Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2020 Feb;28(1):29-39.
doi: 10.1177/2292550319880922. Epub 2019 Oct 24.

Comparative Cost-Effectiveness of Cranioplasty Implants

Adam Binhammer  1 , Josie Jakubowski  1 , Oleh Antonyshyn  1   2 , Paul Binhammer  1   2
Affiliations

Comparative Cost-Effectiveness of Cranioplasty Implants

Adam Binhammer et al. Plast Surg (Oakv). 2020 Feb.

Abstract
in English, French

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.

Keywords: PEEK; PMMA; autogenous bone; cost; cranioplasty; operative time; titanium implants.

PubMed Disclaimer

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Manually shaped titanium mesh relies on intraoperative manipulation of a 2-dimensional sheet of titanium mesh into a 3-dimensional shape. It is a simple and effective technique for small defects.
Figure 2.
Figure 2.
Autogenous cranioplasty necessitates harvesting of split skull bone graft. For a large bifrontal defect, bilateral parietal craniotomies are performed to harvest bone graft (A), which is split into inner and outer tables. The inner table bone reconstructs the craniotomy donor sites, while outer table grafts are carved and assembled to reconstruct the skull defect (B).
Figure 3.
Figure 3.
Polyetheretherketone (PEEK) cranioplasty employs a prefabricated polymer implant to resurface a stable skull defect.
Figure 4.
Figure 4.
Intraoperative fabrication of a patient-specific polymethyl methacrylate (PMMA) implant using a custom mold (A; Calavera Surgical Design, Toronto, Canada) provides a polymer implant which fits the defect and restores normal skull shape (B).
Figure 5.
Figure 5.
Three-dimensional computed tomography (CT) demonstrating a right craniofrontal dysplasia (A). The extent of tumour ablation and therefore the size and shape of the skull defect are “unknown” prior to surgery. A patient-specific titanium mesh can be shaped intraoperatively (B) using a press and custom mold and forming tool (Calavera Surgical Design, Toronto, Canada) and trimmed appropriately to fit any defect. The titanium mesh is versatile in that it can be adapted to any shape and size of defect, can incorporate bone grafts, and can be used in reconstructing paranasal sinus regions.
Figure 6.
Figure 6.
Operative time (minutes) for cranial vault reconstruction. Outliers removed; after adjusting for age, autogenous implants were associated with a greater operative time compared to manually shaped titanium implants (P < .01). *Significant difference (P < .05).
Figure 7.
Figure 7.
Intensive care unit (ICU) and ward stay for cranial vault reconstructive patients treated with various implant types. Data are presented as mean ± standard deviation (SD) days. When outliers were removed and the data adjusted for age, patients treated with custom patient-specific titanium implants and polymethyl methacrylate (PMMA) implants remained in the ward longer (2.4 ± 1.1 and 2.1 ± 1.0 days, respectively) than those treated with manually shaped titanium implants (P < .05). After adjusting for age, there was no statistically significant difference between implant types and ICU stay. *Significant difference (P < .05).
Figure 8.
Figure 8.
Total cost (CAD$CAD) for cranial vault reconstruction. Outliers removed; after adjusting for age, polymethyl methacrylate (PMMA), and polyetheretherketone (PEEK) implants are associated with greater costs compared to manually shaped titanium implants (P < .05). *Significant difference (P < .05).
Figure 9.
Figure 9.
Complication rates for patients treated with various cranioplasty implant types (n = 119). Data are presented as the total incidence of complications including headache, seizures, and pain, some of which may not be related to cranioplasty. Complications requiring surgical intervention are all related to the cranioplasty and range from scar revision, fluid aspiration, lumbar drain to implant removal. Polymethyl methacrylate (PMMA; acrylic) and polyetheretherketone (PEEK) were associated with higher complication rates (29% and 27%, respectively).
See this image and copyright information in PMC

References

    1. De Bonis P, Frassanito P, Mangiola A, Nucci CG, Anile C, Pompucci A. Cranial repair: how complicated is filling a “hole”? J Neurotrauma. 2012;29(6):1071–1076. doi:10.1089/neu.2011.2116 PubMed PMID: 22059899. - PubMed
    1. Kuo JR, Wang CC, Chio CC, Cheng TJ. Neurological improvement after cranioplasty—analysis by transcranial doppler ultrasonography. J Clin Neurosci. 2004;11(5):486–489. doi:10.1016/j.jocn.2003.06.005 PubMed PMID: 15177389. - PubMed
    1. Dujovny M, Aviles A, Agner C, Fernandez P, Charbel FT. Cranioplasty: cosmetic or therapeutic? Surg Neurol. 1997;47(3):238–241. PubMed PMID: 9068693. - PubMed
    1. Piazza M, Grady MS. Cranioplasty. Neurosurg Clin N Am. 2017;28(2):257–265. doi:10.1016/j.nec.2016.11.008 PubMed PMID: 28325460. - PubMed
    1. Zanotti B, Zingaretti N, Verlicchi A, Robiony M, Alfieri A, Parodi PC. Cranioplasty: review of Materials. J Craniofac Surg. 2016;27(8):2061–2072. doi:10.1097/SCS.0000000000003025 PubMed PMID: 28005754. - PubMed

LinkOut - more resources