BACKGROUND: Craniofacial injuries contribute substantially to morbidity after blunt trauma, with orbital fractures seen in approximately 10–25% of all traumatic facial fractures. Orbital blow-out fractures occur when an orbital wall is fractured with an intact orbital rim, and usually occurs after significant blunt trauma from an object larger than the orbital aperture. The aim of this study is to determine the impact of age, injury severity, and mechanism of injury on orbital blow-out fracture patterns. METHODS: We retrospectively reviewed all patients admitted to a regional Level 2 Trauma Center, who sustained blunt orbital fractures, over an 11-year period, from January 2006 to December 2016. We excluded all patients who had orbital rim fractures and all penetrating trauma. Only patients who had a computed tomography scan of their face on presentation were included. There were 825 patients who met inclusion criteria. Individual charts were reviewed for demographics, length-of-stay(LOS), mechanism of injury(MOI), injury severity score(ISS), and mortality. Individual facial CT scans were reviewed along with the formal radiologist report to determine fracture locations. Statistical significance was set at a p value ≤0.05. This study was approved by our Institutional Review Board. RESULTS: Our cohort consisted of 825 patients, with 42 mortalities (5.1%). The mean age was 40.4 years old (range 1–97) and there was an approximate 4:1 male:female ratio. The mean LOS was 5.4 days (range 0–78) and the mean ISS was 14.7(range 1–50). The most common MOI was motor vehicle collisions(MVC) in 211 patients, followed by assault, ground-level mechanical falls, All-Terrain Vehicle(ATV) accidents, motorcycle collisions(MCC), and other mechanisms in 171, 151, 112, 53, and 127 patients, respectively. Overall, the most common orbital blow-out fracture involved the orbital floor in 567 patients (68.7%), followed by the lateral, medial, superior(roof), and posterior walls in 310(37.6%), 183(22.2%), 160(19.3%), and 16(1.8%) patients, respectively. The most common fracture pattern combination was orbital floor and lateral wall fractures in 202 patients (24.5%). The mean number of orbital blow-out fractures per patient in the entire cohort was 1.50. Orbital floor fractures remained the most common blow-out fracture in all age groups, accounting for 72.4% in pediatrics (1–17 years old), 66.4% in adults (18–64 years), and 77.7% in the elderly (age ≥65 years). Patients with ISS <15 were significantly more likely to have an orbital floor fracture when compared to patients with ISS ≥15, with fractures present in 81.1% and 56.9% of patients, respectively(p<0.05). MCC resulted in the highest mean number of orbital blow-out fractures per patient (1.83), which was significantly higher than other mechanisms(p<0.05). Patients who had ground-level mechanical falls were most likely to have orbital floor blow-out fractures (90.0%) compared with other mechanisms(p<0.05). CONCLUSION: Orbital blow-out fractures are a common injury after significant blunt craniofacial trauma. The orbital floor is most frequently involved, and patients who have mechanical falls seem particularly prone to this injury. Patients with lower ISS in our cohort likely had more concentrated craniofacial injuries, explaining their worse fracture patterns. MCC appears to confer the greatest craniofacial trauma with the most severe orbital blow-out fracture patterns. Age did not independently predict fracture patterns.

BACKGROUND: Nasal bone fractures are the most frequent fractures in facial trauma due to its central location and protruding framework. The impact of age on development of late complications after nasal bone fractures has not been well-studied. A greater understanding of the impact of age-related differences on outcomes after nasal bone fractures is essential in order to improve clinical assessment and management. METHODS: A 10-year retrospective chart review of adults with nasal bone fractures presenting to a Level 2 trauma center was performed to evaluate the late complications related to nasal bone fractures. This study variables considered include age, gender, mechanisms of injuries, nasal deformities, sinusitis, olfactory disturbances, airway obstruction, septal perforation, synechiae, types of fractures, and any post-injury operative interventions. Our data was organized into 2 cohorts: adult (aged 18–64 years) and elderly (>64 years). The impact of age on late complications was statistically assessed with statistical significance of p-value less than or equal to 0.05. RESULTS: There were 833 adult patients who sustained nasal fractures from 2007 to 2017. There was 123 patients in the elderly cohort and 710 adult patients aged 18–64 years. The most common mechanism of injury resulting in nasal bone fractures in the elderly was mechanical falls (52%), and the most common mechanism in the adult cohort was motor vehicle accidents (33.8%). There was no statistically significant difference in nasal bone fracture patterns between both groups (p>0.05). Adult patients were more likely to undergo a post-injury operative intervention (p<0.05). There was a higher percentage of elderly patients who had late complications compared to the adult cohort. The most common late complication was olfactory disturbances in both groups. Nasal deformities and airway obstruction, however, were more often reported in the adult cohort, and sinusitis as well as olfactory disturbances are more frequently reported in the elderly (p<0.05). CONCLUSION: Mechanical falls accounted for the majority of nasal bone fractures in the elderly, whereas a motor vehicle accident was the common mechanism of injury in the adult cohort. There was no difference in nasal bone fracture patterns between the elderly and the adult cohorts. Age, however, did affect the decision to undergo operative interventions, especially in the adult cohort. Elderly patients experienced more complications than their adult counterpart. Posttraumatic olfactory disturbance was the most frequent complication reported in both groups, secondary to distortion of the sinus tract. Sinusitis and olfactory disturbances are more likely to be experienced in the elderly.

November 11, 2009 will mark over 90 years of commemorating Armistice Day, the end of World War I. Although conflict in the Middle East reminds us that WWI failed to end all wars, it did serve as both substrate and catalyst for the development of modern plastic and reconstructive surgery. This article will outline those ingredients most directly responsible for the growth of the specialty, tracing its development in response to armed conflict, and implications for continued excellence both in reconstructive surgery and other fields in the future.

Objective. Enzymatic digestion of the pancreas is a fundamental step in islet isolation and there are many ways to administer the enzyme during procurement. The aim of this study was to evaluate the influence of different methods of Liberase delivery during pancreas harvest on the quality and quantity of islets.Methods. Depending on the type of Liberase delivery, 4 groups were created. Group I was intraductal, Group 2 was interstitial, Group 3 was intragallbladder, and Group 4 was no infusion of enzyme. After injection, the pancreata were harvested, digested in Liberase solution, mechanically disrupted, and purified using discontinuous gradient centrifugation. After 24-hour culture, the number, purity, and viability of the isolated islets were determined.Results. Intraductal injection of the enzyme yielded statistically significantly more islets per mouse when compared with interstitial, intragal Hadder, and no injection administration. Although there was a trend toward better islet purity and viability for Group 1, this was not statistically significant.Conclusion. Intraductal administration is the best enzyme delivery method for pancreatic islet isolation. The pancreatic ducts are the most anatomic and physiological way to transport the enzyme uniformly inside the pancreas, determining an adequate digestion and better islet quantity and quality when compared with other delivery methods.

Military surgeons are often consulted for excisional debridement of skin lesions that fail to respond to medical therapy among soldiers who have been operating in areas of Afghanistan where cutaneous leishmaniasis is endemic. Wide surgical excision without knowledge of the primary etiology can lead to a surgical pitfall. Failure to properly treat cutaneous leishmaniasis, however, can lead to medical pitfalls of permanent disfigurement, deformity, and disability. Forward deployed surgeons should be supported by a laboratory that can confirm the presence of atypical organisms in biopsies of these lesions. With a x 100 microscope and Wright-Giemsa stains, a medical treatment facility is able to confirm cutaneous leishmaniasis, which allows for rapid transfer of soldiers for definitive antimicrobial therapy.

We conducted a prospective cohort study in order to determine whether suction drain specimen cultures from orthopaedic surgery predicted an early wound infection. We included 218 consecutive clean orthopaedic operations requiring drains in one unit over a period of 1 year. The suction drain tip, drain fluid and wound discharge specimens were cultured, and the surgical wound was followed up for 3 months. There were six deep and two superficial wound infections. Wound infection was significantly related to positive suction tip culture but not to positive drain fluid culture. Following our methodology for culture, a positive drain tip culture predicts wound infection in 50% and a negative culture virtually excludes the possibility of a deep infection.

Calpain is activated in experimental uremia: Is calpain a mediator of uremia-induced myocardial injury?The cysteine proteases calpain and caspase-3 are known mediators of cell death. The aim of this study was to assess their contribution to the tissue damage found in experimental uremia.Calpain and caspase-3 activities were measured in the hearts of rats that were sham-operated (control), sham-operated and spontaneously hypertensive (SHR), and those rendered uremic by 5/6 nephrectomy (uremic). In an in vitro study, heart myoblasts (Girardi) were incubated with human serum from healthy subjects (control serum conditioned media, CSCM) or uremic patients (uremic serum conditioned media, USCM), in the presence and absence of calpain and caspase-3 inhibitors. After 48 hours the activity of calpain and caspase-3 was measured, and cell injury determined by DNA fragmentation (ELISA) and lactate dehydrogenase (LDH) release. An in situ assay was designed to study how USCM affects calpain activity over time.In the in vivo study, mean calpain activities were almost identical in the control and SHR groups, but calpain and caspase-3 activities were much elevated in the uremic group (P < 0.01 and 0.001 respectively vs. control). The SHR group had significantly higher mean arterial blood pressure (P < 0.001 vs. control, 0.01 vs. uremic). In the in vitro study calpain activity and DNA fragmentation were markedly higher in USCM treated cells compared to CSCM (both P<0.05). Both were reduced in USCM cells containing calpain inhibitors (E64d, calpastatin, or PD 150606). LDH release was raised also in USCM treated cultures (P < 0.05), which only the E64d treatment could significantly reduce (P < 0.02). Caspase-3 activities were similar in USCM and CSCM groups. The in situ assay showed significant increases in calpain activity in USCM treated cells compared to CSCM after just 3.5 hours (P<0.01).In vivo results suggest that the increases in calpain and caspase-3 activity in uremic rat hearts were primarily due to uremia and not to hypertension. In vitro data demonstrate that uremia-induced cell injury can be attenuated by calpain inhibition. Therefore, it is likely that calpain is a mediator of uremia-induced myocardial injury.

Since its clinical inception, our group has worked in clinical and experimental transplantation. The exciting early results of composite tissue allografts (CTA) attracted our attention during the 1980s, when some of the first experimental CTA literature appeared. The recent extraordinary results of clinical CTA grafts, primarily the Louisville and Lyon results, have been highlighted at this meeting. Interestingly, this success followed not long after the first International meeting in Louisville in 1997. This is clearly an exciting new application of transplant techniques to one of the newest and most unique types of transplants. Previous studies used immunosuppression for skin allografting. Early results seem quite exciting and we expect to see a rapid growth of interest and activity in this area. We believe that the entire field would benefit from the novel, highly effective and minimally toxic immune tolerance induction using CD3-immunotoxin (CD3-IT) and deoxyspergualin (DSG).