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PubMed2004

A two-cage reconstruction versus a single mega-cage reconstruction for lumbar interbody fusion: an experimental comparison.

BACKGROUND: Interbody cages are used as an adjunct to anterior lumbar interbody fusion, but exposure and insertion of two cages can be difficult. A biomechanical study was performed to compare the stability and exposed surface for fusion obtained with interbody reconstruction using two traditional cylindrical cages (18-mm diameter) vs. a single expanded mega-cage (24-mm diameter). A single-cage technique could result in safer exposure, shorter operating time, and less cost. METHODS STUDY DESIGN: nondestructive testing of L5-S1 motion segments with cages compared the two configurations, and direct measure of the size of the fusion bed was made. PATIENT SAMPLE: 16 human cadaveric lumbar motion segments. OUTCOME MEASURES: significant differences in motion segment stiffness and cancellous surface areas were compared using a Wilcoxon rank sum test. Motion segments were biomechanically tested intact, and then tested again after insertion of two interbody cages (n=8) or a single mega-cage (n=8). Nondestructive biomechanical loading was performed consisting of: (1) compression (maximum load 900 N); (2) Flexion, extension, left and right lateral bending (maximum moment 18 Nm); and (3) left and right torsion (maximum moment 10 Nm). From the load-deformation curves obtained, stiffness values were calculated to compare the two-cage and the single mega-cage reconstructions. After testing, the specimens were disarticulated and the surface area of the endplate bed created in the cancellous bone (of both vertebrae) was measured to compare the potential vascular surface for osteogenesis with both constructs. RESULTS: The averages of the normalized values of stiffness were significantly greater for the two-cage group as compared to the mega-cage group in flexion only (1.08 vs. 0.74, p<0.05). For extension, torsion and lateral bending there was no significant difference in stiffness. In compression the two-cage group was stiffer, although not significantly (0.92 vs. 0.68, p<0.07). The average cancellous bed surface area was slightly greater for the single-cage reconstruction (1,208 mm(2) vs. 1,155 mm(2)), although this difference was not significant. CONCLUSIONS: The stiffness with a single anterior mega-cage was significantly lower in flexion compared with two standard cages. However, in all other modes of testing the constructs were statistically equivalent, although neither construct was significantly stiffer than the intact specimen. Additionally, the single mega-cage provides an equivalent cancellous bed for fusion as compared to dual cages. While this study is not sufficient to recommend human application, these results and our previous experience with the successful in vivo use of a single cage in rhesus monkeys [4] suggest that the single expanded anterior cage may be an acceptable concept although subsidence risk needs further investigation. The potential advantages of a single mega-cage (safer for the foramen, safer for the vessels, more consistent decortication and possibly cheaper) further suggest that examination should be given to this method as an approach to anterior interbody reconstruction in selected patients.

Aged↗

PubMed1992

Rigid reconstruction plates for immediate reconstruction following mandibular resection for malignant tumors.

Thirty-four primary alloplastic reconstructions of segmental mandibular defects caused by surgery for oral malignancy were performed during a 6-year period. Eighty-eight percent of the tumors were classified as stage III or IV. One third of the patients died during follow-up, nine with their primary reconstruction plate in place. During the follow-up, 12 patients required plate removal because of complications; four of them were treated with another plate. Nineteen of 21 patients alive at the end of follow-up were free of disease. Ten had their primary plate in place, and four had had a secondary plate installed because of plate fracture or screw loosening. Three patients had their mandible permanently reconstructed with bone. The functional and esthetic results were considered excellent or fair in a majority of the cases. Because the 5-year survival rate for patients with advanced mandibular malignancies is 15% to 20%, extensive, definitive reconstructive procedures during primary surgery are usually not justified.

Adult↗

PubMed2005

[Breast reconstruction: late cosmetic results of implant reconstruction].

The long cosmetic outcome of breast implant reconstruction is unknown. The morbidity and cosmetic outcome of 360 patients who underwent immediate breast reconstruction with various types of implant has been prospectively analysed over a 10-year period. 334 patients who completed their reconstruction were suitable for evaluation of their cosmetic outcome. The early complication rate (<2 months) was 9.1%, with an explantation rate of 1.6%. The late complication rate (>2 months) was 23%, with a pathological capsular contracture rate of 11% at two years and 15% at five years, and an implant removal rate of 7%. The revisional surgery rate was 30.2%. The cosmetic results were prospectively assessed using an objective five point global scale. Every patient was scored at each visit once surgery was completed. The overall cosmetic outcome deteriorates in a linear fashion from an initial acceptable result in 86% of patients two years after completion of their reconstruction to only 54% at five years. This fall off in the cosmetic outcome was not associated with the type of implant used, the volume of the implant, the age of the patient or the type of mastectomy incision employed. Radiotherapy was not a significant factor as only 28 patients were irradiated. However, on Cox model analysis pathological capsular contracture was the only factor which significantly contributed to a poor cosmetic outcome(P<0.0001 (relative risk 6.3). In spite of a high revisional surgery rate, deterioration still occurred, suggesting that other unaccounted for variables were responsible. On photographic retrospective review of those patients without a capsular contracture who demonstrated a deterioration in their cosmetic scores, it became clear that a possible reason for their poor result was late asymmetry produced by the failure of both breasts to undergo symmetrical ptosis as the patients aged.

Adult↗

PubMed1999

The transmission/disequilibrium test and parental-genotype reconstruction: the reconstruction-combined transmission/ disequilibrium test.

Spielman and Ewens recently proposed a method for testing a marker for linkage with a disease, which combines data from families with and without information on parental genotypes. For some families without parental-genotype information, it may be possible to reconstruct missing parental genotypes from the genotypes of their offspring. The treatment of such a reconstructed family as if parental genotypes have been typed, however, can introduce bias. In the present study, a new method is presented that employs parental-genotype reconstruction and corrects for the biases resulting from reconstruction. The results of an application of this method to a real data set and of a simulation study suggest that this approach may increase the power to detect linkage.

Genetic Linkage↗

PubMed1990

Secondary ear reconstruction using deep temporal fascia after temporoparietal fascial reconstruction in microtia.

As anatomical study of the temporoparietal fascia (TPF) has advanced, there have been several reports on one-stage reconstruction of microtia using the TPF. To our knowledge, however, no report has described how to do secondary reconstruction if partial necrosis occurs, exposing the cartilage frame. Recently we treated a case of microtia that had become partially necrotic after the patient underwent one-stage reconstruction using the TPF. The deep temporal fascia was elevated to cover the necrotic portion and ensure successful placement of the skin graft. This technique greatly enhances one-stage reconstruction of the auricle using a TPF flap.

Adult↗

PubMed2006

Two-stage reconstructive surgery of a patient with head trauma resulting in extensive cranial bone and dura mater loss caused by postoperative infection: usefulness of a pericranial flap for dura mater reconstruction.

After external decompression for a case of head trauma, epidural abscess formation resulted in extensive cranial bone and dura mater loss, for which two-stage reconstructive surgery was conducted. In the first operation, after thorough debridement of the infected wound, the dura mater was reconstructed using a bipedicle pericranial flap with posterior and anterior pedicles. After the infection had completely subsided, the second operation was performed, reconstructing the cranium with grafted outer-table calvarial bone and cutting bone to reposition an old zygomatic fracture. At this point, the pericranial flap used for dura mater reconstruction in the first operation became a satisfactory graft bed for the grafted bone. The postoperative course was satisfactory, and there was no cranial bone absorption after roughly 2 year, and a favorable shape has been maintained for an extremely satisfying result.

Adult↗

PubMed1991

A comparison of the results following oromandibular reconstruction using a radial forearm flap with either radial bone or a reconstruction plate.

Fifteen cases of oromandibular reconstruction using a radial osteocutaneous flap were compared with 16 in which the mandible was replaced with a reconstruction plate and a forearm flap was used for intraoral lining. All cases involved oral cancer; most had been irradiated. Nine survived in each group. Complications included one infected nonunion in addition to two bone exposures in the bone group, compared with three cases of plate exposure and two bone exposures in the plate group. Functional results were similar in both, but osteointegrated implants were possible only in the patients receiving bone. Cosmesis seemed somewhat better in the plate group. Donor-site problems were common but minor, and long-term forearm function was slightly reduced in both groups. Although the sample sizes were small, the reconstruction plate together with a radial forearm flap appeared to provide effective reconstruction following composite resection. However, we would not recommend this for the younger patient or in benign disease.

Adult↗

PubMed1993

Pre-reconstruction tattooing eliminates the need for skin grafting in nipple areolar reconstruction.

Tattooing the skin of the reconstructed breast as a prelude to reconstruction of the nipple provides a nipple areolar reconstruction that has a uniform color. There is no requirement for a skin graft donor site. Tedious tattooing of the nipple papule is avoided. It is much easier to tattoo a flat surface than a projecting papule, and this technique gives a more uniform color. We believe that this approach to nipple areolar reconstruction provides a simpler, dependable technique.

Female↗

PubMed2001

Prospective evaluation of late cosmetic results following breast reconstruction: I. Implant reconstruction.

The long-term cosmetic outcome of breast implant reconstruction is unknown. The morbidity and cosmetic outcome of 360 patients who underwent immediate postmastectomy breast reconstruction with various types of implants have been analyzed prospectively over a 9-year period. Of these patients, 334 who completed their reconstruction were suitable for evaluation of their cosmetic outcome. The early complication rate (< 2 months) was 9.2 percent, with an explantation rate of 1.7 percent. The late complication rate (> 2 months) was 23 percent, with a pathological capsular contracture rate of 11 percent at 2 years and 15 percent at 5 years and an implant removal rate of 7 percent. The revisional surgery rate was 30.2 percent. The cosmetic results were assessed prospectively using an objective five-point global scale. Every patient was scored at each visit once surgery was completed. The overall cosmetic outcome deteriorated in a linear fashion, from an initial acceptable result of 86 percent 2 years after patients completed their reconstruction to only 54 percent at 5 years. This decline in cosmetic outcome was not associated with the type of implant used, the volume of the implant, the age of the patient, or the type of mastectomy incision employed. Radiotherapy was not a significant factor because only 28 patients were irradiated. Upon Cox model analysis, pathological capsular contracture was the only factor that contributed significantly to a poor cosmetic outcome in which p < 0.0001 (relative risk 6.3). Despite a high revisional surgery rate, deterioration still occurred, suggesting that other unaccounted for variables were responsible. On photographic retrospective review of the patients without capsular contracture who demonstrated deterioration in their cosmetic scores, it became clear that a possible reason for their poor results was late asymmetry produced by the failure of both breasts to undergo symmetrical ptosis with aging.

Adult↗

PubMed2001

Prospective evaluation of late cosmetic results following breast reconstruction: II. Tram flap reconstruction.

Although it is thought that transverse rectus abdominis muscle (TRAM) flap breast reconstruction produces excellent cosmetic results that are maintained over the long term, there is little objective evidence in the literature to support this. One hundred seventy-one consecutive patients who underwent TRAM flap reconstruction were prospectively analyzed over an 8-year period to assess their morbidity and late cosmetic outcome.The early patient complication rate (< 2 months) was 37.4 percent, the late hernia and fat necrosis rates (> 2 months) were 8.8 and 13.5 percent, respectively, and the contralateral symmetrization rate was 33.9 percent. The cosmetic results were evaluated prospectively using an objective five-point global scale. Each patient was scored at each visit once surgery was completed. Follow-up continued until a flap was lost, a patient died, or the point of last patient contact was reached. Six patients died during the study. The actuarial percentage cosmetic outcome remained stable during the study period, with an acceptable result in 96.4 percent of patients at 2 years and in 94.2 percent of patients at 5 years. Only five patients in this series obtained poor cosmetic outcomes, with three due to substantial flap necrosis and two because of poor flap design. Two free TRAM flaps were also lost. Log-rank analysis revealed that neither patient age nor timing of surgery significantly affected the cosmetic outcome. Single pedicle and supercharged (single pedicle) TRAM flaps produced slightly better results than bipedicle and free TRAM flaps. In this prospective longitudinal study, TRAM flap reconstructions were shown to produce aesthetically pleasing results. Moreover, with long-term follow-up, it was demonstrated that these reconstructions maintained their stability.

Abdomen↗

PubMed2002

Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study.

In this study, the effects of procedure type, timing, and other clinical variables on complication rates in mastectomy reconstruction were prospectively evaluated. Using a prospective cohort design, women undergoing first-time, immediate or delayed breast reconstruction were recruited from 12 centers and 23 plastic surgeons. Complication data for expander/implant, pedicle transverse rectus abdominis musculocutaneous (TRAM) flap, and free TRAM flap procedures were evaluated 2 years after surgery in 326 patients. For each patient, the total number of complications was recorded and the complication data were dichotomized in two ways: (1) total complications and (2) major complications (those requiring reoperation, rehospitalization, or nonperioperative intravenous antibiotic treatment). The effects of procedure type, timing, radiotherapy, chemotherapy, age, smoking, and body mass index on complication rates were analyzed using logistic regression. Immediate reconstructions had significantly higher total as well as major complication rates, compared with delayed procedures (p = 0.011 and 0.005, respectively). Furthermore, higher body mass indexes were associated with significantly higher total and major complication rates (p = 0.005 and p < 0.001, respectively). No significant effects on complication rates were noted for procedure type or for the other independent variables, although there was evidence of trends for higher total and major complication rates in implant patients who received radiotherapy and a trend for higher major complication rates in TRAM flap patients who received chemotherapy. It was concluded that (1) immediate reconstructions were associated with significantly higher complication rates than delayed procedures, and (2) procedure type had no significant effect on complication rates.

Body Mass Index↗

PubMed2003

An accelerated approach to tissue expansion for breast reconstruction: experience with intraoperative and rapid postoperative expansion in 370 reconstructions.

Breast reconstruction with tissue expansion is a well-established technique that offers satisfactory aesthetic results with minimal patient morbidity. The traditional period of expansion, however, continues to be a significant source of patient inconvenience and dissatisfaction. The objective of this study was to develop and evaluate a protocol for rapid tissue expansion. A total of 370 breast reconstructions in 314 patients who underwent rapid tissue expansion were retrospectively reviewed. Contraindications to rapid expansion were considered to be previous radiation, mastectomy skin flaps of questionable viability, and an excessively tight skin envelope. All expanders were placed submuscularly and filled to 40 to 50 percent of tissue expander volume. Office expansion was undertaken within 10 to 14 days after the operation and continued on a weekly basis. Each expansion was limited by patient tolerance up to a maximal pressure of 40 mm of water or a volume of 120 cm3. Expansion was considered complete once the expanded breast was 30 to 50 percent larger than the contralateral breast. If required, postoperative chemotherapy was given during the expansion period. Mean patient age was 48 years (range, 23 to 73 years). Two hundred fifty-eight patients had unilateral reconstructions. Three hundred two patients had immediate reconstruction. Mean tissue expander size was 583 cm3 (SD, 108 cm3). Mean intraoperative expansion was 271 cm3, or 46 percent (SD, 9 percent) of the tissue expander size. The first expansion was started 12 days (SD, 3 days) after the operation. The mean volume of each expansion was 88 cm3 (SD, 23 cm3). Expansion was completed in 4.7 office visits (SD, one visit). Mean final expander volume was 672 cm3 (SD, 144 cm3). The expanders were overexpanded by 15.3 percent (SD, 8.4 percent). The mean time between expander placement and the final expansion was 6.6 weeks (SD, 3 weeks). The overall complication rate was 4 percent. Ten patients developed cellulitis, five patients had hematomas requiring drainage, and one expander became exposed. A total of eight expanders were removed: four for cellulitis, one for a hematoma, one because of locally recurrent disease, one because of expander exposure, and one at the patient's request for no medical reason. Intraoperative and rapid postoperative tissue expansion is a safe and reliable technique that offers a significant improvement over conventional techniques. In this accelerated protocol, expansion may be completed in less than 7 weeks. The result is decreased patient morbidity and delays in adjuvant therapy at no detriment to the final surgical outcome.

Adult↗

PubMed2004

Free fibula long bone reconstruction in orthopedic oncology: a surgical algorithm for reconstructive options.

The fibula free flap became popular in orthopedic oncology for limb-sparing long bone tumor resection. It is particularly suitable for intercalary or resection arthrodesis options. In the present series, a surgical reconstruction algorithm was used, enabling each patient to receive a personalized technique. During the years 1998 to 2002, 30 patients underwent limb-sparing surgery for long bone sarcoma. There were 18 males and 12 females. Their mean age was 23 years (range, 9 to 70 years). The diagnoses were Ewing's sarcoma (11 patients), osteogenic sarcoma (eight patients), chondrosarcoma (five patients), giant cell tumor of bone (three patients), high-grade soft-tissue sarcoma (two patients), and leiomyosarcoma of bone (one patient). The majority of tumors where located in the lower extremity (23 patients), mostly in the femur (15 patients with four tumors in the proximal femoral shaft, five tumors in the distal femoral shaft, five tumors in the whole femoral shaft, and one tumor in the proximal femoral head). In seven patients, the upper extremity was involved; in six patients, the radius was involved; and in one patient, the humerus was involved. The free fibula flap was used in three types of approaches: vascularized fibula as an osseous flap only (18 patients), a combination of a vascularized fibula flap in conjunction with an allograft (Capanna's technique; 10 patients), and a free double-barreled fibula (two patients). All flaps survived. Postoperatively, all patients were monitored clinically, radiologically, and by radioisotope bone scan studies. Callus formation and union were shown 2.6 to 8 months postoperatively. Patients who underwent lower extremity reconstruction were nonweightbearing for 3 to 9 months, with a transition period in which they used a brace and gradually increased weightbearing until full weightbearing was achieved. Eight patients had 11 recipient-site complications. Two patients (6.7 percent) had hematomas, and three patients (10 percent) had infection and dehiscence of the surgical wound with bone exposure in one patient; all complications resolved with conservative treatment only. Failure of the hardware fixation system occurred in two patients, mandating surgical correction. No fibula donor-site complications were recorded. In intercalary resections, the use of the vascularized fibula flap as an isolated osseous flap might be insufficient. Different body sites have different stress loads to carry, depending on the age of the patient and on his individual physical status. To achieve initial strength in the early period, the authors combined the free fibula flap with an allograft (Capanna's method) or augmented it as a double-barreled fibula. They propose a surgical algorithm to assist the surgeon with the preferred method for reconstruction of various long bone defects in different body locations at childhood or adulthood. Long bone reconstruction using a vascularized fibula flap, alone or in combination with an allograft, autogenous bone graft, or double-barreled fibula for limb-sparing surgery, is a safe and reliable method with a predictable bony union, good functional outcome, and a low complication rate.

Adolescent↗

PubMed2000

Penalized weighted least-squares image reconstruction for dual energy X-ray transmission tomography.

We present a dual-energy (DE) transmission computed tomography (CT) reconstruction method. It is statistically motivated and features nonnegativity constraints in the density domain. A penalized weighted least squares (PWLS) objective function has been chosen to handle the non-Poisson noise added by amorphous silicon (aSi:H) detectors. A Gauss-Seidel algorithm has been used to minimize the objective function. The behavior of the method in terms of bias/standard deviation tradeoff has been compared to that of a DE method that is based on filtered back projection (FBP). The advantages of the DE PWLS method are largest for high noise and/or low flux cases. Qualitative results suggest this as well. Also, the reconstructed images of an object with opaque regions are presented. Possible applications of the method are: attenuation correction for positron emission tomography (PET) images, various quantitative computed tomography (QCT) methods such as bone mineral densitometry (BMD), and the removal of metal streak artifacts.

Algorithms↗

PubMed2001

Automated seed detection and three-dimensional reconstruction. II. Reconstruction of permanent prostate implants using simulated annealing.

We present an algorithm, based on simulated annealing, for automatic seed matching and three-dimensional spatial coordinate reconstruction using either three radiographic films or three fluoroscopic images taken from different perspectives. The matching problem is defined in the framework of combinatorial optimization, which allows robust reconstruction in presence of calibration imprecision, patient movements, and isometric distortions. Furthermore, by using a global criterion to select the correct matching, we evade common problems of the three-film method and its variants in presence of noise. The algorithm has been tested on 112 clinical cases and 100 simulated implants and used clinically on more than 100 cases. Simulated implants were reconstructed with an average error of 0.21 mm. For clinical cases, comparison of the precision is performed between results obtained with this new method and results obtained using the three-film technique. Compared to the latter technique, the reconstruction precision was improved in 62% of the clinical cases.

Algorithms↗

PubMed1996

Accurate three-dimensional reconstruction of intravascular ultrasound data. Spatially correct three-dimensional reconstructions.

BACKGROUND: The geometrical accuracy of conventional three-dimensional (3D) reconstruction methods for intravascular ultrasound (IVUS) data (coronary and peripheral) is hampered by the inability to register spatial image orientation and by respiratory and cardiac motion. The objective of this work was the development of improved IVUS reconstruction techniques. METHODS AND RESULTS: We developed a 3D position registration method that identifies the spatial coordinates of an in situ IVUS catheter by use of simultaneous ECG-gated biplane digital cinefluoroscopy. To minimize distortion, coordinates underwent pincushion correction and were referenced to a standardized calibration cube. Gated IVUS data were acquired digitally, and the spatial locations of the imaging planes were then transformed relative to their respective 3D coordinates, rendered in binary voxel format, resliced, and displayed on an image-processing workstation for off-line analysis. The method was tested by use of phantoms (straight tube, 360 degrees circle, 240 degrees spiral) and an in vitro coronary artery model. In vivo feasibility was assessed in patients who underwent routine interventional coronary procedures accompanied by IVUS evaluation. Actual versus calculated point locations were within 1.0 +/- 0.3 mm of each other (n = 39). Calculated phantom volumes were within 4% of actual volumes. Phantom 3D reconstruction appropriately demonstrated complex morphology. Initial patient evaluation demonstrated method feasibility as well as errors if respiratory and ECG gating were not used. CONCLUSIONS: These preliminary data support the use of this new method of 3D reconstruction of vascular structures with use of combined vascular ultrasound data and simultaneous ECG-gated biplane cinefluoroscopy.

Blood Vessels↗

PubMed1996

[Postoperative swallowing function in tongue and oral floor cancer patients reconstructed with a recto-abdominal myocutaneous free flap after glossectomy--quantitative assessment of reconstructed tissue movement].

We examined the postoperative swallowing function of 12 tongue and oral floor cancer patients reconstructed with a recto-abdominal myocutaneous free flap after glossectomy. On the basis of the resection site, the present cases were classified into either anterior type or lateral type. Subjective evaluation of postoperative swallowing function was obtained from self-reports from patients. The movement of the reconstructed tissue was evaluated videofluorographically during swallowing, by tracking the movement of two small pellets temporarily attached to the anterior and central portions of the reconstructed tongue. The trajectory of the two pellets and the selected point of the hyoid bone were recorded together with the distance between the plate and the tongue dorsum, and between the posterior pharyngeal wall and the tongue base. Using a personal computer, a quantitative study of the video images was performed. The results were summarized as follows. 1) The movement pattern of the reconstructed tissue was generally saccadic rather than smooth. It was suggested that the swallowing pattern of the patients was different to that of normal controls. 2) Postoperative swallowing function was poorer in cases of the anterior type when compared to the lateral type. 3) In general, cases which showed relatively wide movement range appeared to achieve subjectively satisfactory swallowing function.

Adult↗

PubMed2000

[Femoral reconstruction with massive allograft implanted in a split femur. Mid-term results of 18 reconstructions].

PURPOSE OF THE STUDY: Extensive loss of femoral bone subsequent to implant loosening raises an unsolved problem. The purpose of this work was to examine mid-term results of 18 iterative total hip arthroplasties with femoral reconstruction using massive allografts performed between 1986 and 1997. MATERIALS AND METHODS: Using the Vives classification, the femoral bone lesions were grade 3 (n =2) and grade 4 (n =16). The reconstruction was achieved with radiated massive allografts measuring 11 to 35 cm implanted in a split host femur. Charnley-Kerboull implants with a long stem were cemented in the reconstructed femurs. RESULTS: Mean follow-up was 4 years 10 months (range 2 to 9 years). Nine complications in 7 hips were observed: 6 trochanter nonunions, two recurrent prosthesis dislocations and 1 femoral fracture. At last follow-up, the functional result was excellent or very good in 12 hips (Merle d'Aubigné classification). A stable fixation persisted for 15 implants and 3 had loosened. Graft-host femur consolidation was achieved in all cases except 1. There were 3 cases with extensive resorption of the graft including 2 associated with loosening of the femoral component. DISCUSSION: Reconstruction of the femur after extensive bone loss using a massive allograft appears to be a useful method for restoring bone tissue and providing immediate mechanical support for the femur.

Adult↗