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Evaluating Complex Cranial Defects using the Reconstructive Ladder: A review of materials
Edgar Soto, BS1, Carter J. Boyd,MD1, Ryan Restrepo, MD1, Rene P. Myers,MD 1 1University of Alabama at Birmingham, Birmingham, Al

Background: A variety of studies have independently investigated primary calvarial reconstruction, but few have examined high risk complex cranial defects. Up to 33% of patients who undergo reconstruction have hostile pre-existing conditions with coexisting soft tissue and osseous defects due to history of radiation, prior failed cranioplasty, or concurrent infections. Though studies have evaluated autologous reconstruction for hostile craniums there is a paucity of studies comparing alloplastic and autologous reconstruction for hostile defects. Our objective was to retrospectively evaluate the use of alloplastic reconstruction alongside autologous reconstruction for hostile cranial defects.

Methods: An IRB approved retrospective review of patients who underwent cranioplasty of a hostile site at tertiary referral center between January 2008 and December 2018 was performed. The patients were stratified into three groups based on the type of implant used: autogenous (bone), alloplastic (PEEK, Titanium, PMMA), or mixed (combination of both types of graft). The primary outcome metric was a complication in the year following cranioplasty, identified by flap or bone graft failure, necrosis, or infection. Statistical analysis included t-tests and chi-square tests where appropriate using SPSS.

Results: There were 43 total cases in this time period; 15 autogenous, 23 alloplastic, and 5 mixed. The purely autogenous group had the highest complication rate (85%) and the alloplastic group had the lowest complication rate (38%). When stratified by specific material used for reconstruction (15 bone, 14 PEEK, 10 titanium, and 5 PMMA), overall complication rate was statistically significant (p=0.009; chi square test) with PEEK implants having the lowest complication rate (21%). The analysis documented an overall complication rate that was statistically different between the three groups (p=0.012).

Conclusion: This analysis interestingly found that in the setting of hostile cranial defects, cranioplasties would benefit from the use of prosthetic implants instead of autologous bone grafts, not only for avoidance of donor site morbidity but also for decrease in overall complications

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