Cranioplasty with hydroxyapatite or acrylic is associated with a reduced risk of all-cause and infection-associated explantation

Long-Term Follow-Up of Custom-Made Porous Hydroxyapatite Cranioplasties: Analysis of Infections in Adult and Pediatric Patients

In neurosurgery, cranioplasty (CP) stands as a pivotal surgical intervention, particularly following head trauma or various neurosurgical interventions. This study scrutinizes the intricacies of CP, emphasizing its prevalence and associated complications, with a specific focus on custom-made porous hydroxyapatite (PHA) implants. The investigation spans 687 patients (with 80 patients of pediatric age, less than 14 years old) across 26 neurosurgical centers in five European countries. Methodologically, this study delves into patient characteristics, complications, and infection data through a comprehensive post-marketing on-site surveillance approach. Notably, infections emerged as the primary complication, affecting 41 patients (6% of implants) with a clear distinction in onset patterns between pediatric (with more infections, 10% versus 5.4% in adults and an earlier onset of complications) and adult populations. Out of these 41 cases, cranioplasty explantation was required in 30 patients, 4.4% of the total population. Furthermore, bifrontal decompression correlated with a significantly elevated infection risk as compared to unilateral decompression (12.5% versus 5.1%) which remains after the examination of possible confounding factors. These findings provide substantial insights into the complexities of CP, suggesting the necessity for tailored strategies in pediatric and adult cases and cautioning against bifrontal decompressions. Despite acknowledging limitations and calling for prospective studies with long term follow-up, this research advances our understanding of the use of PHA CP, guiding clinical decision-making and emphasizing the importance of customized approaches for diverse patient cohorts.

Diagnostic, clinical management, and outcome of bone flap-related osteomyelitis after cranioplasty

OBJECTIVES

We aimed to describe diagnostic, management, and outcome of bone flap-related osteomyelitis after cranioplasty.

METHODS

Patients followed up in our tertiary care hospital for bone flap-related osteomyelitis after cranioplasty were included in a retrospective cohort (2008-2021). Determinants of treatment failure were assessed using logistic regression and Kaplan-Meier curves analysis.

RESULTS

The 144 included patients (81 [56.3%] males; median age 53.4 [interquartile range [IQR], 42.6-62.5] years) mostly presented wound abnormalities (n = 115, 79.9%). All infections were documented, the main pathogens being Staphylococcus aureus (n = 64, 44.4%), Cutibacterium acnes (n = 57, 39.6%), gram-negative bacilli (n = 40, 27.8%) and/or non-aureus staphylococci (n = 34, 23.6%). Surgery was performed in 140 (97.2%) cases, for bone flap removal (n = 102, 72.9%) or debridement with flap retention (n = 31, 22.1%), along with 12.7 (IQR, 8.0-14.0) weeks of antimicrobial therapy. After a follow-up of 117.1 (IQR, 62.5-235.5) weeks, 37 (26.1%) failures were observed: 16 (43.2%) infection persistence, three (8.1%) relapses, 22 (59.5%) superinfections and/or two (1.7%) infection-related deaths. Excluding superinfections, determinants of the 19 (13.4%) specific failures were an index craniectomy for brain tumor (odds ratio = 4.038, P = 0.033) and curettage of bone edges (odds ratio = 0.342, P = 0.048).

CONCLUSION

Post-craniectomy bone flap osteomyelitis are difficult-to-treat infection, necessitating prolonged antimicrobial therapy with appropriate surgical debridement, and advocating for multidisciplinary management in dedicated reference centers.

Traumatic Fracture Treatment: Calcium Phosphate Bone Substitute Case-Control Study in Humerus, Radius, Tibia Fractures-Assessing Efficacy and Recovery Outcomes

To date, insufficient investigation has been carried out on the biocompatibility of synthetic bioactive bone substitute materials after traumatically induced bone fractures in clinical conditions. This study encompasses the safety, resorption, healing process, and complications of surgical treatment. Our current hypothesis posits that calcium phosphate-based bone substitutes could improve bone healing. In this retrospective case-control study, over 290 patients who underwent surgical treatment for acute fractures were examined. Bone defects were augmented with calcium phosphate-based bone substitute material (CP) in comparison to with empty defect treatment (ED) between 2011 and 2018. A novel scoring system for fracture healing was introduced to assess bone healing in up to six radiological follow-up examinations. Furthermore, demographic data, concomitant diseases, and complications were subjected to analysis. Data analysis disclosed significantly fewer postoperative complications in the CP group relative to the ED group (p < 0.001). The CP group revealed decreased risks of experiencing complications (p < 0.001), arthrosis (p = 0.01), and neurological diseases (p < 0.001). The fracture edge, the fracture gap, and the articular surface were definably enhanced. Osteosynthesis and general bone density demonstrated similarity (p > 0.05). Subgroup analysis focusing on patients aged 64 years and older revealed a diminished complication incidence within the CP group (p = 0.025). Notably, the application of CP bone substitute materials showed discernible benefits in geriatric patients, evident by decreased rates of pseudarthrosis (p = 0.059). Intermediate follow-up evaluations disclosed marked enhancements in fracture gap, edge, and articular surface conditions through the utilization of CP-based substitutes (p < 0.05). In conclusion, calcium phosphate-based bone substitute materials assert their clinical integrity by demonstrating safety in clinical applications. They substantiate an accelerated early osseous healing trajectory while concurrently decreasing the severity of complications within the bone substitute cohort. In vivo advantages were demonstrated for CP bone graft substitutes.

Cranial meningioma with bone involvement: surgical strategies and clinical considerations

BACKGROUND

Intracranial meningioma with bone involvement and primary intraosseous meningioma is uncommon. There is currently no consensus for optimal management. This study aimed to describe the management strategy and outcomes for a 10-year illustrative cohort, and propose an algorithm to aid clinicians in selecting cranioplasty material in such patients.

METHODS

A single-centre, retrospective cohort study (January 2010-August 2021). All adult patients requiring cranial reconstruction due to meningioma with bone involvement or primary intraosseous meningioma were included. Baseline patient and meningioma characteristics, surgical strategy, and surgical morbidity were examined. Descriptive statistics were performed using SPSS v24.0. Data visualisation was performed using R v4.1.0.

RESULTS

Thirty-three patients were identified (mean age 56 years; SD 15) There were 19 females. Twenty-nine patients had secondary bone involvement (88%). Four had primary intraosseous meningioma (12%). Nineteen had gross total resection (GTR; 58%). Thirty had primary 'on-table' cranioplasty (91%). Cranioplasty materials included pre-fabricated polymethyl methacrylate (pPMMA) (n = 12; 36%), titanium mesh (n = 10; 30%), hand-moulded polymethyl methacrylate cement (hPMMA) (n = 4; 12%), pre-fabricated titanium plate (n = 4; 12%), hydroxyapatite (n = 2; 6%), and a single case combining titanium mesh with hPMMA cement (n = 1; 3%). Five patients required reoperation for a postoperative complication (15%).

CONCLUSION

Meningioma with bone involvement and primary intraosseous meningioma often requires cranial reconstruction, but this may not be evident prior to surgical resection. Our experience demonstrates that a wide variety of materials have been used successfully, but that pre-fabricated materials may be associated with fewer postoperative complications. Further research within this population is warranted to identify the most appropriate operative strategy.

Paradigm Shift in Materials for Skull Reconstruction Facilitated by Science and Technological Integration

The surgical repair of a bone deficiency in the skull caused by a prior procedure or accident is known as cranioplasty. There are various types of cranioplasties, but the majority entail raising the scalp and reshaping the skull using either the original piece of bone from the skull or a specially molded graft created from Titanium (plate or mesh), artificial bone in place of, a stable biomaterial (prefabricated customized implant to match the exact contour and shape of the skull). Cranioplasty, one of the oldest surgical treatments for cranial abnormalities, has undergone several changes throughout the years to discover the best material to improve patient outcomes. Various materials have been utilized in cranioplasty throughout history. As biomedical technology progresses, surgeons will have access to new materials. There is still no agreement on the optimum material, and research into biologic and nonbiologic alternatives is ongoing in the hopes of finding the finest reconstruction material. The materials and techniques used in cranioplasty are covered in this article.