ENOUS AND HOMOLOGOUS

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1 USE OF FROZEN CRANIAL BONE FLAPS FOR AUTOG- ENOUS AND HOMOLOGOUS GRAFTS IN CRANIOPLASTY AND SPINAL INTERBODY FUSION K E N N E T H H. ABBOTT, M.D. Department of Neurosurgery, The Ohio State University, Columbus, Ohio (Received for publication January ~7, 1953) CCASIONALLY the neurosurgeon finds it necessary in the course of a craniotomy for various conditions to leave a wide decompression, and therefore must sacrifice all or a part of a cranial bone flap. Under such circumstances he must either discard the bone or find a suitable method of preserving it. If suitably preserved it m a y be replaced at a later date, thus avoiding the use of artificial materials or other autogenous or homologous bone to fill in the cranial defect. It is the purpose of this paper to report m y experience with freezing of such cranial bone flaps and later replacing t h e m and following their course for a period of years. Attention will also be called to the value of preserving cranial bone in this manner for use in homologous cranioplasty in depressed skull fractures, after removal of tumors of the skull, and in other situations where tantalum, plastics, autogenous or homologous bone might be used for cranioplasty. Although little has been recorded concerning the use of cranial bone preserved by freezing, it has become apparent from conversation with many O FIG. 1. Case 1. Left lateral view of autogenous cranial graft ~6 months after operation. 380

USE OF FROZEN CRANIAL BONE FLAPS FOR GRAFTS 381 neurosurgeons that such autogenous and homologous grafts are being used not infrequently. It therefore seems advisable to record these experiences.

2 USE OF FROZEN CRANIAL BONE FLAPS FOR GRAFTS 381 neurosurgeons that such autogenous and homologous grafts are being used not infrequently. It therefore seems advisable to record these experiences. The writer's experience began in January 1950, as a matter of necessity for decompressive purposes after the removal of a left frontal parasagittal meningioma when acute edema developed in the left frontal lobe. Rather than preserve the bone flap in alcohol, merthiolate, or other antiseptics, freezing was chosen as the method of preservation. The bone flap was wrapped in sterile towels, put in a sterile pan, and again wrapped in sterile towels. A few hours later it was placed in a "deep freeze" at the writer's home. The bone lay in the deep freeze at -10~ (-~3.3~ for 16 days. Three hours after removing the bone flap from the freezer it was aseptically inspected at the operating table and found to be in the same'condition as when it was removed from the skull. It was then replaced to its former site as an autogenous graft. The wound healed per primam with x-ray evidence of a normal take of this frozen preserved autogenous graft. Roentgenograms have been made of this graft at frequent intervals and now after e years the graft shows no evidence of serious shrinkage or loss of calcium content (Fig. 1). (X-rays of the graft at 3~ months appear the same as in Fig. 1.) Since this first experience with freezing a bone flap, the writer has used this same procedure in a total of 5 similar cases.* In addition there are on hand several bone flaps that have not been replaced. Thus there has developed a cranial bone bank which is proving useful for homologous grafts. Because experience in these cases has been so favorable, a brief review of the use of frozen cranial bone for homologous bone grafts for cranial defects will be detailed as well as their use in a modification of the Cloward type of spinal interbody fusion after removal of a protruded intervertebral disc. REPORTS OF CASES GROUP A. AUTOGENOUS CRANIAL GRAFTS Case 1. Female, aged 43 years. On Jan. 34, 1950, a left frontotemporoparietal craniotomy was performed for the removal of a parasagittal meningioma, angiomatous in type, weighing 300 gm. The bone flap was removed this same date because of severe cerebral edema. The flap was placed in the deep freezer chamber and on Feb. 9, 1950, was replaced. Postoperative roentgenograms taken at 13 months and 36 months (Fig. 1) show an excellent take of the graft. Case 2. Female, aged 43 years. On Mar. 8, 1950, a left parietofrontal craniotomy was performed for the removal of a meningioma. On March 18 subdural and epidural hemorrhages were evacuated. On March 19 the patient was again returned to surgery because of progressive severe cerebral edema with coincident symptoms of severe increased intracranial pressure. On April 10 osteomyelitis of the bone flap * Since this was submitted for publication 4 more such grafts have proven successful (~ autogenous and ~ homologous).

KENNETH H. ABBOTT Fro. ~. Case 2. (A) X-ray taken ~ months after replacement of autoclaved and frozen (5 months) bone flap, showing beginning absorption of the bone.

The bone flap was removed, autoclaved, suitably wrapped, and placed in the deep freezer chamber. On Sept. 7, 1950, the autoclaved bone flap was replaced.

3 KENNETH H. ABBOTT Fro. ~. Case 2. (A) X-ray taken ~ months after replacement of autoclaved and frozen (5 months) bone flap, showing beginning absorption of the bone. (B) Showing severe absorption of graft ~6 months after replacement. was disclosed. The bone flap was removed, autoclaved, suitably wrapped, and placed in the deep freezer chamber. On Sept. 7, 1950, the autoclaved bone flap was replaced. Postoperative roentgenograms in November 1950 (Fig. ~A) disclosed early absorptive changes in the graft, while those made in November 195~ (Fig. ~B) show very severe absorption of the bone flap. FIG. 8. Case 3. Left lateral view showing frozen (~4 days) autogenous graft 16 months after operation.

USE OF FROZEN CRANIAL BONE FLAPS FOR GRAFTS 383 Comment. This is the only infected and subsequently autoclaved and frozen cranial bone flap I have a t t e m p t e d to replace.

4 USE OF FROZEN CRANIAL BONE FLAPS FOR GRAFTS 383 Comment. This is the only infected and subsequently autoclaved and frozen cranial bone flap I have a t t e m p t e d to replace. I t is also the only cranial graft t h a t has shown severe absorption. There are p r o b a b l y several reasons w h y such bone absorbs rather than maintains its normal structure and calcium content. I t seems probable t h a t the infection, plus the heat of autoclaving, m a y have so altered its structure as to prevent revascu]arization and remineralization. Case 3. Male, aged 48 years. On Aug. ~0, 1950 a left temporofroutal craniotomy was performed for evacuation of a chronic subdural hematoma. On Aug. ~, 1950, a postoperative subdural and epidural blood clot was removed. Because of acute cerebral edema the bone flap was removed and placed in the deep freezer chamber. On Aug. 30, 1950, the patient was again returned to surgery. There was a small amount of blood clot with a large accumulation of cerebrospinal fluid in the epidural and subdural spaces. He recovered with moderate neurologic residuals. Hence, the bone flap was not replaced until Sept. 14, The postoperative x-rays taken on Jan. ~3, 195~ (Fig. 3), 16 months after replacement of the bone flap, show the autogenous graft has taken well without demineralization. Case 4. Male, aged 68 years. On Sept. ~3, 1950 a right temporofrontoparietal craniotomy was carried out for the evacuation of a massive chronic subdural hematoma. On Sept. ~4, 1950 the patient was returned to surgery for evacuation of postoperative hemorrhage. On Sept. ~6, 1950, because of severe cerebral edema, FIo. 4. Case 5. Lateral view showing frozen (~3 days) autogenous cranial bone graft 9 months after replacement.

884 KENNETH H. ABBOTT the bone flap was removed and placed in the deep freezer chamber. He made an uneventful recovery. On Nov. 9, 1950, the bone flap was replaced. No postoperative x-rays were taken.

5 884 KENNETH H. ABBOTT the bone flap was removed and placed in the deep freezer chamber. He made an uneventful recovery. On Nov. 9, 1950, the bone flap was replaced. No postoperative x-rays were taken. The patient expired consequent to a coronary occlusion on Jan. 31,1951. Autopsy revealed a perfect take of the autogenous skull graft without local complications. There was no evidence of loss of calcium content or absorption of the graft. Unfortunately, no postoperative roentgenograms were available in this case. Case 5. Male, aged 8 years. On Feb. 19, 1953, a right frontotemporoparietal craniotomy was performed for a probable frontal lobe tumor, but none was found. The brain was under considerable increased tension, the pulse was slow, and the blood pressure was moderately elevated; hence it became apparent that decompression was mandatory. The dura mater was not closed, the brain being protected by a thin film of polyethylene sutured loosely in place. The bone flap was removed and placed in the deep freezer chamber. Subsequent studies of the tissue removed for biopsy revealed an "eosinophilic encephalitis." [This has been studied by several neuropathologists and no further diagnosis could be made.] By Mar. 14, 1953, the edema had subsided and the bone flap was replaced. Postoperative x-ray films made in December 1953 (Fig. 4) gave evidence of a satisfactory take of the frozen autogcnous graft. GROUP ~B. HOMOLOGOUS CRANIAL GRAFTS (to cranium) Case 6. Male, aged 45 years. On Sept. 1, 1951 a frontal osteoma was removed. A frozen homologous cranial bone was used as a graft carefully fitted to fill in the area and correct the disfigurement. The bone used had been frozen approximately 389 months and came from a patient who had succumbed following operative removal of a glioblastoma multiforme that necessitated a decompression. Postoperative roentgenograms 8 months later show an excellent take of the graft (Fig. 5). Case 7. Female, aged 39 years. On Apr. 18, 1953 an osteoid-osteoma was removed from the temporofrontal area. A frozen homologous cranial bone graft was used to fill in the area of defect. A successful take of the graft is shown by roentgenograms taken 8 months later (Fig. 6). Case 8. Male, aged 9 years. On Mar. 38, 1953 an old small depressed frontal skull fracture was elevated. Although some of the fragments were used to close the defect, more material was needed to fill in the remaining small defect; hence a small piece of frozen cranial bone was chosen. The wound healed satisfactorily. Roentgenograms taken in November 1953 (7 months later) revealed an excellent take of the graft (Fig. 7) and there was a very good cosmetic result. Case 9. Male, aged 16 years. One year previously, an eosinophilic granuloma had been removed (by another neurosurgeon), leaving a pulsating defect in the right frontotemporal area. This had worried the patient and he came in for a plastic procedure. On Aug. 11, 1953 a frozen homologous cranial bone graft was wired into the area, followed by primary union of the wound.

6 USE OF FROZEN CRANIAL BONE FLAPS FOR GRAFTS 385 FIG. 5. Case 6. Lateral view of frozen homologous cranial graft 8 months after operation. Fro. 6. Case 7. Lateral view of frozen homologous cranial graft 8 months after operation.

386 KENNETH H. ABBOTT FIG. 7 (left). Case 8. X-ray of homologous cranial graft 7 months after operation. Fro. 8 (right). Case 9. X-ray of homologous cranial graft 4 months after operation.

8) revealed a good take of the graft, and inspection of the wound disclosed complete disappearance of the defect, leaving a satisfactory cosmetic result. GROUP C.

7 386 KENNETH H. ABBOTT FIG. 7 (left). Case 8. X-ray of homologous cranial graft 7 months after operation. Fro. 8 (right). Case 9. X-ray of homologous cranial graft 4 months after operation. Postoperative x-rays made in December 195~ (Fig. 8) revealed a good take of the graft, and inspection of the wound disclosed complete disappearance of the defect, leaving a satisfactory cosmetic result. GROUP C. HOMOLOGOUS CRANIAL GRAFTS (Spinal fusion--modified Cloward interbody fusion) The writer has now used multiple discs of frozen homologous cranial bone for fusion of the lumbar vertebral bodies (interbody fusion) after removal of the major portion of the intervertebral disc. The technique employed is a modification of Cloward's I operation for the fusion of the vertebral bodies: A guarded auger drill with pre-set depth stop is used to make the proper size "hole" in the intervertebral area, thus freshening the contiguous edges of the bodies of the vertebrae. Discs of cranial bone are carefully made with a hole saw of the same diameter as the auger drill. These are carefully placed in the intervertebral hole made by the auger. The Cloward vertebral spreader is released and the discs can be seen to seat themselves into the bodies of the vertebrae. Excellent stabilization of the bodies of the vertebrae can be demonstrated immediately. X-ray evidence of fusion of the vertebral bodies with preservation of the disc space has been demonstrated at a 6-month postoperative period. The technique for "pre-fit dowels" was first carried out by Wiltberger using autogenous bone dowels from the ilium. The writer has chosen to use the harder bone in the hope of maintaining the disc space.* * More recently a "pre-fit dowel" of iliac cancellous bone has been inserted between two cranial bone discs. This is done to facilitate earlier interbody fusion.

DISCUSSION While it is true that freezing has long been a satisfactory method of preserving bone by orthopedic surgeons, and freezing of soft tissues (nerves, arteries, tendons, fascia, etc.

8 USE OF FROZEN CRANIAL BONE FLAPS FOR GRAFTS 387 However, the time interval (10 months) is not long enough to evaluate the method. These discs of skull bone can be seen in place at the lumbosacral level in the roentgenogram shown in Fig. 9. DISCUSSION While it is true that freezing has long been a satisfactory method of preserving bone by orthopedic surgeons, and freezing of soft tissues (nerves, arteries, tendons, fascia, etc.) has been used for other grafting purposes, to our knowledge this is the first report wherein the freezing of cranial bone has been described for autogenous and/or homologous Fro. 9. Lateral view of lumbosacral area showing g buttons of homologous cranial bone for interbody fusion in situ 6 months after operation. grafting on the skull itself. While it has proven successful in the writer's hands, he is cognizant of the problems peculiar to this and other methods of preserving bone. Attempts to maintain sterility of the skull bone have been done by the following means. First, the bone is immediately wrapped in several sterile towels and as quickly as possible is placed in a freezing chamber where it is "quick-frozen" and then it is not touched again until ready for use. In recent cases the bone has been dipped in or sprinkled with an aqueous solution of penicillin and streptomycin. It is hoped that this will further protect the graft from contamination. Furthermore, it has been the policy to place variable amounts of penicillin and streptomycin solution in the cranial bone-grafted wound just before the closure is completed. The patient is placed on heavy antibiotic therapy for ~ days before and for 5 days after the bone-graft operation. Whether or not other measures to prevent infection should be tried remains to be seen. So far the precautions as outlined have been sufficient to prevent infection of the graft. Some have suggested that each patient should be placed on heavy antibiotic therapy before each cranial operation. Then if a cranial bone graft is removed it will contain sufficient antibiotic to prevent growth of contaminating organisms. This may be possible but it seems doubtful. The desirability of having a separate small "deep freeze" type of unit to be used for this bone is immediately apparent. When one has to use a small corner of a large freezer unit used for other purposes, all too frequently various "accidents" will happen to the preciously preserved bone flap. In preparing "skull bone discs" for a modification of the Cloward I type of fusion of the bodies of the vertebrae (interbody fusion) I have chosen to use a "hole saw" and prepare these all at one time from a section of skull

9 388 KENNETH H. ABBOTT bone. They are packaged in groups of four discs and kept in the freezer unit at -10~ (-s176 This procedure has saved a great deal of time and has avoided further trauma and pain to the patient necessitated in the usual procedures. The writer has not as yet studied the important factors of changes in structure of the cranial bone caused by freezing. The degree of shrinkage of the graft has not been fully ascertained. It has been established that most homologous bone grafts shrink by at least ten per cent. Some of the cranial bone grafts herein studied may have shrunk a little, but it has not been of sufficient degree to be of clinical significance. Studies concerning this matter are under way and will be the subject of a future report. The course of one autogenous graft (Case ~, Group A) is of special interest for it was an infected bone flap which was autoclaved and then preserved by freezing for 5 months. This is the only graft that has shown serious severe absorption. It would therefore seem inadvisable to preserve and use such a graft. A similar disappointing experience was demonstrated with merthiolate-preserved cranial bone used for a homologous cranial graft. SUMMARY A method of preserving cranial bone flaps by rapid freezing for use either as autogenous or homologous grafts in the skull is described. Its successful use in 5 cases of autogenous cranial grafts and 4 of homologous cranial grafts is detailed. Incidental use of homologous grafts of frozen skull bone in the form of small discs for interbody fusions in a modification of the Cloward and Wiltberger type of spinal fusion is recorded. The matters of sterility, contamination, and bone shrinkage are discussed. It is concluded that the freezing of cranial bone when available is a safe, satisfactory, and desirable method. This method allows the use of a normal body tissue for grafting in the skull or spine, rather than using metal and plastic substances. REFERENCE 1. CLOWARD, R.B. The treatment of ruptured lumbar intervertebral discs by vertebral body fusion. I. Indications, operative technique, after care. J. Neurosurg., 1958, 10:

Surgical Care at the District Hospital. EMERGENCY & ESSENTIAL SURGICAL CARE

Surgical Care at the District Hospital 1 17 Orthopedic Techniques Key Points 2 17.1 Traction Use an appropriate method of traction to treat fractures of the extremities and cervical spine Apply extremity