Publications by authors named "Michael P Grant"

72 Publications

Resolution of Vertical Gaze Following a Delayed Presentation of Orbital Floor Fracture With Inferior Rectus Entrapment: The Contributions of Charles E. Iliff and Joseph S. Gruss in Orbital Surgery.

Craniomaxillofac Trauma Reconstr 2020 Dec 18;13(4):253-259. Epub 2020 Nov 18.

Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.

Introduction: Orbital floor fractures occur commonly as a result of blunt trauma to the face and periorbital region. Orbital floor fractures with a "trapdoor" component allow both herniation and incarceration of contents through a bone defect into the maxillary sinus as the bone rebounds faster than the soft tissue, trapping muscle, fat, and fascia in the fracture site. In children, the fractured floor, which is often hinged on one side, tends to return toward its original anatomical position due to the incomplete nature of the fracture and elasticity of the bone. The entrapment of the inferior rectus muscle itself is considered a true surgical emergency-prolonged entrapment frequently leads to muscle ischemia and necrosis leading to permanent limitation of extraocular motility and difficult to correct diplopia. For this reason, prompt surgical intervention is recommended by most surgeons. In adults, true entrapment of the muscle itself is not as common because the orbital floor is not as elastic and fractures are more complete.

Methods: We present an adult patient with an isolated orbital floor fracture with clinical and radiologic evidence of true entrapment of the inferior rectus muscle itself.

Results: Despite the delayed surgical repair (4 days after the injury), the patient's inferior rectus muscle function returned to near normal with mild upward gaze diplopia.

Conclusions: Inferior rectus entrapment in adults may more likely be associated with immobilization of the muscle without total vascular compression/incarceration significant enough to lead to complete ischemic necrosis.
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http://dx.doi.org/10.1177/1943387520965804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797985PMC
December 2020

Surgical Treatment and Visual Outcomes of Adult Orbital Roof Fractures.

Plast Reconstr Surg 2021 Jan;147(1):82e-93e

From the Division of Plastic, Reconstructive, and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center; the Department of Plastic and Reconstructive Surgery, Johns Hopkins University; and the Division of Plastic and Reconstructive Surgery, University of Maryland School of Medicine.

Background: Fractures of the orbital roof require high-energy trauma and have been linked to high rates of neurologic and ocular complications. However, there is a paucity of literature exploring the association between injury, management, and visual prognosis.

Methods: The authors performed a 3-year retrospective review of orbital roof fracture admissions to a Level I trauma center. Fracture displacement, comminution, and frontobasal type were ascertained from computed tomographic images. Pretreatment characteristics of operative orbital roof fractures were compared to those of nonoperative fractures. Risk factors for ophthalmologic complications were assessed using univariable/multivariable regression analyses.

Results: In total, 225 patients fulfilled the inclusion criteria. Fractures were most commonly nondisplaced [n = 118 (52.4 percent)] and/or of type II frontobasal pattern (linear vault involving) [n = 100 (48.5 percent)]. Eight patients underwent open reduction and internal fixation of their orbital roof fractures (14.0 percent of displaced fractures). All repairs took place within 10 days from injury. Traumatic optic neuropathy [n = 19 (12.3 percent)] and retrobulbar hematoma [n = 11 (7.1 percent)] were the most common ophthalmologic complications, and led to long-term visual impairment in 51.6 percent of cases.

Conclusions: Most orbital roof fractures can be managed conservatively, with no patients in this cohort incurring long-term fracture-related complications or returning for secondary treatment. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm2. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000007436DOI Listing
January 2021

Tungsten Increases Sex-Specific Osteoclast Differentiation in Murine Bone.

Toxicol Sci 2021 Jan;179(1):135-146

Division of Experimental Medicine, McGill University, Montreal, Quebec H4A 3J1, Canada.

Tungsten is a naturally occurring metal that is increasingly used in industry and medical devices, and is labeled as an emerging environmental contaminant. Like many metals, tungsten accumulates in bone. Our previous data indicate that tungsten decreases differentiation of osteoblasts, bone-forming cells. Herein, we explored the impact of tungsten on osteoclast differentiation, which function in bone resorption. We observed significantly elevated osteoclast numbers in the trabecular bone of femurs following oral exposure to tungsten in male, but not female mice. In order to explore the mechanism(s) by which tungsten increases osteoclast number, we utilized in vitro murine primary and cell line pre-osteoclast models. Although tungsten did not alter the adhesion of osteoclasts to the extracellular matrix protein, vitronectin, we did observe that tungsten enhanced RANKL-induced differentiation into tartrate-resistant acid phosphatase (TRAP)-positive mononucleated osteoclasts. Importantly, tungsten alone had no effect on differentiation or on the number of multinucleated TRAP-positive osteoclasts. Enhanced RANKL-induced differentiation correlated with increased gene expression of differentiated osteoclast markers Nfatc1, Acp5, and Ctsk. Although tungsten did not alter the RANK surface receptor expression, it did modulate its downstream signaling. Co-exposure of tungsten and RANKL resulted in sustained positive p38 signaling. These findings demonstrate that tungsten enhances sex-specific osteoclast differentiation, and together with previous findings of decreased osteoblastogenesis, implicate tungsten as a modulator of bone homeostasis.
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http://dx.doi.org/10.1093/toxsci/kfaa165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797767PMC
January 2021

The Prevalence of Blood-Borne Pathogens in Maxillofacial Trauma Patients.

J Craniofac Surg 2020 Nov/Dec;31(8):2285-2288

Division of Plastic, Reconstructive, and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center.

Background: Blood-borne pathogen infections (BPIs), caused by the human immunodeficiency virus, hepatitis C and hepatitis B viruses pose an occupational hazard to healthcare workers. Facial trauma reconstruction surgeons may be at elevated risk because of routine use of sharps, and a higher than average incidence of BPIs in the trauma patient population.

Methods: The authors retrospectively reviewed health records of patients admitted to a level 1 trauma center with a facial fracture between January 2010 and December 2015. Patient demographics, medical history, mechanism of injury, type of fracture, and procedures performed were documented. The authors detemined the frequency of human immunodeficiency virus, hepatitis B, and hepatitis C diagnosis and utilized univariable/multivariable analyses to identify risk factors associated with infection in this population.

Results: In total, 4608 consecutive patients were included. Infections were found in 4.8% (n = 219) of patients (human immunodeficiency virus 1.6%, hepatitis C 3.3%, hepatitis B 0.8%). 76.3% of BPI patients in this cohort were identified by medical history, while 23.7% were diagnosed by serology following initiation of care. 39.0% of all patients received surgical treatment during initial hospitalization, of whom 4.3% had a diagnosed BPI. History of intravenous drug use (odds ratio [OR] 6.79, P < 0.001), assault-related injury (OR 1.61, P = 0.003), positive toxicology screen (OR 1.56, P = 0.004), and male gender (OR 1.53, P = 0.037) were significantly associated with a BPI diagnosis.

Conclusion: Patients presenting with facial fractures commonly harbor a BPI. The benefit of early diagnosis and risk to surgical staff may justify routine screening for BPI in high risk facial trauma patients (male, assault-related injury, and history of intravenous drug use).
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http://dx.doi.org/10.1097/SCS.0000000000006897DOI Listing
November 2020

COVID-19 Outbreak Among Employees at a Meat Processing Facility - South Dakota, March-April 2020.

MMWR Morb Mortal Wkly Rep 2020 Aug 7;69(31):1015-1019. Epub 2020 Aug 7.

On March 24, 2020, the South Dakota Department of Health (SDDOH) was notified of a case of coronavirus disease 2019 (COVID-19) in an employee at a meat processing facility (facility A) and initiated an investigation to isolate the employee and identify and quarantine contacts. On April 2, when 19 cases had been confirmed among facility A employees, enhanced testing for SARS-CoV-2, the virus that causes COVID-19, was implemented, so that any employee with a COVID-19-compatible sign or symptom (e.g., fever, cough, or shortness of breath) could receive a test from a local health care facility. By April 11, 369 COVID-19 cases had been confirmed among facility A employees; on April 12, facility A began a phased closure* and did not reopen during the period of investigation (March 16-April 25, 2020). At the request of SDDOH, a CDC team arrived on April 15 to assist with the investigation. During March 16-April 25, a total of 929 (25.6%) laboratory-confirmed COVID-19 cases were diagnosed among 3,635 facility A employees. At the outbreak's peak, an average of 67 cases per day occurred. An additional 210 (8.7%) cases were identified among 2,403 contacts of employees with diagnosed COVID-19. Overall, 48 COVID-19 patients were hospitalized, including 39 employees and nine contacts. Two employees died; no contacts died. Attack rates were highest among department-groups where employees tended to work in proximity (i.e., <6 feet [2 meters]) to one another on the production line. Cases among employees and their contacts declined to approximately 10 per day within 7 days of facility closure. SARS-CoV-2 can spread rapidly in meat processing facilities because of the close proximity of workstations and prolonged contact between employees (1,2). Facilities can reduce this risk by implementing a robust mitigation program, including engineering and administrative controls, consistent with published guidelines (1).
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http://dx.doi.org/10.15585/mmwr.mm6931a2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454899PMC
August 2020

Low-Dose Computed Tomographic Scans for Postoperative Evaluation of Craniomaxillofacial Fractures: A Pilot Clinical Study.

Plast Reconstr Surg 2020 08;146(2):366-370

From the Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital School of Medicine; the Department of Surgery, George Washington University; Trauma and Emergency Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center; the Division of Plastic and Reconstructive Surgery, University of Maryland School of Medicine; and the Division of Plastic, Reconstructive, and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center.

Computed tomographic scans are frequently obtained following craniomaxillofacial fracture reconstruction. The additive radiation from such scans is not trivial; cumulative radiation exposure poses stochastic health risks. In this article, the authors postulate that a low-dose computed tomography protocol provides adequate image quality for postoperative evaluation of reconstructed craniomaxillofacial fractures. This study included patients for whom a computed tomographic scan was indicated following craniomaxillofacial fracture repair at a Level I trauma center. Postoperative craniomaxillofacial computed tomography was performed using a low-dose protocol, rather than standard protocols. A craniomaxillofacial surgeon and a radiologist interpreted the images to determine whether they were of sufficient quality. It was decided a priori that any inadequate low-dose computed tomography would require repeated scanning using standard protocols. The primary endpoint was the need for repeated computed tomography. In addition, the clarity of clinically significant anatomical landmarks on the images was graded on a five-point Likert scale. Twenty patients were scanned postoperatively using the low-dose protocol. Mean radiation dose (total dose-length product) from the low-dose protocol was 71 mGy · cm versus 532 mGy · cm for the preoperative computed tomographic scans that were obtained using conventional protocols (p < 0.001). All 20 low-dose computed tomographic scans were determined to provide satisfactory image quality. No patients required repeated computed tomography secondary to poor image quality. Low-dose computed tomography received high image-quality scores. A low-dose computed tomography protocol that delivers approximately 7.5-fold less radiation than the standard protocols was found to be adequate for postoperative evaluation of craniomaxillofacial fractures. Larger prospective studies may be warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000007017DOI Listing
August 2020

COVID-19 Among Workers in Meat and Poultry Processing Facilities - 19 States, April 2020.

MMWR Morb Mortal Wkly Rep 2020 May 8;69(18). Epub 2020 May 8.

Congregate work and residential locations are at increased risk for infectious disease transmission including respiratory illness outbreaks. SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is primarily spread person to person through respiratory droplets. Nationwide, the meat and poultry processing industry, an essential component of the U.S. food infrastructure, employs approximately 500,000 persons, many of whom work in proximity to other workers (1). Because of reports of initial cases of COVID-19, in some meat processing facilities, states were asked to provide aggregated data concerning the number of meat and poultry processing facilities affected by COVID-19 and the number of workers with COVID-19 in these facilities, including COVID-19-related deaths. Qualitative data gathered by CDC during on-site and remote assessments were analyzed and summarized. During April 9-27, aggregate data on COVID-19 cases among 115 meat or poultry processing facilities in 19 states were reported to CDC. Among these facilities, COVID-19 was diagnosed in 4,913 (approximately 3%) workers, and 20 COVID-19-related deaths were reported. Facility barriers to effective prevention and control of COVID-19 included difficulty distancing workers at least 6 feet (2 meters) from one another (2) and in implementing COVID-19-specific disinfection guidelines.* Among workers, socioeconomic challenges might contribute to working while feeling ill, particularly if there are management practices such as bonuses that incentivize attendance. Methods to decrease transmission within the facility include worker symptom screening programs, policies to discourage working while experiencing symptoms compatible with COVID-19, and social distancing by workers. Source control measures (e.g., the use of cloth face covers) as well as increased disinfection of high-touch surfaces are also important means of preventing SARS-CoV-2 exposure. Mitigation efforts to reduce transmission in the community should also be considered. Many of these measures might also reduce asymptomatic and presymptomatic transmission (3). Implementation of these public health strategies will help protect workers from COVID-19 in this industry and assist in preserving the critical meat and poultry production infrastructure (4).
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http://dx.doi.org/10.15585/mmwr.mm6918e3DOI Listing
May 2020

Pediatric Frontal Bone and Sinus Fractures: Cause, Characteristics, and a Treatment Algorithm.

Plast Reconstr Surg 2020 04;145(4):1012-1023

From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital; the Rush Medical College of Rush University; and the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center.

Background: The purpose of this study was to assess the incidence, cause, characteristics, presentation, and management of pediatric frontal bone fractures.

Methods: A retrospective cohort review was performed on all patients younger than 15 years with frontal fractures that presented to a single institution from 1998 to 2010. Charts and computed tomographic images were reviewed, and frontal bone fractures were classified into three types based on anatomical fracture characteristics. Fracture cause, patient demographics, management, concomitant injuries, and complications were recorded. Primary outcomes were defined by fracture type and predictors of operative management and length of stay.

Results: A total of 174 patients with frontal bone fractures met the authors' inclusion criteria. The mean age of the patient sample was 7.19 ± 4.27 years. Among these patients, 52, 47, and 75 patients were classified as having type I, II, and III fractures, respectively. A total of 14, 9, and 24 patients with type I, II, and III fractures underwent operative management, respectively. All children with evidence of nasofrontal outflow tract involvement and obstruction underwent cranialization (n = 11).

Conclusions: The authors recommend that type I fractures be managed according to the usual neurosurgical guidelines. Type II fractures can be managed operatively according to the usual pediatric orbital roof and frontal sinus fracture indications (e.g., significantly displaced posterior table fractures with associated neurologic indications). Lastly, type III fractures can be managed operatively as for type I and II indications and for evidence of nasofrontal outflow tract involvement. The authors recommend cranialization in children with nasofrontal outflow tract involvement.

Clinical Question/level Of Evidence: Risk, II.
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http://dx.doi.org/10.1097/PRS.0000000000006645DOI Listing
April 2020

Discussion: Underdiagnosis of Nasoorbitoethmoid Fractures in Patients with Zygoma Injury.

Plast Reconstr Surg 2020 04;145(4):1009-1010

From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital; and R Adams Cowley Shock Trauma Center, University of Maryland Medical Center.

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http://dx.doi.org/10.1097/PRS.0000000000006733DOI Listing
April 2020

Differences in Facial Fracture Patterns in Pediatric Nonaccidental Trauma.

J Craniofac Surg 2020 Jun;31(4):956-959

Division of Plastic and Reconstructive Surgery.

Background: The purpose of this study was to characterize differences in facial fracture injury patterns among pediatric patients at highest risk of abusive head trauma/nonaccidental trauma (age ≤ 5 years).

Methods: Using the National Trauma Databank from 2007 to 2015, patients (age ≤ 5 years) suffering facial fractures were included. Demographics and injury characteristics were compared between those sustaining accidental versus nonaccidental trauma (NAT).

Results: Over 9 years 9741 patients were included with 193 patients (2.0%) suffering NAT. Nonaccidental trauma patients were younger (median [interquartile range]; 0 [0, 2] versus 3 [1, 4], P < 0.001), and more frequently were insured by Medicaid (76.7% versus 41.9%, P < 0.001). NAT patients were more likely to sustain mandible fractures (38.9% versus 21.1%, P < 0.001), but less likely to sustain maxilla (9.8% versus 18.3%, P = 0.003), or orbital fractures (31.1% versus 53.4%, P < 0.001). Nonaccidental trauma patients had fewer instances of multiple facial fracture sites (8.9% versus 22.6%, P < 0.001). Among those sustaining mandible fractures, NAT patients were more likely to sustain condylar fractures (75.8% versus 48.4%, P < 0.001), but less likely to sustain subcondylar fractures (0% versus 13.2%, P = 0.002), or angle fractures (1.6 versus 8.7%, P = 0.048).

Conclusions: Differences exist in facial fracture patterns in accidental versus nonaccidental trauma within the pediatric population at highest risk for abusive head trauma. Specifically, NAT is associated with fractures of the mandibular condyle and involve fewer facial fracture sites. In the appropriate context, presence of these fractures/patterns should increase suspicion for NAT.
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http://dx.doi.org/10.1097/SCS.0000000000006294DOI Listing
June 2020

Orbital Injuries From Self-Inflicted Gunshots: Patterns, Management, and Visual Outcomes.

Ophthalmic Plast Reconstr Surg 2020 Mar/Apr;36(2):152-156

Division of Plastic, Reconstructive & Maxillofacial Surgery, R Adams Cowley Shock Trauma Center.

Purpose: Self-inflicted facial gunshots (SIGSWs) typically result in a spectrum of severe injuries to facial structures, including the orbit and globe. Roughly three-quarters of those who arrive to the hospital will survive their injuries, and recidivism is typically low. Therefore, effective management is paramount to preserve vision, and long-term quality of life. The objective of this study is to characterize the common injuries to the orbit, globe, and periocular structures following SIGSWs, their management, and their eventual visual and reconstructive outcomes.

Methods: Retrospective review of trauma registry records at a Level 1 trauma center for patients who presented alive following SIGSWs involving the globe and/or orbit from 2007 to 2016.

Results: Of the 47 patients who presented with SIGSWs to the orbit, 33 (70%) were discharged alive from the hospital. Management strategies for these patients fell into 3 groups, based on the involved structures: i) Open globe injuries (Type I: n = 12, 34%) ii) Orbital fractures with preserved globe and optic nerve (Type II: n = 15, 43%), and iii) Optic nerve injuries with preserved globe (Type III: n = 8, 23%). Compared with Type II and III injuries, patients who had Type I injuries were more likely to die prior to hospital discharge (46% vs. 20% vs. 12%, p = 0.04), undergo ophthalmologic intervention (73% vs. 6% vs. 11%, p = 0.01), and more surgery (6 vs. 3 vs. 0.5 mean surgeries, p < 0.001). Type II injuries most frequently underwent debridement and reconstruction of the bony orbit. Type III and Type I injuries were associated with worse initial and final visual acuity, with the majority (100% and 75%, respectively) having No Light Perception (NLP) on initial exam, and no visual recovery during the follow-up period (median follow up= 25 months).

Conclusions: Management and visual outcomes of orbital injuries from SIGSWs is determined by whether the globe and optic nerve are preserved. Open globe injury by itself is associated with higher mortality and significant permanent vision loss.
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http://dx.doi.org/10.1097/IOP.0000000000001499DOI Listing
December 2019

Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies.

Obes Surg 2020 02;30(2):707-713

Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.

Background: Bariatric surgery remains underutilized at a national scale, and insurance company reimbursement is an important determinant of access to these procedures. We examined the current state of coverage criteria for bariatric surgery set by private insurance companies.

Methods: We surveyed medical policies of the 64 highest market share health insurance providers in the USA. ASMBS guidelines and the CMS criteria for pre-bariatric evaluation were used to collect private insurer coverage criteria, which included procedures covered, age, BMI, co-morbidities, medical weight management program (MWM), psychosocial evaluation, and a center of excellence designation. We derive a comprehensive checklist for pre-bariatric patient evaluation.

Results: Sixty-one companies (95%) had defined pre-authorization policies. All policies covered the RYGB, and 57 (93%) covered the LAGB or the SG. Procedures had coverage limited to center of excellence in 43% of policies (n = 26). A total of 92% required a BMI of 40 or above or of 35 or above with a co-morbidity; however, 43% (n = 23) of policies covering adolescents (n = 36) had a higher BMI requirement of 40 or above with a co-morbidity. Additional evaluation was required in the majority of policies (MWM 87%, psychosocial evaluation 75%). Revision procedures were covered in 79% (n = 48) of policies. Reimbursement of a second bariatric procedure for failure of weight loss was less frequently found (n = 41, 67%).

Conclusions: A majority of private insurers still require a supervised medical weight management program prior to approval, and most will not cover adolescent bariatric surgery unless certain criteria, which are not supported by current evidence, are met.
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http://dx.doi.org/10.1007/s11695-019-04243-2DOI Listing
February 2020

Contemporary Characterization of Injury Patterns, Initial Management, and Disparities in Treatment of Facial Fractures Using the National Trauma Data Bank.

J Craniofac Surg 2019 Oct;30(7):2052-2056

Division of Plastic and Reconstructive Surgery.

Background: Contemporary description of facial fracture patterns and factors associated with early operative intervention at trauma centers is lacking. The purpose of this study was to characterize injuries and initial treatment patterns of patients suffering from facial fractures.

Methods: Using the National Trauma Databank from 2007 to 2015, patients suffering from facial fractures were included. Demographics, injury characteristics, and outcomes including operative interventions were assessed.

Results: Over 9 years, 626,270 patients were included: 74.5% were male, 39.0% suffered traumatic brain injury (TBI), and 23.3% severe noncraniofacial injuries (chest, abdomen, and/or extremity Abbreviated Injury Score ≥3). A total of 537,594 (85.8%) patients were admitted and 184,206 (34.3%) underwent operations for their facial injuries during the index hospitalization. The frequency and patterns of fractures varied by age, sex, race, and mechanism of injury. Operative intervention rates were highest for mandible (63.2%) and lowest for orbit fractures (1.0%). Multiple regression revealed that multiple factors were independently associated with the odds of early fracture repair including: female versus male (odds ratio [95% confidence interval]: 0.96 [0.94-0.98]), age >65 versus <18 years (0.62 [0.59-0.64]), non-white race (0.95 [0.94-0.97]), uninsured versus Medicaid (0.88 [0.86-0.90]), hospital bed size (>600 vs ≤200 beds, 1.67 [1.61-1.73]), TBI (0.70 [0.69-0.71]), and C-spine injury (0.93 [0.90-0.96]).

Conclusions: Facial fractures are common among many demographic cohorts, and multiple patient and injury-specific factors influenced fracture patterns and management. Early operative intervention was highest for mandible fractures and lowest for orbit fractures. Multiple factors including age, sex, insurance status, hospital characteristics, and race/ethnicity were independently associated with early operative intervention, highlighting disparities in care.
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http://dx.doi.org/10.1097/SCS.0000000000005862DOI Listing
October 2019

Characterization of Age-Related Injury Patterns and Surgical Treatment of Pediatric Facial Fractures: Analysis of the National Trauma Data Bank.

J Craniofac Surg 2019 Oct;30(7):2189-2193

Division of Plastic & Reconstructive Surgery, R Adams Cowley Shock Trauma Center.

Background: Presentation of pediatric facial fractures varies widely and many injuries are encountered infrequently by most practitioners. This study summarizes injury patterns in a large cohort of facial fractures and their subsequent surgical management.

Methods: Demographic and clinical characteristics of patients 18 years of age or younger admitted between 2009 and 2015 to trauma centers participating in the National Trauma Data Bank were examined. Craniofacial fractures and reconstructive procedures performed at index admission were selected based on ICD-9 and AIS codes. A multivariable analysis was used to determine independent determinants of surgical repair.

Results: Out of 60,094 pediatric patients evaluated in the US emergency departments, 48,821 patients were admitted and underwent open treatment (n = 8364; 17.1%) or closed treatment (n = 4244; 8.7%) of facial fractures. Falls were the most common mechanism of injury in infants and toddlers (<2-year-old, 44.4%, P <0.001), while motor vehicle collisions (32.9%, P <0.001) and assault (22.1%, P <0.001) were most commonly seen in adolescents (12-18-year-old). The frequency and odds of repair of facial fractures increased with advancing age, more so with open than closed treatment in adolescents (73.0%) as compared to infants and toddlers (50.3%). Children who sustained mandible fractures are the most likely to require surgical treatment at index-admission (odds ratio = 13.9, 95% confidence interval 13.1-14.8, P <0.001).

Conclusions: Population-based data shows that pediatric fracture patterns and associated early repair vary significantly with age. Patient demographics and hospital characteristics are significant determinants of surgical treatment that should be related to clinical outcomes in future studies.
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http://dx.doi.org/10.1097/SCS.0000000000005789DOI Listing
October 2019

Survival following Self-Inflicted Gunshots to the Face.

Plast Reconstr Surg 2019 08;144(2):415-422

From the Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital; the Department of Surgery, the Division of Plastic and Reconstructive Surgery, and the Department of Neurosurgery, University of Maryland School of Medicine; and the Division of Plastic, Reconstructive, and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center.

Background: Self-inflicted gunshot wounds involving the face are highly morbid. However, there is a paucity of objective estimates of mortality. This study aims to provide prognostic guidance to clinicians that encounter this uncommon injury.

Methods: A retrospective review of patients presenting to R Adams Cowley Shock Trauma Center (a Level I trauma center) with self-inflicted gunshot wounds to the face from 2007 to 2016. Isolated gunshot wounds to the calvaria or neck were excluded. The data were analyzed to determine predictors of survival.

Results: Of the 69 patients that met inclusion criteria, 90 percent were male and 80 percent were Caucasian, with an age range of 21 to 85 years. The most frequently seen injury patterns showed submental (57 percent), intraoral (22 percent), and temporal (12 percent) entry sites. Fewer than half (41 percent) of the cohort sustained penetrative brain injury. Overall, there were 18 deaths (overall mortality, 26 percent), 17 of which were secondary to brain injury. Independent predictors of death included penetrative brain injury (OR, 17; p < 0.0001) and age. Mortality was 17 percent among patients younger than 65 years, compared with 73 percent for those aged 65 years or older (p = 0.0001). Gastrostomy placement was independently associated with 25 percent reduction in length of hospitalization (p = 0.0003).

Conclusions: Despite tremendous morbidity, the overwhelming majority of patients who present with facial self-inflicted gunshot wounds will survive, especially if they are young and have no penetrative brain injury. These findings should help guide clinical decisions for this devastating injury.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000005842DOI Listing
August 2019

Postoperative Outcomes in Obese Patients That Undergo Ventral Hernia Repair versus Ventral Hernia Repair with Concurrent Panniculectomy.

Plast Reconstr Surg 2019 Apr;143(4):1211-1219

From the Division of Plastic, Reconstructive, and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center; and the Division of Plastic and Reconstructive Surgery, University of Maryland Medical Center.

Background: The safety of concurrent panniculectomy during ventral hernia repair remains a widely debated topic. This study aims to compare outcomes in obese patients who undergo ventral hernia repair with concurrent panniculectomy versus ventral hernia repair alone.

Methods: An 8-year retrospective cohort study was performed on obese patients who underwent ventral hernia repair. Patients were divided into those who underwent concurrent panniculectomy and those who did not. Postoperative complications were compared between these groups.

Results: A total of 223 patients were analyzed: 122 in the ventral hernia repair with concurrent panniculectomy group and 101 in the ventral hernia repair-only group. Median follow-up duration was 141 days. Patients in the ventral hernia repair with concurrent panniculectomy group had more surgical-site occurrences (57 percent versus 40 percent; p = 0.012). Both groups had similar rates of surgical-site occurrences that required an intervention (39 percent versus 31 percent; p = 0.179) and similar rates of hernia recurrence (23 percent versus 29 percent; p = 0.326). Multivariate analysis showed that concurrent panniculectomy increased the risk of surgical-site occurrences by two-fold; however, it did not increase the risk of surgical-site occurrences that required an intervention.

Conclusions: The addition of a panniculectomy to ventral hernia repair increases surgical-site occurrences but does not increase complications that require an intervention. As such, ventral hernia repair with concurrent panniculectomy can be considered in obese patients with a symptomatic panniculus who wish to have a single-stage operation and the lifestyle benefits of a panniculectomy.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000005471DOI Listing
April 2019

Patient-reported Outcomes in Facial Reconstruction: Assessment of FACE-Q Scales and Predictors of Satisfaction.

Plast Reconstr Surg Glob Open 2018 Dec 5;6(12):e2004. Epub 2018 Dec 5.

Department of Surgery, Division of Plastic, Reconstructive, and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Md.

Background: There is a paucity of patient-reported outcome measures for facial trauma reconstruction. To measure satisfaction and health-related quality of life (HRQOL), following repair of traumatic facial fractures, we used the FACE-Q, a set of patient-reported outcome instruments designed for aesthetic facial surgery. As a step toward validating the scales for facial trauma, we evaluated their reliability.

Methods: This is a prospective study of patients following primary repair of traumatic facial fractures at a level 1 trauma center from 2016 to 2018. Six FACE-Q scales with relevance to the facial trauma population were completed by patients at their 1-month postoperative visits. Predictors of satisfaction were examined using multiple linear regression models. Reliability of the scales in this population was evaluated using psychometric methods.

Results: One hundred eighty-five participants fulfilled inclusion criteria. Mean scores for the 6 scales ranged from 59 (SD = 15) for Recovery-Early Life Impact to 94 (SD = 13) for . Predictors of lower satisfaction and/or HRQOL include current tobacco smoking status, mandibulomaxillary fixation, and Le Fort pattern fractures. All scales were found to have good to excellent reliability (Cronbach's alpha = 0.824-0.969).

Conclusions: Following repair of facial fractures, patient-reported outcomes can be reliably measured using FACE-Q scales. On average, patients report poor health-related quality of life in the early postoperative period. Predictors of low satisfaction and/or poor HRQOL include current smoking habit, mandibulomaxillary fixation, and Le Fort fractures.
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http://dx.doi.org/10.1097/GOX.0000000000002004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326617PMC
December 2018

Pediatric Nasoorbitoethmoid Fractures: Cause, Classification, and Management.

Plast Reconstr Surg 2019 01;143(1):211-222

From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital; Rush Medical College of Rush University; the Division of Plastic Surgery, University of Washington Medical Center; the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center; the Department of Biostatistics, Boston University School of Public Health; and the Division of Pediatric Plastic Surgery, University Hospital Rainbow Babies and Children's Hospital.

Background: Currently, there is a paucity of information on the presentation and proper management of pediatric nasoorbitoethmoid fractures. The purpose of this study was to examine the incidence, cause, associated injuries, and management of these fractures. Furthermore, the authors sought to assess outcomes after transnasal wiring or suture canthopexy for type III nasoorbitoethmoid fractures.

Methods: A retrospective cohort review was performed of all patients with nasoorbitoethmoid fractures who presented to a Level I trauma center from 1990 to 2010. Charts and computed tomographic imaging were reviewed, and nasoorbitoethmoid fractures were labeled based on the Markowitz-Manson classification system. Patient fracture patterns, demographics, characteristics, and outcomes were recorded. Univariate and multivariate methods were used to compare groups.

Results: A total of 63 pediatric patients were identified in the study period. The sample's mean age was 8.78 ± 4.08 years, and 28.6 percent were girls. The sample included 18 type I injuries, 28 type II injuries, and 17 type III injuries. No significant demographic differences were found between patients with type I, II, and III fractures (p > 0.05). Operative intervention was pursued in 16.7, 46.4, and 82.4 percent of type I, II, and III nasoorbitoethmoid fractures, respectively. In patients with type III nasoorbitoethmoid fractures, no patients with transnasal wiring developed telecanthus.

Conclusions: Pediatric nasoorbitoethmoid fractures are uncommon injuries. Type I fracture can often be treated with close observation. However, type II and III injury patterns should be evaluated for operative intervention. Transnasal wiring is an effective method to prevent traumatic telecanthus deformity in type III fracture patterns.
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http://dx.doi.org/10.1097/PRS.0000000000005106DOI Listing
January 2019

Tissue-derived microparticles reduce inflammation and fibrosis in cornea wounds.

Acta Biomater 2019 02 19;85:192-202. Epub 2018 Dec 19.

Translational Tissue Engineering Center, Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD 21231, USA; Wilmer Eye Institute, Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, MD 21231, USA; Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21231, USA. Electronic address:

Biological materials derived from the extracellular matrix (ECM) of tissues serve as scaffolds for rebuilding tissues and for improved wound healing. Cornea trauma represents a wound healing challenge as the default repair pathway can result in fibrosis and scar formation that limit vision. Effective treatments are needed to reduce inflammation, promote tissue repair, and retain the tissue's native transparency and vision capacity. Tissue microparticles derived from cornea, cartilage and lymph nodes were processed and screened in vitro for their ability to reduce inflammation in ocular surface cells isolated from the cornea stroma, conjunctiva, and lacrimal gland. Addition of ECM particles to the media reduced expression of inflammatory genes and restored certain tear film protein production in vitro. Particles derived from lymph nodes were then applied to a rabbit lamellar keratectomy corneal injury model. Application of the tissue particles in a fibrin glue carrier decreased expression of inflammatory and fibrotic genes and scar formation as measured through imaging, histology and immunohistochemistry. In sum, immunomodulatory tissue microparticles may provide a new therapeutic tool for reducing inflammation in the cornea and ocular surface and promoting tissue repair. STATEMENT OF SIGNIFICANCE: Damaged cornea will result in scar tissue formation that impedes vision, and new therapies are needed to enhance wound healing in the cornea and to prevent fibrosis. We evaluated the effects of biological scaffolds derived extracellular matrix (ECM) during corneal wound healing. These ECM particles reduced inflammatory gene expression and restored tear film production in vitro, and reduced scar formation and fibrosis genes in the wounded cornea, when applied to in vivo lamellar keratectomy injury model. The immunomodulatory tissue microparticles may provide a new therapeutic tool for reducing inflammation in the cornea and ocular surface and promoting proper tissue repair.
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http://dx.doi.org/10.1016/j.actbio.2018.12.027DOI Listing
February 2019

A Cluster Randomized Controlled Trial of a Total Worker Health Intervention on Commercial Construction Sites.

Int J Environ Res Public Health 2018 10 25;15(11). Epub 2018 Oct 25.

Harvard Center for Work, Health and Wellbeing, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA.

This study evaluated the efficacy of an integrated Total Worker Health program, "All the Right Moves", designed to target the conditions of work and workers' health behaviors through an ergonomics program combined with a worksite-based health promotion Health Week intervention. A matched-pair cluster randomized controlled trial was conducted on ten worksites (five intervention ( = 324); five control sites ( = 283)). Worker surveys were collected at all sites pre- and post- exposure at one- and six-months. Linear and logistic regression models evaluated the effect of the intervention on pain and injury, dietary and physical activity behaviors, smoking, ergonomic practices, and work limitations. Worker focus groups and manager interviews supplemented the evaluation. After controlling for matched intervention and control pairs as well as covariates, at one-month following the ergonomics program we observed a significant improvement in ergonomic practices (B = 0.20, = 0.002), and a reduction in incidences of pain and injury (OR = 0.58, = 0.012) in the intervention group. At six months, we observed differences in favor of the intervention group for a reduction in physically demanding work (B = -0.25, = 0.008), increased recreational physical activity (B = 35.2, = 0.026) and higher consumption of fruits and vegetables (B = 0.87, = 0.008). Process evaluation revealed barriers to intervention implementation fidelity and uptake, including a fissured multiemployer worksite, the itinerant nature of workers, competing production pressures, management support, and inclement weather. The All the Right Moves program had a positive impact at the individual level on the worksites with the program. For the longer term, the multi-organizational structure in the construction work environment needs to be considered to facilitate more upstream, long-term changes.
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http://dx.doi.org/10.3390/ijerph15112354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6265748PMC
October 2018

Injectable Chitosan Hydrogels with Enhanced Mechanical Properties for Nucleus Pulposus Regeneration.

Tissue Eng Part A 2019 03 9;25(5-6):303-313. Epub 2018 Nov 9.

1 Laboratory of Endovascular Biomaterials (LBeV), Centre de Recherche du CHUM (CRCHUM), Montreal, Canada.

Impact Statement: A thermosensitive chitosan-based hydrogel was developed, which mimics the mechanical properties of the human nucleus pulposus (NP) tissue and provides a suitable environment for seeded NP cells to live and produce glycosaminoglycans. This scaffold is injectable through 25G needle and rapidly gels at body temperature. It has the potential to restore mechanical properties and stimulate biological repair of the degenerated intervertebral disc (IVD). It could therefore be used for the minimally invasive treatment of degenerated IVD, which affects more than one person out of five in the world.
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http://dx.doi.org/10.1089/ten.TEA.2018.0170DOI Listing
March 2019

Short Link N promotes disc repair in a rabbit model of disc degeneration.

Arthritis Res Ther 2018 08 29;20(1):201. Epub 2018 Aug 29.

Orthopaedics Research Laboratory, Lady Davis Institute for Medical Research - Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montréal, QC, H3T 1E2, Canada.

Background: The degeneration of the intervertebral disc (IVD) is characterized by proteolytic degradation of the extracellular matrix, and its repair requires the production of an extracellular matrix with a high proteoglycan-to-collagen ratio characteristic of a nucleus pulposus (NP)-like phenotype in vivo. At the moment, there is no medical treatment to reverse or even retard disc degeneration. The purpose of the present study was to determine if a low dose of short link N (sLN), a recently discovered fragment of the link N peptide, could behave in a manner similar to that of link N in restoring the proteoglycan content and proteoglycan-to-collagen ratio of the disc in a rabbit model of IVD degeneration, as an indication of its potential therapeutic benefit in reversing disc degeneration.

Methods: Adolescent New Zealand white rabbits received an annular puncture with an 18-gauge needle into two noncontiguous discs to induce disc degeneration. Two weeks later, either saline (10 μL) or sLN (25 μg in 10 μL saline) was injected into the center of the NP. The sLN concentration was empirically chosen at a lower molar concentration equivalent to half that of link N (100 μg in 10 μL). The effect on radiographic, biochemical and histologic changes were evaluated.

Results: Following needle puncture, disc height decreased by about 25-30% within 2 weeks and maintained this loss for the duration of the 12-week study; a single 25-μg sLN injection at 2 weeks partially restored this loss in disc height. sLN injection led to an increase in glycosaminoglycans (GAG) content 12 weeks post-injection in both the NP and annulus fibrosus (AF). There was a trend towards maintaining control disc collagen-content with sLN supplementation and the GAG-to-collagen ratio in the NP was increased when compared to the saline group.

Conclusions: When administered to the degenerative disc in vivo, sLN injection leads to an increase in proteoglycan content and a trend towards maintaining control disc collagen content in both the NP and AF. This is similar to link N when it is administered to the degenerative disc. Thus, pharmacologically, sLN supplementation could be a novel therapeutic approach for treating disc degeneration.
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http://dx.doi.org/10.1186/s13075-018-1625-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6116458PMC
August 2018

Utility of Postoperative Mandibulomaxillary Fixation After Rigid Internal Fixation of Isolated Mandibular Fractures.

J Craniofac Surg 2018 Jun;29(4):930-936

Division of Plastic, Reconstructive, and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center.

Purpose: The utility of postoperative mandibulomaxillary fixation (MMF) after open reduction and internal fixation (ORIF) of mandible fractures is debated. The purpose of this study is to analyze if patients undergoing ORIF with postoperative MMF have improved outcome compared with those treated with ORIF alone.

Methods: A retrospective study was performed on patients who underwent ORIF of isolated mandibular fractures. Patients were divided into those placed in MMF postoperatively (ORIF with MMF) and those who were not (ORIF only). Postoperative complications and follow-up compliance were compared.

Results: A total of 238 patients were identified. Of these, 204 had sufficient follow-up with 94 patients in the ORIF with MMF group and 107 patients in the ORIF only group. Both groups had similar minor complication rates (13% vs 12%, P = 0.83) and major complication rates (16% vs 13%, P = 0.69). After adjusting for potential confounders, the use of postoperative MMF did not reduce the risk of minor (P = 0.34) or major complications (P = 0.57). Patients with postoperative MMF had a 5% lost to follow-up rate compared to 20% in the ORIF only group.

Conclusion: Postoperative MMF does not improve clinical outcome after ORIF in patients with isolated mandible fractures but has the potential benefit of improving follow-up compliance.
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http://dx.doi.org/10.1097/SCS.0000000000004368DOI Listing
June 2018

Pediatric Zygomaticomaxillary Complex Fracture Repair: Location and Number of Fixation Sites in Growing Children.

Plast Reconstr Surg 2018 07;142(1):51e-60e

From the Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine; and the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center.

Background: Relatively few reports have been published investigating the operative management of pediatric zygomaticomaxillary complex fractures. The purpose of this study was to assess pediatric zygomaticomaxillary complex fracture management and associated complications, and potentially describe a standard treatment paradigm for these cases.

Methods: A retrospective cohort review was performed of all patients younger than 15 years presenting to a single institution with zygomaticomaxillary complex fractures from 1990 to 2010. Patient demographics, concomitant injuries, management details, and complications were recorded. Complications were compared among patients by dentition stage, number of fixation points, and identity of fixation sites.

Results: A total of 36 patients with 44 unique zygomaticomaxillary complex fractures met the authors' inclusion criteria. Thirty-two fractures exhibited at least 2.0 mm of diastasis along at least one buttress (73 percent), and all but one of these were managed operatively. Among operatively managed patients with deciduous dentition, two-point fixation was associated with a lower overall complication rate compared with one- and three-point fixation (0 percent versus 75 percent and 75 percent; p = 0.01). Furthermore, rigid plate-and-screw fixation at the zygomaticomaxillary buttress was not associated with an increased complication rate in operatively managed patients with deciduous dentition (40 percent versus 50 percent; p = 0.76).

Conclusions: The authors' results suggest that two-point fixation is an effective management strategy for repair of displaced zygomaticomaxillary complex fractures in children. In addition, rigid plate-and-screw fixation at the zygomaticomaxillary buttress in children with deciduous dentition appears to be safe and effective when performed.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000004487DOI Listing
July 2018

Link N as a therapeutic agent for discogenic pain.

JOR Spine 2018 Mar 15;1(1):e1008. Epub 2018 Mar 15.

Division of Orthopaedic Surgery McGill University Montreal QC Canada.

Neurotrophins (NTs) are the major contributors of sensory axonal sprouting, neural survival, regulation of nociceptive sensory neurons, inflammatory hyperalgesia, and neuropathic pain. Intervertebral disc (IVD) cells constitutively express NTs. Their expression is upregulated by proinflammatory cytokines present in the IVD during degeneration, which can promote peripheral nerve ingrowth and hyperinnervation, leading to discogenic pain. Currently, there are no targeted therapies that decrease hyperinnervation in degenerative disc disease. Link N is a naturally occurring peptide with a high regenerative potential in the IVD. Therefore, the suitability of Link N as a therapeutic peptide for suppressing NTs, which are known modulators and mediators of pain, was investigated. The aim of the present study is to determine the effect of Link N on NTs expression, nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and their cognate receptors TrkA and TrkB as they are directly correlated with symptomatic back pain. Furthermore, the neurotransmitter (substance P) was also evaluated in human annulus fibrosus (AF) cells stimulated with cytokines. Human AF cells isolated from normal IVDs were stimulated with interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) in the presence or absence of Link N. NGF release in the media was evaluated by Western blotting. Total RNA was isolated and gene expression was measured using real-time PCR. Gene expression of NGF, BDNF, TrkA, and TrkB significantly decreased in human disc cells stimulated with either IL-1β or TNF-α supplemented with Link N when compared to the cells stimulated only with IL-1β or TNF-α. NGF protein expression was also suppressed in AF cells coincubated with Link N and IL-1β when compared to the cells stimulated only with IL-1β. Link N can suppress the stimulation of NGF, BDNF, and their receptors TrkA and TrkB in AF cells in an inflammatory milieu. Thus, coupled with previous observations, this suggests that administration of Link N has the potential to not only repair the discs in early stages of the disease but also suppress pain.
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http://dx.doi.org/10.1002/jsp2.1008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6686832PMC
March 2018

Is there more to the clinical outcome in posttraumatic reconstruction of the inferior and medial orbital walls than accuracy of implant placement and implant surface contouring? A prospective multicenter study to identify predictors of clinical outcome.

J Craniomaxillofac Surg 2018 Apr 1;46(4):578-587. Epub 2018 Feb 1.

Klinikum der LMU Muenchen, Klinik und Poliklinik für Mund-, Kiefer- und Gesichtschirurgie, Lindwurmstr. 2a, 80337, München, Germany.

Purpose: Reconstruction of orbital wall fractures is demanding and has improved dramatically with the implementation of new technologies. True-to-original accuracy of reconstruction has been deemed essential for good clinical outcome, and reasons for unfavorable clinical outcome have been researched extensively. However, no detailed analysis on the influence of plate position and surface contour on clinical outcome has yet been published.

Materials And Methods: Data from a previous study were used for an ad-hoc analysis to identify predictors for unfavorable outcome, defined as diplopia or differences in globe height and/or globe projection of >2 mm. Presumed predictors were implant surface contour, aberrant implant dimension or position, accuracy of reconstructed orbital volume, and anatomical fracture topography according to the current AO classification.

Results: Neither in univariable nor in multivariable regression models were unfavorable clinical outcomes associated with any of the presumed radiological predictors, and no association of the type of implant, i.e., standard preformed, CAD-based individualized and non-CAD-based individualized with its surface contour could be shown.

Conclusion: These data suggest that the influence of accurate mechanical reconstruction on clinical outcomes may be less predictable than previously believed, while the role of soft-tissue-related factors may have been underestimated.
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http://dx.doi.org/10.1016/j.jcms.2018.01.007DOI Listing
April 2018

Office-Based Three-Dimensional Printing Workflow for Craniomaxillofacial Fracture Repair.

J Craniofac Surg 2018 Jul;29(5):e440-e444

Division of Plastic, Reconstructive, and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD.

Three-dimensional printing of patient-specific models is being used in various aspects of craniomaxillofacial reconstruction. Printing is typically outsourced to off-site vendors, with the main disadvantages being increased costs and time for production. Office-based 3-dimensional printing has been proposed as a means to reduce costs and delays, but remains largely underused because of the perception among surgeons that it is futuristic, highly technical, and prohibitively expensive. The goal of this report is to demonstrate the feasibility and ease of incorporating in-office 3-dimensional printing into the standard workflow for facial fracture repair.Patients with complex mandible fractures requiring open repair were identified. Open-source software was used to create virtual 3-dimensional skeletal models of the, initial injury pattern, and then the ideally reduced fractures based on preoperative computed tomography (CT) scan images. The virtual 3-dimensional skeletal models were then printed in our office using a commercially available 3-dimensional printer and bioplastic filament. The 3-dimensional skeletal models were used as templates to bend and shape titanium plates that were subsequently used for intraoperative fixation.Average print time was 6 hours. Excluding the 1-time cost of the 3-dimensional printer of $2500, roughly the cost of a single commercially produced model, the average material cost to print 1 model mandible was $4.30. Postoperative CT imaging demonstrated precise, predicted reduction in all patients.Office-based 3-dimensional printing of skeletal models can be routinely used in repair of facial fractures in an efficient and cost-effective manner.
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http://dx.doi.org/10.1097/SCS.0000000000004460DOI Listing
July 2018

Link-N: The missing link towards intervertebral disc repair is species-specific.

PLoS One 2017 8;12(11):e0187831. Epub 2017 Nov 8.

Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands.

Introduction: Degeneration of the intervertebral disc (IVD) is a frequent cause for back pain in humans and dogs. Link-N stabilizes proteoglycan aggregates in cartilaginous tissues and exerts growth factor-like effects. The human variant of Link-N facilitates IVD regeneration in several species in vitro by inducing Smad1 signaling, but it is not clear whether this is species specific. Dogs with IVD disease could possibly benefit from Link-N treatment, but Link-N has not been tested on canine IVD cells. If Link-N appears to be effective in canines, this would facilitate translation of Link-N into the clinic using the dog as an in vivo large animal model for human IVD degeneration.

Materials And Methods: This study's objective was to determine the effect of the human and canine variant of Link-N and short (s) Link-N on canine chondrocyte-like cells (CLCs) and compare this to those on already studied species, i.e. human and bovine CLCs. Extracellular matrix (ECM) production was determined by measuring glycosaminoglycan (GAG) content and histological evaluation. Additionally, the micro-aggregates' DNA content was measured. Phosphorylated (p) Smad1 and -2 levels were determined using ELISA.

Results: Human (s)Link-N induced GAG deposition in human and bovine CLCs, as expected. In contrast, canine (s)Link-N did not affect ECM production in human CLCs, while it mainly induced collagen type I and II deposition in bovine CLCs. In canine CLCs, both canine and human (s)Link-N induced negligible GAG deposition. Surprisingly, human and canine (s)Link-N did not induce Smad signaling in human and bovine CLCs. Human and canine (s)Link-N only mildly increased pSmad1 and Smad2 levels in canine CLCs.

Conclusions: Human and canine (s)Link-N exerted species-specific effects on CLCs from early degenerated IVDs. Both variants, however, lacked the potency as canine IVD regeneration agent. While these studies demonstrate the challenges of translational studies in large animal models, (s)Link-N still holds a regenerative potential for humans.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0187831PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5679057PMC
November 2017

Erratum to "The "Crumple Zone" hypothesis: Association of frontal sinus volume and cerebral injury after craniofacial trauma" [J Craniomaxillofac Surg 45 (2017) 1094-1098].

J Craniomaxillofac Surg 2017 11 18;45(11):1907. Epub 2017 Sep 18.

Division of Plastic, Reconstructive and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jcms.2017.08.014DOI Listing
November 2017

An Inspection Tool and Process to Identify Modifiable Aspects of Acute Care Hospital Patient Care Units to Prevent Work-Related Musculoskeletal Disorders.

Workplace Health Saf 2018 Mar 8;66(3):144-158. Epub 2017 Aug 8.

1 Harvard T.H. Chan School of Public Health.

A dearth of practical resources is available for evaluating ergonomic risk factors in dynamic health care work environments. Of particular need are tools for inspecting patient care environments for hazards. The goal of this study was to describe the development and application of an inspection tool and a process for identifying hazards inherent in the modifiable aspects of the physical environment to reduce injury risk to hospital workers. Through an iterative and participatory process, the tool and inspection process were developed with three purposes in mind: (a) create a framework for the inspection of physical work environments and physical conditions of work associated with injury risk (hazards), (b) document the physical conditions, and (c) provide feedback to decision makers. The tool and process were used by an ergonomics researcher on four patient care units as part of the Be Well, Work Well Total Worker Health® intervention. The resulting inspection process provided a structured method for recognizing hazards in the dynamic modifiable physical work environment and reporting both observations and recommendations to decision makers. The development and implementation of the inspection tool provided guidance to modify the physical work environment by implementing ergonomic solutions. The tool allowed the organization to plan and prioritize ergonomic hazard abatement (e.g. resource allocation and tracking trends). Within a Total Worker Health® framework, this tool can measure work practices which can then be used to inform organizational programs and policies within a health care setting.
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http://dx.doi.org/10.1177/2165079917718852DOI Listing
March 2018