# Beyond decompression: predictors of cranioplasty failure in pediatric patients – a meta-analysis

## TL;DR

This study finds that pediatric cranioplasty has high complication rates, with factors like delayed surgery and non-titanium materials increasing risks.

## Contribution

The study identifies specific predictors of cranioplasty failure in children, offering insights for improving surgical outcomes.

## Key findings

- Delayed cranioplasty and large skull defects significantly predict bone resorption.
- Non-titanium fixation materials and ventriculoperitoneal shunts are linked to higher infection rates.
- Autologous bone grafts were used in 77.6% of cases, but resorption still occurred in nearly 30%.

## Abstract

Pediatric cranioplasty following decompressive craniectomy is associated with high complication rates, particularly bone resorption and infection. Unlike adult populations, children face unique anatomical and physiological challenges, and the lack of viable alternatives to autologous bone graft further complicates outcomes. This meta-analysis aims to evaluate the current state of pediatric cranioplasty, identifying key predictors of bone resorption and infection, and assessing outcomes to guide future clinical improvements.

A systematic search was conducted in MEDLINE/PubMed and Web of Knowledge using combinations of the terms "cranioplasty," "pediatric," "children," and "decompressive craniectomy." Studies were included if they reported quantitative data on outcomes in pediatric populations. Risk of bias were assessed using the ROBINS-I tool.

Seven retrospective case series encompassing 594 patients were analysed. The average age of patients was 8.4 years, with a mean follow-up of 37.8 months. The mean time from craniectomy to cranioplasty was 12.5 weeks. Autologous bone graft was used in 77.6% of cases. The rate of bone resorption requiring reoperation approached 30%, and infection occurred in approximately 10% of patients. Delayed cranioplasty (> 6 weeks), large skull defect area, underlying cerebral contusion, and comminuted fractures significantly predicted bone graft resorption. The use of ventriculoperitoneal shunts, cranial implants, and non-titanium fixation materials were associated with higher infection and resorption rates.

Pediatric cranioplasty carries unacceptably high complication rates for an elective procedure. Early intervention and the use of titanium fixation may reduce the burden of reoperation. Further prospective studies are necessary to establish standardized surgical protocols and explore alternative materials.

The online version contains supplementary material available at 10.1007/s00701-025-06637-x.