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

Neurosurgical Review volume 35, pages 527–535 (2012)Cite this article

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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References

  1. Alesch F, Bauer R (1985) Polyacryl prosthesis for cranioplasty—their production in silicon rubber casts. Acta Neurochir (Wien) 77:68–71

    Article  CAS  Google Scholar 

  2. Andrzejak S, Fortuniak J, Wrobel-Wisniewska G, Zawirski M (2005) Clinical evaluation of the polypropylene-polyester knit used as a cranioplasty material. Acta Neurochir (Wien) 147:973–976

    Article  CAS  Google Scholar 

  3. Auguste KI, McDermott MW (2006) Salvage of infected craniotomy bone flaps with the wash-in, wash-out indwelling antibiotic irrigation system. Technical note and case series of 12 patients. J Neurosurg 105:640–644

    PubMed  Article  Google Scholar 

  4. Bhargava D, Bartlett P, Russell J, Liddington M, Tyagi A, Chumas P (2009) Construction of titanium cranioplasty plate using craniectomy bone flap as template. Acta Neurochir (Wien) 152(1):173–176

    Article  Google Scholar 

  5. Bishop A, Gooch R, Eguchi A, Jeffrey S, Smallwood L, Anderson J, Estevez AG (2009) Mitigation of peroxynitrite-mediated nitric oxide (NO) toxicity as a mechanism of induced adaptive NO resistance in the CNS. J Neurochem 109:74–84

    PubMed  Article  CAS  Google Scholar 

  6. Bruce JN, Bruce SS (2003) Preservation of bone flaps in patients with postcraniotomy infections. J Neurosurg 98:1203–1207

    PubMed  Article  Google Scholar 

  7. Cabraja M, Klein M, Lehmann TN (2009) Long-term results following titanium cranioplasty of large skull defects. Neurosurg Focus 26:E10

    PubMed  Article  Google Scholar 

  8. Chen TM, Tsai JC, Burnouf T (2008) Cranioplasty using osteoconductive scaffold and platelet glue. J Trauma 65:1321–1327

    PubMed  Article  Google Scholar 

  9. Cheng YK, Weng HH, Yang JT, Lee MH, Wang TC, Chang CN (2008) Factors affecting graft infection after cranioplasty. J Clin Neurosci 15:1115–1119

    PubMed  Article  Google Scholar 

  10. Dashti SR, Baharvahdat H, Spetzler RF, Sauvageau E, Chang SW, Stiefel MF, Park MS, Bambakidis NC (2008) Operative intracranial infection following craniotomy. Neurosurg Focus 24:E10

    PubMed  Article  Google Scholar 

  11. Dujovny M, Aviles A, Agner C, Fernandez P, Charbel FT (1997) Cranioplasty: cosmetic or therapeutic? Surg Neurol 47:238–241

    PubMed  Article  CAS  Google Scholar 

  12. Eppley BL (2005) Biomechanical testing of alloplastic PMMA cranioplasty materials. J Craniofac Surg 16:140–143

    PubMed  Article  Google Scholar 

  13. Fathi AR, Marbacher S, Lukes A (2008) Cost-effective patient-specific intraoperative molded cranioplasty. J Craniofac Surg 19:777–781

    PubMed  Article  Google Scholar 

  14. Fodstad H, Love JA, Ekstedt J, Friden H, Liliequist B (1984) Effect of cranioplasty on cerebrospinal fluid hydrodynamics in patients with the syndrome of the trephined. Acta Neurochir (Wien) 70:21–30

    Article  CAS  Google Scholar 

  15. Gladstone HB, McDermott MW, Cooke DD (1995) Implants for cranioplasty. Otolaryngol Clin North Am 28:381–400

    PubMed  CAS  Google Scholar 

  16. Gliese M, Handel G, Brawanski A (2000) A simple and cosmetically ideal method for cranioplasty. Zentralbl Neurochir 61:155–157

    PubMed  Article  CAS  Google Scholar 

  17. Golz T, Graham CR, Busch LC, Wulf J, Winder RJ (2010) Temperature elevation during simulated polymethylmethacrylate (PMMA) cranioplasty in a cadaver model. J Clin Neurosci 17(5):617–622

    PubMed  Article  CAS  Google Scholar 

  18. Gooch MR, Gin GE, Kenning TJ, German JW (2009) Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases. Neurosurg Focus 26:E9

    PubMed  Article  Google Scholar 

  19. Grant FC, Norcross NC (1939) Repair of cranial defects by cranioplasty. Ann Surg 110:488–512

    PubMed  Article  CAS  Google Scholar 

  20. Grantham EC, Landis HP (1948) Cranioplasty and the post-traumatic syndrome. J Neurosurg 5:19–22

    PubMed  Article  CAS  Google Scholar 

  21. Jankowitz BT, Kondziolka DS (2006) When the bone flap hits the floor. Neurosurgery 59:585–590

    PubMed  Article  Google Scholar 

  22. Josan VA, Sgouros S, Walsh AR, Dover MS, Nishikawa H, Hockley AD (2005) Cranioplasty in children. Childs Nerv Syst 21(3):200–204

    PubMed  Article  CAS  Google Scholar 

  23. Joseph V, Reilly P (2009) Syndrome of the trephined. J Neurosurg 111:650–652

    PubMed  Article  Google Scholar 

  24. Kalteis T, Luring C, Gugler G, Zysk S, Caro W, Handel M, Grifka J (2004) Acute tissue toxicity of PMMA bone cements. Z Orthop Ihre Grenzgeb 142:666–672

    PubMed  Article  CAS  Google Scholar 

  25. Kelly ME, Fourney DR, Guzman R, Sadanand V, Griebel RW, Sanche SE (2006) Propionibacterium acnes infections after cranial neurosurgery. Can J Neurol Sci 33:292–295

    PubMed  Google Scholar 

  26. Kirby BS, Doyle A, Gilula LA (2003) Acute bronchospasm due to exposure to polymethylmethacrylate vapors during percutaneous vertebroplasty. AJR Am J Roentgenol 180:543–544

    PubMed  Google Scholar 

  27. Kobayashi S, Hara H, Okudera H, Takemae T, Sugita K (1987) Usefulness of ceramic implants in neurosurgery. Neurosurgery 21:751–755

    PubMed  Article  CAS  Google Scholar 

  28. Lee SC, Wu CT, Lee ST, Chen PJ (2009) Cranioplasty using polymethyl methacrylate prostheses. J Clin Neurosci 16:56–63

    PubMed  Article  CAS  Google Scholar 

  29. Li C, Mason J, Yakimicki D (2004) Thermal characterization of PMMA-based bone cement curing. J Mater Sci Mater Med 15:85–89

    PubMed  Article  CAS  Google Scholar 

  30. Liang W, Xiaofeng Y, Weiguo L, Gang S, Xuesheng Z, Fei C, Gu L (2007) Cranioplasty of large cranial defect at an early stage after decompressive craniectomy performed for severe head trauma. J Craniofac Surg 18:526–532

    PubMed  Article  Google Scholar 

  31. Manson PN, Crawley WA, Hoopes JE (1986) Frontal cranioplasty: risk factors and choice of cranial vault reconstructive material. Plast Reconstr Surg 77:888–904

    PubMed  Article  CAS  Google Scholar 

  32. Marbacher S, Andres RH, Fathi AR, Fandino J (2008) Primary reconstruction of open depressed skull fractures with titanium mesh. J Craniofac Surg 19:490–495

    PubMed  Article  Google Scholar 

  33. Marchac D, Greensmith A (2008) Long-term experience with methylmethacrylate cranioplasty in craniofacial surgery. J Plast Reconstr Aesthet Surg 61:744–752

    PubMed  Article  CAS  Google Scholar 

  34. Matic DB, Manson PN (2004) Biomechanical analysis of hydroxyapatite cement cranioplasty. J Craniofac Surg 15:415–422

    PubMed  Article  Google Scholar 

  35. Matic D, Phillips JH (2002) A contraindication for the use of hydroxyapatite cement in the pediatric population. Plast Reconstr Surg 110:1–5

    PubMed  Article  Google Scholar 

  36. Matsuno A, Tanaka H, Iwamuro H, Takanashi S, Miyawaki S, Nakashima M, Nakaguchi H, Nagashima T (2006) Analyses of the factors influencing bone graft infection after delayed cranioplasty. Acta Neurochir (Wien) 148(5):535–540

    Article  CAS  Google Scholar 

  37. Moreira-Gonzalez A, Jackson IT, Miyawaki T, Barakat K, DiNick V (2003) Clinical outcome in cranioplasty: critical review in long-term follow-up. J Craniofac Surg 14:144–153

    PubMed  Article  Google Scholar 

  38. Nakamura T, Takashima T, Isobe K, Yamaura A (1980) Rapid neurological alteration associated with concave deformity of the skin flap in a craniectomized patient. Case report. Neurol Med Chir (Tokyo) 20:89–93

    Article  CAS  Google Scholar 

  39. Odom GL, Woodhall B, Wrenn FR (1952) The use of refrigerated autogenous bone flaps for cranioplasty. J Neurosurg 9:606–610

    PubMed  Article  CAS  Google Scholar 

  40. Rotaru H, Baciut M, Stan H, Bran S, Chezan H, Iosif A, Tomescu M, Kim SG, Rotaru A, Baciut G (2006) Silicone rubber mould cast polyethylmethacrylate-hydroxyapatite plate used for repairing a large skull defect. J Craniomaxillofac Surg 34:242–246

    PubMed  Article  Google Scholar 

  41. Saringer W, Nobauer-Huhmann I, Knosp E (2002) Cranioplasty with individual carbon fibre reinforced polymere (CFRP) medical grade implants based on CAD/CAM technique. Acta Neurochir (Wien) 144:1193–1203

    Article  CAS  Google Scholar 

  42. Staffa G, Nataloni A, Compagnone C, Servadei F (2007) Custom made cranioplasty prostheses in porous hydroxy-apatite using 3D design techniques: 7 years experience in 25 patients. Acta Neurochir (Wien) 149:161–170

    Article  CAS  Google Scholar 

  43. Vanaclocha V, Saiz-Sapena N, Garcia-Casasola C, De Alava E (1997) Cranioplasty with autogenous autoclaved calvarial bone flap in the cases of tumoural invasion. Acta Neurochir (Wien) 139:970–976

    Article  CAS  Google Scholar 

  44. Winkler PA, Stummer W, Linke R, Krishnan KG, Tatsch K (2000) The influence of cranioplasty on postural blood flow regulation, cerebrovascular reserve capacity, and cerebral glucose metabolism. Neurosurg Focus 8:e9

    PubMed  Article  CAS  Google Scholar 

  45. Yamaura A, Makino H (1977) Neurological deficits in the presence of the sinking skin flap following decompressive craniectomy. Neurol Med Chir (Tokyo) 17:43–53

    Article  CAS  Google Scholar 

  46. Yano H, Tanaka K, Matsuo T, Tsuda M, Akita S, Hirano A (2006) Cranioplasty with auto-purified bone flap after infection. J Craniofac Surg 17:1076–1079

    PubMed  Article  Google Scholar 

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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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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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Corresponding author

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

Keywords

  • Patient-specific implant
  • Cranioplasty
  • Skull bone flap
  • Bone replacement material polymethyl methacrylate—PMMA
  • Brain tumors
  • Trauma
  • Brain