Background: Cranial bone defects secondary to decompression craniectomy associated with the Global War on Terror pose a unique reconstructive challenge. The objective of this study was to evaluate the outcome of alloplastic reconstruction using custom-designed implants for large craniectomy defects from warfare-related cranial trauma. Methods: A review of injured personnel who underwent decompression craniectomy reconstruction and subsequent alloplastic cranial reconstruction in the National Capital Region was performed from 2003 to 2008 (n = 99). Collected data included mechanism of injury, evacuation time, Glasgow Coma Scale score, decompression craniectomy type, and implant type. Outcomes included complications and retention of implants. Results: Average patient age was 25 years (range, 18 to 53 years). All patients were men. Follow-up was 2.4 years. Improvised explosive device blasts were responsible for 46 percent of injuries. The initial Glasgow Coma Scale score was 7. On arrival to the continental United States, it was 9. Time for evacuation to the continental United States was 6 days. Eighty-eight percent had hemicraniectomies and 12 percent had bifrontal craniectomies. Successful reconstruction with retention of the implant occurred in 95 percent. Five (three hemicraniectomy and two bifrontal) patients underwent implant removal because of infection. Seventy-three patients were complication-free. The reoperation rate with recontouring, drainage, or removal was 18 percent. After reconstruction, seven patients developed hematomas/hygromas, three patients developed seizures, and 10 percent had contour abnormalities (temporal hollowing) requiring revisions. Conclusions: Despite war wound contamination, massive cranial defects can be successfully reconstructed using custom alloplastic implants. However, reconstruction of frontal cranial defects in proximity to the airways and orbits was associated with infection and implant removal.
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