The impact of previous surgery on scaphoid nonunion reconstruction: a retrospective study of 95 cases

We retrospectively compared 64 scaphoid reconstructions in cases that had not undergone previous surgery with 31 cases in which previous surgery had been performed. The characteristics of the groups were similar except that there were more smokers in the group without previous surgery and a more frequent use of vascularized bone grafts in the group with previous surgery. At final follow-up, 66 and 65 months, respectively, after reconstruction, union incidence was 89% and 90%. In patients with previous surgery, grip strength was higher but not when expressed in percent of the contralateral hand. There were no differences in pinch strength, active wrist motion, functional scores, carpal height or scapholunate angle. We conclude that repeat surgery to the scaphoid did not seem to be a major risk factor for the overall outcomes, keeping in mind that a vascularized bone graft was more frequently used for secondary reconstructions.Level of evidence: III.

Splitting and Splaying Apart of the Craniomaxillofacial Skeleton by Medially Directed Disruptive Forces of Unusual Etiologies- A Case Series

Introduction

Extreme forces directed towards the centre of the facial region can produce devastating injuries, with disruption of the mandible, maxilla and naso-orbito-ethmoid complex, with or without frontal bone involvement. The magnitude and trajectory of the force and nature of the impacting object, dictate the degree of displacement and comminution of the craniomaxillofacial skeletal components, as well as the extent of soft tissue loss sustained.

Diagnosis & Challenges

To elucidate various challenges faced in the management of four cases of extreme craniomaxillofacial injuries, caused by centrally directed forces of rather unusual etiologies, namely, a traversing bullet, a bamboo rod, a heavy iron cattle tethering peg and a metal electrical pole. In each of the cases, the force of impact resulted in splitting and splaying apart of the facial skeleton, with a resultant increase in its transverse width, and an ensuing severe facial deformity and functional debility.

Rationale & Interventions

A ߢBottom-up, Outside-in' surgical sequence was employed to carry out reduction, fixation and reconstruction of the deranged maxillofacial skeletal architecture and restoration of the soft tissue morphology.

Outcomes & Lessons

The transverse dimensions of the flared out facial frames could be re-established and restored to their pre-trauma status successfully in all the cases, thereby achieving excellent esthetic and functional outcomes. Despite the extensive and serious nature of the injuries sustained, gross residual craniofacial defects, deformities and asymmetries, as well as debilitating functional deficits, could be effectively and successfully averted.

Maxillofacial reconstruction with prefabricated prelaminated osseous free flaps

BACKGROUND

The prefabricated fibula flap is an advanced method of occlusal-based reconstruction that combines placement of osseointegrated dental implants with prelamination, using a split skin graft on the fibula, weeks prior to the definitive reconstruction. This approach is resource intensive but has several advantages including eliminating the delay from reconstruction to dental rehabilitation.

METHODS

A retrospective cohort study of all prefabricated fibula flaps used for mandible and maxillary reconstruction from 2012 to 2020 was performed. Outcome measures were implant survival, implant utilization and functional dental rehabilitation.

RESULTS

A total of 17 prefabricated fibula flaps were performed including two analogue and 15 digital plans. There were nine maxillary and eight mandibular reconstructions, of which 11 were primary and seven were secondary. There were no free flap failures. A total of 65 implants were placed (average 3.8, median 3 implants). There was one implant failure at 6 years giving a 1.5% failure rate. There was 91% implant utilization and 94% functional dental rehabilitation.

CONCLUSION

The prefabricated fibula flap provides outstanding dental rehabilitation in well-selected patients.

Secondary Reconstruction of the Zygomaticomaxillary Complex

Zygomaticomaxillary (ZMC) fractures are the second most common facial fractures after nasal bone fractures. The zygoma, with its location and multiple points of articulations, lends itself to both facial structure and esthetics. Secondary ZMC deformities are complications of inadequate primary correction, delayed repair, or lack of repair. Secondary revisions of ZMC aim to correct ZMC displacement and projection and to address orbital discrepancies. Extensive correction involving significant orbital and malar defects requires zygomatic repositioning osteotomies and would greatly benefit from the utilization of virtual surgical planning, intraoperative navigation, and imaging. Minor corrections in malar projection can be corrected by onlay grafting and soft tissue augmentation and resuspension. Isolated or minor orbital corrections can be managed by autogenous or alloplastic material to restore lost orbital volume and anatomy.