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BACKGROUND: Immature dura in children has a greater osteogenic potential than mature dura in adults, making problematic large cranial (skull) defects less likely. However, when such large cranial defects do occur in children, fewer reconstructive options are available in comparison to adults (titanium mesh, patient-specific implants, cryopreserved bone). For these challenges, we studied a novel technique of a patient-specific, bilaminar resorbable mesh utilizing BMP-2 as a strategy to provide initial structural support for the skull, followed by bone healing, without permanent foreign body problems.
METHODS: Outcomes of consecutive children (less than 12 years of age) with long-standing critical-sized cranial vault defects were studied (n=21). Our technique of patient-specific, bilaminar resorbable mesh with BMP-2 was compared to previously-used techniques: bone substitutes (calcium phosphates), titanium mesh, or autologous bone grafts (split bone or bone mill granules). We evaluated operative times, blood loss, complications, reoperations, and bone healing (3D CT scans) after 6 and 12 months.
RESULTS: Defects in the groups were similar overall, (avg. 82cm2, range 55-135cm2), with the exception of the autologous bone graft group (avg. 64cm2). Autologous bone grafting had the longest operative time (1.5 times longer than the BMP-2 group) and the greatest blood loss (1.6 times greater than the BMP-2 construct group). Perioperative complications and reoperation rates were highest in the bone substitute and titanium mesh groups (46% and 38%) in comparison to the autologous and BMP-2 construct groups (12% and 5%). The bone substitution group had difficulties with wound breakdown and implant exposure. Bone healing was superior in the BMP-construct group (80% at 6 months and 95% at 12 months). Autologous bone had good healing (74%) in the smaller defects only (< 50cm2). There was minimal to no healing in the bone substitution group and the titanium mesh groups.
CONCLUSIONS: For the challenging problem of large cranial defects in children, patient-specific bilaminar resorbable mesh with BMP-2 provides a novel option for reconstruction with minimal complications compared to existing alternative methods.