RU2821664C1 - Method of reconstructive surgery for depressed fracture of calvarium bones - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to neurosurgery. 2–4 milling holes are made in the intact bone. Osteoplastic trepanation is performed using a craniotome and a Gigli wire saw at distance of 1 cm from the fracture line. Bone flap is formed on a feeding muscular-periosteal pedicle including fragments. Compression is eliminated by reposition of bone fragments of the fractured skull. Bone fragments are fixed on the inner side of the bone flap with a titanium mesh plate modelled on the curvature of its inner surface and the size of the bone flap. Formed bone flap on the feeding muscular-periosteal pedicle is placed in the existing skull defect and fixed with bone sutures or titanium mini-plates to the edges of the intact bone. Wound is closed in layers. In case of open craniocerebral wounds, titanium mini-plates or bone sutures fixing the bone flap to the edges of the intact bone are placed outside the wound of soft tissues of the cranial integument.

EFFECT: method enables performing a one-stage bone-preserving reconstructive operation, eliminate compression of the brain with bone fragments, provide a good cosmetic effect, reducing the rate of postoperative complications, reducing the length of wound healing, hospitalization and length of temporary disability.

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Description

The invention relates to the field of medicine, namely to neurosurgery, and can be used in the treatment of depressed fractures of the bones of the calvarium. The essence of the method is a reconstructive operation to eliminate a depressed fracture of the bones of the cranial vault, based on performing osteoplastic trepanation with the inclusion of a depression zone in the bone flap, preserving the muscular-periosteal pedicle that feeds it, with repositioning bone fragments and fixing them on the inside of the bone flap, modeled by the curvature of its inner surface and size by a titanium mesh plate.

Depressed skull fractures are a disruption of the integrity of the skull bones that cause focal volumetric effects on the brain. Distant fractures of the calvarial bones require removal of compressing bone fragments in order to avoid compression of the brain and its further progression, as well as its consequences. Indications for surgery include compression of the brain, as well as a cosmetic defect. Before eliminating a depressed fracture, a question arises in the neurosurgeon’s head: whether to remove bone fragments or perform their reposition, and how to replace the resulting bone defect. The technique for removing depressed fractures of the calvarial bones varies depending on the location, nature of the fracture and the age of the patient, but mainly includes resection craniotomy, which is carried out in two ways. In most cases, a horseshoe-shaped or linear incision is made in the soft integument of the head, which is separated from the bone in one flap or in layers: first, a skin-aponeurotic flap, and then the periosteum is peeled off with a rasp. On the side of the edge of the depressed fracture, a milling hole is made in the intact bone, from which all bone fragments are removed with pliers. The second option is used for depressed fractures located in the projection of the superior sagittal or transverse sinuses. In this case, 4 burr holes are placed along the border of the fracture on the sides of the sinus, which are connected to each other along the perimeter of the distant fracture, then the entire fracture is gradually resected according to the principle from the periphery to the center (Surgery of the central nervous system. Part one. Edited by Prof. V .M. Ugryumova - Publishing house "Medicine" Leningrad department, 1969. - Neurosurgery: a guide for doctors. - Volume 1. Lectures, seminars, clinical discussions / Ed. O.N. Drevalya. - M.: Litterra, 2012. - Surgery of severe traumatic brain injury. Under the general editorship of Krylova V.V., Talypova A.E., Grin A.A., Levchenko O. .V. ABV-press, 2022 - 880 p.).

The disadvantage of resection trepanation is the need for repeated surgery to close the bone defect. If it is possible to perform primary cranioplasty, synthetic biopolymer materials are used for this purpose. This is accompanied by a high risk of developing local inflammatory reactions associated with the thermal, toxic and allergenic effect of the components of the mixture, as well as a rejection reaction to a foreign body. For reconstructive surgery to close bone defects of the skull, metal implants are also used, among which the most widely used is a titanium mesh plate with high strength. The disadvantages of this method include necrosis and trophic ulcers of the skin flap, and exposure of the implant.

A common disadvantage of using any alloplastic materials during their intraoperative modeling to close a defect is the risk of obtaining an unsatisfactory cosmetic result when restoring the natural relief of the cranial vault, especially in an anatomical zone with a complex configuration.

When performing surgical treatment of depressed skull fractures, preference is given to bone-preserving reconstructive operations. Reconstruction of depression of the skull bones can be performed by repositioning the fracture, which is carried out using an instrument brought epidurally to the center of compression from an applied burr hole in the intact bone adjacent to the fracture site. To reposition bone fragments in case of fractures of the cranial vault bones, a special device can also be used, which ensures stretching of the depressed part of the cranial vault bone by screwing the device into the bone of the cranial vault (see patent No. 2 775 195).

The disadvantage of these methods is the inability to easily inspect the dura mater and, if necessary, perform hemostasis and seal the dura mater.

There is a known method for treating a depressed fracture of the skull bones in children (see patent No. 2 683 067), in which the impression is eliminated by removing bone fragments of the broken area of the skull, then they are evenly placed on the bed of the bone defect formed with a hemostatic sponge "Tachocomb" and a second one is placed on top Tachocomb sponge.

The disadvantages of this method are the lack of resistance to mechanical stress, the risk of resorption of bone fragments, their rejection, the risk of suppuration, the risk of mobility of bone fragments and deformation of the skull.

The closest to the claimed method is a method of reconstructive surgery with extended trepanation using a craniotome with the formation of a free bone flap including fragments. After treatment with an antiseptic, bone fragments are sutured together with sutures, placed in the existing defect of the skull and fixed with bone sutures to the edges (autocranioplasty) (Demyanenko V.A., Kabanyan A.B., Baidakov A.P., Erzhakov S.V., Firsov A.L., Shatilov A.I. Reconstructive operations for depressed skull fractures in children. Kuban Scientific Medical Bulletin - 2012. - No. 6 (135). The disadvantage of this method, chosen as a prototype, is resorption, subsidence and exposure of the bone flap, divergence of the edges of the postoperative wound with the formation of fistulas. Another disadvantage is the development of purulent-inflammatory complications, especially with open injuries.

A very important disadvantage of this method is that the bone fragments are sutured together with sutures and fixed with bone sutures to the edges of the defect, and this does not provide the necessary rigidity and strength of the autograft, and, therefore, increases the risk of migration of bone fragments and deformation of the skull at the site of cranioplasty.

The purpose of the invention is to perform a one-stage bone-preserving reconstructive operation to eliminate compression of the brain by bone fragments with a good cosmetic effect and create conditions for reducing the incidence of postoperative complications.

The technical result of the task is achieved by the fact that in the method of reconstructive surgery for eliminating a depressed fracture of the bones of the cranial vault, based on performing osteoplastic trepanation with the inclusion of a depression zone in the bone flap, preserving the muscular-periosteal pedicle that feeds it, with the reposition of bone fragments and their fixation from the inside of the bone flap, modeled by the bend of its inner surface and size with a titanium mesh plate.

The method is carried out as follows.

The skin incision is made taking into account the blood supply and innervation of the skull, forming an aponeurotic skin flap depending on the shape and area of the damaged area of the bone and without exfoliating the periosteum with adjacent soft tissues. In the intact bone, at a distance of 1 cm from the edge of the fracture, 2-4 burr holes are placed and from them, along the perimeter of the fracture with a margin of 1 cm, using a craniotome and a Gigli wire saw, a bone flap is cut out, including the depression zone, while preserving the muscular-periosteal pedicle that feeds it , repositioning of bone fragments is performed. A titanium mesh plate is modeled based on the inner surface of the bone flap and its dimensions. Fixation of bone fragments is carried out on the inside of the bone flap, modeled with a titanium mesh plate, secured with screws along the perimeter of the fracture. Primary plastic surgery of the bone defect is performed with a bone flap formed in this way on a feeding musculoperiosteal pedicle with its fixation with titanium mini-plates along the edge of the defect to the intact bones of the cranial vault.

The invention is illustrated in the following figures:

Figure 1 shows a preoperative CT scan of the brain of patient R. in axial (A) and coronal (B) projections, which reveals a depressed comminuted fracture of the left parietal bone, with fragments displaced into the cranial cavity by 6 mm; the largest fragment measures 25x13x3mm. In fig. Figure 2 shows an intraoperative photograph: the inner surface of a bone autograft on a feeding musculoperiosteal pedicle after repositioning bone fragments and fixing them with a simulated titanium mesh plate. In fig. Figure 3 shows an intraoperative photograph of a simulated bone autograft on a feeding muscular-periosteal pedicle, fixed to the edges of the defect of the calvarial bones. In fig. Figure 4 shows a postoperative CT scan of the brain of patient R. in axial (A) and coronal (B) projections. The condition is determined after eliminating a depressed fracture with primary autocranioplasty after repositioning bone fragments. The bone fragments were compared satisfactorily with the restoration of the natural relief of the cranial vault. The titanium mesh plate is modeled taking into account the curvature of the inner surface of the bone flap and fits tightly to it. In fig. Figure 5 shows a preoperative CT scan of the brain of patient V. in axial (A) and coronal (B) projections. A depressed fracture of the left parietal bone to a depth of 9 mm is determined, causing compression of the adjacent part of the brain. In fig. Figure 6 shows a postoperative CT scan of the brain of patient V. in axial (A) and coronal (B) projections. The condition is determined after the elimination of a depressed fracture with primary autocranioplasty after repositioning bone fragments and fixing them with a titanium mesh plate along the inner surface of the cranial vault. The bone fragments were compared satisfactorily with the restoration of the natural relief of the cranial vault. The titanium plate is tightly adjacent to the inner surface of the bone flap.

Clinical example 1.

Patient R., 38 years old, was admitted to the neurosurgery clinic on August 30, 2023 at the Military Medical Academy named after. CM. Kirov with a diagnosis of open traumatic brain injury. Compression of the brain by bone fragments. Moderate brain contusion with the formation of contusion lesions in the left frontal and parietal lobes. Depressed comminuted fracture of the left parietal bone. Linear fracture of the left parietal bone, comminuted fracture of the squama of the left temporal bone. Lacerated and bruised wound of the left parietal region. On a computed tomography scan of the skull and brain dated August 30, 2023. a depressed comminuted fracture of the left parietal bone is determined, with fragments displaced into the cranial cavity by 6 mm; the largest fragment measures 25x13x3mm (Fig. 1, A, B).

Surgery:

On August 30, 2023, a reconstructive operation was performed using the claimed method: elimination of a depressed comminuted fracture of the left parietal bone. Primary cranioplasty of a calvarial bone defect with autologous bone with reposition of bone fragments fixed with a titanium mesh plate in the left parietal region, on the feeding muscular-periosteal pedicle.

Under general multicomponent anesthesia with tracheal intubation (see anesthesiologist's note) with the patient in the supine position, with the head fixed in the midline in a Mayfield-Keys clamp, after processing the surgical field, a layer-by-layer linear biauricular incision about 25 cm long was made posterior to the lacerated wound. . The aponeurotic skin flap is detached. Along the edge of the comminuted depressed fracture, 3 trephine holes were placed. Along the perimeter of this fracture, at a distance of 10 mm from its borders, a bone flap on the periosteal-muscular pedicle was formed using a trephine. A bone flap with a comminuted depressed fracture is raised with an elevator and thrown back on a musculoperiosteal pedicle to the base of the skull. The integrity of the dura mater is preserved. Mechanically, using curved bone sequestral forceps according to Van Buren, reposition of bone fragments at the site of the depressed fracture was performed. After modeling using a titanium mesh plate bender along the inner surface of the bone flap along the linear fracture line, bone fragments were fixed with this plate from the side of the inner surface of the bone flap (Fig. 2).

The simulated bone flap is placed in place and fixed with titanium mini plates on self-tapping screws outside the area of the lacerated wound (Fig. 3). In the projection of the lacerated wound onto the aponeurosis, separate interrupted sutures were applied from the inner surface. The postoperative wound is sutured in layers. On the control computed tomography of the skull and brain dated September 12, 2023: the condition is determined after the elimination of the depressed fracture with primary autocranioplasty after repositioning the bone fragments. The bone fragments were compared satisfactorily with the restoration of the natural relief of the cranial vault. The titanium plate is modeled taking into account the bending of the inner surface of the bone flap and is tightly adjacent to the inner cortical plate of the bone flap (Fig. 4, A, B). Despite the presence of a lacerated wound in the projection of a depressed fracture, the postoperative course was without complications. The wounds healed by primary intention. The stitches were removed on time. The patient was discharged in satisfactory condition.

Clinical example 2.

Patient V., 24 years old, was treated at the Department of Neurosurgery of the Military Medical Academy named after S.M. Kirov from September 26, 2023 until 06.10.2023 with a diagnosis of: Closed craniocerebral injury dated September 19, 2023. Compression of the brain by bone fragments in the left parietal region. Moderate brain contusion. Subarachnoid hemorrhage. Depressed impression fracture of the left parietal bone. On a computed tomography scan of the skull and brain dated September 27, 2023. a depressed fracture of the left parietal bone to a depth of 9 mm is determined, causing compression of the adjacent part of the brain (Fig. 5 A, B).

A reconstructive operation was performed using the claimed method: elimination of a depressed comminuted fracture of the left parietal bone. Primary cranioplasty of a calvarial bone defect with autologous bone with reposition of bone fragments fixed with a titanium mesh plate in the left parietal region, on the feeding muscular-periosteal pedicle. The operation went without complications. The wound healed by primary intention. On the control computed tomography of the skull and brain dated September 28, 2023: the condition is determined after eliminating the depressed fracture with primary autocranioplasty after repositioning the bone fragments and fixing them with a titanium mesh plate along the inner surface of the cranial vault. The bone fragments were compared satisfactorily with the restoration of the natural relief of the cranial vault. The titanium mesh plate is tightly adjacent to the inner surface of the bone flap (Fig. 6 A, B). The patient was discharged in satisfactory condition without complications.

The result of the invention is the ability to:

1) eliminate a depressed fracture of the bones of the calvarium,

2) perform autocranioplasty with your own viable bone tissue,

3) achieve a satisfactory cosmetic effect,

4) provide the necessary rigidity and strength of the autograft,

5) exclude migration of bone fragments and deformation of the skull at the site of cranioplasty,

6) avoid further repeated operations and the development of “trepanned syndrome”.

Four patients were operated on using this method in the neurosurgery clinic; all of them had good functional, therapeutic and cosmetic results; no complications were noted during the surgical treatment of this category of patients using the developed method.

The inventive method reduces the risks of complications in the postoperative period, such as: lysis of the bone flap, necrosis of the skin flap, failure of the sutures, the formation of fistulas, suppuration of the postoperative wound. This method also reduces wound healing time, hospitalization and the duration of temporary disability, even in patients with open craniocerebral injuries.

Claims (2)

1. A method of reconstructive surgery for a depressed fracture of the bones of the cranial vault, characterized by the fact that from 2-4 burr holes placed in the intact bone, osteoplastic trepanation is performed using a craniotome and a Gigli wire saw at a distance of 1 cm from the fracture line with the formation of bone flap on the feeding muscular-periosteal pedicle, including fragments, compression is eliminated by repositioning bone fragments of the broken area of the skull, bone fragments are fixed on the inner side of the bone flap, modeled by the bend of its inner surface and size with a titanium mesh plate, the formed bone flap on the feeding muscular - the periosteal pedicle is placed in the existing defect of the skull and fixed with bone sutures or titanium mini-plates to the edges of the intact bone, and the wound is sutured in layers. 2. The method according to claim 1, characterized in that in case of open craniocerebral wounds, titanium mini-plates or bone sutures that fix the bone flap to the edges of the intact bone are placed outside the wound of the soft tissues of the skull.