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1.  Enoxaparin Prevents Steroid-Related Avascular Necrosis of the Femoral Head 
The Scientific World Journal  2014;2014:347813.
Nontraumatic osteonecrosis of the femoral head is still a challenging problem in orthopedic surgery. It is responsible for 10% of the 500,000 hip replacement surgeries in the USA and affects relatively young, active patients in particular. Main reasons for nontraumatic osteonecrosis are glucocorticoid use, alcoholism, thrombophilia, and hypofibrinolysis (Glueck et al., 1997; Orth and Anagnostakos, 2013). One pathomechanism of steroid-induced osteonecrosis is thought to be impaired blood flow to the femoral head caused by increased thrombus formation and vasoconstriction. To investigate the preventive effect of enoxaparin on steroid-related osteonecrosis, we used male New Zealand white rabbits. Osteonecrosis was induced by methylprednisolone-injection (1 × 20 mg/kg body weight). Control animals were treated with phosphate-buffered saline. Treatment consisted of an injection of 11.7 mg/kg body weight of enoxaparin per day (Clexane) in addition to methylprednisolone. Four weeks after methylprednisolone-injection the animals were sacrificed. Histology (hematoxylin-eosin and Ladewig staining) was performed, and empty lacunae and histological signs of osteonecrosis were quantified. Histomorphometry revealed a significant increase in empty lacunae and necrotic changed osteocytes in glucocorticoid-treated animals as compared with the glucocorticoid- and Clexane-treated animals and with the control group. No significant difference was detected between the glucocorticoid and Clexane group and the control group. This finding suggests that cotreatment with enoxaparin has the potential to prevent steroid-associated osteonecrosis.
PMCID: PMC4106066  PMID: 25110730
2.  The accuracy of computer-assisted primary mandibular reconstruction with vascularized bone flaps: iliac crest bone flap versus osteomyocutaneous fibula flap 
The intention of mandibular reconstruction is to restore the complex anatomy with maximum possible functionality and high accuracy. The aim of this study was to evaluate the accuracy of computer-assisted surgery in primary mandibular reconstruction with an iliac crest bone flap compared with an osteomyocutaneous fibula flap.
Materials and methods
Preoperative computed tomography data of the mandible and the iliac crest or fibula donor site were imported into a specific surgical planning software program. Surgical guides were manufactured using a rapid prototyping technique for translating the virtual plan, including information on the transplant dimensions and shape, into real-time surgery. Using postoperative computed tomography scans and an automatic surface-comparison algorithm, the actual postoperative situation was compared with the preoperative virtual simulation.
The actual flap position showed a mean difference from the virtual plan of 2.43 mm (standard deviation [SD] ±1.26) and a surface deviation of 39% <2 mm and 15% <1 mm for the iliac crest bone flap, and a mean difference of 2.18 mm (SD ±1.93) and a surface deviation of 60% <2 mm and 37% <1 mm for the osteomyocutaneous fibula flap. The position of the neomandible reconstructed with an osteomyocutaneous fibula flap indicated a mean difference from the virtual plan of 1.25 mm (SD ±1.31) and a surface deviation of 82% <2 mm and 57% <1 mm, in contrast to a mean difference of 1.68 mm (SD ±1.25) and a surface deviation of 63% <2 mm and 38% <1 mm for the neomandible after reconstruction with an iliac crest bone flap. For shape analysis, a similarly high accuracy could be calculated for both flaps.
Virtual surgical planning is an effective method for mandibular reconstruction with vascularized bone flaps, and can help to restore the anatomy of the mandible with high accuracy in position and shape. It seems that primary mandibular reconstruction with the osteomyocutaneous fibula flap is more accurate compared with the vascularized iliac crest bone flap.
PMCID: PMC4064953  PMID: 24966700
computer-assisted surgery; virtual planning; vascularized bone flaps; surgical guide; primary mandibular reconstruction
3.  Evaluation of computer-assisted mandibular reconstruction with vascularized iliac crest bone graft compared to conventional surgery: a randomized prospective clinical trial 
Trials  2014;15:114.
Computer-assisted surgery plays an increasingly important role in mandibular reconstruction, ensuring the best possible masticatory function and aesthetic outcome.
Twenty patients were randomly assigned to computer-assisted or conventional mandibular reconstruction with vascularized iliac crest bone graft in a prospective study design.
Virtual surgical planning was based on preoperative CT-data using specific surgical planning software. A rapid prototyping guide transferred the virtual surgery plan to the operation site. During surgery the transplant ischemic time, reconstruction time, time for shaping the transplant and amount of bone removed were measured. Additionally, the difference in the intercondylar distance before and after surgery was calculated.
Computer-assisted surgery shortened the time of transplant ischemia (P < 0.005) and defect reconstruction (P < 0.001) compared to conventional surgery. The time to saw and shape the transplant at the donor site was shorter using conventional surgery (P < 0.005); therefore, the overall time for surgery didn’t change (P = 0.527). In the computer-assisted group, the amount of bone harvested equaled the defect size, whereas the transplant size in the conventional group exceeded the defect site by 16.8 ± 5.6 mm (P < 0.001) on average. The intercondylar distance before compared to after surgery was less affected in the computer-assisted than in the conventional group (P < 0.001).
The presented study shows that computer-assisted surgery can help reduce the time for mandibular defect reconstruction and consequently the transplant ischemic time. In the computer-assisted group, the iliac crest donor site defect was downsized and the postoperative condyle position was less altered, reducing possible risks of postoperative complications and donor site morbidity.
Trial Registration
PMCID: PMC3998950  PMID: 24716651
Computer-assisted surgery; Mandibular reconstruction; Vascularized iliac crest bone graft; Surgical guide; Virtual planning
4.  Lateral nasal osteotomy: a comparative study between the use of osteotome and a diamond surgical burr - a cadaver study 
Head & Face Medicine  2013;9:41.
The ultimate goal of rhinoplasty is to achieve a controllable, reliable and an aesthetically pleasing result. Various approaches and instruments have been introduced for the correction of the bony walls of the nose to improve predictability of the procedure and to minimize the associated trauma. We conducted a cadaveric study comparing the results of osteotomy of the nasal wall using a diamond surgical burr with those using a 2-mm osteotome.
Material and methods
Bilateral osteotomy of the nasal wall was performed on 10 cadavers. The 20 lateral nasal osteotomies were carried out on 7 females and 3 males of an age range between 61-91 years. A 2-mm osteotome was used percutaneously to perforate the lateral nasal wall of the right side. On the left side a 2-mm diamond surgical burr was introduced via an intraoral approach to thin out the lateral nasal wall. The in-fracture of the nasal bone was accomplished by controlled finger pressure. The nasal mucosa was inspected endoscopically and also dissected to identify any perforations or lacerations. The pattern of nasal fracture and the presence of any fragmentation of the bony segments were assessed clinically.
The in-fracturing of the nasal bone was accomplished by gentle pressure on the left side, but required more force on the contra lateral side. On the left side the in-fractured lateral nasal wall remained as one piece and no irregularities were seen. On the right side 3-5 bony fragments of irregular sizes and shapes were detected. There were 3-4 tears of the nasal mucosa, where the osteotome was applied. However, no mucosal tears were detected at the side, where the surgical burr was used.
Osteotomy of the lateral nasal wall with a diamond burr via intraoral approach is more precise and associated with fewer complications in comparison with the use of the osteotome.
PMCID: PMC3878258  PMID: 24354807
Lateral osteotomy; Osteotome; Diamond burr
5.  Three-dimensional evaluation of postoperative swelling in treatment of zygomatic bone fractures using two different cooling therapy methods: a randomized, observer-blind, prospective study 
Trials  2013;14:238.
Surgical treatment and complications in patients with zygomatic bone fractures can lead to a significant degree of tissue trauma resulting in common postoperative symptoms and types of pain, facial swelling and functional impairment. Beneficial effects of local cold treatment on postoperative swelling, edema, pain, inflammation, and hemorrhage, as well as the reduction of metabolism, bleeding and hematomas, have been described.
The aim of this study was to compare postoperative cooling therapy applied through the use of cooling compresses with the water-circulating cooling face mask manufactured by Hilotherm in terms of beneficial impact on postoperative facial swelling, pain, eye motility, diplopia, neurological complaints and patient satisfaction.
Forty-two patients were selected for treatment of unilateral zygomatic bone fractures and were divided randomly to one of two treatments: either a Hilotherm cooling face mask or conventional cooling compresses. Cooling was initiated as soon as possible after surgery until postoperative day 3 and was applied continuously for 12 hours daily. Facial swelling was quantified through a three-dimensional optical scanning technique. Furthermore, pain, neurological complaints, eye motility, diplopia and patient satisfaction were observed for each patient.
Patients receiving a cooling therapy by Hilotherm demonstrated significantly less facial swelling, less pain, reduced limitation of eye motility and diplopia, fewer neurological complaints and were more satisfied compared to patients receiving conventional cooling therapy.
Hilotherapy is more efficient in managing postoperative swelling and pain after treatment of unilateral zygomatic bone fractures than conventional cooling.
Trial registration
German Clinical Trials Register ID: DRKS00004846
PMCID: PMC3729713  PMID: 23895539
Zygomatic bone fracture; Three-dimensional optical scanner; Hilotherm; Conventional cooling
6.  Carotid sinus syndrome as the presenting symptom of cystadenolymphoma 
Head & Face Medicine  2012;8:31.
Carotid sinus syndrome is a serious manifestation of head and neck malignancy. The purpose of this study was to clarify the presence of carotid sinus syndrome in a patient with cystadenolymphoma. To our knowledge carotid sinus syndrome secondary to cystadenolymphoma has not been reported to date. A 45-year-old woman with one-week-old swelling in the left mandibular angle having disturbing symptoms of vertigo, consciousness and sinus arrest. Holter monitoring revealed several episodes of sinus arrest. Ultrasonography showed a well-defined space-occupying lesion of about 31 mm in length and 17 mm in width located in the deep lobe of the left parotid gland. Computerized tomography (CT) showed a large mass extending into the carotid space and protruding into the parapharyngeal space. Parotidectomy was performed. Surgical removal of the tumor resulted in complete amelioration of symptoms and disappearance of electrocardiogram abnormalities. Here we report on a clinical case of carotid sinus syndrome associated with cystadenolymphoma. To our knowledge carotid sinus syndrome secondary to cystadenolymphoma has not been reported to date, and is made more remarkable as a possible differential diagnosis after clarification of all possible causes. Early diagnosis and immediate management can minimize complications.
PMCID: PMC3528468  PMID: 23151249
Cystadenolymphoma; Warthin’s tumor; Parotid gland tumors; Syncope; Carotid sinus syndrome
7.  Arthroscopy or ultrasound in undergraduate anatomy education: a randomized cross-over controlled trial 
BMC Medical Education  2012;12:85.
The exponential growth of image-based diagnostic and minimally invasive interventions requires a detailed three-dimensional anatomical knowledge and increases the demand towards the undergraduate anatomical curriculum. This randomized controlled trial investigates whether musculoskeletal ultrasound (MSUS) or arthroscopic methods can increase the anatomical knowledge uptake.
Second-year medical students were randomly allocated to three groups. In addition to the compulsory dissection course, the ultrasound group (MSUS) was taught by eight, didactically and professionally trained, experienced student-teachers and the arthroscopy group (ASK) was taught by eight experienced physicians. The control group (CON) acquired the anatomical knowledge only via the dissection course. Exposure (MSUS and ASK) took place in two separate lessons (75 minutes each, shoulder and knee joint) and introduced standard scan planes using a 10-MHz ultrasound system as well as arthroscopy tutorials at a simulator combined with video tutorials. The theoretical anatomic learning outcomes were tested using a multiple-choice questionnaire (MCQ), and after cross-over an objective structured clinical examination (OSCE). Differences in student’s perceptions were evaluated using Likert scale-based items.
The ASK-group (n = 70, age 23.4 (20–36) yrs.) performed moderately better in the anatomical MC exam in comparison to the MSUS-group (n = 84, age 24.2 (20–53) yrs.) and the CON-group (n = 88, 22.8 (20–33) yrs.; p = 0.019). After an additional arthroscopy teaching 1% of students failed the MC exam, in contrast to 10% in the MSUS- or CON-group, respectively. The benefit of the ASK module was limited to the shoulder area (p < 0.001). The final examination (OSCE) showed no significant differences between any of the groups with good overall performances. In the evaluation, the students certified the arthroscopic tutorial a greater advantage concerning anatomical skills with higher spatial imagination in comparison to the ultrasound tutorial (p = 0.002; p < 0.001).
The additional implementation of arthroscopy tutorials to the dissection course during the undergraduate anatomy training is profitable and attractive to students with respect to complex joint anatomy. Simultaneous teaching of basic-skills in musculoskeletal ultrasound should be performed by medical experts, but seems to be inferior to the arthroscopic 2D-3D-transformation, and is regarded by students as more difficult to learn. Although arthroscopy and ultrasound teaching do not have a major effect on learning joint anatomy, they have the potency to raise the interest in surgery.
PMCID: PMC3473305  PMID: 22958784
Arthroscopy; Education, Anatomic competence, Randomized controlled trial, Knee joint, Shoulder joint, Students; Medical, Musculoskeletal ultrasound
8.  Bone remodeling to correct maxillary deficiency after growth cessation 
This case report presents a 22-year-old girl with class III malocclusion due to maxillary deficiency. The patient was referred for presurgical orthodontics; however, she rejected the surgery. This case was treated by means of Tongue appliance and slow palatal expansion, followed by lower fixed appliance, reverse chin cup, and upper fixed appliance. Tongue appliance and slow palatal expansion were used at the beginning of the treatment. After 6 months, reverse chin cup and lower fixed appliance were added. Six months later reverse chin cup was removed and upper fixed appliance was mounted. Positive overbite and over jet were achieved after 24 months of active treatment. Nasolabial angle also showed improvement. Nonsurgical treatment of adult class III patients is a difficult procedure; however, this patient was treated nonsurgically.
PMCID: PMC3700158  PMID: 23833499
Bone remodeling; class III malocclusion; growth modification; maxillary deficiency; nonsurgical treatment
9.  Analysis of trigeminal nerve disorders after oral and maxillofacial intervention 
Head & Face Medicine  2010;6:24.
Quantitative sensory testing (QST) is applied to evaluate somatosensory nerve fiber function in the spinal system. This study uses QST in patients with sensory dysfunctions after oral and maxillofacial surgery.
Orofacial sensory functions were investigated by psychophysical means in 60 volunteers (30 patients with sensory disturbances and 30 control subjects) in innervation areas of the infraorbital, mental and lingual nerves. The patients were tested 1 week, 4 weeks, 7 weeks and 10 weeks following oral and maxillofacial surgery.
QST monitored somatosensory deficits and recovery of trigeminal nerve functions in all patients. Significant differences (p < 0.05) between control group and patients were shown for cold, warm and mechanical detection thresholds and for cold, heat and mechanical pain thresholds. Additionally, QST monitored recovery of nerve functions in all patients.
QST can be applied for non-invasive assessment of sensory nerve function (Aβ-, Aδ- and C-fiber) in the orofacial region and is useful in the diagnosis of trigeminal nerve disorders in patients.
PMCID: PMC2984556  PMID: 20977760

Results 1-9 (9)