Multidisciplinary Approach for Improved Outcomes in Secondary Cranial Reconstruction: Introducing the Pericranial-Onlay Cranioplasty Technique

AbstractBACKGROUND:Although materials for secondary cranial reconstruction have evolved with time, the overall approach in terms of bone flap/implant reconstruction after necessary delay has remained constant.OBJECTIVE:To present our cases series of 50 consecutive secondary cranial reconstruction patients and to describe a multidisciplinary cranioplasty approach developed to reduce morbidity, to minimize infection, and to improve aesthetic appearance.METHODS:Standard technique teaches us to place the bone flap and/or alloplastic implant directly over the dura or dural protectant after scalp flap re-elevation. However, this procedure is fraught with high complication rates, including infection. While raising the previously incised scalp flap overlying the full-thickness calvarial defect, the dissection is performed within the loose areolar tissue plane beneath the galea aponeurosis, thus leaving vascularized pericranium intact over the dura.RESULTS:A total of 50 consecutive patients were treated by the senior author encompassing 46 cranioplasties using the pericranial-onlay approach, along with 4 isolated temporal soft tissue reconstructions with liquid poly-methyl-methacrylate. Of the 46 cranioplasties (> 5 cm2), only 1 autologous bone flap developed deep infection necessitating bone flap removal (1 of 46, 2.17%; 95% confidence interval, 0.003-11.3). None of the alloplastic custom implants placed have developed any infection requiring removal.CONCLUSION:This multidisciplinary approach illustrated in our case series, including our “pericranial-onlay” technique described here for the first time, has the potential to improve patient outcomes, to decrease perioperative morbidity, and to minimize costs associated with postoperative infections after secondary cranial reconstruction.

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SILK flow diverter for complex intracranial aneurysms: a Canadian registry

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-011708 ◽

2015 ◽

Vol 8 (3) ◽

pp. 273-278 ◽

Cited By ~ 34

Author(s):

Jai Jai Shiva Shankar ◽

Donatella Tampieri ◽

Daniela Iancu ◽

Maria Cortes ◽

Ronit Agid ◽

...

Keyword(s):

Case Report ◽

Intracranial Aneurysms ◽

Clinical Performance ◽

Case Series ◽

Flow Diverter ◽

Case Report Form ◽

Complication Rates ◽

Anterior Circulation ◽

Perioperative Morbidity ◽

Number Of Patients

IntroductionThe SILK flow diverter (SFD) is used for the treatment of complex intracranial aneurysms. Small case series have been reported in the literature but few studies with a large number of patients have been published. We present our experience with the SFD for the treatment of intracranial aneurysms in Canada.MethodsCenters across Canada using SFDs were contacted to fill out a case report form for patients treated with an SFD in their center. Individual centers were responsible for approval from their ethics committee. Image analysis was performed by individual operators. The case report forms were collected and the final analysis was performed.ResultsA total of 92 patients were treated with SFDs in eight centers in Canada between January 2009 and August 2013. The aneurysms were located in the posterior circulation in 16 patients and in the anterior circulation in 76 patients. Most aneurysms (75%) were saccular in shape; 22% were fusiform and 3% were blister aneurysms. The size of the aneurysms varied from 2 to 60 mm with the neck varying from 2 to 60 mm. Perioperative morbidity and mortality were 8.7% and 2.2%, respectively. At the last available follow-up, 83.1% of the aneurysms were either completely or near-completely occluded. The rate of complications was higher for fusiform aneurysms (p<0.001).ConclusionsThe SFD appears to be an important tool for the treatment of complex intracranial aneurysms. Treatment outcomes and complication rates remain a problem, but should be considered in the context of available alternative interventions. Ongoing analysis of flow-diverting stents for radiographic and clinical performance is required.

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Four petal evisceration versus standard technique: A retrospective study

European Journal of Ophthalmology ◽

10.1177/1120672120950160 ◽

2020 ◽

pp. 112067212095016

Author(s):

Stefano Ranno ◽

Massimiliano Serafino ◽

Paolo Nucci

Keyword(s):

Surgical Techniques ◽

Case Series ◽

Standard Technique ◽

Complication Rates ◽

Inclusion Criteria ◽

Implant Exposure ◽

Case Series Study ◽

Series Study ◽

Low Rate

Purpose: To compare the four-petal evisceration technique and the standard evisceration technique. Methods: In this retrospective, comparative case series study, sixteen charts of patients fulfilled the inclusion criteria and were were reviewed. Orbital implant exposition and complication rates between the two surgical techniques were evaluated. Results: A total of 16 eye of 16 patients fulfilled the inclusion criteria and were included in the analysis (eight in the four petal group and eight in the standard evisceration group). During postoperative follow-up there were no cases of implant exposure or migration in the four-petal group and two cases (25%) of implant exposure in the standard evisceration group. Exposed orbital implants dimension were both 16 mm and patients eviscerated for phtisis bulbi All surgeries were uneventful, and there were no serious complications during the study. Conclusion: Four petal evisceration technique seems particularly useful in patients with phtisis bulbi because it allowed the placement of an implant significantly larger than the standard technique with low rate of esposition.

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Sinking Skin Flap Syndrome following Posttraumatic Hydrocephalus

Case Reports in Neurological Medicine ◽

10.1155/2021/6682310 ◽

2021 ◽

Vol 2021 ◽

pp. 1-8

Author(s):

Ashish Chugh ◽

Prashant Punia ◽

Sarang Gotecha

Keyword(s):

Decompressive Craniectomy ◽

Postoperative Period ◽

Skin Flap ◽

Case Series ◽

Bone Flap ◽

Complication Rates ◽

Review Of Literature ◽

Trendelenburg Position ◽

Vp Shunt ◽

Shunt Occlusion

Introduction. Complications following craniotomy are not uncommon and Sinking Skin Flap Syndrome (SSFS) constitutes a rare entity that may present after a large Decompressive Craniectomy. Although the entity is widely reported, the literature mostly consists of case reports. Authors present a case series of three patients with review of literature highlighting the various factors which can prove therapeutic and can help in avoidance of complications. Materials and Methods. The study was conducted over a period of 3 years, from 2016 to 2019, and included 212 patients who underwent unilateral Decompressive Craniectomy (DC) for trauma in our institute. All 212 patients underwent a similar DC following a strict institutional protocol and the craniectomies were performed by the same surgical team. At total of 160 patients survived and elective cranioplasty was planned at a 3-month interval. Out of a total of 160 patients who survived, 38 developed hydrocephalus, 3 patients presented with hydrocephalus acutely and had to be shunted before cranioplasty and underwent ventriculoperitoneal (VP) shunting on the opposite side of craniectomy. All 3 of these patients developed SSFS and were the focus of this case series wherein review of literature was done with emphasis being laid on the salient features towards management of SSFS in such precranioplasty shunted patients. These 3 patients were treated via rehydration using normal saline (NS) till the Central Venous Pressure (CVP) equaled 8–10 cm of water, nursing in Trendelenburg position and shunt occlusion using silk 3-0 round bodied suture tied over a “C”-loop of VP shunt tube over clavicle. This was followed by cranioplasty within 2 days of presentation using a flattened, nonconvex artificial Polymethyl Methacrylate (PMMA) bone flap with central hitch suture taken across the bone flap and release of shunt tie in immediate postoperative period. The PMMA bone flap was made intraoperatively after measuring the defect size accurately after exposure of defect. 3D printing option was not availed by any patient considering the high cost and patients’ poor socioeconomic status. Results. Out of a total of 212 patients, thirty-eight patients (19%) developed posttraumatic hydrocephalus and out of 38, three presented with SSFS over the course of time. Two patients presented with hemiparesis of the side opposite to sunken flap while 1 other patient was brought by relatives in stuporous state. All 3 were subjected to VP shunt tie, rehydration, and cranioplasty using flattened artificial bone flap and showed gradual recovery in postoperative period without any complications. Conclusion. Various factors like nursing in Trendelenburg position, adequate rehydration, early cranioplasty after resolution of oedema, preoperative tying of VP shunt and its subsequent release in immediate postoperative period, use of flattened PMMA bone flaps, placement of a central dural hitch suture across the bone, and a preoperative central burr hole in the bone flap may accelerate healing and, in most cases, reversal of sensory-motor deficits along with reduction in complication rates.

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Orthopedic management of myelomeningocele with a multidisciplinary approach: a systematic review of the literature

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-021-02643-8 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Parnian Shobeiri ◽

Ana Presedo ◽

Amirali Karimi ◽

Sara Momtazmanesh ◽

Fardis Vosoughi ◽

...

Keyword(s):

Multidisciplinary Approach ◽

Case Reports ◽

Case Series ◽

Severe Form ◽

Complication Rates ◽

Spinal Deformities ◽

Multidisciplinary Management ◽

Foot And Ankle ◽

Review Of The Literature ◽

Significant Burden

Abstract Background Myelomeningocele (MMC) is the most common and severe form of spina bifida and imposes a significant burden on patients and the healthcare system. Recently, the multidisciplinary management of MMC has become popular. Herein, we aimed to review the orthopedic management, outcomes, and complications of the of patients with MMC eyeing a multidisciplinary approach. Methods We searched PubMed and EMBASE to find relevant studies published before August 2020. All studies that included clinical management of MMC patients and published earlier than 2000 were considered for review on the condition that they reported at least one orthopedic intervention and the rate of complications. We excluded review articles, case reports, case series, letters, commentaries, editorials, and conference abstracts. The primary and secondary goals of our review were to report the outcomes and complication rates of multidisciplinary management for MMC patients. Results Twenty-six studies included data for the management of 229,791 patients with MMC and were selected. Sixteen studies reported multidisciplinary management in addition to orthopedic management. From those, 11 (42.31%) included urologic management, 13 (50%) neurosurgical management, 11 (42.31%) neurologic management, and 5 (19.23%) gastrointestinal management. All studies included postnatal operations and related management. No randomized clinical trial was found in our search. Conclusion Orthopedic approaches play a key role in MMC management by alleviating spinal deformities, particularly scoliosis, and hip, foot, and ankle complications. However, the most appropriate management, whether surgical or non-surgical, may vary for different patients, given disease severity and the age of patients. Graphical abstract

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Arthroscopic Subtalar Joint Arthrodesis: Topical Review

Foot & Ankle International ◽

10.1177/10711007211035397 ◽

2021 ◽

pp. 107110072110353

Author(s):

Hesham Oshba ◽

Raghda Hasan AboBakr Shaaban ◽

Islam Abdelrahman ◽

Nikolaos Gougoulias

Keyword(s):

Subtalar Joint ◽

Surgical Techniques ◽

Case Series ◽

Deformity Correction ◽

Weighted Average ◽

Complication Rates ◽

Level Of Evidence ◽

Perioperative Morbidity ◽

Improved Outcomes ◽

Accelerated Rehabilitation

Background: Advances in foot and ankle arthroscopy over the last 2 decades have allowed for subtalar joint arthrodesis to be performed arthroscopically. The potential advantages of the arthroscopic technique include higher fusion rates, lower complications, reduced perioperative morbidity, and accelerated rehabilitation. Arthroscopic arthrodesis may, however, not be appropriate in the setting of complex deformity correction or the need for other open procedures. Methods: Surgical techniques of arthroscopic subtalar joint arthrodesis are described. Outcomes and complications associated with these procedures are presented, based on a comprehensive literature review. Thirteen Level IV studies of moderate quality were included. Results and Conclusion: Excellent arthrodesis union rates were achieved (average 96%, range 86%-100%), at a weighted average union time of 8.8 weeks (95% confidence interval 7.9-9.7). The overall complication rate was 21% (87/415 feet; range 10%-36.4%). Metal irritation was the most common complication (11.2%), followed by nerve injury (4.2%) and infection (0.9%). Similar fusion rates have been reported when comparing arthroscopic and open arthrodesis. Complication rates are also similar, excerpt for infection, which may be lower with arthroscopy. Three different approaches were used to access the subtalar joint with similar union and complication rates. There was no evidence that the use of bone graft or more than 1 screw improved outcomes. The superiority of arthroscopic subtalar fusion over open techniques cannot be demonstrated by the available studies. Level of Evidence: Level IV, case series.

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Herpetic Whitlow of the Hand in Infants

Journal of Hand and Microsurgery ◽

10.1055/s-0040-1710199 ◽

2020 ◽

Author(s):

Mohammad M. Al-Qattan ◽

Nada G. AlQadri ◽

Ghada AlHayaza

Keyword(s):

Bacterial Infection ◽

Case Reports ◽

Case Series ◽

Individual Case ◽

Senior Author ◽

Secondary Bacterial Infection ◽

Clinical Appearance ◽

History Of ◽

Mode Of Transmission ◽

Time Of Presentation

Abstract Introduction Herpetic whitlows in infants are rare. Previous authors only reported individual case reports. We present a case series of six infants. Materials and Methods This is a retrospective study of six cases of herpetic whitlows in infants seen by the senior author (MMA) over the past 23 years (1995–2017 inclusive). The following data were collected: age, sex, digit involved in the hand, mode of transmission, time of presentation to the author, clinical appearance, presence of secondary bacterial infection, presence of other lesions outside the hand, method of diagnosis, treatment, and outcome. Results All six infants initially presented with classic multiple vesicles of the digital pulp. In all cases, there was a history of active herpes labialis in the mother. Incision and drainage or deroofing of the vesicles (for diagnostic purposes) resulted in secondary bacterial infection. Conclusion The current report is the first series in the literature on herpetic whitlows in infants. We stress on the mode of transmission (from the mother) and establishing the diagnosis clinically. In these cases, no need for obtaining viral cultures or polymerase chain reaction; and no medications are required. Once the vesicles are disrupted, secondary bacterial infection is frequent and a combination of oral acyclovir and intravenous antibiotics will be required.

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Complications and Revisions After Spine Surgery in Patients With Skeletal Dysplasia: Have We Improved?

Global Spine Journal ◽

10.1177/2192568221994786 ◽

2021 ◽

pp. 219256822199478

Author(s):

Karim Shafi ◽

Francis Lovecchio ◽

Maria Sava ◽

Michael Steinhaus ◽

Andre Samuel ◽

...

Keyword(s):

Spine Surgery ◽

Skeletal Dysplasia ◽

Spinal Surgery ◽

Cardiovascular Health ◽

Surgical Complication ◽

Case Series ◽

Neurologic Complication ◽

Complication Rates ◽

Retrospective Case ◽

Average Patient

Study Design: Retrospective case series. Objective: To report contemporary rates of complications and subsequent surgery after spinal surgery in patients with skeletal dysplasia. Methods: A case series of 25 consecutive patients who underwent spinal surgery between 2007 and 2017 were identified from a single institution’s skeletal dysplasia registry. Patient demographics, medical history, surgical indication, complications, and subsequent surgeries (revisions, extension to adjacent levels, or for pathology at a non-contiguous level) were collected. Charlson comorbidity indices were calculated as a composite measure of overall health. Results: Achondroplasia was the most common skeletal dysplasia (76%) followed by spondyloepiphyseal dysplasia (20%); 1 patient had diastrophic dysplasia (4%). Average patient age was 53.2 ± 14.7 years and most patients were in excellent cardiovascular health (88% Charlson Comorbidity Index 0-4). Mean follow up after the index procedure was 57.4 ± 39.2 months (range). Indications for surgery were mostly for neurologic symptoms. The most commonly performed surgery was a multilevel thoracolumbar decompression without fusion (57%). Complications included durotomy (36%), neurologic complication (12%), and infection requiring irrigation and debridement (8%). Nine patients (36%) underwent a subsequent surgery. Three patients (12%) underwent a procedure at a non-contiguous anatomic zone, 3 (12%) underwent a revision of the previous surgery, and another 3 (12%) required extension of their previous decompression or fusion. Conclusions: Surgical complication rates remain high after spine surgery in patients with skeletal dysplasia, likely attributable to inherent characteristics of the disease. Patients should be counseled on their risk for complication and subsequent surgery.

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Open Appendicectomy under Spinal Anesthesia—A Valuable Alternative during COVID-19

The Surgery Journal ◽

10.1055/s-0041-1725933 ◽

2021 ◽

Vol 07 (02) ◽

pp. e69-e72

Author(s):

Dinh Van Chi Mai ◽

Alex Sagar ◽

Oliver Claydon ◽

Ji Young Park ◽

Niteen Tapuria ◽

...

Keyword(s):

United Kingdom ◽

Patient Satisfaction ◽

Spinal Anesthesia ◽

Stated Preference ◽

Case Series ◽

District General Hospital ◽

Complication Rates ◽

Open Appendicectomy ◽

Surgical Department ◽

The United Kingdom

Abstract Introduction Concerns relating to coronavirus disease 2019 (COVID-19) and general anesthesia (GA) prompted our department to consider that open appendicectomy under spinal anesthesia (SA) avoids aerosolization from intubation and laparoscopy. While common in developing nations, it is unusual in the United Kingdom. We present the first United Kingdom case series and discuss its potential role during and after this pandemic. Methods We prospectively studied patients with appendicitis at a British district general hospital who were unsuitable for conservative management and consequently underwent open appendicectomy under SA. We also reviewed patient satisfaction after 30 days. This ran for 5 weeks from March 25th, 2020 until the surgical department reverted to the laparoscopic appendicectomy as the standard of care. Main outcomes were 30-day complication rates and patient satisfaction. Results None of the included seven patients were COVID positive. The majority (four-sevenths) had complicated appendicitis. There were no major adverse (Clavien-Dindo grade III to V) postoperative events. Two patients suffered minor postoperative complications. Two experienced intraoperative pain. Mean operative time was 44 minutes. Median length of stay and return to activity was 1 and 14 days, respectively. Although four stated preference in hindsight for GA, the majority (five-sevenths) were satisfied with the operative experience under SA. Discussion Although contraindications, risk of pain, and specific complications may be limiting, our series demonstrates open appendicectomy under SA to be safe and feasible in the United Kingdom. The technique could be a valuable contingency for COVID-suspected cases and patients with high-risk respiratory disease.

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Epiphysiodesis for the treatment of tall stature and leg length discrepancy

Wiener Medizinische Wochenschrift ◽

10.1007/s10354-021-00828-8 ◽

2021 ◽

Author(s):

Madeleine Willegger ◽

Markus Schreiner ◽

Alexander Kolb ◽

Reinhard Windhager ◽

Catharina Chiari

Keyword(s):

Surgical Planning ◽

Multidisciplinary Approach ◽

Treatment Options ◽

Bone Age ◽

Leg Length Discrepancy ◽

Tall Stature ◽

Complication Rates ◽

Leg Length ◽

Growth Prediction ◽

Length Discrepancy

SummaryPainful orthopedic conditions associated with extreme tall stature and leg length discrepancy (LLD) include back pain and adopting bad posture. After failure of conservative treatment options, blocking of the growth plates (epiphysiodesis) around the knee emerged as gold standard in patients with tall stature and LLD in the growing skeleton. Surgical planning includes growth prediction and evaluation of bone age. Since growth prediction is associated with a certain potential error, adequate planning and timing of epiphysiodesis are the key for success of the treatment. LLD corrections up to 5 cm can be achieved, and predicted extreme tall stature can be limited. Percutaneous epiphysiodesis techniques are minimally invasive, safe and efficient methods with low complication rates. In general, a multidisciplinary approach should be pursued when treating children and adolescents with tall stature.

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