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Yan Z, Li X, Xia B, Xue C, Wang Y, Che H, Shen D, Guo S. Predictive factors influencing outcome of early cranioplasty after decompressive craniectomy: a outcome prediction model study. Front Neurol 2024; 15:1384320. [PMID: 38903167 PMCID: PMC11188394 DOI: 10.3389/fneur.2024.1384320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024] Open
Abstract
Objective The timing of cranioplasty (CP) has become a widely debated topic in research, there is currently no unified standard. To this end, we established a outcome prediction model to explore the factors influencing the outcome of early CP. Our aim is to provide theoretical and practical basis for whether patients with skull defects after decompressive craniectomy (DC) are suitable for early CP. Methods A total of 90 patients with early CP after DC from January 2020 to December 2021 were retrospectively collected as the training group, and another 52 patients with early CP after DC from January 2022 to March 2023 were collected as the validation group. The Nomogram was established to explore the predictive factors that affect the outcome of early CP by Least absolute shrinkage analysis and selection operator (LASSO) regression and Logistic regression analysis. Receiver operating characteristic (ROC) curve was used to evaluate the discrimination of the prediction model. Calibration curve was used to evaluate the accuracy of data fitting, and decision curve analysis (DCA) diagram was used to evaluate the benefit of using the model. Results Age, preoperative GCS, preoperative NIHSS, defect area, and interval time from DC to CP were the predictors of the risk prediction model of early CP in patients with skull defects. The area under ROC curve (AUC) of the training group was 0.924 (95%CI: 0.867-0.980), and the AUC of the validation group was 0.918 (95%CI, 0.842-0.993). Hosmer-Lemeshow fit test showed that the mean absolute error was small, and the fit degree was good. The probability threshold of decision risk curve was wide and had practical value. Conclusion The prediction model that considers the age, preoperative GCS, preoperative NIHSS, defect area, and interval time from DC has good predictive ability.
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Affiliation(s)
- Zhongnan Yan
- Department of Neurosurgery, Xi’an Gaoxin Hospital, Xi’an, Shaanxi, China
| | - Xiaolei Li
- Department of Neurosurgery, Xi’an Gaoxin Hospital, Xi’an, Shaanxi, China
| | - Bin Xia
- Department of Neurosurgery, Xi’an Gaoxin Hospital, Xi’an, Shaanxi, China
| | - Chaolin Xue
- Department of Neurosurgery, Xi’an Gaoxin Hospital, Xi’an, Shaanxi, China
| | - Yuangang Wang
- Department of Neurosurgery, Xi’an Gaoxin Hospital, Xi’an, Shaanxi, China
| | - Hongmin Che
- Department of Neurosurgery, Xi’an Gaoxin Hospital, Xi’an, Shaanxi, China
| | - Dongqing Shen
- Department of Neurosurgery, Xi’an Gaoxin Hospital, Xi’an, Shaanxi, China
| | - Shiwen Guo
- Department of Neurosurgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
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Chen K, Liang W, Zhu Q, Shen H, Yang Y, Li Y, Li H, Wang Y, Qian R. Clinical Outcomes After Cranioplasty With Titanium Mesh, Polyetheretherketone, or Composite Bone Cement: A Retrospective Study. J Craniofac Surg 2023; 34:2246-2251. [PMID: 37470720 PMCID: PMC10597434 DOI: 10.1097/scs.0000000000009542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/20/2023] [Indexed: 07/21/2023] Open
Abstract
Cranioplasty is a common neurosurgical procedure; however, the optimal material choice remains controversial. At the time of this writing, autologous bone, the preferred choice for primary cranioplasty, has a high incidence of complications such as infection and resorption, thus requiring frequent use of synthetic materials. Therefore, this study aimed to compare the clinical benefits of titanium mesh (Ti), polyetheretherketone (PEEK), and composite bone cement (CBC) in cranioplasty to provide a clear selection basis for clinicians and patients. This study retrospectively collected data from 207 patients who underwent cranioplasty with Ti (n=129), PEEK (n=54), and CBC (n=24) between January 2018 and December 2020 at Henan Provincial People's Hospital. Postoperative follow-up information after 6 months was used to compare the long-term effects of the 3 materials on the patients. There were no significant differences in the overall complication rate after cranioplasty among the 3 materials. However, subcutaneous effusion was more frequent with PEEK (24.07%) and CBC (20.83%) than with Ti (2.33%). Second, there were no significant differences in the increase in Glasgow Outcome Scale and Karnofsky Performance Status scores after cranioplasty among the 3 materials. Finally, we found that PEEK had the highest patient satisfaction and hospitalization cost, whereas the opposite was true for Ti. Although the surgical outcomes of the 3 implant materials were similar, an examination of clinical outcomes such as patient satisfaction showed significant differences, deepening people's perceptions of the 3 materials.
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Affiliation(s)
- Kui Chen
- Henan University People’s Hospital, Henan Provincial People’s Hospital
| | - Wenjia Liang
- Henan University People’s Hospital, Henan Provincial People’s Hospital
| | - Qingyun Zhu
- School of Clinical Medicine, Henan University, Henan Provincial People’s Hospital
| | - Haoyu Shen
- Zhenzhou University People’s Hospital, Henan Provincial People’s Hospital
| | - Youlei Yang
- Henan University People’s Hospital, Henan Provincial People’s Hospital
- Zhenzhou University People’s Hospital, Henan Provincial People’s Hospital
| | - Yanxin Li
- Zhenzhou University People’s Hospital, Henan Provincial People’s Hospital
| | - Haichun Li
- Department of Neurosurgery, Henan Provincial People’s Hospital
| | - Yonghong Wang
- Department of Neurosurgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University
| | - Rongjun Qian
- Department of Neurosurgery, Henan Provincial People’s Hospital, Henan University People’s Hospital, Zhengzhou University People’s Hospital, The First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, China
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Wei Z, Zhang Z, Zhu W, Weng X. Polyetheretherketone development in bone tissue engineering and orthopedic surgery. Front Bioeng Biotechnol 2023; 11:1207277. [PMID: 37456732 PMCID: PMC10345210 DOI: 10.3389/fbioe.2023.1207277] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/16/2023] [Indexed: 07/18/2023] Open
Abstract
Polyetheretherketone (PEEK) has been widely used in the medical field as an implant material, especially in bone tissue engineering and orthopedic surgery, in recent years. This material exhibits superior stability at high temperatures and is biosecured without harmful reactions. However, the chemical and biological inertness of PEEK still limits its applications. Recently, many approaches have been applied to improve its performance, including the modulation of physical morphology, chemical composition and antimicrobial agents, which advanced the osteointegration as well as antibacterial properties of PEEK materials. Based on the evolution of PEEK biomedical devices, many studies on the use of PEEK implants in spine surgery, joint surgery and trauma repair have been performed in the past few years, in most of which PEEK implants show better outcomes than traditional metal implants. This paper summarizes recent studies on the modification and application of biomedical PEEK materials, which provides further research directions for PEEK implants.
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Affiliation(s)
- Zhanqi Wei
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Ze Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Wei Zhu
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xisheng Weng
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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4
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Zhang J, Su Y, Rao X, Pang H, Zhu H, Liu L, Chen L, Li D, He J, Peng J, Jiang Y. Additively manufactured polyether ether ketone (PEEK) skull implant as an alternative to titanium mesh in cranioplasty. Int J Bioprint 2022; 9:634. [PMID: 36844244 PMCID: PMC9947379 DOI: 10.18063/ijb.v9i1.634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/05/2022] [Indexed: 11/06/2022] Open
Abstract
173Cranioplasty is used for skull defects, involving lifting the scalp and restoring the contour of the skull with the original skull piece, titanium mesh, or solid biomaterial. Additive manufacturing (AM) technology, known as three-dimensional (3D) printing, is now utilized by medical professionals to develop customized replicas of tissues, organs and bones, offering a valid option with perfect anatomic fitting in the individual and skeletal reconstruction. Here, we report a case that underwent titanium mesh cranioplasty 15 years ago. The poor appearance of the titanium mesh weakened the left eyebrow arch and resulted in the formation of a sinus tract. Cranioplasty was performed using an additively manufactured polyether ether ketone (PEEK) skull implant. PEEK skull implants have been successfully implanted without any complications. To our knowledge, this is the first reported case of direct use of fused filament fabrication (FFF)-fabricated PEEK implant for cranial repair. The FFF-printed PEEK customized skull implant could possess simultaneously with adjustable material thickness and more complex structure, tunable mechanical properties, and low processing costs compared with traditional manufacturing processes. While meeting clinical needs, this production method is an appropriate alternative for promoting the use of PEEK materials in cranioplasty.
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Affiliation(s)
- Jiaqi Zhang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China,Laboratory of Neurological Diseases and Brain Function, the Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Yanwen Su
- State Key Laboratory for Manufacturing Systems Engineering, Xi’an Jiaotong University, Xi’an 710049, China,National Medical Products Administration (NMPA) Key Laboratory for Research and Evaluation of Additive Manufacturing Medical Devices, Xi’an Jiaotong University, Xi’an 710049, China
| | - Xiao Rao
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China,Laboratory of Neurological Diseases and Brain Function, the Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Huanhao Pang
- State Key Laboratory for Manufacturing Systems Engineering, Xi’an Jiaotong University, Xi’an 710049, China,National Medical Products Administration (NMPA) Key Laboratory for Research and Evaluation of Additive Manufacturing Medical Devices, Xi’an Jiaotong University, Xi’an 710049, China
| | - Hui Zhu
- State Key Laboratory for Manufacturing Systems Engineering, Xi’an Jiaotong University, Xi’an 710049, China,National Medical Products Administration (NMPA) Key Laboratory for Research and Evaluation of Additive Manufacturing Medical Devices, Xi’an Jiaotong University, Xi’an 710049, China
| | - Liang Liu
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China,Sichuan Clinical Research Center for Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Ligang Chen
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China,Sichuan Clinical Research Center for Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Dichen Li
- State Key Laboratory for Manufacturing Systems Engineering, Xi’an Jiaotong University, Xi’an 710049, China,National Medical Products Administration (NMPA) Key Laboratory for Research and Evaluation of Additive Manufacturing Medical Devices, Xi’an Jiaotong University, Xi’an 710049, China
| | - Jiankang He
- State Key Laboratory for Manufacturing Systems Engineering, Xi’an Jiaotong University, Xi’an 710049, China,National Medical Products Administration (NMPA) Key Laboratory for Research and Evaluation of Additive Manufacturing Medical Devices, Xi’an Jiaotong University, Xi’an 710049, China,Corresponding authors: Yong Jiang () Jianhua Peng () Jiankang He ()
| | - Jianhua Peng
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China,Academician (Expert) Workstation of Sichuan Province, the Affiliated Hospital of Southwest Medical University, Luzhou 646000, China,Corresponding authors: Yong Jiang () Jianhua Peng () Jiankang He ()
| | - Yong Jiang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China,Laboratory of Neurological Diseases and Brain Function, the Affiliated Hospital of Southwest Medical University, Luzhou 646000, China,Institute of Epigenetics and Brain Science, Southwest Medical University, Luzhou 646000, China,Corresponding authors: Yong Jiang () Jianhua Peng () Jiankang He ()
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Ji T, Yao P, Zeng Y, Qian Z, Wang K, Gao L. Subgaleal Effusion and Brain Midline Shift After Cranioplasty: A Retrospective Study Between Polyetheretherketone Cranioplasty and Titanium Cranioplasty After Decompressive Craniectomy. Front Surg 2022; 9:923987. [PMID: 35937601 PMCID: PMC9351718 DOI: 10.3389/fsurg.2022.923987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/10/2022] [Indexed: 11/21/2022] Open
Abstract
Cranioplasty with polyetheretherketone (PEEK) has recently shown better cerebral protection performance, improved brain function, and aesthetic contour compared with titanium mesh. However, whether patients undergoing PEEK cranioplasty tend to develop subgaleal effusions remains elusive. This retrospective study included patients who underwent cranioplasty with PEEK implants or titanium mesh after decompressive craniectomy between July 2017 and July 2020. Patient information, including general information, location, size of the defect, subgaleal depth, and brain midline shift was collected and statistically analyzed. There were 130 cases of cranioplasty, including 35 with PEEK implants and 95 with a titanium mesh. Patients who underwent cranioplasty with a PEEK implant had a higher subgaleal effusion rate than those who underwent cranioplasty with titanium mesh (85.71% vs. 53.68%, P < 0.001), while a midline shift >5 mm was more frequently observed in the PEEK group than in the titanium group (20% vs. 6.3%, P = 0.021). The PEEK material was the only factor associated with subgaleal effusion after cranioplasty (OR 5.589, P = 0.002). Logistic regression analysis further showed that age was a protective factor against midline shift in the PEEK cranioplasty group (OR 0.837, P = 0.029). Patients who underwent cranioplasty with PEEK implants were more likely to develop severe subgaleal effusion and significant brain midline shifts than those with titanium mesh implants.
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Affiliation(s)
- Tao Ji
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Peiwen Yao
- School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Yu Zeng
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Zhouqi Qian
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Ke Wang
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
- Correspondence: Liang Gao Ke Wang
| | - Liang Gao
- School of Clinical Medicine, Nanjing Medical University, Nanjing, China
- Correspondence: Liang Gao Ke Wang
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Shi Y, Liu J, Du M, Zhang S, Liu Y, Yang H, Shi R, Guo Y, Song F, Zhao Y, Lan J. Customized Barrier Membrane (Titanium Alloy, Poly Ether-Ether Ketone and Unsintered Hydroxyapatite/Poly-l-Lactide) for Guided Bone Regeneration. Front Bioeng Biotechnol 2022; 10:916967. [PMID: 35837554 PMCID: PMC9273899 DOI: 10.3389/fbioe.2022.916967] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/09/2022] [Indexed: 12/15/2022] Open
Abstract
Sufficient bone volume is indispensable to achieve functional and aesthetic results in the fields of oral oncology, trauma, and implantology. Currently, guided bone regeneration (GBR) is widely used in reconstructing the alveolar ridge and repairing bone defects owing to its low technical sensitivity and considerable osteogenic effect. However, traditional barrier membranes such as collagen membranes or commercial titanium mesh cannot meet clinical requirements, such as lack of space-preserving ability, or may lead to more complications. With the development of digitalization and three-dimensional printing technology, the above problems can be addressed by employing customized barrier membranes to achieve space maintenance, precise predictability of bone graft, and optimization of patient-specific strategies. The article reviews the processes and advantages of three-dimensional computer-assisted surgery with GBR in maxillofacial reconstruction and alveolar bone augmentation; the properties of materials used in fabricating customized bone regeneration sheets; the promising bone regeneration potency of customized barrier membranes in clinical applications; and up-to-date achievements. This review aims to present a reference on the clinical aspects and future applications of customized barrier membranes.
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Affiliation(s)
- Yilin Shi
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
- Shandong Key Laboratory of Oral Tissue Regeneration, Jinan, China
- Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
| | - Jin Liu
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
- Shandong Key Laboratory of Oral Tissue Regeneration, Jinan, China
- Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
| | - Mi Du
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
- Shandong Key Laboratory of Oral Tissue Regeneration, Jinan, China
- Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
| | - Shengben Zhang
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
- Shandong Key Laboratory of Oral Tissue Regeneration, Jinan, China
- Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
| | - Yue Liu
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
- Shandong Key Laboratory of Oral Tissue Regeneration, Jinan, China
- Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
| | - Hu Yang
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
- Shandong Key Laboratory of Oral Tissue Regeneration, Jinan, China
- Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
| | - Ruiwen Shi
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
- Shandong Key Laboratory of Oral Tissue Regeneration, Jinan, China
- Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
| | - Yuanyuan Guo
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
- Shandong Key Laboratory of Oral Tissue Regeneration, Jinan, China
- Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
| | - Feng Song
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
- Shandong Key Laboratory of Oral Tissue Regeneration, Jinan, China
- Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
| | - Yajun Zhao
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
- Shandong Key Laboratory of Oral Tissue Regeneration, Jinan, China
- Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
| | - Jing Lan
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
- Shandong Key Laboratory of Oral Tissue Regeneration, Jinan, China
- Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
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Medical 3D Printing with a focus on Point-of-Care in Cranio- and Maxillofacial Surgery. A systematic review of literature. ANNALS OF 3D PRINTED MEDICINE 2022. [DOI: 10.1016/j.stlm.2022.100059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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8
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Histological Processing of CAD/CAM Titanium Scaffold after Long-Term Failure in Cranioplasty. MATERIALS 2022; 15:ma15030982. [PMID: 35160928 PMCID: PMC8839919 DOI: 10.3390/ma15030982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/17/2022] [Accepted: 01/25/2022] [Indexed: 02/01/2023]
Abstract
Cranioplasty is a frequently performed procedure after craniectomy and includes several techniques with different materials. Due to high overall complication rates, alloplastic implants are removed in many cases. Lack of implant material osseointegration is often assumed as a reason for failure, but no study has proven this in cranioplasty. This study histologically evaluates the osteointegration of a computer-aided design and computer-aided manufacturing (CAD/CAM) titanium scaffold with an open mesh structure used for cranioplasty. A CAD/CAM titanium scaffold was removed due to late soft tissue complications 7.6 years after cranioplasty. The histological analyses involved the preparation of non-decalcified slices from the scaffold’s inner and outer sides as well as a light-microscopic evaluation, including the quantification of the bone that had formed over the years. Within the scaffold pores, vital connective tissue with both blood vessels and nerves was found. Exclusive bone formation only occurred at the edges of the implant, covering 0.21% of the skin-facing outer surface area. The inner scaffold surface, facing towards the brain, did not show any mineralization at all. Although conventional alloplastic materials for cranioplasty reduce surgery time and provide good esthetic results while mechanically protecting the underlying structures, a lack of adequate stimuli could explain the limited bone formation found. CAD/CAM porous titanium scaffolds alone insufficiently osseointegrate in such large bone defects of the skull. Future research should investigate alternative routes that enable long-term osteointegration in order to reduce complication rates after cranioplasty. Opportunities could be found in mechano-biologically optimized scaffolds, material modifications, surface coatings, or other routes to sustain bone formation.
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