title: Autologous bone flap cranioplasty following decompressive craniectomy is combined with a high complication rate in pediatric traumatic brain injury patients.
abstract: OBJECTIVE
  Decompressive craniectomy (DC) is a last treatment option of refractory intracranial hypertension in traumatic brain injury (TBI) patients. Replacement of the autologous bone flap is the preferred method to cover the cranial defect after brain swelling has subsided. Long term outcomes and complications after replacement of the autologous bone flap in pediatric patients were studied in comparison to young, healthy adults.
  
  
  METHODS
  Medical records of 27 pediatric patients who underwent DC and subsequent replacement of the bone flap between 1998 and 2011 were reviewed retrospectively. Patients were divided into two age groups (group 1: 18 children < 15 years; group 2:9 adolescents 15-18 years). For comparative reasons, a young adult control group of 39 patients between 18 and 30 years was additionally evaluated.
  
  
  RESULTS
  With 81.8 % resorption of the bone flap, this was the major complication in young children. In up to 54.4 % of patients, a surgical revision of the osteolytic bone flap became necessary. However, in some pediatric patients, the osteolysis resolved spontaneously and further operations were not required. Probable enabling factors for bone flap resorption were young age (0-7 years), size of craniectomy, permanent shunt placement, and extent of dural opening/duraplasty. Other complications were bone flap infections, loosening of the re-inserted bone flap, and postoperative hematomas.
  
  
  CONCLUSIONS
  There is an unacceptably high complication rate after reimplantation of the autologous bone following DC in pediatric TBI patients, especially in young children up to seven years of age. Artificial or synthetic cranioplasties may be considered as alternatives to initial bone flap reimplantation in the growing child. Despite the fact that DC is an effective treatment in TBI with persistent intracranial hypertension, it is important to realize that DC is not only combined with replacement of the autologous bone flap but also with a high rate of additional complications especially in pediatric patients.
authors: Department of Neurological Surgery, University Hospital Carl-Gustav-Carus, Technical University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany, hippocampus@dr-daniel-martin.com.
authors: K Daniel
authors: KD
authors: Martin
authors: Benjamin
authors: B
authors: Franz
authors: Matthias
authors: M
authors: Kirsch
authors: Witold
authors: W
authors: Polanski
authors: Maja
authors: M
authors: von der Hagen
authors: Gabriele
authors: G
authors: Schackert
authors: Stephan B
authors: SB
authors: Sobottka
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D064592:Autografts; D001930:Brain Injuries / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D056424:Decompressive Craniectomy / Q000009:adverse effects* / Q000379:methods*; D005260:Female; D006406:Hematoma / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D019586:Intracranial Hypertension / Q000601:surgery*; D008297:Male; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D012886:Skull / Q000601:surgery*; D013524:Surgical Flaps / Q000009:adverse effects*; D013530:Surgical Wound Infection / Q000453:epidemiology; D016896:Treatment Outcome; D055815:Young Adult