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Advanced Ne
Advanced Neurologyurology Outcomes of implant usage for depressed skull fractures

1. Introduction have been seen to develop less inflectional complications
going forward [10,13] .
Traumatic brain injuries (TBIs) are a worldwide issue that
is associated with high levels of mortality and morbidity [1,2] . With the goal of improving patient outcomes in
Skull fractures vary in etiology as several factors influence addressing DSF, an effective route may involve optimization
the fracture such as bone mineralization and trauma of the implantation approach required in surgical
type [3,4] . Depressed skull fractures (DSFs) are a subset of management. Specifically, the decision in implant material
fractures characterized by a portion of the inner table of utilized can hold considerable weight. In the current
the skull displacing and lying above the outer table [5,6] . review, outcome measures for the surgical management of
Incidence of depressed skull fractures (DSFs) within TBI DSF among various types of implant material are reported
[5]
patients ranges from 2% to 11% . In DSFs, there is often in a coherent fashion. We organized a systematic review
underlying brain damage of two different varieties: direct by organizing the available data regarding outcomes of
damage to tissue and indirect damage via hematomas surgically treated DSF between different implant materials
compressing the brain tissue . Recent advancements of to address the question of how implant material may affect
[4]
computed tomography (CT) and magnetic resonance the post-operative outcomes of DSF patients.
imaging (MRI) provide better understanding of diagnosing
DSFs and survival interventions. 2. Methods
Treatment for DSFs includes either surgical interventions, 2.1. Eligibility criteria
such as cranioplasty or conservative treatment. Surgery is Retrospective cohort studies, case series, and case reports
pursued based on indications, such as neurologic, infective, were included in this systematic review. Our analysis
and cosmetic issues and open skull fractures are managed included the study design, country, number of patients,
in two stages: through primary reconstruction or delayed age, sex, preoperative Glasgow coma scale (GCS), fracture
cranioplasty [5,7] . Previously, delayed cranioplasty was location, primary implant material, time to encounter,
preferred due to reduction of infections such as meningitis time to cranioplasty, presence of complications,
and osteomyelitis . However, several limitations are postoperative GCS, length of stay, and follow-up duration.
[8]
presented in these patients’ lives. Furthermore, recent Inclusion criteria pertained to studies reporting use of
studies have shown no difference in infection rate specific implant material within treatment for depressed
between delayed cranioplasty and immediate titanium skull fractures. Exclusion criteria included studies not
mesh reconstruction [8,9] . Although it is preferable to use sufficiently disaggregated for extracting data pertaining
patients’ own bone material, due to several reasons, rather to depressed skull fractures, those failing to specifically
than artificial mesh during surgery, cases of DSF may be report surgical approach regarding implant material.
near impossible for bone material reconstruction [9,10] . Non-primary data including presentations, letters to the
Furthermore, recent work has demonstrated a higher editor, editorials, and other sources that appeared non-
failure rate with autologous bone due to infection and peer-reviewed were strictly excluded. Articles written
bone flap necrosis [10,11] . Urgent cranioplasty using artificial in languages other than English, or cadaver/non-human
material such as titanium mesh, methyl methacrylate studies were excluded from the study. The selection
(PMMA), and several unique varieties has become more process is shown in Figure 1.
common .
[9]
2.2. Information sources
Primary reconstruction for DSF was developed to avoid
delayed cranioplasty, prevent further CSF complications, A literature search was performed in Web of Science,
and for cosmetic reasons . Variations and effectiveness Scopus, and PubMed from their inception to September
[12]
of the different implants is a field of ongoing research. 2022 to identify studies reporting the outcome of implant
Differences in tissue tolerance, cost, and resistance to usage in subsequent duraplasty in treatment of depressed
infections and other characteristics are considered when skull fractures. The search strategy was developed by
choosing the specific alloplastic material . Titanium one reviewer (A.N.) by consulting the peer review of
[13]
mesh bone grafts have been seen to be effective in electronic search strategies (PRESS) criteria . This
[14]
preventing an inflammatory reaction . PMMA, similarly, review was reported in accordance with the Preferred
[13]
has been popular recently due to the ease of confirmation Reporting Items for Systematic Reviews and Meta-
and application . Studies have shown no significant Analyses (PRISMA) . The search strategy is (depressed
[9]
[13]
difference between these two alloplastic materials, and skull fracture) AND (implant OR shunt OR inlay OR onlay
both have demonstrated similar results, both functionally OR patch OR mesh OR titanium OR cranioplasty). Study
and cosmetically [10,13] . However, titanium mesh patients selection was performed by one reviewer (A.N.) and data

Volume 2 Issue 1 (2023) 2 https://doi.org/10.36922/an.247