Dear Editor,
We read with great interest Malikov et al's case report/technical note entitled “PMMA
cranioplasty making by using open-source CAD software, PLA printers, and silicone
rubber molds: technical note with two illustrative cases.”[1] We were the first in the literature to begin an ultra-low-cost patient-specific
polymethyl methacrylate (PMMA) cranioplasty implant service in Pakistan, that too
in a public sector hospital, and we have already published our technical note and
limited case series with 1-year follow-up.[2] Since then, our technique has been adopted by our colleagues at neighboring centers,
and we have amassed an experience of over 50 cases, and many of our patients are in
long-term follow-up. At the national level, the lowest cost offered by commercial
companies for a patient-specific PMMA implant exceeded US$ 1,000 and US$ 10,000 for
titanium and polyetheretherketone (PEEK) hemicraniectomy implants, respectively. The
vast majority of the Pakistani population are poor and underprivileged, and the trauma
cohort who require this operation are actually those who could never meet these costs
in their lifetime. Free-hand PMMA cranioplasty was utilized in virtually all cases
nationally. After beginning our initial service, the total cost to manufacture an
implant in consumables was US$ 40. The printer we used was a locally assembled Chinese
Prusa i3 clone. Thus, production cost was exponentially cheaper than commercial rates,
and in our experience, our clinical and aesthetic outcomes are the same, if not better.
Naturally, when one intends to offer a service for the patient benefit rather than
profit, affordability is one of the most important parameters, especially in the impoverished
developing world. We would be delighted to know the exact specification of the printer
used by Malikov et al, the cost of disposables and printing of each implant, and the
context of this cost in their patient's socioeconomic demographic/health care system,
and whether commercial options were as extortionate for their general public as it
was for ours.
Once we began this service, we became a national referral center. The service began
with a single neurosurgeon, without any formal IT training, experimenting, and printing
these implants with an ambition to advance global neurosurgery. We now require the
resources for a full-time service. This means the need for a departmental printer,
arguably of a better spec to the bare minimum leisure 3D printer used at home, and
capacity building by training clinical fellows and residents in the design process
to meet the demands for national service in a timely fashion. It would be interesting
to learn more about Malikov et al's exact workflow and cost breakdowns. Is the authors'
patient-specific PMMA cranioplasty service in a public sector hospital? Do the patients
have to pay out of their pocket for these implants? If this is a public sector service,
has the author's volume of referrals increased, and if so, how are they coping with
meeting the demands? Finally, it would be of great use to hear the authors' experience
on the learning curve with these open-access software packages, which are arguably
not as user-friendly as the purpose-built (but much more costly!) software. In our
own experience, when began this service, we initially found even simple implant designing
difficult, but within the space of 10 to 20 patients, we have been proficient in the
design process of even complex orbital defects, including neurofibromatosis type 2
and plexiform tumors that require radical tumor resection and subsequent skull base
reconstruction. Perhaps instead of paper-based publications/technical notes offering
limited information, we should produce virtual tutorials and online workshops that
teach viewers the design process in enough detail to equip them to begin such a service
if required in their local setup. We congratulate the authors on beginning this service
in their country and wish them all the best in advancing global neurosurgery.
