Complications of Hydroxyapatite Bone Cement in Secondary Pediatric Craniofacial Reconstruction

Abstract

Hydroxyapatite cement has become a popular alternative to bone grafts in reconstructing the calvarium. Although animal studies have shown promising results with use of hydroxyapatite, human clinical studies have shown mixed results including significant rates of infection. This is a retrospective chart review during a 7-year period (1997-2003) of 20 patients who underwent secondary forehead cranioplasty with hydroxyapatite cement (Norian Craniofacial Reconstruction System). Basic demographics including age, sex, and diagnosis were identified. Characteristics of the defects were recorded including size, location, and depth (full versus partial thickness). The volume of hydroxyapatite and any adjunctive procedures were identified. The postoperative course was analyzed for length of follow-up and the presence of infections.Twenty patients were identified in which Norian had been used and 3 patients were lost to follow-up. Secondary forehead asymmetry was the most common presentation. The mean volume of hydroxyapatite used was 24.4 mL. All patients had initially acceptable aesthetic results. Of the 17 patients, 10 (59%) ultimately had infectious complications. Infection occurred on a mean of 17.3 months after surgery (range, 4 mo to 4 y), and the mean amount of hydroxyapatite used was 32.5 mL (infections) versus 14.3 mL (no infections). Of the 10 patients with complications, 9 required surgical debridement and subsequent delayed reconstruction. Although hydroxyapatite cement can yield excellent aesthetic results, its use in secondary reconstruction has yielded unacceptably high infection rates leading to discontinuation of its use in this patient population.

Titanium cranioplasty in children and adolescents

“…Minimal complication rates are seen with short term follow up, however Wong reported 75% of full thickness calvarial reconstructions failing due to infection with a mean follow up of 51 months leading the authors to discontinue the use of hydroxyapatite cement in paediatric cases (Wong et al, 2011). In adults hydroxyapatite cements have been associated with significant complication rates such as infection, material exposure, fragmentation and inflammatory tissue reaction and although they may be suitable for select cases for contouring purposes their use for full thickness defects is generally discouraged (Moreira-Gonzalez et al, 2003;Matic and Manson, 2004;Zins et al, 2010;Wong et al, 2011). Custom made hydroxyapatite ceramic implants have been reported by one large study of 114 patients since 1997 with no reported failures, although the defect size and length of follow up are not stated (Stefini et al, 2013).…”

“…These studies are summarised in Table 3 (Barone and Jimenez 1997;Blum et al, 1997;Choi et al, 1998;Durham et al, 2003;Cohen et al, 2004;Grant et al, 2004;Josan et al, 2004;David et al, 2005;Pang et al, 2005;Gosain et al, 2009;Biskup et al, 2010;Singh et al, 2010;Rogers et al, 2011;Wong et al, 2011;Frassanito et al, 2012;Lin et al, 2012;Piedra et al, 2012;Bowers et al, 2013;Stefini et al, 2013;Martin et al, 2014;Piitulainen et al, 2015;Greene et al, 2008) M A N U S C R I P T…”

“…Since 1997 fifteen studies report biomaterials in paediatric cranioplasty (Blum et al, 1997;Choi et al, 1998;Durham et al, 2003;Cohen et al, 2004;Josan et al, 2004;David et al, 2005;Pang et al, 2005;Gosain, at al., 2009;Singh et al, 2010;Wong et al, 2011;Lin et al, 2012;Stefini et al, 2013;Martin et al, 2014;Piitulainen et al, 2015;Frassanito et al, 2012).…”

“…Biomaterials in current use include acrylics, ceramics, polyethene, polyetheretherketone (PEEK) and titanium (Cho and Gosain., 2004;Hanasono et al, 2009). Each material has relative merits and disadvantages, however the principle concerns in using biomaterials in paediatric cranioplasty relate to the possible deleterious effects of a rigid material on normal cranial growth, intracranial migration of reconstruction components and high incidences of failure through infection, adverse tissue reactions and material breakage (Resnick et al, 1990;Wong et al, 2011;Yaremchuk et al, 1994;Beck et al, 2002;Papay et al, 1995;Kosaka et al, 2003;Josan et al, 2004;Moreira-Gonzalez et al, 2003).…”

Bioactive glass-containing cranial implants: an overview

“…The first studies using fiber-reinforced composites (FRCs) in medicine and dentistry occurred in the early 1960s, but more extensive research started in the early 1990s which led to introduction of FRCs as reconstructive material for damaged dental hard tissues [14][15][16][17][18]. The first approved surgical applications were found in cranial surgery [18].…”