During my deployment at Bagram Air Base, Afghanistan, I saw firsthand the ramifications associated with a lack of treatment options for skull repair in developing countries.
In one case, a young boy was severely injured after reaching to pick up what he thought was a toy buried in the ground. It turned out to be one of millions of land mines left by the former Soviet Union during withdrawal from the Soviet-Afghan war. The mine exploded, and the young boy needed a decompressive craniectomy performed by military neurosurgeons to relieve pressure in the skull and save his life. He later returned for a cranioplasty, a procedure that restores the integrity of the skull with an implant. In this case, doctors used titanium mesh, a common option in countries with limited resources. Unfortunately, this material is known to be associated with an increased risk of delayed wound complications. By the time I saw the patient, the titanium mesh had eroded through his skin. He needed several additional procedures to repair the damage.
Cases like this are typical in developing countries. When patients acquire a bone defect, it is preferable in most cases to use the patient’s own bone flap. When the flap is not salvageable, synthetic materials are the next best option. Here in the United States, third-party companies produce anatomically precise patient-specific cranial implants using the patient’s CT scans. However, the cost for this type of implant is often prohibitive in countries with developing economies. Options for calvarial reconstruction in these regions are limited in many regards. Titanium mesh implants do not readily conform to many three-dimensional defects and can be associated with wound contracture, poor cosmesis (cosmetic appearance) and delayed wound erosion. Polymethyl methacrylate (PMMA), or bone cement, implants have to be manually shaped or directly poured into the defect. The cosmesis of this form of implant is often limited and depends on the ability of the surgeon to shape the implant appropriately before the cement hardens.