Robert Bentley

Custom-made titanium cranioplasty: early and late complications of 151 cranioplasties and review of the literature

A diverse range of techniques is available for reconstruction of full-thickness calvarial defects and the optimum substrate for cranioplasty remains unproven. During a 9-year period, 149 patients underwent insertion of 151 custom-made titanium cranioplasties using the same technique. Data relating to patient demographics, indication for cranioplasty, and site and size of the defect were collected from the clinical records. Patients were followed up in all cases for a mean of 1 year 2 months (range 7 days to 8 years 8 months). Early complications requiring intervention were experienced in 7% and included seroma, haematoma, and continued bleeding necessitating implant removal in one patient. One death occurred at 3 days post-operation due to haemorrhagic stroke. Late self-limiting complications such as seroma were experienced in 19% of patients, however complete failure requiring implant removal was seen in only 4% of cases. Infection was the cause of failure in all cases. A comprehensive literature review was carried out and data abstracted to compare reported failure rates in other techniques of full-thickness cranial reconstruction. This review shows that custom-made patient-specific titanium cranioplasties compare very favourably to the other published techniques and remain a tried and tested option for reconstruction of all sizes of full-thickness calvarial defect.

Multicentre study of operating time and inpatient stay for orthognathic surgery

Orthognathic surgery has advanced considerably since its development in the mid-twentieth century, and in most maxillofacial units mandibular and maxillary osteotomies are routine procedures. However, to enable accurate health planning and costing, and to obtain meaningful consent, it is important to have reliable data for duration of operation and inpatient stay. Virtually every aspect of orthognathic surgery has been researched, but we know of no recent studies that have looked specifically at how long the procedures take and how long patients stay in hospital. We retrospectively studied a sample of patients who had had orthognathic operations at six maxillofacial units in the United Kingdom (UK) to assess these measures. We looked at 411 operations which included 139 bilateral sagittal split osteotomies, 53 Le Fort I osteotomies, and 219 bimaxillary osteotomies. The study showed that the mean (SD) operating time for bilateral sagittal split osteotomy is 2h 6min (46min), 1h 54min (45minutes) for Le Fort I osteotomy, and 3h 27min (60min) for bimaxillary osteotomy. The duration of postoperative hospital stay was also measured. Fifty percent of patients spent one night in hospital after bilateral sagittal split osteotomy, whereas 39% and 9% of patients spent two and three nights, respectively. Forty-five percent of patients spent one night in hospital after Le Fort I osteotomy, whereas 34%, 13%, and 2% spent two, three, and four nights, respectively. Forty-one percent of patients spent two nights in hospital after bimaxillary osteotomy, whereas 34%, 21%, and 3% spent one, three, and four nights, respectively. This data provides evidence for national benchmarks.

Psychological characteristics of women who require orthognathic surgery: comparison with untreated controls

Improvement in appearance is an important motivation for orthodontic treatment and orthognathic surgery, and two possible underlying causes are objective physical abnormalities, or the patients personality type that leads them to concentrate on their appearance and request unnecessary interventions. Questionnaires that measure personality traits were given to 30 women who required orthognathic operations, and a control group of 30 other women. Traits measured were: satisfaction with the appearance of the face, head, and body; tendency to compare their appearance with that of others; the extent to which they are aware of their appearance and how they thought they should look; sense of self identity; depression; anxiety; and self-esteem. The only difference between patients and controls was that patients were more dissatisfied with their facial appearance than the others. Orthognathic patients were psychologically normal except that they had more dissatisfaction with their facial appearance. As this was the only difference, it is likely that their desire for operation was caused by a genuine physical abnormality rather than a perceived exaggerated aesthetic problem. It seems, therefore, that any patient who seeks orthognathic treatment because they have a personality that causes them to dwell on their appearance (which may lead them to hold unrealistic expectations of intervention) are screened out of the process before they begin treatment.

Proposal for establishment of the UK Cranial Reconstruction Registry (UKCRR).

Abstract Background. The increasing utilisation of decompressive craniectomy for traumatic brain injury and stroke has led to an increase in the number of cranioplasties undertaken. Cranioplasty is also undertaken following excision of tumours originating from or invading the skull vault, removal of bone flaps due to post-operative infection, and decompressive craniectomy for the management of rarer causes of brain oedema and/or refractory intracranial hypertension. The existing literature which mainly consists of single-centre, retrospective studies, shows a significant variation in practice patterns and a wide range of morbidity. There also exists a need to measure the outcome as perceived by the patients themselves with patient reported outcome measures (PROMs; functional outcome, quality of life, satisfaction with cosmesis). In the UK, the concept of long-term surveillance of neurosurgical implants is well established with the UK shunt registry. Based on this background, we propose to establish the UK Cranial Reconstruction Registry (UKCRR). Aim. The overarching aim of the UKCRR is to collect high-quality data about cranioplasties undertaken across the UK and Ireland in order to improve outcomes for patients. Methods. Any patient undergoing reconstruction of the skull vault with autologous bone, titanium, or synthetic material in participating units will be eligible for inclusion. Data will be submitted directly by participating units to the Outcome Registry Intervention and Operation Network secure platform. A Steering Committee will be responsible for overseeing the strategic direction and running of the UKCRR. Outcome measures. These will include re-operation due to a cranioplasty-related issue, surgical site infection, re-admission due to a cranioplasty-related issue, unplanned post-operative escalation of care, adverse events, length of stay in admitting unit, destination at discharge from admitting unit, mortality at discharge from admitting unit, neurological status and PROMs during routine follow-up. Conclusion. The UKCRR will be an important pillar in the ongoing efforts to optimise the outcomes of patients undergoing cranioplasty.

Changing incidence and management of penetrating neck injuries in the South East London trauma centre

INTRODUCTION A total of 17 cases of penetrating neck injury were managed by the otolaryngology team at King’s College Hospital over a 3-year period in the 1980s. In April 2010 King’s College Hospital became the major trauma centre for South East London. This prospective cohort study compares the incidence, changing demographic features and treatment outcomes of penetrating neck trauma in South East London over the previous 23 years. METHODS Data were collected over a 12-month period (April 2010 to March 2011) and a selective management protocol was introduced to standardise initial investigations and further treatment. RESULTS The past 23 years have seen a 550% increase in the incidence of penetrating neck injuries in South East London, with a marked increase in gun crime. Only 38% of cases underwent negative neck exploration in 2011 compared with 65% in 1987. Selective conservative management based on the absence of haemodynamic instability or radiological findings reduces length of hospital stay, lightens surgical workload and cuts costs without affecting morbidity or mortality. CONCLUSIONS The increased incidence of penetrating neck injury is a reflection of more interpersonal violence rather than a consequence of the larger South East London trauma centre catchment area. Tackling this problem requires focus on wider issues of community prevention. Sharing of data between the four London trauma centres and the police is needed to help prevent interpersonal violence and develop a universal treatment algorithm for other institutions to follow.

Leonard Buttons: A Reliable Method of Intraoperative Intermaxillary Fixation in Bilateral Mandibular Fractures

PURPOSE To retrospectively audit outcomes of using Leonard buttons (LBs) as intraoperative intermaxillary fixation in conjunction with open reduction-internal fixation of bilateral mandibular fractures. PATIENTS AND METHODS Seventy-seven patients were included in this study. The fracture reduction score was obtained from postoperative radiographs by use of 3-tiered scoring system. Medical case notes were obtained for clinicodemographic data, including operation length, postoperative occlusion scores, periodontal status, and complications. RESULTS The cohort predominantly comprised male patients (87%), with a mean age of 26 years. The major cause of injury was interpersonal violence (87%). The fracture pattern most treated was angle-parasymphysis fracture (70.1%). The mean length of follow-up was 83.81 ± 79.33 days. The mean overall reduction score was 6.95 ± 1.03 in the LB group and 6.40 ± 1.68 in the arch bar (AB) group (P = .275). When the occlusion scores were evaluated, the difference between the 2 groups was statistically significant (P = .027). The mean operation length was shorter in the LB group compared with the AB group (142.05 ± 32.31 minutes vs 161.00 ± 24.04 minutes, P = .013). Oral hygiene was poor in 7 patients in the LB group (11.3%) and in 5 patients in the AB group (33.3%) (P = .05). No significant correlation was observed between number of LBs placed with overall reduction and occlusion scores. No significant relation was observed for number of LBs and periodontal status, infection, and nonunion. CONCLUSIONS This pilot study suggests that LBs are able to achieve equally good reduction as ABs but have better occlusion scores, with a shorter operating time, and show better gingival health. LBs are a viable alternative to ABs in providing intraoperative intermaxillary fixation for bilateral mandibular fractures. However, further prospective, randomized studies should be undertaken to obtain conclusive evidence.

Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre

There is a subgroup of patients with mandibular fractures who could safely and effectively be managed in an outpatient day-care unit. Suitability depends on medical, social, and operative factors, and identification of the correct criteria will govern management after that in the emergency department. Reduced use of beds would lead to less money being spent on emergency treatment, and increased capacity for elective surgery. The aims of this study were to identify a group of patients with mandibular fractures whose duration of operation and period of recovery would be suitable for treatment in the day-care unit, and to evaluate the potential financial benefits. Inpatients were assessed for day surgery using medical, social, and surgical criteria. Each patients suitability for discharge was assessed two, three, and five hours postoperatively. A financial feasibility study was made retrospectively on a larger sample of patients with mandibular fractures. The discharge criteria from the day-care unit were fully met by 26/40 patients at five hours postoperatively, mean (range) duration of operation was 145 (40-285) minutes, and mean (SD) Mandibular Injury Severity Score was 13 (3), range 7-20. When all the criteria were combined (n=100), 12 of the patients were suitable for day care. With 24 bed-day savings/100 patients, potential earnings would increase to around £80 000/year at this hospital. In conclusion, we have identified a group of patients who were suitable for management of mandibular fractures in the day-care unit. Considerable cost savings are anticipated.

Preservation of the temporalis muscle during cranioplasty.

T s flap is viable postoperatively. The flap is raised in the subgaleal layer and, where the scalp overlies the bony defect, a plane is readily found between the scalp and dura. t is necessary to detach the temporalis muscle to enable adeuate access to the cranial vault for neurosurgical procedures. ailure to handle and reattach the temporalis muscle carefully uring cranioplasty can lead to temporal hollowing.1 Previusly described methods of reattaching the temporalis muscle nclude titanium miniplates and microscrews, but these can ead to problems of palpable screws and muscle slippage.2,3 We describe a safe, quick, and effective method of anchorng the temporalis muscle to the cranioplasty plate using on-absorbable sutures through prefabricated holes in the ranioplasty plate.

Implementation of an oral and maxillofacial surgery trauma team in a major trauma centre

In 2010, Kings College Hospital in London was designated as a major trauma centre. To deal with the increasing number of patients, an integrated oral and maxillofacial team of the week was established in 2012 to provide a consultant-led, emergency service dedicated to acute care, and it was anticipated that this would reduce the duration of stay by 0.3 bed-days. To assess the effect of the new system, we compared the duration of stay between 1 October and 31 January 2011-2012 with the same period in 2012-2013. We also assessed the activity and training of registrars, and the departments perception of the post of trauma registrar. The mean total duration of stay had decreased significantly by 0.84 days (p=0.03), the mean delay to operation had decreased by 0.3 days, and the mean postoperative stay had decreased by 0.5 days. During one week, the trauma registrar did 12 operations at various sites in the hospital. The new system was a cost-effective way of improving emergency OMFS care and it can be recommended to other centres with similar profiles.

Late Reactivation of Cherubism in a Patient With New-Onset Polycystic Ovary Syndrome

PURPOSE The aim of the present study was to describe a case of cherubism with late progression, after skeletal maturity had been reached, that coincided with a recent diagnosis of polycystic ovary syndrome (PCOS). PATIENTS AND METHODS We reviewed the published data and searched for any reported association between cherubism and PCOS. We also reviewed the cases of late reactivation of cherubism. RESULTS This is, to our knowledge, the first case report of cherubism associated with PCOS. CONCLUSION Cherubism is a rare condition, which, in its normal course, becomes quiescent after puberty. Only a few cases of late growth have been reported. The understanding of the condition has evolved in recent years, with a better appreciation of the underlying genetics and pathogenesis of the disease. However, much remains unknown about this rare entity. We describe a case of cherubism reactivation that coincided with changes related to PCOS. Both PCOS and cherubism are associated with a low-grade inflammatory state.