Abstract Objective Cranioplasty is routinely performed in neurosurgery. One of its underestimated problems is the high postoperative complication rate of up to 40%. Due to the lack of good prospective studies and the low number of patients (5–20 each year) receiving alloplastic materials, decisions in favor or against a certain material are based on subjective empirical or eco-nomic reasons. The main goal of this first prospective, randomized multicenter study in Germany of custom-made titanium and hydroxyapatite (HA) implants was to compare lo-cal and systemic infections related to the implant within the first six months after implanta-tion. Secondary objectives included comparing reoperation rates, the complication rate, clinical and neurological outcome, and health-related quality of life. Methods The study included patient screening and randomization 6–8 weeks before operation, pre-, intra and postoperative documentation until discharge, and postoperative follow-ups after one and six months. Approval for the study was obtained from the local ethics committee. The study design was published on www.clinicaltrials.gov. Results A total of 52 patients were included in the study. The rate of local, implant associated wound infection in the HA group was 2 out of 26 (7.7%) patients and 5 out of 24 (20.8%) patients in the titanium group (p=0.407 n.s.). Systemic inflammation within six months after operation affected none of the patients in the HA group and 4 out of 24 (37.5%) pa-tients in the titanium group (p=0.107 n.s.). In both groups, 7 patients had to be reoperated after the six-month follow-up (26.9% in the HA group and 29.2% in the titanium group; n.s.). Re-surgery with explantation was necessary in 3 patients in each group (11.5% in the HA group and 12.5% in the titanium group; n.s.). The results demonstrated a significantly higher number of epidural hematomas in the HA group compared to none in the titanium group. Altogether, 46 AE were measured in 27 patients (54%). An improvement of the neurologi-cal outcome after six months was experienced by 43% of the patients in the HA group and 26.3% in the titanium group (p=0.709 n.s.). Conclusion The study emphasizes that cranioplasty is a high-risk intervention. Compared to tita-nium, HA shows a benefit in the infection rate and the neurological outcome, but has at the same time a higher postoperative risk for epidural hematoma. Depending on the individual conditions both materials have their place in future therapy of cranioplasty.

Abstract Objective Cranioplasty is routinely performed in neurosurgery. One of its underestimated problems is the high postoperative complication rate of up to 40%. Due to the lack of good prospective studies and the low number of patients (5–20 each year) receiving alloplastic materials, decisions in favor or against a certain material are based on subjective empirical or eco-nomic reasons. The main goal of this first prospective, randomized multicenter study in Germany of custom-made titanium and hydroxyapatite (HA) implants was to compare lo-cal and systemic infections related to the implant within the first six months after implanta-tion. Secondary objectives included comparing reoperation rates, the complication rate, clinical and neurological outcome, and health-related quality of life. Methods The study included patient screening and randomization 6–8 weeks before operation, pre-, intra and postoperative documentation until discharge, and postoperative follow-ups after one and six months. Approval for the study was obtained from the local ethics committee. The study design was published on www.clinicaltrials.gov. Results A total of 52 patients were included in the study. The rate of local, implant associated wound infection in the HA group was 2 out of 26 (7.7%) patients and 5 out of 24 (20.8%) patients in the titanium group (p=0.407 n.s.). Systemic inflammation within six months after operation affected none of the patients in the HA group and 4 out of 24 (37.5%) pa-tients in the titanium group (p=0.107 n.s.). In both groups, 7 patients had to be reoperated after the six-month follow-up (26.9% in the HA group and 29.2% in the titanium group; n.s.). Re-surgery with explantation was necessary in 3 patients in each group (11.5% in the HA group and 12.5% in the titanium group; n.s.). The results demonstrated a significantly higher number of epidural hematomas in the HA group compared to none in the titanium group. Altogether, 46 AE were measured in 27 patients (54%). An improvement of the neurologi-cal outcome after six months was experienced by 43% of the patients in the HA group and 26.3% in the titanium group (p=0.709 n.s.). Conclusion The study emphasizes that cranioplasty is a high-risk intervention. Compared to tita-nium, HA shows a benefit in the infection rate and the neurological outcome, but has at the same time a higher postoperative risk for epidural hematoma. Depending on the individual conditions both materials have their place in future therapy of cranioplasty.