Place and role of titanium mesh in reconstruction of the frontal bone after trauma

Abstract

The proper approach and surgical plan in solving impressive comminuted frontal bone trauma is reflected in adequate fixation of numerous fragments, which have to go through proper repositioning and osteosynthesis to achieve adequate stability of the fragments and to return the original contour of the frontal bone and/or frontal sinus walls. We carried out the restoration of the normal bone contour through a quick and easy way of treating frontal fractures using titanium 3D mesh - a technique that involves 'pulling the bone to the network' and fixing it with the mono cortical screws. We present our experience with this technique in solving the case of frontal impressive and comminuted fractures, on the material of 43 patients at the Centre for Medical Emergencies and Neurotrauma Emergency Centre of the Clinical Centre of Serbia through a retrospective cohort study accompanied with technical aspects and clinical results of this simple method application. The study was previously approved by the Ethics Committee of the Clinical Centre of Serbia. In the period of three years 43 patients had fractures in the area of the frontal bone and frontal sinus. The surveyed period was 1st January 2013 to 31st December 2016. The youngest patient was 17 and the oldest 78 years, the average age being 29 years. The main cause was traffic accidents in 29/43 (67.44%) patients, sport in 4/43 (9.30%), falling down from one's own height in 5/43 (11.63%), a fall from a height higher than 2m in 4/43 (9.30%) and machinery operation in 1/43 (2.33%). The ratio towards sex distribution was men/women 3:1. All patients were operated within the period of six days after the injury. The diagnostic evaluation of patients was made with multi slice computed tomography with 3D reconstruction (3D MDCT) pre- and postoperatively, all patients were controlled on the examinations within the follow-up period of the first 12 postoperative months. The stability of the fragments during the surgical procedure was achieved fully, the position of fragments in the reconstructive act was in satisfactory anatomic contours. The aesthetic results were satisfactory and there were no complications related to the procedure applied, such as uncontrolled bleeding from sinus infection, damage to the rear wall of the sinuses and brain. The effectiveness of the applied procedure indicated to us that we had no deformities of the forehead contour and that the full cosmetic result was achieved. The usage of the titanium 3D mesh in solving such complex impressive comminuted fractures showed as the procedure of choice because in a simple manner with good surgical approach it gives excellent results and the procedure is performed with minimal morbidity in addressing primarily comminuted fracture of the anterior wall of frontal sinus and the frontal bone.

Pravilan pristup i hirurški plan u rešavanju impresivne kominutivne traume čeone kosti ogleda se u adekvatnoj fiksaciji brojnih ulomaka koji moraju proći kroz adekvatnu repociziju i osteosintezu da bi se postigla adekvatna stabilnost ulomaka i vratila prvobitna kontura čeone kosti i/ili zidova čeonog sinusa. Obnovu normalne konture kosti sproveli smo kroz brz i jednostavan način lečenja frontalnog preloma korišćenjem titanijum 3D mesh-a. Tehnika podrazumeva 'izvući kost na mrežu' i fiksirati je monokortikalnim šrafovima. Iznosimo naša iskustva sa ovom tehnikom u slučaju rešavanja frontalne impresivne i kominutivne frakture, na bolesničkom materijalu od 43 pacijenta u Centru za zbrinjavanje urgentnih stanja i neurotraume Urgentnog centra Kliničkog Centra Srbije, kroz retrospektivnu kohortnu studiju, propraćeno kroz tehnički aspekt i kliničke rezultate primene ove jednostavne metode. Studija je prethodno odobrena od Etičkog odbora KCS. U periodu od tri godine njih 43 su imali prelome u predelu čeone kosti i čeonog sinusa. Period praćenja je od 01. januara 2013. godine do 31. decembra 2016. godine. Najmlađi bolesnik imao je 17, a najstariji 78 godina, sa prosekom 29 godina. Glavni uzrok su bile saobraćajne nesreće, kod 29/43 (67,44%) pacijenata, sport, kod 4/43 (9,30%), pad sa svoje visine, 5/43 (11,63%), pad sa visine veće od 2m, 4/43 (9,30%) i rukovanje mašinama, 1/43 (2,33%). Odnos prema polnoj distribuciji muškarci/žene je 3:1. Svi pacijenti su operisani u periodu od 6 dana posle povrede. Dijagnostička evaluacija pacijenata načinjena je multislajsnom kompjuterizovanom tomografijom sa 3D rekonstrukcijom (MDCT 3D) pre i postoperativno. Svi pacijenti su kontrolisani na pregledima kroz period praćenja od prvog do 12. postoperativnog meseca. Stabilnost fragmenata tokom operativnog zahvata postignuta je u potpunosti, pozicija fragmenata u rekonstruktivnom aktu je u zadovoljavajućim anatomskim konturama. Estetski rezultati bili su zadovoljavajući i bez komplikacija vezanih za primenjeni postupak, kao što je nekontrolisano krvarenje iz sinusa, infekcije, oštećenja zadnjeg zida sinusa i mozga. Efektivnost primenjenog postupka ukazala nam je da nismo imali deformitete konture čela i da je postignut potpun kozmetički rezultat. Primena metoda sa titanijum 3D mesh-om u rešavanju ovako složenih kominutivnih impresivnih preloma pokazala se kao postupak izbora jer na jednostavan način uz dobar hirurški pristup daje odlične rezultate, a sam postupak se izvodi uz minimalan morbiditet u rešavanju prevashodno kominutivnih preloma prednjeg zida čeonog sinusa i čeone kosti.