Complications and Failures of Autologous Heterotopic Cranial Bone versus Alloplastic Cranioplasties

Fresh autologous cranial bone graft has traditionally been regarded as the ideal cranioplasty material; however, long-term comparisons of outcomes with modern alloplastic materials are absent in the literature. The authors evaluated complications and failures among cranioplasties performed with fresh, heterotopic, cranial bone graft versus 3 common alloplastic materials.

Random-effects meta-analyses of logit-transformed proportions were performed on studies published between 1971 and 2021 to evaluate complications and failures of cranioplasties performed with fresh, autologous, heterotopic cranial bone; polyetheretherketone (PEEK); polymethylmethacrylate (PMMA); or titanium with a mean follow-up of 12 months or more. Generalized mixed model meta-regressions were performed to account for heterogeneity and to evaluate the contributions of moderators to outcomes variables.

A total of 1490 patients (mean age, 33.9 ± 10.8 years) were included. Pooled, all-cause complications were 6.2% for fresh, heterotopic, autologous cranial bone (95% CI, 2.1% to 17.0%; I2 = 55.0; P = 0.02), 18.5% for PEEK (95% CI, 14.0% to 24.0%; I2 = 0.0%; P = 0.58), 26.1% for titanium (95% CI, 18.7% to 35.1%; I2 = 60.6%; P < 0.01), and 28.4% for PMMA (95% CI, 12.9% to 51.5%; I2 = 88.5%; P < 0.01). Pooled all-cause failures were 2.2% for fresh autologous cranial bone (95% CI, 0.4% to 10.6%; I2 = 0.0%; P = 0.45), 6.3% for PEEK (95% CI, 3.2% to 12.3%; I2 = 15.5%; P = 0.31), 11.4% for titanium (95% CI, 6.7% to 18.8%; I2 = 60.8%; P < 0.01), and 12.7% for PMMA (95% CI, 6.9% to 22.0%; I2 = 64.8%; P < 0.01). Meta-regression models indicated that each alloplastic subtype significantly and independently predicted higher complications, whereas titanium and PMMA were significant predictors for all-cause failures compared with autologous bone. All 3 subtypes were predictive of higher cranioplasty failures secondary to infection compared with autologous bone.

Cranioplasties performed with fresh, autologous, heterotopic cranial bone grafts resulted in lower complication and failure rates compared with alloplastic materials.