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Hydroxyapatite cranioplasty: a retrospective evaluation of osteointegration in 17 cases

  • Original Article - Neurosurgical technique evaluation
  • Published:
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Abstract

Background

Cranial reconstruction with autologous bone is still the gold standard although several biomaterials are available to re-establish the integrity of the cranial vault. Due to their biological and morphological characteristics, hydroxyapatite implants show promising results in small clinical cohort studies, especially within the paediatric population. Its biocompatibility and osteoconductivity should allow the formation of osseous bridging at the skull-prosthesis interface.

Objective

To examine the possible occurrence of osteointegration and to quantify it.

Methods

A retrospective study of patients with a hydroxyapatite implant from 2010 to 2014 at our neurosurgical department was conducted. Demographic, surgical and radiological data were studied. A senior neuroradiologist, a staff member neurosurgeon and a resident neurosurgeon independently performed the radiological evaluation. A new software analysis technique was developed to objectively quantify the degree of osteointegration.

Results

Seventeen implants were evaluated with an average patient age of 39 years and a mean follow-up of 155 weeks. Through radiologic evaluation, osseous bridging was deemed higher than 50% in six prostheses and higher than 75% in three. In five patients, no osteointegration could be seen. The remaining patients exhibited sparse signs of osteointegration, estimated between 10 and 50%. Software analysis showed an average osteointegration ratio of 37.4% with a 400-HU filter and 27.3% with a 700-HU filter.

Conclusion

In this small retrospective study of cranial hydroxyapatite implants, osteointegration did occur and to a degree of more than 50% in 1/3 of the patients.

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Acknowledgements

Software analysis technique was developed together with Materialise (Leuven, Belgium).

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Authors and Affiliations

  1. Department of Neurosurgery, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium

    Wim Maenhoudt, Giorgio Hallaert, Jean-Pierre Kalala, Edward Baert, Frank Dewaele & Dirk Van Roost

  2. Department of Neuroradiology, Ghent University Hospital, Ghent, Belgium

    Wouter Bauters

Authors
  1. Wim Maenhoudt
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  2. Giorgio Hallaert
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  3. Jean-Pierre Kalala
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  4. Edward Baert
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Corresponding author

Correspondence to Wim Maenhoudt.

Ethics declarations

Each patient signed an informed consent. Approval of the Ethics Committee of the hospital was obtained.

Competing interests

The authors declare that they have no competing interests.

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Comments

Even if there are a number of papers dealing with HA cranioplasty implants, very few papers have really examined the possibility of osteointegration. Since HA cranioplasty is expensive, the plus offered by this method of cranial reconstruction is bone integration. This makes HA a biological material differently from all the other materials used for cranioplasty (PEEK, PMMA, titanium...) which are materials not integrated into the skull and acting as a foreign body.

There are very few published papers with a good CT follow-up study to demonstrate osteointegration. Furthermore, to my knowledge, this is the first study to demonstrate a relationship between CT data and gadolinium MRI data. MRI can show the presence of small new vessels within the cranioplasty than confirming bone colonisation.

The results of the study with a long follow-up in an adult population show that in a majority of cases, osteointegration did occur even if to a different degree.

With the limit of the small number of cases and of the retrospective data collection, these patients show that it is possible and feasible to use a biological material for cranial reconstruction.

The authors have described one case of HA cranioplasty fracture 2 years after implantation. There is an important message never presented before: we can probably measure with gadolinium MRI (this is the only message never presented before the presence of osteointegration was already reported in a few cases in live patients).

Franco Servadei

Milan, Italy

This article is part of the Topical Collection on Neurosurgical technique evaluation

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Maenhoudt, W., Hallaert, G., Kalala, JP. et al. Hydroxyapatite cranioplasty: a retrospective evaluation of osteointegration in 17 cases. Acta Neurochir 160, 2117–2124 (2018). https://doi.org/10.1007/s00701-018-3694-6

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  • DOI: https://doi.org/10.1007/s00701-018-3694-6

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