灭活自体颅骨回植钛铆钉固定的临床应用

目的 总结灭活自体颅骨回植以钛铆钉固定进行颅骨修补术的临床应用经验。方法 2000年3月至2003年12月对21例急性颅脑损伤等去骨瓣减压或颅骨本身受肿瘤侵蚀的患者，行自体颅骨普通冰箱冰冻保存后煮沸消毒，早期回植或受肿瘤侵蚀的骨瓣灭活后一期回植，以钛铆钉固定，随访观察修复效果。结果 所有病例伤口均一期愈合，无并发症发生，随访6个月至2年半，X射线片及CT显示回植骨瓣边缘吸收未超出钛铆钉固定范围，头颅外观及牢度良好，肿瘤无复发。结论 灭活自体颅骨回植进行颅骨修补术，方法简单、实用，利用钛铆钉固定可有效防止因回植骨瓣边缘吸收而导致的牢度下降。     

Ethylene oxide gas sterilization: a simple technique for storing explanted skull bone. Technical note

The authors evaluated the effectiveness of a simple technique using ethylene oxide (EtO) gas sterilization and room temperature storage of autologous bone grafts for reconstructive cranioplasty following decompressive craniectomy. The authors retrospectively analyzed data in 103 consecutive patients who underwent cranioplasty following decompressive craniectomy for any cause at the University of Illinois at Chicago between 1999 and 2005. Patients with a pre-existing intracranial infection prior to craniectomy or lost to follow-up before reconstruction were excluded. Autologous bone grafts were cleansed of soft tissue, hermetically sealed in sterilization pouches for EtO gas sterilization, and stored at room temperature until reconstructive cranioplasty was performed. Cranioplasties were performed an average of 4 months after decompressive craniectomy, and the follow-up after reconstruction averaged 14 months. Excellent aesthetic and functional results after single-stage reconstruction were achieved in 95 patients (92.2%) as confirmed on computed tomography. An infection of the bone flap occurred in eight patients (7.8%), and the skull defects were eventually reconstructed using polymethylmethacrylate with satisfactory results. The mean preservation interval was 3.8 months in patients with uninfected flaps and 6.4 months in those with infected flaps (p = 0.02). A preservation time beyond 10 months was associated with a significantly increased risk of flap infection postcranioplasty (odds ratio [OR] 10.8, p = 0.02). Additionally, patients who had undergone multiple craniotomies demonstrated a trend toward increased infection rates (OR 3.0, p = 0.13). Data in this analysis support the effectiveness of this method, which can be performed at any institution that provides EtO gas sterilization services. The findings also suggest that bone flaps preserved beyond 10 months using this technique should be discarded or resterilized prior to reconstruction.     

Salvage of infected craniotomy bone flaps with the wash-in, wash-out indwelling antibiotic irrigation system. Technical note and case series of 12 patients

OBJECT: When complicated by infection, craniotomy bone flaps are commonly removed, discarded, and delayed cranioplasty is performed. This treatment paradigm is costly, carries the risks associated with additional surgery, and may cause cosmetic deformities. The authors present their experience with an indwelling antibiotic irrigation system used for the sterilization and salvage of infected bone flaps as an alternative to their removal and replacement. METHODS: The authors retrospectively reviewed the medical records for 12 patients with bone flap infections following craniotomy who received treatment with the wash-in, wash-out indwelling antibiotic irrigation system. Infected flaps were removed and scrubbed with povidone-iodine solution and soaked in 1.5% hydrogen peroxide while the wound was debrided. The bone flaps were returned to the skull and the irrigation system was installed. Antibiotic medication was infused through the system for a mean of 5 days. Intravenous antibiotic therapy was continued for 2 weeks and oral antibiotics for 3 months postoperatively. Wound checks were performed at clinic follow-up visits, and there was a mean follow-up period of 13 months. Eleven of the 12 patients who had undergone placement of the bone flap irrigation system experienced complete resolution of the infection. In five patients there was involvement of the nasal sinus cavities, and in four there was a history of radiation treatment. In the one patient whose infection recurred, there was both involvement of the nasal sinuses and a history of extensive radiation treatment. CONCLUSIONS: Infected bone flaps can be salvaged, thus avoiding the cost, risk, and possible disfigurement associated with flap removal and delayed cranioplasty. Although prior radiation treatment and involvement of the nasal sinuses may interfere with wound healing and clearance of the infection, these factors should not preclude the use of irrigation with antibiotic agents for bone flap salvage.     

Cranioplasty using autogenous bone cryopreserved with dimethylsulfoxide (DMSO)

It is generally agreed that the autogenous bone flap which has been removed at the time of external decompression would be superior to any artificial material if it can be used in cranioplasty. Cranioplasty using autogenous frozen bone graft has been reported and showed good results except for infection and severe bone absorption. We conducted 39 cases of cranioplasty with cryopreserved autogenous bone in the presence of 10% of Dimethylsulfoxide (DMSO), which has been reported as a cryoprotective agent. Although no remarkable histological effects have been recognized in frozen bone with or without DMSO, we have obtained excellent clinical results without bone absorption in 24 of the cases. These results suggest that DMSO is helpful for frozen bone preservation.     

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.     

Cranioplasty using the patient's autogenous bone preserved by freezing--an examination of post-operative infection rates

The current technique for cranioplasty using artificial bone requires further improvement with regard to infection, strength and comfort through good fitting. We have carried out cranioplasty using the patient's autogenous bone flap obtained during first surgery. It was immersed in 200 mg of Amikacin Sulphate, and frozen at -16 degrees C until its use in cranioplasty. From 1980 to 1998, cranioplasty has been carried out on 206 patients. They consisted of 118 males and 88 females, and their age ranged in our institute from 1 to 81; average age 51.1. Ruptured aneurysm (48%), head injury (14%), intracranial hemorrhage (23%) and cerebral infarction (12%) were the major causes requiring decompression surgery. We analyse the bone preservation period and the time between cranioplasty and the onset of infection. The infection rates per bone preservation periods, the causes of decompression and age groups are studied. Of the 208 case studies, infection necessitating bone removal or debridement was noted in 8 cases (3.88%). Average bone preservation period in the infected group was 31.1 days as compared with 54.9 days for the non-infected group (p < 0.05). Not patient age but the type of head injury is also a significant factor in post cranioplasty infection.     

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.     

胫骨皮瓣修复小腿感染性骨皮缺损的应用

目的探讨胫骨皮瓣在修复小腿感染性骨皮缺损中的应用及效果。方法2000年2月～2005年3月，收治因外伤致小腿开放性骨折68例。男47例，女21例，年龄8～59岁。按Gustilo分型均为Ⅲ型。其中4例一期行胫骨皮瓣游离移植术，64例急诊术后形成小腿感染性骨皮缺损。胫骨缺损长度4～18cm，皮肤缺损范围8cm×3cm～22cm×11cm，创面均有脓性渗出物。经中药薰洗湿敷后，利用胫骨皮瓣通过游离移植、交腿移位和同侧移位方法，重建患肢胫骨支架连续性并修复创面。切取皮瓣范围9cm×4cm～25cm×12cm，骨瓣长度为6～21cm。结果术后1例因血管危象经探查再吻合血管失败，改用腓骨皮瓣修复。1例切取胫骨皮瓣21cm，因近端为延长血管蒂，骨膜与骨瓣剥离过长，随访6个月近端仍延迟愈合；余患者3～5个月骨瓣与受区胫骨愈合。68例均获随访6个月～5年，43例随访2年以上者均能负重行走，步态无明显异常，能从事原工作。结论在充分抗感染的基础上，根据患肢具体情况采用胫骨皮瓣游离移植、交腿移位和同侧移位一期重建胫骨支架连续性及修复皮肤缺损创面，适用于小腿多种类型骨皮缺损创面，成功率高，能保留患肢，为功能恢复创造条件。     

Intraoperative template-molded bone flap reconstruction for patient-specific cranioplasty

Cranioplasty is a common neurosurgical procedure. Free-hand molding of polymethyl methacrylate (PMMA) cement into complex three-dimensional shapes is often time-consuming and may result in disappointing cosmetic outcomes. Computer-assisted patient-specific implants address these disadvantages but are associated with long production times and high costs. In this study, we evaluated the clinical, radiological, and cosmetic outcomes of a time-saving and inexpensive intraoperative method to mold custom-made implants for immediate single-stage or delayed cranioplasty. Data were collected from patients in whom cranioplasty became necessary after removal of bone flaps affected by intracranial infection, tumor invasion, or trauma. A PMMA replica was cast between a negative form of the patient's own bone flap and the original bone flap with exactly the same shape, thickness, and dimensions. Clinical and radiological follow-up was performed 2?months post-surgery. Patient satisfaction (Odom criteria) and cosmesis (visual analogue scale for cosmesis) were evaluated 1 to 3?years after cranioplasty. Twenty-seven patients underwent intraoperative template-molded patient-specific cranioplasty with PMMA. The indications for cranioplasty included bone flap infection (56%, n?=?15), calvarian tumor resection (37%, n?=?10), and defect after trauma (7%, n?=?2). The mean duration of the molding procedure was 19?±?7?min. Excellent radiological implant alignment was achieved in 94% of the cases. All (n?=?23) but one patient rated the cosmetic outcome (mean 1.4?years after cranioplasty) as excellent (70%, n?=?16) or good (26%, n?=?6). Intraoperative cast-molded reconstructive cranioplasty is a feasible, accurate, fast, and cost-efficient technique that results in excellent cosmetic outcomes, even with large and complex skull defects.     

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.     

Effect of microorganisms isolated by preoperative osseous sampling on surgical site infection after autologous cranioplasty: A single-center experience

PurposeThe most frequent postoperative complication in autologous cranioplasty (AC) is infection. European recommendations include osseous sampling before cryogenic storage of a bone flap. We evaluated the clinical impact of this sampling.MethodsAll patients who underwent decompressive craniectomy (DC) and AC in our center between November 2010 and September 2021 were reviewed. The main outcome was the rate of reoperation for infection of the cranioplasty. We evaluated risk factors for bone flap infection, rate of reoperation for any reason (hematoma, skin erosion, cosmetic request, or bone resorption), and radiological evidence of bone flap resorption.ResultsA total of 195 patients with a median age of 50 (interquartile range: 38.0–57.0) years underwent DC and AC between 2010 and 2021. Of the 195 bone flaps, 54 (27.7%) had a positive culture, including 48 (88.9%) with Cutibacterium acnes. Of the 14 patients who underwent reoperation for bone flap re-removal for infection, 5 and 9 had positive and negative bacteriological cultures, respectively. Of patients who did not have bone flap infection, 49 and 132 had positive and negative bacteriological cultures, respectively. There were no significant differences between patients with and without positive bacteriological culture of bone flaps in the rates of late bone necrosis and reoperation for bone flap infection.ConclusionsA positive culture of intraoperative osseous sampling during DC is not associated with a higher risk of re-intervention after AC.     

Use of the Rhomboid Major Muscle Flap for Esophageal Repair

A 16-year-old boy sustained vehicular blunt trauma with delayed esophageal rupture that resulted in empyema and an esophagopleurocutaneous fistula. Diverting esophagostomy, gastrostomy, and transpyloric jejunostomy were performed, and these procedures permitted satisfactory nutritional support of the patient.Staged direct closure of the esophagus buttressed by a rhomboid muscle flap preserved normal esophageal function. Both clinical application and cadaver dissections have demonstrated that the rhomboid flap has an excellent blood supply and that it can be used to repair lesions on either side in the upper half of the esophagus. Because this flap is extrathoracic, it is not usually distorted by intrathoracic sepsis or previous thoracic incisions. The rhomboid major muscle flap is an excellent alternative to conventional autogenous grafts for esophageal repair.     

Subtotal reconstruction of the burned auricle

The goal for external ear reconstruction is to restore the function of the helical rim in order to provide support for eyeglasses and to provide a cosmetically acceptable auricle. Reconstruction necessitates both flap coverage and flexible framework formation. This article reviews 22 patients who underwent subtotal reconstruction of the auricles after burns. The study was conducted from 1996 to 2003. The study group consisted of 14 male and 8 female patients aged 6-43 years (mean 21.9 years). Different modalities have been used: the temporoparietal fascial flap (eight patients), the subcutaneous pocket technique (11 patients), the pre-auricular skin flap (four patients), and the post-auricular skin flap (three patients). The flaps were used for coverage of fabricated autogenous cartilage in all patients. Both aesthetic and functional outcome was satisfactory.     

Umbilical reconstruction using a modified inverted C-V flap with conjoint flaps

Abstract

The umbilicus is an important aesthetic feature of the abdomen. Because of its location, the umbilicus can be injured after abdominal surgical procedures. Various methods have been devised to reconstruct the umbilicus by using local flaps, purse-string sutures, or a cartilage graft, but there are no ideal methods. The authors have created a modified inverted C-V flap with conjoint flaps. A 10-year-old boy presented with deformed umbilicus because he had undergone surgical correction of an omphalocele. The drawback of the traditional C-V flap method is the transverse long abdominal scar because of the long length of the V flap. However, by using two conjoint flaps at the superior part of the C-V flap, the length of V flap can be more short and the umbilical wall can be reconstructed by rotation of two conjoint flaps. It is also good for making a sinusoidal pocket and it makes the umbilicus deeper and more natural-looking. After the operation, there were no complications like flap necrosis, infection, haematoma, and so on. The patient was satisfied with the results The patient had a more attractive umbilicus than the one with the other previous technique. This new method makes a natural-looking umbilicus with less of a transverse scar and an adequate sinusoidal pocket and umbilical wall.     

Reconstruction of large defects in the scalp with fasciocutaneous flaps.

Although recent reports have emphasised free microsurgical transfer for reconstruction of extensive defects in the scalp, in our experience a carefully planned scalp flap is a simpler and safer method than a free transfer. Twenty-one patients with defects as large as 10%-60% of the scalp surface area were reconstructed; the calvarium was resected in five cases and the dura mater in two. In 18 cases the flaps were based on a single pedicle: the superficial temporal artery. In three cases the blood supply of the flaps was based on three major homolateral arteries: the superficial temporal, the posterior auricular, and the occipital. The blood supply of all scalp flaps was based on the interconnected network of the aponeurotic plexus and the pedicles were included into flap in 18 cases. The principles of fasciocutaneous flaps were applied for all 21 scalp flaps. The reconstruction of the skull was delayed in all cases, and the dura was replaced by free autogenous periosteum. The donor area was covered with a skin graft in all cases. In all patients the aesthetic and functional results were considered excellent by them and by us. There were no postoperative complications.     

胫后血管蒂小腿内侧复合组织瓣的临床应用

目的探讨以胫后血管为蒂小腿内侧复合组织瓣的临床应用效果和有关问题。方法1992年9月～1999年5月应用小腿内侧复合组织瓣修复四肢骨和软组织缺损12例,其中开放性骨折并骨和软组织缺损7例,慢性溃疡并骨髓炎2例,恶性黑色素瘤2例,骨肿瘤切除术后骨和软组织缺损1例。缺损范围2.5cm×5.0cm～4.5cm×11.0cm。游离移植5例,桥式转移3例,逆行移位4例,其中骨膜肌皮瓣加自体松质骨或同种异体脱钙骨移植8例,肌皮瓣4例。皮瓣最大12cm×25cm,最小6cm×8cm。结果10例皮瓣全部成活,创面Ⅰ期愈合;2例皮瓣远端小部分坏死,经切除坏死痂皮后换药,创面Ⅱ期愈合。10例创面修复后16周X线片示骨愈合。术后经6～18个月随访,除1例术后2个月死于肿瘤转移外,其余均取得满意效果。结论小腿内侧复合组织瓣血供充分,血管口径粗,蒂长,皮瓣切取面积大,是修复肢体大面积软组织缺损合并骨缺损的理想组织瓣。     

Temporoparietal Fascia Flaps for Surgical Treatment of Cartilage Exposure After the First-Stage Microtia Reconstruction

Significant improvements have been achieved in microtia reconstruction using an autogenous costal cartilage framework. However, complications such as skin necrosis and cartilage exposure often destroy the final contour of the reconstructed auricle. Local fascia flaps are commonly used in salvage surgery because of their reliability and satisfactory results. Here, we report the case of a 26-year-old woman with multiple skin necroses and cartilage exposure on day 21 after the first-stage microtia reconstruction. The exposure area was covered by a temporoparietal fascia flap as a single-stage procedure. The most essential subunits survived, and the esthetic concours were harmonious and natural at 12 months postoperatively. Temporoparietal fascia flaps are recommended as the surgical treatment for multiple skin necroses and cartilage exposure in microtia reconstruction. The axial-pattern temporoparietal fascia flap is reliable for salvage auricular reconstruction and ensures satisfactory results at long-term follow-up.     

Microbial contamination assessment of cryostored autogenous cranial bone flaps: should bone biopsies or swabs be performed?

Background

Autogenous cranioplasty infection requiring bone flap removal is under-recognised as a major complication causing significant morbidity. Microbial contamination of stored bone flaps may be a significant contributing factor. Current infection control practices and storage procedures vary. It is not known whether ‘superficial’ swabs or bone cultures provide a more accurate assessment.

Method

Twenty-five skull flaps that were cryo-stored for more than 6 months were studied. Two swab samples (superficial and deep) and a bone biopsy sample were taken from each skull flap sample and cultured. Half blood agar and half chocolate agar plates were inoculated with the swabs for anaerobic and aerobic cultures respectively. The bone biopsy samples were cultured in brain-heart broth and subcultured similar to the swabs for 5 days.

Results

Incidence of microbial contamination was 20 % in the bone flaps studied. One swab culture and five bone biopsy cultures were positive for bacterial growth, all of which contained Propionibacterium acnes (p?=?0.014). Positive cultures were from bone flaps stored less than 18 months, whereas no growth was obtained from bone flaps that were stored longer (p?=?0.014).

Conclusions

Bone biopsy culture is a more sensitive technique of assessing microbial contamination of cryo-stored autogenous bone flaps than swab cultures. The clinical implications of in vitro demonstration of microbial contamination require further study.     

局部肌瓣转移和自体红骨髓注射治疗胫骨骨折骨不连

目的报告局部转移肌瓣和注射自体红骨髓治疗胫骨骨折不连接的效果。方法对15例伤后10～42个月,平均22个月仍不连接的胫骨骨折实施切开复位、带锁髓内钉固定、髂骨植骨和局部转移肌瓣覆盖,术后12～15d局部注射自体红骨髓治疗。结果随访表明所有病例骨折均得到连接,术后3～11个月(平均4.8个月)愈合,除2例术后出现切口皮缘小块坏死经换药愈合外,创口均一期愈合,没有发生感染和内固定失败。结论在稳固内固定和植骨以外,局部转移肌瓣和注射自体红骨髓治疗胫骨骨折不愈合能取得满意疗效。