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

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.

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.

Normal changes in orbital volume during childhood.

OBJECT: The aim of this study was to construct a model of changes in orbital volume that occur throughout childhood from the age of 1 month to 15 years, which could be used for comparative studies of disease states affecting orbital growth. METHODS: Using the procedure of segmentation on magnetic resonance images obtained in 67 healthy children, orbital volume was measured and plotted against age. During the first few months of life left orbital volume is on average 15 cm3 in male and 13 cm3 in female infants; these volumes increase to 26 cm3 and 24 cm3, respectively, by the time the child reaches 15 years of age. During the first few months of life right orbital volume is on average 16 cm3 in male and 13 cm3 in female infants; these volumes increase to 27 cm3 and 25 cm3, respectively, by the time the child is 15 years old. This represents an overall increase in orbital volume by a factor of 1.7 in boys and 1.8 in girls. By the time the child has reached 5 years of age, the orbital volume for both right and left sides has reached on average 77% of the volume seen at 15 years in both sexes. The differences between the two sides are not statistically significant for either sex. The change in orbital volume that is associated with age in general displays a linear pattern. Throughout childhood, orbital volumes are larger in boys than in girls, but share a similar growth pattern. The difference between the two sexes tends toward statistical significance during the first 5 years of life (left orbit p = 0.1, right orbit p = 0.04). CONCLUSIONS: During early childhood, orbital volume increases in a linear fashion, achieving a significant proportion of its final growth by the time the child is 5 years old.

Changes in orbital volume during childhood in cases of craniosynostosis.

OBJECT: Controversy remains concerning the timing of frontoorbital advancement (FOA) surgery performed for craniosynostosis. Reduced orbital volume and degree of exorbitism are often cited as reasons for early surgical intervention. To date, however, little attention has been given to orbital volume and its changes during the first few years of life as an indicator of orbital growth in children with craniosynostosis. Knowledge of orbital volume and growth patterns in individuals with craniosynostosis and those with normal cranial structures will enable surgeons to refine both the type and timing of surgical intervention required, thus obtaining the optimum outcome for their patients. METHODS: Using the procedure of segmentation, orbital volumes in 50 children with various forms of craniosynostosis were measured on preoperative computerized tomography scans. Changes in average volume that occur with increasing age were calculated and compared with a model of normal orbital volume growth. At presentation the children with craniosynostosis ranged in age from 1 to 29 months, with 82% of them within the 1st year of life. Several interesting observations emerged from this study. Excluding patients with unilateral coronal synostosis, there was no difference between orbital volumes measured on the right and left sides, allowing mean orbital volume measurements to be used for comparative purposes. Although children with craniosynostosis begin life with significantly smaller orbital volumes, overall normal mean volumes for both sexes are attained by 13 months of age, with volumes approaching normal by 6 months of age in male infants and by 8 months of age in female infants. Changes in orbital volume associated with age generally appear to be similar in most forms of craniosynostosis. There appears to be no significant difference in changes in orbital volume between children with syndromic or nonsyndromic forms of bicoronal synostosis. Orbital volume is significantly reduced on the ipsilateral affected side in cases of unicoronal synostosis in comparison with the contalateral side, but it is not significantly lower than that of normal. Finally, FOA surgery appears to restore normal growth of orbital volume. CONCLUSIONS: The results of this study indicate that the underlying mechanism leading to craniosynostosis and restriction of orbital volume "burns out" and begins to lose its major effects within the first few months of life. It would appear that FOA surgery should be delayed until the end of the second half of the 1st year of life, thus maximizing the effects of accelerated normal orbital growth and reducing the risks of relapse.