Justin L. Bellamy

Clinical outcomes in cranioplasty: risk factors and choice of reconstructive material.

Background: Continuing advances in cranioplasty have enabled repair of increasingly complicated cranial defects. However, the optimal materials and approaches for particular clinical scenarios remain unclear. This study examines outcomes following cranioplasty for a variety of indications in patients treated with alloplastic material, autogenous tissue, or a combination of both. Methods: The authors conducted a retrospective analysis on 180 patients who had 195 cranioplasties performed between 1993 and 2010. Results: Materials used for cranioplasty included alloplastic for 42.6 percent (83 of 195), autologous for 19.0 percent (37 of 195), and both combined for 38.5 percent (75 of 195). Mean defect size was 70.5 cm2. A subset of patients had undergone previous irradiation (12.2 percent; 22 of 180) or had preoperative infections (30.6 percent; 55 of 180). The most common complication was postoperative infection (15.9 percent; 31 of 195). Factors that significantly predisposed to complications included preoperative radiation, previous infection, and frontal location. Preoperative radiation was the strongest predictor of having any postoperative complications, with an adjusted odds ratio of 6.91 (p < 0.005). Irradiated patients (OR, 7.96; p < 0.05) and patients undergoing frontal cranioplasties (OR, 2.83; p < 0.05) were more likely to require repeated operation. Preoperative infection predisposed patients to exposure of hardware in alloplastic reconstructions (OR, 3.13; p < 0.05). Conclusions: Despite the evolution of cranioplasty techniques and materials, complications are not uncommon. The choice of reconstructive material may modify the risk of developing postoperative complications but appears less important than the clinical history in affecting outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Severe infectious complications following frontal sinus fracture: the impact of operative delay and perioperative antibiotic use.

Background: The purpose of this study was to investigate whether a delay in operative management of frontal sinus fractures is associated with increased risk of serious infections. Methods: Retrospective chart review was performed of 242 consecutive patients with surgically managed frontal sinus fractures who presented to the R Adams Cowley Shock Trauma Center between 1996 and 2011. Collected patient characteristics included demographics, surgical management, hospital course, and complications. All computed tomographic imaging was reviewed to evaluate involvement of the posterior table and nasofrontal outflow tract. Serious infections included meningitis, encephalitis, brain abscess, frontal sinus abscess, and osteomyelitis. Delayed operative interventions were defined as procedures performed more than 48 hours after admission. Adjusted relative risk estimates were obtained using multivariable regression. Results: There were 14 serious infections (5.8 percent). All patients with serious infections had both involvement of the posterior table and nasofrontal outflow tract injury. The cumulative incidence of serious infection in these patients was 10.8 percent. After adjustments for confounding, multivariable regression showed that operative delay beyond 48 hours was independently associated with a 4.03-fold (p < 0.05) increased risk for serious infection; external cerebrospinal fluid drainage catheter use and local soft-tissue infection conferred a 4.09-fold (p < 0.05) and 5.10-fold (p < 0.001) increased risk, respectively. Antibiotic use beyond 48 hours postoperatively was not associated with fewer infections. Conclusions: Delay in operative management of frontal sinus fractures in patients requiring operative intervention is associated with an increased risk for serious infections. Continued antibiotic prophylaxis beyond the perioperative period provides little benefit in preventing serious infections. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Do adjunctive flap-monitoring technologies impact clinical decision making? An analysis of microsurgeon preferences and behavior by body region.

Background: Multiple perfusion assessment technologies exist to identify compromised microvascular free flaps. The effectiveness, operability, and cost of each technology vary. The authors investigated surgeon preference and clinical behavior with several perfusion assessment technologies. Methods: A questionnaire was sent to members of the American Society for Reconstructive Microsurgery concerning perceptions and frequency of use of several technologies in varied clinical situations. Demographic information was also collected. Adjusted odds ratios were calculated using multinomial logistic regression accounting for clustering of similar practices within institutions/regions. Results: The questionnaire was completed by 157 of 389 participants (40.4 percent response rate). Handheld Doppler was the most commonly preferred free flap-monitoring technology (56.1 percent), followed by implantable Doppler (22.9 percent) and cutaneous tissue oximetry (16.6 percent). Surgeons were significantly more likely to opt for immediate take-back to the operating room when presented with a concerning tissue oximetry readout compared with a concerning handheld Doppler signal (OR, 2.82; p < 0.01), whereas other technologies did not significantly alter postoperative management more than simple handheld Doppler. Clinical decision making did not significantly differ by demographics, training, or practice setup. Conclusions: Although most surgeons still prefer to use standard handheld Doppler for free flap assessment, respondents were significantly more likely to opt for immediate return to the operating room for a concerning tissue oximetry reading than an abnormal Doppler signal. This suggests that tissue oximetry may have the greatest impact on clinical decision making in the postoperative period.

The importance of timing in optimizing cranial vault remodeling in syndromic craniosynostosis.

Background: The purpose of this study was to gain insight into the impact of age at repair on relapse rates in syndromic patients undergoing cranial vault remodeling. Methods: Retrospective chart review was performed for patients surgically treated for syndromic craniosynostosis from 1990 to 2013. Surgical procedures were assigned a Whitaker category based on need for reoperation as follows: no additional surgery required (category I); minor contouring revisions required (II); major revisions required (III); or failure of original surgery (IV). Age at surgery was grouped as follows: younger than 6 months; aged 6 to 9 months; and older than 9 months. Multivariable logistic regression analysis was performed to determine the relationship between age at surgery and need for reoperation by Whitaker category. Results: Fifty-two patients undergoing a total of 65 planned cranial vault remodeling procedures were included. Multivariate logistic regression analysis revealed that patients younger than 6 months at the time of primary surgery carried a 4.10 greater odds (95 percent CI, 1.31 to 12.87; p = 0.016) of requiring a subsequent major reoperation, and being older than 9 months of age carried a 13.2 greater odds (95 percent CI, 1.39 to 124.30; p = 0.024) of requiring a subsequent minor revision. Conclusions: Timing of surgery is an important factor to consider when planning vault remodeling in syndromic craniosynostosis. Based on our institution’s experience, when there is no concern for elevated intracranial pressure the ideal operative window for these procedures in the syndromic population appears to be 6 to 9 months of age. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Pediatric Orbital Floor Fractures: Outcome Analysis of 72 Children with Orbital Floor Fractures.

Background: Orbital floor fractures are uncommon in the pediatric population. The aim of this study was to review the presentation, management, and outcomes for children with these injuries. Methods: A retrospective review was performed on 72 consecutive children with orbital floor fractures over a 21-year period. Results: Seventy-two patients with 76 fractures were identified. Mean follow-up time was 14.2 ± 4 months. The majority (50 percent) of patients suffered minimally displaced fractures, whereas 17 percent (13 of 76) suffered blowout fractures and 5 percent (four of 76) suffered trapdoor fractures. Nineteen percent of children (14 of 72) presented with decreased visual acuity and 8 percent (six of 72) had enophthalmos on presentation. Thirty-three percent (24 of 72) underwent surgery. The most common indications for surgery were size of the fracture, followed by muscle entrapment. Fracture width and the defect width–to–orbital width ratios were significantly greater in the operative cohort versus their conservatively managed counterparts (20.7 mm versus 7.7 mm, p < 0.05, and 0.54 versus 0.32, p < 0.05, respectively). Surgery was not associated with improved visual outcomes (p < 0.05). However, patients who underwent reconstruction had a significantly lower adjusted risk of enophthalmos on follow-up (relative risk, 0.02; 95 percent CI, 0.00 to 0.49; p < 0.05). Conclusions: Operative intervention prevents enophthalmos in pediatric patients with pediatric orbital floor fractures, and patients who present with decreased visual acuity should be cautioned that surgical intervention does not improve visual outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Facial fractures of the upper craniofacial skeleton predict mortality and occult intracranial injury after blunt trauma: an analysis

Purpose The aim of this article was to assess how regional facial fracture patterns predict mortality and occult intracranial injury after blunt trauma. Methods Retrospective chart review was performed for blunt-mechanism craniofacial fracture patients who presented to an urban trauma center from 1998 to 2010. Fractures were confirmed by author review of computed tomographic imaging and then grouped into 1 of 5 patterns of regional involvement representing all possible permutations of facial-third injury. Mortality and the presence of occult intracranial injury, defined as those occurring in patients at low risk at presentation for head injury by Canadian CT Head Rule criteria, were evaluated. Relative risk estimates were obtained using multivariable regression. Results Of 4540 patients identified, 338 (7.4%) died, and 171 (8.1%) had intracranial injury despite normal Glasgow Coma Scale at presentation. Cumulative mortality reached 18.8% for isolated upper face fractures, compared with 6.9% and 4.0% for middle and lower face fractures (P < 0.001), respectively. Upper face fractures were independently associated with 4.06-, 3.46-, and 3.59-fold increased risk of death for the following fracture patterns: isolated upper, combined upper, panfacial, respectively (P < 0.001). Patients who were at low risk for head injury remained 4 to 6 times more likely to suffer an occult intracranial injury if they had involvement of the upper face. Conclusions The association between facial fractures, intracranial injury, and death varies by regional involvement, with increasing insult in those with upper face fractures. Cognizance of the increased risk for intracranial injury in patients with upper face fractures may supplement existing triage tools and should increase suspicion for underlying or impending neuropathology, regardless of clinical picture at presentation.

Defining Population-Specific Craniofacial Fracture Patterns and Resource Use in Geriatric Patients: A Comparative Study of Blunt Craniofacial Fractures in Geriatric versus Nongeriatric Adult Patients.

Background: This study investigates the hypothesis that mechanisms of injury, fracture patterns, and burden to the health care system differ between geriatric and nongeriatric populations sustaining blunt-force craniofacial trauma. Methods: A 5-year retrospective chart review of patient records and computed tomographic imaging was performed. Demographic and outcome data were extracted for equally numbered samples of blunt-mechanism facial fracture patients aged 60 years or older (geriatric), and adult patients aged 18 to 59 years (adult nongeriatric). Comparisons were made between these two populations using t tests and multivariable logistic regression. Results: One thousand eighty-seven geriatric and 1087 nongeriatric patients were included. Geriatric patients were significantly more likely to be Caucasian, female, and have sustained fractures as the result of falling. They also had significantly longer hospital stays, were more likely to die, and were more likely to be discharged to home with services. Mandible fractures and panfacial fractures were significantly more common in the nongeriatric population. Geriatric age was associated with doubled length of hospitalization for patients with midface fractures. Logistic regression revealed that significantly higher incidences of orbital floor, maxillary, and condylar fractures in geriatric patients were dependent on geriatric age status, rather than mechanism of injury alone. Conclusions: Resource allocation for geriatric patients with craniofacial trauma should differ from that of their nongeriatric adult counterparts, with more resources allocated to supportive care during hospitalization and assistive care after discharge. The authors’ data indicate that structural and biological changes in the craniofacial skeleton contribute to differences in fracture location independent of mechanism of injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Extracapsular mandibular condyle fractures are associated with severe blunt internal carotid artery injury: Analysis of 605 patients

Background: Mandibular condyle fractures are common following facial trauma and carry an increased risk for concomitant blunt carotid artery injuries. Further elucidation of this relationship may improve vascular injury screening and management. Methods: A retrospective cohort study was performed for all patients sustaining condylar fractures presenting to a large trauma center over twelve years. Fracture locations were classified according to the Strasbourg Osteosynthesis Research Group (1, condylar head; 2, condylar neck; and 3, extracapsular condylar base). Carotid artery injury severity was based on the Biffl scale. Severe vascular injury was defined as a Biffl score greater than I. Results: 605 patients were identified with mandibular condyle fractures consisting of 21.0 percent (n = 127) condylar head; 26.8 percent (n = 162) condylar neck; and 52.2 percent (n = 316) extracapsular condylar base. The incidence of vascular injuries in this population was 5.5 percent (n = 33), of which 75.8 percent (n = 25) were severe. Severe vascular injuries occurred in 1.6 percent (n = 2) of condylar head, 2.5 percent (n = 4) of condylar neck, and 6.0 percent (n = 19) of extracapsular condylar base fractures (p < 0.05). Extracapsular condylar base fractures were independently associated with a 2.94-fold increased risk of a severe blunt carotid artery injury compared with other condyle fractures on multivariable analysis (p < 0.05). Conclusions: Extracapsular subcondylar fractures should heighten suspicion for concomitant blunt carotid artery injury. The data support a force transmission mechanism of injury in addition to direct injury from bony fragments. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Risk, II.

Patient-Reported Assessment of Functional Gait Outcomes following Superior Gluteal Artery Perforator Reconstruction.

Background: Harvesting the superior gluteal artery perforator (SGAP) flap involves dissection of vessels through the gluteal muscle, potentially compromising gait and ambulation. We compared patient-reported gait and ambulation problems between SGAP flap and deep inferior epigastric perforator (DIEP) flap reconstructions. Methods: Forty-three patients who underwent bilateral free flap breast reconstruction (17 SGAP, 26 DIEP) participated in the study. The Lower Extremity Functional Score (LEFS) was administered with a supplementary section evaluating gait, balance, fatigue, and pain. Patients evaluated how they felt 2 months postoperatively and at time of survey administration. Multivariate regressions were fit to assess association between type of reconstruction and self-reported lower extremity function controlling for potential confounding factors. Results: Although there was no significant difference in overall LEFS between the cohorts on the date of survey, the SGAP patients reported greater difficulty performing the following activities after surgery (P < 0.05): work, usual hobbies, squatting, walking a mile, walking up stairs, sitting for an hour, running, turning, and hopping. The SGAP patients also reported easier fatigue (P < 0.01) both during the early postoperative period and on the date of survey. Conclusions: SGAP flap surgery causes no statistically significant differences in overall LEFS. However, SGAP patients did report donor-site morbidity with decreased ability to perform certain activities and increased fatigue and pain in the longer follow-up period. We feel that patients should be educated regarding gait issues and undergo physical therapy during the early postoperative period.

Abstract 84: fractures of the mandibular condylar base are associated with severe blunt internal carotid artery injuries.

Neil M Vranis, BA1; Gerhard S Mundinger, MD2; Justin L Bellamy, BS3; Abhishake Banda, MD, DDS2; Robin Yang, MD, DDS2; Amir H Dorafshar, MBChB2; Eduardo D Rodriguez, MD, DDS2 1University of Maryland School of Medicine, Baltimore, MD, Division of Plastic, Reconstructive and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, The Johns Hopkins University School of Medicine, Baltimore, MD