A retrospective descriptive study of cranioplasty failure rates and contributing factors in novel 3D printed calcium phosphate implants compared to traditional materials

Michael Koller,Sean Murphy,Gillian Shok,Uzma Samadani,Sheena Kiaei,Daniel Rafter

doi:10.1186/s41205-020-00066-5

Michael Koller, Sean Murphy + Show 4 more

Open Access

https://doi.org/10.1186/s41205-020-00066-5

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Abstract

BackgroundFailure rates with cranioplasty procedures have driven efforts to improve graft material and reduce reoperation. One promising allograft source is a 3D-printed titanium mesh with calcium phosphate filler. This study evaluated failure rates and pertinent characteristics of these novel 3D-grafts compared to traditional materials.MethodsSixty patients were retrospectively identified who underwent a cranioplasty between January 2015–December 2017. Specific data points related to graft failure were collected for all surgical admissions, from the primary injury to their most recent. These included, but were not limited to, initial physical exam findings, vitals, comorbid conditions, surgery length, estimated blood loss, incision type, and need for revision. Failure rates of 3D-printed allografts were compared to traditional grafts.ResultsA total of 60 subjects were identified who underwent 71 unique cranioplasty procedures (3D = 13, Synthetic = 12, Autologous = 46). There were 14 total failures, demonstrating a 19.7% overall failure rate. Specifically, 15.4% (n = 2) of 3D, 19.6% (n = 9) of autologous, and 25.0% (n = 3) of synthetic grafts required revision. Patients receiving 3D-grafts had the shortest overall mean surgery times (200.8 ± 54.3 min) and lowest infection rates (7.7%) compared to autologous (210.5 ± 47.9 min | 25.0%) and synthetic models (217.6 ± 77.3 min | 8.7%), though significance was unable to be determined. Tobacco use and trap-door incisions were associated with increased failure rates relative to straight or curved incisions in autologous grafts. Cranioplasties performed less than 3 months after craniectomy appeared to fail more often than those performed at least three months after craniectomy, for the synthetic group.ConclusionWe concluded that 3D-printed cranioplasty grafts may lead to lower failure rates and shorter surgery times compared to traditional cranioplasty materials in our limited population. 3D-implants hold promise for cranial reconstruction after TBI.

Highlights

Failure rates with cranioplasty procedures have driven efforts to improve graft material and reduce reoperation
Decompressive craniectomy (DC) is a common neurosurgical intervention in which a large section of the skull is removed in the setting of severe traumatic brain injury (TBI)
We evaluated cranioplasty procedures performed at a level-1 trauma hospital in the United States, focusing on the unique factors with the potential to affect outcomes in 3D-printed grafts, autologous grafts, and other synthetic allografts cohorts

Summary

Introduction

Failure rates with cranioplasty procedures have driven efforts to improve graft material and reduce reoperation. Once the underlying pathology has been corrected, the contour of the skull is reconstructed either with the autologous bone flap or a synthetic implant via cranioplasty. This is done for cosmesis as well as to reduce complications from DC including seizure, posttraumatic hydrocephalus, and syndrome of trephined [4,5,6,7]. While cranioplasty is a routine and technically straightforward procedure, current data demonstrates failure and complication rates as high as 40% due to infection, hardware exposure, and autologous bone resorption [8,9,10]. There has been a focus on shorter operating times, optimizing time between craniectomy and cranioplasty, and managing patient comorbidities to improve outcomes [11,12,13]

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