保留骨膜对体内保存自体颅骨生理活性的影响

目的探讨保留骨膜对体内保存颅骨骨瓣生理活性的影响。方法 2012～2013年去骨瓣减压骨瓣均行体内皮下保存。2012年无骨膜组32例,颅骨骨瓣均未保留骨膜;2013年保留骨膜组35例颅骨骨瓣均保留骨膜,均于术后4～8周内早期行颅骨成形术,术后60个月内定期行CT检查,以观察自体颅骨愈合及骨吸收情况。结果 35例保留骨膜修补术病人颅骨均存活,骨愈合率高,修补术后1、6、12和24、60个月颅骨愈合率分别为0、54.3%、80%、100%、100%;术后颅骨吸收率均为0。无骨膜组修补术32例病人颅骨均存活,骨愈合率低,修补术后1、6、12和24、60个月颅骨愈合率分别为0%、18.8%、56.3%、81.3%、84.4%;术后5年随访有5例病人出现不同程度的颅骨吸收及颅骨塌陷,有3例病人再行钛网颅骨修补。结论保留骨膜颅骨骨瓣体内保存并早期原位回植能够保证回植颅骨骨瓣的生理活性,术后出现自体骨吸收几率低。     

自体深低温保存颅骨修复颅骨缺损的临床应用

目的观察16例去骨瓣减压术后颅骨缺损病人应用深低温保存自体颅骨作为修补材料修补缺损的效果。方法将游离颅骨骨瓣于术中在无菌条件下封存入两层无菌塑料袋中,术后转入-80℃深低温冰箱保存;修补颅骨缺损时,从深低温冰箱中取出,以碘伏浸泡消毒30分钟,用颅骨锁或钛板连接片固定颅骨。结果经深低温保存颅骨骨瓣未缩小。16例自体颅骨移植病例切口均呈甲类愈合,外形美观,无感染、无皮下积液。术后头部CT三维重建显示颅骨骨缝对合严密,ECT99mTc-MDP静态显像移植骨区放射性核素浓聚。结论自体深低温保存颅骨能有效修复去骨瓣减压术后的颅骨缺损;移植骨瓣可以存活。     

自体颅骨瓣修补颅骨缺损68例

目的探讨自体颅骨瓣修补颅骨缺损的疗效。方法将68例患者去骨瓣减压后获得的颅骨干燥后保存于普通家用冰箱的冷冻层。术前高温高压灭菌30 min。采用常规颅骨修补术式。结果除术后早期头皮下积液1例、切口感染1例外,余患者通过术后头颅CT检查,骨瓣密度均匀,骨缘无明显吸收,外观满意。结论自体颅骨瓣修补颅骨缺损,术前颅骨保存方便,条件简单,术后并发症少,疗效满意。     

自体骨和钛网杂交修补颅骨缺损的应用研究

目的探索自体骨联合钛网作为新的颅骨修补方法的可行性。方法前瞻性研究绍兴市中心医院收治的60例去骨瓣减压术并行颅骨修补的患者。随机分成自体骨修补组、单纯钛网修补组及自体骨联合钛网杂交修补组共3组,使用自体骨修补的,去骨瓣减压术时记录骨瓣大小,并将之包埋体内皮下保存,3～6月后取出再记录骨瓣大小。随访记录术后并发症。结果 40例自体骨保存的患者,骨瓣大小均有不同程度的缩小,单纯自体骨修补的患者修补术后出现骨瓣松动3例,单纯使用钛网修补的患者术后出现钛网外露2例,自体骨和钛网杂交修补组未出现骨瓣松动及钛网外露情况。结论自体骨和钛网杂交修补颅骨缺损,能最大程度的减少颅骨缺损面积,保证骨瓣的稳定性,有效避免骨瓣外露的发生,降低手术费用,适合临床推广应用。     

颅内肿瘤切除术颅骨锁联合自体骨瓣回植的护理配合

目的探讨颅内肿瘤切除术颅骨锁联合自体骨瓣回植的护理配合效果。方法对53例颅内肿瘤切除术颅骨锁联合自体骨瓣回植患者的临床资料进行回顾性分析。结果本组患者手术时间3~5 h,患者切口均一期愈合,无1例出现感染、排斥反应等,出院后3~6个月随访,患者神志清、语言动作基本恢复正常。无并发症,头颅外观正常颅骨牢固度好,未见凹陷或松动,所有患者骨质吸收范围均未超过锁钉直径范围。结论手术室护士熟练掌握手术步骤,术中密切配合与护理是手术安全顺利的保证。     

自体颅骨瓣体外酒精保存在Ⅱ期修补中的应用

目的:探讨自体颅骨瓣在Ⅱ期修补中的应用。方法:将开颅去骨瓣减压手术中去除的颅骨瓣体外酒精浸泡密封后常温下保存,待Ⅱ期手术修补颅骨时取出经消毒后回植到颅骨缺损处,四周固定。结果:本组自体颅骨瓣用于Ⅱ期颅骨修补28例,术后均Ⅰ期愈合,无感染及皮下积液等并发症。结论:自体颅骨瓣体外酒精保存,用于Ⅱ期颅骨修补,既减少了患者家属的经济负担,又无不良反应及并发症,效果满意。     

多孔离体颅骨瓣原位修复颅骨缺损的护理

对28例颅骨缺损病人采用多孔离体颅骨瓣原位修复术，科学实施离体颅骨的保存及其回植前后的护理。结果均回植成功，无1例出现并发症，骨瓣部位外表美观。     

自体颅骨瓣皮下储存及再植修复颅骨缺损——(附10例报告)

本文报告10例自体颅骨瓣左下腹皮下储存和回植修复颅骨缺损。左下腹是储骨较合适的部位。埋存2个月以上的颅骨瓣表面形成白色纤维状包膜,并有不同程度的骨吸收,组织学切片表明在骨瓣上保留少量骨膜,不仅可减少骨吸收,而且有益于骨母细胞的增生。本文介绍了手术操作方法、注意事项及其优点。随访4～12个月,骨瓣生长情况良好。     

自体颅骨粉一期修复颅骨缺损的临床应用

目的探讨用自体颅骨骨粉一期修复颅骨缺损的临床应用. 方法 1999年10月～2002年12月,采用自体颅骨骨粉加医用黏合剂原位黏合,对128例重型颅脑损伤、急性颅内血肿、颅骨肿瘤及脑肿瘤并颅骨侵犯开颅术后行一期再植成形术,术后随访3～24个月,通过CT或X线片观察骨质生长情况. 结果一次完成减压及成形术,时间较常规手术延长5～l0分钟,修复颅骨外观正常,无凹陷、突出,术后12个月再植骨与正常颅骨完全融合,类似正常颅骨形态.再植修复成功123例,占96.1%,5例因骨粉量少成形欠佳,但未见脑搏动和缺损综合征,均不需二期修补. 结论自体颅骨骨粉加医用黏合剂一期颅骨再植成形术,能够有效避免传统的二期颅骨缺损修补术和并发症.     

三种材料修补颅骨缺损的疗效分析

颅骨缺损是颅脑外伤手术后常见的后遗症,一般3个月后可行颅骨修补.颅骨修补材料种类繁多,但目前临床使用的材料主要有3种:自体颅骨、金属材料(如钛板、钛网)和非金属材料(硅橡胶涤纶网、羟基磷灰石、珊瑚等).本院1995年1月至2005年4月,采用自体颅骨骨瓣、硅橡胶涤纶网、钛金属网3种材料修补颅骨缺损患者共205例,报告如下.     

The use of frozen autogenous bone flaps in delayed cranioplasty revisited

OBJECTIVE: To reevaluate the use of frozen autogenous bone flaps for patients undergoing delayed cranioplasty. METHODS: In the past 12 years, 49 patients have undergone delayed cranioplasty using frozen autogenous bone flaps. Bone flaps removed during the initial operation were sealed in three sterilized vinyl bags and stored at -35 degrees C (n = 37) or -84 degrees C (n = 12) for 4 to 168 days (mean, 50.6 d). The bone flaps were thawed at room temperature and replaced in their original positions. After cranioplasty, we monitored resorption of the bone flaps with computed tomography and evaluated the clinical and aesthetic results. Follow-up periods ranged from 14 to 147 months (mean, 59.2 mo). RESULTS: For 47 patients (95.9%), there were no complications during the follow-up period; there was slight thinning of the bone flap in some cases, but clinical and aesthetic results were highly satisfactory. Resorption was observed for a 12-year-old boy who had undergone cranioplasty, using two pieces of bone flap, 66 days after the initial operation. A 14-year-old boy with a cerebral contusion experienced a bone flap infection. Both patients underwent a second cranioplasty procedure, with ceramic plates. CONCLUSION: The clinical and aesthetic results of delayed cranioplasty using frozen autogenous bone flaps were satisfactory. The most important factor for success was excellent contiguity between the flap and the bone edge.     

Autogenous skull cranioplasty: fresh and preserved (frozen), with consideration of the cellular response.

Every craniotomy requires immediate replacement of a fresh autograft of skull or, in the presence of cerebral swelling, delayed reimplantation of preserved autogenous skull. Resumption of osteogenesis, the index of viability, determines the effectiveness of these segments of calvaria in protecting the brain and restoring skull conformity. The cellular response in skull replaced either at the end of craniotomy or after frozen preservation was studied by light and fluorescence microscopy, skull roentgenograms, and radionuclide scintigraphy. In 5 patients eventual total remodeling of skull was found at the time of a second craniotomy performed from 1 to 19 years after the first. In 12 patients skull sections removed aseptically at craniotomy were frozen and stored for 1 to 35 months at -20 degrees C in bacitracin. This cytotoxic preservative method fixed the tissue, which appeared unchanged on light microscopy and was sterile on bacteriological and fungal cultures. In 53 patients who underwent autogenous cranioplasty with skull stored frozen for 3 weeks to 19 months, 48 operations were totally successful. Complications included infections in 2 patients, resorption in 2 infants, and incomplete restoration in 1 adult. In 10 patients the sequential dynamics of skull revitalization were found to be: revascularization, resorption, and accretion. The repair of membranous skull is similar to that of endochondral bone of the skeleton. Skull is metabolically intensely active after reimplantation and is the ideal material for cranioplasty.     

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.     

Bone flap storage following craniectomy: a survey of practices in major Australian neurosurgical centres

Introduction: The resurgence of decompressive craniectomy surgeries for management of intracranial hypertension has led to a parallel increase in cranioplasty procedures for subsequent reconstruction of the resultant extensive skull defects. Most commonly, cranioplasties are performed using the patients' own cryopreserved skull flaps. Currently, there are no standardized guidelines for freeze‐storage of bone flaps either nationally or internationally. In this initial study, the authors surveyed major neurosurgical centres throughout Australia to document current clinical practices. Methodology: Twenty‐five neurosurgical centres affiliated with major public, teaching hospitals in all Australian states were included in the current survey study. A standardized survey guide incorporating standardized questions was used for data collection either by phone interviews and/or electronic (email) communication. Details regarding bone flap preparation following craniectomy, temperature and duration of freeze‐storage, infection control/micro‐contamination detection protocols, pre‐implantation procedures were specifically recorded. Results: Cranioplasty using cyropreserved autogenous bone flaps remains the most common (96%) mode of skull defect reconstruction in major neurosurgical centres throughout Australia. Following the initial craniotomy, the harvested skull flaps were most frequently (88%) double‐ or triple‐bagged under dry, sterile conditions. In 16% of hospitals, skull flaps were irrigated either with antibiotic mixed‐saline or Betadine prior to cryopreservation. Skull biopsies or swabs were obtained from the skull flaps for micro‐contamination studies in accordance with departmental protocol in 68% of hospitals surveyed. Subsequently, the bone flaps were cryopreserved at wide ranging temperatures between ?18°C to ?83°C, for variable time intervals (6 months to ‘until patient deceased’). Twelve neurosurgical centres (48%) elected for bone flap storage to be undertaken at the local bone bank. In the remainder (52%) of the hospitals, bone flaps were cryopreserved in locally maintained freezers. Prior to re‐implantation of the skull flaps at subsequent cranioplasty surgeries, six (24%) of the neurosurgical centres had specific thawing procedures involving immersion of the frozen bone flaps in Ringer's solution and/or Betadine. Further pre‐implantation bacteriological cultures from bone biopsies or swabs were obtained only in three (12%) hospitals. Conclusions: This study has documented highly varied skull flap cryopreservation and storage practices in neurosurgical centres throughout Australia. These differences may contribute to relatively high complication rates of infection and bone resorption reported in the literature. The results of the current study argue for the further need of high quality clinical and basic science research, which aims to characterize the effect of current skull flap management practices and freeze‐storage conditions on the biological and biomechanical properties of skull bone.     

Management of a large skull defect utilizing a vascularized free omental transfer

A patient who underwent prior cranial surgery and radiation therapy and had the loss of his bone and skin flaps is presented. Basal cell carcinoma of a skin graft, placed on the dura mater and osteomyelitis of the surrounding cranium subsequently occurred. This problem of infection, neoplasia, cerebral protection, coverage, and cosmesis was managed successfully with a complex repair. The repair utilized autogenous fascia lata for the replacement of dura mater, rib and iliac crest bone for an autogenous cranioplasty, a free vascularized omental transfer for soft tissue bulk overlying the cranioplasty, and an autogenous split thickness skin graft over the omentum for coverage. Subsequent partial resorption of the autogenous cranioplasty necessitated the placement of a methyl methacrylate cranioplasty.     

Cranioplasty with customized titanium and PEEK implants in a mechanical stress model

Large skull defects as a result of craniectomies due to cerebral insults, trauma, or tumors create functional and aesthetic disturbances for the patient. Cranioplasty with implants in these cases are an alternative to autogenous bone transplantation. In our clinic, customized titanium or optima poly-ether-ether ketone (PEEK) implants are used to reconstruct craniectomy defects. To compare the two materials we investigated the structural changes of the implants fixed to a sintered polyamide skull model under mechanical stress in four simplified models. In a standard testing machine, the models were subjected to a load under a quasi-static loading rate of 1.925?mm/min. Fractures of the PEEK implants occurred at a force of 24.2 and 24.5?kN with a displacement of 8.4 and 8?mm. The titanium implants showed no deformation, but extensive damage was seen in the polyamide skull models. The highest pressures achieved were 45.8 and 50.9?kN. In a simplified model with quasi-static loading, both implants withstood forces that were higher than those capable of causing skull fractures. It seems that the mechanical properties of PEEK could provide better protection when used for cranioplasty in patients after craniectomy if reconstruction with autogenous bone is not possible.     

Management and Aesthetic Results of Support Grafts in Saddle Nose Surgery

To define the surgical management and long-term aesthetic results of patients undergoing rhinoplasty with support graft for saddle nose, 147 patients have been included in this retrospective study. One hundred forty-four autogenous grafts (bone or cartilage) and three processed irradiated bovine cartilage grafts have been used during the period 1980–1997. Two approaches have been employed: open rhinoplasty and endonasal approach. Most of cases have been treated with bony grafts (116 bone graft versus 26 cartilage grafts). Global follow-up after surgery for long-term aesthetic study was 8.5 years. Among the different autogenous that have been used in our series, the calvarial bone had the most interesting results in terms of resorption. In patients with important saddle nose deformity, we recommend calvarial bone as a material of choice for dorsonasal reconstruction. It provides excellent and natural long-term feel to the nasal complex.     

Preservation of bone flaps in patients with postcraniotomy infections

OBJECT: Management of postcraniotomy wound infections has traditionally consisted of operative debridement and removal of devitalized bone flaps followed by delayed cranioplasty. The authors report the highly favorable results of a prospective study in which postcraniotomy wound infections were managed with surgical debridement to preserve the bone flaps and avoid cranioplasty. METHODS: Since 1990, 13 patients with postcraniotomy wound infections have been prospectively treated with open surgical debridement and replacement of the bone flap. All patients received a full course of systemic antibiotic agents based on the determination of the bacterial culture and antibiotic sensitivity. Notable risk factors for infection included prior craniotomies, radiotherapy, and skull base procedures. The mean long-term follow-up period was 35 +/- 20 months. In all five patients who underwent craniotomies without complications, bone flap preservation was possible with full resolution of the infection and without the need for additional surgery. Among the eight patients with risk factors, bone preservation was possible in six patients, although two required minor wound revisions (without bone flap removal). Both patients who underwent craniofacial procedures required an additional procedure in which the bone flap was removed for recurrent infection (one after 2 months and the other after 29 months). CONCLUSIONS: In patients with uncomplicated postcraniotomy infections, simple operative debridement is sufficient and it is not necessary to discard the bone flaps and perform cranioplasties. Even patients with risk factors such as prior surgery or radiotherapy can usually be treated using this strategy. Patients who undergo craniofacial surgeries involving the nasal sinuses are at higher risk and may require bone flap removal.     

Reliability of cranial flap fixation techniques: comparative experimental evaluation of suturing, titanium miniplates, and a new rivet-like titanium clamp (CranioFix): technical note

OBJECTIVE: To ensure patients' safety, the mechanical strength of cranial flap refixation techniques and implants (sutures, titanium miniplates, and new rivet-like titanium clamps) had to be validated. METHODS: With craniotomied cadaver skulls for each refixation technique, load-bearing tests were performed by applying an external force until an impression depth of the cranial flap of 2 mm was reached and the results were compared. RESULTS: CranioFix (Aesculap AG, Tuttlingen, Germany) and miniplates were revealed to be the strongest fixation devices, although with miniplates, the plastic deformation started from the beginning of load application, whereas CranioFix additionally provided a better spring-elastic reserve and a higher reproducibility of fixation strength not dependent on bone thickness and consistency. Flaps fixed by sutures were dislocated from the start. CONCLUSION: Although CranioFix offers distinct advantages over miniplates, both proved to be definitely superior to suturing, which is still used in many centers. Therefore, whether suturing can still be regarded as a state-of-the-art technique must be reconsidered.     

Novel approach to calvarial bone transport using a rabbit model

Calvarial defects sometimes require cranioplasty to protect the brain. Alloplastic materials, such as acrylic resin, hydroxyapatite ceramics, and titanium, involve various problems, such as vulnerability, infection, deformity resulting from growth, and high cost. We devised a new bone transport model in the rabbit based on the distraction osteogenesis theory of Ilizarov. Twelve Japan white rabbits with a mean body weight of 2.5 kg aged 12 weeks were used. Craniectomy (7 x 14 mm) was performed in 12 rabbits. Trapezoid bone osteotomy was performed anterior to the calvarial defect in 10 rabbits. The distraction device (Extension-plates) was fixed between the trapezoid bone island and the skull. Distraction was initiated 5 days postoperatively. The device was activated once every other day, with approximately 0.75 mm or 0.5 mm per activation. Bone distraction was continued until the rod could not be moved. The lengths of distraction were 4 mm in two cases, 5 mm in one case, 6 mm in one case, and 7 mm in two cases, with a mean of 5.5 +/- 0.56 mm. Both radiographic and histological findings showed osteogenesis by intramembranous ossification and trans-chondroid bone formation. Distraction osteogenesis has potential clinical applications in cranioplasty, especially in children because usage of autogenous bone is difficult if not impossible in most cases.