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Intraoperative template-molded bone flap reconstruction for patient-specific cranioplasty

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Abstract

Cranioplasty is a common neurosurgical procedure. Free-hand molding of polymethyl methacrylate (PMMA) cement into complex three-dimensional shapes is often time-consuming and may result in disappointing cosmetic outcomes. Computer-assisted patient-specific implants address these disadvantages but are associated with long production times and high costs. In this study, we evaluated the clinical, radiological, and cosmetic outcomes of a time-saving and inexpensive intraoperative method to mold custom-made implants for immediate single-stage or delayed cranioplasty. Data were collected from patients in whom cranioplasty became necessary after removal of bone flaps affected by intracranial infection, tumor invasion, or trauma. A PMMA replica was cast between a negative form of the patient’s own bone flap and the original bone flap with exactly the same shape, thickness, and dimensions. Clinical and radiological follow-up was performed 2 months post-surgery. Patient satisfaction (Odom criteria) and cosmesis (visual analogue scale for cosmesis) were evaluated 1 to 3 years after cranioplasty. Twenty-seven patients underwent intraoperative template-molded patient-specific cranioplasty with PMMA. The indications for cranioplasty included bone flap infection (56%, n = 15), calvarian tumor resection (37%, n = 10), and defect after trauma (7%, n = 2). The mean duration of the molding procedure was 19 ± 7 min. Excellent radiological implant alignment was achieved in 94% of the cases. All (n = 23) but one patient rated the cosmetic outcome (mean 1.4 years after cranioplasty) as excellent (70%, n = 16) or good (26%, n = 6). Intraoperative cast-molded reconstructive cranioplasty is a feasible, accurate, fast, and cost-efficient technique that results in excellent cosmetic outcomes, even with large and complex skull defects.

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Acknowledgments, funding, and disclosure

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. We are indebted to the radiology technicians from the Institute of Neuroradiology, Bern University Hospital and University of Bern, Bern, Switzerland, for their diligent three-dimensional computer tomography reconstructions. Finally, we are especially grateful for the editorial support of Jeannie Wurz, Department of Intensive Care Medicine, Bern University Hospital, Bern, Switzerland and Susan Wieting, Department of Neurosurgery, Bern University Hospital, Bern, Switzerland.

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Authors and Affiliations

  1. Department of Neurosurgery, University Hospital Bern, Bern, Switzerland

    Serge Marbacher, Lukas Andereggen, Andreas Raabe & Jürgen Beck

  2. Department of Neurosurgery, Kantonsspital Aarau, 3010, Aarau, Switzerland

    Serge Marbacher, Salome Erhardt, Ali-Reza Fathi & Javier Fandino

Authors
  1. Serge Marbacher
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  2. Lukas Andereggen
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  3. Salome Erhardt
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  4. Ali-Reza Fathi
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  5. Javier Fandino
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  6. Andreas Raabe
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  7. Jürgen Beck
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Correspondence to Serge Marbacher.

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Comments

Siamak Asgari, Ingolstadt, Germany

The authors presented a retrospective study about 27 patients, who underwent one- or two-stage surgery for cranioplasty. Indication for cranioplasty were posttraumatic skull defects (n = 2), resection of tumors with skull involvement (n = 10), and bone flap infection (n = 15). The authors described a method of template-molded PMMA cranioplasty. The authors gave a very detailed analysis of intraoperative characteristics and the postoperative cosmetic results. Altogether, the described cranioplasty procedure is very cost-effective and showed excellent radiological and esthetic results. Finally, the main limitation of this strategy, the autologous bone resorption, was mentioned.

Philippe Bijlenga, Geneva, Switzerland

With more and more decompressive craniectomies performed for different reasons, a simple, safe, quick, and low-cost solution for cranioplasty, as described in this article, is very welcome.

The authors describe a simple method to generate a negative print of the patient’s bone flap that can then be used as a cast to build a Palacos® cement replica. This article shows that the method is not only feasible but also safe and rapid and presented an excellent radiological and cosmetic outcome in 27 patients. The method that is described in this article presents a long list of advantages and a unique limitation that resides in the absolute need of the original patient’s bone flap to serve as a model. Readers are invited to make their own experience and the future will tell us if the technique holds its promises and becomes a worldwide standard.

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Marbacher, S., Andereggen, L., Erhardt, S. et al. Intraoperative template-molded bone flap reconstruction for patient-specific cranioplasty. Neurosurg Rev 35, 527–535 (2012). https://doi.org/10.1007/s10143-012-0376-3

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  • DOI: https://doi.org/10.1007/s10143-012-0376-3

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