Outcomes of Cranioplasty Strategies for High-Risk Complex Cranial Defects: A 10-Year Experience

INTRODUCTION

Although the literature contains reports of the risks and complications of calvarial vault reconstruction for acquired defects, there are few publications addressing the specific patient population who require such reconstructions in cases preceded by prior infection, radiation, massive associated soft tissue trauma, and so on. We define such clinical presentations as a hostile environment for large surface area reconstruction. Our objective is to compare the safety and efficacy of autologous bone and alloplastic reconstruction in hostile cranial defects.

METHODS

An institutional review board-approved retrospective review of patients who underwent cranioplasty of a hostile site at the University of Alabama at Birmingham between January 2008 and December 2018 was performed. The patients were stratified into 3 groups based on the type of implant used: autogenous (bone), alloplastic (polyetheretherketone [PEEK], titanium, polymethyl methacrylate), or mixed (combination of bone and prosthetic). The primary outcome metric was a complication in the year after cranioplasty, identified by implant failure, necrosis, or infection. Statistical analysis included t tests and χ2 tests where appropriate using SPSS.

RESULTS

There were 55 total cases in this period: 27 autogenous, 23 alloplastic, and 5 mixed. The purely autogenous group had the highest complication rate (44%), and the alloplastic group had the lowest complication rate (38%), which was not statistically different between the 3 groups (P = 0.121). When stratified by specific material used for reconstruction (27 bone, 14 PEEK, 10 titanium, and 5 polymethyl methacrylate), overall complication rate was statistically significant (P = 0.009, χ2 test), with PEEK implants having the lowest complication rate (21%).

CONCLUSIONS

This analysis interestingly found that in the setting of hostile cranial defects, cranioplasties would benefit from the use of prosthetic implants instead of autologous bone grafts, not only for avoidance of donor site morbidity but also for a decrease in overall complications.

Comorbidity Trends in Patients Requiring Sternectomy and Reconstruction: Updated Data Analysis From 2005 to 2020

INTRODUCTION

Comorbidity trends after median sternectomy were studied at our institution by Vasconze et al (Comorbidity trends in patients requiring sternectomy and reconstruction. Ann Plast Surg. 2005;54:5). Although techniques for sternal reconstruction have remained unchanged, the patient population has become more complex in recent years. This study offers insight into changing trends in this patient population.

METHODS

A retrospective review was performed of patients who underwent median sternectomy followed by flap reconstruction at out institution between 2005 and 2020. Comorbidities, reconstruction method, average laboratory values, and complications were analyzed.

RESULTS

A total of 105 patients were identified. Comorbidities noted were diabetes (27%), immunosuppression (16%), hypertension (58%), renal insufficiency (23%), chronic obstructive pulmonary disease (16%), and tobacco utilization (24%). The most common reconstruction methods were omentum (45%) or pectoralis major flaps (34%). Thirty-day mortality rates were 10%, and presence of at least 1 complication was 34% (hematoma, seroma, osteomyelitis, dehiscence, wound infection, flap failure, and graft exposure). Univariate analysis demonstrated that sex (P = 0.048), renal insufficiency, surgical site complication, wound dehiscence, and flap failure (P < 0.05) had statistically significant associations with mortality. In addition, body mass index, creatinine, and albumin had a significant univariate association with mortality (P < 0.05).

CONCLUSIONS

Similar to the original study, there is an association between renal insufficiency and mortality. However, the mortality rate is decreased to 10%, likely because of improved medical management of patients with increasing comorbidities (80% with greater than one comorbidity). This has led to the increased use of omentum as a first-line option. Subsequent wound dehiscence and flap failure demonstrate an association with mortality, suggesting that increasingly complex patients are requiring a method of reconstruction once used a last resort as a first-line option.

The Surgical Experience aboard USNS COMFORT (T-AH-20) during Operation Continuing Promise 2015

In 2015, the United States Navy hospital ship (USNS) COMFORT, deployed to 11 Caribbean and Latin American countries over a six-month period to provide humanitarian civic assistance. Personnel from the United States Navy and multiple nongovernmental organizations collaborated to offer surgical and medical care. Data from past deployments aid in planning for future missions by prioritizing finite resources and maximizing care. The data analyzed included all patients evaluated and treated by the Directorate of Surgical Services of the USNS COMFORT between April and September 2015. Comparative and descriptive statistics were performed to analyze patient demographics, surgical subspecialty performing the procedures, types of general and pediatric surgical procedures performed, operative times, and complication rates. Of the 1256 surgical cases performed aboard USNS COMFORT during CP15, 24.8 per cent were general surgery cases, followed by 16 per cent ophthalmology, 10.6 per cent pediatric surgery, 10 per cent plastic surgery, and eight additional specialties with <10 per cent of the cases each. Total operative time was 1253 hours with a total room time of 1896.5 hours. The identified complication rate was 1.99 per cent across all specialties. The USNS COMFORT platform offers the unique capability to provide humanitarian surgical assistance. Reporting these data demonstrate that there is a need for humanitarian assistance and this can be provided safely through the Continuing Promise mission. Future deployments may target resources toward the surgical services with higher volumes, which were general surgery, ophthalmology, pediatric surgery, and plastic surgery.

The Surgical Experience Aboard USNS COMFORT (T-AH-20) during Operation Continuing Promise 2015

In 2015, the United States Navy hospital ship (USNS) COMFORT, deployed to 11 Caribbean and Latin American countries over a six-month period to provide humanitarian civic assistance. Personnel from the United States Navy and multiple nongovernmental organizations collaborated to offer surgical and medical care. Data from past deployments aid in planning for future missions by prioritizing finite resources and maximizing care. The data analyzed included all patients evaluated and treated by the Directorate of Surgical Services of the USNS COMFORT between April and September 2015. Comparative and descriptive statistics were performed to analyze patient demographics, surgical subspecialty performing the procedures, types of general and pediatric surgical procedures performed, operative times, and complication rates. Of the 1256 surgical cases performed aboard USNS COMFORT during CP15, 24.8 per cent were general surgery cases, followed by 16 per cent ophthalmology, 10.6 per cent pediatric surgery, 10 per cent plastic surgery, and eight additional specialties with <10 per cent of the cases each. Total operative time was 1253 hours with a total room time of 1896.5 hours. The identified complication rate was 1.99 per cent across all specialties. The USNS COMFORT platform offers the unique capability to provide humanitarian surgical assistance. Reporting these data demonstrate that there is a need for humanitarian assistance and this can be provided safely through the Continuing Promise mission. Future deployments may target resources toward the surgical services with higher volumes, which were general surgery, ophthalmology, pediatric surgery, and plastic surgery.

Strength and histology of a nanofiber scaffold in rats

BACKGROUND

Full-thickness soft tissue defects from congenital absence or traumatic loss are difficult to surgically manage. Healing requires cell migration, organization of an extracellular matrix, inflammation, and wound coverage. PLCL (70:30 lactide:caprolactone, Purac), poly(propylene glycol) nanofibrous scaffolds enhance cell infiltration in vitro. This study compares strength and tissue ingrowth of aligned and unaligned nanofibrous scaffolds to absorbable and permanent meshes. We hypothesize that PLCL nanofibrous grafts will provide strength necessary for physiological function while serving as a scaffold to guide native tissue regeneration in vivo.

MATERIALS AND METHODS

Abdominal wall defects were created in 126 rats followed by underlay implantation of Vicryl, Gore-Tex, aligned, or unaligned PLCL Nanofiber mesh. Specimens were harvested at 2, 6, and 12 wk for strength testing and 2, 12, and 24 wk for histopathologic evaluation. Specimens were graded for cellular infiltration, multinucleated giant cells (MNG), vascularity, and tissue organization. Mean scores were compared and analyzed with non-parametric testing.

RESULTS

The PLCL grafts maintained structural integrity until at least 12 wk and exhibited substantial tissue replacement at 24 wk. At 12 wk, only the aligned PLCL had persistent cellular infiltration of the graft, whereas both aligned and unaligned PLCL grafts showed the presence of MNG. The presence of MNGs decreased in the aligned PLCL graft by 24 wk.

CONCLUSIONS

The aligned PLCL nanofiber mesh offers early strength comparable to Gore-Tex but breaks down and is replaced with cellular ingrowth creating a favorable option in management of complex surgical wounds or native soft tissue defects.

Inhalation of single vs multiple metered-dose bronchodilator actuations from reservoir devices. An in vitro study

Differences in inhalation technique with reservoir or spacer devices may affect metered-dose inhaler (MDI) dose availability to a patient.

PURPOSE

This study examined the effect of single vs multiple actuations of an MDI into reservoir devices on dose delivery of albuterol, with three clinically available reservoir brands.

METHODS

An in vitro lung model simulated inspiration from the MDI reservoir system. Albuterol (Proventil; Schering) was delivered by MDI, with the Monaghan Aerochamber, the Diemolding Healthcare Division (DHD) aerosol cloud enhancer (ACE), and the Schering InspirEase, using standardized volumes and inspiratory flows of 30 L min(-1). The MDI was actuated into each brand of reservoir 1, 2, or 3 times in rapid succession, followed by a single inhalation. Aerosol dose at the reservoir mouthpiece was captured on a cotton filter, dissolved in ethanol, and measured with a spectrophotometer at 278 nm.

RESULTS

For all three brands of reservoir, less accumulated dose of drug is delivered with multiple actuations than with multiple single actuations each followed by inhalation. The total dose in milligrams increased significantly with two multiple actuations compared with one actuation in the Aerochamber and ACE (p<0.01), but not in the InspirEase (p>0.05). The Aerochamber, ACE, and InspirEase delivered a mean total dose (SD) of 0.0264 mg (0.012), 0.0271 mg (0.007), and 0.0136 mg (0.006), respectively, with one actuation compared to 0.0485 mg (0.011), 0.0453 mg (0.013), and 0.0218 mg (0.009) with two multiple actuations. The increase in total dose with three multiple actuations was not significant compared to two actuations for any of the brands tested (p>0.05). Although total dose increased with multiple actuations, a decline in efficiency was seen with two and three multiple actuations, compared to single actuation. The dose delivered per actuation decreased for the Aerochamber, ACE, and InspirEase from 0.0264 mg (0.012), 0.0271 mg (0.007), and 0.0136 mg (0.006) with one actuation, to 0.0243 mg (0.006), 0.0226 mg (0.006), and 0.0109 mg (0.005), respectively, with two multiple actuations, for losses of 8.0%, 16.6%, and 19.9% in dose per actuation for each brand. A further decline in delivery per actuation to 0.0164 mg (0.001), 0.0184 mg (0.004), and 0.0097 mg (0.005) for the 3 brands, respectively, was found with 3 multiple actuations before inhalation. This was a loss of 37.9%, 32.1%, and 28.7% of the dose per single actuation in each brand. There was no significant difference between the Aerochamber and the ACE in dose availability with 1, 2, or 3 actuations, but both of these brands provided significantly more drug than the InspirEase.

CONCLUSION

Maximal aerosol bronchodilator from an MDI reservoir was given by single actuations each followed by a breath. Two rapid actuations followed by a breath will give a significant accumulation of dose with some loss when compared to two single actuations each followed by inhalation. Three multiple actuations led to a loss of approximately one third of the drug dose obtainable with three single actuations each followed by inhalation, for all three brands.