Infection, Local Complication, and Graft Failure Rates in Alloplastic Cranioplasty Reconstruction Comparing Titanium Mesh (Ti), Polymethyl Methacrylate (PMMA), Polyether Ether Ketone (PEEK), and Norion Implants: A Systematic Review
Jeremie Oliver, BS, BA, Joseph Banuelos Mancilla, BS, Krishna Vyas, MD, PhD, MHS, Basel Sharaf, MD, DDS.
Mayo Clinic, Rochester, MN, USA.
PURPOSE: There are currently numerous options for plastic surgeons to repair acquired defects of the cranium. Traditionally, autologous bone tissue was used as the gold-standard in cranial vault reconstruction, dating back to the early 1600ís. More recently, alloplastic cranioplasty was developed and has evolved significantly over the years as numerous alterations have been implemented, including the development of different materials to serve as a medium of repair to the defect, such as Titanium Mesh (Ti), Polymethyl Methacrylate (PMMA), Polyether Ether Ketone (PEEK), and Norion implants. There is little data in the literature today comparing the surgical outcomes of these various types of alloplastic cranioplasty methods, and there has yet to be published a systematic review of such outcomes among the alloplastic materials we have compared in this study. Our objective in this study was to compare postoperative rates of infection, local complications and allograft failures following cranioplasty reconstruction using Ti, PMMA, PEEK, and Norion implants.
METHODS: This constitutes the first systematic review of available literature on four different methods of alloplastic cranioplasty reconstruction, including Ti, PMMA, PEEK, and Norion implants, using the Newcastle-Ottawa Quality Assessment Scale guidelines for article identification, screening, eligibility and inclusion. The electronic literature search included Medline/Pubmed, Scopus and Cochrane Database.
RESULTS: A total of 79 studies and 4,764 adult patients were included in our review (Ti=2281, PMMA=1917, PEEK=520, Norion=46). Overall, Ti was associated with the lowest post-operative infection rate (4.82%, p=0.0007, Pearsonís exact test) compared to all other sub-groups. Norion implants were associated with the highest infection rate (19.56%, p=0.0014, 2-Tail Fisherís exact test), local complication rate (26.06%, p=0.0049, 2-Tail Fisherís exact test), and graft failure rate (15.22%, p=0.0061, 2-Tail Fisherís exact test) compared to all other implant types. PEEK implants were associated with the lowest local complication rate (6.15%, p=0.0002, Pearsonís exact test) compared to all other implant types.
CONCLUSION: This study qualifies as a preliminary analysis that begins to address the knowledge gap in determining the infection, local surgical complication and failure rates in alloplastic cranioplasty procedures, although longer-term and randomized trials are warranted to validate any association found in this study.
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