Changes in the volume and density of calvarial split bone grafts after alveolar ridge augmentation

OBJECTIVES: One main problem occurring after bone grafting is resorption, leading to insufficient bone volume and quality, and may subsequently cause dental implant failure. Comparison of graft volume and bone density of iliac crest and calvarial transplants determined by animal studies demonstrates significantly lower resorption of bone grafts harvested from the skull. This paper is the first clinical study evaluating bone volume and density changes of calvarial split bone grafts after alveolar ridge reconstruction. MATERIAL AND METHODS: Bone volume and density were determined using CT scans and the software program Dicom Works in a total of 51 calvarial grafts after alveolar ridge augmentation in 15 patients. CT scans were taken in all 15 patients immediately after grafting (T0) and before implantation after a postoperative period of 6 months (T1). In five patients (26 calvarial grafts), a 1-year follow-up was performed (T2). RESULTS: A mean volume reduction of 16.2% at T1 (15 patients) and 19.2% at T2 (five patients) was observed. Bone density was high--about 1000 Hounsfield units--and did not change during the 1-year period. At the time of implantation, 41 transplants were classified as quality 1 bone and 10 as quality 2-3 bone. Grafting area and the technique used for grafting (inlay or onlay graft) did not affect the postoperative bone volume reduction. Generalized osteoporosis did not increase the resorption rate of calvarial transplants. CONCLUSION: Based on these findings, calvarial split bone grafts are a promising alternative for alveolar ridge reconstruction in dental implantology.

Evaluation of late results in breast reconstruction by latissimus dorsi flap and prosthesis implantation

BACKGROUND: Breast reconstruction by latissimus dorsi myocutaneous flap in combination with a prosthesis is a widely used, well-established procedure. Short- and medium-term evaluation after this procedure is well described in the literature, but there have been no evaluations of the late course (over 10 years) published until now. METHODS: In a retrospective study, 68 patients operated on by means of this technique at the authors' institution from 1981 to 1993 resulting in a minimal follow-up of 10 years were included. Patients were invited to an interrogation, clinical examination, and photographic documentation (n = 51). Incidence of late flap or prosthesis-related complications, number of and indications for corrective procedures, and the correlation of the patients' subjective judgment and objective results in the late course have been the main interest of the authors' survey. RESULTS: The authors found that 50 percent of the patients needed a late reoperation for change or removal of the prosthesis. Seven (10 percent) of 68 patients needed a definitive removal of the implant in the late course. Assessment of the photographic documentation of the late result by four nonprofessionals showed that the objective aesthetic results of a considerable number of the authors' reconstructions were not sufficient. CONCLUSION: The procedure combines two basic techniques of reconstructive surgery, the soft-tissue restoration by a pedicled flap as the autologous reconstructive component and the volume reconstruction by prosthesis. Therefore, these patients are subject to a cumulation of the basic morbidity of the two techniques. The authors conclude that the indication for this procedure should be restricted to patients not qualifying for "pure" reconstructive techniques.

The relationship between coagulation and the extend of surgery and postoperative infection in surgical infants below 6 months of age

AIM: First to assess coagulation changes after surgery in children below 6 months of age. Second to detect differences attributable to the extent of surgery and postoperative infection. MATERIALS AND METHODS: Blood counts, haemoglobin concentration (Hb), haematocrit (Ht), prothrombine time (PT), activated partial thromboplastine time (aPTT) and thrombelastography (TEG) were studied pre- and 2+/-1/2 d postoperatively. Patients were divided in 3 groups. I: minor surgery without access to the abdomen or thorax (n=51); II: abdominal or thoracic interventions (n=24); III: abdominal surgery with postoperative sepsis (n=11). RESULTS: Preoperative values of Hb, Ht and INR were related to the age of the infant. Postoperatively clot strength and formation rate increased in gr. I (p<0.05). In gr. II, clot formation was initiated earlier (p<0.05) even though PT decreased (p<0.05). In group III, patients postoperatively developed a tendency for hypocoagulability in all TEG-parameters, but not in plasmatic coagulation. Postoperative TEG measurements were significantly inferior in gr. III when compared to gr. I and II. CONCLUSION: Our findings suggest activation of whole blood coagulation in the uncomplicated postoperative period despite of a decrease in plasmatic coagulation. In sepsis, only thrombelastography, but not plasmatic coagulation was affected.

Reconstruction of the severely atrophic mandible using calvarial split bone grafts for implant-supported oral rehabilitation

OBJECTIVES: This article describes reconstruction of the severely atrophic mandible using calvarial bone grafts for implant-supported prosthetic oral rehabilitation. The study aim was to evaluate the efficacy of the treatment by determining implant survival and complication rates, and the extent of the postoperative graft resorption. STUDY DESIGN: Ten patients who underwent the treatment were followed clinically and radiologically using panoramic radiographs and CT scans during a mean postoperative period of 30 months. RESULTS: Good bone healing was observable 6 months postoperatively. The height reduction measured on panoramic radiographs was insignificant (mean 0.68 mm). Only minor complications occurred. Implant survival was 95%. Prosthodontic treatment was successfully performed in all cases, resulting in an improvement of oral function. Histological analysis of 1 bone biopsy showed minimal resorptive changes in otherwise very dense bone. CONCLUSION: Augmentation using calvarial grafts is a promising treatment alternative for the severely atrophic mandible.

Multicentre study on peri- and postoperative central venous oxygen saturation in high-risk surgical patients

Introduction Low central venous oxygen saturation (ScvO2) has been associated with increased risk of postoperative complications in high-risk surgery. Whether this association is centre-specific or more generalisable is not known. The aim of this study was to assess the association between peri- and postoperative ScvO2 and outcome in high-risk surgical patients in a multicentre setting. Methods Three large European university hospitals (two in Finland, one in Switzerland) participated. In 60 patients with intra-abdominal surgery lasting more than 90 minutes, the presence of at least two of Shoemaker's criteria, and ASA (American Society of Anesthesiologists) class greater than 2, ScvO2 was determined preoperatively and at two hour intervals during the operation until 12 hours postoperatively. Hospital length of stay (LOS) mortality, and predefined postoperative complications were recorded. Results The age of the patients was 72 ± 10 years (mean ± standard deviation), and simplified acute physiology score (SAPS II) was 32 ± 12. Hospital LOS was 10.5 (8 to 14) days, and 28-day hospital mortality was 10.0%. Preoperative ScvO2 decreased from 77% ± 10% to 70% ± 11% (p < 0.001) immediately after surgery and remained unchanged 12 hours later. A total of 67 postoperative complications were recorded in 32 patients. After multivariate analysis, mean ScvO2 value (odds ratio [OR] 1.23 [95% confidence interval (CI) 1.01 to 1.50], p = 0.037), hospital LOS (OR 0.75 [95% CI 0.59 to 0.94], p = 0.012), and SAPS II (OR 0.90 [95% CI 0.82 to 0.99], p = 0.029) were independently associated with postoperative complications. The optimal value of mean ScvO2 to discriminate between patients who did or did not develop complications was 73% (sensitivity 72%, specificity 61%). Conclusion Low ScvO2 perioperatively is related to increased risk of postoperative complications in high-risk surgery. This warrants trials with goal-directed therapy using ScvO2 as a target in high-risk surgery patients.

Are there accurate predictors of long-term vital and functional outcomes in cardiac surgical patients requiring prolonged intensive care?

BACKGROUND AND OBJECTIVE: The decision to maintain intensive treatment in cardiac surgical patients with poor initial outcome is mostly based on individual experience. The risk scoring systems used in cardiac surgery have no prognostic value for individuals. This study aims to assess (a) factors possibly related to poor survival and functional outcomes in cardiac surgery patients requiring prolonged (> or = 5 days) intensive care unit (ICU) treatment, (b) conditions in which treatment withdrawal might be justified, and (c) the patient's perception of the benefits and drawbacks of long intensive treatments. METHODS: The computerized data prospectively recorded for every patient in the intensive care unit over a 3-year period were reviewed and analyzed (n=1859). Survival and quality of life (QOL) outcomes were determined in all patients having required > or =5 consecutive days of intensive treatment (n=194/10.4%). Long-term survivors were interviewed at yearly intervals in a standardized manner and quality of life was assessed using the dependency score of Karnofsky. No interventions or treatments were given, withhold, or withdrawn as part of this study. RESULTS: In-hospital, 1-, and 3-year cumulative survival rates reached 91.3%, 85.6%, and 75.1%, respectively. Quality of life assessed 1 year postoperatively by the score of Karnofsky was good in 119/165 patients, fair in 32 and poor in 14. Multivariate logistic regression analysis of 19 potential predictors of poor outcome identified dialysis as the sole factor significantly (p=0.027) - albeit moderately - reducing long-term survival, and sustained neurological deficit as an inconstant predictor of poor functional outcome (p=0.028). One year postoperatively 0.63% of patients still reminded of severe suffering in the intensive station and 20% of discomfort. Only 7.7% of patients would definitely refuse redo surgery. CONCLUSIONS: This study of cardiac surgical patients requiring > or =5 days of intensive treatment did not identify factors unequivocally justifying early treatment limitation in individuals. It found that 1-year mortality and disability rates can be maintained at a low level in this subset of patients, and that severe suffering in the ICU is infrequent.

Surgical anatomy of the nail apparatus

Nail surgery is an integral part of dermatologic surgery. An in-depth knowledge of the anatomy, biology, physiology, and gross pathology of the entire nail unit is essential. In particular, knowledge of nail histopathology is necessary to perform diagnostic nail biopsies and other nail procedures correctly.

Lesser tuberosity osteotomy for total shoulder arthroplasty. Surgical technique

BACKGROUND: Recent studies have suggested that tenotomy and repair of the subscapularis tendon carried out for anterior approaches to the shoulder can be followed by failure of the tendon repair and by changes resulting in permanent loss of subscapularis function. We hypothesized that release of the subscapularis with use of a superficial osteotomy of the lesser tuberosity followed by repair of the two opposing bone surfaces would lead to consistent bone-to-bone healing, which would be possible to monitor radiographically, and would lead to satisfactory clinical and structural outcomes. METHODS: Thirty-nine shoulders in thirty-six consecutive patients who, at an average age of fifty-seven years, had undergone total shoulder replacement through an anterior approach involving an osteotomy of the lesser tuberosity were evaluated at an average of thirty-nine months. Assessment included a standardized interview and physical examination, scoring according to the system described by Constant and Murley, and imaging with conventional radiography and computed tomography to assess healing of the osteotomy site and changes in the subscapularis. RESULTS: The osteotomized tuberosity fragment healed in an anatomical position in all shoulders, and no cuff tendon ruptures were observed. At the time of follow-up, thirty-three (89%) of thirty-seven shoulders evaluated with a belly-press test had a negative result and twenty-seven (75%) of thirty-six shoulders evaluated with a lift-off test had an unequivocally normal result. Fatty infiltration of the subscapularis muscle increased after the operation (p < 0.0001) and was at least stage two in eleven (32%) of thirty-four shoulders. The fatty infiltration had progressed by one stage in eight (24%) of the thirty-four shoulders, by two stages in five shoulders (15%), and by three stages in two shoulders (6%). CONCLUSIONS: Osteotomy of the lesser tuberosity provides an easy anterior approach for total shoulder replacement and is followed by consistent bone-to-bone healing, which can be monitored, and good subscapularis function. In the presence of documented anatomical healing of the osteotomy site, postoperative fatty infiltration of the subscapularis muscle remains unexplained and needs to be investigated further as it is associated with a poorer clinical outcome.

Microbial colonization patterns predict the outcomes of surgical treatment of intrabony defects

AIM: To explore the impact of bacterial load and microbial colonization patterns on the clinical outcomes of periodontal surgery at deep intrabony defects. MATERIALS AND METHODS: One hundred and twenty-two patients with advanced chronic periodontitis and at least one intrabony defect of >3 mm were recruited in 10 centres. Before recruitment, the infection control phase of periodontal therapy was completed. After surgical access and debridement, the regenerative material was applied in the test subjects, and omitted in the controls. At baseline and 1 year following the interventions, clinical attachment levels (CAL), pocket probing depths (PPD), recession (REC), full-mouth plaque scores and full-mouth bleeding scores were assessed. Microbial colonization of the defect-associated pocket was assessed using a DNA-DNA checkerboard analysis. RESULTS: Total bacterial load and counts of red complex bacteria were negatively associated with CAL gains 1 year following treatment. The probability of achieving above median CAL gains (>3 mm) was significantly decreased by higher total bacterial counts, higher red complex and T. forsythensis counts immediately before surgery. CONCLUSIONS: Presence of high bacterial load and specific periodontal pathogen complexes in deep periodontal pockets associated with intrabony defects had a significant negative impact on the 1 year outcome of surgical/regenerative treatment.

Bacterial decontamination of surgical wounds treated with Lavasept

In a prospective randomized controlled double-blind study in 50 acutely injured patients, bacterially contaminated type 2-4 soft tissue wounds were treated with moist dressings of 0.2% Lavasept (fractionated polyhexamethylenbiguanide and macrogolum 4000) solution (n=28) in comparison with Ringer solution (n=22). Standardized swabs were taken on days 0, 2, 8 and 15 and investigated for microorganisms. For a quantitative evaluation, the number of colony forming units (CFU) was determined by a serial dilution technique. The tissue compatibility and anti-inflammatory effect were rated on a scale of 0 (=bad) to 3 (=very good). The most frequently found microorganism was Staphylococcus aureus, which was isolated from 13 wounds. Use of Lavasept led to a faster and significant reduction in microorganisms on the wound surfaces. The number of CFU per wound remained constant or decreased, in contrast to the wounds treated with Ringer solution. This was true for both Gram-positive and Gram-negative bacteria. There was no evidence of impaired wound healing in either group. The anti-inflammatory effect and the tissue compatibility of Lavasept were rated significantly better than that of Ringer solution. It is concluded that Lavasept combines antiseptic action with good tissue compatibility.

Multimodal augmented reality system for surgical microscopy

Image-guided, computer-assisted neurosurgery has emerged to improve localization and targeting, to provide a better anatomic definition of the surgical field, and to decrease invasiveness. Usually, in image-guided surgery, a computer displays the surgical field in a CT/MR environment, using axial, coronal or sagittal views, or even a 3D representation of the patient. Such a system forces the surgeon to look away from the surgical scene to the computer screen. Moreover, this kind of information, being pre-operative imaging, can not be modified during the operation, so it remains valid for guidance in the first stage of the surgical procedure, and mainly for rigid structures like bones. In order to solve the two constraints mentioned before, we are developing an ultrasoundguided surgical microscope. Such a system takes the advantage that surgical microscopy and ultrasound systems are already used in neurosurgery, so it does not add more complexity to the surgical procedure. We have integrated an optical tracking device in the microscope and an augmented reality overlay system with which we avoid the need to look away from the scene, providing correctly aligned surgical images with sub-millimeter accuracy. In addition to the standard CT and 3D views, we are able to track an ultrasound probe, and using a previous calibration and registration of the imaging, the image obtained is correctly projected to the overlay system, so the surgeon can always localize the target and verify the effects of the intervention. Several tests of the system have been already performed to evaluate the accuracy, and clinical experiments are currently in progress in order to validate the clinical usefulness of the system.