Publications by authors named "Kalle Aitasalo"

34 Publications

A large calvarial bone defect in a child: osteointegration of an implant.

World Neurosurg 2019 Jan 23. Epub 2019 Jan 23.

Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland; PO Box 23, 90029 OYS, Finland; Medical Research Center Oulu, and PEDEGO Research Unit, University of Oulu, Oulu, Finland.

Background: This is an original report describing the long-term follow-up outcome of a cranioplasty. A large calvarial bone defect of a child was reconstructed with a bioactive and biostable non-metallic implant.

Case Description: This is a case study of a young child with an infantile fibrosarcoma of occipital bone. The malignancy in an occipital bone was removed from a child of 2.5 years of age, and the defect site was reconstructed with an on-lay glass fibre-reinforced composite - bioactive glass implant. After 5 years and 7 months, the follow-up examination showed no signs of a recidive. During the follow-up period, the contour of the reconstructed area followed skull anatomical development. Computed tomography demonstrated considerably large areas (approximately 70 % of the total area) of bone on-growth to the peridural surface of the implant.

Conclusions: In the future, a synthetic cranioplasty material that is capable to integrate with cranial bone may be considered superior to cryopreserved bone grafts in younger age groups.
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http://dx.doi.org/10.1016/j.wneu.2019.01.028DOI Listing
January 2019

Cranioplasty After Severe Traumatic Brain Injury: Effects of Trauma and Patient Recovery on Cranioplasty Outcome.

Front Neurol 2018 9;9:223. Epub 2018 Apr 9.

Department of Biomaterials Science and Turku Clinical Biomaterials Centre--TCBC, Institute of Dentistry, University of Turku, Turku, Finland.

Background: In patients with severe traumatic brain injury (sTBI) treated with decompressive craniectomy (DC), factors affecting the success of later cranioplasty are poorly known.

Objective: We sought to investigate if injury- and treatment-related factors, and state of recovery could predict the risk of major complications in cranioplasty requiring implant removal, and how these complications affect the outcome.

Methods: A retrospective cohort of 40 patients with DC following sTBI and subsequent cranioplasty was studied. Non-injury-related factors were compared with a reference population of 115 patients with DC due to other conditions.

Results: Outcome assessed 1 day before cranioplasty did not predict major complications leading to implant removal. Successful cranioplasty was associated with better outcome, whereas a major complication attenuates patient recovery: in patients with favorable outcome assessed 1 year after cranioplasty, major complication rate was 7%, while in patients with unfavorable outcome the rate was 42% ( = 0.003). Of patients with traumatic subarachnoid hemorrhage (tSAH) on admission imaging 30% developed a major complication, while none of patients without tSAH had a major complication ( = 0.014). Other imaging findings, age, admission Glasgow Coma Scale, extracranial injuries, length of stay at intensive care unit, cranioplasty materials, and timing of cranioplasty were not associated with major complications.

Conclusion: A successful cranioplasty after sTBI and DC predicts favorable outcome 1 year after cranioplasty, while stage of recovery before cranioplasty does not predict cranioplasty success or failure. tSAH on admission imaging is a major risk factor for a major complication leading to implant removal.
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http://dx.doi.org/10.3389/fneur.2018.00223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5904383PMC
April 2018

A glass fiber-reinforced composite - bioactive glass cranioplasty implant: A case study of an early development stage implant removed due to a late infection.

J Mech Behav Biomed Mater 2015 Mar 7;55:191-200. Epub 2015 Nov 7.

Department of Otorhinolaryngology - Head and Neck Surgery, Division of Surgery and Cancer Diseases, Turku University Hospital, PO Box 52, 20521 Turku, Finland; City of Turku Welfare Division, PO Box 670, 20101 Turku, Finland.

This case study describes the properties of an early development stage bioactive glass containing fiber-reinforced composite calvarial implant with histology that has been in function for two years and three months. The patient is a 33-year old woman with a history of substance abuse, who sustained a severe traumatic brain injury later unsuccessfully treated with an autologous bone flap and a custom-made porous polyethylene implant. She was thereafter treated with developmental stage glass fiber-reinforced composite - bioactive glass implant. After two years and three months, the implant was removed due to an implant site infection. The implant was analyzed histologically, mechanically, and in terms of chemistry and dissolution of bioactive glass. Mechanical integrity of the load bearing fiber-reinforced composite part of the implant was not affected by the in vivo period. Bioactive glass particles demonstrated surface layers of hydroxyapatite like mineral and dissolution, and related increase of pH was considerably less after two and three months period than that for fresh bioactive glass. There was a difference in the histology of the tissues inside the implant areas near to the margin of the implant that absorbed blood during implant installation surgery, showed fibrous tissue with blood vessels, osteoblasts, collagenous fibers with osteoid formation, and tiny clusters of more mature hard tissue. In the center of the implant, where there was less absorbed blood, only fibrous tissue was observed. This finding is in line with the combined positron emission tomography - computed tomography examination with (18F)-fluoride marker, which demonstrated activity of the mineralizing bone by osteoblasts especially at the area near to the margin of the implant 10 months after implantation. Based on these promising reactions found in the bioactive glass containing fiber-reinforced composite implant that has been implanted for two years and three months, calvarial reconstruction with the presented material appears to be a feasible method.
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http://dx.doi.org/10.1016/j.jmbbm.2015.10.030DOI Listing
March 2015

Outcomes of cranioplasty with synthetic materials and autologous bone grafts.

World Neurosurg 2015 May 11;83(5):708-14. Epub 2015 Feb 11.

Department of Neurosurgery, Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland.

Objective: Using current surgical methods, cranioplasty is associated with a high complication rate. We analyzed if there are preexisting medical conditions associated with complications and compared the effect of different implant materials on the degree of complications.

Methods: A retrospective review of the medical records of all patients who underwent cranioplasty for cranial bone defects during the period 2002-2012 was conducted, and 100 consecutive cranioplasty procedures that met eligibility criteria were identified. Patients were analyzed in 4 groups, which were created based on the cranioplasty material: autograft (n = 20), bioactive fiber-reinforced composite (n = 20), hydroxyapatite (n = 31), and other synthetic materials (n = 29). Survival estimates were constructed with Kaplan-Meier curves, and the differences between categorical variable levels were determined using a log-rank test. Multiple comparisons were adjusted using a Šidák correction.

Results: During a median follow-up time of 14 months (interquartile range 3-39 months), 32 of 100 patients (32.0%) developed at least 1 complication. A minor complication occurred in 13 patients (13.0%), whereas 19 patients (19.0%) developed a major complication, which required reoperation or removal of the implant. In the autograft subgroup, 40.0% of patients required removal of the cranioplasty. The 3-year survival of the autograft subgroup was lower compared with other subgroups of synthetic materials. In hydroxyapatite and bioactive fiber-reinforced composite groups, fewer complications were observed compared with the autograft group.

Conclusions: Based on these results, synthetic materials for cranial bone defect reconstruction exhibit more promising outcomes compared with autograft. There were differences in survival rates among synthetic materials.
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http://dx.doi.org/10.1016/j.wneu.2015.01.014DOI Listing
May 2015

Paediatric cranial defect reconstruction using bioactive fibre-reinforced composite implant: early outcomes.

Acta Neurochir (Wien) 2015 Apr 10;157(4):681-7. Epub 2015 Feb 10.

Division of Surgery and Cancer Diseases, Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, PO Box 52, 20521, Turku, Finland,

Background: In children, approximately half of cryopreserved allograft bone flaps fail due to infection and resorption. Synthetic materials offer a solution for allograft bone flap resorption. Fibre-reinforced composite with a bioactive glass particulate filling is a new synthetic material for bone reconstruction. Bioactive glass is capable of chemically bonding with bone and is osteoinductive, osteoconductive and bacteriostatic. Fibre-reinforced composite allows for fabricating thin (0.8 mm) margins for implant, which are designed as onlays on the existing bone. Bioactive glass is dissolved over time, whereas the fibre-reinforced composite serves as a biostable part of the implant, and these have been tested in preclinical and adult clinical trials. In this study, we tested the safety and other required properties of this composite material in large skull bone reconstruction with children.

Method: Eight cranioplasties were performed on seven patients, aged 2.5-16 years and having large (>16 cm(2)) skull bone defects. The implant used in this study was a patient-specific, glass-fibre-reinforced composite, which contained a bioactive glass particulate compound, S53P4.

Results: During follow-up (average 35.1 months), one minor complication was observed and three patients needed revision surgery. Two surgical site infections were observed. After treatment of complications, a good functional and cosmetic outcome was observed in all patients. The implants had an onlay design and fitted the defect well. In clinical and imaging examinations, the implants were in the original position with no signs of implant migration, degradation or mechanical breakage.

Conclusions: Here, we found that early cranioplasty outcomes with the fibre-reinforced composite implant were promising. However, a longer follow-up time and a larger group of patients are needed to draw firmer conclusions regarding the long-term benefits of the proposed novel biomaterial and implant design. The glass-fibre-reinforced composite implant incorporated by particles of bioactive glass may offer an original, non-metallic and bioactive alternative for reconstruction of large skull bone defects in a paediatric population.
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http://dx.doi.org/10.1007/s00701-015-2363-2DOI Listing
April 2015

Craniofacial bone reconstruction with bioactive fiber-reinforced composite implant.

Head Neck 2014 May 1;36(5):722-8. Epub 2013 Aug 1.

Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, Turku, Finland.

Background: A novel, bioactive, fiber-reinforced composite implant is a solution to address the shortcomings in craniofacial bone reconstruction. A longitudinal clinical investigation with a follow-up time of 4 years was conducted.

Methods: A cranial bone reconstruction with the implant was performed on 12 patients. In these patients, the reasons for craniotomies resulting in craniofacial bone defects were traumatic and spontaneous intracranial bleeding as well as infections to the primary reconstruction material. The implant material consisted of a supporting fiber-reinforced framework, porous inner layers, and a bioactive glass (BG; S53P4) filling. The framework and the porous layers were made of a bisphenol-a-glycidyl methacrylate and triethyleneglycoldi-methacrylate (pBisGMA-pTEGDMA) resin matrix, which was reinforced with silanized E-glass.

Results: In clinical examinations and skull X-rays, the implants were in original positions providing the expected functional and aesthetic outcome at all time points.

Conclusion: The implants functioned appropriately, which would provide a potential solution for craniofacial bone reconstruction in the future.
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http://dx.doi.org/10.1002/hed.23370DOI Listing
May 2014

Bioactive glass S53P4 in mastoid obliteration surgery for chronic otitis media and cerebrospinal fluid leakage.

Ann Otol Rhinol Laryngol 2012 Sep;121(9):563-9

Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Hospital and University of Turku, Turku, Finland.

Objectives: We evaluated the results of cases of chronic otitis media treated with mastoid obliteration surgery using bioactive glass S53P4.

Methods: Twenty-five patients with chronic otitis media and 1 patient with cerebrospinal fluid leakage without chronic infection were treated with bioactive glass S53P4. Twenty patients had had previous surgery because of chronic otitis media with or without cholesteatoma. A mastoid obliteration was performed with bioactive glass S53P4 granules and a musculoperiosteal flap with or without bone paté. In 2 patients with a bony dehiscence at the middle cranial fossa, a bioactive glass plate was used to support the protruding dura. In addition, in 3 patients, occlusion of a dural fistula was needed The median follow-up period was 34.5 months (range, 1 to 182 months).

Results: Excluding the 2 patients with only 1 month of follow-up at our department, 96% of the patients had a dry, safe ear or only intermittent otorrhea. In 92% of the patients, the objective of achieving a smaller or nonexistent cavity was achieved.

Conclusions: Bioactive glass S53P4 is a noteworthy material in mastoid obliteration surgery.
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http://dx.doi.org/10.1177/000348941212100901DOI Listing
September 2012

Post-traumatic morbidity is frequent in children with frontobasilar fractures.

Int J Pediatr Otorhinolaryngol 2012 May 25;76(5):670-4. Epub 2012 Feb 25.

Department of Otolaryngology - Head and Neck Surgery, Turku University Hospital and University of Turku, Finland.

Objective: Frontobasilar fractures are potentially life-threatening injuries also in pediatric populations, often due to associated intracranial trauma. This retrospective study was performed at a tertiary care university hospital to evaluate the management and outcome of pediatric frontobasilar fractures. The secondary aim was to re-evaluate the computerized tomography images to reveal all the skull base fracture sites predicting morbidity.

Methods: A retrospective analysis of all the 20 consecutive pediatric patients diagnosed with and treated for a frontobasilar fracture at the Turku University Hospital, Turku, Finland during 1995-2010 was performed. The referral area of this tertiary care university hospital covers 750,000 inhabitants of whom approximately 20% are 18 years or younger.

Results: The mean annual incidence of frontobasilar fractures was 1.1 per 100,000 children aged 18 years and under. A road traffic accident was the most common etiological factor. Other factors included being hit by a heavy object, falling from a height, and falling to the ground. The mean Glasgow Coma Scale score was 10 and loss of consciousness was initially detected in 15 (75%) patients in the emergency unit. Twelve (60%) patients had an intracranial injury, 17 (85%) had facial bone fractures, and 15 (75%) had a fracture of the anterior cranial base. The middle cranial fossa and sella were affected in five (25%) of the patients. There seem to be no long-term neuroendocrine sequelae following brain injury, not even when the sella or the hypophyseal area was affected. Twelve (60%) patients were treated operatively. One patient died after one week of intensive care treatment. Only four (20%) patients had no post-traumatic implications, eight (40%) suffered from various long-term sequelae, and five (25%) had permanent neurological or neuropsychological sequelae.

Conclusions: Frontobasilar fractures in childhood are rare and often associated with intracranial trauma and long-term morbidity. However, according to this study, 75% of the patients showed no permanent neurological or neuropsychological sequelae.
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http://dx.doi.org/10.1016/j.ijporl.2012.01.040DOI Listing
May 2012

[Head and neck reconstructions].

Duodecim 2011 ;127(18):1953-61

HYKS:n plastiikkakirugian klinikka ja Helsingin yliopisto.

Tissue reconstructions of the head and neck are required both in the repair of tissue defects following the surgical excision of malignant tumors and in the treatment of various other facial deformities. While it is usually possible to repair a damaged tissue or organ region, functional restoration is very difficult. The aim is radical excision of the tumor, and successful reconstruction will provide quality of life for the patient even after an extensive surgical procedure. The goal of the new reconstructive procedures is as natural outcome as possible, but the risk for postoperative complications must be taken into account.
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December 2011

Mandibular reconstruction using free bone flap after preoperative chemoradiation.

Eur Arch Otorhinolaryngol 2012 May 12;269(5):1513-8. Epub 2011 Oct 12.

Department of Otorhinolaryngology, Head and Neck Surgery, Turku University Hospital, PL 52, 20521 Turku, Finland.

When treating head and neck cancer of an advanced stage, additional therapy modalities are often combined with surgery. This sets new challenges for the reconstructive surgery, especially after segmental mandibulectomy. There is continuous discussion considering the optimal timing of the surgery with relation to other treatment methods such as radiation therapy and chemotherapy. In this work, we have analyzed a series of 10 patients treated with segmental mandibulectomy and preoperative irradiation or chemoradiation in our institute between 1999 and 2006. Surgery was scheduled within 5 weeks from the radiation therapy. 9 out of 10 reconstruction flaps were vital at the last follow-up. In general the outcome of these patients was consistent with the results published earlier by other institutes using postoperative irradiation or chemoradiation. We conclude that preoperative irradiation does not have negative impact on microvascular reconstruction with free bone flap and this procedure offers an equal option for the treatment of these patients.
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http://dx.doi.org/10.1007/s00405-011-1795-4DOI Listing
May 2012

Novel composite implant in craniofacial bone reconstruction.

Eur Arch Otorhinolaryngol 2012 Feb 1;269(2):623-8. Epub 2011 Jun 1.

Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Hospital, P.O. BOX 52, 20521, Turku, Finland.

Bioactive glass (BAG) and polymethyl methacrylate (PMMA) have been used in clinical applications. Antimicrobial BAG has the ability to attach chemically to surrounding bone, but it is not possible to bend, drill or shape BAG during the operation. PMMA has advantages in terms of shaping during the operation, but it does not attach chemically to the bone and is an exothermic material. To increase the usefulness of BAG and PMMA in skull bone defect reconstructions, a new composite implant containing BAG and PMMA in craniofacial reconstructions is presented. Three patients had pre-existing large defects in the calvarial and one in the midface area. An additive manufacturing (AM) model was used preoperatively for treatment planning and custom-made implant production. The trunk of the PMMA implant was coated with BAG granules. Clinical and radiological follow-up was performed postoperatively at 1 week, and 3, 6 and 12 months, and thereafter annually up to 5 years. Computer tomography (CT) and positron emission tomography (PET-CT) were performed at 12 and 24 months postoperatively. Uneventful clinical recovery with good esthetic and functional outcome was seen. CT and PET-CT findings supported good clinical outcome. The BAG-PMMA implant seems to be a promising craniofacial reconstruction alternative. However, more clinical experience is needed.
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http://dx.doi.org/10.1007/s00405-011-1607-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259392PMC
February 2012

A national series of 244 sinonasal cancers in Finland in 1990-2004.

Eur Arch Otorhinolaryngol 2012 Feb 18;269(2):615-21. Epub 2011 May 18.

Department of Otorhinolaryngology-Head and Neck Surgery, Oulu University Hospital, Oulu, Finland.

Sinonasal cancer is still a somewhat controversial entity because most series are single-center studies. The aim of this study was to give more accurate and generalisable information about treatment of the neck and prognosis of sinonasal cancer. Retrospective, population-based, multicentre study. Altogether 244 patients diagnosed in 1990-2004 were evaluated. The 3- and 5-year disease-specific survival (DSS) rates after treatment with curative intent were 68 and 57%, respectively. Regional status at the time of the diagnosis (P < 0.001, log rank) and local recurrence (P = 0.02, log rank) during the follow-up had a statistically significant effect on DSS. Initially 13% of the patients were diagnosed with neck metastasis. The proportion of regional recurrences during the follow-up was 9%, but it did not have a statistically significant impact on DSS (P = 0.68, log rank). Histopathology had no statistically significant impact on survival in this material of 244 patients. In conclusion, routine elective neck treatment of all sinonasal cancer patients is not recommended, but the importance of the treatment of the primary location is emphasised.
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http://dx.doi.org/10.1007/s00405-011-1615-xDOI Listing
February 2012

Blood pressure and free flap oxygenation in head and neck cancer patients.

Acta Otolaryngol 2011 Jul 17;131(7):757-63. Epub 2011 Mar 17.

Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, Finland.

Conclusion: This study suggests that although oxygen partial pressure in tissue (p(ti)O(2)) measurement is a feasible method for continuous postoperative monitoring of free flaps, low correlation between blood pressure (BP) and p(ti)O(2) might predict compromised overall outcome. Thus, it is of utmost importance to keep the BP optimal for adequate perfusion of re-anastomosed tissue transfers.

Objective: Optimal BP is an important factor in assuring adequate blood flow in a free flap. Tissue oxygenation in free flaps as a postoperative monitoring target is in routine clinical use in some clinics. Correlation between p(ti)O(2) and systemic BP was investigated.

Methods: Ten consecutive patients underwent resection of head and neck squamous cell carcinoma followed by microvascular reconstruction with a free microvascular flap. P(ti)O(2) of each flap was continuously monitored for 3 postoperative days with a polarographic measurement system. BP was measured invasively and continuously during the operation and during the first postoperative day at the intensive care unit. The correlation coefficient between p(ti)O(2) and BP was analysed.

Results: The correlation coefficient between p(ti)O(2) and BP was relatively high in all patients with uneventful flap survival (r (mean) = 0.63, n = 5). In flaps with haemodynamic problems or compromised flap vitality the correlation appeared low (r(mean) = -0.02, n = 5).
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http://dx.doi.org/10.3109/00016489.2011.554438DOI Listing
July 2011

Perfusion in free breast reconstruction flap zones assessed with positron emission tomography.

Microsurgery 2010 Sep;30(6):430-6

Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Hospital, Turku, Finland.

The aim of this pilot study was to determine the postoperative blood perfusion (BF(PET)) and perfusion heterogeneity (BF(PET) HG) in free microvascular breast reconstruction flap zones with positron emission tomography (PET). Regional BF(PET) and BF(PET) HG of the adipose tissue in medial, central, and lateral parts of 13 free flaps were assessed on the first postoperative morning with PET using oxygen-15-labeled water ([(15)O]H(2)O) in 12 patients undergoing breast reconstruction with a deep inferior epigastric perforator (DIEP) or a transverse rectus abdominis muscle (TRAM) flap. The mean BF(PET) values did not differ between DIEP and TRAM flaps (P = 0.791). The mean BF(PET) values were higher in zone III compared with zone I (P = 0.024). During follow-up, fat necrosis was identified in three patients in the medial part (zone II) of the flap. However, the adipose tissue BF(PET) assessed on the first postoperative day from all zones of the flap using PET with radiowater was normal. The BF(PET) HG was higher in the control side (i.e., in the healthy breast tissue) compared with the flap (P = 0.042). The BF(PET) HG was lower in zone III than in zone I (P = 0.03) and in zone II (P < 0.001). In this pilot study, PET was used for the first time for studying the adipose tissue perfusion in different zones in free flaps in a clinical setup, finding that the mean BF(PET) values did not differ between DIEP and TRAM flaps, and that zone II was sometimes not as well perfused as zone III supporting revisited zone division.
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http://dx.doi.org/10.1002/micr.20770DOI Listing
September 2010

Survey of current functional outcomes assessment practices in patients with head and neck cancer: initial project of the head and neck research network.

J Otolaryngol Head Neck Surg 2010 Oct;39(5):523-31

Department of Speech Pathology and Audiology, Faculty of Rehabilitation Medicine, University of Alberta, and Institute for Reconstructive Sciences in Medicine, Misericordia Community Hospital, Edmonton, AB.

Background: Functional outcomes assessment has become increasingly important in informing treatment decisions in the area of head and neck cancer. However, consistency of assessment methods across studies has been lacking. For the literature to inform clinical decision making, consensus regarding outcomes measurements is necessary.

Objective: The Head and Neck Research Network (HNRN) was founded in January 2008 to become a conduit for high-quality research in the area of functional outcomes in patients with head and neck defects. The present study surveyed experts in functional outcomes assessment to determine what are considered the most important tools for assessing speech and swallowing and what background patient characteristics are important to capture.

Design, Participants, And Measures: Respondents to the online survey included 54 participants with a background in speech-language pathology, with the majority of respondents from the United States, Canada, and the United Kingdom.

Results And Conclusions: The results from the survey indicated that clinicians consider both subjective and objective measures as important to use when assessing function. More advanced technical tools were often rated as less important; however, it also was noted that clinicians were most often not able to access these tools or were unfamiliar with them.
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October 2010

Management and outcome of pediatric skull base fractures.

Int J Pediatr Otorhinolaryngol 2010 Nov 25;74(11):1245-50. Epub 2010 Aug 25.

Department of Otolaryngology - Head and Neck Surgery, Turku University Hospital and University of Turku, Finland.

Objective: The management of skull base fractures in the pediatric age group continues to be a major challenge even for experienced multidisciplinary teams. This retrospective study was undertaken at a tertiary care academic hospital to evaluate the management and outcome of pediatric skull base fractures.

Methods: Retrospective analysis covering a period of 13.5 years (from 1996 to 2009) and 63 patients (mean age 10.7 years; range 1-18 years) was performed.

Results: A road traffic accident was the most frequent etiological factor (38%). The most common skull base fracture type was temporal bone fracture (64%). Longitudinal temporal fractures were observed in 45% and transversal in 23% of these patients; in 10 cases (25%) the fracture was comminuted or mixed type. A fracture involving the spheno-ethmoidal complex was the second most common type of basilar skull fracture (41%) followed by fracture through the orbital bone (35%). Forty-three percent of the patients had a concomitant intracranial injury. Early neurological deficits were diagnosed in 21 patients (33%) and 10 patients (16%) had permanent neurological deficits. One patient died after 1 week of intensive care treatment. Fifty-four patients (86%) were discharged home and 8 patients (13%) were discharged for further rehabilitation. Glasgow Coma Scale score of 8 or lower correlated with moderate to poor outcome.

Conclusions: We conclude that skull base fracture is a rare injury in childhood. Mortality is uncommon, but this trauma is commonly associated with intracranial injury. Early neurological deficits are caused by traumatic brain injury and were observed in one-third of the patients. However, only less than one-sixth suffered from permanent neurological or neuropsychiatric disorders.
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http://dx.doi.org/10.1016/j.ijporl.2010.07.023DOI Listing
November 2010

The use of pedicled temporal musculoperiosteal flap with or without free calvarial bone graft in maxillary reconstructions.

Eur Arch Otorhinolaryngol 2010 Aug 16;267(8):1299-304. Epub 2010 Mar 16.

Department of Otorhinolaryngology, Head and Neck Surgery, Turku University Central Hospital, 20520 Turku, Finland.

Various techniques have been used to repair maxillary defects. The aim of this study was to evaluate the suitability of pedicled temporal musculoperiosteal flap (PTMF) and free calvarial bone graft for the reconstruction of maxillary defects. In this retrospective series, 34 patients operated on from 1995 to 2006 at Turku University Central Hospital because of defects of maxilla reconstructed using PTMF with or without free calvarial bone graft were evaluated. The diagnosis, the indication for surgery, the location and staging of the tumours, and the type of radiotherapy used were reviewed. The classification of the maxillary defects was performed according to the classification of Brown (Br J Oral Maxillofac Surg 40:183-190, 2002) and the success rates of the reconstructions were evaluated. Of the patients, 32 had been operated on due to a malignant tumour, one due to a benign tumour and one due to posttraumatic palatal defect. Preoperative radiotherapy (n = 14), preoperative chemoradiotherapy (n = 2) or postoperative radiotherapy (n = 11) had been used in the tumour group. As a reconstructive method, PTMF had been used with (n = 21) or without (n = 13) free calvarial bone graft. The use of free calvarial bone graft did not have a significant effect on flap survival. At 1-month follow-up, the flap survival in the 32 patients was 71.9%, whereas 28.1% of the patients suffered from partial flap loss, but there was no total flap loss. At 6-month follow-up, the flap survival in 26 patients was 76.9%, whereas 7.7% of the patients suffered from partial flap loss, and there were four (15.4%) total flap losses. If unilateral alveolar maxillectomy had been performed (Brown classification a), at 1-month follow-up, the flap survival was 82.6%, 17.4% of the patients suffered from partial flap loss, and there was no total flap loss. At 6-month follow-up, the flap survival was 89.5%, while 10.5% of the patients suffered from partial flap loss, and there was no total flap loss. The application of PTMF with or without free calvarial bone graft for reconstruction of limited palatal and maxillary defects appears to be feasible.
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http://dx.doi.org/10.1007/s00405-010-1225-zDOI Listing
August 2010

The limitations of tissue-oxygen measurement and positron emission tomography as additional methods for postoperative breast reconstruction free-flap monitoring.

J Plast Reconstr Aesthet Surg 2010 Feb 6;63(2):314-21. Epub 2008 Dec 6.

Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Central Hospital, FIN-20521, Turku, Finland.

Twelve patients who underwent breast reconstruction with a microvascular flap were monitored postoperatively with continuous partial tissue oxygenation (p(ti)O(2)) measurement. The regional blood flow (BF) of the entire flap was evaluated with positron emission tomography (PET) using oxygen-15-labelled water on the first postoperative (POP) morning to achieve data of the perfusion of the entire flap. A re-exploration was carried out if the p(ti)O(2) value remained lower than 15 mmHg for over 30 min. The mean p(ti)O(2) value of the flaps was 52.9+/-5.5 mmHg, whereas the mean BF values were 3.3+/-1.0 ml per 100 g min(-1). One false-positive result was detected by p(ti)O(2) measurement, resulting in an unnecessary re-exploration. Another re-operation suggested by the low p(ti)O(2) results was avoided due to the normal BF results assessed with PET. Totally, three flaps were re-explored. This prospective study suggests that continuous tissue-oxygen measurement with a polarographic needle probe is reliable for monitoring free breast flaps from one part of the flap, but assessing perfusion of the entire flap requires more complex monitoring methods, for example, PET. Clinical examination by experienced personnel remains important in free-breast-flap monitoring. PET could be useful in assessing free-flap perfusion in selected high-risk patients as an alternative to a re-operation when clinical examination and evaluation by other means are unreliable or present controversial results.
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http://dx.doi.org/10.1016/j.bjps.2008.09.029DOI Listing
February 2010

Long-term microscopic and tissue analytical findings for 2 frontal sinus obliteration materials.

J Oral Maxillofac Surg 2008 Aug;66(8):1699-707

Department of Otorhinolaryngology and Head and Neck Surgery, Turku University Hospital, Turku, Finland.

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http://dx.doi.org/10.1016/j.joms.2007.11.020DOI Listing
August 2008

Reconstruction of orbital wall defects with bioactive glass plates.

J Oral Maxillofac Surg 2008 Apr;66(4):639-46

Department of Otorhinolaryngology and Head and Neck Surgery, Turku University Hospital, Turku, Finland.

Purpose: Synthetic bioactive glass (BAG) is used in many surgical applications. Special bioactive glasses do not favor microbial growth. This study evaluated the clinical outcome of bioactive glass plates in reconstructive orbital surgery.

Patients And Methods: In a retrospective series of 49 patients, 35 orbital floors and 6 orbital medial and superior walls were reconstructed after fronto-orbital trauma, and 8 patients were treated with BAG plates after fronto-orbital tumor resection. These patients were evaluated in terms of reconstruction materials, complications, and functional outcomes.

Results: During the 2-year follow-up, 3 of the 35 orbital floor trauma reconstructions were reoperated (9%) because of diplopia, and new reconstructions with BAG were performed. In all of the 8 patients with tumors and in 6 of the patients undergoing orbital wall reconstruction, the plates were in the correct position after reconstruction, and none had to be removed. One patient with a benign tumor and 7 of the 8 patients with malignant tumors survived to the 2-year follow-up.

Conclusions: Reconstructive surgery of the orbit is one of the most demanding challenges in head and neck surgery. In orbital defect reconstruction, a BAG plate seems to be a well-tolerated and reliable reconstruction material alternative; however, BAG plates are brittle and rigid, and cannot be molded and shaped by a surgeon. The use of a stainless steel template of equal shape and size to a BAG plate is recommended to ameliorate this deficiency.
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http://dx.doi.org/10.1016/j.joms.2007.11.019DOI Listing
April 2008

Monitoring microvascular free flaps with tissue oxygen measurement and PET.

Eur Arch Otorhinolaryngol 2008 Jul 30;265 Suppl 1:S105-13. Epub 2008 Jan 30.

Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Central Hospital, 20521 Turku, Finland.

Tissue oxygen measurement and positron emission tomography (PET) were evaluated as methods for predicting ischemia in microvascular free flaps of the head and neck. Ten patients with head and neck squamous cell cancer underwent resection of the tumour followed by microvascular reconstruction with a free flap. Tissue oxygenation of the flap (P(ti)O(2)) was continuously monitored for three postoperative (POP) days and the blood flow of the flap was assessed using oxygen-15 labelled water and PET. In three free flaps a perfusion problem was suspected due to a remarkable drop in P(ti)O(2)-values, due to two anastomosis problems and due to POP turgor. No flap losses occurred. During the blood flow measurements with PET [mean 8.5 mL 100 g(-1) min(-1 )(SD 2.5)], the mean P(ti)O(2) of the flaps [46.8 mmHg (SD 17.0)] appeared to correlate with each other in each patient (p<0.05, n=10). Tissue oxygenation measurement is a feasible monitoring system of free flaps. The perfusion-study with PET correlates with P(ti)O(2)-measurement.
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http://dx.doi.org/10.1007/s00405-008-0585-0DOI Listing
July 2008

Bioactive glass hydroxyapatite in fronto-orbital defect reconstruction.

Plast Reconstr Surg 2007 Dec;120(7):1963-1972

Turku, Finland From the Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Hospital.

Background: Synthetic bioactive ceramics and glasses have osteoconductive properties. These materials are capable of chemically bonding to the bone tissue. In addition, special bioactive glasses do not favor microbial growth. In this study, the clinical outcome of bioactive glass and hydroxyapatite in head and neck surgery was evaluated.

Methods: In a retrospective series of 150 patients, 62 patients underwent reconstruction with frontal sinus obliteration after chronic frontal sinusitis, 65 patients were operated on for fronto-orbital traumas, and 23 patients underwent reconstruction after fronto-orbital tumor resections. These patients were evaluated for surgical procedures, reconstruction materials, complications, and functional outcomes.

Results: Three of the 62 frontal sinus occlusions underwent operation (4.8 percent) during the follow-up of 5 years. The reoperations were caused by a new mucocele. In fronto-orbital reconstructions, we have reoperated on the orbital floor in four cases (7 percent). All 12 benign tumor patients and six of 11 malignant tumor patients survived during a follow-up of 3 years. Two of the 23 (9 percent) complicated tumor and trauma patients underwent reoperation because of a local mucocele.

Conclusions: Treatment of severe head and neck defects with biomaterial is a suitable alternative to conventional methods. Bioactive materials seem to be stable and reliable at clinical follow-up. The reconstructions with bioactive glass and hydroxyapatite are associated with good functional and aesthetic results without donor-site morbidity. However, more long-term outcomes of studied biomaterials are needed to determine whether they are capable of competing with traditional tissue grafts.
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http://dx.doi.org/10.1097/01.prs.0000287319.34425.27DOI Listing
December 2007

A review of 59 consecutive patients with lesions of the anterior cranial base operated on using the subcranial approach.

J Craniomaxillofac Surg 2006 Oct 11;34(7):405-11. Epub 2006 Sep 11.

Department of Otorhinolaryngology, Head and Neck Surgery, Turku University Central Hospital, Turku, Finland.

Introduction: Lesions of the anterior cranial fossa are still a challenge for the surgeon. Since Joram Raveh introduced the concept of a subcranial approach in 1978 it has been used in the treatment of lesions extending into the anterior cranial fossa. Our experience with the subcranial approach during the past 8 years at Turku University Central Hospital is described.

Patients: Fifty-nine consecutive patients underwent surgery using the subcranial approach for treating various benign and malignant neoplasms, for repair of frontobasal-midfacial fractures, and for repair of cerebrospinal fluid leaks.

Methods: Patient records were retrospectively reviewed, with special focus on surgical technique, early outcome, and complications.

Results: Nineteen of the patients were operated on because of combined fronto-naso-orbital and skull base fractures, 37 were tumour cases, and 3 patients required surgical repair for cerebrospinal fluid leakage. Significant complications consisted of two cases of meningitis. However, they were successfully treated with antibiotics. The most common late complaint was olfactory nerve dysfunction (44), other late complications such as diplopia (4), enophthalmos (2), scar tissue in the nasal cavity (2), and trigeminal nerve dysfunction (2) were also encountered.

Conclusion: The subcranial approach affords exposure to the orbital, sphenoethmoidal, and clivus regions, as well as to the nasal and paranasal cavities. On the basis of this review, it is concluded that it is a safe and effective approach for treating lesions involving the anterior skull base.
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http://dx.doi.org/10.1016/j.jcms.2006.04.007DOI Listing
October 2006

Bioactive glass S53P4 in frontal sinus obliteration: a long-term clinical experience.

Head Neck 2006 Sep;28(9):834-41

Department of Otorhinolaryngology, Head and Neck Surgery, Turku University Hospital, FIN-20521 Turku, Finland.

Background: Synthetic, osteoconductive, and antimicrobial bioactive glass (BAG) has been used in many surgical applications.

Methods: BAG was used as obliteration material in a series of osteoplastic frontal sinus operations on 42 patients suffering from chronic frontal sinusitis, which could not be cured with other means of treatment.

Results: Accurate obliteration of sinuses was achieved in 39 patients. Uneventful recovery and clinical outcome were seen in 92% of the patients. Histopathologic samples harvested at 1, 5, and 10 years after obliteration revealed a healing process progressing from the fibrous tissue phase to bone formation with scattered fibrous tissue and bony obliteration maintaining BAG granule remnants. Fourier-transform infrared (FTIR) studies showed bone produced by BAG to be similar to natural frontal bone. Micorobiologic cultures obtained with histologic samples revealed no growth of bacteria.

Conclusions: BAG appears to be a reliable frontal sinus obliteration material, providing favorable conditions for total bony sinus obliteration.
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http://dx.doi.org/10.1002/hed.20436DOI Listing
September 2006

Functional evaluation of microvascular free flaps with positron emission tomography.

J Plast Reconstr Aesthet Surg 2006 ;59(2):158-65

Department of Otorhinolaryngology, Head and Neck Surgery, Turku University Central Hospital, FIN-20521 Turku, Finland.

Background: The aim of this study was to assess blood flow (BF) of microvascular free flaps studied with positron emission tomography (PET) in patients with head and neck squamous cell cancer (HNSCC) undergoing major radical surgery 3-4 weeks after high-dose radiotherapy.

Methods: Five patients underwent resection of the HNSCC of the oral cavity followed by microvascular reconstruction with a radial forearm flap. Regional BF in oral and neck tissues was measured with PET using radiolabelled water ([15O]H2O) twice (1-2 and 12-14 days, respectively) following radical surgery.

Results: In the first postoperative PET study, the median BF in the cutaneous flap area was 5.1 mL/100 g/min, and in the muscle contra-lateral to the recipient site 19.9 mL/100 g/min. A low flap-to-muscle BF ratio appeared to correlate with circulatory incongruity, and thus with poorer flap success. The follow-up study on the second postoperative week supported the results of the primary PET scan.

Conclusions: This pilot study suggests that PET using [15O]H2O is a feasible method to quantitatively evaluate BF of the whole free flap in patients operated on for oral
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http://dx.doi.org/10.1016/j.bjps.2005.04.016DOI Listing
June 2006

Preoperative hyperfractionated accelerated radiotherapy and radical surgery in advanced head and neck cancer: a prospective phase II study.

Radiother Oncol 2006 Feb 22;78(2):146-51. Epub 2005 Nov 22.

Department of Oncology and Radiotherapy, University of Turku, Turku, Finland.

Background And Purpose: To evaluate whether preoperative hyperfractionated accelerated radiotherapy (RT) combined with major radical surgery is feasible and successful in the treatment of advanced primary head and neck cancer.

Patients And Methods: Ninety four patients with histologically confirmed head and neck squamous cell cancer (HNSCC) in the oral cavity (41/96; 43%), supraglottis (14/96; 15%), glottis (5/96; 5%), oropharynx (16/96; 17%), nasal cavity/paranasal sinuses (8/96; 8%), nasopharynx (3/96; 3%), hypopharynx (7/96; 7%) and two (2%) with unknown primary tumour and large cervical lymph nodes entered into the study. 21/96 patients (22%) had stage II, 17/96 (18%) stage III and 58/96 patients (60%) stage IV disease. The patients received preoperative hyperfractionated RT 1.6 Gy twice a day, 5 days a week to a median tumour dose of 63 Gy with a planned break for 11 days (median) after the median dose of 37 Gy. Then, after a median of 27 days the patients underwent major radical surgery of the primary tumour and metastatic lymph nodes including reconstructions with pedicled or microvascular free flaps when indicated as a part of the scheduled therapy. 12/96 patients had only ipsilateral or bilateral neck dissections.

Results: After a median follow-up time of 37.2 mos 77/96 (80.2%) patients had complete locoregional control. All but 2 patients had complete histological remission after surgery. 40/96 pts were alive without disease, two of them after salvage surgery. 32/96 patients had relapsed; 15 had locoregional and 13 distant relapses, 4 patients relapsed both locoregionally and distantly. Fifty patients have died; 29 with locoregional and/or distant relapse, eight patients died of second malignancy, and 19 had intercurrent diseases. Disease-specific and overall survival at 3 years was 67.7 and 51%, respectively. Acute grade three mucosal reactions were common, but transient and tolerable. Late grade 3-4 adverse effects were few.

Conclusions: Preoperative hyperfractionated accelerated RT can be successfully combined with major radical surgery in the treatment of HNSCC. The amount of serious late adverse effects was not increased.
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http://dx.doi.org/10.1016/j.radonc.2005.11.002DOI Listing
February 2006

[Bioactive glass in the surgery of head and neck].

Duodecim 2004 ;120(16):1986-93

TYKS:n korva-, nenä- ja kurkkutautien klinikka, Turku.

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April 2005

Fibrous dysplasia of the sphenoid sinus and skull base presents in an adult with localized temporal headache.

J Craniofac Surg 2004 Mar;15(2):261-3

Department of Ear, Nose, and Throat Diseases, Central Hospital of Satakunta, Pori, Finland.

Fibrous dysplasia (FD) of the sphenoidal sinus is a rare disease, especially during adulthood. We report a case of FD of the right sphenoidal sinus in an adult male patient who presented with nonspecific symptoms limited to headache localized to the right temporal area and to the inferior orbital rim of both sides. Magnetic resonance imaging revealed a dense mass that occupied the entire right sphenoidal sinus and skull base with typical ground-glass opacification and bony sclerosis of the whole sphenoidal wall. The diagnosis of FD was confirmed on pathological examination of a biopsy taken through sphenotomy. The patient underwent a subcranial craniotomy for tumor resection. After more than 4 years of follow-up, the patient was disease-free. On the basis of these clinical features, it is important to consider sphenoidal FD in both young and adult patients complaining of an unexplained headache, because it may present unusually with headache localized to the temporal region or the inferior orbital rim.
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http://dx.doi.org/10.1097/00001665-200403000-00021DOI Listing
March 2004

Treatment of squamous cell carcinoma of the oral cavity, oropharynx and hypopharynx--an analysis of 174 patients in south western Finland.

Acta Oncol 2003 ;42(7):756-62

Department of Oncology and Radiotherapy, Turku University Central Hospital, Turku, Finland.

The purpose of this study was to determine the efficacy and feasibility of full-dose preoperative radiation therapy (RT) in head and neck cancer presenting in the oral cavity, oro- and hypopharynx, within a single university hospital district. During a seven-year period, 1989 to 1995, 174 patients with squamous cell carcinoma (SCC) of the oral cavity (OC, 70% of all patients), oropharynx (OP, 15%) and hypopharynx (HP, 15%) were referred to Turku University Central Hospital. All patients were seen by a tumor board consisting of an ENT (ear-nose-throat) head and neck surgeon, a radiation oncologist and a dentist. Potentially curative treatment was given to 142 patients. Of these, 88 (62%) had preoperative RT, 6 (4%) postoperative RT, 34 (24%) definitive RT and 14 patients (10%) were treated with surgery only. The radiation dose was > or = 50 Gy. averagely 64 Gy. The major endpoints of the study were local control, overall survival and major complications of the combined treatment. The 5-year relative survival rate (RSR) was 40% for all, and 43% for patients treated with curative intent. For these, the local control at 5 years was 60%; the disease-specific 5-year survival rate was 65% for the patients with lingual SCC, 45% for those with other oral tumor localizations. 64% for the oropharynx patients and 47% for those with tumor in their hypopharynx, while it was 55% for all patients. The preoperative radiotherapy was fairly well tolerated. Ten (7%) of the patients treated with curative intent suffered major complications, and four patients had evidence of osteoradionecrosis. With the exception of patients with early SCC the outcome remains rather poor in this group of cancer patients who often have marked co-morbidity. In our opinion, preoperative radiotherapy to a dose of 62-64 Gy can safely be given, and remains a feasible means to treat patients with oral, oropharyngeal or hypopharyngeal cancer.
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http://dx.doi.org/10.1080/02841860310010907DOI Listing
January 2004

Frontal sinus and skull bone defect obliteration with three synthetic bioactive materials. A comparative study.

J Biomed Mater Res B Appl Biomater 2003 Jul;66(1):364-72

Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Hospital, Finland.

Three synthetic bioactive materials were studied in an experimental model to compare their usability in a frontal sinus and a skull bone defect obliteration. Bioactive glass number 9 (BAG(1)), bioactive glass number 13 (BAG(2)), and hydroxyapatite (HA) granules were investigated. BAG(1) and HA granules have been previously tested clinically. The clinical usefulness of BAG(2) granules has not been tested. Upper bony walls of 45 Elco rabbits' frontal sinuses were drilled open from four separate holes with the use of a standard method. The skull bone defects and the sinuses in frontal bone were filled with BAG(1) or BAG(2) on one side, and with HA on the other side. Two parallel posterior defects were covered with a pedicled periosteum flap, and two anterior defects with a free flap. The resorption of materials, new bone, and fibrous-tissue formation were observed with a histomorphometric method at 1, 3, and 6 months postoperatively. Scanning-electron microscopy (SEM) and Fourier-transform infrared spectroscopy (FTIR) were done at 6 months. In histomorphometry, the new bone formation increased with all the investigated materials throughout the study (p < 0.001), but the results showed higher new bone formation in the defects filled with BAG(1) than in corresponding BAG(2)- or HA- filled defects. New bone formation and resorption of materials were faster in defects covered by pedicled than by free periosteum flaps (p < 0.001). Intimate contact between the used materials and new bone was confirmed by SEM. FTIR analysis of bone produced by BAG(1) and BAG(2) was of the same type as natural frontal bone. BAG(2) can be manufactured in various shapes, and thus, could possibly be used in clinical conditions requiring a special anatomical implant shape. However, more research is needed regarding this property of BAG(2).
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http://dx.doi.org/10.1002/jbm.b.10023DOI Listing
July 2003