Outcome and complications after treatment of facial fractures at different times in polytrauma patients

Time to wound closure in facial soft tissue injuries following road traffic accidents

The 6-hour (6-h) time to wound closure was a controversial issue as studies have shown that time was not a substantial factor. Wounds in the face are often considered to have a lower infection risk. Despite this, the cause of injury was not extensively discussed in relation to this context. The primary objective was to investigate the association between the 6-h time to wound closure and wound complications following emergency management of facial soft tissue injuries (STIs). Additionally, the secondary objective was to explore other factors contributing to wound complications. A retrospective record review was conducted in our hospital in Kuala Lumpur, Malaysia, from 1 January 2017 to 31 December 2021. Medical records of patients with facial STIs due to road traffic accidents were included. Simple random sampling was used to select records meeting inclusion criteria. Data on demographic, injury, and treatment characteristics were collected using a standardized proforma. Descriptive, univariate and multivariate analyses were performed, including chi-square tests and binary logistic regression. A total of 295 patient records were included, with most patients being males (77.3%) and of Malay ethnicity (54.9%). The median age was 31.0 years. Majority of patients were treated within 6 h of injury (93.9%). Complications were documented in 6.1% of cases, including wound dehiscence and infection. Multivariate analysis revealed a significant association between 6-h time to closure and wound complications (OR: 7.53, 95% CI: 1.90-29.81, p = 0.004). Grade of surgeon on duty (OR: 4.61, 95% CI: 1.25-16.95, p = 0.02) and diabetes mellitus (OR: 6.12, 95% CI: 1.23-30.38, p = 0.03) were also shown to have a statistically significant association with wound complications. A 6-h time to wound closure, grade of surgeon on duty and diabetes mellitus were three major factors involved in facial wound complications following road traffic accidents.

Evaluation of Different Patterns of Zygomaticoorbital Complex Fractures

Study Design

Very few studies exist regarding the fracture pattern variability of the zygomaticoorbital (ZMO) complex. The retrospective evaluation of a large series of surgically treated unilateral ZMO fractures would in certain circumstances help intraoperative predictability and define sensitive indicators for open reduction and internal fixation.

Objective

The aim of this study was to investigate the different fracture patterns after ZMO complex injury regarding the 5 anatomic sutures of the zygoma as well as the concomitance of the paranasal buttress and maxillary sinus wall fracture.

Methods

The medical records of all patients with unilateral ZMO fractures who underwent surgical intervention in a single trauma center department between April 2015 and June 2020 were retrospectively reviewed. Demographic and anamnesis data, radiologic findings, and surgical reports were evaluated. According to the preoperative radiologic evaluation, ZMO fractures were classified as unisutural, bisutural, trisutural, tetrasutural, and complete based on the number of zygomatic sutures. The prevalence of various fracture patterns was analyzed. The impact of patient's age and trauma etiology on the fracture pattern was evaluated using descriptive statistical analysis.

Results

The study included 492 patients with unilateral ZMO fractures, with a mean age of 49.93 years (SD = 20.66) and a male:female ratio of 2.23:1. The most affected age group was 19-44 years (41.67%) and tripping falls were the most common etiology (27.24%). Trisutural (57.32%) and unisutural fractures (23.17%) were the most common, followed by tetrasutural (8.94%), bisutural (8.54%), and complete fractures (2.03%). A trisutural fracture involving the zygomaticomaxillary suture, the infraorbital rim, and the zygomaticosphenoidal suture was the most common fracture pattern (52.03%). Most fractures were observed in the zygomaticosphenoidal suture (86.99%), followed by the infraorbital rim (74.59%) and the zygomaticomaxillary suture (68.29%). Fractures of the maxillary sinus wall and the paranasal buttress co-existed in 9.55% and 31.30% of all cases, respectively. No correlation was detected between age and fracture pattern (P = .4111). Tripping falls and bicycle accidents significantly influenced the fracture pattern (P < .0001).

Conclusions

According to the results, knowledge of the fracture pattern variability of the ZMO complex could in certain circumstances designate CT or CBCT as mandatory before operating on ZMO fractures. Consequently, unnecessary incisions could be avoided. The high concomitance of paranasal buttress fracture also suggests its intraoperative surgical exploration. Further studies should correlate the clinical findings with indication for surgery and postoperative outcome for the different fracture patterns described.

Development of a new critical size defect model in the paranasal sinus and first approach for defect reconstruction-An in vivo maxillary bone defect study in sheep

Fractures of the paranasal sinuses often require surgical intervention. Persisting bone defects lead to permanent visible deformities of the facial contours. Bone substitutes for reconstruction of defects with simultaneous induction of new bone formation are not commercially available for the paranasal sinus. New materials are urgently needed and have to be tested in their future area of application. For this purpose critical size defect models for the paranasal sinus have to be developed. A ≥2.4 cm large bilateral circular defect was created in the anterior wall of the maxillary sinus in six sheep via an extraoral approach. The defect was filled with two types of an osteoconductive titanium scaffold (empty scaffold vs. scaffold filled with a calcium phosphate bone cement paste) or covered with a titanium mesh either. Sheep were euthanized after four months. All animals performed well, no postoperative complications occured. Meshes and scaffolds were safely covered with soft tissue at the end of the study. The initial defect size of ≥2.4 cm only shrunk minimally during the investigation period confirming a critical size defect. No ingrowth of bone into any of the scaffolds was observed. The anterior wall of the maxillary sinus is a region with low complication rate for performing critical size defect experiments in sheep. We recommend this region for experiments with future scaffold materials whose intended use is not only limited to the paranasal sinus, as the defect is challenging even for bone graft substitutes with proven osteoconductivity. Graphical abstract.

Aspirin, heparin and ischemia time in microvascular free flap surgery - their influence and an optimal anticoagulation protocol

BACKGROUND

Microvascular surgery has become a standardized technique for reconstruction of large tissue defects in Head and Neck Reconstructive Surgery. However, the main dreaded complications are thrombosis of blood vessels or major bleeding after surgery. Several different anticoagulation protocols have been established in the last decades to overcome these problems with varying degrees of success.

METHODS

Over a period of six years, a standardized anticoagulation protocol including acetylsalicylic acid (ASA) and unfractionated heparin (UFH) for direct intraoperative and postoperative administration was established, optimized and compared to a previously used non-standardized protocol. A total of 178 flap surgeries were included in the development and optimization process of the protocol.

RESULTS

ASA significantly increased the risk of complications when used for longer than 72 h (OR = 2.52; p = 0.002; 95% CI 1.39-4.59). Administration of UFH reduced flap loss (bolus: OR 0.68; p = 0.47; 95% CI 0.24-1.93; continuous UFH administration: OR = 0.61; p = 0.33; 95% CI 0.22-1.66), however doses greater than 500 IU/ h of UFH as continuous infusion increased the risk of complications. Reduction in ischemia time had no effect on the occurrence of complications.

CONCLUSION

Anticoagulation regimes in microvascular surgery can influence the postoperative complication rate. The optimal protocol should consist of a combination of ASA and UFH for the intraoperative and direct postoperative phase. Prolonged administration of ASA as well as doses &gt;500 IU/ h of UFH are to be avoided due to the increased complication rate.

Feasibility of Implant Strain Measurement for Assessing Mandible Bone Regeneration

Nonunion is one of the most dreaded complications after operative treatment of mandible fractures or after mandible reconstruction using vascularized and non-vascularized bone grafts. Often diagnosis is made at advanced stage of disease when pain or complications occur. Devices that monitor fracture healing and bone regeneration continuously are therefore urgently needed in the craniomaxillofacial area. One promising approach is the strain measurement of plates. An advanced prototype of an implantable strain measurement device was tested after fixation to a locking mandible reconstruction plate in multiple compression experiments to investigate the potential functionality of strain measurement in the mandibular region. Compression experiments show that strain measurement devices work well under experimental conditions in the mandibular angle and detect plate deformation in a reliable way. For monitoring in the mandibular body, the device used in its current configuration was not suitable. Implant strain measurement of reconstruction plates is a promising methodical approach for permanent monitoring of bone regeneration and fracture healing in the mandible. The method helps to avoid or detect complications at an early point in time after operative treatment.

Factors associated with delays in medical and surgical open facial fracture management

Objectives

Open fractures are at risk of infection because of exposure of bone and tissue to the environment. Facial fractures are often accompanied by other severe injuries, and therefore fracture management may be delayed until after stabilization. Previous studies in this area have examined timing of multiple facets of care but have tended to report on each in isolation (eg, antibiotic initiation).

Methods

This was a retrospective study of adult patients admitted to five trauma centers from January 1, 2017 to March 31, 2021 with open facial fractures. Variables collected included demographics, injury mechanism, details on facial and non-facial injuries, facial fracture management (irrigation and debridement (I&D), irrigation without debridement, open reduction internal fixation (ORIF), antibiotics), and other hospital events. The study hypothesized that the presence of serious non-facial injuries would be associated with delays in facial fracture management. The primary aims were to describe open facial fracture management practices and examine factors associated with early versus delayed fracture management. A secondary aim was to describe infection rates. Early treatment was defined as within 24 hours of arrival for I&D, irrigation without debridement, and ORIF and within 1 hour for antibiotics.

Results

A total of 256 patients were included. Twenty-seven percent had major trauma (Injury Severity Score ≥16). The presence of serious head injury/traumatic brain injury was associated with delayed I&D (OR_early=0.04, p<0.01), irrigation without debridement (OR_early=0.09, p<0.01), and ORIF (OR_early=0.10, p<0.01). Going to the OR within 24 hours was associated with early I&D (OR_early=377.26, p<0.01), irrigation without debridement (OR_early=13.54, p<0.01), and ORIF (OR_early=154.92, p<0.01). The infection rate was 4%.

Conclusions

In this examination of multiple aspects of open facial fracture management, serious injuries to non-facial regions led to delays in surgical fracture management, consistent with the study hypothesis.

Level of evidence

Level III, prognostic/epidemiological.

Inpatient Versus Outpatient Operative Management of Isolated Facial Fractures

BACKGROUND

Patients with isolated facial fractures requiring operative fixation can be managed on an inpatient or outpatient basis. The goal of this study was to compare the safety of each approach using a large multi-institutional database.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Project was reviewed for facial fractures between 2005 and 2018. Groups were identified using inpatient and outpatient status as designated in the database. Patients who required additional procedures, concurrent procedures, or other emergency procedures were excluded. Descriptive statistics were used for group comparisons and logistic regression models were used to identify risk factors for complications.

RESULTS

We identified 3350 patients who underwent operative fixation of isolated facial fractures. The majority of these cases (70.3%) were done on an outpatient basis. Compared to those in the outpatient group, patients in the inpatient group were older, had more medical comorbidities, had higher wound class, and had higher American Society of Anesthesiologists class. Complication (6.3% versus 2.3%), reoperation (4.3% versus 1.7%), and readmission (6.9% versus 2.5%) rates were all higher in the inpatient group (P < 0.01). By logistic regression analysis, the odds ratios for complications, reoperation, and readmission were higher in the inpatient group. After adjusting for imbalanced preoperative patient characteristics, the increased risk of complications in the inpatient group persisted [odds ratio (OR) = 1.9, confidence interval (CI) 1.2-3.0, P = 0.01] while the risk of reoperation (OR = 1.7, CI 1.0-2.9, P = 0.08) and risk of readmission (OR = 1.4, CI 0.7-2.6, P = 0.33) no longer showed statistical significance between the inpatient and outpatient groups.

CONCLUSIONS

Inpatient operative management of isolated facial fractures is associated with an almost 2-fold increased risk of complications, though no increased risk of reoperation or readmission.

National Disparities in Insurance Coverage of Comprehensive Craniomaxillofacial Trauma Care

Background:

Comprehensive craniomaxillofacial trauma care includes correcting functional deficits, addressing acquired deformities and appearance, and providing psychosocial support. The aim of this study was to characterize insurance coverage of surgical, medical, and psychosocial services indicated for longitudinal facial trauma care and highlight national discrepancies in policy.

Methods:

A cross-sectional analysis of insurance coverage was performed for treatment of common functional, appearance, and psychosocial facial trauma sequelae. Policies were scored for coverage (3), case-by-case coverage (2), no mention (1), and exclusion (0). The sum of points determined coverage scores for functional sequelae, acquired-appearance sequelae, and psychosocial sequelae, the sum of which generated a Comprehensive Coverage Score.

Results:

Medicaid earned lower comprehensive coverage scores and lower coverage scores for psychosocial sequelae than did private insurance (P = 0.02, P = 0.02). Medicaid CCSs were lowest in Oklahoma, Arkansas, and Missouri. Private insurance CCSs and psychosocial sequelae were highest in Colorado and Delaware, and lowest in Wisconsin. Coverage scores for functional sequelae and for acquired-appearance sequelae were similar for Medicaid and private policies. Medicaid coverage scores were higher in states that opted into Medicaid expansion (P = 0.04), states with Democrat governors (P = 0.02), states with mandated paid leave (P = 0.01), and states with >40% total population living >400% above federal poverty (P = 0.03). Medicaid comprehensive coverage scores and coverage scores for psychosocial sequelae were lower in southeastern states. Private insurance coverage scores for functional sequelae and for ASCSs were lower in the Midwest.

Conclusions:

Insurance disparities in comprehensive craniomaxillofacial care coverage exist, particularly for psychosocial services. The disparities correlate with current state-level geopolitics. There is a uniform need to address national and state-specific differences in coverage from both Medicaid and private insurance policies.

Sequencing of Fixation in Panfacial Fracture: A Systematic Review

Objective

In panfacial fracture management, the controversy still exists in the sequencing of fixation. The purpose of this systematic review is to establish the best sequence pattern which assists in achieving definite facial width, vertical height and anteroposterior projection.

Methods

The review was conducted according to the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) guidelines. Two independent authors performed a comprehensive search of the PUBMED, EBSCO, J-Gate, SCOPUS and NDH for articles published up until December 2018. Sequence of fixation, timing of intervention, outcome, follow-up period and complications were evaluated for patients with panfacial fracture.

Results

In total, 202 articles were identified from the databases. After screening and full text analysis, 25 studies were included in this systematic review. Nineteen studies reported bottom-to-top sequence and two studies reported top-to-bottom approach. However, four studies reported both the approaches. The follow-up period ranges from 3 weeks to 4 years.

Conclusion

Based on the literature support and evidence, good and satisfactory outcome achieved in "Bottom-top and outside-in" sequence when compared with other sequence pattern. Early repair of panfacial fracture is advised for proper reduction and fixation, but can be delayed in accompanying life-threatening injuries. Complications are perceptible in all the sequences; it can be avoided by definitive treatment planning and stepwise management.

Treatment of Facial Fractures at a Level 1 Trauma Center: Do Medicaid and Non-Medicaid Enrollees Receive the Same Care?

BACKGROUND

Timing of surgical treatment of facial fractures may vary with the patient age, injury type, and presence of polytrauma. Previous studies using national data sets have suggested that trauma patients with government insurance experience fewer operations, longer length of hospital stay (LOS), and worse outcomes compared with privately insured patients. The objective of this study is to compare treatment of facial fractures in patients with and without Medicaid insurance (excluding Medicare).

METHODS

All adults with mandibular, orbital, and midface fractures at a Level 1 Trauma Center between 2009 and 2018 were included. Statistical analyses were performed to assess the differences in the frequency of surgery, time to surgery (TTS), LOS, and mortality based on insurance type.

RESULTS

The sample included 1541 patients with facial fractures (mandible, midface, orbital), of whom 78.8% were male, and 13.1% (208) were enrolled in Medicaid. Mechanism of injury was predominantly assault for Medicaid enrollees and falls or motor vehicle accidents for non-Medicaid enrollees (P < 0.001). Patients with mandible and midface fractures underwent similar rates of surgical repair. Medicaid enrollees with orbital fractures underwent less frequent surgery for facial fractures (24.8% versus 34.7%, P = 0.0443) and had higher rates of alcohol and drug intoxication compared with non-Medicaid enrollees (42.8% versus 31.6%, P = 0.008). TTS, LOS, and mortality were similar in both groups with facial fractures.

CONCLUSIONS

Overall, the treatment of facial fractures was similar regardless of the insurance type, but Medicaid enrollees with orbital fractures experienced less frequent surgery for facial fractures. Further studies are needed to identify specific socioeconomic and geographic factors contributing to these disparities in care.

Maxillofacial injuries in severely injured patients after road traffic accidents-a retrospective evaluation of the TraumaRegister DGU® 1993-2014

Objectives

It was the aim of the study to analyse the prevalence of maxillofacial trauma (MFT) in severely injured patients after road traffic accidence (RTA) and to investigate associated factors.

Materials and methods

In a retrospective study, data from patients after RTA by the TraumaRegister DGU® from 1993 to 2014 were evaluated for demographical and injury characteristics. The predictor variable was mechanism of injury and the outcome variables were type of injury, severity and hospital resources utilization.

Results

During the investigation period, n = 62,196 patients were enclosed with a prevalence of maxillofacial injuries of 20.3% (MFT positive). The injury severity score of MFT-positive patients was higher than in the MTF-negative subgroup (27 ± 12.8 vs. 23.0 ± 12.7). If MFT positive, 39.8% show minor, 37.1% moderate, 21.5% serious and 1.6% severe maxillofacial injuries. Injuries of the midface occurred in 60.3% of MTF-positive patients. A relevant blood loss (> 20% of total blood volume) occurred in 1.9%. MFT-positive patients had a higher coincidence with cervical spine fractures (11.3% vs. 7.8%) and traumatic brain injuries (62.6% vs. 34.8%) than MFT-negative patients. There was a noticeable decrease in the incidence of facial injuries in car/truck drivers during the study period.

Conclusions

Every 5th patient after RTA shows a MFT and the whole trauma team must be aware that this indicates a high prevalence of traumatic brain and cervical spine injuries.

Clinical relevance

Even if sole injuries of the face are seldom life threatening, maxillofacial expertise in interdisciplinary trauma centres is strongly recommended.

[Frequency and management of complex facial fractures-an oral and maxillofacial surgical assessment]

INTRODUCTION

The treatment of facial fractures is an integral part of the oral and maxillofacial surgical treatment spectrum. In the case of complex fractures that involve multiple levels of the facial skeleton associated with severe concomitant injuries, an individual and interdisciplinary treatment approach is needed, which requires the infrastructure of a national trauma center.

OBJECTIVE

The aim of this study was to analyze the incidence and management of patients with complex facial fractures and considering the concomitant injury pattern.

MATERIAL AND METHODS

A retrospective analysis of patients with complex facial fractures during the years 2009-2015 admitted to the emergency surgical department of a national trauma center was carried out. The identification of appropriate patient cases was based on the International Statistical Classification of Diseases and Related Health Problems (ICD) coding of electronic patient data. Only patients with at least a combination of mandibular and midfacial fractures (2-level fractures) were considered. Patients with mainly dentoalveolar fractures and simple nasal bone fractures were not included. The evaluation of the electronic medical records included the etiology, fracture pattern, associated severe injuries on the basis of the injury severity score (ISS), treatment regimen as well as the length of the hospital stay.

RESULTS

In the 7‑year study period, 3382 patients were identified with facial fractures. Of these, 128 patients (3.78%) presented with a complex fracture pattern with a combination of mandibular fractures and fractures of the midface. The majority of these patients (n = 92) had less severe concomitant injuries (ISS ≤ 16), while 36 patients showed severe concomitant injuries (ISS > 16). The incidence of a 3-level fracture involving the mandible, midface and anterior skull base was only 0.47% and could be detected in 16 patients, of which 10 were classified as polytrauma (ISS > 16).

CONCLUSION

The incidence of complex fractures of the facial skeleton was comparatively low with almost 4%. More than one in four patients with complex injury patterns of the facial skeleton exhibited severe concomitant life-threatening injuries, necessitating an interdisciplinary management with the specialized infrastructure of a nationwide trauma center.