Faculty Bibliography

PURPOSE: Blunt internal carotid artery injuries (BCAIs) can result from craniofacial trauma, yet the association between craniofacial fractures and BCAIs is poorly understood. MATERIALS AND METHODS: A retrospective cohort study of patients with blunt-mechanism facial fracture(s) presenting to a large trauma center was undertaken to identify facial fracture patterns predictive of BCAIs. Predictor variables included specific facial fracture patterns. Additional variables included demographic, injury mechanism, and associated injury classifications. Outcome variables included the presence or absence of BCAIs. All radiographic fracture patterns were confirmed by author review of computed tomographic imaging. BCAIs were confirmed and graded using the Biffl system. Differences in fracture patterns and demographic parameters in patients who presented with versus without concomitant BCAIs were compared, and relative risks for BCAI were calculated. Existing Eastern Association for the Surgery of Trauma Level III Blunt Cerebrovascular Injury (BCVI) screening criteria then were applied to the dataset to determine if additional fracture patterns would be useful in BCAI screening as determined by alterations in screening sensitivity and specificity. RESULTS: Seventy BCAIs were identified in 54 of 4,398 patients with facial fractures (1.2%). Bilateral fractures in each facial third, complex midface, Le Fort, and subcondylar fractures, fractures in association with the cervical spine, and basilar skull fractures were high risk for concomitant BCAI. Twenty percent of BCAIs would not have been captured by existing Eastern Association for the Surgery of Trauma Level III BCVI screening criteria. When patients meeting these screening criteria were removed from the study population, Le Fort I and subcondylar fractures were the only fracture patterns conferring increased risk for BCAI. Addition of these criteria to existing criteria improved the screening negative predictive value. CONCLUSION: Specific facial fracture patterns, including bilateral fractures in any facial third and complex midface, Le Fort I, and subcondylar fractures, confer increased risk of BCAI, especially in association with basilar skull fractures. Suspicion for BCAI in these patients may improve diagnosis and enable prompt therapeutic intervention. Addition of Le Fort I fractures to existing BCAI screening criteria improves sensitivity and may be of clinical utility in ruling out BCAIs.

BACKGROUND: The integrated model of plastic surgery education, shortly to become the standard for all 6-year programs, has set minimal but no maximal exposure to plastic surgery. The authors hypothesized that the first 3 years of integrated training will show variability among residency programs. METHODS: Rotation schedules for all 42 integrated programs were analyzed for plastic surgery versus 18 nonplastic surgery rotations for postgraduate years 1, 2, and 3 as well as cumulatively for the first 3 years. Rotations "strongly suggested" by the Residency Review Committee on Plastic Surgery and American Board of Plastic Surgery were also examined. RESULTS: Postgraduate years 1 through 3 spent a wide range of 3 to 19 months (SD +/- 4.9 months) on plastic surgery (mean, 9.1 months). General surgery also varied dramatically, with 8 to 21 months (SD +/- 4.0 months) of exposure (mean, 16.3 months). Surgical subspecialty rotations ranged substantially from 1 to 6 months (SD +/- 1.0 months). Plastic surgery exposure was greater in programs based within plastic surgery departments than within divisions (13.8 versus 8.3 months, p < 0.005). Eighteen programs (42.9 percent) had dedicated hand surgery rotations, while seven (16.7 percent) had time dedicated for research. There was also wide variability in the inclusion of 18 nonplastic surgery rotations as well as specific "strongly suggested" rotations. CONCLUSIONS: The plastic surgery experience in the first 3 years of residency training varies by a greater than 6-fold difference among integrated programs. This was also found in the 2.5-fold and 6-fold differences in general surgery and subspecialty surgery experiences. Since standardized residency training is an expectation by both accrediting bodies and the public, this variability may warrant closer attention.

The exact molecular mechanisms governing articular chondrocytes remain unknown in skeletal biology. In this study, we have found that ESET (an ERG-associated protein with a SET domain, also called SETDB1) histone methyltransferase is expressed in articular cartilage. To test whether ESET regulates articular chondrocytes, we carried out mesenchyme-specific deletion of the ESET gene in mice. ESET knock-out did not affect generation of articular chondrocytes during embryonic development. Two weeks after birth, there was minimal qualitative difference at the knee joints between wild-type and ESET knock-out animals. At 1 month, ectopic hypertrophy, proliferation, and apoptosis of articular chondrocytes were seen in the articular cartilage of ESET-null animals. At 3 months, additional signs of terminal differentiation such as increased alkaline phosphatase activity and an elevated level of matrix metalloproteinase (MMP)-13 were found in ESET-null cartilage. Staining for type II collagen and proteoglycan revealed that cartilage degeneration became progressively worse from 2 weeks to 12 months at the knee joints of ESET knock-out mutants. Analysis of over 14 pairs of age- and sex-matched wild-type and knock-out mice indicated that the articular chondrocyte phenotype in ESET-null mutants is 100% penetrant. Our results demonstrate that expression of ESET plays an essential role in the maintenance of articular cartilage by preventing articular chondrocytes from terminal differentiation and may have implications in joint diseases such as osteoarthritis.

Background: To date, very few experimental studies have addressed the effect of bone drilling technique and sequence on dental implant osseointegration. In this study, we hypothesized that there would be no differences in osseointegration when reducing the number of drills for osteotomy compared to the conventional drilling protocols. Methods: Seventy-two implants (diameter 3.75 mm and diameter 4.2 mm, n=36 for each diameter) were bilaterally placed in the tibia of 18 beagles for 1, 3, and 5 weeks. Half of the implants of each diameter were placed using a simplified drilling procedure (pilot and final drill) and the other half were placed using a conventional drilling procedure (all drills in sequence). The retrieved samples were subjected to histologic/histomorphometric evaluation. Results: Histology showed that new bone formed around the implant and inflammation or bone resorption was not evident for both groups. Histomorphometrically, the simplified group presented significantly higher bone-to-implant contact and bone area fraction occupancy as compared to the conventional group after 1 week, however, no differences were detected at 3 and 5 weeks. Conclusion: It can be suggested that bone responses to the implant with the simplified protocol is comparable to the conventional protocol.

INTRODUCTION: Many surgeons fear that closed-suction drains serve as a portal for bacterial entry into surgical spaces. Despite a lack of supporting evidence, postoperative antibiotics are often prolonged while drains remain in place. METHODS: Medical records of all patients who underwent intraoperative Jackson-Pratt drain placement and sterile removal over a 12-month period were prospectively analyzed. RESULTS: Fifty-four patients with 101 drains were included. Drains were in place for 5 to 43 days [mean (SD), 13.5 (6.3) days]. Sixty-three percent of drains had positive cultures. All patients received perioperative antibiotics. Thirty-nine patients received postoperative antibiotics [mean (SD), 13.8 (13.8) days]. There were 2 cases of cellulitis. One patient required reoperation. CONCLUSIONS: Sixty-six drains (65.3%) were placed in the presence of prosthetic material. Although nearly two thirds of drains were colonized with bacteria, our wound infection rate was extremely low (5.6%). Thus, closed-suction drains may be left in place for an extended period without increasing the risk of infection, even in the presence of prosthetic material.

OBJECTIVE: This study evaluated the effect of drilling speed on early bone healing in dog tibiae. STUDY DESIGN: Thirty-six implants (4.0-mm diameter x 10-mm length) were placed in the proximal tibiae of 6 beagles with drilling speeds of 100, 500, and 1000 rpm, and insertion torque was recorded. Bone-to-implant contact (BIC) and bone area fraction occupancy (BAFO) were evaluated. RESULTS: Significant increase from 1 to 3 weeks was observed for all groups for BIC, whereas no significant differences between 1 and 3 weeks were detected for the 100- and 500-rpm groups for BAFO (P > .34 and P > .46, respectively). A significant difference from 1 to 3 weeks was observed for the 1000-rpm group (P < .03). The 100- and 500-rpm groups presented significantly higher BAFO than the 1000-rpm group at 1 week (P = .002). CONCLUSIONS: Drilling speed is one of the decisive factors for early osseointegration, and overall, drilling at 1000 rpm seemed to yield the strongest biologic responses.