Caudally directed upper-instrumented vertebra pedicle screws associated with minimized risk of proximal junctional failure in patients with long posterior spinal fusion for adult spinal deformity.

BACKGROUND CONTEXT: It is unknown whether upper instrumented vertebra (UIV) pedicle screw trajectory and UIV screw-rod angle are associated with development of proximal junctional kyphosis (PJK) and/or proximal junctional failure (PJF). PURPOSE: To determine whether (1) the cranial-caudal trajectory of UIV pedicle screws and (2) UIV screw-vertebra angle are associated with PJK and/or PJF after long posterior spinal fusion in patients with adult spinal deformity (ASD). STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: We included 96 patients with ASD who underwent fusion from T9-T12 to the pelvis (>5 vertebrae fused) between 2008 and 2015. OUTCOME MEASURES: Pedicle screw trajectory was measured as the UIV pedicle screw-vertebra angle (UIV-PVA), which is the mean of the two angles between the UIV superior endplate and both UIV pedicle screws. (Positive values indicate screws angled cranially; negative values indicate screws angled caudally.) We measured UIV rod-vertebra angle (UIV-RVA) between the rod at the point of screw attachment and the UIV superior endplate. METHODS: During ≥2-year follow-up, 38 patients developed PJK, and 28 developed PJF. Mean (± standard deviation) UIV-PVA was -0.9° ± 6.0°. Mean UIV-RVA was 87° ± 5.2°. We examined the development of PJK and PJF using a UIV-PVA/UIV-RVA cutoff of 3° identified by a receiver operating characteristic curve, while controlling for osteoporosis, age, sex, and preoperative thoracic kyphosis. RESULTS: Patients with UIV-PVA ≥3° had significantly greater odds of developing PJK (odds ratio 2.7; 95% confidence interval: 1.0-7.1) and PJF (odds ratio 3.6; 95% confidence interval: 1.3-10) compared with patients with UIV-PVA <3°. UIV-RVA was not significantly associated with development of PJK or PJF. CONCLUSIONS: In long thoracic fusion to the pelvis for ASD, UIV-PVA ≥3° was associated with 2.7-fold greater odds of PJK and 3.6-fold greater odds of PJF compared with UIV-PVA <3°. UIV-RVA was not associated with PJK or PJF. LEVEL OF EVIDENCE: III.

Pediatric frontal sinus fractures: outcomes and treatment algorithm.

Pediatric frontal sinus fractures are a rare clinical entity. Owing to the large amount of force required to fracture the frontal sinus, it is often associated with severe intracranial and craniofacial injuries. The treatment of frontal sinus fractures is controversial, with many different established algorithms based mainly on the adult population. The authors present their experience with pediatric frontal sinus fractures; they also present a treatment algorithm. A retrospective review of the Cincinnati Children's Hospital Medical Center trauma database was performed. From 1998 to 2010, the authors identified patients between the ages of 0 and 18 with frontal sinus fractures and analyzed demographics, fracture pattern, associated injuries, methods of treatment, and complications. Descriptive statistics and univariate analyses were performed.A total of 39 patients were included in the study with a mean follow-up of 31.2 months. Fractures of the anterior and posterior table with displacement greater than one table width were significantly associated with higher hospital costs, higher velocity mechanism of injuries, lower Glasgow Coma Scale scores, nasofrontal outflow tract (NFOT) involvement, and cerebrospinal fluid leak. There were no differences in short- and long-term complications. Additionally, these patients were more likely to be treated surgically in the form of obliteration or cranialization.Patients without NFOT involvement can be managed with observation only. Patients with NFOT involvement or persistent cerebrospinal fluid leak should be treated with obliteration or cranialization, respectively, to reduce the risk of severe complications.

Extended composite temporoparietal fascial flap: clinical implications for tissue engineering in mandibular reconstruction.

BACKGROUND: The authors have expanded upon a well-described and widely used flap in the head and neck region. The purpose of the cadaver study was to determine the feasibility, angiosome, and the potential application of this pedicled flap in bone tissue engineering of the mandible. METHODS: A total of 6 fresh human cadaver heads were dissected for a total of 12 flaps. The extended composite temporoparietal fascial flap, based on the superficial temporal artery (STA) and including cranial periosteum, was dissected and the dimensions were measured. Through a combined submandibular and preauricular incision, the mandible was exposed and the dimensions were measured from the sigmoid notch to the gonion angle and from the gonion angle to the symphysis. CT angiography and silicone injections were performed to identify the vascular anatomy of the flap. RESULTS: The combined distance from the sigmoid notch to the gonion and the gonion to the symphysis, plotted versus the cranial apex to tragus length, demonstrated adequate flap dimensions in all specimens for hemi-mandibular reconstruction. The average flap length was 16.5 ± 1.40 cm and the average flap width was 11.4 ± 0.98 cm, resulting in an average flap surface area of 94.5 ± 13.08 cm. Radiographic images and silicone injections confirmed STA perfusion of the cranial periosteum. CONCLUSIONS: The extended composite temporoparietal fascial flap with periosteum can be a viable option for providing vascularized periosteum in tissue-engineered craniofacial reconstruction.

External fixation in a low-velocity gunshot wound to the mandible.

Low-velocity gunshot wounds to the mandible are complex injuries that can be aesthetically and functionally devastating. Despite advances in plating systems and surgical techniques, repair of such injuries remains a challenging endeavor. Traditionally, external fixation has resulted in longer treatment times and the need for revision surgery. Rigid fixation has many proponents because of shorter postoperative treatment times and fewer complications. We report a case of a low-velocity gunshot injury to the mandible with comminution and a full-thickness soft tissue wound treated definitively with maxillomandibular fixation and an external fixation device.