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

Abstract

Background Failure 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. Methods Sixty 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. Results A 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. Conclusion We 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.

Cranial bone flap resorption—pathological features and their implications for clinical treatment

“…The literature regarding a potential correlation between graft material and infection rate is inconsistent [1,3,17,19,20,22,24,38,42]. Matsuno et al describe a significant infection rate for titanium mesh compared to autologous bone flaps and PMMA [26].…”

Cost differences between autologous and nonautologous cranioplasty implants: A propensity score–matched value driven outcomes analysis

“…However, our autologous failure rate falls within the range of other published reports, which describe autologous cranioplasty failure rates of 7–40%. 6 , 7 , 8 , 17 , 34 , 35 , 36 Significant efforts are being made within both autologous and custom cranioplasty protocols/materials to lessen rates of postimplantation infection, necrosis, and resorption. 37 , 38 …”

An algorithmic approach of reconstruction for cranioplasty failure: A case series

“…[2,32] Furthermore, with the advancement of computer-assisted 3-dimensional printing techniques, the use of custom-made synthetic grafts not only reduces operation time and failure rate but also provides satisfying cosmetic contours. [2,33] However, some issues should be carefully considered before deciding on the optimal synthetic materials. PMMA accommodates skull growth poorly and should not be used in pediatric patients.…”