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2008 Annual Meeting Abstracts

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Frontal-Basilar Injury: A Novel Treatment Algorithm Based on Anatomical Fracture Pattern & Failure of Conventional Techniques
Eduardo D. Rodriguez, M.D., D.D.S, Matthew G. Stanwix, M.D., Arthur J. Nam, M.D, M.S., Hugo St. Hilaire, M.D., D.D.S, Oliver P. Simmons, M.D., Michael P. Grant, M.D., Paul N. Manson, M.D..
University of Maryland-R Adams Cowley Shock Trauma Center, Baltimore, MD, USA.

PURPOSE:
Management of frontal-basilar injury (FBI) has undergone significant evolution over the past 50 years. Complications of various treatment strategies have been reported, but the studies lack sufficient statistical power. We propose a statistically valid treatment protocol for FBI based on injury pattern, method of treatment, and observed complication(s).
METHODS:
An IRB approved retrospective review was conducted on FBI patients admitted to two large academic centers from 1988 - 2005. Fractures were categorized by location, displacement, comminution, and nasofrontal duct (NFD) involvement. Treatments and their associated complications were compiled. Demographic data including age, sex, mechanism of injury (MOI), length of stay (LOS), injury severity score (ISS), admission glasgow coma scale (GCS), associated injuries and mortality were also collated. Associations were based on Pearson’s correlation coefficients, outcome measures evaluated by Chi Square and Student’s t-tests using continuous variables.
RESULTS:
1,097 FBI patients were identified, 87 expired and 136 excluded for insufficient data, leaving a study cohort of 874 patients. Average age was 33.5 years (88% male) and motor vehicle collision was the predominant MOI (42%). NFD injury was found in most patients (71.3%), and strongly associated with posterior wall involvement (91%), and anterior table displacement (68%, comminuted 88%). 521 patients (47.5%) had surgical management with 10.4% complication rate and 353 observed with 3.1% complication rate. All patients with complications except one had NFD injury (98.5%). The most common injury pattern was simultaneous anterior-posterior displaced (39.4%). Those patients with NFD involvement were best managed by obliteration or cranialization (complications of 8.9% and 8.4%, p <0.05 compared to all data). Obliteration with fat, and osteoneogenesis had the highest complication rates (22% and 42.9% respectively). Isolated anterior fractures, either non-displaced (AND) or displaced (AD) without NFD injury were best managed by observation (no complications, p<0.05), while AND or AD with NFD injury were best managed by reconstruction, cranialization, or obliteration. Isolated posterior fractures did not have a statistically significant treatment preference, except those without NFD involvement could be safely observed. Anterior-posterior fractures, non-displaced (APND) with intact NFD could be safely observed (p<0.05), and those with NFD injuries should be treated by obliteration, cranialization, or observation. Anterior-posterior displaced injuries with NFD involvement were best managed by obliteration or cranialization (11.8%, 9.5% complications, p value <0.05). Five patients suffering infectious complications (one acute and four persistent) with bony and soft tissue sequelae, had successful resolution following a one-staged procedure that included debridement and simultaneous free tissue transfer with no subsequent complications.
CONCLUSION:
An algorithm for treatment of FBI was statistically validated. Patients without NFD injury can be safely observed, however those with a NFD injury appear to have a better outcome if treated according to the algorithm. Based on the analyses, osteoneogenesis or obliteration with fat appears to be associated with an unacceptable complication rate. A single stage approach that obliterates the sino-nasal cavity with vascularized free tissue holds promise.


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