Hydroxyapatite cement (HAC) is an osteoconductive material that serves as a scaffold over and inside which bone can grow without intervening fibrous tissue. With micropore diameters of 2–5 nm, HAC is highly resistant to infection. Whether it should be used as the sole bone substitute during cranioplasty or as an adjunct to other materials, it is still a matter of debate, and no direct answer really exists. At our institution, bone flap is always repositioned and fixed with titanium screws prior to layering the HAC. As reconstructive retrosigmoid cranioplasty was combined with an underlay hourglass-shaped autologous pericranium duraplasty, no postoperative wound infections or meningitis were observed nor were clinically significant cerebrospinal fluid (CSF) leaks reported. In the perspective of reducing the postoperative CSF leak rate as much as possible, it is advisable to focus the upcoming research not only on cranioplasty but also on the combination duraplasty-cranioplasty, which yielded very good results in our experience.
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