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Cranioplasty for repair of a large bone defect in a growing skull fracture in children
ARTICLE IN PRESS Journal of Cranio-Maxillofacial Surgery (2007) 35, 185–188 r 2007 European Association for Cranio-Maxillofacial Surgery doi:10.1016/j.jcms.2007.04.002, available online at http://www.sciencedirect.com
Cranioplasty for repair of a large bone defect in a growing skull fracture in children Jean-Rodolphe VIGNES1, N u Owase JEELANI2, Michel DAUTHERIBES1, Franc¸ois SAN-GALLI1, Dominique LIGUORO1 1
Department of Neurosurgery A (Head: Prof. D. Liguo¯ro), CHU de Bordeaux, University of Bordeaux 2, Bordeaux, France; 2Department of Neurosurgery (Head: Dr. N. Kitchen), NHNN, University College of London, London, UK
SUMMARY. Introduction: In infants, calvarial defects are generally repaired with autologous grafts. However, with large defects, these techniques can be associated with complications such as bone graft resorption, loss of blood, or local infection. Alternative materials are available for cranioplasty including metals or acrylic. Case report: We report the case of a 3.2 kg boy who had a traumatic vaginal delivery and developed a growing skull fracture resulting in a large cranial defect (50 cm2). We describe a specific technique of cranioplasty by interposing a titanium plate between the duroplasty and bone elements, without fixation, with autologous bone fragments deposited over the mesh. Long-term follow-up was satisfactory. Conclusion: For large skull defects in infants, the technique described affords protection to the intracranial components, induces osteogenesis in a growing cranial skeleton, and provides satisfactory aesthetic results. r 2007 European Association for Cranio-Maxillofacial Surgery
Keywords: skull fracture, cranioplasty, craniocerebral trauma, vacuum extraction, titanium
forceps were necessary. Initial clinical examination demonstrated a cephalhaematoma in the right frontoparietal region. Neurological status was satisfactory with an APGAR score of 10 at 5 min after delivery. A CT scan demonstrated a small, linear skull fracture with moderate brain contusion. Development was satisfactory, but the head circumference was increased by the persistent cephalhaematoma. After 2 months, a subcutaneous cephalic swelling was observed (Fig. 1A), showing a transmitted impulse with the child’s cough and cry. X-ray (Fig. IB) and CT scan (Fig. 1C) of the skull showed a large meningocoele associated with enlargement of the skull fracture. The diagnosis of a growing skull fracture was established and surgical treatment considered. Skin incision was fashioned around the meningocoele. The procedure consisted of dividing the reactive gliosis followed by a duroplasty. Dural exposure required marginal bone resection around the perimeter of the bone defect, which was estimated at 50 cm2. Dura repair was performed with an autogenous flap of pericranium. In order to repair the skull, we decided to interpose a 0.4 mm thickness titanium plate (2ME Biomesh, Codman, France; Fig. 2A) between the dura and the skull (Fig. 2B). On the top of this plate, we spread autologous bone fragments (taken during dural by exposure) to induce ossification (Fig. 2C). At the end of the procedure, skin resection was necessary. The postoperative outcome was excellent and the patient was discharged
INTRODUCTION Growing skull fractures are a rare traumatic complications with a prevalence of about 1% of all infants fractures (Nairn Ur et al., 1994; Muhonen et al., 1995). Although early diagnosis and prompt surgical treatment are necessary to reduce complications (de Djientcheu et al., 2006), in practice, large defects are not exceptional. Reconstruction of such cranial defects is a challenge and surgery has to meet high functional and aesthetic demands specially in children (Springer et al., 2006). Although autogenous bone is preferred, in certain large defects, particularly in younger individuals, other allograft methods may be useful (Hockley et al., 1990). For cranioplasty, a number of materials is available, including acrylic (Chiarini et al., 2004) or acrylic mixed with hydroxyapatite (Rotaru et al., 2006) and metals. We describe a case of a growing skull fracture caused by birth trauma, with a large bone defect which necessitated an allogeneic cranioplasty. CASE REPORT A primiparous and primigravida young woman underwent a difficult delivery during vaginal birth of a 3.2 kg boy. Tarnier’s forceps and Wrigley’s No source of support. 185
ARTICLE IN PRESS 186 Journal of Cranio-Maxillofacial Surgery
Fig. 1 – Preoperative status. (A) Clinical examination showed a large skull tumefaction. (B) Radiograph with the bone fracture (arrows). (C) CT scan showed a growing skull fracture of the fronto-parietal bone.
Fig. 2 – (A) Titanium plate. (B) Meningocoele. (C) Interposition of a 0.4 mm titanium plate between dura and skull. (D) Autologous bone fragments deposited.
on day 7. At 2 years follow-up (Fig. 2), no complication was identified and the child remained seizure free. An MRI (magnetic resonance imaging) showed a small residual defect (Fig. 3B), but there was no bone resorption on CT scan (Fig. 3C).
DISCUSSION For cranioplasty, the patient’s own bone can provide significant immediate and long-term biological advances (and resource benefits) that come with using autologous tissues (Hayward, 1999). However the repair of large cranial defect can be difficult using this method (Durham et al., 2003). In a study of children and adolescents, after decompression craniectomy, autologous cranioplasty has a high rate (almost 50%)
of bone resorption (Grant et al., 2004). This resorption was correlated with the skull defect area and necessitated repeat surgery. Springer et al. (2006) have proposed a mechanism of bone genesis. During cerebral growth, the cranial cavity increases by centrifugal cranial expansion with bone resorption on the inside, and bone apposition on the outside. Centrifugal cranial expansion should remain undisturbed in infants after bone transplantation explaining uncontrolled bone resorption (Springer et al., 2006). It has also been demonstrated that autologous grafts may become infected, up to 10% (Josan et al., 2005) and this is correlated with the size of the defect (bilateral cranioplasty having a higher risk than unilateral ones). Moreover, large surgical fields tend to result in greater blood loss, particularly in infants. This loss has a direct correlation with increased
ARTICLE IN PRESS Cranioplasty for repair of a large bone defect in a growing skull fracture in children 187
Fig. 3 – Evaluation two years postoperatively. (A) Radiograph with the titanium mesh. (B) MRI with no active cystic lesion, no hydrocephalus. Mesh was placed over the dura mater (arrow). (C) CT scan showing the position of the titanium implant, over the dura mater (fine arrows). Bone fragments were placed over the mesh (large arrow). (D) Favourable aesthetic outcome.
surgical infection risk (Triulzi et al., 1992). Finally, a limited skin incision, which reduces surgical exposure, is preferable in children. Titanium is a non-ferromagnetic metal of low atomic number. It is the most biocompatible metal known and is widely used as an implant material (Malis, 1989). Titanium mesh cranioplasty appears to be a reasonable method for the reconstruction of significant calvarial defects (Ducic, 2006). The results are satisfactory with minimal morbidity and moderate complications (Malis, 1989; Blake et al., 1990; Josan et al., 2005). From an economic perspective, although the patient’s bone is cheaper (Hayward, 1999), some studies (Grant et al., 2004) have demonstrated that half of all large autogenous cranioplasties have bone resorption and require further operations. Postoperative images (including MRI) have excellent quality when titanium is used for cranioplasty (Chandler et al., 1994). This mesh can be moulded, cut, stretched or bent to fit any (bone) area and three-dimensionally, contoured. On the top of this mesh, we lay autologous chip cancellous, at the same depth as the skull, to promote osteogenesis. However, cranial defect repairs in children require several special considerations. The human calvarium reaches 50% of its adult size at birth, and the critical age is the 6–12 months old period when the most
active phase of brain growth occurs. Consequently, it is necessary to monitor patients, at least during this period. The paediatric skull is a dynamic structure that prohibits the use of rigid fixation (Cohen et al., 2004) especially in the temporal region (Kosaka et al., 2003). Numerous reports have noted the migration of materials, particularly screws breaching the dura and damaging brain tissue (Papay et al., 1995; Kosaka et al., 2003). For these reasons we decided to not fix the titanium mesh but to simply lay it under the defect according the cranial growth theory with bone resorption on the inside (Springer et al., 2006). We think this free moving mesh was adapting particularly well to the growth constraints of the skull. The twoyear follow-up of our case confirms the value of our treatment choice.
CONCLUSION In cases with large bone defects, allografts should be considered, even in infants. We demonstrate an original surgical technique utilizing a titanium allograft over the dura (without fixation) and autologous bone grafted on top of the mesh. Longterm results (functional and aesthetic) were good.
ARTICLE IN PRESS 188 Journal of Cranio-Maxillofacial Surgery
References Blake GB, MacFarlane MR, Hinton JW: Titanium in reconstructive surgery of the skull and face. Br J Plast Surg 43: 528–535, 1990 Chandler CL, Uttley D, Archer DJ, MacVicar D: Imaging after titanium cranioplasty. Br J Neurosurg 8: 409–414, 1994 Chiarini L, Figurelli S, Pollastri G, Torcia E, Ferrari F, Albanese M, Nocini PF: Cranioplasty using acrylic material: a new technical procedure. J Craniomaxillofac Surg 32: 5–9, 2004 Cohen AJ, Dickerman RD, Schneider SJ: New method of pediatric cranioplasty for skull defect utilizing polylactic acid absorbable plates and carbonated apatite bone cement. J Craniofac Surg 15: 469–472, 2004 de Djientcheu VP, Njamnshi AK, Ongolo-Zogo P, Kobela M, Rilliet B, Essomba A, Sosso MA: Growing skull fractures. Childs Nerv Syst 22: 721–725, 2006 Ducic Y: Titanium mesh and hydroxyapatite cement cranioplasty: a report of 20 cases. J Oral Maxillofac Surg 60: 272–276, 2006 Durham SR, McComb JG, Levy ML: Correction of large (425 cm2) cranial defects with ‘‘reinforced’’ hydroxyapatite cement: technique and complications. Neurosurgery 52: 842–845, 2003; discussion 845 Grant GA, JoUey M, Euenbogen RG, Roberts TS, Gruss JR, Loeser JD: Failure of autologous bone-assisted cranioplasty following decompressive craniectomy inchildren and adolescents. J Neurosurg 100: 163–168, 2004 Hayward RD: Cranioplasty: don’t forget the patient’s own bone is cheaper than titanium. Br J Neurosurg 13: 490–491, 1999 Hockley AD, Goldin JH, Wake MJ, Iqbal J: Skull repair in children. Pediatr Neurosurg 16: 271–275, 1990 Josan VA, Sgouros S, Walsh AR, Dover MS, Nishikawa H, Hockley AD: Cranioplasty in children. Childs Nerv Syst 21: 200–204, 2005 Kosaka M, Miyanohara T, Wada Y, Kamiishi H: Intracranial migration of fixation wires following correction of craniosynostosis in an infant. J Craniomaxillofac Surg 31: 15–19, 2003
Malis LI: Titanium mesh and acrylic cranioplasty. Neurosurgery 25: 351–355, 1989 Muhonen MG, Piper JG, Menezes AH: Pathogenesis and treatment of growing skull fractures. Surg Neurol 43: 367–372, 1995; discussion 372–363 Naim Ur R, Jamjoom Z, Jamjoom A, Murshid WR: Growing skull fractures: classification and management. Br J Neurosurg 8: 667–679, 1994 Papay FA, Hardy S, Morales Jr L, Walker M, Enlow D: ‘‘False’’ migration of rigid fixation appliances in pediatric craniofacial surgery. J Craniofac Surg 6: 309–313, 1995 Rotaru H, Baciut M, Stan H, Bran S, Chezan H, Iosif A, Tomescu M, Kim SG, Rotaru A, Baciut G: Silicone rubber mould cast polyethylmethacrylate–hydroxyapatite plate used for repairing a large skull defect. J Craniomaxillofac Surg 34: 242–246, 2006 Springer IN, Acil Y, Kuchenbecker S, Bolte H, Warnke PH, Abboud M, Wiltfang J, Terheyden H: Bone graft versus BMP-7 in a critical size defect—cranioplasty in a growing infant model. Bone 37: 563–569, 2006 Triulzi DJ, Vanek K, Ryan DH, Blumberg N: A clinical and immunologic study of blood transfusion and postoperative bacterial infection in spinal surgery. Transfusion 32: 517–524, 1992
Jean-Rodolphe VIGNES, MD, PhD Service de Neurochirurgie A, Hoˆpital Pellegrin 1, Place Amelie Raba-Le´on 33076 Bordeaux Cedex, France Tel.: +33 5 56 79 55 43 Fax: +33 5 56 79 61 55 E-mail: [email protected] Paper received 20 October 2006 Accepted 26 March 2007
Cranioplasty for repair of a large bone defect in a growing skull fracture in children Jean-Rodolphe VIGNES1, N u Owase JEELANI2, Michel DAUTHERIBES1, Franc¸ois SAN-GALLI1, Dominique LIGUORO1 1
Department of Neurosurgery A (Head: Prof. D. Liguo¯ro), CHU de Bordeaux, University of Bordeaux 2, Bordeaux, France; 2Department of Neurosurgery (Head: Dr. N. Kitchen), NHNN, University College of London, London, UK
SUMMARY. Introduction: In infants, calvarial defects are generally repaired with autologous grafts. However, with large defects, these techniques can be associated with complications such as bone graft resorption, loss of blood, or local infection. Alternative materials are available for cranioplasty including metals or acrylic. Case report: We report the case of a 3.2 kg boy who had a traumatic vaginal delivery and developed a growing skull fracture resulting in a large cranial defect (50 cm2). We describe a specific technique of cranioplasty by interposing a titanium plate between the duroplasty and bone elements, without fixation, with autologous bone fragments deposited over the mesh. Long-term follow-up was satisfactory. Conclusion: For large skull defects in infants, the technique described affords protection to the intracranial components, induces osteogenesis in a growing cranial skeleton, and provides satisfactory aesthetic results. r 2007 European Association for Cranio-Maxillofacial Surgery
Keywords: skull fracture, cranioplasty, craniocerebral trauma, vacuum extraction, titanium
forceps were necessary. Initial clinical examination demonstrated a cephalhaematoma in the right frontoparietal region. Neurological status was satisfactory with an APGAR score of 10 at 5 min after delivery. A CT scan demonstrated a small, linear skull fracture with moderate brain contusion. Development was satisfactory, but the head circumference was increased by the persistent cephalhaematoma. After 2 months, a subcutaneous cephalic swelling was observed (Fig. 1A), showing a transmitted impulse with the child’s cough and cry. X-ray (Fig. IB) and CT scan (Fig. 1C) of the skull showed a large meningocoele associated with enlargement of the skull fracture. The diagnosis of a growing skull fracture was established and surgical treatment considered. Skin incision was fashioned around the meningocoele. The procedure consisted of dividing the reactive gliosis followed by a duroplasty. Dural exposure required marginal bone resection around the perimeter of the bone defect, which was estimated at 50 cm2. Dura repair was performed with an autogenous flap of pericranium. In order to repair the skull, we decided to interpose a 0.4 mm thickness titanium plate (2ME Biomesh, Codman, France; Fig. 2A) between the dura and the skull (Fig. 2B). On the top of this plate, we spread autologous bone fragments (taken during dural by exposure) to induce ossification (Fig. 2C). At the end of the procedure, skin resection was necessary. The postoperative outcome was excellent and the patient was discharged
INTRODUCTION Growing skull fractures are a rare traumatic complications with a prevalence of about 1% of all infants fractures (Nairn Ur et al., 1994; Muhonen et al., 1995). Although early diagnosis and prompt surgical treatment are necessary to reduce complications (de Djientcheu et al., 2006), in practice, large defects are not exceptional. Reconstruction of such cranial defects is a challenge and surgery has to meet high functional and aesthetic demands specially in children (Springer et al., 2006). Although autogenous bone is preferred, in certain large defects, particularly in younger individuals, other allograft methods may be useful (Hockley et al., 1990). For cranioplasty, a number of materials is available, including acrylic (Chiarini et al., 2004) or acrylic mixed with hydroxyapatite (Rotaru et al., 2006) and metals. We describe a case of a growing skull fracture caused by birth trauma, with a large bone defect which necessitated an allogeneic cranioplasty. CASE REPORT A primiparous and primigravida young woman underwent a difficult delivery during vaginal birth of a 3.2 kg boy. Tarnier’s forceps and Wrigley’s No source of support. 185
ARTICLE IN PRESS 186 Journal of Cranio-Maxillofacial Surgery
Fig. 1 – Preoperative status. (A) Clinical examination showed a large skull tumefaction. (B) Radiograph with the bone fracture (arrows). (C) CT scan showed a growing skull fracture of the fronto-parietal bone.
Fig. 2 – (A) Titanium plate. (B) Meningocoele. (C) Interposition of a 0.4 mm titanium plate between dura and skull. (D) Autologous bone fragments deposited.
on day 7. At 2 years follow-up (Fig. 2), no complication was identified and the child remained seizure free. An MRI (magnetic resonance imaging) showed a small residual defect (Fig. 3B), but there was no bone resorption on CT scan (Fig. 3C).
DISCUSSION For cranioplasty, the patient’s own bone can provide significant immediate and long-term biological advances (and resource benefits) that come with using autologous tissues (Hayward, 1999). However the repair of large cranial defect can be difficult using this method (Durham et al., 2003). In a study of children and adolescents, after decompression craniectomy, autologous cranioplasty has a high rate (almost 50%)
of bone resorption (Grant et al., 2004). This resorption was correlated with the skull defect area and necessitated repeat surgery. Springer et al. (2006) have proposed a mechanism of bone genesis. During cerebral growth, the cranial cavity increases by centrifugal cranial expansion with bone resorption on the inside, and bone apposition on the outside. Centrifugal cranial expansion should remain undisturbed in infants after bone transplantation explaining uncontrolled bone resorption (Springer et al., 2006). It has also been demonstrated that autologous grafts may become infected, up to 10% (Josan et al., 2005) and this is correlated with the size of the defect (bilateral cranioplasty having a higher risk than unilateral ones). Moreover, large surgical fields tend to result in greater blood loss, particularly in infants. This loss has a direct correlation with increased
ARTICLE IN PRESS Cranioplasty for repair of a large bone defect in a growing skull fracture in children 187
Fig. 3 – Evaluation two years postoperatively. (A) Radiograph with the titanium mesh. (B) MRI with no active cystic lesion, no hydrocephalus. Mesh was placed over the dura mater (arrow). (C) CT scan showing the position of the titanium implant, over the dura mater (fine arrows). Bone fragments were placed over the mesh (large arrow). (D) Favourable aesthetic outcome.
surgical infection risk (Triulzi et al., 1992). Finally, a limited skin incision, which reduces surgical exposure, is preferable in children. Titanium is a non-ferromagnetic metal of low atomic number. It is the most biocompatible metal known and is widely used as an implant material (Malis, 1989). Titanium mesh cranioplasty appears to be a reasonable method for the reconstruction of significant calvarial defects (Ducic, 2006). The results are satisfactory with minimal morbidity and moderate complications (Malis, 1989; Blake et al., 1990; Josan et al., 2005). From an economic perspective, although the patient’s bone is cheaper (Hayward, 1999), some studies (Grant et al., 2004) have demonstrated that half of all large autogenous cranioplasties have bone resorption and require further operations. Postoperative images (including MRI) have excellent quality when titanium is used for cranioplasty (Chandler et al., 1994). This mesh can be moulded, cut, stretched or bent to fit any (bone) area and three-dimensionally, contoured. On the top of this mesh, we lay autologous chip cancellous, at the same depth as the skull, to promote osteogenesis. However, cranial defect repairs in children require several special considerations. The human calvarium reaches 50% of its adult size at birth, and the critical age is the 6–12 months old period when the most
active phase of brain growth occurs. Consequently, it is necessary to monitor patients, at least during this period. The paediatric skull is a dynamic structure that prohibits the use of rigid fixation (Cohen et al., 2004) especially in the temporal region (Kosaka et al., 2003). Numerous reports have noted the migration of materials, particularly screws breaching the dura and damaging brain tissue (Papay et al., 1995; Kosaka et al., 2003). For these reasons we decided to not fix the titanium mesh but to simply lay it under the defect according the cranial growth theory with bone resorption on the inside (Springer et al., 2006). We think this free moving mesh was adapting particularly well to the growth constraints of the skull. The twoyear follow-up of our case confirms the value of our treatment choice.
CONCLUSION In cases with large bone defects, allografts should be considered, even in infants. We demonstrate an original surgical technique utilizing a titanium allograft over the dura (without fixation) and autologous bone grafted on top of the mesh. Longterm results (functional and aesthetic) were good.
ARTICLE IN PRESS 188 Journal of Cranio-Maxillofacial Surgery
References Blake GB, MacFarlane MR, Hinton JW: Titanium in reconstructive surgery of the skull and face. Br J Plast Surg 43: 528–535, 1990 Chandler CL, Uttley D, Archer DJ, MacVicar D: Imaging after titanium cranioplasty. Br J Neurosurg 8: 409–414, 1994 Chiarini L, Figurelli S, Pollastri G, Torcia E, Ferrari F, Albanese M, Nocini PF: Cranioplasty using acrylic material: a new technical procedure. J Craniomaxillofac Surg 32: 5–9, 2004 Cohen AJ, Dickerman RD, Schneider SJ: New method of pediatric cranioplasty for skull defect utilizing polylactic acid absorbable plates and carbonated apatite bone cement. J Craniofac Surg 15: 469–472, 2004 de Djientcheu VP, Njamnshi AK, Ongolo-Zogo P, Kobela M, Rilliet B, Essomba A, Sosso MA: Growing skull fractures. Childs Nerv Syst 22: 721–725, 2006 Ducic Y: Titanium mesh and hydroxyapatite cement cranioplasty: a report of 20 cases. J Oral Maxillofac Surg 60: 272–276, 2006 Durham SR, McComb JG, Levy ML: Correction of large (425 cm2) cranial defects with ‘‘reinforced’’ hydroxyapatite cement: technique and complications. Neurosurgery 52: 842–845, 2003; discussion 845 Grant GA, JoUey M, Euenbogen RG, Roberts TS, Gruss JR, Loeser JD: Failure of autologous bone-assisted cranioplasty following decompressive craniectomy inchildren and adolescents. J Neurosurg 100: 163–168, 2004 Hayward RD: Cranioplasty: don’t forget the patient’s own bone is cheaper than titanium. Br J Neurosurg 13: 490–491, 1999 Hockley AD, Goldin JH, Wake MJ, Iqbal J: Skull repair in children. Pediatr Neurosurg 16: 271–275, 1990 Josan VA, Sgouros S, Walsh AR, Dover MS, Nishikawa H, Hockley AD: Cranioplasty in children. Childs Nerv Syst 21: 200–204, 2005 Kosaka M, Miyanohara T, Wada Y, Kamiishi H: Intracranial migration of fixation wires following correction of craniosynostosis in an infant. J Craniomaxillofac Surg 31: 15–19, 2003
Malis LI: Titanium mesh and acrylic cranioplasty. Neurosurgery 25: 351–355, 1989 Muhonen MG, Piper JG, Menezes AH: Pathogenesis and treatment of growing skull fractures. Surg Neurol 43: 367–372, 1995; discussion 372–363 Naim Ur R, Jamjoom Z, Jamjoom A, Murshid WR: Growing skull fractures: classification and management. Br J Neurosurg 8: 667–679, 1994 Papay FA, Hardy S, Morales Jr L, Walker M, Enlow D: ‘‘False’’ migration of rigid fixation appliances in pediatric craniofacial surgery. J Craniofac Surg 6: 309–313, 1995 Rotaru H, Baciut M, Stan H, Bran S, Chezan H, Iosif A, Tomescu M, Kim SG, Rotaru A, Baciut G: Silicone rubber mould cast polyethylmethacrylate–hydroxyapatite plate used for repairing a large skull defect. J Craniomaxillofac Surg 34: 242–246, 2006 Springer IN, Acil Y, Kuchenbecker S, Bolte H, Warnke PH, Abboud M, Wiltfang J, Terheyden H: Bone graft versus BMP-7 in a critical size defect—cranioplasty in a growing infant model. Bone 37: 563–569, 2006 Triulzi DJ, Vanek K, Ryan DH, Blumberg N: A clinical and immunologic study of blood transfusion and postoperative bacterial infection in spinal surgery. Transfusion 32: 517–524, 1992
Jean-Rodolphe VIGNES, MD, PhD Service de Neurochirurgie A, Hoˆpital Pellegrin 1, Place Amelie Raba-Le´on 33076 Bordeaux Cedex, France Tel.: +33 5 56 79 55 43 Fax: +33 5 56 79 61 55 E-mail: [email protected] Paper received 20 October 2006 Accepted 26 March 2007