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

Abstract

Objective

Cranioplasty remains an essential procedure following craniectomy but is associated with high morbidity. We investigated factors associated with outcomes following first alloplastic cranioplasty.

Methods

A single-centre, retrospective cohort study of patients undergoing first alloplastic cranioplasty at a tertiary neuroscience centre (01 March 2010–01 September 2021). Patient demographics and craniectomy/cranioplasty details were extracted. Primary outcome was all-cause explantation. Secondary outcomes were explantation secondary to infection, surgical morbidity and mortality. Multivariable analysis was performed using Cox proportional hazards regression or binary logistic regression.

Results

Included were 287 patients with a mean age of 42.9 years [SD = 15.4] at time of cranioplasty. The most common indication for craniectomy was traumatic brain injury (32.1%, n = 92). Cranioplasty materials included titanium plate (23.3%, n = 67), hydroxyapatite (22.3%, n = 64), acrylic (20.6%, n = 59), titanium mesh (19.2%, n = 55), hand-moulded PMMA cement (9.1%, n = 26) and PEEK (5.6%, n = 16). Median follow-up time after cranioplasty was 86.5 months (IQR 44.6–111.3). All-cause explantation was 12.2% (n = 35). Eighty-three patients (28.9%) had surgical morbidity. In multivariable analysis, the risk of all-cause explantation and explantation due to infection was reduced with the use of both hydroxyapatite (HR 0.22 [95% CI 0.07–0.71], p = .011, HR 0.22 [95% CI 0.05–0.93], p = .040) and acrylic (HR 0.20 [95% CI 0.06–0.73], p = .015, HR 0.24 [95% CI 0.06–0.97], p = .045), respectively. In addition, risk of explantation due to infection was increased when time to cranioplasty was between three and six months (HR 6.38 [95% CI 1.35–30.19], p = .020). Mean age at cranioplasty (HR 1.47 [95% CI 1.03–2.11], p = .034), titanium mesh (HR 5.36 [95% CI 1.88–15.24], p = .002), and use of a drain (HR 3.37 [95% CI 1.51–7.51], p = .003) increased risk of mortality.

Conclusions

Morbidity is high following cranioplasty, with over a tenth requiring explantation. Hydroxyapatite and acrylic were associated with reduced risk of all-cause explantation and explantation due to infection. Cranioplasty insertion at three to six months was associated with increased risk of explantation due to infection.

Keywords:

• Cranioplasty
• morbidity
• mortality
• titanium
• acrylic
• hydroxyapatite

Acknowledgements

Portions of this work were presented in poster form at the Society of British Neurological Surgeons Spring Meeting, Manchester, March 2019, and orally at the online congress of the European Association of Neurological Surgeons, October 2021.

Disclosure statement

CPM is a clinical research fellow at the University of Liverpool, funded by a grant from The Brain Tumour Charity. There are no known conflicts of interest to declare from any author.

Additional information

Funding

The authors reported there is no funding associated with the work featured in this article.