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Experiences in cranial bone grafting
EXPERIENCES IN CRANIAL BONE G R A F T I N G
1
By JOHN GROCOTT, F.R.C.S. From the Plastic Unit, North Staffordshire Royal Infirmary IN'the short series of cases discussed, the material used for repair was autogenous bone. The advantages of this medium far outweigh those of all other material. The donor area of choice was the iliac crest. Here again the advantages can be enumerated as : (I) the large area of bone available ; (2) the natural curvature of the bone ; (3) this area of the body tolerates interference far more than the thoracic cage, both from the aspect of pain and from that of chest complications after the operation ; (4) the subsequent disability consists as a rule only of pain, fairly severe for the first day or two, but rapidly diminishing, and in the normal course of events only slight stiffness on walking after three weeks. Over a large number of cases where bone has been taken from the iliac crest, not in this present short series, only on one occasion has a patient ever come back after quite a long period with any trouble, and that was with a small residual abscess. T H E TECHNIQUE OF OPERATION
The defect in the cranium is exposed by an incision which usually involves excising the old scar and extending the ends the necessary amount to get a clear
FIG. I Typical defect. Shows (I) eburnated bone edges ; (2) dura and aponeurosis fused.
CANCELLOUS EXPOSED.....~,.._~~ BONE
Defect prepared.
FIG. 2 Bone edges nibbled square.
view of the whole of the defect. The periosteum of the skull itself is then incised around the edges of the defect, about I in. away from the edge. This strip is elevated and turned inwards and excised. This allows the scar over the surface of 1 The substance of a talk given at the meeting of the British Association of Plastic Surgeons in St Albans, September I95 o. 5I
52
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
the dura to lie flat within the limits of the bony defect. The rounded edges of the defect are then nibbled away with good sharp nibbling forceps to give as nearly as possible a straight-cut edge of bone which is reasonably vascular (Figs. I and 2). An accurate assessment of the amount of bone necessary can now be made. At this stage the ha~mostasis of the area can be completed, and the original scalp flaps are replaced, covering the wound temporarily while the iliac bone is exposed. I f the defect is large, it will be necessary to expose the whole of the outer plate of the iliac bone. This can be done with an incision extending from the anterior superior spine to the posterior superior spine running along the crest of the bone. With care, and using broad, very sharp chisels, it is possible to elevate all of the outer table of the bone as far down as the acetabulum, thus providing a large oval piece of bone with a thin layer of compact bone on one side and a slightly thinner layer ILIAC BONE OUTER SURFACE PLAN
SECTION
SPINE
Fro. 3 T h e m a x i m u m donor area (whole of o u t e r plate). ( s m o o t h concave side).
N o t e curves
of cancellous bone on the other (Fig. 3). A rough pattern can be cut from the skull defect at this stage to give an approximate idea of how much bone is required, although I have found it wiser to cut rather an excess. The preparation of the graft itself consists of cutting gussets in the edge, as the degree of curvature of the graft is hardly enough to conform to the degree of curvature of the skull in the particular area, although again this depends on the individual case. It is intended that the smooth surface of the graft--that is, the compact bone--should lie in contact with the dura, which is fairly avascular, so that the vascular cancellous bone will be in contact with the vascular covering flaps of the scalp, thereby giving the bone graft the maximum blood supply in the shortest time and getting early union. To fit the graft into place, it is necessary to remove a narrow strip of cancellous bone around the whole circumference so that the thin compact bone can just be inserted under the margins of the skull defect (Figs. 4 and 5). Mechanically this looks unsound, but it can be easily protected during the period of convalescence, and in a very short period, as soon as five to six weeks, quite firm union has taken place. Of all the cases discussed later, only in one case did any slipping take place in the immediate post-operative period, and in this particular
EXPERIENCES
IN
CRANIAL
BONE
GRAFTING
53
case an efficient fitting on the lower margins of the graft could not be obtained. T h i s was in Case I, where extensive bone loss in the frontal area had to be repaired.
~
A
B
_4~_-G ., N SR SE EATS$C TVO IUC E CU UT R ATURE
~ICANCELLOUSBONE
co.PACT BONE FIG. 4 A, Graft cut with broad chisels (on generous side). B, Edges trimmed off, leaving shelf of compact bone.
Fitting.
FIG. 5 Graft is sprung in. Note smooth compact bone in contact with dura. POST-OPERATIVE CARE
T h e r e was no intracranial trouble in any o f the cases. Antibiotics were not given routinely, but only where there was any elevation o f t e m p e r a t u r e at the end o f the first day, and they were given specifically as a post-operative measure in cases where the dura had to be damaged to free the adherent scar and there was consequent leakage o f cerebrospinal fluid at the time o f operation. CASE REPORTS
Case x.--A young male aduk (Fig. 6, A tO E) was injured in a mining accident and was admitted to hospital with a compound depressed frontal bone. Both frontal sinuses were badly crushed. I carried out the first operation (February I947). This consisted of removing all the loose fragments of bone and all the remains of the frontal sinuses, including mucous membrane. I was able to get a complete ablation of both frontal sinuses, and, fortunately, at the time there was no leakage of cerebrospinal fluid, so the damage to the bone obviously finished at the junction of the floor of the anterior fossa with the posterior wall of the frontal sinuses. In June I947 I performed a second operation to restore the skull defect. A large iliac crest bone graft was inserted to fill the defect. This particular case was the one where the bone graft slipped a little and left a slight gap at the lower end. Convalescence was satisfactory, but he had this narrow defect at the lower margin of the graft, which will need repair with linear bone grafts
54
BRITISH JOURNAL
OF PLASTIC
SURGERY
FIG. 6 A, Post-operative defect. B, As above (oblique view). C~ After bone graft. D, Radiograph (after bone grafting). E, Radiograph (tangential view).
EXPERIENCES
IN
CRANIAL BONE
GRAFTING
55
later. The patient up to the present has not returned for this to be done as he feels quite happy, and there is no sign of the light-headedness and vertigo that one usually associates with a gap in the cranium. Case 2.--A boy of 8 years. This was a case of an old compound fracture of the parietal bone which had happened three years previously. The interesting point was
FIG. 7 A, Radiograph (lateral) immediately after grafting. B, Radiograph (antero-posterior) immediately after grafting. C, Radiograph (antero-posterior) ten months later. D, Radiograph (antero-posterior) twenty months later.
the follow-up of the radiographs (Fig. 7, A to D). The bone graft was done on I3th February I947 by the usual method--an iliac bone graft. There was no post-operative trouble. On X-ray examination on 7th December I948 the graft showed considerable thickening, and clinically was very firmly united. A further radiograph taken on 28th August I95O showed no further bone laid down, so that the graft had obviously become static at a slightly less density than the skull. Case 3 (road accident).--A boy of i2 years. He was admitted to hospital on I2th August I948. I operated on him on admission and found a compound depressed fracture
56
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
of the parietal bone. There was damage to the dura at the time, and quite an extensive area of bone had to be removed. This operation was followed by some degree of aphasia for two months. His mental condition improved slowly over a period, and his second operation was on 26th January 195 o. The dura was found to be adherent to the thin skin of the scar, and unfortunately was opened in three places during scar dissection with resultant small leaks. The bone graft was fitted with extra care, and quite reasonable
D, Radiograph (tangential view) one year later.
scalp flaps were available after excision of scar tissue. Firm union of these over the bone graft was obtained. He had full penicillin treatment after the operation, and fortunately there was no leakage of cerebrospinal fluid at any time. The radiograph taken in February x95o shows the graft in place in the defect Jn the antero-posterior and lateral position. The latest radiograph shows union. Clinically the graft is very firm. There is a little unevenness of contour due to some slight degree of absorption of the cancellous part of the bone, although this appears to cause no trouble and the cranium is complete (Fig. 8, A to D). Case 4 (mining accident).--A Pole, aged about 40. Admitted on 4th November I947 with a compound depressed frontal fracture. At operation I found he had both frontal sinuses smashed. The maxilla was tilted backwards and the nasal bridge depressed
EXPERIENCES
IN
CRANIAL BONE GRAFTING
FIG. 9 A, Soon after first operation. B , After bone grafts (lateral). C, After bone grafts (anteroposterior). D, Radiograph (antero-posterior) grafts in situ. E, Ra.diog.raph (lateral) grafts zn s~tu.
57
~8
BRITISH JOURNAL OF PLASTIC SURGERY
FIG. IO
D, Radiograph (lateral) before grafting. E, Radiograph (antero-posterior) after grafting. F, R a d i o g r a p h (tangential) after grafting.
EXPERIENCES
IN
CRANIAL
BONE
GRAFTING
59
at least ~ in. underneath the frontal bone. The maxilla was reduced. The nasal fracture was reduced. All the loose fragments of bone in the frontal area were removed, and the frontal sinuses were removed in toto. The crista galli was floating, and there were obvious lacerations in the dura underneath the frontal lobes. The only solution to this problem was to apply a large fascia lata graft to the floor of the anterior fossa. This was done, and the wound was sutured and drained because of the severe contamination with coal dust and the damage to the nose. With the aid of antibiotics post-operative convalescence was extremely smooth. The patient could not speak English, and would insist on getting out of bed on the second day. It was almost impossible to keep him in bed, but fortunately he showed no ill-effects whatever from this procedure. He also did extremely well with regard to rehabilitation--I think he rehabilitated himself! On and May 1948 a right iliac crest bone graft was applied to the frontal area ; and to build up the contours o f the forehead, which in this particular patient were rather rounded, I removed chips from the iliac bone and packed them carefully on the top of the basal plate of bone. Unfortunately, some absorption of the chips took place later, leaving an irregular forehead, ,so that on i6th March 1949 I again excised scars, and a further sheet of iliac bone from the left side was implanted to make a good supra-orbital ridge. Fig. 9, D and E shows dense bone in the forehead region, but there is still a little absorption in the region of the supra-orbital arteries. This appears to be a common result, and is probably due to pressure of the pulsating vessel. Functionally this man is quite fit, and has no complaints except anosmia. He has been back at work in the mine for a considerable period (Fig. 9, A to E). Case 5.--Male, aged about 4 o. This patient was referred to me by a physician with a request for biopsy of the frontal bone, because investigation of his headaches had revealed the fact that there was rarefaction of almost the whole of the left frontal bone. At the first operation the biopsy was done through a post-mortem type of incision, turning a large flap forwards and a large flap backwards. It was found that the bone was invaded b y an angioma, which appeared to be simple and quite amenable to surgery at the time. I therefore removed the whole of the affected bone, and left the dura exposed. This included removal of the left frontal sinus and closure of the upper end of the frontal duct. His post-operative period was quite smooth and uneventful, but the later effects were :some dizziness and light-headedness, exacerbated by rapid movement of the head, which I attributed to the cranial defect. A second operation was done on 29th October 1947. T h e gap was again filled with a large iliac bone graft. Healing took place uneventfully, but the same trouble again appeared after two or three months : notching of the edge o f the graft from the supra-orbital artery. The final cosmetic result is not perfect, but this could be overcome, if necessary, by the use of either a fat or a fascia lata graft slid under the skin in the region of this vessel. The patient has been advised that this would .cure his deformity, but he is not particularly interested. Clinically he is quite well, but although the headaches are very much better they have not quite disappeared (Fig. IO, A to F). F r o m m y few cases I am impressed by the success o f autogenous b o n e grafts in the skull and elsewhere. Although in some there was partial absorption, this was remedied without any extensive procedure. Foreign materials o f whatever k i n d have, ill m y experience, not been successful.
1
By JOHN GROCOTT, F.R.C.S. From the Plastic Unit, North Staffordshire Royal Infirmary IN'the short series of cases discussed, the material used for repair was autogenous bone. The advantages of this medium far outweigh those of all other material. The donor area of choice was the iliac crest. Here again the advantages can be enumerated as : (I) the large area of bone available ; (2) the natural curvature of the bone ; (3) this area of the body tolerates interference far more than the thoracic cage, both from the aspect of pain and from that of chest complications after the operation ; (4) the subsequent disability consists as a rule only of pain, fairly severe for the first day or two, but rapidly diminishing, and in the normal course of events only slight stiffness on walking after three weeks. Over a large number of cases where bone has been taken from the iliac crest, not in this present short series, only on one occasion has a patient ever come back after quite a long period with any trouble, and that was with a small residual abscess. T H E TECHNIQUE OF OPERATION
The defect in the cranium is exposed by an incision which usually involves excising the old scar and extending the ends the necessary amount to get a clear
FIG. I Typical defect. Shows (I) eburnated bone edges ; (2) dura and aponeurosis fused.
CANCELLOUS EXPOSED.....~,.._~~ BONE
Defect prepared.
FIG. 2 Bone edges nibbled square.
view of the whole of the defect. The periosteum of the skull itself is then incised around the edges of the defect, about I in. away from the edge. This strip is elevated and turned inwards and excised. This allows the scar over the surface of 1 The substance of a talk given at the meeting of the British Association of Plastic Surgeons in St Albans, September I95 o. 5I
52
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
the dura to lie flat within the limits of the bony defect. The rounded edges of the defect are then nibbled away with good sharp nibbling forceps to give as nearly as possible a straight-cut edge of bone which is reasonably vascular (Figs. I and 2). An accurate assessment of the amount of bone necessary can now be made. At this stage the ha~mostasis of the area can be completed, and the original scalp flaps are replaced, covering the wound temporarily while the iliac bone is exposed. I f the defect is large, it will be necessary to expose the whole of the outer plate of the iliac bone. This can be done with an incision extending from the anterior superior spine to the posterior superior spine running along the crest of the bone. With care, and using broad, very sharp chisels, it is possible to elevate all of the outer table of the bone as far down as the acetabulum, thus providing a large oval piece of bone with a thin layer of compact bone on one side and a slightly thinner layer ILIAC BONE OUTER SURFACE PLAN
SECTION
SPINE
Fro. 3 T h e m a x i m u m donor area (whole of o u t e r plate). ( s m o o t h concave side).
N o t e curves
of cancellous bone on the other (Fig. 3). A rough pattern can be cut from the skull defect at this stage to give an approximate idea of how much bone is required, although I have found it wiser to cut rather an excess. The preparation of the graft itself consists of cutting gussets in the edge, as the degree of curvature of the graft is hardly enough to conform to the degree of curvature of the skull in the particular area, although again this depends on the individual case. It is intended that the smooth surface of the graft--that is, the compact bone--should lie in contact with the dura, which is fairly avascular, so that the vascular cancellous bone will be in contact with the vascular covering flaps of the scalp, thereby giving the bone graft the maximum blood supply in the shortest time and getting early union. To fit the graft into place, it is necessary to remove a narrow strip of cancellous bone around the whole circumference so that the thin compact bone can just be inserted under the margins of the skull defect (Figs. 4 and 5). Mechanically this looks unsound, but it can be easily protected during the period of convalescence, and in a very short period, as soon as five to six weeks, quite firm union has taken place. Of all the cases discussed later, only in one case did any slipping take place in the immediate post-operative period, and in this particular
EXPERIENCES
IN
CRANIAL
BONE
GRAFTING
53
case an efficient fitting on the lower margins of the graft could not be obtained. T h i s was in Case I, where extensive bone loss in the frontal area had to be repaired.
~
A
B
_4~_-G ., N SR SE EATS$C TVO IUC E CU UT R ATURE
~ICANCELLOUSBONE
co.PACT BONE FIG. 4 A, Graft cut with broad chisels (on generous side). B, Edges trimmed off, leaving shelf of compact bone.
Fitting.
FIG. 5 Graft is sprung in. Note smooth compact bone in contact with dura. POST-OPERATIVE CARE
T h e r e was no intracranial trouble in any o f the cases. Antibiotics were not given routinely, but only where there was any elevation o f t e m p e r a t u r e at the end o f the first day, and they were given specifically as a post-operative measure in cases where the dura had to be damaged to free the adherent scar and there was consequent leakage o f cerebrospinal fluid at the time o f operation. CASE REPORTS
Case x.--A young male aduk (Fig. 6, A tO E) was injured in a mining accident and was admitted to hospital with a compound depressed frontal bone. Both frontal sinuses were badly crushed. I carried out the first operation (February I947). This consisted of removing all the loose fragments of bone and all the remains of the frontal sinuses, including mucous membrane. I was able to get a complete ablation of both frontal sinuses, and, fortunately, at the time there was no leakage of cerebrospinal fluid, so the damage to the bone obviously finished at the junction of the floor of the anterior fossa with the posterior wall of the frontal sinuses. In June I947 I performed a second operation to restore the skull defect. A large iliac crest bone graft was inserted to fill the defect. This particular case was the one where the bone graft slipped a little and left a slight gap at the lower end. Convalescence was satisfactory, but he had this narrow defect at the lower margin of the graft, which will need repair with linear bone grafts
54
BRITISH JOURNAL
OF PLASTIC
SURGERY
FIG. 6 A, Post-operative defect. B, As above (oblique view). C~ After bone graft. D, Radiograph (after bone grafting). E, Radiograph (tangential view).
EXPERIENCES
IN
CRANIAL BONE
GRAFTING
55
later. The patient up to the present has not returned for this to be done as he feels quite happy, and there is no sign of the light-headedness and vertigo that one usually associates with a gap in the cranium. Case 2.--A boy of 8 years. This was a case of an old compound fracture of the parietal bone which had happened three years previously. The interesting point was
FIG. 7 A, Radiograph (lateral) immediately after grafting. B, Radiograph (antero-posterior) immediately after grafting. C, Radiograph (antero-posterior) ten months later. D, Radiograph (antero-posterior) twenty months later.
the follow-up of the radiographs (Fig. 7, A to D). The bone graft was done on I3th February I947 by the usual method--an iliac bone graft. There was no post-operative trouble. On X-ray examination on 7th December I948 the graft showed considerable thickening, and clinically was very firmly united. A further radiograph taken on 28th August I95O showed no further bone laid down, so that the graft had obviously become static at a slightly less density than the skull. Case 3 (road accident).--A boy of i2 years. He was admitted to hospital on I2th August I948. I operated on him on admission and found a compound depressed fracture
56
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
of the parietal bone. There was damage to the dura at the time, and quite an extensive area of bone had to be removed. This operation was followed by some degree of aphasia for two months. His mental condition improved slowly over a period, and his second operation was on 26th January 195 o. The dura was found to be adherent to the thin skin of the scar, and unfortunately was opened in three places during scar dissection with resultant small leaks. The bone graft was fitted with extra care, and quite reasonable
D, Radiograph (tangential view) one year later.
scalp flaps were available after excision of scar tissue. Firm union of these over the bone graft was obtained. He had full penicillin treatment after the operation, and fortunately there was no leakage of cerebrospinal fluid at any time. The radiograph taken in February x95o shows the graft in place in the defect Jn the antero-posterior and lateral position. The latest radiograph shows union. Clinically the graft is very firm. There is a little unevenness of contour due to some slight degree of absorption of the cancellous part of the bone, although this appears to cause no trouble and the cranium is complete (Fig. 8, A to D). Case 4 (mining accident).--A Pole, aged about 40. Admitted on 4th November I947 with a compound depressed frontal fracture. At operation I found he had both frontal sinuses smashed. The maxilla was tilted backwards and the nasal bridge depressed
EXPERIENCES
IN
CRANIAL BONE GRAFTING
FIG. 9 A, Soon after first operation. B , After bone grafts (lateral). C, After bone grafts (anteroposterior). D, Radiograph (antero-posterior) grafts in situ. E, Ra.diog.raph (lateral) grafts zn s~tu.
57
~8
BRITISH JOURNAL OF PLASTIC SURGERY
FIG. IO
D, Radiograph (lateral) before grafting. E, Radiograph (antero-posterior) after grafting. F, R a d i o g r a p h (tangential) after grafting.
EXPERIENCES
IN
CRANIAL
BONE
GRAFTING
59
at least ~ in. underneath the frontal bone. The maxilla was reduced. The nasal fracture was reduced. All the loose fragments of bone in the frontal area were removed, and the frontal sinuses were removed in toto. The crista galli was floating, and there were obvious lacerations in the dura underneath the frontal lobes. The only solution to this problem was to apply a large fascia lata graft to the floor of the anterior fossa. This was done, and the wound was sutured and drained because of the severe contamination with coal dust and the damage to the nose. With the aid of antibiotics post-operative convalescence was extremely smooth. The patient could not speak English, and would insist on getting out of bed on the second day. It was almost impossible to keep him in bed, but fortunately he showed no ill-effects whatever from this procedure. He also did extremely well with regard to rehabilitation--I think he rehabilitated himself! On and May 1948 a right iliac crest bone graft was applied to the frontal area ; and to build up the contours o f the forehead, which in this particular patient were rather rounded, I removed chips from the iliac bone and packed them carefully on the top of the basal plate of bone. Unfortunately, some absorption of the chips took place later, leaving an irregular forehead, ,so that on i6th March 1949 I again excised scars, and a further sheet of iliac bone from the left side was implanted to make a good supra-orbital ridge. Fig. 9, D and E shows dense bone in the forehead region, but there is still a little absorption in the region of the supra-orbital arteries. This appears to be a common result, and is probably due to pressure of the pulsating vessel. Functionally this man is quite fit, and has no complaints except anosmia. He has been back at work in the mine for a considerable period (Fig. 9, A to E). Case 5.--Male, aged about 4 o. This patient was referred to me by a physician with a request for biopsy of the frontal bone, because investigation of his headaches had revealed the fact that there was rarefaction of almost the whole of the left frontal bone. At the first operation the biopsy was done through a post-mortem type of incision, turning a large flap forwards and a large flap backwards. It was found that the bone was invaded b y an angioma, which appeared to be simple and quite amenable to surgery at the time. I therefore removed the whole of the affected bone, and left the dura exposed. This included removal of the left frontal sinus and closure of the upper end of the frontal duct. His post-operative period was quite smooth and uneventful, but the later effects were :some dizziness and light-headedness, exacerbated by rapid movement of the head, which I attributed to the cranial defect. A second operation was done on 29th October 1947. T h e gap was again filled with a large iliac bone graft. Healing took place uneventfully, but the same trouble again appeared after two or three months : notching of the edge o f the graft from the supra-orbital artery. The final cosmetic result is not perfect, but this could be overcome, if necessary, by the use of either a fat or a fascia lata graft slid under the skin in the region of this vessel. The patient has been advised that this would .cure his deformity, but he is not particularly interested. Clinically he is quite well, but although the headaches are very much better they have not quite disappeared (Fig. IO, A to F). F r o m m y few cases I am impressed by the success o f autogenous b o n e grafts in the skull and elsewhere. Although in some there was partial absorption, this was remedied without any extensive procedure. Foreign materials o f whatever k i n d have, ill m y experience, not been successful.