Cranial bone grafting for alveolar clefts: a 25-year review of outcomes.

BACKGROUND: Cranial bone grafting for an alveolar cleft obtains membranous bone from a low-morbidity donor site. Although iliac crest bone is the favored donor site, there are no objective analyses of three-dimensional radiologic outcomes with cranial bone grafting and no studies evaluating complications and long-term outcomes in a large series of patients undergoing cranial bone grafting. METHODS: A retrospective chart review was conducted on patients who underwent alveolar bone grafting from the cranium over a 25-year period performed by a single surgeon. Data collected included patient characteristics, complications, and clinical outcomes. Radiologic analysis of graft outcomes was determined using Amira volume-rendering software on the most recent 10 consecutive patients. RESULTS: The authors' study cohort included 308 patients, with an average age of 11.5 years. Complications involved harvesting the graft in 3.5 percent, the donor site in 1 percent, and the recipient site in 17.2 percent. Regrafting was required in 7.1 percent, with a clinical success rate of 92.9 percent. The average alveolar defect was 1.19 ml preoperatively and 0.19 ml postoperatively, with 85 percent fill of the cleft defect by radiologic analysis. CONCLUSIONS: Cranial bone grafting for the alveolar cleft is a low-morbidity operation and has success similar to that of iliac crest bone grafting. It should be considered more often as a viable option for the alveolar cleft patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Protocol management of late-stage pressure ulcers: a 5-year retrospective study of 101 consecutive patients with 179 ulcers.

BACKGROUND: Despite a 12 to 82 percent pressure ulcer recurrence rate, no standard protocol exists for postoperative management. The authors reviewed a single surgeon's experience using a standard protocol: surgery and immediate reconstruction regardless of nutrition, intraoperative bone culture guiding postoperative antibiotic use, and hospital admission for 3 weeks of flat bedrest before graduated sitting. METHODS: A 5-year retrospective chart review was performed on consecutive surgically treated pressure ulcers. A search of billing records identified 101 patients with 179 ulcers. Data abstracted included demographics, comorbidities, location and stage of ulcers, treatment history with outcomes, and laboratory data. RESULTS: Seventy-nine percent of the patients were men with a mean age of 49.4 years. Of 179 ulcers, 49.7 percent were ischial, 26.8 percent were sacral, and 19 percent were trochanteric; 87.7 percent of ulcers were stage 4. Primary closure was performed on 45.8 percent; others underwent flap closure. There was no correlation between positive bone cultures and recurrence or complications. The overall recurrence rate was 16.8 percent at a mean period of 435.9 days. New ulcer occurrence was 14.5 percent and the complication rate was 17.3 percent. Admission prealbumin and albumin did not correlate with recurrence or complication. Mean follow-up was 629 days. CONCLUSIONS: A standard clinical pathway for pressure ulcer treatment improves long-term outcomes; the authors' protocol's validity is supported by low recurrence and complication rates. Nutritional data do not predict outcome. Intraoperative bone cultures are the most valid method of diagnosing osteomyelitis; results should not delay definitive treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.