bone Remodeling after Reduction of Nasal Bone Fracture on Computed Tomography Imaging.

BackgroundA number of studies have reported complication after reduction of nasal bone fractures. Among complicated cases, some showed improvement in shape of the nose with passage of time. Therefore, we examined these changes using computed tomography (CT) images taken over intervals.MethodsCT scans of 50 patients with new nasal bone fractures were reviewed, and the images were compared amongst preoperative, immediately postoperative, and one month scans. Changes in nasal bone shape, were evaluated based on the angle of nasal bone arch between the nasal bone and frontal process of maxilla, overall shape of arch, mal-alignment of fracture segments involving bony irregularity or bony displacement. These evaluations were used to separate postoperative outcomes into 5 groups: excellent, good, fair, poor, and very poor.ResultsImmediate postoperative nasal shape was excellent in 10 cases, good in 31 cases, fair in 8 cases, and poor results in a single case. Postoperative shape at one month was excellent in 37 cases, good in 12 cases, fair in a single case.ConclusionThe overall shape of nasal bone after fracture reduction tended to improve with passage of time.

Quantitative validation of a computer-aided maxillofacial planning system, focusing on soft tissue deformations.

Aim:The aim of this study was to evaluate the accuracy of 3D soft tissue predictions generated by a computer-aided maxillofacial planning system in patients undergoing orthognathic surgery.Methods and Materials:Twenty patients with dentofacial dysmorphosis were treated with orthognathic surgery after a preoperative orthodontic treatment. Fourteen patients had an Angle Class II malocclusion; three patients had an Angle class III malocclusion, and three patients had an Angle Class I malocclusion. Skeletal asymmetry was observed in six patient. The surgeries were planned using the Maxilim software. Computer assisted surgical planning was transferred to the patient by digitally generated splints. The validation procedures were performed in the following steps: (1) Standardized registration of the pre- and postoperative Cone Beam CT volumes; (2) Automated adjustment of the bone-related planning to the actual operative bony displacement; (3) Simulation of soft tissue changes; (4) Calculation of the soft tissue differences between the predicted and the postoperative results by distance mapping.Statistical Analysis and Results:Eighty four percent of the mapped distances between the predicted and actual postoperative results measured between -2 mm and +2 mm. The mean absolute linear measurements between the predicted and actual postoperative surface was 1.18. Our study shows the overall prediction was dependent on neither the surgical procedures nor the dentofacial deformity type.Conclusion:Despite some shortcomings in the prediction of the final position of the lower lip and cheek area, this software promises a clinically acceptable soft tissue prediction for orthognathic surgical procedures.

Does C₁ fracture displacement correlate with transverse ligament integrity?

The Rule of Spence states that displacement of the C₁ lateral masses by >6.9-8.1 mm suggests loss of transverse ligament integrity. The purpose of this study was to establish the thresholds of C₁ displacement on CT scans that correspond to transverse ligament disruption. Over four years, consecutive patients with acute C₁ fractures with at least three fracture lines were analyzed. CT measurements and MRI were assessed by blinded observers for bony displacement in the axial (internal and external lateral mass separation), coronal and sagittal planes and transverse ligament integrity. Eighteen patients were studied. Mean CT bony measurements were as follows: internal border lateral mass separation (ILM) 23.3 ± 3.4 mm, external border lateral mass separation (ELM) 50.3 ± 4.3 mm, total C₁ lateral mass overhang over the C₂ superior process (LMO) 5.4 ± 1.3 mm. Twelve patients were identified as having intact transverse ligament and six had transverse ligament disruption. There was no difference in mean normalized ILM, ELM, or LMO between patients with or without transverse ligament integrity (P > 0.05). There was no correlation between bony displacement and transverse ligament integrity. CT scans post-injury may not show the position of maximal displacement. If there is clinical concern about a possible transverse ligament injury, MRI should be performed.

Fractures of the pelvis in children: a review of the literature

Trauma is the leading cause of death in children. Pelvic ring injuries account for 0.3-4% of all paediatric injuries. The pattern of fractures differs to that seen in adults as it is more ductile. Pelvic ring injuries tend to be more stable as the relatively thick periosteum restricts bony displacement. Intrapelvic viscera are not well protected and can sustain injury in the absence of pelvic fractures. These injuries have traditionally been treated non-operatively. In this paper, we comprehensively review the literature and propose a protocol for treatment taking into consideration associated organ injuries, hemodynamic status of the patient, patient's age, type of fracture and the stability of the pelvic ring.

CT and MRI-based Diagnosis of Craniocervical Dislocations: The Role of the Occipitoatlantal Ligament

Craniocervical dislocations are rare, potentially devastating injuries. A diagnosis of craniocervical dislocations may be delayed as a result of their low incidence and paucity of diagnostic criteria based on CT and MRI. Delay in diagnosis may contribute to neurological injury from secondary displacement resulting from instability. The purpose of this study was to define CT and MRI-based diagnostic criteria for craniocervical dislocations to facilitate early injury recognition and stabilization. Using CT and MRI, we (1) described the bony articular displacements characterize craniocervical injuries; (2) described the ligamentous injuries that characterize craniocervical injuries; and (3) determined whether neurologic injuries were associated with bony or ligamentous injury. Using a prospectively collected spinal cord injury database, we identified 18 patients with acute, traumatic occipitocervical injuries. We reviewed CT scans and MR images to document the height of the occipitoatlantal and atlantoaxial joints and integrity of craniocervical ligaments. Medical records were reviewed for neurological status. The primary measurements were number of patients with articular displacement, location of bony displacement, and number of patients with ligamentous injury. Thirteen of 18 patients had displacement outside the normal range. Six patients demonstrated displacement of both occipitoatlantal and atlantoaxial joints, whereas five patients presented with displacement through the atlantoaxial joints only. Two patients had an abnormal basion-dental interval only. Of 17 patients with MR images, the cruciate ligament was injured in 11 patients, indeterminate in four, and intact in two. All five patients with occipitoatlantal articular displacement had injury to the occipitoatlantal capsule. No patient had occipitoatlantal capsular injury without occipitoatlantal articular displacement. Three cases of complete spinal cord injury were found after occipitoatlantal-atlantoaxial dislocations. Three patients with occipitoatlantal-atlantoaxial dislocations were neurologically intact. The five patients with atlantoaxial dislocations and patients without displacement or ligamentous injury were neurologically intact. Five patients had cruciate ligament rupture or indeterminate injury but no joint diastasis. The occipitoatlantal joint capsules stabilize the occipitoatlantal joint; disruption of the occipitoatlantal capsule may suggest the presence of instability. Based on these findings, we identified two distinct injury patterns: isolated atlantoaxial injuries (Type I) and combined occipitoatlantal-atlantoaxial injuries (Type II). Occipitoatlantal joint capsule integrity differentiated these subsets and Type II injuries had a higher percentage of complete spinal cord injuries on presentation.

Early post-treatment changes of circumaxillary sutures in young patients treated with rapid maxillary expansion

To test the null hypothesis that circumaxillary sutures do not show bony displacement in response to rapid maxillary expansion (RME) therapy. Subjects consisted of eight growing patients (two male and six female) with Angle Class I malocclusion, bilateral posterior crossbite, transverse maxillary deficiency, deep palatal vault, and dental crowding at the start of the treatment. A Hyrax palatal expander was used for each patient, and activation protocol required the screw to be turned three times per day (0.25 mm per turn) for an average of 18 days for all subjects. Multislice computed tomography (CT) scans were performed before rapid palatal expansion (time T0) and again at the end of the active expansion phase (time T1) without removing the expander. Measurements were carried out directly on the CT image using the OsiriX Imaging software program. Data were analyzed statistically by using the Wilcoxon signed rank test. All linear measurements showed an increase between T0 and T1 and RME determined a widening of suture; however, sutures far from the maxilla showed a smaller degree of disarticulation. The hypothesis is rejected. Early treatment with RME produced a significant bony displacement by circumaxillary suture opening. The amount of changes of sutures depends on different factors relating to the subjects and varies between different sutures, showing that sutures that articulate directly with the maxilla face a greater influence by the RME compared with those located further away.

Kryptonite Bone Cement Prevents Pathologic Sternal Displacement

Wire cerclage closure of sternotomy is the standard of care despite evidence of pathologic sternal displacement (> 2 mm) during physiologic distracting forces (coughing). Postoperative functional recovery, respiration, pain, sternal dehiscence, and infection are influenced by early bone stability. This translational research report provides proof-of-concept (part A) and first-in-man clinical data (part B) with use of a triglyceride-based porous adhesive to rapidly enhance the stability of conventional sternal closure. In part A, fresh human cadaver blocks were subjected to midline sternotomy and either conventional wire closure or modified adhesive closure. After 24 hours at 37 degrees C, using a biomechanical test apparatus, a step-wise increase in lateral distracting force simulated physiologic stress. Sternal displacement was measured by microdisplacement sensors. In part B, a selected clinical case series was performed and sternal perfusion assessed by serial single photon emission computed tomography imaging. Wire closure resulted in measurable bony displacement with increasing load. Pathologic displacement (> or = 2 mm) was observed in all regional segments at loads 400 newton (N) or greater. In contrast, adhesive closure completely eliminated pathologic displacement at forces 600 N or less (p < 0.001). In patients, adhesive closure was not associated with adverse events such as adhesive migration, embolization, or infection. There was excellent qualitative correlation between cadaver and clinical computed tomographic images. Sternal perfusion was not compromised by adhesive closure. This first-in-man series provides proof-of-concept indicating that a novel biologic bone adhesive is capable of rapid sternal fixation and complete elimination of pathologic sternal displacement under physiologic loading conditions. A randomized clinical trial is warranted to further define the potential risks and benefits of this innovative technique.