Skull Bone Flap Fixation – Reliability and Efficacy of a New Grip-Like Titanium Device (Skull Grip) versus Traditional Sutures: A Clinical Randomized Trial

Abstract Background Traumatic brain injury (TBI) and stroke have devastating consequences and are major global public health issues. For patients that require a cerebral decompression after suffering a TBI or stroke, a decompressive craniectomy (DC) is the most commonly performed operation. However, retrospective non-randomized studies suggest that a decompressive craniotomy (DCO; also known as hinge or floating craniotomy), where a bone flap is replaced but not rigidly fixed, has comparable outcomes to DC. The primary aim of this project was to understand the current extent of usage of DC and DCO for TBI and stroke worldwide. Method A questionnaire was designed and disseminated globally via emailing lists and social media to practicing neurosurgeons between June and November 2019. Results We received 208 responses from 60 countries [40 low- and middle-income countries (LMICs)]. DC is used more frequently than DCO, however, about one-quarter of respondents are using a DCO in more than 25% of their patients. The three top indications for a DCO were an acute subdural hematoma (ASDH) and a GCS of 9-12, ASDH with contusions and a GCS of 3-8, and ASDH with contusions and a GCS of 9-12. There were 8 DCO techniques used with the majority (60/125) loosely tying sutures to the bone flap. The majority (82%) stated that they were interested in collaborating on a randomized trial of DCO vs. DC. Conclusion Our results show that DCO is a procedure carried out for TBI and stroke, especially in LMICs, and most commonly for an ASDH. The majority of the respondents were interested in collaborating on a is a future randomized trial.

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Biomechanics of a novel reversibly expandable dynamic craniotomy bone flap fixation plate

Journal of Neurosurgery ◽

10.3171/2018.8.jns172614 ◽

2020 ◽

Vol 132 (2) ◽

pp. 560-567 ◽

Cited By ~ 1

Author(s):

Rohit Khanna ◽

Lisa Ferrara ◽

Sohit Khanna

Keyword(s):

Peak Load ◽

Bone Flap ◽

Intracranial Volume ◽

Compression Tests ◽

Static Compression ◽

Low Profile ◽

Flap Fixation ◽

Tension Testing ◽

Fixation Plate ◽

Static Shear

OBJECTIVEBiomechanical evaluation of a novel expandable cranial fixation plate was assessed in cadavers. The dynamic craniotomy procedure uses low-profile reversibly expandable plates that allow cranial decompression by providing for intracranial volume expansion without removal of the bone flap. The plates allow reversible outward movement of the bone flap upon an increase in intracranial pressure (ICP) and also retract the bone flap and prevent it from sinking inside the cranium once the ICP normalizes.METHODSA comparative evaluation of the extent of ICP control with an increase in intracranial volume between various bone flap fixation techniques was undertaken along with testing of the expandable plate compliance. Static compression tests of the plates were performed to assess bone flap fixation and prevention of sinking. Quasi-static shear tension testing of the plates was undertaken to test the tolerance of the plates for expansion. Fatigue shear tension evaluation of the plates was undertaken to assess tolerance for repetitive expansion and contraction.RESULTSThe dynamic craniotomy provided superior control of ICP with an increase in intracranial volume compared to the hinged craniotomy and standard craniotomy techniques (p < 0.001). Static compression results revealed that the plates withstood bone flap sinkage with a mean peak load of 643.3 ± 26.1 N and a mean inward bone flap displacement of 1.92 ± 0.09 mm. Static shear tension results indicated that the plates could withstand a peak expansion of 71.6 mm. Dynamic shear tension testing of the plates with repetitive 15-mm outward expansion and retraction for a total of up to 500 cycles revealed no cracking and no failure points.CONCLUSIONSThe reversibly expandable plates provide for a low-profile bone flap fixation with rigid restriction of bone flap sinking and also enable cranial decompression with a high tolerance for repetitive expansion and contraction.

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Syndrome of the trephined

Journal of Neurosurgery ◽

10.3171/2009.3.jns0984 ◽

2009 ◽

Vol 111 (4) ◽

pp. 650-652 ◽

Cited By ~ 51

Author(s):

Vivek Joseph ◽

Peter Reilly

Keyword(s):

Subdural Hematoma ◽

Skin Flap ◽

Neurological Status ◽

Bone Flap ◽

Acute Subdural Hematoma ◽

Skull Bone ◽

Midline Shift ◽

Scalp Flap ◽

Dependent Position ◽

Syndrome Of The Trephined

“Syndrome of the trephined” or “sinking skin flap syndrome” is an unusual syndrome in which neurological deterioration occurs following removal of a large skull bone flap. The neurological status of the patient can occasionally be strongly related to posture. A 77-year-old male patient with an acute subdural hematoma was treated using a hemicraniectomy and evacuation of the hematoma. On the 9th postoperative day there was deterioration in sensorium associated with a sunken scalp flap and worsening midline shift on CT. A significant improvement in sensorium and a filling up of the scalp flap occurred after maintaining the patient's head in a dependent position. The patient subsequently made an excellent recovery following replacement of the bone flap. The pathophysiology of “syndrome of the trephined” or “sinking skin flap syndrome” is reviewed.

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Mini titanium plates; hearkening the end of nonrigid cranial bone flap fixation

Pakistan Journal of Medical Sciences ◽

10.12669/pjms.334.12003 ◽

2017 ◽

Vol 33 (4) ◽

Author(s):

Muhammad Junaid ◽

Syed Sarmad Bukhari ◽

Mobasher Ahmad Saeed ◽

Mamoon Ur Rashid

Keyword(s):

Bone Flap ◽

Cranial Bone ◽

Flap Fixation

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Autologous Skull Bone Flap Sterilization After Decompressive Craniectomy: An Update

World Neurosurgery ◽

10.1016/j.wneu.2016.03.042 ◽

2016 ◽

Vol 90 ◽

pp. 478-483 ◽

Cited By ~ 1

Author(s):

Paolo Missori ◽

Daniele Marruzzo ◽

Sergio Paolini ◽

Arsen Seferi ◽

Marco Fricia ◽

...

Keyword(s):

Decompressive Craniectomy ◽

Bone Flap ◽

Skull Bone

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Dynamic Decompressive Craniotomy with a Novel Reversibly Expandable Plate

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0036-1594013 ◽

2016 ◽

Vol 78 (04) ◽

pp. 386-389 ◽

Cited By ~ 2

Author(s):

Rohit Khanna

Keyword(s):

Progressive Increase ◽

Bone Flap ◽

Cranial Bone ◽

Intracranial Volume ◽

Volume Increase ◽

Significant Control ◽

Decompressive Craniotomy ◽

Skull Model ◽

Flap Fixation ◽

Fixation Plate

Objective To assess the feasibility of a dynamic craniotomy procedure with the use of a novel reversibly expandable cranial bone flap fixation plate. The expandable plate allows outward bone flap migration with an increase in intracranial volume or intracranial pressure (ICP). Methods Dynamic craniotomy intracranial hypertension compliance was evaluated in a skull model with progressive increase in intracranial volume and compared with the standard craniotomy with fixed plates. Results Dynamic craniotomy provided significant control of ICP with increasing intracranial volume compared with the standard craniotomy. With an incremental increase in intracranial volume from 360 mL to 600 mL, the ICP increased from 2.6 to 91.9 mm Hg with the standard craniotomy, whereas with the dynamic craniotomy the ICP for similar intracranial volume increased from 2.5 to 25 mm Hg (p < 0.00001). Conclusions The dynamic craniotomy procedure provides superior control of ICP with an abrupt intracranial volume increase when compared with the standard craniotomy.

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Analysis, optimization and prototyping of a parallel RCM mechanism of a surgical robot for craniotomy surgery

Industrial Robot the international journal of robotics research and application ◽

10.1108/ir-08-2017-0144 ◽

2018 ◽

Vol 45 (1) ◽

pp. 78-88 ◽

Cited By ~ 6

Author(s):

Mohammadreza Dehghani ◽

Majid Mohammadi Moghadam ◽

Pourya Torabi

Keyword(s):

3D Modeling ◽

Design Methodology ◽

Surgical Robot ◽

Bone Flap ◽

Optimized Design ◽

Concept Design ◽

Skull Bone ◽

Content Type ◽

Milling Tool ◽

Kinematic Performance

Purpose Removing the bone flap is a compulsory step in open skull surgeries and is very cumbersome and time-consuming. Exerting large forces during the milling and cutting of the skull renders the surgeon exhausted and consequently increases probable errors in further task of manipulating the sensitive brain tissue. This paper aims to present the development of a robotic system capable of perforating and cutting the required bone flap without restraining the surgeon. Design/methodology/approach For the purpose of optimization, the target workspace is estimated by 3D modeling of the sample skull and bone flaps of targeted surgeries. The optimization considers kinematic performance matrices and the extracted workspace requirements by assigning scores to each possible design and finally selects the design with highest score. Findings The design utilizes a parallel remote center of motion mechanism. Coordinating the remote center of motion (RCM) of the mechanism with the center of a sphere which circumscribes the skull, the milling tool is always nearly perpendicular to the skull bone. The paper presents the concept design, optimization criteria and finally the optimal design of the robot and the fabricated prototype. Tests indicate that the prototype is able to sweep the target workspace and to exert the required forces for bone milling. Originality value The workspace requirements of the craniotomy/craniectomy surgeries are investigated and converted into one quantitative target workspace. An optimized design for a surgical robot is developed which satisfies the workspace requirements of the targeted surgeries.

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