RU2279252C2 - Method for cranioplasty - Google Patents

Abstract

FIELD: medicine, neurosurgery.

SUBSTANCE: while carrying out osseous-plastic cranial trepanation one should cut out an osseous transplant through cutting foramens. Moreover, the cutting from the edge of cutting foramen during 0.5 cm should be made at the angle of 90° against osseous surface, then at the angle of 45° and, not achieving 0.5 cm to the edge of the following cutting foramen - against at the angle of 90°. Into cuttings made at the angle of 90° it is necessary to introduce N-shaped clamps designed out of shape-memory metal. Clamps should be rotated around vertical axis for the angle of 90° so, that clamp's pedicles should be located fro the external and internal sides of the transplant and cranial bones. The clamp has the thickness being equal to that of a cutting, and a clamp's crosspiece along its pedicle has the size being 0.5 cm more against the clamp's thickness, and its thickness being equal to that of a clamp. Clamps should be introduced simultaneously, by pairs, being opposite to each other. The innovation enables to decrease post-operational complications due to decreased transplant's mobility and increased strength of its fixation.

EFFECT: higher efficiency.

1 cl, 3 dwg, 1 ex

Description

The invention relates to medicine, namely to neurosurgery, and can be used in the surgical treatment of skull defects after trepanation.

A conceptual approach to the problem of closing post-traumatic defects of the skull is based on sealing the cranial cavity. This is due to the fact that a complex of adverse factors is developing that adversely affects the social and domestic rehabilitation of patients. Clinically, skull defects manifest themselves as trepanation syndrome. This concept includes local periostein-sheath pains in the area of the defect, common headaches, prolapse of the contents of the skull into a bone defect during physical exertion, a cough, and a tilt of the head. Meteopathic syndrome associated with increased headaches with changes in atmospheric pressure. In this regard, there is a need for cranioplasty.

Indications for cranioplasty can be divided into therapeutic, cosmetic and preventive. The main therapeutic indication for closing a skull defect is the need to seal the cranial cavity and protect the brain from external influences. Cosmetic indications include, first of all, extensive disfiguring skull defects mainly in the frontal and frontal-orbital regions, since these patients are often in a state of oppression and experience a sense of inferiority.

Preventive indications include cases where the closure of a bone defect is performed in order to prevent brain contusion in individuals suffering from epileptic seizures, as additional trauma can lead to the development of status epilepticus. An advantage of cranioplasty should be considered the earliest restoration of general clinical, biological, immunological, electrophysiological and x-ray biological parameters. In addition, early restoration of the tightness of the cranial cavity and meninges prevents the development of a rough scar-adhesion process, creates conditions for the normalization of hemo- and cerebrospinal circulation, prevents the displacement and deformation of the ventricular system and subshell spaces, provides the most complete restoration of central nervous system functions and is a preventive measure post-traumatic epilepsy and other complications.

A device for cranioplasty is known, which consists of a plate and at least three fixing elements made in the form of cotter pins made of porous titanium nickelide, each of which has a flattened head with spikes and a trapezoidal rod with a diverging end (A.S. 1655477, A 61 V 17/58 “Device for cranioplasty”, BI No. 22, 06.15.91, p. 26).

The disadvantages of the device are that the cranioplasty device is very bulky in size, this device uses two nickelide-titanium materials and self-hardening plastic, the graft of self-hardening plastic does not have bioenergy and, as a result, the graft is rejected. Moreover, to fix the device, it is necessary to additionally form holes on the side of the bones of the cranial vault for fixation of the graft.

A device for osteosynthesis of the bones of the cranial vault, consisting of bone plates made of a material having a shape memory effect, and curved in the shape of the curvature of the skull in the area of the defect (AS No. 1491496, A 61 B 17/58 "Device for osteosynthesis of bones of the cranial vault ”, B. I. No. 25.07.89).

The disadvantages of the device are that the laths are very bulky, which leads to technical difficulties when suturing the wound in layers.

There are various fixators for fixing endoprostheses that cover defects in the bones of the skull, made of metal with shape memory (omega-shaped, S-shaped, wave-shaped brackets). Patent No. 213113, A 61 B 17/80, B.I. No. 20, part 3 of 07/20/99, p. 359.

Disadvantages:

- when installing these brackets, the graft may be shifted towards the place of fixation of the device;

- does not create reliable fixation and the possible displacement of the graft in the direction of the cranial cavity is not prevented;

- a significant thickness of these brackets sometimes creates the appearance of a foreign body under the skin of the patient’s head, which reduces the cosmetic properties of the operation;

- these fixatives do not fill the space (gap) between the bone graft and the edge of the bone defect of the cranial vault, which was previously sawn with a Jigley file;

- the fixation of the graft to the donor site occurs only on one side - the outside, which does not create sufficient strength and immobility of the graft;

- to install these fixatives, it is necessary to make additional holes in the graft and around the perimeter of the bone defect.

The closest in technical essence is the method of traditional cranioplasty by closing the skull defect with its own bone, which was resected during bone-plastic decompressive trepanation of the skull (regarding the removal of intracerebral hematomas, brain tumors, etc.). At the same time, several milling holes are made along the perimeter of the intended surgical access to the bone with the help of a neurosurgical scoop and special drills (spear-shaped and cone-shaped). Sections of the bone between the holes are sawn with a Jigley or Olivecron wire saw. Their use is preferable, since they form the narrowest gap when cutting in the bone. In order to prevent injuries of the dura mater (TMT), the file is carried out by placing it on a special conductor, which is carried out between the bone and the TMT from one hole to another. Having attached special handles to both ends of the saw, they cut the bone from the inside out, producing a cut plane at an angle of 45 degrees, connecting milling holes around the entire perimeter of the removed bone fragment. Such an oblique cut of the bone prevents subsequent failure of it in the cranial cavity and allows you to put the bone flap at the end of the operation more accurately. The bone graft is stored for some time in a special formalin solution, and then after a certain period of time, by repeated surgery, it is replaced with a trepanation defect in the bones of the cranial vault. In this case, the transplant is fixed by lavsan thread ligatures through the formed additional holes in the transplant along the perimeter of the bone defect [S.I. Elizarovsky, R.P. Kalashnikov. Operative Surgery and Topographic Anatomy, M .: Medicine, 1979, ed. the second one. S. - 144-146].

The disadvantages of the prototype:

- the bone graft after surgery, due to the cutting of the bone flap with a Jigley file, is smaller (along the entire perimeter it goes into shavings of at least 2 mm, which is equal to the outer diameter of the Jigley file);

- due to a decrease in the transplant area, there may be some displacement of the graft both to the sides and to the cranial cavity;

- the fixing dacron threads do not create sufficient strength and fixation stability; when the graft is fixed, the latter can be displaced both to the side and to the cranial cavity;

- fixation of the bone graft with lavsan threads sometimes creates the prerequisites for the formation of ligature fistulas;

- to fix the bone graft, it is necessary to make additional holes around the perimeter of the bone defect and the graft for conducting mylar threads.

The objective of the present invention is to develop a method that improves the efficiency of the operation, and to reduce postoperative complications, by eliminating the mobility of the graft and increasing the strength of its fixation.

The task is achieved by the fact that when performing cranioplasty, including osteoplastic trepanation of the skull, a bone graft is cut. For this, milling holes are made, which are then connected by cuts passing at different angles. Propyl from the milling hole for 0.5 cm is made perpendicular to the surface of the bone, then at an angle of 45 degrees and, not reaching 0.5 cm to the edge of the next milling hole, again at an angle of 90 degrees. The removed bone graft is preserved and, during the subsequent operation, is set in place of the defect formed. In order to fix the transplant into the sections of cuts made at an angle of 90 degrees, H-shaped staples are inserted, made of metal with shape memory. The staples are first inserted with legs along the direction of cut, then they are turned around the vertical axis 90 degrees so that the legs of the bracket are located on the outer and inner sides of the graft and the edges of the bone. The bracket has paired legs connected by a jumper. The thickness of the bracket corresponds to the size of the cut as it should freely enter. The jumper of the staple has a dimension along the legs equal to the thickness of the cut (i.e., the thickness of the staple) plus 0.5 mm, so that when the staples are rotated in the cut 90 degrees around the vertical axis, the bones are wedged out and firmly fixed. The brackets are inserted simultaneously and in pairs, placed against each other, on both sides of the milling holes, in areas having cuts with an angle of 90 degrees.

The novelty of the method:

1. In case of osteoplastic trepanation, graft cutting is performed starting from the milling hole over 0.5 cm, first perpendicular to the bone surface, then at an angle of 45 degrees and, not reaching 0.5 cm to the edge of the next milling hole, again at an angle 90 degrees to the surface of the bone. The implementation of the cut, thus, allows you to create areas for the introduction of staples and creates an area of contact between the graft and the bone of the skull, preventing the displacement of the graft inside the skull.

2. Into the cuts made at an angle of 90 degrees, H-shaped staples are inserted and rotated around the vertical axis of the staples by 90 degrees.

3. Staples made of metal with shape memory effect.

4. After the bracket is rotated, its legs are located on the external and internal sides of the graft and the skull bone. With the manifestation of the memory effect of the form, the legs of the staples come together and hold the graft relative to the skull in the desired position much stronger than dacron threads.

5. The jumper of the bracket has a dimension along the legs equal to the thickness of the bracket or the amount of cut plus 0.5 mm, therefore, when the bracket is rotated, a wedging effect is created, thereby increasing the fixation strength.

6. The brackets are inserted in pairs, placed against each other. This introduction of fixing brackets eliminates the displacement of the graft in the horizontal plane.

The invention is illustrated by drawings, where

figure 1 shows a diagram of a bone graft cutting:

1 - milling holes;

2 - a section of bone with a cutting angle of 90 degrees;

3 - a section of bone with a cutting angle of 45 degrees;

4 - skin;

5 - aponeurosis;

6 - bone;

7 - bone graft;

8 - skin-muscle-aponeurotic flap;

AA shows a cut with a cut angle of 90 degrees;

BB shows a cut with a cut angle of 45 degrees;

figure 2 shows the shape of an N-shaped bracket:

a) the shape of the bracket in working condition;

b) the shape of the bracket when treated with refrigerant prior to administration;

c) along CC — the cross section of the jumper of the bracket;

figure 3 shows the fixation of the bone graft with N-shaped staples:

1 - milling holes;

2 - a section of bone with a cutting angle of 90 degrees;

3 - a section of bone with a cutting angle of 45 degrees;

4 - skin;

5 - aponeurosis;

6 - bone;

7 - bone graft;

8 - skin-muscle-aponeurotic flap;

9 - H-shaped bracket made of metal with shape memory;

according to DD installation of the bracket in the working position.

The essence of the method is as follows.

When osteoplastic trepanation of the skull around the perimeter of the bone section proposed for resection, 5-6 milling holes were made. Bony gaps between the milling holes along the conductor were sawn with a Jigley file. Within 0.5 cm from the edges of the milling holes, the bone was first sawn at an angle of 90 degrees, then the cutting angle was changed to 45 degrees. Without reaching 0.5 cm to the next milling hole, the angle of cut was again changed by 90 degrees. The remaining gaps between the milling holes were cut in the same way. As a result, along the edges of the milling holes on both sides an interosseous cut was created with a length of 0.5 cm in the direction strictly perpendicular to the bone surface for installation of an H-shaped fixing bracket of metal with shape memory in it. The peculiarity of the H-shaped bracket is that in the longitudinal direction (along the legs) it has a thickness of 2 mm with the initial form of some rapprochement of the legs along the edges. The thickness of the bracket is equal to the width of the cut. The jumper between the two legs has two sizes: in one direction, its thickness is equal to the thickness of the bracket and the size of the cut, i.e. 2 mm, which makes it possible to insert an H-shaped bracket into the prepared gap along the edges of the milling holes. In another, perpendicular, direction along the legs, the size of the bridge is 0.5 mm larger than the thickness of the bracket. The height of the lintel varies from 3 to 12 mm and is selected individually depending on the thickness of the compared bone edges.

The H-shaped bracket is cooled by the refrigerant, the paired legs beyond the edges are unbent, and the bracket in the longitudinal direction is brought into the prepared perpendicular interosseous gap in the region of the edges of the milling holes. In this case, the lower paired legs of the bracket are inserted under the bones of the skull and graft, and the others are outside these bones, after which, using the clamp, the bracket rotates 90 degrees relative to the vertical axis. Under the influence of human tissue temperature, the ends of paired legs come closer together (shape memory effect), while the staple legs hold the graft from the outside and from the inside. On the diametrically opposite side of the graft, another H-shaped bracket is simultaneously wound up and also rotated 90 degrees around its vertical axis. At the same time, the H-shaped bracket jumper increased by 0.5 mm creates the effect of graft wedging simultaneously from two sides. In the same way, the remaining brackets are installed against each other along the edges of all milling holes. At the same time, the legs of the N-shaped bracket are located both outside and inside. Such a capture of the graft and bones of the skull with the legs of the bracket excludes their displacement in the horizontal and vertical plane. The jumper of the bracket, located in the perpendicular cut, creates a wedging effect and additional strength of fixation of the graft. A bone gap sawn at an angle of 45 degrees between two perpendicular cuts eliminates the displacement of the graft into the cranial cavity and creates the largest area of contact between the bone edges for subsequent bone regeneration.

Example. Patient K. was hospitalized in the NDO on January 21, 2001, 2 hours after a road injury in a coma. After a general clinical and X-ray examination (2-projection skull X-ray, Echo-ES, CT of the brain) the diagnosis was established: Closed head injury, severe brain contusion with compression of the left hemisphere of the brain with an acute subdural hematoma, cerebral edema, dislocation syndrome in the stage of clinical subcompensation, bruises of the soft tissues of the head, face. An emergency operation was performed under ETN: Osteoplastic trepanation in the parietal-temporal region on the left, removal of acute subdural hematoma, drainage.

Operation protocol: After processing the surgical field under ETN + local infiltration anesthesia with 0.5% novocaine 30.0 in the parietal-temporal region, a horseshoe-shaped incision was made on the left. Hemostasis. A skin-muscle-aponeurotic flap was formed, with the base allotted to the ear, fixed, processed. Five milling holes were made around the perimeter of the bone section intended for resection. A jigley saw was brought into the epidural space through a conductor through milling holes. Sections of the bone, at a distance of 0.5 cm from the edges of the milling holes, are cut at an angle of 90 degrees (perpendicular to the surface of the bone), the rest of the section of the interosseous gap between the milling holes is sawn at an angle of 45 degrees. The remaining interosseous spaces were cut in the same way. The bone was removed, processed, and stored in a tissue laboratory. The dura mater is sharply tense, swells, does not pulsate, is opened horseshoe-shaped, blood clots up to 100 ml are found under it, which were gradually removed with a spatula and by washing with physiological saline. A revision of the subdural space was carried out, the source of bleeding - the sheath vessel was identified, the latter coagulated. The surgical field is washed with physiological saline, a distinct pulsation and expansion of the substance of the brain are noted. TMT is sutured with mylar threads. The musculocutaneous aponeurotic flap was put in place, the wound was sutured with the removal through a separate incision of polyvinyl chloride drainage installed in the subaponeurotic space. 24 days after the complex treatment, the patient was discharged for outpatient aftercare and medical examination at a neurologist at the place of residence. Rehabilitation treatment was carried out.

The patient was hospitalized in the HHO in a planned manner after 6 months with a diagnosis of Traumatic brain disease, post-trepanation defect of the parietal-temporal region on the left, right-sided hemiparesis, episindrom, post-traumatic encephalopathy.

A general clinical, neurological, radiological electrophysiological, ophthalmic examination was performed.

On July 18, 2001, an operation was performed under ETN: Meningolysis, cranioplasty of a defect in the parietal-temporal region on the left with canned autobone and graft fixation with H-shaped brackets made of Ti-Ni.

Under ETN and local infiltration anesthesia with a solution of novocaine 0.5% -40.0, an incision of soft tissues to the bone was made in the old postoperative scar. The edges of the bone defect are separated. The musculocutaneous flap is separated from the meninges, turned away from the ear, fixed. The cicatricial scar is excised. The canned autograft is placed in the area of the trepanation defect, the H-shaped brackets are treated with refrigerant, the edges of the paired legs are divorced and the brackets are placed in the area of previously formed sections of cuts with a cutting angle of 90 degrees along the edges of diametrically opposite milling holes. After inserting the staples, the clamp is rotated around the vertical axis by 90 degrees, while the pair of legs of the staple, contracting under the influence of ambient temperature, cover the graft and the edge of the skull defect from the outside and from the inside. In the same way, the bone graft was fixed in the remaining formed perpendicular cuts along the edges of the remaining milling holes. The braces were introduced in pairs, against each other, while simultaneously rotating them around the vertical axis by 90 degrees, wedging the graft. A skin-aponeurotic flap was put in place, sutures were placed on the skin, a rubber graduate was installed in the subaponeurotic space. The graduate was removed on the 2nd day after the operation, the sutures were removed on the 10th day, healing by first intention, was discharged on the 14th day after the operation.

Examined on an outpatient basis a year after the operation, a neurological, X-ray examination was performed, positive dynamics were noted in the form of a decrease in headaches and a reduction in epilepsy attacks. On radiographs and CT, signs of transplant consolidation with the edges of the bone defect were revealed. No bone graft displacement, no cosmetic defects were found.

Conclusion: 14 patients were operated on using this method in the conditions of HCW, all received a good functional, therapeutic and cosmetic result, there were no complications during surgical treatment of this category of patients with the developed method.

Claims (2)

1. The cranioplasty method, including osteoplastic trepanation of the skull by cutting a bone graft through milling holes connected by cuts passing at an angle of 45 ° followed by closing the skull defect with the same graft and fixing it, characterized in that it cuts from the edge of the milling hole for 0.5 cm is produced at an angle of 90 ° to the bone surface, then at an angle of 45 °, and not reaching 0.5 cm to the edge of the next milling hole, again at an angle of 90 °, in the cuts made at an angle of 90 °, set H- form staples made of metal with shape memory, which are rotated around the vertical axis by 90 °, so that the staples of the staples are located on the outer and inner sides of the graft and bones of the skull, the staple has a thickness equal to the cut width, and the jumper between the legs has two size: in one direction, its thickness is equal to the thickness of the bracket, and in the perpendicular direction along the legs, its size is 0.5 mm larger than the thickness of the bracket. 2. The method according to claim 1, characterized in that the brackets are introduced simultaneously in pairs, positioning against each other.

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