Comparative Cost-Effectiveness of Cranioplasty Implants.

PURPOSE: The aim of this study was to compare operative duration and total hospital costs incurred for patients undergoing elective cranioplasty with a variety of materials, including manually shaped autogenous bone graft and titanium mesh, custom patient-specific titanium mesh, polymethyl methacrylate (PMMA) acrylic, and polyetheretherketone (PEEK) implants. METHODS: A single-centre retrospective chart review was used. Patient demographics, defect characteristics, total operative time, and length of hospital stay were obtained. Total costs were sourced from Sunnybrook and standardized to the 2014 to 2015 year. Bivariate and age-controlled multivariate analyses were performed with (n = 119) and without (n = 101) outliers. RESULTS: When outliers were removed, an age-controlled analysis revealed that autogenous implants resulted in an operative time of 178 ± 37 minutes longer than manually shaped titanium implants (P < .01). The average cost of cranioplasty was CAD$18 335 ± CAD$10 265 for manually shaped titanium implants, CAD$31 956 ± CAD$31 206 for custom patient-specific titanium implants, CAD$20 786 ± CAD$13 075 for PMMA, CAD$14 291 ± CAD$5562 for autogenous implants, and CAD$27 379 ± CAD$4945 for PEEK implants (P = .013). When outliers were removed, cranioplasty with PMMA and PEEK incurred greater costs, CAD$4442 ± CAD$2100 and CAD$13 372 ± CAD$2728, respectively, more than manually shaped titanium implants (P < .01). CONCLUSIONS: Manually shaped titanium mesh is the most cost-effective implant choice for small cranial defects. Large unknown defects and frontal paranasal sinus defects are most effectively treated with autogenous bone or titanium mesh. Despite prolonged operative duration and inpatient admission, total costs were not significantly increased. Both PMMA and PEEK implants were significantly more costly, which may be a result of higher complications necessitating reoperation.

OBJECTIF: La présente étude visait à comparer la durée de l'opération et les coûts hospitaliers totaux engagés pour les patients qui subissaient une cranioplastie non urgente faisant appel à divers matériaux : greffon osseux autologue et treillis de titane façonnés à la main, implant PMMA et implant PEEK. MÉTHODOLOGIE: Les chercheurs ont réalisé une analyse rétrospective monocentrique des dossiers. Ils ont colligé les renseignements démographiques sur les patients, les caractéristiques de l'anomalie, la durée totale de l'opération et la durée du séjour hospitalier. Ils ont extrait les coûts totaux de Sunnybrook et les ont standardisés pour l'année 2014-2015. Ils ont effectué des analyses bivariées et multivariées contrôlées selon l'âge en incluant (n=119) et en excluant (n=101) les valeurs aberrantes. RÉSULTATS: Après l'élimination des valeurs aberrantes, une analyse contrôlée selon l'âge a révélé que les implants autologues s'associaient à une opération plus longue de 178 ± 37 min que les implants de titane façonnés à la main (p<0,01). Le coût moyen de la cranioplastie s'élevait à 18 335 CAD$ ± 10 265 CAD$ pour les implants de titane façonnés à la main, à 31 956 CAD$ ± 31 206 CAD$ pour les implants de titane adaptés aux patients, à 20 786 CAD$ ± 13 075 CAD$ pour les implants en PMMA, à 14 291 CAD$ ± 5 562 CAD$ pour les implants autologues et à 27 379 CAD$ ± 4 945 CAD$ pour les implants en PEEK (p=0,013). Une fois les valeurs aberrantes éliminées, la cranioplastie par PMMA ou PEEK étaient les plus coûteuses, à 4 442 CAD$ ± 2 100 CAD$ et 13 372 CAD$ ± 2 728 CAD$ de plus que les implants de titane façonnés à la main (p<0,01). CONCLUSIONS: Les treillis de titane façonnés à la main présentent le meilleur rapport coût-efficacité en cas d'anomalies crâniennes bénignes. Le traitement des graves anomalies d'origine inconnue et des anomalies des sinus paranasaux frontaux les plus efficaces sont l'os autologue ou le treillis de titane. Malgré une opération et un séjour hospitalier prolongés, les coûts totaux n'augmentaient pas de manière significative. Les implants de PMMA et de PEEK étaient considérablement plus cher, peut-être à cause du plus fort taux de complications donnant lieu à une réopération.

Risk Factors for Titanium Mesh Implant Exposure Following Cranioplasty.

PURPOSE: Titanium mesh is used to reconstruct the neurocranium in cranioplasties. Though it is generally well-tolerated, erosion of the overlying soft tissue with exposure of the implant is a complication that adversely affects patient outcomes. The purpose of this study is to investigate potential risk factors for titanium mesh exposure. METHODS: This study comprises all consecutive patients who underwent titanium mesh cranioplasty between January 2000 and July 2016. A retrospective chart review was conducted to extract demographics, details of management, and outcome. Latest postoperative computed tomography scans were reviewed to document the thickness of soft tissue coverage over the implant and the presence of significant extradural dead space deep to it. RESULTS: Fifty patients were included. Implant exposure occurred in 7 (14%), while threatened exposure was observed in 1 additional patient, for a total complication count of 8 (16%).Four (50%) exposure and 3 (7.1%) nonexposure patients underwent preoperative radiotherapy (odds ratio [OR] = 19.67, P = 0.018). Similarly, 4 (50%) exposure and 5 (11.9%) nonexposure patients had a free flap tissue transfer for implant coverage (OR = 6.50, P = 0.046). Postoperative computed tomography scans revealed significant thinning of soft tissues over titanium mesh in 7 (87.5%) exposure and 15 (35.7%) nonexposure patients (OR = 10.71 P = 0.040). No significant association was found between transposition/rotation flap, postoperative radiotherapy, or the presence of significant extradural dead space, and exposure (P = 0.595, P = 0.999, P = 0.44). CONCLUSION: Preoperative radiotherapy, free flap coverage, and soft tissue atrophy resulted in greater odds of titanium mesh exposure. The findings of this study provide important considerations for reconstructive surgeons using titanium mesh for cranioplasty.