Utilización de hueso craneal particulado de calota para prevención de defectos óseos en la cirugía de las craneosinostosis

Servicio de Cirugía Maxilofacial. Hospital Clínico Universitario de Valencia
Neurocirugia (Asturias, Spain) (Impact Factor: 0.29). 12/2010; 21(2). DOI: 10.4321/S1130-14732010000200004
Source: OAI

ABSTRACT Se considera que hasta un 20% de intervenidos de craneosinostosis requieren cirugías secundarias. Son varias las técnicas que se han venido utilizando dentro de la cirugía craneofacial para la reconstrucción de grandes defectos óseos en pacientes pediátricos a lo largo de los años. Presentamos una nueva técnica de obtención de injerto de hueso para el recubrimiento de defectos óseos craneales, en la que se utiliza hueso particulado, obtenido de la calota del paciente mediante un berbiquí y unificado con un adhesivo de fibrina. Está técnica es sencilla y provoca poca morbilidad en el paciente. Además, permite obtener una importante cantidad de hueso. Desde el año 2007 utilizamos el hueso particulado autólogo obtenido de la calota del paciente para la corrección de defectos óseos grandes o pequeños que se nos presentaban en la cirugía craneofacial practicada sobre todo en pacientes pediátricos. Aunque los materiales aloplásticos y sustitutos de hueso han sido utilizados para la reconstrucción de cráneos, el hueso autógeno es la mejor opción. A diferencia de los materiales sintéticos, los injertos autógenos tienen una más rápida osteointegración ya que son osteogénicos, osteoinductivos y osteoconductivos, siendo además el injerto de la misma naturaleza que el hueso donante. La morbilidad producida al paciente por la obtención del hueso de la calota con esta técnica es mínima, en comparación con otras zonas donantes como costilla o cadera. La utilización del hueso particulado autólogo durante la cirugía de las craneosinostosis reduce la necesidad de segundas intervenciones por defectos de osificación secundarios. Por otro lado, su obtención es fácil y la cantidad de hueso extraído es suficiente para los pacientes pediátricos.

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    ABSTRACT: To review the results and complications of the surgical treatment of craniosynostosis in 283 consecutive patients treated between 1999 and 2007. Our series consisted of 330 procedures performed in 283 patients diagnosed with scaphocephaly (n=155), trigonocephaly (n=50), anterior plagiocephaly (n=28), occipital plagiocephaly (n=1), non-syndromic multi-suture synostosis (n=20), and with diverse craniofacial syndromes (n=32; 11 Crouzon, 11 Apert, 7 Pfeiffer, 2 Saethre-Chotzen, and 2 clover-leaf skull). We used the classification of Whitaker et al. to evaluate the surgical results. Complications of each technique and time of patients' hospitalization were also recorded. The surgeries were classified in 12 different types according to the techniques used. Type I comprised endoscopic assisted osteotomies for sagittal synostosis (42 cases). Type II included sagittal suturectomy and expanding osteotomies (46 cases). Type III encompassed procedures similar to type II but that included frontal dismantling or frontal osteotomies in scaphocephaly (59 cases). Type IV referred to complete cranial vault remodelling (holocranial dismantling) in scaphocephaly (13 cases). Type V belonged to fronto-orbital remodelling without fronto-orbital bandeau in trigonocephaly (50 cases). Type VI included fronto-orbital remodelling without fronto-orbital bandeau in plagiocephaly (14 cases). In Type VII cases of plagiocephaly with frontoorbital remodelling and fronto-orbital bandeau were comprised (14 cases). Type VIII consisted of occipital advancement in posterior plagiocephaly (1 case). Type IX included standard bilateral fronto-orbital advancement with expanding osteotomies (30 cases). Type X was used in multi-suture craniosynostosis (15 cases) and consisted of holocranial dismantling (complete cranial vault remodelling). Type XI included occipital and suboccipital craniectomies in multiple suture craniosynostosis (10 cases) and Type XII instances of fronto-orbital distraction (26 cases). The mortality rate of the series was 2 out of 283 cases (0.7%). These 2 patients died one year after surgery. All complications were resolved without permanent deficit. Mean age at surgery was 6.75 months. According to Whitaker et al's classification, 191 patients were classified into Category I (67.49%), 51 into Category II (18.02%), 30 into Category III (10.6%) and 14 into Category IV (4.90%). Regarding to craniofacial conformation, 85.5 % of patients were considered as a good result and 15.5% of patients as a poor result. Of the patients with poor results, 6.36% were craniofacial syndromes, 2.12% had anterior plagiocephaly and 1.76% belonged to non-syndromic craniosynostosis. The most frequent complication was postoperative hyperthermia of undetermined origin (13.43% of the cases), followed by infection (7.5%), subcutaneous haematoma (5.3%), dural tears (5%), and CSF leakage (2.5%). The number of complications was higher in the group of re-operated patients (12.8% of all). In this subset of reoperations, infection accounted for 62.5%, dural tears for 93% and CSF leaks for 75% of the total. In regard to the surgical procedures, endoscopic assisted osteotomies presented the lowest rate of complications, followed by standard fronto-orbital advancement in multiple synostosis, trigonocephaly and plagiocephaly. The highest number of complications occurred in complete cranial vault remodelling (holocranial dismantling) in scaphocephaly and multiple synostoses and after the use of internal osteogenic distractors. Of note, are two cases of iatrogenic basal encephalocele that occurred after combined fronto-facial distraction. The best results were obtained in patients with isolated craniosynostosis and the worst in cases with syndromic and multi-suture craniosynostosis. The rate and severity of complications were related to the type of surgical procedure and was higher among patients undergoing re-operations. The mean time of hospitalization was also modified by these factors. Finally, we report our considerations for the management of craniosynostosis taking into account each specific technique and the age at surgery, complication rates and the results of the whole series.
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    ABSTRACT: Norian CRS, Bone Cement (Synthes CMF), and Mimix (Lorenz) have been used to reconstruct large cranio-orbital defects in 85 patients. Resorbable mesh (Macropore), used in combination in selected patients, obviates dura pulsations that have been postulated to cause fragmentation of alloplastic material. Norian is composed of monocalcium phosphate, monohydrate, alpha-tricalcium phosphate, and calcium carbonate. Admixture with NaPO4 creates dahllite, which has a higher carbonate content (4%--6%) than hydroxyapatite (0%). CRS is soluble at low pH, facilitating its resorption and replacement by bone. In contradistinction, Mimix is converted to aqueous solution at 37 degrees C, supports fibrovascular ingrowth and bony interdigitation at the implant-material surface. Forty-five adults (mean age=42 years) and 40 children (mean age=8 years) were evaluated with respect to etiology of defect, size, location, gram usage of alloplast material, type of alloplast, postoperative clinical course, and complications. A minimum of 3-year follow-up is available; 22 adult patients additionally underwent resorbable mesh reconstruction. There were 7 (8%) complications, including infection, extrusion, a sterile loculated fluid collection and fragmentation. No difference in complication rate was noted between biomaterials. Two additional patients exhibited resorption (Norian), necessitating reaugmentation. Alloplastic replacement of cranio-orbital defects has recently advanced dramatically. Bivalved cranial bone grafting with its attached morbidity and sequelae can be avoided. Resorbable mesh allows for the placement of alloplast material in larger defects while avoiding dura pulsation causing alloplast fragmentation. In avoiding titanium type reconstruction, it obviates any interference with radiologic diagnosis and radiotherapeutic modalities. Long-term results are needed to assess bone growth within alloplast and to study bone growth in alloplastic reconstructed pediatric patients.
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    ABSTRACT: Closure of calvarial defects in children is problematic because the supply of autologous bone is limited and alloplastic materials are not advocated. The authors previously showed that cranial particulate bone graft applied over the coronal gap during primary fronto-orbital advancement reduced the incidence of residual osseous defects. The purpose of this study was to determine the effectiveness of particulate bone graft for established calvarial defects. The authors analyzed consecutive children who had undergone cranioplasty with inlay particulate bone grafting between 1989 and 2007. Particulate bone was harvested from parietal calvaria or from the endocortex of the cranial elements using a hand-driven brace and bit. Patient records were reviewed for age at the time of cranioplasty, operative indication, size of defect, and length of follow-up. Outcome variables included persistent osseous defects, need for further cranioplasty, and complications. Thirty-eight children had inlay particulate bone grafting at an average age of 8.0 years (range, 3 to 20 years). The average defect size was 66.5 cm (range, 5 to 250 cm). Indications for inlay grafting were revision fronto-orbital advancement, bony gaps following primary cranial remodeling, congenital defects, trauma, and tumor. Mean follow-up was 6.1 years (range, 0.5 to 18 years). Three patients (7.9 percent) had small persistent osseous defects, and one (2.6 percent) required another cranioplasty. Inlay autologous cranial particulate bone graft effectively heals established cranial defects in children. Particulate bone graft can be harvested in infants and young children, does not require neurosurgical assistance, and has minimal morbidity.
    Plastic and Reconstructive Surgery 08/2008; 122(2):563-71. DOI:10.1097/PRS.0b013e31817d61c1 · 2.99 Impact Factor
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