Endoscope-assisted versus open repair of craniosynostosis: a comparison of perioperative cost and risk.

BACKGROUND: Craniosynostosis, the premature closure of calvarial sutures, results in characteristic skull deformations. Correction of craniosynostosis has traditionally involved an open cranial vault remodeling procedure. A technique recently developed uses an endoscope to perform a strip craniectomy in conjunction with a postoperative molding helmet to guide cranial growth. Few studies compare these 2 approaches to the treatment of the various forms of craniosynostosis. In this study, we present a single institution's experience with open cranial vault remodeling and endoscope-assisted strip craniectomy. METHODS: This study is a retrospective review of 57 patients that underwent craniosynostosis repair by either the endoscope-assisted or open techniques, and compared operating room times, blood loss, volume of transfused blood, length of hospital stay, and overall costs. RESULTS: The endoscopic technique is performed on younger children (4.7 months vs 10.6 months, P = 0.001), has shorter operating room times (2 hours 13 minutes vs 5 hours 42 minutes, P = 0.001), lower estimated blood loss (74.4 mL vs 280.2 mL, P = 0.001), less transfused blood (90.6 mL vs 226.9 mL), shorter hospital stays (1.2 days vs 4.9 days, P = 0.001), and decreased cost ($24,404 vs $42,744, P = 0.008) relative to the traditional open approach. CONCLUSIONS: Issues with the endoscope-assisted procedure primarily concerned the postoperative helmet regimen, specifically patient compliance (17.1% noncompliance rate) and minor skin breakdown (5.7%). The endoscope-assisted repair with postoperative helmet molding therapy is a cost-effective procedure with less operative risk and minimal postoperative morbidity. This is a valuable treatment option in younger patients with compliant caregivers.

Three- and four-dimensional computed tomographic angiography studies of the supraclavicular artery island flap.

BACKGROUND: The supraclavicular artery island flap is a useful regional option in head and neck reconstruction. Previous studies have recorded pedicle length, caliber, and ink injection studies of the supraclavicular artery. This study presents a three- and four-dimensional appraisal of the vascular anatomy and perfusion of the supraclavicular artery island flap using a novel computed tomographic technique. METHODS: Ten supraclavicular artery island flaps were harvested from fresh cadavers. Each flap was injected with contrast media and subjected to dynamic computed tomographic scanning using a GE Lightspeed 16-slice scanner. Static computed tomographic scanning was also undertaken using a barium-gelatin mixture. Images were viewed using both General Electric and TeraRecon systems, allowing the appreciation of vascular territory (three-dimensional) and analysis of perfusion flow (four-dimensional). RESULTS: The entire skin paddle was perfused in the majority (nine of 10) of flaps. One of the flaps was perfused only 50 percent. In this case, the pedicle artery was found to be much smaller than the other flap pedicles. Direct linking vessels and recurrent flow by means of the subdermal plexus were found to convey the flow of contrast between adjacent perforators. This explains how perfusion extends to adjacent perforators by means of interperforator flow, and how perfusion is maintained all the way to the distal periphery of the flap. CONCLUSIONS: Using this imaging technique, the authors elucidated the vascular anatomy of the supraclavicular artery island flap. This study confirms previous clinical findings that the supraclavicular artery island flap is a reliable option and gives surgeons new information for future flap refinement.

Hemipelvectomy for severe decubitus ulcers in patients with previous spinal cord injury.

BACKGROUND: Patients with spinal cord injury (SCI) frequently have pressure ulcers. Surgery is sometimes needed to close them. In rare cases, hemipelvectomy is warranted for extremely severe complications. METHODS: We conducted a retrospective study using national Department of Veterans Affairs (DVA) computer data sets to identify clinical features of SCI patients who underwent hemipelvectomy for life-threatening septic complications of decubitus ulcers. RESULTS: Among the approximately 4 million patients receiving care in the DVA system, more than 40,000 patients were treated on an inpatient basis for SCI during the search period (fiscal years 1989 to 1998). They represent approximately 20% of the total national patient pool. There were 56 patients who supposedly had undergone hemipelvectomy. Chart review eliminated cases that did not meet our inclusion criteria, resulting in 8 evaluable cases. All had complete SCI due to trauma and later developed severe pressure sores with pelvic osteomyelitis or life-threatening soft tissue infection. CONCLUSIONS: This series is the largest reported to date. The surgery involved significant blood loss (mean 2.6 L). Reoperations and complications were common. The mortality rate was 25%, but the survivors were all markedly improved by the surgery. Some of the complications appeared to be related more to the SCI than to the pelvic sepsis or surgery, suggesting that meticulous perioperative care may be valuable in reducing the complication rate in SCI patients undergoing this radical operation for very severe sequelae of pressure ulcers.