Z. Arnež; G. Papa; N. Renzi; V. Ramella; N. Panizzo; F. Toffanetti
University Department for Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine and Surgery, Cattinara University Hospital, Trieste, Italy
Vyšlo v časopise:
ACTA CHIRURGIAE PLASTICAE, 51, 1, 2009, pp. 27-31
bony tissues, traditionally performed by electric or power driven reciprocating
or oscillating saws, not only generates substantial heat – which can interfere
with normal bone healing process – but can also damage underlying soft tissues
(blood vessels, nerves) and cause permanent functional impairment. The saw is
controlled exclusively by the surgeon’s experience and dexterity and does not
stop when it comes into contact with tissues of different density. Some authors
speculate that the actual rate of soft tissue damage in such procedures is
higher than that reported in the literature (12). For these reasons it is
important to perform osteotomies with instruments which only cut bone, thus
preserving adjacent soft tissues. Such an instrument would increase the
applicability of the method, as well as enhance the safety and quality of the
Ultrasound has been
used in industry for cutting hard substance ever since the early 1950s (8).
Soon afterwards it was introduced into medicine and first used in 1957 in oral
surgery, for cutting dento-osseous structures (15). In 1972 it was used in
thoracic surgery (13). At present ultrasound technology is used in almost every
hospital for surgical aspiration in laparoscopic surgery, fragmentation of
kidney stones and soft tissue dissection by harmonic scalpel (2, 3, 5, 16, 18,
ultrasound in the form of the piezoelectric bone scalpel has been introduced in
maxillofacial and craniofacial surgery for osteotomies of viscero- and
neurocranial bones of reduced thickness (osteotomies of orbital walls,
mandibular osteotomies and craniotomies) (12).
We report the use of
a piezoelectric bone scalpel for cutting bones of larger thickness
(metacarpal, fibula, rib and rib cartilage) where high precision is required to
protect underlying neurovascular bundles.
In this way – for the
first time, to our knowledge – the field of application of this
machine/instrument has been enlarged to include hand and reconstructive
microsurgery taking advantage of its principal qualities, namely precision and
safety during osteotomy when a significant risk of damaging soft tissues
MATERIALS AND METHODS
In our Department for
Plastic and Reconstructive Surgery at Cattinara University Hospital in Trieste
(Italy) we started to use the ultrasound machine at the beginning of 2008,
initially for debridement of chronic wounds and ulcers, taking advantage of its
mechanic-vibratory, cavitation and thermal energy permitting elimination of
fibrinous and necrotic materials from the wound bed and thus reducing bacterial
load while preserving viable tissues.
Later we expanded its
use to include head and neck reconstruction (osteotomies of nasal bones and
However, here we
present only three cases where piezoelectric bone scalpel has been successfully
used in an innovative way for osteotomies of larger diameter bones (metacarpal,
fibula, rib and rib cartilage), proving its great applicability in hand and
Our osteotomies were
performed using an ultrasound-activated device produced by Genera® (Italia Medica, Milano, Italy). The device consists of
a console and piezoelectric hand-piece with changeable tips (Fig. 1, 2,
It operates in
continuous mode, activating the tip, which is made of titanium and fixed to
a hand-piece, a piezoelectric transducer vibrating at
a frequency of 26 kHz and making transversal movements of 15–30 μm from peak to peak. The vibrating tip is continuously
irrigated and cooled by cold saline solution with the help of
a peristaltic pump. Tip vibration changes the cooling solution into an
aerosol which, in addition to cooling, also cleans bone detritus and blood from
the operating field. Another feature offered by the vibrating tip and the
cooling liquid is “cavitation” – the production of microscopic bubbles of
saline which increase the mechanical effects (cutting) of piezoelectric bone
scalpel. The ultrasound energy force on Genera® Ultrasonic console is set to 90W. In our experience,
compared with other similar devices, such force is necessary for cutting bones
of larger thickness. The Genera console offers two independent channels,
permitting greater reliability. Because of such specific characteristics the
osteotomy line is made by the precise and controled progressive
micro-fracturing and dispersing of bony tissue. Furthermore, cavitations
created by vibrations augment the mechanic effects of the device and stimulate
the process of repair. Injury to the soft tissues is avoided by special
software and microprocessors which limit the bone scalpel’s action only to bone
but also by its precise, progressive and controlled cutting action, which lets
the surgeon “feel” when the bone has been thoroughly cut (12, 17).
woman presented after having sustained open fractures of the 3rd and 4th metacarpal bones and incomplete amputation of the 5th finger with extensive contusion of soft tissues on the dorsum
of the right hand while hit by a rock when climbing in French Alps. Her
primary treatment was performed in France and consisted of primary debridement,
bone fixation of the 3rd and 4th metacarpal by plate and screws and secondary amputation
of the 5th finger, which presented non curable venous
insufficiency at the level of proximal phalanx. The amputation stump was
covered by necrotic masses and required shortening. Our operative plan was
elimination of all necrotic tissues on the dorsum of the hand with aesthetic
amputation of the 5th ray proximal to the head of the metacarpal
and simultaneous cover of the dorsum of the hand by a reversed radial
forearm island flap. Since intact palmar arches are necessary for such
a reconstruction we opted for a precise method of oblique cutting the
neck of the 5th metacarpal by Genera® Ultrasonic, providing necessary protection of the
neurovascular bundles. Amputation with osteotomy regularized the aesthetic
profile of the hand, permitted flap coverage and shortened postoperative
rehabilitation (Fig. 4, 5, 6).
woman was diagnosed with carcinoma of the left body of the mandible involving
oral mucosa. She was offered radical tumour excision with ipsilateral neck
dissection and reconstruction with a free osteo-cutaneous fibular flap,
which she accepted. While the ENT surgical team was performing the oncologic
part of the procedure, the plastic surgery team was harvesting the fibular free
flap. Both proximal and distal osteotomies of the fibular bone were performed
by using Genera® Ultrasonic in a progressive,
controlled and precise manner. Due to the substantial bone thickness the
cutting time compared to cutting with an oscillating saw was about 30% longer,
but since no protection of the peroneal artery with bone retractors was
necessary when performing distal osteotomy – as would be usual when using an
oscillating saw – fibula harvesting took no longer than usual.
woman underwent an operation for breast cancer by modified radical mastectomy
with simultaneous autologous reconstruction by a DIEAP free flap. The
microsurgical anastomosis was planned to ipsilateral internal mammary vessels.
We planned to remove part of the 3rd rib cartilage to gain access to the recipient vessels. Harvesting of
ribs/rib cartilages usually requires special instruments and can easily cause
pneumothorax or bleeding, either from intercostals or internal mammary vessels
or their branches. Cutting the rib cartilage at the level of sterno-costal
joint and 4 cm laterally by Genera piezoelectric scalpel permits easy and
fast removal of the rib cartilage/rib with complete preservation of the intact
recipient vessels which are required for problem-free microvascular anastomosis
(see Fig. 3).
reconstructive surgical procedures using Genera® Ultrasonic to perform osteotomies were completed
successfully, with no complication either to bony structures/cartilage or soft
tissues. Blood vessels or neurovascular pedicles remained untouched and
functioning, resulting in free or pedicled flap transfer with no vascular
complications and consequently no (partial or total) flap loss. The patient
undergoing aesthetic amputation of the 5th ray amputation presented no sensory loss, and the patient undergoing
mandible reconstruction by free fibula flap showed primary bone healing at
X-ray and CT-scan controls three months after the operation.
Cutting thick bones
(>10mm) by Genera® Ultrasonic takes 20–30% more time than is
the case with a conventional oscillating saw. We believe the precision of
the cut and preservation of underlying soft tissues more than compensate for
this slight increase in time spent.
Learning to use the
Genera® Ultrasonic is easy and quick. It only takes
a few minutes to understand the function of the device and a few more
to be able to use it correctly and safely.
has found many applications in medicine (2, 3, 5, 16–18, 19).
The machine that we are
using is, in a simplified way, just a tool to produce ultrasound, but
at the same time its specific characteristics can be modified as required: the
tips of the bone scalpel are interchangeable, offering different length and
shapes as needed; furthermore, the frequency of vibration as well as the power of
the machine can be regulated. The increased power level (90W) seems to be
necessary for cutting thicker bones (such as the fibula or metacarpal in our
case). At the same time this increased power only produces a moderated
quantity of heat at the tip of the bone scalpel, reducing osteonecrosis at the
cutting surface to a minimum (4).
The effects on bony
tissue of cutting bones by ultrasound energy have been extensively analysed in
the literature (1, 6, 9–11, 14). They include a less smooth cutting
surface compared to that produced when cutting with a conventional
electrical saw. However, the major advantages of cutting by ultrasound are the
absence of microfractures, only modest heating at cutting surface and the
creation of cavitations.
features prevent structural alterations (necrosis) of bony tissue – as proven
by histology and electron microscopy –
and facilitate bone healing after bone fixation.
The possibilities for
use of the Genera® Ultrasonic are numerous. It has been widely
used for treatment of chronic skin ulcers and in cranio-maxillo-facial surgery
for cutting cranial and facial bones (thickness <10mm). In our department we
have used it (other than for debridement of venous, arterial and combined lower
extremity ulcers) for the removal of a nasal bone invaded by a local
recurrence of basocellular carcinoma (primarily operated elsewhere) because we
wanted to preserve untouched the underlying nasal mucosa which appeared on
CT-scan not to be involved. In this case the ultrasound technology was applied
to cut bone of moderate thickness.
In the three case
reports presented the osteotomized bone was much thicker. To our knowledge
reports of cases of this sort have not been published before and extend the use
of piezoelectric bone scalpel to new fields – hand surgery and reconstructive
microsurgery – where precision of cutting and protection of neurovascular
structures is of paramount importance. In fact, in the patient with soft tissue
necrosis on the dorsum of the hand and amputation of the 5th finger after being hit by a rock while climbing in
the Alps (Case 1), the osteotomy proximal to the metacarpal head (aesthetic
amputation of the 5th ray) was neat (see Fig. 5) and the
neurovascular bundle remained untouched. Integrity of the palmar vascular
arches made it possible for us to harvest the distally based radial forearm
flap for easy and fast coverage of the exposed metacarpal fractures and
Selectivity of bone
scalpel for bony tissues has been confirmed during harvesting of the
osteocutaneous fibular flap for reconstruction of the mandible and oral mucosa
after demolition by oncology surgeons. It has been possible to cut the fibula,
a bone of important diameter, twice, proximally and distally, with no risk
of lesion of damaging the vascular pedicle. Sculpturing fibula with multiple
osteotomies into a new hemi-mandible, or a double-barrel fibula, are
particularly good indications for the use of Genera® Ultrasonic, since the bone can be cut precisely for
effective and stable bone fixation with reconstructive plate or mini plates
while preserving the integrity of peroneal vessels which, together with
a perfect microvascular anastomosis, is critical for survival of the flap.
The mechanism of
irrigation in the phase of osteotomy during which the liquid is vaporized
combines efficient washing and cooling of bone surfaces, thus reducing the risk
of overheating the bone and soft tissues and subsequent complications, namely
necrosis, vascular thrombosis and non-union. Clinically we have not observed
any of these features in tissues adjacent to the osteotomy site where heat
could have been dissipated (7, 12).
possibility of choosing the appropriate bone scalpel tip from a variety of
different length, diameter and form permits differentiated use of this
instrument with bony tissues.
with the piezoelectric bone scalpel is also possible with larger
diameter/thickness of bones. At the same time, adjacent soft tissues are not in
danger from cutting or thermal damage, reducing the risk of damaging
neurovascular structures – which is of primary importance in hand and
reconstructive microsurgery. These features contribute to the safety and easy
execution of the procedure.
The resulting bony cut
is precise and permits immediate and safe bone fixation.
Osteotomy of bones of
>1cm thickness takes 20–30% longer than when using a conventional
oscillating saw, though the increased safety of the procedure more than
compensates for this.
of Plastic Surgery, Cattinara Hospital
di Fiume N°447
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