Reduction Of Bone Fractures Research Articles

Reduction of Zygomatic Bone Fracture by Two Different Treatment Protocols

Background: Zygomatic bone, a malar bone or cheekbone usually works as eye socket. All over the world, around 15 to 20 million people are traumatized with road accidents. Over 50% of these statistics are diagnosed with zygomatic fractured bone. There are different approaches of therapy to treat zygomatic fractured bone. In this research, two approaches have been studied. The Percutaneous Hook approach is extraoral while Keen’s approach is intraoral. The objective of this study was to evaluate outcomes of two different treatment protocols (percutaneous bone hook method and Keen’s method) for reduction of zygomatic bone fracture. Methods: This comparative analytical study conducted at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Liaquat University Hospital, Hyderabad, Pakistan. Subjects with displaced isolated zygomatic bone fracture were divided in two groups, Group A (Percutaneous Hook Method) and Group B (Keen’s Method). The data was analyzed through SPSS and p<0.05 was considered as statistically significant. Results: Males were predominantly affected in both groups as compared to females i.e., Group A male patients were 22(73.52%) while in Group B male patients were 23(79.41%). Road traffic accidents were the most common etiological factor in both groups. There was a significant difference between the groups in diplopia, cheek flattening and mean mouth opening at postoperative 2nd, 4th and 6th week. The obtained p-value=0.01 was less than 0.05; therefore, the results were statistically significant. Conclusion: It was observed that percutaneous hook method had better outcomes compared to Keen’s method in reducing isolated zygomatic bone fracture. Keywords: Bone Fracture; Treatment Protocols; Zygoma.

Closed reduction and locked intramedullary nailing of diaphyseal long bone fractures without intra-operative imaging and fracture table.

Early closed reduction and locked intramedullary (IM) nailing has become the standard treatment for diaphyseal long bone fractures in high income countries. The low and middle income countries (LMICs) are still lagging behind in transiting from open surgical reduction and non-operative modalities to closed reduction due to lack of requisite equipment. However, some surgeons in LMICs are beginning to achieve closed reduction even without the equipment. A prospective descriptive study was done on a total of 251 fresh diaphyseal fractures of the humerus, femur and tibia fixed with a locked nail over a 5½-year period. The fractures were grouped into those that had open reduction, closed reduction or reduction with a finger. Closed reduction was done for 135 (53.8%) fractures belonging to 123 patients. The mean and range of the patients' ages were 41.33 and 13-81years, respectively. Males constituted 69.9% and mostly (48%) sustained fractures in motorcycle accident. There was a significant negative association between closed reduction and fracture-to-surgery interval (p < 0.001). Closed reduction also had positive associations with: (i) humerus and tibia fractures (p < 0.001), (ii) middle, distal and segmental fractures (p = 0.025), (iii) retrograde approach to femur fracture nailing (p < 0.001), and (iv) wedge or multifragmentary type femur fractures (p = 0.005). With constant practice, it is possible to achieve closed reduction of many fresh diaphyseal long bone fractures in spite of the limitations imposed on surgeons in LMICs by poor health systems and grossly inadequate fracture care facilities.

Precisely Closed Reduction of Nasal Bone Fracture Assisted With Plain Film Measurements Under the Picture Archiving and Communication System.

To prevent aesthetic and functional deformities, precisely closed reduction is crucial in the management of nasal fractures. Plain film radiography (PF), ultrasonography (USG), and computed tomography can help confirm the diagnosis and classification of fractures and assist in performing closed reduction. However, no study in the literature reports on precisely closed reduction assisted with PF measurements under the picture archiving and communication system (PACS). We retrospectively evaluated 153 patients with nasal bone fracture between January 2013 and December 2017. Surgeons conducted precisely closed reduction assisted with PF measurement of the distance between the fracture site and nasal tip under PACS on 34 patients (group A). Another group on 119 patients were reduced under surgeon's experience (group B). No significant differences in age, gender, Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification, and reduction outcome were observed between group A and group B (P > .05). The operative time of the group A was significantly lower (12.50 ± 4.64 minutes) compared to group B (23.78 ± 11.20 minutes; P < .001). After adjusted age, gender, and AO classification, patients in group A scored 10.46 minutes less on the operative time than those in group B (P < .001). In addition, the severity of nasal bone fracture (AO classification, β = 3.37, P = .002) was positive associated with the operative time. In this study, closed reduction in nasal bone fracture assisted with PF measurements under PACS was performed precisely, thereby effectively decreasing operative time and the occurrence of complications. This procedure requires neither the use of new instruments or C-arm nor USG or navigation experience. Moreover, reduction can be easily performed using this method, and it requires short operative time, helps achieve great reduction, less radiation exposures, and is cost-effective.

Simultaneous Use of Bioabsorbable and Nonbioabsorbable Packing Materials During Closed Reduction of a Nasal Bone Fractures.

The nasal packing material after closed reduction of nasal bone fracture may be bioabsorbable or nonbioabsorbable. To investigate the usefulness of the packing method using bioabsorbable and nonbioabsorbable materials simultaneously, a chart review was retrospectively performed involving 255 patients. Group A (n = 119), Nasopore (bioabsorbable) was cut appropriately and packed, and subsequently, supportive packing with Merocel (nonbioabsorbable) was performed. Group B (n = 78), nasal packing was performed with Vaseline roll gauze. Group C (n = 49), packed only Merocel. Pain and rhinorrhea were significantly lower in Merocel + Nasopore group (P < 0.05). It is thought that rhinorrhea is reduced by less mucosal irritation and maximizing the discharge absorption capacity by using Merocel and Nasopore simultaneously. By packing Nasopore first, pain is thought to be reduced by reducing the contact surface between Merocel and the injured mucosa and preventing a direct force to the fracture site. Therefore, our packing method, which uses Merocel and Nasopore simultaneously, can be recommended because it can provide sufficient support for the reduced fracture site, cause less pain, and maximize discharge absorption.

Comparison of postoperative outcomes between early and delayed surgery for pediatric nasal fractures.

BackgroundPediatric nasal fractures, unlike adult nasal fractures, are treated surgically as early as 7 days after the initial trauma. However, in some cases, a week or more elapses before surgery, and few studies have investigated the consequences of delayed surgery for pediatric nasal fractures. The purpose of this study was to evaluate the postoperative outcomes of pediatric nasal fractures according to the time interval between the initial trauma and surgery.MethodsThe records of pediatric patients under 12 years old who underwent closed reduction of nasal bone fracture from March 2012 to February 2020 were reviewed. The interval between trauma and surgery was divided into within 7 days (early reduction) and more than 7 days (delayed reduction). Postoperative results were classified into five grades (excellent, good, moderate, poor, and very poor) based on the degree of reduction shown on computed tomography.ResultsNinety-eight patients were analyzed, of whom 51 underwent early reduction and 47 underwent delayed reduction. Forty-two (82.4%) of the 51 patients in the early reduction group showed excellent results, and nine (17.6%) showed good results. Thirty-nine (83.0%) of the 47 patients in the delayed reduction group showed excellent results and eight (17.0%) showed good results. No statistically significant difference in outcomes was found between the two groups (chi-square test p=0.937). However, patients without septal injury were significantly more likely to have excellent postoperative outcomes (chi-square test p<0.01).ConclusionNo statistically significant difference was found in the outcomes of pediatric nasal fractures between the early and delayed reduction groups. Successful surgical results were found even in patients who received delayed reduction (more than 7 days after trauma).

Effectiveness of Closed Reduction in the treatment of nasal bone fractures

This study was conducted to investigate the effectiveness of closed reduction of nasal bone fracture according to severity. It was a retrospective study carried on 60 patients with mean age of 30.2 years (range 10-67 years) who have undergone a closed reduction of a nasal bone fracture at Gandaki Medical College Teaching Hospital from January 2017 to December 2019. The patient with nasal bone fracture who underwent surgical intervention with closed reduction under General anaesthesia were included in this study. Fracture severity was evaluated according to Hwang et al.’s classification method. All patients underwent closed reduction with external nasal splinting under General anesthesia. The patients were followed-up for at least three months to assess the complications, such as fracture recurrence and functional abnormality in the Department. The most common cause of nasal bone fracture was road traffic accidents 25 (41.6%) followed by physical assaults 18 (30%), fall injuries 12 (20%), other incidences 3 (5%), and industrial accidents 2 (3%). Forty-three (72%) cases underwent closed reduction within 24 hours of those who arrived within 4-6 hour of nasal injury in the hospital and the remaining 17 (28%) cases were reduced after 5 days of trauma. Concurrent fracture found in 8 (13%) cases and it included maxillary, zygomatic, orbital, frontal bone fracture. Nasal bone fracture mostly occurs in road traffic accidents. Closed reduction with good alignment is the preferred method. Septorhinoplasty and extracorporeal septoplasty should be applied in difficult and comminuted nasoseptal fracture.

Damage control surgery (DCS) in the management of maxillofacial bomb blast patients during the Yemen civil conflict. Neighboring Level 1 trauma hospital experience

Study design:Application of Damage Control Surgery (DCS) in Oral and maxillofacial surgery is still evolving, therefore, the current study hopes to share our experience in the management of bomb blast patients.Objectives:The objectives of the current study is to share our experience in the management of maxillofacial bomb blast injuries emphasizing on DCS.Methods:This was a retrospective study of combatant Yemeni war patients who were transported across the border from Yemen and treated in Najran, Kingdom of Saudi Arabia from December 2015 to December 2019. Information such as etiology of injury, age, zone of injury and mechanisms of bomb blast associated injuries, treatment protocol and complications. The treatment protocols adopted include; DCS in which exploration to control soft tissue bleeding was done and when bone bleeding could not be controlled, immediate reduction and osteosynthesis of bone fractures was carried out. Early Definitive Surgery (EDS) was done in patients that were hemodynamically stable with open reduction and internal fixation (ORIF) of all facial bone fractures. Closed reduction and fixation were done with the use of arch bars while in conservative approach, patients were placed only on soft diet. Data was stored and analyzed using IBM SPSS Statistics for IOS Version 25 (Armonk, NY: IBM Corp).Results:A total of 235 (57.6%) patients sustained bomb blast injuries from the 408 war casualties. Other patients (42.4%) sustained other types of injuries. All the patients were males. Their ages ranged from 21 to 53 years with mean (SD) at 27.3 (5.6) years. DCS was carried out in a large proportion of the patients totaling 78 (33.2%) patients, while EDS was carried out in 58 (24.7%) hemodynamically stable patients. ORIF was the main treatment modality for the fractures in 136 (57.9%) of the patients.Conclusion:The result of the study showed a large proportion of the patients were managed with DCS. DCS should be seen as a strategy in stabilizing the patients before definitive surgery is performed.

Can Acetaminophen Pretreatment Decrease the Pain Associated With Closed Nasal Bone Reduction? A Triple-Blind Randomized Clinical Trial

<h3>Purpose</h3> Nasal bone fracture is a common maxillofacial injury, which is usually managed under local anesthesia because it is fast and effective but painful. We designed this study to see if pre-emptive analgesia with acetaminophen can reduce the pain associated with nasal bone reduction under local anesthesia. <h3>Patients and Methods</h3> This was a triple-blind, randomized clinical trial. Our sample was patients with nose fracture (eligible for closed reduction) who presented to our nasal fracture clinic and they were divided into 2 arms. Medication was randomly delivered via packages, and the surgeon, patients, and data analyzer were all blind to the intervention. Demographic data along with the visual analog scale pain scores (1 to 10 score from least to most severe pain) during local anesthesia, during reduction, and 24 hours after reduction were recorded, then analyzed using χ², nonparametric Mann-Whitney test, and correlation analysis. <h3>Results</h3> One hundred participants were divided into 2 arms (placebo or acetaminophen 500-mg tablet 45 minutes before reduction). The patients were mostly men (74%), and the most common mechanism was involvement in a fight (30%). Pain scores, as well as surgeon satisfaction analysis, returned no statistical difference between the 2 groups. Correlation analysis was performed, and the only factor for pain severity during reduction was the number of tries needed. <h3>Conclusions</h3> Acetaminophen pretreatment did not add analgesia any more than that of placebo. Its use before reduction of nasal bone fracture is not justified.

Use of porous custom-made cones for meta-diaphyseal bone defects reconstruction in knee revision surgery: a clinical and biomechanical analysis.

Although the practice of metaphyseal reconstruction has obtained successful clinical and radiological results in revision total knee surgery, off-the-shelf devices aren't an effective solution for all patients as they do not cover the full range of clinical possibilities. For this reason, during severe knee revisions, custom-made porous titanium cementless metaphyseal cones are nowadays employed as alternative to traditional surgeries. The aim of this study is to understand the benefits gained by the use of the custom-made cones against the performance of more traditional techniques, such as the use of cemented or cementless stems. Thus, a retrospective study on eleven patients and a biomechanical finite element analysis (FEA) was developed, based upon three clinical cases of the clinical analyzed cohort. Eleven patients underwent staged total knee arthroplasty revision with the use of 16 custom-made cones to correct severe femoral and tibial meta-diaphyseal bone defects. Clinical scores and range of movement were observed during the follow-up period (mean follow-up 26 ± 9.4months). Reason for surgery was periprosthetic joint infection (PJI) in eight patients and post-traumatic osteomyelitis in the other three patients. Three patients previously affected by PJI were selected among the eleven patients of the clinical population. For those patients, bone geometries and implants during surgery were replicated in silico and analyzed during different daily activities. For the same patients, as alternative solution for surgery, the use of cemented or cementless stems was also simulated by FEA. Stress patterns in different region of interest and risk of fracture in the bone were calculated and compared. No loosening, component migration, or mismatches between preoperative planning and intraoperative findings were clinically registered. Biomechanical results demonstrated that the use of custom-made cones induces a more homogeneously distributed bone stress than the other two techniques that concentrate the stress in spotted regions. The risk of fracture is comparable between the use of custom-made cones and cemented technique, while press-fit configurations increase the risk of fracture (more than 35%). Based upon the clinical evidence and the findings after the FEAs, the practice of porous custom-made metaphyseal cones in severe revisions of knee arthroplasties is showing promising biomechanical results. The homogeneous stresses distributions and the lower bone stress gradient could justify a reduction of bone fractures and the risk of implant loosening which could be the explanation to the successful clinical outcomes.

鼻骨骨折整復術におけるポータブルエコー ( Venue 40® ) の有用性

鼻骨骨折整復術におけるポータブルエコー ( Venue 40® ) の有用性

Reverse umbrella technique – percutaneous reduction of frontal bone fracture using an intermaxillary fixation screw device

Fractures of the frontal sinus account for approximately 5%–15% of all maxillofacial fractures with a slight male preponderance.1 The standard management involves an access coronal flap for open reduction and internal fixation, but this has some unwanted risks such as scar, alopecia, paraesthesia, and facial nerve weakness.2 We report a safe and effective percutaneous technique for closed reduction of a non-comminuted isolated anterior table fracture of the frontal sinus with the use of intermaxillary fixation (IMF) screws under image intensifier guidance.

Three-dimension CT assisted treatment of nasal fracture

Objective:To investigate the diagnosis and evaluation methods of nasal bone fractures after nasal trauma, and the guiding significance of three-dimensional CT imaging technology for its treatment. Method:A total of 255 patients with nasal bone fractures were randomly selected from our hospital. All patients underwent CT scan of the nasal bones and reconstructed on a computer system. The reconstructed CT images were observed, measured and evaluated. Analyze the morphological characteristics of nasal bone fractures and evaluate the involvement of other facial structures. Result:Among 255 patients with nasal trauma, there were traumatic nasal bone fractures, including 71 cases（27.8%） with simple nasal bone fractures, 143 cases（56.1%） with traumatic nasal septum deviation, and 41 cases（16.1%） with other fractures. External nasal fracture classification: type Ⅰ（unilateral nasal bone or maxillary frontal fracture） 91 cases（35.7%）， type Ⅱ（bilateral nasal bone or fracture） 21 cases（8.2%），type Ⅲ（with trauma Nasal septum deviation） 143 cases（56.1%）. A total of 214 patients（83.9%） underwent surgical treatment, and underwent nasal endoscopic reduction of nasal bone fractures under local anesthesia, and 77 patients（30.2%） underwent nasal septum surgery. Conclusion:CT three-dimensional imaging technology can clearly display the location of the nasal bone fracture, the shape of the fracture line, the number of fragments formed by the fracture, and quantitative analysis of the deformity caused by it, which plays an important role in its diagnosis and treatment.

Long-term Stability after Reduction of Mandible Fracture by Keyhole Plate: Evaluation at the Time of Plate Removal

BackgroundVarious types of miniplates have been developed and used for the reduction of facial bone fractures. We introduced Yang’s Keyhole (YK) plate, and reported on its short-term stability. The purpose of this study was to evaluate the long-term stability of the YK plate, as a follow-up study, by examining the patients who had used the YK plate among the patients with the reduction of mandible fractures and who visited for plate removal.MethodsWe reviewed the medical records of 16 patients who underwent mandibular fracture fixation using a YK plate (group I) and 17 patients who underwent mandibular fracture fixation using a conventional plate (group II). Assessment was then made on malunion, occlusal stability, discomfort during the application, and clinical symptoms.ResultsFrom January 2015 to December 2017, a total of 36 patients underwent mandibular fracture surgery using a YK plate. A total of 16 patients received plate removal. Among them, 15 were male and 1 female. The average age was 26 years. The applied surgical sites were the 12 on mandibular angle, 4 on mandibular symphysis, and 2 on subcondyle. The application period of YK plate was an average of 335 days. During the same period, 45 people underwent surgery on the conventional plate. A total of 17 patients received plate removal. Among them, 15 were male and 2 females. The average age was 36 years. The applied surgical sites were the 8 on mandibular angle, 4 on mandibular symphysis, and 2 on subcondyle. The application period of the conventional plate was an average of 349 days. No malocclusion occurred at the time of removal, and occlusion was stable. No patient complained of joint disease or discomfort.ConclusionThe YK plate system, in which the screw was first inserted and the plate was applied, for clinical convenience did not cause any particular problem and no significant difference from the conventional plate.

Miniplate osteosynthesis in fracture surgeries: Case series with review of concepts

PurposeMiniplates were initially developed as targets for foot and hand fractures, but they have been used in the treatment of fixation of small bone fragments, reduction of long bone fractures and non-union treatment, which have been difficult to treat. In this study, the authors used miniplates to treat fractures of the upper extremities, lower extremities, and pelvis obtained good outcomes. Herein, the authors report these good outcomes and review the current concept of miniplates. Patients and methodsForty-two patients treated with miniplates between March 2012 and March 2017 who attended follow-up for > 1 year were included in this retrospective study. Miniplates were selected according to purpose, which was classified into three categories: fixation, reduction, and stability enhancement. For fixation, miniplates were used to fix distal fibular fractures occurring distal to the syndesmosis and treat patellar and olecranon fractures with severe comminution. For reduction, miniplates were used to reduce the tibia during intramedullary nailing in tibiofibular shaft fractures, while reduction was performed in advance of definitive plating fixation in patients with humeral and pelvic fractures. To enhance stability, the miniplate was inserted after autobone graft for atrophic nonunion at the humeral shaft following nail insertion. The validity of a miniplate was analyzed by reviewing the published literature on the use of miniplates in orthopedic fracture surgeries. ResultsBony union was achieved in all cases. No specific postoperative complications were observed; however, mild pain and limited range of motion observed in two patients were resolved after implant removal. Sixteen studies on fracture treatment using miniplates reported clinically fair outcomes. ConclusionMiniplates are not just small metal plates. Depending on the location and treatment of the fracture, the miniplate can effectively fix small bone fragments, help the main plate to maintain the reduction of large bone fragments, and increase the fixation force for nonunion treatment.

An analysis on the effect of the three-incision combined approach for complex fracture of tibial plateau involving the posterolateral tibial plateau

BackgroundThe clinical effect of the three-incision combined approach for complex fracture of tibial plateau involving the posterior tibial plateau was discussed.MethodsA retrospective analysis was performed for 13 cases receiving surgery for complex fracture of tibial plateau from July 2015 to June 2019. They received surgery via the three-incision combined approach, and regular postoperative reexamination was performed at the outpatient clinic. During the last follow-up, Hospital for Special Surgery (HSS) Knee Scoring System was used to assess the knee joint function; the Lysholm score was used to assess the knee mobility. The anterior, posterior, and rotational stabilities of the knee joint were assessed by the Lachman test and pivot-shift test.ResultsThere was no nonunion and delayed union, implant loosening and fracture, or refracture, and neither were there neurological symptoms or restricted mobility in daily life. During the follow-up, none of the cases were found with restriction of knee mobility caused by internal fixation or apparent pain. The HSS score during the last follow-up was 86–100 (average, 90.2 ± 6.8), and the excellent and good rate was 100%; the Lysholm score was 86–100 (average, 95.7 ± 2.6). All cases were negative for the Lachman test and pivot-shift test. The knee flexion mobility was 100~140° (average, 127.2° ± 11.4°). Postoperative X-ray indicated anatomical reduction of bone fractures in all cases. Loss of reduction or loosening and fracture of internal fixation was not observed by postoperative regular reexaminations. The posterior tibial slope at 6 months after surgery was 6~16° (average, 10.66 ± 2.58°), the varus angle was 84~89° (average, 86.52 ± 1.46°), the Rasmussen radiological score was 12~18 (average, 16.12 ± 1.35), and the excellent and good rate was 100%.ConclusionThe three-incision combined approach proved safe and reliable for complex fracture of tibial plateau involving the posterior tibial plateau and is worthy of further popularization.

Effect of lidocaine on pain caused by nasal pack removal after closed reduction of nasal bone fractures.

BackgroundPain caused by nasal pack removal after closed reduction of nasal bone fractures is a common problem. This study investigated the effect of infiltrating lidocaine into nasal packs on the pain caused by pack removal after closed reduction of nasal bone fractures.MethodsSeventy-five patients who underwent closed reduction of nasal bone fractures between March 2016 and March 2018 were enrolled in this prospective, randomized, single-blind study. Merocel (hydroxylated polyvinyl acetate) packs were applied bilaterally and retained for 5 days. Twenty minutes before removal, both packs were rehydrated with 6 mL of 2% lidocaine in 26 patients and with 6 mL of saline in 24 patients; the packs were not rehydrated in 25 patients. Visual analog scale (VAS) scores for pain on removal were recorded.ResultsThe mean VAS score was 5.3±2.0 in all patients, 3.8±1.5 in the lidocaine group, 5.8±1.4 in the saline group, and 6.3±2.1 in the non-rehydrated group. There was a significant difference in the pain score between the lidocaine and saline groups (P<0.001) but not between the saline and non-rehydrated groups (P=0.186).ConclusionsInfiltration of lidocaine into Merocel packs reduced the pain caused by pack removal after closed reduction of nasal bone fractures.

Comparison of emergence agitation between succinylcholine and rocuronium-sugammadex in adults following closed reduction of a nasal bone fracture: a prospective randomized controlled trial

BackgroundSugammadex allows rapid recovery from rocuronium-induced neuromuscular blockade. Succinylcholine is often used for brief surgeries but is associated with myalgia, headache, histamine release, and increased lactate levels. Thus, we hypothesized that succinylcholine may affect emergence agitation (EA) and compared the effects of succinylcholine and rocuronium-sugammadex on EA in patients undergoing closed reduction of a nasal bone fracture under general anesthesia.MethodsForty-two patients were prospectively enrolled and allocated randomly to the succinylcholine group (group SC) or the rocuronium-sugammadex group (group RS; each n = 21). Neuromuscular block and its reversal were achieved with succinylcholine and normal saline in group SC, whereas rocuronium and sugammadex were administered in group RS. After surgery, the incidence of EA as a primary outcome, the incidence of dangerous EA, and duration of EA as secondary outcomes were compared.ResultsThe incidence of EA was higher in group SC than in group RS (90.5% vs. 47.6%, respectively; relative risk [RR] 4.3; 95% confidence interval [CI] 1.2 to 15.7; P = .006). The incidence of dangerous EA increased in group SC compared to group RS (33.3% vs. 4.8%, respectively; RR 2.1; 95% CI 1.3 to 3.4; P = .045). The duration of agitation was longer in group SC than in group RS [106.5 (65.1) vs. 40.4 (26.0) sec; mean difference 66.1 s; 95% CI 31.0 to 101.1; effect size 1.3; P = .001).ConclusionSuccinylcholine increases the incidence, severity, and duration of EA compared to rocuronium-sugammadex in patients undergoing closed reduction of a nasal bone fracture.Trial registrationCRiS Registration number KCT0002673. Initial registration date was 31 January 2018 (Retrospectively registered).

Characterization of the Severe Phenotype of Pyruvate Kinase Deficiency

Background: Pyruvate kinase deficiency (PKD) is the most common cause of chronic hereditary non-spherocytic hemolytic anemia. The spectrum of disease in PKD is broad, ranging from an incidentally discovered mild anemia to a severe transfusion-dependent anemia. Splenectomy partially ameliorates the anemia and reduces the transfusion burden in the majority of patients. Because hemoglobin poorly correlates with symptoms in PKD, transfusion requirements are typically used clinically to classify disease severity with those who are regularly transfused despite splenectomy recognized as the most severely affected subgroup. Aim: To compare demographics, complications, and laboratory results between the most severely-affected PKD patients (those that are splenectomized and regularly transfused) with non-regularly transfused splenectomized PKD patients. Methods: After ethics committee approval, patients were enrolled on the PKD Natural History Study, a prospective 30 site international study. All patients had molecularly confirmed PKD. Only splenectomized patients were included in the analysis. Transfusion frequency was observed over a 3-year period. Patients were divided into two groups based on transfusion frequency: the severe phenotype group was defined as those who receive regular transfusions (≥6 discrete red cell transfusion episodes per year) and the control group did not receive regular transfusions. Phenotype stability over the 3-year period was also assessed. Results: 154 splenectomized patients with PKD were included: 30 patients in the severe PKD phenotype group and 124 patients in the comparison PKD group. Results of the analysis comparing the two groups are described in the Table. Severely affected patients were more likely to be female (77% versus 51%, p=0.013), older at the time of splenectomy (median age: 5 versus 3.6, p=0.011), have iron overload (93% vs. 51%, p&amp;lt;0.0001), have received chelation therapy (90% vs. 42%, p&amp;lt;0.0001), and had more lifetime transfusions (median: 77 versus 15, p&amp;lt;0.0001). Rates of other PKD complications including pulmonary hypertension, extramedullary hematopoiesis, liver cirrhosis, endocrinopathy, and bone fracture appear similar between the two groups. Laboratory values, including hemoglobin, total bilirubin, normalized PK enzyme activity, and median absolute reticulocyte count appear similar between the two groups. The underlying genetic mutation patterns (missense mutations versus non-missense mutations) were also similar between the groups. Phenotype stability over time was highly variable: of the patients with a severe phenotype at enrollment, 62% had a severe phenotype during the first follow-up year and 39% had a severe phenotype at the second follow-up year. Conclusions: Patients with PKD who are regularly transfused despite splenectomy appeared to have similar rates of PKD-associated complications (except for iron overload) and similar relevant laboratory values and genotypes when compared to those who are not regularly transfused after splenectomy. The similarity observed between severe phenotype patients and comparison patients with PKD may result from a protective effect of transfusion (e.g. reduction of bone fractures and extramedullary hematopoiesis) or could suggest transfusion-dependence is an artificial signifier of disease severity, reflective of provider practices and patient symptoms rather than an actual distinct phenotype. Transfusion requirements in severe PKD appear to fluctuate significantly over time. Disclosures Al-Samkari: Dova: Consultancy, Research Funding; Agios: Consultancy, Research Funding; Moderna: Consultancy. van Beers:RR Mechatronics: Research Funding; Agios Pharmaceuticals, Inc.: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Research Funding; Pfizer: Research Funding. Barcellini:Agios: Consultancy, Other: Advisory board; Apellis: Consultancy; Incyte: Consultancy, Other: Advisory board; Bioverativ: Consultancy, Other: Advisory board; Novartis: Research Funding, Speakers Bureau; Alexion: Consultancy, Research Funding, Speakers Bureau. Eber:Agios Pharmaceuticals, Inc.: Consultancy. Glader:Agios Pharmaceuticals, Inc: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Chonat:Alexion: Other: advisory board; Agios Pharmaceuticals, Inc.: Other: advisory board. Kuo:Pfizer: Consultancy; Novartis: Consultancy, Honoraria; Celgene: Consultancy; Agios: Consultancy; Alexion: Consultancy, Honoraria; Apellis: Consultancy; Bioverativ: Other: Data Safety Monitoring Board; Bluebird Bio: Consultancy. Despotovic:Dova: Honoraria; Novartis: Research Funding; Amgen: Research Funding. Kwiatkowski:Celgene: Consultancy; Terumo: Research Funding; Apopharma: Research Funding; bluebird bio, Inc.: Consultancy, Research Funding; Agios: Consultancy; Imara: Consultancy; Novartis: Research Funding. Thompson:Baxalta: Research Funding; Novartis: Consultancy, Research Funding; bluebird bio, Inc.: Consultancy, Research Funding; Celgene: Consultancy, Research Funding. Ravindranath:Agios Pharmaceuticals, Inc.: Other: I am site PI on several Agios-sponsored studies, Research Funding. Rothman:Pfizer: Consultancy, Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Agios: Honoraria, Research Funding. Verhovsek:Sickle Cell Awareness Group of Ontario: Membership on an entity's Board of Directors or advisory committees; Sickle Cell Disease Association of Canada: Membership on an entity's Board of Directors or advisory committees, Research Funding; Canadian Haemoglobinopathy Association: Membership on an entity's Board of Directors or advisory committees; Vertex: Consultancy. Kunz:Novartis: Membership on an entity's Board of Directors or advisory committees. Sheth:CRSPR/Vertex: Other: Clinical Trial Steering committee; Apopharma: Other: Clinical trial DSMB; Celgene: Consultancy. London:United Therapeutics: Consultancy; ArQule, Inc: Consultancy. Grace:Novartis: Research Funding; Agios Pharmaceuticals, Inc: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Clinical usefulness of fixation of absorbable implants with cyanoacrylate in comminuted fractures of the maxilla.

BackgroundThe open reduction of craniofacial bone fractures requires internal fixation using metal plates and screws, which have been considered the gold standard. However, metal implants pose a risk of palpation, protrusion, and foreign body reaction, and they may require an additional operation for removal. Recently, good results have been reported for absorbable implants which complement the disadvantages of metal implants. This study presents the results of using absorbable mesh, plates, and screws with cyanoacrylate for more accurate and firmer fixation of comminuted fractures of the maxilla.MethodsIn total, 235 patients underwent operations for comminuted fractures of the maxilla. From January 2012 to December 2014, absorbable mesh and screws were used in 114 patients, while from January 2015 to December 2017, absorbable mesh, plates, and screws with cyanoacrylate were used in 121 patients. Open reduction of the bone fragments was performed, after which absorbable implants were accurately molded and fixed by screws.ResultsAll patients underwent postoperative computed tomography scans, which showed highly accurate reduction and firm fixation in the patients who underwent procedures using absorbable implants, screws, and cyanoacrylate. There were no postoperative complications or cases of abnormal facial contour.ConclusionWhen absorbable implants and screws are used for maxillary fractures, no additional surgery to remove the metal plate is required. In addition, the use of cyanoacrylate enables accurate and firm fixation of the tiny bone fragments that cannot be fixed with screws.

Premedication with dexmedetomidine to reduce emergence agitation: a randomized controlled trial

BackgroundNasal bone fracture is the most common type of facial fracture, and the high incidence of severe emergence agitation occurring after closed reduction of the nasal bone fracture can be challenging to manage. The purpose of this trial was to evaluate whether pre-operative administration of dexmedetomidine is effective in reducing the incidence and severity of emergence agitation in adults undergoing closed reduction of nasal bone fractures.MethodsIn this randomized controlled trial, 90 patients who were scheduled to undergo closed reduction of a nasal bone fracture were prospectively included and were randomly assigned to either the control group (n = 45; 0.9% saline infusion) or the dexmedetomidine group (n = 45; 1 μ/kg over 10 min, pre-operatively). The primary endpoint was Aono’s four-point scale scores after anesthesia. The recovery time and numeric rating scale score were assessed as secondary endpoints.ResultsAono’s four-point scale scores were lower in the dexmedetomidine group than in the control group (median: 1 [1] vs. 1 [1, 2], 95% confidence interval of difference: 0.01 to 0.02, P = 0.02). The number, severity, and duration of agitation episodes were significantly lower in the dexmedetomidine group than in the control group. Furthermore, the number of patients exhibiting intraoperative movement was lower in the dexmedetomidine group.ConclusionsPre-operative administration of dexmedetomidine demonstrated several significant benefits, such as a lower incidence of emergence agitation, reduced agitation severity, and a shorter duration of agitation. Additionally, we observed more stable maintenance of intraoperative anesthesia with less movement during the surgery.Trial registrationIdentifier: KCT0000585 (registration date: 12–19- 2012).