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Sunderland IR, Edwards G, Mainprize J, Antonyshyn O. A technique for intraoperative creation of patient-specific titanium mesh implants. Plast Surg (Oakv) 2015. [DOI: 10.1177/229255031502300204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Prefabricated, patient-specific alloplastic implants for cranioplasty reduce surgical complexity, decrease operative times, minimize exposure and risk of contamination, and have resulted in improved aesthetic results. However, in creating a prefabricated custom implant using a patient's computed tomography data, a stable, unalterable defect must be clearly defined before surgery. In the event that an intraoperative modification of an exiting skull defect is required, or in cases of tumour resection in which the size of the skull defect is unknown preoperatively, these prefabricated implants cannot be used. The ideal method for alloplastic cranioplasty would enable cost-effective creation of a patient-specific implant with the capacity for intraoperative modification. The present article describes a novel technique of cranioplasty that uses a patient's computed tomography data to create a custom forming tool (ie, mold), enabling intraoperative creation of a patient-specific titanium mesh implant. The utility of these implants in creating a custom reconstructive solution in cases in which the size of the skull defect is unknown preoperatively will be demonstrated using two case presentations.
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Affiliation(s)
- Ian Rp Sunderland
- Division of Plastic and Reconstructive Surgery, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Glenn Edwards
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
| | - James Mainprize
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
| | - Oleh Antonyshyn
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
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Kim JS, Cheong JH, Ryu JI, Kim JM, Kim CH. Bone Flap Resorption Following Cranioplasty after Decompressive Craniectomy: Preliminary Report. Korean J Neurotrauma 2015; 11:1-5. [PMID: 27169057 PMCID: PMC4847489 DOI: 10.13004/kjnt.2015.11.1.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 11/23/2014] [Accepted: 12/08/2014] [Indexed: 11/22/2022] Open
Abstract
Objective Resorption of autologous bone flap grafts is a known long-term complication of cranioplasty following decompressive craniectomy (DC). We analyzed our data to identify risk factors for bone flap resorption (BFR) following cranioplasty. Methods A total of 162 patients who underwent cranioplasty following DC due to life-threatening elevated intracranial pressure between October 2003 and December 2012, were included in our investigation. Follow-up exceeded one year. Results BFR occurred as a long-term complication in 9 of the 162 patients (5.6%). The affected patients consisted of individuals who had undergone DC for traumatic brain injury (TBI; n=4), for subarachnoid hemorrhage (SAH; n=3), for cerebral infarction (n=1), and intracerebral hemorrhage (n=1). Logistic regression analysis identified no significant risk factors for BFR. Conclusion TBI and SAH as initial diagnoses are more often associated with BFR than other diagnoses. This finding may influence future surgical decision making, especially in patients with possible risk factors for BFR. A prospective study with a large number of patients is needed to identify potential predictors of BFR such as bone flap sterilization and preservation.
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Affiliation(s)
- Ji Sang Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
| | - Jin Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
| | - Je Il Ryu
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
| | - Jae Min Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
| | - Choong Hyun Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
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103
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Cho HR, Roh TS, Shim KW, Kim YO, Lew DH, Yun IS. Skull Reconstruction with Custom Made Three-Dimensional Titanium Implant. Arch Craniofac Surg 2015; 16:11-16. [PMID: 28913212 PMCID: PMC5556788 DOI: 10.7181/acfs.2015.16.1.11] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 08/09/2014] [Accepted: 10/23/2014] [Indexed: 12/05/2022] Open
Abstract
Background Source material used to fill calvarial defects includes autologous bones and synthetic alternatives. While autologous bone is preferable to synthetic material, autologous reconstruction is not always feasible due to defect size, unacceptable donor-site morbidity, and other issues. Today, advanced three-dimensional (3D) printing techniques allow for fabrication of titanium implants customized to the exact need of individual patients with calvarial defects. In this report, we present three cases of calvarial reconstructions using 3D-printed porous titanium implants. Methods From 2013 through 2014, three calvarial defects were repaired using custommade 3D porous titanium implants. The defects were due either to traumatic subdural hematoma or to meningioma and were located in parieto-occipital, fronto-temporo-parietal, and parieto-temporal areas. The implants were prepared using individual 3D computed tomography (CT) data, Mimics software, and an electron beam melting machine. For each patient, several designs of the implant were evaluated against 3D-printed skull models. All three cases had a custom-made 3D porous titanium implant laid on the defect and rigid fixation was done with 8 mm screws. Results The custom-made 3D implants fit each patient's skull defect precisely without any dead space. The operative site healed without any specific complications. Postoperative CTs revealed the implants to be in correct position. Conclusion An autologous graft is not a feasible option in the reconstruction of large calvarial defects. Ideally, synthetic materials for calvarial reconstruction should be easily applicable, durable, and strong. In these aspects, a 3D titanium implant can be an optimal source material in calvarial reconstruction.
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Affiliation(s)
- Hyung Rok Cho
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Suk Roh
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu Won Shim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Oock Kim
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Hyun Lew
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - In Sik Yun
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
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104
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Ohla V, Bayoumi AB, Hefty M, Anderson M, Kasper EM. Complex single step skull reconstruction in Gorham's disease - a technical report and review of the literature. BMC Surg 2015; 15:24. [PMID: 25880917 PMCID: PMC4365769 DOI: 10.1186/s12893-015-0014-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 02/24/2015] [Indexed: 11/13/2022] Open
Abstract
Background Gorham’s disease is a rare osteolytic disorder characterized by progressive resorption of bone and replacement of osseous matrix by a proliferative non-neoplastic vascular or lymphatic tissue. A standardized treatment protocol has not yet been defined due to the unpredictable natural history of the disease and variable clinical presentations. No single treatment has proven to be superior in arresting the course of the disease. Trials have included surgery, radiation and medical therapies using drugs such as calcium salts, vitamin D supplements and hormones. We report on our advantageous experience in the management of this osteolyic disorder in a case when it affected only the skull vault. A brief review of pertinent literature about Gorham’s disease with skull involvement is provided. Case presentation A 25-year-old Caucasian male presented with a skull depression over the left fronto-temporal region. He noticed progressive enlargement of the skull defect associated with local pain and mild headache. Physical examination revealed a tender palpable depression of the fronto-temporal convexity. Conventional X-ray of the skull showed widespread loss of bone substance. Subsequent CT scans showed features of patchy erosions indicative of an underlying osteolysis. MRI also revealed marginal enhancement at the site of the defect. The patient was in need of a pathological diagnosis as well as complex reconstruction of the afflicted area. A density graded CT scan was done to determine the variable degrees of osteolysis and a custom made allograft was designed for cranioplasty preoperatively to allow for a single step excisional craniectomy with synchronous skull repair. Gorham’s disease was diagnosed based on histopathological examination. No neurological deficit or wound complications were reported postoperatively. Over a two-year follow up period, the patient had no evidence of local recurrence or other systemic involvement. Conclusions A single step excisional craniectomy and cranioplasty can be an effective treatment for patients with Gorham’s disease affecting the skull vault only. Preoperative planning by a density graded CT aids to design a synthetic bone flap and is beneficial in skull reconstruction. Systemic involvement is variable in this patient’s population.
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Affiliation(s)
- Victoria Ohla
- Department of Neurochirurgie, Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Germany.,Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, LMOB Suite 3B, Boston, MA, 02215, USA
| | - Ahmed B Bayoumi
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, LMOB Suite 3B, Boston, MA, 02215, USA
| | - Markus Hefty
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Matthew Anderson
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ekkehard M Kasper
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, LMOB Suite 3B, Boston, MA, 02215, USA.
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105
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Stieglitz LH, Fung C, Murek M, Fichtner J, Raabe A, Beck J. What happens to the bone flap? Long-term outcome after reimplantation of cryoconserved bone flaps in a consecutive series of 92 patients. Acta Neurochir (Wien) 2015; 157:275-80. [PMID: 25534126 DOI: 10.1007/s00701-014-2310-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 12/05/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reimplantation of cryoconserved autologous bone flaps is a standard procedure after decompressive craniotomies. Aseptic necrosis and resorption are the most frequent complications of this procedure. At present there is no consensus regarding the definition of the relevant extent and indication for surgical revision. The objective of this retrospective analysis was to identify the incidence of bone flap resorption and the optimal duration of follow-up. METHODS Between February 2009 and March 2012, 100 cryoconserved autologous bone flaps were reimplanted at the Department of Neurosurgery, Inselspital Bern. Three patients were not available for follow-up, and five patients died before follow-up. All patients underwent follow-up at 6 weeks and a second follow-up more than 12 months postoperatively. A clinical and CT-based score was developed for judgment of relevance and decision making for surgical revision. RESULTS Mean follow-up period was 21.6 months postoperatively (range: 12 to 47 months); 48.9 % (45/92) of patients showed no signs of bone flap resorption, 20.7 % (19/92) showed minor resorption with no need for surgical revision, and 30.4 % (28/92) showed major resorption (in 4 % of these the bone flap was unstable or collapsed). CONCLUSIONS Aseptic necrosis and resorption of reimplanted autologous bone flaps occurred more frequently in our series of patients than in most reports in the literature. Most cases were identified between 6 and 12 months postoperatively. Clinical observation or CT scans of patients with autologous bone flaps are recommended for at least 12 months. Patient-specific implants may be preferable to autologous bone flaps.
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106
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Zanotti B, Zingaretti N, Almesberger D, Verlicchi A, Stefini R, Ragonese M, Guarneri GF, Parodi PC. Enhancing dermal and bone regeneration in calvarial defect surgery. Indian J Plast Surg 2015; 47:325-32. [PMID: 25593416 PMCID: PMC4292108 DOI: 10.4103/0970-0358.146581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION To optimize the functional and esthetic result of cranioplasty, it is necessary to choose appropriate materials and take steps to preserve and support tissue vitality. As far as materials are concerned, custom-made porous hydroxyapatite implants are biomimetic, and therefore, provide good biological interaction and biointegration. However, before it is fully integrated, this material has relatively low mechanical resistance. Therefore, to reduce the risk of postoperative implant fracture, it would be desirable to accelerate regeneration of the tissues around and within the graft. OBJECTIVES The objective was to determine whether integrating growth-factor-rich platelet gel or supportive dermal matrix into hydroxyapatite implant cranioplasty can accelerate bone remodeling and promote soft tissue regeneration, respectively. MATERIALS AND METHODS The investigation was performed on cranioplasty patients fitted with hydroxyapatite cranial implants between 2004 and 2010. In 7 patients, platelet gel was applied to the bone/prosthesis interface during surgery, and in a further 5 patients, characterized by thin, hypotrophic skin coverage of the cranial lacuna, a sheet of dermal matrix was applied between the prosthesis and the overlying soft tissue. In several of the former groups, platelet gel mixed with hydroxyapatite granules was used to fill small gaps between the skull and the implant. To confirm osteointegration, cranial computed tomography (CT) scans were taken at 3-6 month intervals for 1-year, and magnetic resonance imaging (MRI) was used to confirm dermal integrity. RESULTS Clinical examination performed a few weeks after surgery revealed good dermal regeneration, with thicker, healthier skin, apparently with a better blood supply, which was confirmed by MRI at 3-6 months. Furthermore, at 3-6 months, CT showed good biomimetism of the porous hydroxyapatite scaffold. Locations at which platelet gel and hydroxyapatite granules were used to fill gaps between the implant and skull appeared to show more rapid integration of the implant than untreated areas. Results were stable at 1-year and remain so to date in cases where follow-up is still ongoing. CONCLUSIONS Bone remodeling time could be reduced by platelet gel application during cranioplasty with porous hydroxyapatite implants. Likewise, layering dermal matrix over such implants appears to promote dermal tissue regeneration and the oshtemo mimetic process. Both of these strategies may, therefore, reduce the likelihood of postsurgical fracture by promoting mechanical resistance.
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Affiliation(s)
- Bruno Zanotti
- Neurosurgery Clinic, University of Udine, Reggio Emilia, Italy
| | - Nicola Zingaretti
- Department of Plastic and Reconstructive Surgery, University of Udine, Reggio Emilia, Italy
| | - Daria Almesberger
- Department of Plastic and Reconstructive Surgery, University of Udine, Reggio Emilia, Italy
| | - Angela Verlicchi
- Neurology Unit, Free University of Neuroscience "Anemos", Reggio Emilia, Italy
| | | | - Mauro Ragonese
- Urologic Clinic, Catholic University Medical School of Rome, Italy
| | - Gianni Franco Guarneri
- Department of Plastic and Reconstructive Surgery, University of Udine, Reggio Emilia, Italy
| | - Pier Camillo Parodi
- Department of Plastic and Reconstructive Surgery, University of Udine, Reggio Emilia, Italy
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107
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Lam S, Kuether J, Fong A, Reid R. Cranioplasty for large-sized calvarial defects in the pediatric population: a review. Craniomaxillofac Trauma Reconstr 2014; 8:159-70. [PMID: 26000090 DOI: 10.1055/s-0034-1395880] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/20/2014] [Indexed: 01/10/2023] Open
Abstract
Large-sized calvarial defects in pediatric patients pose a reconstructive challenge because of children's unique physiology, developing anatomy, and dynamic growth. We review the current literature and outcomes with autologous and alloplastic cranioplasty in the pediatric population.
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Affiliation(s)
- Sandi Lam
- Department of Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Justin Kuether
- Division of Plastic Surgery, Department of Surgery, University of Chicago, Chicago, Illinois
| | - Abigail Fong
- Division of Plastic Surgery, University of Chicago, Chicago, Illinois
| | - Russell Reid
- Division of Plastic Surgery, Department of Surgery, University of Chicago, Chicago, Illinois
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108
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Ko AL, Nerva JD, Chang JJ, Chesnut RM. Traumatic Fracture of a Polymethyl Methacrylate Patient-Specific Cranioplasty Implant. World Neurosurg 2014; 82:536.e11-3. [DOI: 10.1016/j.wneu.2013.09.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 09/13/2013] [Indexed: 11/28/2022]
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109
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Servadei F, Iaccarino C. The therapeutic cranioplasty still needs an ideal material and surgical timing. World Neurosurg 2014; 83:133-5. [PMID: 25153284 DOI: 10.1016/j.wneu.2014.08.031] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 08/15/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Franco Servadei
- Neurosurgery-Neurotraumatology Unit and Department of Emergency Medicine, University Hospital of Parma, Parma, Italy; IRCCS-ASMN Hospital Reggio Emilia, Italy.
| | - Corrado Iaccarino
- Neurosurgery-Neurotraumatology Unit and Department of Emergency Medicine, University Hospital of Parma, Parma, Italy; IRCCS-ASMN Hospital Reggio Emilia, Italy
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110
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Sundseth J, Sundseth A, Berg-Johnsen J, Sorteberg W, Lindegaard KF. Cranioplasty with autologous cryopreserved bone after decompressive craniectomy: complications and risk factors for developing surgical site infection. Acta Neurochir (Wien) 2014; 156:805-11; discussion 811. [PMID: 24493001 PMCID: PMC3956933 DOI: 10.1007/s00701-013-1992-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 12/30/2013] [Indexed: 12/05/2022]
Abstract
Background Renewed interest has developed in decompressive craniectomy, and improved survival is shown when this treatment is used after malignant middle cerebral artery infarction. The aim of this study was to investigate the frequency and possible risk factors for developing surgical site infection (SSI) after delayed cranioplasty using autologous, cryopreserved bone. Methods This retrospective study included 74 consecutive patients treated with decompressive craniectomy during the time period May 1998 to October 2010 for various non-traumatic conditions causing increased intracranial pressure due to brain swelling. Complications were registered and patient data was analyzed in a search for predictive factors. Results Fifty out of the 74 patients (67.6 %) survived and underwent delayed cranioplasty. Of these, 47 were eligible for analysis. Six patients (12.8 %) developed SSI following the replacement of autologous cryopreserved bone, whereas bone resorption occurred in two patients (4.3 %). No factors predicted a statistically significant rate of SSI, however, prolonged procedural time and cardiovascular comorbidity tended to increase the risk of SSI. Conclusions SSI and bone flap resorption are the most frequent complications associated with the reimplantation of autologous cryopreserved bone after decompressive craniectomy. Prolonged procedural time and cardiovascular comorbidity tend to increase the risk of SSI.
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Affiliation(s)
- J Sundseth
- Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Postboks 4950, Nydalen, 0424, Oslo, Norway,
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111
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Piedra MP, Nemecek AN, Ragel BT. Timing of cranioplasty after decompressive craniectomy for trauma. Surg Neurol Int 2014; 5:25. [PMID: 24778913 PMCID: PMC3994696 DOI: 10.4103/2152-7806.127762] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 01/31/2014] [Indexed: 11/30/2022] Open
Abstract
Background: The optimal timing of cranioplasty after decompressive craniectomy for trauma is unknown. The aim of this study was to determine if early cranioplasty after decompressive craniectomy for trauma reduces complications. Methods: Consecutive cases of patients who underwent autologous cranioplasty after decompressive craniectomy for trauma at a single Level I Trauma Center were studied in a retrospective 10 year data review. Associations of categorical variables were compared using Chi-square test or Fisher's exact test. Results: A total of 157 patients were divided into early (<12 weeks; 78 patients) and late (≥12 weeks; 79 patients) cranioplasty cohorts. Baseline characteristics were similar between the two cohorts. Cranioplasty operative time was significantly shorter in the early (102 minutes) than the late (125 minutes) cranioplasty cohort (P = 0.0482). Overall complication rate in both cohorts was 35%. Infection rates were lower in the early (7.7%) than the late (14%) cranioplasty cohort as was bone graft resorption (15% early, 19% late), hydrocephalus rate (7.7% early, 1.3% late), and postoperative hematoma incidence (3.9% early, 1.3% late). However, these differences were not statistically significant. Patients <18 years of age were at higher risk of bone graft resorption than patients ≥18 years of age (OR 3.32, 95% CI 1.25-8.81; P = 0.0162). Conclusions: After decompressive craniectomy for trauma, early (<12 weeks) cranioplasty does not alter the incidence of complication rates. In patients <18 years of age, early (<12 weeks) cranioplasty increases the risk of bone resorption. Delaying cranioplasty (≥12 weeks) results in longer operative times and may increase costs.
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Affiliation(s)
- Mark P Piedra
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Andrew N Nemecek
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Brian T Ragel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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112
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Stefini R, Esposito G, Zanotti B, Iaccarino C, Fontanella MM, Servadei F. Use of "custom made" porous hydroxyapatite implants for cranioplasty: postoperative analysis of complications in 1549 patients. Surg Neurol Int 2013; 4:12. [PMID: 23493459 PMCID: PMC3589836 DOI: 10.4103/2152-7806.106290] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Accepted: 10/17/2012] [Indexed: 11/04/2022] Open
Abstract
Background: Cranioplasty is a surgical intervention aimed at reestablishing the integrity of skull defects, and should be considered the conclusion of a surgical act that began with bone flap removal. Autologous bone is still considered the treatment of choice for cranioplasty. An alternative choice is bioceramic porous hydroxyapatite (HA) as it is one of the materials that meets and comes closest to the biomimetic characteristics of bone. Methods: The authors analyzed the clinical charts, compiled by the neurosurgeon, of all patients treated with custom-made porous HA devices (Custom Bone Service Fin-Ceramica, Faenza) from which epidemiological and pathological data as well as material-related complications were extrapolated. Results: From November 1997 to December 2010, 1549 patients underwent cranioplasty with the implantation of 1608 custom-made porous HA devices. HA was used in 53.8% of patients for decompressive craniectomy after trauma or intracranial hemorrhage, while the remaining cases were for treated for comminuted fracture, cutaneous or osseous resection, cranial malformation, autologous bone reabsorption or infection or rejection of previously implanted material. The incidence of adverse events in patients treated for cranioplasty, as first line treatment was 4.78% (56 events/1171 patients), and 5.02%, (19 events/378 patients) at second line. Conclusion: This study demonstrates that HA is a safe and effective material, is well tolerated in both adult and pediatric patients, and meets the requirements necessary to repair craniolacunia.
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Affiliation(s)
- Roberto Stefini
- Department of Neurosurgery, University of Brescia, Spedali Civili, Brescia, Italy
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113
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de Monaco BA, Fonoff ET, Teixeira MJ. Early resorption of an artificial bone graft made of calcium phosphate for cranioplasty: case report. Neuropsychiatr Dis Treat 2013; 9:1801-2. [PMID: 24265553 PMCID: PMC3833462 DOI: 10.2147/ndt.s43806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The treatment of uncomplicated osteoma consists of an en bloc resection, or curettage, of the tumor, followed by cranioplasty. Here, we present a case report of a patient treated for a parietal osteoma, followed by a calcium phosphate cranioplasty, with early resorption after 3 months, which was presented by a sinking flap above the resection area. This case suggests that synthetic cranioplasty should be preferred, even in small skull-gap areas.
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Affiliation(s)
- Bernardo Assumpção de Monaco
- Division of Functional Neurosurgery, Department of Neurology, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil
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114
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Wheeler J, Phillips J. Pediatric facial fractures and potential long-term growth disturbances. Craniomaxillofac Trauma Reconstr 2012; 4:43-52. [PMID: 22379506 DOI: 10.1055/s-0031-1272901] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Fractures of the pediatric craniofacial skeleton can be challenging to manage. The initial injury and subsequent treatment can cause long-term growth disturbances yielding problematic secondary deformities. This review considers the normal growth of the craniofacial skeleton and typical facial fracture presentations in children and discusses the potential long-term sequelae from these injuries and their management.
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Affiliation(s)
- Jonathan Wheeler
- The Hospital for Sick Children, Centre for Craniofacial Care and Research, Toronto, Ontario
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115
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Goodrich JT, Sandler AL, Tepper O. A review of reconstructive materials for use in craniofacial surgery bone fixation materials, bone substitutes, and distractors. Childs Nerv Syst 2012; 28:1577-88. [PMID: 22872276 DOI: 10.1007/s00381-012-1776-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Accepted: 04/13/2012] [Indexed: 11/29/2022]
Abstract
Over the last 40 years, craniofacial surgery, in general, and surgery for craniosynostosis, in particular, has witnessed the introduction of a number of new materials for use in operations involving the cranial vault. Some of these materials have proven quite useful over time, while others have failed to meet their stated objectives. In this review, the more popular implant materials are analyzed, and their relative merits and drawbacks are discussed. Craniofacial surgery in the pediatric population has its own unique limitations, quite different from the adult population and those issues are reviewed as well.
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Affiliation(s)
- James Tait Goodrich
- Division of Pediatric Neurosurgery, Leo Davidoff Department of Neurological Surgery, Children's Hospital at Montefiore, Bronx, New York, USA.
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116
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Frassanito P, Massimi L, Caldarelli M, Tamburrini G, Di Rocco C. Complications of delayed cranial repair after decompressive craniectomy in children less than 1 year old. Acta Neurochir (Wien) 2012; 154:927-33. [PMID: 22198327 DOI: 10.1007/s00701-011-1253-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 12/08/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Decompressive craniectomy is an effective treatment option in case of refractory intracranial hypertension after severe head injury. The incidence of complications following cranial repair after decompressive craniectomy for traumatic brain injury is not negligible, particularly in infants and young toddlers. However, only a few dedicated papers can be found in the literature. METHOD We describe the complications observed in two boys and one girl under 1 year of age that were treated in the last decade by hemicranial decompressive craniotomy and enlarging hemispheric duraplasty, and subsequent cranial repair by means of autologous bone-flap replacement. FINDINGS Despite good clinical and neurological outcome, the postoperative clinical course was complicated in all cases by early or late evidence of subdural fluid collections associated to the occurrence of hydrocephalus and causing recurrent dislocation and progressive resorption of the autologous bone flap. CONCLUSIONS Infants less than 1 year old, undergoing decompressive craniectomy after traumatic brain injury, experience a high rate of complications following subsequent cranial repair. Subdural collections and resorption of the autologous bone flap are to be considered as extremely common complications.
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Affiliation(s)
- Paolo Frassanito
- Pediatric Neurosurgery, Policlinic A. Gemelli, Catholic Medical School, Rome, Italy.
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Markiewicz MR, Bell RB. The Use of 3D Imaging Tools in Facial Plastic Surgery. Facial Plast Surg Clin North Am 2011; 19:655-82, ix. [DOI: 10.1016/j.fsc.2011.07.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Reconstruction of the scalp with a calvarial defect. Surg Today 2011; 41:189-96. [PMID: 21264753 DOI: 10.1007/s00595-009-4262-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Accepted: 07/24/2009] [Indexed: 10/18/2022]
Abstract
PURPOSE To review our clinical cases and devise a protocol for selecting the best operative methods to reconstruct the scalp with a calvarial defect. METHODS We reviewed the original disease, the areas and depths of the scalp and calvarial defects, the methods of reconstruction, and complications in 20 patients. RESULTS The defect was caused by secondary cranial infection following decompressive craniectomy for intracranial hemorrhage (ICH) in 11 patients; extensive removal of the scalp and calvaria for resection of a malignant tumor in 6 patients; and by secondary cranial infection following removal of a malignant tumor in 3 patients. Cranial infection was frequently associated with abscess formation around the fixation screws and plates, suggesting that artificial materials induced the infection. We reconstructed the defect using free flaps in 15 patients and using local flaps in 5 patients. CONCLUSIONS When restoring the calvaria in the primary operation, the use of metal screws and plates should be minimized to prevent cranial infection and subsequent scalp and calvaria defects. Local flaps are appropriate for reconstructing relatively small defects (<20 cm(2)), whereas free flaps are better for reconstructing relatively large defects (>25 cm(2)).
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Bhaskar IP, Zaw NN, Zheng M, Lee GYF. Bone flap storage following craniectomy: a survey of practices in major Australian Neurosurgical centres. ANZ J Surg 2010; 81:137-41. [DOI: 10.1111/j.1445-2197.2010.05584.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Decompressive craniectomy is widely used to treat intracranial hypertension following traumatic brain injury (TBI). Two randomized trials are currently underway to further evaluate the effectiveness of decompressive craniectomy for TBI. Complications of this procedure have major ramifications on the risk-benefit balance in decision-making during evaluation of potential surgical candidates. To further evaluate the complications of decompressive craniectomy, a review of the literature was performed following a detailed search of PubMed between 1980 and 2009. The author restricted her study to literature pertaining to decompressive craniectomy for patients with TBI. An understanding of the pathophysiological events that accompany removal of a large piece of skull bone provides a foundation for understanding many of the complications associated with decompressive craniectomy. The author determined that decompressive craniectomy is not a simple, straightforward operation without adverse effects. Rather, numerous complications may arise, and they do so in a sequential fashion at specific time points following surgical decompression. Expansion of contusions, new subdural and epidural hematomas contralateral to the decompressed hemisphere, and external cerebral herniation typify the early perioperative complications of decompressive craniectomy for TBI. Within the 1st week following decompression, CSF circulation derangements manifest commonly as subdural hygromas. Paradoxical herniation following lumbar puncture in the setting of a large skull defect is a rare, potentially fatal complication that can be prevented and treated if recognized early. During the later phases of recovery, patients may develop a new cognitive, neurological, or psychological deficit termed syndrome of the trephined. In the longer term, a persistent vegetative state is the most devastating of outcomes of decompressive craniectomy. The risk of complications following decompressive craniectomy is weighed against the life-threatening circumstances under which this surgery is performed. Ongoing trials will define whether this balance supports surgical decompression as a first-line treatment for TBI.
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Abstract
Decompressive Craniectomy (DC) is used to treat elevated intracranial pressure that is unresponsive to conventional treatment modalities. The underlying cause of intracranial hypertension may vary and consequently there is a broad range of literature on the uses of this procedure. Traumatic brain injury (TBI), middle cerebral artery (MCA) infarction, and aneurysmal subarachnoid hemorrhage (SAH) are three conditions for which DC has been predominantly used in the past. Despite an increasing number of reports supportive of DC, the controversy over the suitability of the procedure and criteria for patient selection remains unresolved. Although the majority of published studies is retrospective, the recent publication of several randomized prospective studies prompts a reevaluation of the utility of DC. We review the literature concerning the use of DC in TBI, MCA infarction, and SAH and address the evidence regarding common questions pertaining to the timing of and laterality of the procedure. We conclude that at the time of this review, there still remains insufficient data to support the routine use of DC in TBI, stroke or SAH. There is evidence that early and aggressive use of DC in good-grade patients may improve outcome, but the notion that DC is indicated in these patients is contentious. At this point, the indication for DC should be individualized and its potential implications on long-term outcomes should be comprehensively discussed with the caregivers.
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Faleiro RM, Faleiro LCM, Caetano E, Gomide I, Pita C, Coelho G, Brás E, Carvalho B, Gusmão SNS. Decompressive craniotomy: prognostic factors and complications in 89 patients. ARQUIVOS DE NEURO-PSIQUIATRIA 2008; 66:369-73. [DOI: 10.1590/s0004-282x2008000300017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2007] [Accepted: 04/23/2008] [Indexed: 11/22/2022]
Abstract
Decompressive craniotomy (DC) is applied to treat post-traumatic intracranial hypertension (ICH). The purpose of this study is to identify prognostic factors and complications of unilateral DC. Eighty-nine patients submited to unilateral DC were retrospectively analyzed over a period of 30 months. Qui square independent test and Fisher test were used to identify prognostic factors. The majority of patients were male (87%). Traffic accidents had occurred in 47% of the cases. 64% of the patients had suffered severe head injury, while pupillary abnormalities were already present in 34%. Brain swelling plus acute subdural hematoma were the most common tomographic findings (64%). Complications occurred in 34.8% of the patients: subdural effusions in 10 (11.2%), hydrocephalus in 7 (7.9%) and infection in 14 (15.7%). The admittance Glasgow coma scale was a statistically significant predictor of outcome ( p=0.0309).
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Faleiro RM, Faleiro LCM, Oliveira MM, Silva T, Caetano EC, Gomide I, Pita CC, Lopes G, Gusmão S. [Decompressive craniectomy in children and adolescents with head injury: analysis of seven cases]. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 64:839-44. [PMID: 17057894 DOI: 10.1590/s0004-282x2006000500024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Accepted: 06/23/2006] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Decompressive craniectomy (DC) is a surgical technique used to treat patients with elevated intracranial pressure often found in head injury. Its indication remains a controversial issue in the pediatric population. OBJECTIVE To report seven cases managed with this technique. METHOD Retrospective study of seven patients, aged from 2 to 17 years, treated with unilateral DC due to increased intracranial pressure (ICP) as a consequence of head injury. All patients had ICP monitored post operatively and the DC classified as ultra-early (<6h), early (6-12h) or late (>24h) according to the time of its application. The minimum follow-up was six months. RESULTS Patients were evaluated with CT scans and clinical exams, and graded according the Glasgow Outcome Scale (GOS). Three patients deceased (GOS1), one was in vegetative state (GOS2), two recovered but still requiring nursing care (GOS3 and 4), and one had a full recovery (GOS5) at hospital discharge. After six months the GOS2 and a GOS3 patients achieved full recovery (GOS5). Subdural collection (2), hydrocephalus (1) and superficial infection (1) occurred as complication. Two patients had autologous cranioplasty and the other two heterologous cranioplasty. CONCLUSION Decompressive craniectomy remains a feasible treatment method to lower the ICP, but is not safe from complications. A multicentric study should be done for appropriate protocol treatment of pediatric patients.
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Affiliation(s)
- Rodrigo Moreira Faleiro
- Hospital Pronto Socorro João XXIII, Rua Timbiras 3642/801, 30140-062 Belo Horizonte MG, Brazil.
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