Complications of titanium cranioplasty—a retrospective analysis of 174 patients

Background

Titanium cranioplasty (TC) has been associated with high complication rates, but abundant data are lacking. We aimed to determine the incidence and type of complications following TC and risk factors for complications.

Methods

A retrospective review was performed on 174 patients who underwent TC at two London units over a seven year period. Data were collected on demographics, primary pathology, perioperative details, complications and functional outcome. Skull defect size was estimated using 3-dimensional computed tomographic reconstructions.

Results

The overall complication rate was 26.4 % (46/174), and plate removal rate10.3 % (18/174). The commonest complication was infection, which accounted for 69 % of plate removals. Patients who had undergone craniectomy for trauma had a higher complication rate (35 vs 21 %; p?=?0.043) and plate removal rate (16 vs 7 %; p?=?0.049) than others. There was a non-significant trend towards the association of craniectomy-to-cranioplasty interval of 4–8 months with the lowest complication rate and shortest postoperative hospital stay. Patients with a skull defect larger than 100 cm² had the highest complication rate (p?<?0.001), highest plate removal rate (p?=?0.039), and longest postoperative hospital stay (p?=?0.019). Bifrontal versus unilateral cranioplasty was associated with a significantly higher complication rate (40 vs 14 %) and length of hospital stay (5.0 vs 2.9 days). There was no perioperative mortality and no change between pre-operative and post-operative functional outcome.

Conclusion

In the largest UK study on cranioplasty to date, we have demonstrated that size of defect, traumatic aetiology and bifrontal insertion are risk factors for complications. Our results suggest that the timing of cranioplasty may be important with late (> 12 months) TC associated with a higher rate of complications, although further prospective studies on the optimal timing of TC are required to establish the observed trend. Our data can help clinicians stratify risk to inform the consent process and aid pre-operative planning.     

Extubation of a difficult airway after thyroidectomy: use of a flexible bronchoscope via the LMA-Classic?

Purpose

We report an extubation strategy for a patient scheduled for thyroidectomy who had several factors indicating that it would be a difficult extubation.

Clinical features

A 75-yr-old man with thyroid cancer presented for total thyroidectomy. He had anatomical features predictive of a difficult upper airway. Therefore, his trachea was intubated while he was awake using a flexible bronchoscope. The tumour had invaded the trachea, necessitating total thyroidectomy, 3-cm tracheal resection, and primary tracheal anastomosis. The left recurrent laryngeal nerve (RLN) was inherently involved in the tumour and sacrificed. A ??guardian suture?? placed between the chin and the chest maintained the head and neck in flexion, thereby avoiding traction on the tracheal anastomosis. Immediate postoperative extubation was desirable, given the new tracheal anastomosis; however, complicating factors included left RLN paralysis, tracheal anastomosis, potential for tracheomalacia or supraglottic airway swelling, and the guardian suture preventing neck extension. In addition, there were anatomical features raising the suspicion of difficult reintubation should it be necessary. With the patient deeply anesthetized, the endotracheal tube was removed and replaced with the Laryngeal Mask Airway (LMA)-Classic? as a bridging device to facilitate bronchoscopic examination. It allowed us to visualize the tracheal repair, tracheal movement, vocal cord function, and supraglottic structures. The patient emerged from anesthesia and was extubated uneventfully.

Conclusion

We describe a viable extubation strategy used in a patient after complex thyroid surgery involving tracheal resection. By using the LMA-Classic? as a bridging device and to facilitate bronchoscopic examination, we were able to address the above concerns and safely manage the extubation phase in this patient.     

Intragastric penetration of a gastric band -- a severe complication after gastric banding?

In morbid obese patients the adjustable laparoscopic gastric banding is an effective procedure with a widespread acceptance. Pouch dilatation, band slipping, port-penetration and port infection are the most known complications. We report on three patients with a penetration of an adjustable gastric band. The main symptom of penetration was the increase of weight. The reasons for penetration are a lesion of the serosa intraoperatively or a overfilling of the band. In our patients the treatment was in two cases the explantation of the band. In one case the patient showed no signs of peritonitis and didn't want the explantation of the band. Our recommendation in case of penetration is the removal of the band, because every penetration can be the source of a lethal outcome.     

Potentiation of transforming growth factor (TGF-β1) by natural coral and fibrin in a rabbit cranioplasty model

The association of a biodegradable material and a growth factor could be of clinical value for treating bone defects. We therefore tested the association of transforming growth factor (TGF-1) in fibrin glue and coral granules to heal skull defects in rabbits. Adult rabbits underwent a double trepanation symmetrically in both parietal bones. Using histomorphometry, we compared bone repair after 1 month in control animals (n=5) and in animals treated with either TGF-1 as a single injection of 1 g in methylcellulose (n=5) or in fibrin glue (n=5), or with coral granules in fibrin glue (n=4) or with coral granules and TGF-1 1 g in fibrin glue (n=5). We measured the diameter of the remaining defect and the surface of the bone growth. TGF-1 without coral in either methyl cellulose or fibrin induced a partial closure of the defect as assessed by a significant decrease in the defect diameter, compared with the control group. However, the association of TGF-1 in fibrin and coral induced an area of the bone growth higher than in any other groups (P<0.05). Two months after surgery, this triple association induced a better healing of the defect than coral alone or control group. In each group treated with TGF-1, the mineralization rate was increased not only at the treated side but also in the contralateral defect which was untreated, suggesting a diffusion of the growth factor. Indeed, when pooled together, the diameter of the defect at the contralateral side of 14 animals that had received TGF-1 was reduced compared with the control group. Significant coral granules resorption occurred between month 1 and 2 and was unchanged by the addition of TGF-1. In conclusion, the triple association of coral granules and TGF-1 in fibrin could be of interest for treating bone defects.     

Osteonecrosis of the femoral head after osteosynthesis of a proximal femur fracture with a 95° condylar plate

Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of subtrochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.     

Osteonecrosis of the femoral head after osteosynthesis of a proximal femur fracture with a 95° condylar plate

Summary Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of subtrochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.      

Pulmonary atelectasis manifested after induction of anesthesia: a contribution of sinobronchial syndrome?

A 31-year-old man underwent general anesthesia for sinus surgery. Anesthesia was induced with midazolam and butorphanol, and an endotracheal tube was orally placed with a bronchoscope, due to difficulty with temporomandibular joint opening. Ventilation difficulty and increased peak inspiratory pressure were noticed shortly after tracheal intubation, and bronchoscopy was performed for diagnosis. The bronchi were filled with a clear mucous secretion. Removal of the secretion improved respiration and decreased the peak inspiratory pressure. A chest roentgenogram taken prior to extubation showed right upper lobe atelectasis. A diagnosis of sinobronchial syndrome was made postoperatively. The etiology of the acutely developed atelectasis was unclear. However, the latent syndrome may have induced excessive airway secretion with stimuli such as endotracheal intubation.     

Vasospasm after use of a tourniquet: another cause of postoperative limb ischemia?

IMPLICATIONS:Two previously reported causes of postoperative limb ischemia after use of a tourniquet, compartment syndrome and arterial thromboembolism, require aggressive and invasive management. We report another probable cause that can be managed nonsurgically: vasospasm.     

The migration of a BioScrew® as a differential diagnosis of knee pain, locking after ACL reconstruction: a report of two cases

Introduction: Problems with the initial fixation strength and widening of the femoral and tibial canal after ACL reconstruction using a triple or quadruple semitendinosus autograft have led to the introduction of the so-called Hybrid fixation with the additional use of interference screws. Pain and intraarticular migration have been reported with metal interference screws requiring implant removal (Am J Knee Surg 11:32–34, 2000, Arthroscopy 11:289–291, 1995) but not yet with bioabsorbable screws. Materials and methods: We report on two cases were the intraarticular position of a bioabsorbable interference screw possibly due to migration in the early postoperative period lead to symptoms, the need for further surgery, and implant removal. Results: A preoperative MRI revealed the diagnosis. After removal of the tibial interference screw both knees were settling down, albeit with residual instability and only a moderate clinical result. Discussion: Despite the attractiveness of bioabsorbable screws due to the very fact that they are being reabsorbed over time, there is a slight risk of migration in the first month after the operation. In any suspicious case an MRI will easily clarify the diagnosis.This study was carried out at the Department of MRI, Klinik für Radiologische Diagnostik, Klinkum Saarbrücken, Winterberg 1, 66119 Saarbrücken     

Long-term prognosis of nerve palsy after total hip arthroplasty: results of two-year-follow-ups and long-term results after a mean time of 8 years

Introduction

Nerve damage is a rare but serious complication after THA. There exist only little data about the outcome of these patients particularly regarding the long-term results later than 2 years postoperatively. Aim of this study is to answer the following questions: Is the recovery to be expected for light nerve lesions different from the severe ones? Is there a possibility of nerve recovery more than 2 years after THA? Is the potential of nerve recovery depending on the affected nerve?

Materials and methods

This study investigates 2,255 primary THA as well as revision surgeries performed from 1988 to 2003 relating to iatrogenic nerve lesion. We classified the nerve lesion according to the core muscle strength in severe (M0–M2) and light (M3–M4) nerve damage and differentiated between femoral, sciatic and superior gluteal nerve, according to the electromyography.

Results

We found 34 cases of iatrogenic nerve damage representing an incidence of 1.5 %. 17 of 34 (50 %) patients showed a complete recovery after 2 years. Out of the remaining 17 patients, six out of seven patients with a final examination after a median time of 93 months achieved further improvement. The different nerves showed no significant different potential of recovery.

Conclusions

In contrast to the literature, an improvement beyond the limit of 2 years is probable and independent of the nerve affected.     

Surgical correction of buried penis after traffic accident – a case report

Background

Buried penis, most commonly seen in children, is particularly debilitating in adults, resulting in inability to void while standing and it also affects vaginal penetration. We report a case of buried penis due to a traffic accident, which caused dislocation of the fractured pubic bone that shifted inside and pulled the penis by its suspensory ligament.

Case presentation

A 55-year-old man was admitted to our hospital with a chief complaint of hidden penis while in the sitting position. He had suffered a pelvic fracture in a traffic accident four years previously, and his penis was covered with suprapubic fat when he was in a sitting position. He was unable to have sexual intercourse. We performed a penile lengthening procedure, including inverse V-Y-plasty of the dorsal skin of the penile root, suspensory desmotomy and fat removal, under general anesthesia. There was a good cosmetic result with satisfactory penile erection, which allowed successful sexual intercourse after surgery.

Conculsion

We performed penile elongation surgery with inverse V-Y-plasty of the dorsal skin of the penile root, suspensory desmotomy, and fat removal. Surgical treatment of buried penis achieves marked aesthetic and functional improvement, and benefits the majority of patients, resulting in satisfactory erection and successful sexual intercourse.     

Patient satisfaction after surgery for trigeminal neuralgia – development of a questionnaire

Summary Objective. This project aimed to prepare a self complete patient satisfaction survey for patients who have undergone surgery for trigeminal neuralgia and then assess its reproducibility, validity and acceptability in one centre.Methods. The questionnaire, for initial use in patients who had undergone posterior fossa surgery for trigeminal neuralgia, was designed after a systematic review of the surgical literature had been performed and discussions held at the US and UK Trigeminal Neuralgia Support group meetings. It underwent several changes after input from neurosurgeons, patients, copywriter and statistician and finally contained 44 questions, the SF12, Hospital Anxiety and Depression Scale (HAD), Brief Pain Inventory (BPI) and McGill Pain questionnaire (MPQ). From the total number of 413 patients in the database of one centre the questionnaire was sent with a covering letter to 305 patients, the rest had died (25), were lost to follow up (26) or did not meet the inclusion criteria (56). One patient had bilateral PSR. The completed questionnaires were evaluated by an independent physician, neurosurgeon and patient. A repeat questionnaire was sent to 10% of the patients to check reproducibility.Results. The questionnaires were well completed with a final response rate of 92%. It appeared to be highly acceptable and reproducible but needed adjustment to improve its validity before being used in other centres and for all surgical procedures. A new questionnaire is proposed which could be used on an annual basis.Conclusions. A questionnaire has been developed for use in patients who have undergone surgical management for trigeminal neuralgia and which is acceptable to patients.     

Does Anatomy Explain the Origin of a Leak after Sleeve Gastrectomy?

Background

Sleeve gastrectomy is a bariatric surgical procedure that may result in particular morbidity or mortality due to gastric fistula in the proximal part of the gastric tube. Two theories are currently proposed to explain this specific leak location. The vascular theory attributes the leaks to reduced perfusion in the gastric tube, and the mechanical theory suggests the etiology as gastric tube hyper-pressure due to pyloric conservation. The aim of this study was to map the arterial gastric vascular supply on fresh cadavers after performing sleeve gastrectomy to evaluate the effect of vascular changes on gastric leakage.

Methods

We performed sleeve gastrectomies on 11 cadaveric trunks with a detailed anatomical study of the gastric vascular supply after latex injection in the three branches arising from the celiac trunk.

Results

In 55 % of cases, the sleeve procedure changed the gastric vascular supply. In 9.1 %, it divided the three left gastric artery branches arising from the lesser curvature. Few changes were noted in the antrum or pylorus.

Conclusions

This anatomical study demonstrates that the vascular supply of the proximal part of the gastric tube can be damaged by a sleeve procedure, which can sever one or more of the branches arising from the left gastric artery. Such weakness could be exacerbated by disparities in vascular supply. The uninterrupted vascular supply of the antrum and pylorus may explain the preferential localization of the fistula to the proximal part of the gastric tube.     

Is Clostridium difficile infection a particular problem after reversal of ileostomy?

Aim Clostridium difficile infection (CDI) is a cause of morbidity and mortality in hospitals. Various independent risk factors have been identified, including age and antibiotic exposure. This study attempted to determine whether surgery and associated antibiotic use influence the development of CDI. Method A retrospective review of all patients with a diagnosis of CDI diagnosed during admission to a colorectal unit was conducted over a 20‐month period. Patient records were cross‐referenced with a microbiology database to identify previous episodes of infection and cases of recurrence. Results There were 38 CDI episodes in 29 patients, including nine with recurrence. In 33, the use of antibiotics prior to the onset of CDI was documented, but in 14 (37%) patients this was limited to perioperative prophylaxis. The incidence of CDI after various procedures was as follows: ileostomy closure (4.2%), right hemicolectomy (2.1%) and anterior resection (1%). Conclusion Ileostomy closure may carry a higher risk of CDI.     

Case reports - Fracture of a ceramic acetabular insert after ceramic-onceramic THA–a case report

No Abstract available.