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Titanium plate reconstruction of the osseous defect after harvest of a composite free flap using the deep circumflex iliac artery
British Journal of Oral and Maxillofacial Surgery (2004) 42, 254—256
SHORT COMMUNICATION
Titanium plate reconstruction of the osseous defect after harvest of a composite free flap using the deep circumflex iliac artery S.M. Halsnad, D.K. Dhariwal*, A.P. Bocca, P.L. Evans, S.C. Hodder Department of Oral and Maxillofacial Surgery, Morriston Hospital, Swansea SA6 6NL, Wales, UK Accepted 26 January 2004
KEYWORDS Titanium plate; Osseous defect
Summary Hernia formation following harvest of bicortical iliac crest bone occurs infrequently as a late complication and may lead to chronic pain at the donor site and rarely to obstruction and strangulation of bowel. We describe the use of a custom-made titanium plate used to reconstruct the iliac donor site following harvest of a DCIA composite free flap. A pre-operative 3D CT and stereolithography model of the ilium are used to fabricate a titanium plate of the desired shape and size. This plate is used to reconstruct the donor site defect at the time of primary surgery. This technique may reduce late complications following DCIA composite free flap harvest. © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Autogenous bone grafts are commonly taken from the iliac crest for reconstruction in maxillofacial surgery. Recent advances in microvascular techniques have enabled large vascularised bicortical grafts to be harvested. The natural contour and predominantly cancellous nature of the iliac crest makes it the donor site of choice for reconstruction after segmental resection. One of the late complications is herniation through the defect in the iliac crest. The extensive dissection, with disruption of the overlying muscle and fascial attachments, increases the risk of both groin and ventral hernias. The large bony defect forms a rigid ring through which abdominal pressure can result in evisceration of abdominal contents.1 *Corresponding author. Tel.: +44-1792-703515; fax: +44-1792-703068. E-mail address: [email protected] (D.K. Dhariwal).
Hernias after grafts from the iliac crest were first described in 1945.2 Challis et al.3 reported a strangulated hernia that required resection of two feet (50 cm) of necrotic bowel. Hernias may cause symptoms months or years after the graft, which range from long standing lower abdominal pain to acute abdominal discomfort with obstruction or strangulation that require operation. There have been few reports on methods to reconstruct defects at the iliac donor site, and these are often done as secondary procedures. Stevens and Banuls4 reported a case of failed soft tissue reconstruction that was treated successfully with a monocortical graft from the opposite side of the pelvis. Other methods have included rib grafting,5 bone graft reinforced with titanium mesh,4 and synthetic mesh grafts alone.6 Taylor et al.7 described immediate reconstruction of the contour of the iliac crest using MacroPore OS sheets (Macropore, Inc., San Diego, CA, USA), with improved quality of life in the early postoperative period.
0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjoms.2004.01.015
Titanium plate reconstruction
255
We describe a method of primary reconstruction of large osseous defects of the ilium after harvest of composite free flaps using the deep circumflex iliac artery (DCIA) which has been used successfully with no short term or long term complications.
Technique Patients who require large resections in the maxillofacial region and for whom reconstruction with
Figure 1
DCIA free composite osseous flaps is planned have three-dimensional computed tomograms (CT) of the ilium (2 mm slices with 1 mm overlap, Toshiba aquilion CT scanner). A stereolithography model is used to plan the size and shape of the desired bone flap (Fig. 1). A dental stone replica is created, on to which a 0.4 mm thick titanium sheet is swaged by gradual compression over a 4-day-period to copy the contour of site of harvest of the flap at the iliac crest (Fig. 2). Multiple holes are drilled to facilitate reattachment of the reflected soft tissues and
Stereolithography model of ilium with planned donor site for DCIA osseous graft.
Figure 2
Titanium plate for primary iliac reconstruction.
256
S.M. Halsnad et al. The subcutaneous tissues and skin are closed in layers.
Results Large iliac osseous defects in four patients were reconstructed with titanium plates over a period of 3 years. Patients were followed up for a mean of 21 months (range: 13—35). There were no infective complications, and patients had less limping and pain and were mobilised faster than expected in the immediate postoperative period. There have been no long term complications.
Discussion The use of a customised titanium plate to reconstruct large osseous iliac defects offers restoration of good bony contour and may reduce the risk of hernia formation in the long term. We think that the increased costs (£650 including models, materials, and labour) are justified in patients at high risk of developing a hernia. Figure 3 Titanium plate in situ, held in place with titanium screws. Note perforations for attachment of mesh, muscle and ligaments.
to allow osteosynthesis with titanium screws to the ilium. The design planned on the stereolithography model is used as a template for the iliac bone graft. After the flap has been harvested, the autoclaved custom-made plate is positioned over the defect and fixed with 2.4 mm AO screws (Fig. 3). The defect in the internal oblique muscle is closed with polypropylene (Prolene) mesh. The transversus abdominis, tensor fasciae latae, and sartorius muscles, and the inguinal ligament, are reattached with non-absorbable sutures and anchored to the perforations in the plate.
References 1. Bosworth DM. Repair of hernias through iliac—crest defects. J Bone Jt Surg 1955;37A:1069—73. 2. Oldfield MC. Iliac hernia after bone grafting. Lancet 1945;i:810—2. 3. Challis JH, Lyttle JA, Stuart AT. Strangulated lumbar hernia and volvulus following removal of the iliac crest. Acta Orthop Scand 1975;46:230—3. 4. Stevens KJ, Banuls M. Iliolumbar hernia following bone grafting. Eur Spine J 1994;3:118—9. 5. Hardy JH. Iliac crest reconstruction following full thickness graft: a preliminary note. Clin Orthop 1977;123:32—3. 6. Seiler JG, Johnson J. Iliac crest autogenous bone grafting: donor site complications. J South Orthop Assoc 2000;9:91—7. 7. Taylor W, Ames C, Cataletto MM. MacroPore reconstruction system: early experience in immediate iliac crest contour recontruction. Clinical series in resorbable fixation. http://www.macropore.com/pdf/WP-Retrospective.pdf; http://www.macropore.com/pdf/WP-Retrospective.pdf
SHORT COMMUNICATION
Titanium plate reconstruction of the osseous defect after harvest of a composite free flap using the deep circumflex iliac artery S.M. Halsnad, D.K. Dhariwal*, A.P. Bocca, P.L. Evans, S.C. Hodder Department of Oral and Maxillofacial Surgery, Morriston Hospital, Swansea SA6 6NL, Wales, UK Accepted 26 January 2004
KEYWORDS Titanium plate; Osseous defect
Summary Hernia formation following harvest of bicortical iliac crest bone occurs infrequently as a late complication and may lead to chronic pain at the donor site and rarely to obstruction and strangulation of bowel. We describe the use of a custom-made titanium plate used to reconstruct the iliac donor site following harvest of a DCIA composite free flap. A pre-operative 3D CT and stereolithography model of the ilium are used to fabricate a titanium plate of the desired shape and size. This plate is used to reconstruct the donor site defect at the time of primary surgery. This technique may reduce late complications following DCIA composite free flap harvest. © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Autogenous bone grafts are commonly taken from the iliac crest for reconstruction in maxillofacial surgery. Recent advances in microvascular techniques have enabled large vascularised bicortical grafts to be harvested. The natural contour and predominantly cancellous nature of the iliac crest makes it the donor site of choice for reconstruction after segmental resection. One of the late complications is herniation through the defect in the iliac crest. The extensive dissection, with disruption of the overlying muscle and fascial attachments, increases the risk of both groin and ventral hernias. The large bony defect forms a rigid ring through which abdominal pressure can result in evisceration of abdominal contents.1 *Corresponding author. Tel.: +44-1792-703515; fax: +44-1792-703068. E-mail address: [email protected] (D.K. Dhariwal).
Hernias after grafts from the iliac crest were first described in 1945.2 Challis et al.3 reported a strangulated hernia that required resection of two feet (50 cm) of necrotic bowel. Hernias may cause symptoms months or years after the graft, which range from long standing lower abdominal pain to acute abdominal discomfort with obstruction or strangulation that require operation. There have been few reports on methods to reconstruct defects at the iliac donor site, and these are often done as secondary procedures. Stevens and Banuls4 reported a case of failed soft tissue reconstruction that was treated successfully with a monocortical graft from the opposite side of the pelvis. Other methods have included rib grafting,5 bone graft reinforced with titanium mesh,4 and synthetic mesh grafts alone.6 Taylor et al.7 described immediate reconstruction of the contour of the iliac crest using MacroPore OS sheets (Macropore, Inc., San Diego, CA, USA), with improved quality of life in the early postoperative period.
0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjoms.2004.01.015
Titanium plate reconstruction
255
We describe a method of primary reconstruction of large osseous defects of the ilium after harvest of composite free flaps using the deep circumflex iliac artery (DCIA) which has been used successfully with no short term or long term complications.
Technique Patients who require large resections in the maxillofacial region and for whom reconstruction with
Figure 1
DCIA free composite osseous flaps is planned have three-dimensional computed tomograms (CT) of the ilium (2 mm slices with 1 mm overlap, Toshiba aquilion CT scanner). A stereolithography model is used to plan the size and shape of the desired bone flap (Fig. 1). A dental stone replica is created, on to which a 0.4 mm thick titanium sheet is swaged by gradual compression over a 4-day-period to copy the contour of site of harvest of the flap at the iliac crest (Fig. 2). Multiple holes are drilled to facilitate reattachment of the reflected soft tissues and
Stereolithography model of ilium with planned donor site for DCIA osseous graft.
Figure 2
Titanium plate for primary iliac reconstruction.
256
S.M. Halsnad et al. The subcutaneous tissues and skin are closed in layers.
Results Large iliac osseous defects in four patients were reconstructed with titanium plates over a period of 3 years. Patients were followed up for a mean of 21 months (range: 13—35). There were no infective complications, and patients had less limping and pain and were mobilised faster than expected in the immediate postoperative period. There have been no long term complications.
Discussion The use of a customised titanium plate to reconstruct large osseous iliac defects offers restoration of good bony contour and may reduce the risk of hernia formation in the long term. We think that the increased costs (£650 including models, materials, and labour) are justified in patients at high risk of developing a hernia. Figure 3 Titanium plate in situ, held in place with titanium screws. Note perforations for attachment of mesh, muscle and ligaments.
to allow osteosynthesis with titanium screws to the ilium. The design planned on the stereolithography model is used as a template for the iliac bone graft. After the flap has been harvested, the autoclaved custom-made plate is positioned over the defect and fixed with 2.4 mm AO screws (Fig. 3). The defect in the internal oblique muscle is closed with polypropylene (Prolene) mesh. The transversus abdominis, tensor fasciae latae, and sartorius muscles, and the inguinal ligament, are reattached with non-absorbable sutures and anchored to the perforations in the plate.
References 1. Bosworth DM. Repair of hernias through iliac—crest defects. J Bone Jt Surg 1955;37A:1069—73. 2. Oldfield MC. Iliac hernia after bone grafting. Lancet 1945;i:810—2. 3. Challis JH, Lyttle JA, Stuart AT. Strangulated lumbar hernia and volvulus following removal of the iliac crest. Acta Orthop Scand 1975;46:230—3. 4. Stevens KJ, Banuls M. Iliolumbar hernia following bone grafting. Eur Spine J 1994;3:118—9. 5. Hardy JH. Iliac crest reconstruction following full thickness graft: a preliminary note. Clin Orthop 1977;123:32—3. 6. Seiler JG, Johnson J. Iliac crest autogenous bone grafting: donor site complications. J South Orthop Assoc 2000;9:91—7. 7. Taylor W, Ames C, Cataletto MM. MacroPore reconstruction system: early experience in immediate iliac crest contour recontruction. Clinical series in resorbable fixation. http://www.macropore.com/pdf/WP-Retrospective.pdf; http://www.macropore.com/pdf/WP-Retrospective.pdf