广泛头皮深度烧伤伴颅骨全层坏死的治疗

我们自１９９０年４月至１９９３年５月共治疗８例广泛头皮深度烧伤伴有颅骨全层坏死的病例，早期经头颅ＣＴ及￣９９ｍ锝同位素颅骨扫描检查明确颅内损伤及颅骨坏死范围后，采用吻合血管的血流量大的肌皮瓣或游离皮瓣移植，在保留坏死颅骨情况下Ⅰ期修复创面。８例中４例创面Ⅰ期愈合，另３例在已愈合皮瓣保护下多次清创去除死骨。经术后１～４年随访表明，坏死颅骨作为修复支架保留，避免了颅骨缺损可能造成的并发症及后遗症。本组仅１例于入院后２４ｈ因颅脑严重损伤而死亡。我们所介绍的这一方法为类似严重病例的治疗提供了有效手段。     

Preservation of devitalized calvarium following high-voltage electrical injury: case reports

Three victims of electrical injury with necrosis of a portion of the skull had excision of overlying necrotic soft tissue soon after injury with immediate coverage of the devitalized bone with soft-tissue flaps. In two instances, the flap was from adjacent scalp; in the other a free myocutaneous flap was used. All wounds healed without sequestration of bone. Necrosis of the calvarium was substantiated by evidence of nonperfusion on a radionucleotide bone scan. In each instance, a followup bone scan showed evidence of regeneration of bone. This experience supports an earlier observation which suggested that devitalized but intact calvarium following electrical injury does not need to be removed and is the perfect in situ bone graft.     

Management of acute calvarial burns in children

BACKGROUND: Although rare, head burns involving the calvarium are a serious complication of burns and electrical injury, and present therapeutic challenges to the surgical burn care team. We evaluated our experiences and compared available strategies to address this challenge. METHODS: Records of all burned children between January 1986 and December 2000 were reviewed. Twenty-seven children (15 boys and 12 girls) with scalp burns extending at least into the outer table of bone were identified and compared with a matched group of 30 patients admitted for acute thermal burns without skull injury. RESULTS: Flame burn was the injury mechanism in 78% of these patients and electrical injury was the injury mechanism in 22%. The incidence of calvarial burns in our patient population was 1.2% for thermal burns and 5.6% for electrical injuries during the study period. The age distribution was biphasic, with maximums in infancy for thermal burns and in puberty for electrical injuries. Eight of 27 patients (29.6%) developed full-thickness calvarial bone defects. In 23 patients, calvarial burn wound coverage was achieved with bone debridement and immediate or delayed placement of autograft skin. In four patients (all with electrical injury), local scalp flaps were required for closure. The length of hospital stay and overall number of acute operative procedures significantly increased for patients with calvarial burns. CONCLUSION: Acute calvarial burns are safely managed by bone debridement in combination with staged autografting or early flap coverage. Although flap coverage reduces the number of required procedures, the extensive wound size in thermal burns restricts acute flap procedures primarily to electrical injuries. Compared with patients without skull injury, length of hospital stay and the number of acute operative procedures are tremendously increased in patients with calvarial burns.     

Regeneration of full layer necrosis of the skull following high voltage electrical injury

Scalp and skull necrosis often follow high voltage electrical injury to the head. Classically reconstruction of the scalp and skull is performed after sequestration of the necrotic bone. The relatively frequent complication of epidural infection, however, detracts from this approach. As an alternative we have attempted to induce regeneration of devitalized bone by covering it with a vascular tissue flap. A typical patient is described in this report with results which indicate that at least partial regeneration of the necrotic tissue can occur, thus one-stage management of such wounds is possible.     

Calvarial bone cavernous hemangioma with intradural invasion: An unusual aggressive course—Case report and literature review

IntroductionCavernous hemangioma of the skull is a rare pathological diagnosis, accounting for 0.2% of bone tumors and 7% of skull tumors. Usually calvarial bone cavernous hemangioma are associated with a benign clinical course and, despite their enlargement and subsequent erosion of the surrounding bone, the inner table of the skull remains intact and the lesion is completely extracranial.Presentation of a caseThe authors present the unique case of a huge left frontal bone cavernous malformation with intradural extension and brain compression determining a right hemiparesis.DiscussionCalvarial cavernous hemangiomas are benign tumors. They arise from vessels in the diploic space and tend to involve the outer table of the skull with relative sparing of the inner table. More extensive involvement of the inner table and extradural space is very unusual and few cases are reported in literature. To the best of our knowledge, intradural invasion of calvarial hemangioma has not been previously reported.ConclusionOur case highlights the possibility of an aggressive course of this rare benign pathology.     

Burns of the skull with underlying intracranial meningioma.

A 68-year-old white-skinned male fell head first into a fireplace while having a seizure. Extensive burns of the skull were sustained requiring removal of the necrotic bone. The patient had an underlying meningioma. Healing of the skull was obtained using a latissimus dorsi flap. After the scalp was completely healed, the meningioma was successfully resected with significant improvement in the patient's mental function.     

A case of congenital skull defect complicated with arachnoid cyst]

A 3-month-old boy was referred to our hospital with left temporal bone defect and bulging skin. The skull defect had been recognized since birth. There was no family history of any congenital anomaly and his physical development was normal for his age. His bulged left temporal region was covered by normal skin and a skull defect measuring 2 x 2 cm in size was palpated at the center. CT scan revealed skull defect at the pterion accompanied with widening of the middle cranial fossa. Arachnoid cyst of the middle cranial fossa was also suspected. The skull defect gradually enlarged and especially on crying the left temporal skin bulging became more marked. The bone edge of the defect was thin and was deflected outward. The operation was planned and performed at the age of 11 months. After excision and fenestration of the arachnoid cyst, duraplasty and cranioplasty were performed using split-thickness calvarial bone graft. Splitting the frontal calvarial bone suitable for the defect, the outer table was returned to the donor site, and the inner table was fixed into the defect. Follow-up CT one year after surgery revealed a satisfactory cosmetic result and no bone resorption. Split calvarium cranioplasty is considered to be even more useful in an infant.     

Hemispheric brain volume replacement with free latissimus dorsi flap as first step in skull reconstruction

Large skull defects lead to progressive depression deformities, with resulting neurological deficits. Thus, cranioplasty with various materials is considered the first choice in therapy to restore cerebral function. A 31-year-old female presented with a massive left-sided hemispheric substance defect involving bone and brain tissue. Computed tomography showed a substantial convex defect involving the absence of calvarial bone as well as more than half of the left hemisphere of the brain, with a profound midline shift and a compression of the ventricular system. There was a severe problem due to multiple deep-skin ulcerations at the depression margin, prone to skin perforation with a probability of intracranial infection. In a first step, a free myocutaneous latissimus dorsi flap was transplanted for volume replacement of the hemispheric brain defect, and 4 months later, artificial bone substitute was implanted in order to prevent progressive vault depression deformity. Healing was uneventful, and the patient showed definite neurological improvement postoperatively. Free tissue transfer can be a valuable option in addition to cranioplasty in the treatment of large bony defects of the skull. Besides providing stable coverage for the reconstructed bone or its substitute, it can also serve as a volume replacement.     

Development of flattening and apparent fragmentation following ischemic necrosis of the capital femoral epiphysis in a piglet model

BACKGROUND: The repair response that follows ischemic necrosis of the immature femoral head and the biological processes that are responsible for the development of femoral head deformity and fragmentation have not been clearly defined. A piglet model was used to study the radiographic and histopathologic changes that occur prior to and during the development of femoral head deformity and fragmentation following ischemic necrosis. METHODS: Twenty-five male piglets were studied. A nonabsorbable ligature was placed tightly around the femoral neck to disrupt the blood supply to the capital femoral epiphysis. The animals were killed three days to eight weeks following the induction of ischemia. Radiographs of whole and sectioned femoral heads were made, and the radiographic findings were correlated with the histopathologic changes observed in the specimens. RESULTS: Mild femoral head flattening was observed by four weeks after the induction of ischemia, and severe flattening and fragmentation were observed by eight weeks. The predominant repair response observed following revascularization was osteoclastic bone resorption. Prior to the development of flattening, a large area of osteoclastic bone resorption was observed in the central region of the femoral head. Many osteoclasts were present along the revascularization front, which we believe were responsible for active resorption of the necrotic trabecular bone. Appositional new-bone formation, the hallmark of the repair response in adult ischemic necrosis, was not observed in the area of bone resorption. Instead, the areas of resorbed bone were replaced with a fibrovascular tissue that persisted for up to eight weeks. Appositional new-bone formation was observed, but it was limited to small areas in which revascularization was not followed by osteoclastic bone resorption and in which necrotic trabecular bone was still present. The simultaneous presence of the areas of bone resorption and new-bone formation contributed to the fragmented radiographic appearance of the femoral head. CONCLUSIONS: The predominant repair response observed in the piglet model of ischemic necrosis was osteoclastic bone resorption. The early bone loss, the lack of new-bone formation, and the persistence of fibrovascular tissue in the areas of bone resorption compromised the structural integrity of the femoral head and produced progressive femoral head flattening over time. The repair response was different from that observed in femoral heads removed from adult patients with ischemic necrosis and from that observed in the adult rabbit model of ischemic necrosis. Clinical Relevance: The piglet model of ischemic necrosis may be useful for the investigation of the biological processes that lead to the development of femoral head deformity following ischemic necrosis of the immature femoral head.     

Restoration of the mandible by full-thickness calvarial bone flap.

Two patients with reconstruction of a massive mandibular defect with vascularized full-thickness calvarial bone flaps are reported. In Patient 1, the mandibular body developed osteomyelitis and once was replaced with a metallic prosthesis. The prosthesis later perforated the skin and was removed. Full-thickness calvarial bone flaps were elevated bilaterally to reconstruct the mandibular body. In Patient 2, the mandible was totally destroyed by invasion of squamous cell carcinoma. The lower one-half of the face was resected and replaced with a large island scalp flap with full-thickness calvarial bone.     

自体颅骨外板、下颌骨外板整复颅颌面创伤后继发鼻畸形

目的　探讨自体颅骨外板、下颌骨外板移植在颅颌面创伤后继发鼻畸形矫正中的应用。方法　 1997～ 2 0 0 2年我们对 4 4例颅颌面创伤合并鼻畸形患者 ,运用颅颌面外科诊断和手术技术 ,为其恢复颅颌面骨性轮廓结构 ,同时运用自体颅骨外板或下颌骨外板移植重建鼻支架矫正鼻畸形。结果　所有病例伤口均一期愈合 ,治疗效果满意。经 6个月～ 2年随访观察 ,无感染、无鼻背皮肤红肿坏死、支架无外露及移位 ,骨吸收不明显 ,供区无并发症发生。结论　自体颅骨外板、下颌骨外板采取方便 ,切口隐蔽 ,并发症少 ,特别适用于外伤后严重鼻畸形的矫正 ,是一种理想的移植材料。     

Regenerative response to membranous and enchondral lyophilized allogeneic bone in rabbit skull defects.

The regenerative responses of inlays of lyophilized allogeneic bone of membranous (skull) and enchondral (tibia) origin were studied in an experimental cranioplasty model in rabbits. The lyophilized bone particles were also bioassayed for inductive bone production in an orthotopic critical size defect rat model. Three trephined calvarial defects were evaluated in each of 14 adult rabbits. The experimental materials were implanted into two of the defects and the third was left empty for control purposes. The implants disclosed no major structural divergences as assessed by scanning electron microscopy. Healing was evaluated by light microscopy and contact radiography after periods of four and 15 weeks. The lyophilized bone allografts of both embryonic origins displayed a similar fashion of bone regeneration, bone marrow reappearance, and volumetric density of trabecular bone substance and displayed no obvious differences between experimental groups or intervals. The two materials exhibited low osteoinductive potential.     

Intramedullary haemorrhage as a possible cause of avascular necrosis of the femoral head. The histology of 16 femoral heads at the silent stage

We have studied core biopsy specimens from 16 femoral heads affected by idiopathic avascular necrosis at the silent stage, when there were no clinical or radiographic manifestations but scintigraphy was positive. All the specimens showed necrosis of trabeculae and of bone marrow, but the most common and characteristic feature was evidence of old and new haemorrhage in the marrow. In the areas of intramedullary haemorrhages, trabeculae and bone marrow were completely necrotic, with a transitional area of incomplete necrosis between these areas and those without haemorrhagic lesions, where the trabeculae and bone marrow were normal. There was good correlation between necrosis and haemorrhagic episodes, and it was concluded that repeated intramedullary haemorrhage at the silent stage is probably related to the pathogenesis of idiopathic avascular necrosis of the femoral head.     

Magnetic resonance imaging and histopathology in femoral head necrosis

We correlated preoperative magnetic resonance (MR) images and histopathology of eight femoral heads from patients with osteonecrosis. The signal intensity of the MR image was low in the area where fibrovascular tissue, disintegrated fibrovascular tissue, or amorphous necrotic material occupied the medullary space. On the other hand, the necrotic marrow without revascularization showed high signal intensity. Osteonecrosis can be detected by MR imaging as soon as a certain amount of bone marrow is replaced by fibrovascular tissue.     

Magnetic resonance imaging and histopathology in femoral head necrosis

We correlated preoperative magnetic resonance (MR) images and histopathology of eight femoral heads from patients with osteonecrosis. The signal intensity of the MR image was low in the area where fibrovascular tissue, disintegrated fibrovascular tissue, or amorphous necrotic material occupied the medullary space. On the other hand, the necrotic marrow without revascularization showed high signal intensity. Osteonecrosis can be detected by MR imaging as soon as a certain amount of bone marrow is replaced by fibrovascular tissue.     

Infection rate with replacement of bone fragment in compound depressed skull fractures

BACKGROUND: Traditional management of compound depressed skull fractures entails elevation and removal of all bone fragments with delayed cranioplasty. Bone fragment removal is intended to reduce the potential for infection. However, bone fragment removal often necessitates a second operation to repair the resultant calvarial defect. This study examines the postoperative infection rate when bone fragments are replaced primarily. METHODS: A retrospective study was carried out of all patients admitted with the diagnosis of compound depressed skull fracture to a university hospital from 1991 to 1996. RESULTS: Of 52 patients with the diagnosis of compound depressed skull fracture treated at our university hospital over the past 5 years, 32 underwent elevation and repair within 72 hours. All patients except one received antibiotics during surgery and for at least 1.5 days after surgery. Follow-up averaged just over 22 months. In all 32 consecutive patients treated with debridement and elevation of compound depressed skull fractures with primary replacement of bone fragments within 72 hours of injury, there were no infectious sequelae. CONCLUSIONS: Immediate replacement of bone fragments in compound depressed skull fractures does not increase the risk of infectious complications.     

Free vascularized corticoperiosteal bone graft for the treatment of persistent nonunion of the clavicle

Radiation-induced necrosis or infection can result in a persistent nonunion of the clavicle. We describe 3 cases in which a free vascularized corticoperiosteal flap was harvested from the medial aspect of the femoral condyle and transferred to the fractured clavicle by use of microvascular anastomoses. Healing was confirmed by tomography in all 3 patients. The function of the upper extremity was remarkably improved at final follow-up. Vascularized free corticoperiosteal bone flaps are an option in clavicle fracture treatment. The technique of periosteal grafting is ideally suited to chronic nonunions with poor chances of healing on their own. Rapid subperiosteal new bone and improved local blood flow serve to correct many of those changes attributed to necrosis of bone.     

Lateral nasal wall mucoperiosteal flap: a versatile new reconstruction of the inner defect of translocated facial bone segments

From July 1998 to December 2002, 42 patients (including 29 patients who had undergone radiation therapy) underwent a newly designed lateral nasal wall mucoperiosteal flap pedicled anteriorly on the lateral nasal artery of the angular artery to resurface a translocated facial bone segment during a facial translocation approach to the skull base to prevent its avascular necrosis. Of the 42 patients studied, 1 patient had full-thickness flap loss that resulted in bone graft necrosis. Another patient had marginal necrosis. The average length, width, and surface area of the flap was 30 mm, 45 mm, and 1350 mm measured on 5 patients. The mucoperiosteal flap tolerated radiation therapy well. The lateral nasal wall mucoperiosteal flap is a simple, reliable flap that provides ample vascularized tissue to resurface the nude translocated facial bone segment during a facial translocation approach to the skull base. It thus prevents its avascular necrosis even after radiation therapy.     

Extended pericranial flap and bone graft reconstruction in anterior skull base surgery.

OBJECTIVES: The objectives of this study was to establish a rationale for repairing large anterior skull base defects with an extended pericranial flap and split calvarial bone graft; to define large anterior skull base defects as those spanning the anterior cranial measuring at least 3.0 x 4.0 cm; and to describe the surgical technique and compare it with alternative strategies.Study design Thirty-four patients underwent anterior craniofacial resection of anterior skull-based tumors of varying histology with reconstruction using an extended pericranial flap and split calvarial bone graft. RESULTS: The survival of the pericranial flap and bone graft was maintained in 33 of 34 patients. There was 1 episode of postoperative cerebrospinal fluid leak, 1 episode of osteomyelitis of the bone graft and an epidural abscess, and 1 episode of asymptomatic pneumocephalus. CONCLUSION: Split calvarial bone graft with an extended pericranial flap is an effective technique for reconstructing large anterior skull base defects.     

Treatment of osteonecrosis of the femoral head by drilling and muscle-pedicle bone grafting

Sixty-one patients with 68 osteonecrotic femoral heads, at different stages of development, were treated surgically; their average age was 36 years. Necrosis followed a fracture in 43 hips and traumatic dislocation in three. It was idiopathic in 14, cortisone-induced in seven and associated with gout in one. The operation of multiple drilling, curettage of the necrotic bone and muscle pedicle bone grafting was performed in all. Cheilectomy of the superolateral part of the femoral head and adductor tenotomy were added in cases of advanced necrosis. Of the several types of muscle pedicle used, tensor fasciae latae anteriorly and quadratus femoris posteriorly were preferred. Full weight-bearing was not permitted for five to six months. The follow-up period varied from three to 12 years. Hip pain was regularly relieved and abduction and rotation of the joints were improved. Those with post-traumatic or idiopathic necrosis did better than those with cortisone-induced necrosis.