Reconstruction using a frozen autograft for a skull and humeral lesion of synchronous multicentric osteosarcoma after undergoing successful neoadjuvant chemotherapy: a case report and review of the literature.

BACKGROUND: Synchronous multicentric osteosarcoma (SMOS) is a rare disease characterized by simultaneous multicentricity of intraosseous osteosarcoma without visceral involvement. SMOS, including a skull lesion, which occurs relatively rarely, and reconstruction using a frozen autograft after the excision of a lesion of SMOS has been infrequently reported previously. CASE PRESENTATION: We report an 18-year-old girl with SMOS, with lesions located in the left distal femur, right proximal humerus, and left occipital bone. Her major complaint was pain and swelling around the left knee joint. Asymptomatic lesions of the humerus and skull bone were detected on a systemic bone scan. No visceral organ metastasis was observed. A biopsy of the distal femoral lesion revealed osteosarcoma. Based on the histological findings, multiple bone lesions, and absence of visceral lesion, the clinical diagnosis of SMOS was made. After five courses of neoadjuvant chemotherapy with a regimen of doxorubicin and cisplatin, reconstruction using a tumor prosthesis following wide excision of the left distal femur was performed, and total necrosis was histologically observed in the retracted specimen. Following three cycles of adjuvant chemotherapy, tumor excision and reconstruction with a frozen autograft treated with liquid nitrogen was conducted for both lesions of the humerus and skull, rather than tumor prosthesis or synthetics, in order to retain a normal shoulder function, and to obtain a good cosmetic and functional outcome after treatment of the skull lesion. Further adjuvant chemotherapy could not be administered after the completion of the surgical treatment for all lesions because the adverse events due to chemotherapy were observed. At over 5 years after the diagnosis, she remains clinically disease-free. CONCLUSIONS: An early correct diagnosis, the proper management of chemotherapy, and surgical treatment for all lesions are essential for achieving a good clinical outcome, even in SMOS including a skull lesion. By performing reconstruction using a frozen autograft for a proximal humeral lesion and a skull lesion after confirming the good histological efficacy of neoadjuvant chemotherapy for the primary lesion, the excellent function of the shoulder joint and a good cosmetic outcome at the site of the skull lesion was acquired without complications or recurrence.

Pedicled, vascularized occipital bone graft to supplement atlantoaxial arthrodesis for the treatment of pseudoarthrosis.

Atlantoaxial pseudoarthrosis is a challenging postoperative complication. The use of a local, vascularized bone graft, without free tissue transfer, to support a revision atlantoaxial fusion has not been previously described. We report the first surgical patient who received a semispinalis capitis muscle pedicled, occipital bone graft for supplementation of a revision atlantoaxial arthrodesis. A 72-year-old female had a failed atlantoaxial fusion and developed neck pain from continued instability and fractured hardware. The fixation and fusion were revised and supplemented with a novel, pedicled occipital bone graft. A craniectomy was performed in the occipital bone while still attached to the semispinalis capitis muscle to provide graft vascularity. This graft was rotated inferiorly from the skull base to the C1 arch and C2 spinous process in order to supplement a revision atlantoaxial arthrodesis. The patient had excellent clinical recovery over 18-month clinical follow up. The bone graft harvesting and rotation were performed safely and without complication. The 6-month postoperative CT scan showed partial fusion into the graft. This novel surgical technique leverages the advantages of vascularized structural autograft without adding extensive time or morbidity to the procedure as observed in free-tissue transfers. It is a safe and useful salvage technique to supplement revision atlantoaxial fusion surgeries.

Transparapharyngeal and transpterygoid transposition of a pedicled occipital galeopericranial flap: a new flap for skull base reconstruction.

OBJECTIVES: We present the anatomic and cadaveric foundations for novel modifications of the occipital galeopericranial flap for reconstruction of ventral skull base defects. STUDY DESIGN: Anatomic description. METHODS: Using cadaveric dissections and measurements, we investigated the feasibility of transposing pedicled occipital galeopericranial flaps into the nasal cavity and skull base. Two fresh and five preserved human specimens were dissected. RESULTS: Pedicled occipital flaps were transposed into the nasal cavity via a transparapharyngeal-transpterygoid corridor into the nasopharynx. It was demonstrated that the pedicled occipital galeopericranial flap reaches the anterior skull base. CONCLUSIONS: Pedicled occipital flaps transposed into the nasal cavity can reach the anterior skull base and provide another option for vascularized reconstruction in selected patients.

Occipital bone graft for atlantoaxial fusion.

BACKGROUND: Instability of the atlantoaxial segment is frequently encountered in neurosurgical practice. Numerous fusion techniques have been employed at this level. Most commonly, arthrodesis is achieved through bone and wire techniques. We have employed the use of suboccipital bone in lieu of iliac crest autograft in order to avoid the significant morbidity associated with iliac crest graft harvest. METHODS: Twenty one patients suffering instability from various etiologies underwent C1-C2 fusion at our institution using occipital bone graft and wire fixation. A small craniectomy was performed near the foramen magnum, and the bone graft was notched and secured in place using wire fixation. Patients were placed in a Philadelphia or Aspen collar for 6-12 weeks postoperatively, and flexion/extension plain film of the cervical spine were used to evaluate fusion. RESULTS: Long term follow up was available on all patients (mean 32 months, range 12-48 months). Fusion was achieved in 81% of patients within 12 weeks. Specifically, 71% (5/7) of rheumatoid patients were successfully fused. All patients with traumatic C1-C2 instability were fused. No complications were associated with the harvest of the occipital bone. CONCLUSION: The results of fusion via this technique are comparable to other reported series of C1-C2 fusion. Additionally, the complications associated with iliac crest graft harvest were avoided by the use of occipital bone graft. Occipital bone appears to be a suitable bone graft substance for fusion of the C1-C2 level.

Osteogaleal pedicle flap of the occipital region for head and neck reconstruction--anatomic study.

OBJECTIVE: This study was conducted to assess the anatomic viability of an occipital osteogaleal pedicle flap for head and neck reconstruction. DESIGN: Anatomic study in cadavers. METHOD: We studied anatomic details in 50 fresh adult cadavers (100 sides). The dissections were realized after total posterior galea exposition, silicone injection of occipital vessels, and mobilization of the osteogaleal flap, with a 8 x 8-cm square of galea and a 2.5 x 7-cm rectangle of outer-table calvarial bone. RESULTS: Occipital artery obstruction = 4%; artery diameter = 2.69 mm (mean); occipital artery length = 134.25 mm (mean); occipital vein running close to the artery = 93%; area of occipital vessel network on galea = 148.77 cm2 (mean); thickness of outer-table bone graft = 6.07 mm (mean); pedicle length = 116.63 mm; and success in rotation to nose (82%), mandible (70%) and cricoid region (100%). CONCLUSIONS: We concluded that the pedicle osteogaleal occipital flap has favourable anatomic characteristics for its use in head and neck reconstruction.

Occipital calvarial bone graft in posterior occipitocervical fusion.

STUDY DESIGN: Dorsal occipitocervical fusion is associated with a high rate of fusion failure and requires an additional surgical site for donor bone graft harvesting. In this series, an autologous occipital calvarial bone graft obtained from the same occipitocervical incision with contoured metal loops was used in 25 adults to achieve craniovertebral stabilization and fusion. OBJECTIVES: To study the use of autologous occipital calvarial bone grafts in occipitocervical fusion. SUMMARY OF BACKGROUND DATA: Cranial bone grafts have been used successfully in craniofacial reconstruction with good long-term results. In the plastic surgery literature, there are claims that membranous bone grafts are superior to endochondral bone grafts in fusions because of decreased resorption. In recent studies, results have shown successful use of calvarial bone in fusing the upper cervical spine in children. The use of autologous occipital bone in posterior occipitocervical fusions avoids many of the problems associated with traditional donor sites and provides a sufficient quantity of good quality bone for the fusion. This is especially true in the fragile rheumatoid arthritis patient with cranial cervical instability. METHOD: Split-thickness, autologous calvarial bone grafts with contoured loop and cable instrumentation were used for posterior occipitocervical stabilization and fusion in 25 patients, most of whom had rheumatoid arthritis. The calvarial bone graft was harvested from the occipital skull, using a microair impactor, and was secured next to the loop construct. After surgery, all patients were immobilized with external orthoses. RESULTS: None of the patients had hardware failure or complications from the occipital graft procurement. In 22 patients, good alignment, stability, and bony fusion were shown on radiographs. CONCLUSIONS: Occipital calvarial bone graft appears to work as well as other autologous corticocancellous bone grafts routinely used in posterior occipitocervical fusions.

Cranial bone grafts for use in posterior fixation of the cervical spine. Technical note.

Bone grafts are usually an integral part of cervical spine fixation following spinal trauma. Unfortunately, many currently used bone graft donor sites (including the rib, iliac crest, and fibula) cause unacceptable patient morbidity, especially postoperative pain. A readily available source of autologous bone graft for posterior cervical fusion is the occipital bone. This membranous bone offers the advantage of strength and less bone resorption. It has been used at the Sunnybrook Health Science Centre for 4 years as a standard source of bone graft with no morbidity and excellent results for fusion.

Split calvarial grafts in maxillofacial reconstruction.

Experience with thirty-seven patients demonstrating the versatility of the split calvarial graft in facial reconstruction is presented. A total of sixty grafts have been used with no evidence of significant clinical reabsorption, infection, or extrusion; advantages and limitations are discussed. We conclude that the split calvarium represents a readily available and reliable source of membraneous bone for grafting maxillofacial defects with minimal limitations and low morbidity.