Outcomes and Complications of Cranioplasty in the Pediatric Population: A Systematic Review

Background: Pediatric calvarial reconstruction is challenging given the unique anatomical and growth considerations in this population. Successful cranioplasty reconstruction using autologous and alloplastic materials have been reported, but a head-to-head comparison in outcomes is lacking. The purpose of this study is to address the knowledge gap in cranioplasty outcomes using currently available materials.

 

Methods: A systematic review was performed using the guidelines outlined in the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA). The electronic literature search included Medline/Pubmed, Scopus and Cochrane Databases to identify papers on pediatric cranioplasty from January 1990 to December 2017. Only pediatric cranioplasty studies with a minimum of 1 year follow up with reported surgical site occurrences and cranioplasty outcomes were included. Surgical site occurrences (SSO) and infections (SSI) data among the different materials were abstracted. Outcome data comparing fresh bone grafts, banked bone flaps, Titanium Mesh (Ti), Polymethyl Methacrylate (PMMA), Polyether Ether Ketone (PEEK), and Hydroxyapatite (HA) were analyzed. Surgical site occurrences included seromas, hematomas, wound dehiscences, skin or flap necrosis, surgical site infections, and bone flap resorptions.

Results: A total of 27 studies met the inclusion criteria, encompassing 755 pediatric patients. There were 343 patients that underwent autologous cranioplasty (149 fresh bone grafts and 194 banked bone flaps). Alloplastic reconstruction was performed in 412 patients (211 HA, 110 PMMA, 60 Ti, and 31 PEEK). The mean age ranged from 2.9 to 17.4 years and the follow up time averaged 1 to 10 years. Of all materials evaluated, fresh bone grafts and Ti mesh were associated with the lowest surgical site infections (0.7%, and 3.3% respectively; p =<0.0005) and graft failures requiring reoperation (4%, and 3.3% respectively; p =<0.0001). The lowest surgical site occurrence rates were associated with Ti mesh and HA (6.7%, and 9% respectively; p =<0.0001). Banked bone flaps had the highest rates of surgical site occurrences (51%; p =<0.0001) and graft failures (40.2%; p =<0.0001). PEEK implants had the highest rates of surgical site infections (16.1%; p =<0.0005). Graft failure rates for PEEK, PMMA, and HA implants were 19.3%, 16.4%, and 7.1% respectively. Fresh bone grafts had lower rate of resorption (7.4%) compared to banked bone flaps (39.7%; p =<0.0001).

Conclusion: Based on the available studies reviewed, fresh bone graft reconstruction and titanium mesh demonstrated the lowest surgical site infections and graft failure rates. Banked bone flaps demonstrated the highest overall surgical site occurrences and graft failures. Prospective studies evaluating the efficacy of current cranioplasty materials in the pediatric population are needed.