Revisiting Pediatric Cranioplasty: Success And Failures In Two Decades
Pravin K. Patel, MD1, Bruce S. Bauer, MD2.
1University of Illinois, Chicago, IL, USA, 2University of Chicago, Chicago, IL, USA.
Background: Alloplastic bone substitute to solve structural contour defects in the pediatric skull remains an interest as an alternative to autogenous reconstruction. We review our decade experience with autogenous cranioplasty in the context of complications from alloplastic cranioplasty.
Method: We reviewed 193 (149 autogenous and 44 alloplastic) pediatric patients who underwent cranioplasty from 1994 to 2004 with a Minimum follow-up was 10 years. We catalogued indication, surface area of the defect, the technique of each reconstruction, and the accompanying outcome. To assess patterns of failure, a 3-dimensional finite-element-analysis (FEA) was used to simulate traumatic loading at the implant/bone interface.
Results: Autogenous donor sites included split-calvarium and rib. Alloplastic materials included methy-methalcrylate, hydroxyapatite, porous-polyethylene, calcium-phosphate. 36 of 44 patients required removal of the alloplastic implant for fracture, infection, seroma formation and skin breakdown. All patients were reconstructed with autogenous bone without subsequent complications. The 3-dimensional FEA model predicted zone of high strain occurred at the interface bone/alloplastic that propagated throughout the implant.
Conclusions: The unproven, long term record of alloplastic materials in pediatric cranioplasty with low complication rate of autogenous cranioplasty compel us to recommend autogenous bone grafts for primary and revision cranioplasty in children. Alloplastic material should be limited to resurfacing small defects and contour irregularities, after skeletal maturity. The growth and remodeling of the pediatric cranium and physical activity in children contribute to implant failures. Biomechanical analysis demonstrated that traumatic loads at implant/bone interface lead to failure of the implant because of discontinuity of the load transfer.
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