Spontaneous fracture of a titanium mesh cranioplasty implant in a child: A case report

BACKGROUND Titanium mesh cranioplasty is often performed after decompressive craniectomy.Spontaneous fracture of the titanium prosthesis is an extremely rare postoperative complication.Here,we report a 10-year-old boy who presented with a spontaneous fracture of titanium mesh without antecedent head trauma.CASE SUMMARY A 10-year-old boy presented with a 1-wk history of a tender bulge over the left temporo-parieto-occipital scalp.He had undergone a temporo-parieto-occipital titanium mesh cranioplasty 26 mo previously.He denied antecedent head trauma.Computerized tomography disclosed a perpendicular fissure in the titanium mesh,suggesting a diagnosis of spontaneous titanium mesh fracture.He underwent a second temporo-parieto-occipital cranioplasty and made an uneventful recovery.Three-dimensional modeling and finite element analyses were used to explore potential risk factors of titanium mesh fracture.CONCLUSION We report a case of spontaneous fracture of a titanium mesh cranioplasty implant.The current case and literature review indicate that titanium mesh implants should be well-anchored to the base of bony defects to prevent fatigue-induced fractures.

Autogenous Bone Graft versus Artificial Substitutes in Cranioplasty

Cranioplasty is a routine procedure in neurosurgery. However, it has a high postoperative complication rate up to 40%. The lack of good prospective studies and the small number of patients who receive artificial substitutes make it difficult to choose between different materials and the decision is mostly based on subjective or economic reasons. The main goal of this study was to compare the most common complications related to the implant within the first year after implantation. Methods: This prospective randomized clinical study has been carried out on 32 patients with cranial defects of different etiologies, sites and sizes which have been operated in Assiut University Hospital from January 2016 to January 2017. The patients were randomized into two groups: Autologous and Artificial group. Each group has 16 patients. Results: The overall complication rate in autologous group was found to be (25%) and in artificial group (37.5%). Infection in autologous group was found in (6.25%), in artificial group was found in (12.5%). Bone resorption was found in (12.5%). For epidural hematoma and wound dehiscence each has a rate of (6.25%). Poor cosmetic result in (18.75%) of artificial group. Conclusion: Cranioplasty is not without complications. However, good decision making, good timing and proper surgical techniques can provide excellent results. Primary titanium mesh cranioplasty should be considered especially in young adult patients with traumatic aetiology of bone defect.

Cranioplasty after Decompressive Craniectomy Caused an Intracerebral Hemorrhage: A Case Report

Decompressive craniectomy is a common practice for patients with intracranial hypertension. Secondary rigid structural reconstruction following craniectomy can release the effects of atmospheric pressure on the brain, and the brain can become dilated. Although some cases with complications induced by cranioplasty, such as intracranial hematoma, have been reported, no clinical cases with intracerebral hemorrhage after rigid reconstruction have been reported. This case report describes a 39-year-old man with a skull defect following clipping with simultaneous decompressive craniectomy for a subarachnoid hemorrhage. About 25 months later, cranioplasty using a custom-made hydroxyapatite (HAP) ceramic implant was performed. Immediately after the operation, intracerebral hemorrhage was detected on the opposite side by computed tomography (CT). However, there were no physical or neurological findings, the hematoma was completely absorbed within 3 weeks postoperatively, and the skull retained a good shape. This case suggests that rigid reconstruction of a skull defect can influence intracranial conditions, and early postoperative CT is important to detect complications.

Traumatic Acute Subdural Hematoma: Treatment by Evacuation with Decompressive Craniotomy and Cranioplasty, Case Series and Surgical Outcome Analysis

Background: Acute subdural hematoma (ASDH) is considered the most common traumatic brain mass lesion. Its prognosis is still grave despite the improvements in treatment modalities. Its mortality rate was reported to be around 60% until the 1990s. In the last decade, ASDH mortality rate was reduced to the level of 20% - 40%. Standard treatment to decrease intracranial tension via hematoma evacuation is associated with decompressive craniotomy and followed by ICU management. Objective: To evaluate the outcome and prognostic factors in patients of acute subdural hematoma treated by surgical evacuation and decompressive craniotomy. Also, outcome of cranioplasty by repositioning of patients own bone or by synthetic mesh methods is evaluated. Patients and Methods: It is one year retrospective study. It was conducted on 53 patients, in trauma unit, Assiut university hospitals. We report time lag between trauma and performed surgery, initial Glasgow coma scale (GCS), age, sex and presence of other intracranial pathologies. Outcome assessment is based on Glasgow outcome scale (GOS) and fol-low-up extended for 6 months. We include those patients with only (isolated) head trauma, shift of midline more than 5 mm in CT brain. We excluded pa-tients with GCS 3 and fixed dilated pupils as well as patients with GCS higher than 12. We did decompressive craniotomy and duraplasty in all patients. Bone flap of decompressive craniotomy is situated in the abdomen. All func-tionally recovered patients were submitted for cranioplasty with either re-placing patient own bone or by Titanium mesh. Results: We had 39 males and 14 females. Age ranged between 7 and 65 years old. 23 deaths, 10 persis-tent vegetative state, 10 severe disability, 8 moderate disability and 2 good recovery. The outcome analysis was based on 6 month follow-up. Conclu-sion: Acute subdural hematoma is a very serious condition. Mortality and morbidity is intimately related to GCS on admission. Presence of associated cerebral pathology increases mortality and morbidity of patients with post-traumatic acute subdural hematoma. Early evacuation of posttraumatic acute subdural hematoma with decompressive craniotomy is an important method to control raised intracranial tension, reduce shift of midline and very benefi-cial in decreasing mortality and morbidity. Regarding infection and avoiding bone flap resorption, Titanium mesh is better than patient own bone during cranioplasty after patient recovery.

Drainage and Cranioplasty as a Treatment for Traumatic Subdural Hygroma Secondary to Decompressive Craniectomy

Background: Decompressive craniectomy (DC) is performed to accommodate life-threatening brain swelling when medical treatment fails. This procedure carries the risk of developing traumatic subdural hygroma (TSH) that can adversely affect the neurological status of the patient. The treatment for persistence of TSH includes drainage and shunt placement or drainage and membranectomy. In this paper, we present treatment of two patients whose TSH was effectively treated with simple drainage and cranioplasty. Case Presentation: Patient 1: The patient is a 34-year-old female who had bilateral craniectomy for brain swelling. Four weeks later she became less interactive. CT scan showed bilateral subdural hygroma with 2 cm midline shift to the left. Her clinical status improved and CT scans showed resolution of the hygroma after simple evacuation of the hygroma and cranioplasty. Patient 2: The patient is a 57-year-old male who had post-traumatic acute subdural hematoma and brain swelling on the left side. The clot was evacuated and the bone flap was left out. After showing initial improvement, 10 weeks after the initial surgery the patient progressively worsened and became unresponsive. CT scans showed a large subdural hygroma on the right with midline shift to the left. Simple evacuation of the hygroma and cranioplasty was done. This resulted in radiological and clinical improvement of the patient. Conclusions: Both patients underwent simple drainage and cranioplasty, which resulted in clinical and radiological improvement. This finding suggests that other procedures such as membranectomy and shunting may not be necessary to treat TSH.

Cranioplasty with custom made alloplastic prosthetic implant: A case report

Cranial defects often occur due to trauma. The treatment of such defects is a challenge to the skill and knowledge of the practitioner. This article presents one such case, where a 15-year-old boy had suffered extensive loss of the right cranium following a road traffic accident. The patient required rehabilitation of the right fronto-temporal cranial anatomy and was managed using a custom made heat polymerized acrylic alloplastic implant.

The design and application of NiTi shape memory alloy bow staple in cranioplasty

The NiTi shape memory alloy (SMA) bow staple consists of an arched body,one front arm and one rear arm.It has the function of shape memory and manyadvantages,i.e.,high strength,low specific gravity,strong retrieving force,highresistance to fatigue and erosion,nontoxicity,nonmagnetism and goodhistocompatibility.It can be widely used and make the fixation convenient and ef-fective.The staple has been used clinically in 152 cases of cranioplasty.Resultshave showed that duration of the operation is shortened and harm during the op-eration is reduced,because dura mater needn’t be seperated and the skull needn’tbe penetrated through.Some complications can be avoided and the operationbecomes simpler,safer and more reliable.The bow staple is suitable for fixationwith any kind of repairing material in cranioplasty and does not interfere withthe CT and MRI reexaminations.

Cranioplasty of Calvarial Skull Defects: A Comparative Study between Using Three Dimensional Custom-Made Cranioprostheses versus Hand-Made Bone Cement in Restoring Skull Configuration

Introduction: Cranioplasty is the surgical repair of a bony defect or deformity in the skull that is caused after cranial surgery or trauma. It carries cosmetic and protective benefits. Many types of materials are allowed. The subject of this study is to compare the outcome of two different manufacturing processes in reconstruction of calvarial skull defects by using 3D custom-made cranioprostheses versus hand-made bone cement implants. Patient and Methods: This is a prospective comparative study conducted on 20 patients of calvarial skull defects of different etiologies, sites and sizes, admitted in the neurosurgical departments of Cairo and Fayoum Universities in the period from August 2017 to February 2018. Patients are divided into two study groups: (group 1) 10 patients operated upon by 3D custom-made implant;(group 2) operated upon by hand-made bone cement implant. Statistical Analysis Used: Mann-Whitney test and Chi-square test. Results: Craniotomy using 3D custom-made implants gives better results than using bone cement in the functional restoration of skull shape and cranial protection with shorter operative time and less rate of postoperative complications. There is no statistically significant difference between the two study groups regarding cosmetic outcome. Conclusion: 3D custom-made implant is recommended for large and complex skull defects. Further and large studies might be needed.

Titanium mesh implants exposure after cranioplasty in two children: involvement of osteogenesis?

Background: Although technically regarded as a simple procedure, titanium mesh cranioplasty could lead to various surgical complications, including postoperative implant exposure. However, there is little data available on the occurrence and risk factors of this complication in the pediatric population. Cases presentation: Two pediatric male patients, one 12-year-old and one 7-year-old, had decompressive craniectomy after traumatic brain injuries and subsequent cranioplasty with titanium mesh. However, both patients had skin defects developed gradually at the scalp adjacent to the surgical incisions, 11 and 7 months after cranioplasty, respectively. Implants removal surgeries were then delivered and, during the operation, some bone debris were found just beneath the skin defects in both patients. Because microbiological culture results of the exudations were negative, in addition to the long interval between cranioplasty and developments of skin defects, surgical infections might not be major causes of the observed titanium implants exposures. On the other hand, local osteogenesis and impaired scalp blood supply might contribute to their occurrence. Conclusions: Efforts should be made to achieve complete clearance of bone debris and protect scalp blood supply during the initial decompressive craniectomy in order to minimize the risks of subsequent titanium mesh exposures.

Skull repair materials applied in cranioplasty: History and progress

The skull provides protection and mechanical support, and acts as a container for the brain and its accessory organs. Some defects in the skull can fatally threaten human life.Many efforts have been taken to repair defects in the skull, among which cranioplasty is the most prominent technique. To repair the injury, numerous natural and artificial materials have been adopted by neurosurgeons. Many cranioprostheses have been tried in the past decades, from autoplast to bioceramics. Neurosurgeons have been evaluating their advantages and shortages through clinical practice. Among those prostheses, surgeons gradually prefer bionic ones due to their marvelous osteoconductivity,osteoinductivity, biocompatibility, and biodegradability. Autogeneic bone has been widely recognized as the "gold standard" for renovating large-sized bone defects. However, the access to this technique is restricted by limited availability and complications associated with its use. Many metal and polymeric materials with mechanical characteristics analogous to natural bones were consequently applied to cranioplasty. But most of them were unsatisfactory concerning osteoconductiion and biodegradability owe to their intrinsic properties. With the microstructures almost identical to natural bones, mineralized collagen has biological performance nearly identical to autogeneic bone, such as osteoconduction. Implants made of mineralized collagen can integrate themselves into the newly formed bones through a process called "creeping substitution". In this review, the authors retrospect the evolution of skull repair material applied in cranioplasty. The ultimate skull repair material should have microstructure and bioactive qualities that enable osteogenesis induction and intramembranous ossification.

Investigation of operative skills and cranioplasty complications using biomimetic bone(nano-hap/collagen composites)

The aim of the current study was to investigate the operation skills and complications associated with skull defect repair using biomimetic bone(nano-hap/collagen composites). Clinical data from 45 patients with skull defects who underwent cranioplasty with biomimetic bone from January 2014 to January 2017 were retrospectively analyzed.All patients participated in follow-up visits from 8 months to 3 years postoperatively. Cranioplasties were successful in all 45 patients,but 17 patients(20 cases) presented various complications, including subcutaneous hydrops(14 cases), biomimetic bone fixation loosening(4 cases), wound indolence(1 case), and biomimetic bone fragmentation(1 case). Cranioplasty complications in surgeries using biomimetic bone are more common in children than in adults.Understanding the physicochemical properties of biomimetic bone and the normal developmental process in children, as well as mastering the appropriate surgical skills and implementing the effective preventive measures are all ways to reduce and control the incidence of complications associated with biomimetic bone cranioplasty.

Individual Cranium Reconstruction with CAD/CAM

Treatment of cranium and maxilla defects using CAD/ CA M techniques has been under the way. This makes it possible to rehabilitate the defective skull, to protect the intracranial structure from damage and to give t he patient an individual implant with satisfying visual effect at same time. The general process of treatment are picking-up the shape information of defective skull from CT pictures of the patient, reconstructing 3-dimensional model of t he defect part, transforming the image data into manufacture data, and manufactu ring stage by means of choosing manufacture methods and certain material. As the prophase work a set of techniques was illustrated in the paper. The way of transforming helical CT data into an individual implant was introduced generally . Meanwhile, a prospective study of computer aided design and manufacture of tit anium skull for cranioplasty was reported. On these basic efforts, several resea rches and developments of relative techniques were described in detail inclu ding data conversion, 3-dimensional modeling and acquisition of the defect part geometric model. Data conversion focused on three points. The first one is about transforming the original CT information into digital data. The second one is about converting t he bitmap format data into vectorgraph format that is available for geometric mo deling in CAD system. And the third one is about finding a datum of all sect ion information in order to put the single slices together. The reconstructing o f 3-demetional entire skull model is achieved with two kinds of model. The 3D w ire model, which consists of a set of wires, is accomplished by translating the 2D plane information into 3D data in CAD system. This wire model is constructed ulteriorly to a surface model. During the efforts of gaining the surfaces geomet ry of the defect part, different means is used depending on where the defect loc ation is. Once the numerical based 3-dimensional model of the skull defect is e stablished the fixation design becomes a critical factors during the surgery, wh ich decides the vision effect and plays an important role in the success of the operation. For a finer prognosis a fixation interface, which is generated by the borders of the defect part and the surface contours considering the non-affect ed neighboring contours, is arranged.

A high-strength mineralized collagen bone scaffold for large-sized cranial bone defect repair in sheep

Large-sized cranial bone defect repair presents a great challenge in the clinic.The ideal cranioplasty materials to realize the functional and cosmetic recovery of the defect must have sufficient mechanical support,excellent biocompatibility,good osseointegration and biodegradability as well.In this study,a high-strength mineralized collagen(MC)bone scaffold was developed with biomimetic composition,microstructure and mechanical properties for the repair of sheep largesized cranial bone defects in comparison with two traditional cranioplasty materials,polymethyl methacrylate and titanium mesh.The compact MC scaffold showed no distinct pore structure and therefore possessed good mechanical properties.The strength and elastic modulus of the scaffold were much higher than those of natural cancellous bone and slightly lower than those of natural compact bone.In vitro cytocompatibility evaluation revealed that the human bone marrow mesenchymal stem cells(hBMSC)had good viability,attachment and proliferation on the compact MC scaffold indicating its excellent biocompatibility.An adult sheep cranial bone defect model was constructed to evaluate the performances of these cranioplasty materials in repairing the cranial bone defects.The results were investigated by gross observation,computed tomography scanning as well as histological assessments.The in vivo evaluations indicated that compact MC scaffold showed notable osteoconductivity and osseointegration with surrounding cranial bone tissues by promoting bone regeneration.Our results suggested that the compact MC scaffold has a promising potential for large-sized cranial bone defect repair.

Personalized Cranium Defects Restoration Technique Based on Reverse Engineering

The purpose of this paper is to overcome the limitations of the traditional cranial defects restoration technique and better satisfy the aesthetic and comfort demands of different patients. An arithmetic profile curve blending technique was used based on a well-proportioned points cloud data obtained by analyzing computer tomography (CT) images of the patients. This technique uses reverse engineering technique to reconstruct a model of the defective cranium, taking all the characteristics of the protruding cranium into consideration to check the form and appropriateness of the restoration and to adjust the surface in real time to obtain the ideal shape. Then, the model is transferred to a multiple-point forming (MPF) pressure machine to produce a titanium alloy restoration model. The system has greater flexibility, shorter production cycles, and lower cost through the use of digital production technology, guarantees the quality of the cranial defects restoration model, reduces the surgical risks, and alleviates the patients’ pain. In addition, an improved contour curved bridge algorithm technique is used to repair any cranium defects on the contour curve to make the contour more complete and closed.

Repairing skull defects in children with nano-hap/collagen composites: A clinical report of thirteen cases

Objective:To evaluate the clinical results of repairing skull defects with biomimetic bone(nano-hap/collagen composites,NHACs)in children.Methods:Thirteen children with skull defects were treated with NHACs in our hospital.The NHACs molded with the help of a 3D printer were used in the operations.Results:All 13 operations were successful,and patients recovered without infection.Only one patient suffered from subcutaneous hydrops post-operation.The implanted NHACs remained fixed well after 1 year,and their CT HU values raised gradually.Skull shapes of children developed normally.Recovery of neurological and cognitive function was significant.Conclusions:NHAC,chosen to repair skull defects in children,can coexist with normal skull and reduce the negative effects on growth and development.NHAC could be a good choice for children with skull defects.

Biomaterials for reconstruction of cranial defects

Reconstruction of cranial defect is commonly performed in neurosurgical operations. Many materials have been employed for repairing cranial defects. In this paper, materials used for cranioplasty, including autografts, allografts, and synthetic biomaterials are comprehensively reviewed. This paper also gives future perspective of the materials and development trend of manufacturing process for cranioplasty implants.

The diagnosis and treatment strategy of occipital skull mass in hemophilic patients: a rare case report and literature review

Cranial hemophilic pseudotumor (cHPT) is a very rare disease, which is easy to misdiagnose. It is also difficult to manage such patients. We reported the first case of occipital cHPT. Case presentation: Here, we presented a rare case of an occipital bone mass in a 3-year-old boy who was diagnosed with hemophilia A. The mass was misdiagnosed as an aneurysmal bone cyst by pathological examination. After resection, the patient underwent one-stage cranioplasty. However, the patient was admitted again for hematoma caused by an invasive procedure. A second surgery and one-stage cranioplasty were performed at the same time. A follow-up 3 months after discharging showed the patient was uneventful, and the titanium mesh was well fixed. Conclusion: The diagnosis of cHPT requires the combining of history, radiological examination, and pathological examination. Resection is the best choice for symptomatic cHPT. Replacement treatment and less invasive treatment can make perioperative management safer. One-stage cranioplasty for resection of an occipital cHPT can improve the quality of life.

Surgical pitfalls with custom-made porous hydroxyapatite cranial implants

Aim:Cranioplasty implants are used primarily in cases of surgical cranial decompression following pathological elevations of intracranial pressure.Available bone substitutes include porous hydroxyapatite(HA)and polymethylmethacrylate.Whichever material is used,however,prosthetic cranial implants are susceptible to intra-and postsurgical complications and even failure.The aim of this study was to investigate such occurrences in HA cranioplasty implants,seeking not only to determine the likely causes(whether correlated or not with the device itself)but also,where possible,to suggest countermeasures.Methods:We analyzed information regarding failures or complications reported in postmarketing surveillance and clinical studies of patients treated worldwide with custom-made HA cranial implants(Custom Bone Service Fin-Ceramica Faenza,Italy)in the period 1997-2013.Results:The two most common complications were implant fractures(84 cases,2.9%of the total fitted)and infections(51 cases,1.77%).Conclusion:Although cranioplasties are superficial and not difficult types of surgery,and use of custom-made implants are often considered the“easy”option from a surgical perspective,these procedures are nonetheless plagued by potential pitfalls.If performed well they yield more than satisfactory results from the points of view of both the patient and surgeon,but lack of appropriate care can open the door to numerous potential sources of failure,which can compromise-even irreparably-the ability to heal.