LABORATORY INVESTIGATION

J Neurosurg 139:517–527, 2023

Use of adhesive cranial bone flap fixation without

hardware to improve mechanical strength, resist
cerebrospinal fluid leakage, and maintain anatomical
alignment: a laboratory study
Timothy R. Smith, MD, PhD, MPH,1–3 Kevin T. Foley, MD,4 Sourabh Boruah, PhD,5,6
Jonathan R. Slotkin, MD,7 Eric Woodard, MD,8 John B. Lazor, MD, MBA,9 Christy Cavaleri, MS,6
Michael C. Brown, MS,6 Brittany McDonough, MS,6 Brian Hess, MS,6 and
Douglas W. Van Citters, PhD5
1
Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts; 2Computational Neuroscience Outcomes
Center, Brigham and Women’s Hospital, Boston, Massachusetts; 3Harvard Medical School, Boston, Massachusetts; 4Semmes-
Murphey Clinic and Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee; 5Thayer
School of Engineering, Dartmouth College, Hanover, New Hampshire; 6RevBio, Inc., Lowell, Massachusetts; 7Department of
Neurosurgery, Geisinger Health System, Danville, Pennsylvania; 8Department of Neurosurgery, New England Baptist Hospital,
Boston, Massachusetts; and 9Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts

OBJECTIVE Titanium plates and screws (TPS) are the current standard of care for fixation of cranial bone flaps. These
materials have been used for decades but have known potential complications, including flap migration, bone resorption/
incomplete osseous union, hardware protrusion, cosmetic deformity, wound infection/dehiscence, and cerebrospinal fluid
(CSF) leakage. This study evaluated the efficacy of a novel mineral-organic bone adhesive (Tetranite) for cranial bone
flap fixation.
METHODS Craniotomy bone flaps created in human cadaveric skulls were tested under quasistatic and impact load-
ing in the following conditions: 1) uncut skull; 2) bone flaps fixated with TPS alone; and 3) bone flaps fixated with bone
adhesive alone. All fixative surgical procedures were performed by a group of 16 neurosurgeons in a simulated surgical
environment. The position of adhesive-fixated cranial bone flaps was measured using computed tomography and com-
pared with their original native location. The resistance of adhesive-fixated cranial bone flaps to simulated CSF leakage
was also evaluated. Because there was a gap around the circumference of the TPS-fixated specimens that was visible to
the naked eye, pressurized CSF leak testing was not attempted on them.
RESULTS Adhesive-fixated bone flaps showed significantly stiffer and stronger quasistatic responses than TPS-fixated
specimens. The strength and stiffness of the adhesive-fixated specimens were not significantly different from those of
the uncut native skulls. Total and plastic deflections under 6-J impact were significantly less for adhesive-fixed bone
flaps than TPS. There were no significant differences in any subthreshold impact metrics between the adhesive-fixed
and native specimens at both 6-J and 12-J impact levels, with 1 exception. Plastic deflection at 6-J impact was signifi-
cantly less in adhesive-fixated bone flaps than in native specimens. The energy to failure of the adhesive-fixated speci-
mens was not significantly different from that of the native specimens. Time since fixation (20 minutes vs 10 days) did not
significantly affect the impact failure properties of the adhesive-fixated specimens. Of the 16 adhesive-fixated craniotomy
specimens tested, 14 did not leak at pressures as high as 40 mm Hg.
CONCLUSIONS The neurosurgeons in this study had no prior exposure or experience with the bone adhesive. Despite
this, improved resistance to CSF egress, superior mechanical properties, and better cosmetic outcomes were demon-
strated with bone adhesive compared with TPS.
https://thejns.org/doi/abs/10.3171/2022.10.JNS221657
KEYWORDS craniotomy; bone flap fixation; CSF leak; biomechanical strength; bone adhesive; surgical technique

ABBREVIATIONS CSF = cerebrospinal fluid; CT = computed tomography; PMMA = polymethylmethacrylate; TPS = titanium plates and screws; TTCP-PS = tetracalcium
phosphate and phosphoserine.
SUBMITTED July 18, 2022. ACCEPTED October 27, 2022.
INCLUDE WHEN CITING Published online December 16, 2022; DOI: 10.3171/2022.10.JNS221657.

© 2023 The authors, CC BY-NC-ND 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/) J Neurosurg Volume 139 • August 2023 517

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Smith et al.
T
he standard of care for cranial bone flap fixation is
the use of titanium plates and screws (TPS).1 Hard-
ware fixation may be associated with flap migra-
tion due to hardware loosening,2 resorption due to incom-
plete osseous union with surrounding bone, necrosis,3,4
cosmetic imperfections due to hardware protrusion or
flap elevation/depression,5,6 and cerebrospinal fluid (CSF)
leakage.7 This study evaluated the efficacy of an osteo-
conductive, bioresorbable, mineral-organic bone adhesive,
Tetranite (RevBio, Inc.), for cranial bone flap fixation. It
is composed of tetracalcium phosphate and phosphoser-
ine (TTCP-PS). This adhesive has been demonstrated to
be safe and effective for cranial bone flap fixation in an
ovine model,8 with adhesive-fixated flaps showing statis-
tically significantly greater strength and osseointegration
compared with TPS. The unmet need for an adhesive for
bone stabilization is widely recognized.9 The chemical
composition and benchtop strength of TTCP-PS adhesive
have been studied,10–12 and its biocompatibility and osteo-
conductive activity in canine, rabbit, and ovine models are
well documented.8,12–14
Rigid fixation, resistance to migration, the anatomical
profile, cosmesis, protection against CSF egress, and ulti-
mate resorption with replacement by living bone are de-
sired characteristics of an ideal cranial bone flap fixation
product. The mechanical stiffness and strength of fixation
of cranial bone flaps secured using hardware alone and
adhesive alone were measured under impact and quasi-
static loading conditions. The resistance of adhesive-
fixated cranial flaps to fluid leakage was also evaluated.
Furthermore, computed tomography (CT) images were
analyzed to quantify the elevation/depression of adhesive-
fixated cranial flaps compared with their precraniotomy
locations. Penetration depth and kerf area covered by ad-
hesive were measured, and the influence of these factors
on mechanical stiffness and strength was investigated.
Methods
A distribution of bone flap size and frequency of differ-
TABLE 1. Craniotomy size and frequency information from the survey of neurosurgeons, as well as location and size of standardized test
specimens created for this study
Craniotomy Survey of Neurosurgeons (n = 23)
Size Indication
Small Dura repair, ICP management, deep brain stimulation implantation, & CSF otorrhea
Medium Tumor diagnosis or removal, aneurysm, & vascular malformation
Large Trauma, stroke, & hemicraniotomy
Craniotomy Test Specimens Created for This Study
Flap size Width (mm)
1 40
2 70
3 70
4 100
ICP = intracranial pressure.
Values are shown as mean ± SD; nominal unless indicated otherwise.
* Images of typical specimens and exploded views are available in Supplemental Table 1.
518 J Neurosurg Volume 139 • August 2023
ent craniotomies was obtained from a survey of 23 neu-
rosurgeons (Table 1). Craniotomy size varied with indica-
tion. Based on the survey information, craniotomy widths
of 40, 70, and 100 mm were chosen for this study. Bone
segments that were circumferentially larger than the in-
tended craniotomy were harvested from 24 fresh frozen
adult human cadaver heads.
After the scalp was degloved, 4 segments were marked
on each skull using a 3D-printed circular template. One
small, 2 medium, and 1 large segment were marked on
each skull. These segments were removed from the skull
using a neurosurgical drill (Medtronic Midas Rex). The
dura mater was not removed. The bone specimens were
wrapped in gauze and soaked with saline for hydration.
A total of 80 skull segments were removed from the 24
heads. Sixteen segments were not removed because of pre-
existing cracks in the skull.
The skull segments were embedded in customized fix-
tures for subsequent testing. The embedding polymethyl-
methacrylate (PMMA) was shaped like a cylindrical ring
with a fixed outer diameter (200 mm). Inner diameter an-
nuli of 55, 85, or 115 mm were used for the small, medium,
and large segments, respectively. The space within the in-
ner diameter allowed access to the craniotomy flap for the
application of compressive forces, hydrostatic pressure
testing, and measurement of displacement during impact
testing. In addition to the skull segments, an acrylic ring
with Delrin hardware was also embedded in each fixture
to enable mold extraction, watertight sealing, and trans-
portation. Also, 4 steel balls (Φ 2.00 mm) were embedded
within the PMMA and randomly spaced around the cir-
cumference. Three of these served as fiducials for radio-
graphic analysis. The fourth ball was included for redun-
dancy. An exploded illustration of an embedded specimen
and photographs are shown in Supplemental Table 1.
The pressure testing setup is shown in Fig. 1. The speci-
men was clamped on the base with a 1/8-inch rubber gas-
ket, establishing a watertight compartment. A water res-
ervoir was connected to the watertight compartment, and
Width (mm) Patient Case Load (%)
62 ± 50; 40 24 ± 5; 25
76 ± 35; 70 53 ± 12; 50
113 ± 48; 100 36 ± 11; 25
No. of Burr Holes Location on Skull*
1 Frontal bone
2 Frontal & parietal bone
3 Parietal & occipital bone
3 Parietal bone
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FIG. 1. CSF leak test setup. A: Cross-sectional view. B: Exploded view. C: Side view of pressure test setup. D: Image showing
leakage from a native specimen.
hydrostatic pressure was applied to the inner surface of
the specimen by raising the reservoir to the desired height.
The apparatus was equipped with a water heater to main-
tain the test specimen and water at physiological tempera-
tures (37°C). The water was dyed red for easy detection
of leaks.
Flap sizes 1 and 2 were leak tested to establish baseline
data for a pool of specimens in their native (precranioto-
my) condition. A total of 36 specimens were leak tested
prior to craniotomy. A pressure of 30 mm Hg was applied
for 30 seconds. The specimens were frozen until subse-
quent craniotomy and/or testing.
Craniotomies were completed on a total of 64 speci-
mens after thawing. The remaining 16 specimens were
reserved for testing of their mechanical properties in the
native (noncraniotomy) condition. To limit variations in
cranial bone flap geometry, a single neurosurgeon with
extensive experience created all bone flaps. One to 3 burr
holes (Table 1) were created in the specimens using a Φ
14-mm perforator. The cutting tool (Medtronic Midas
Rex Legend with F2-B1 footed attachment; Φ 2.3 mm)
produced a circumferential gap (kerf) between the bone
flap and surrounding skull equivalent to the diameter of
the cutting drill bit. The specimens were kept frozen until
the time of subsequent fixation of the bone flaps to the
surrounding skull. They were then transported to the 3
different test sites, where a total of 16 different neurosur-
geons fixated the flaps after they were thawed and heated
to physiological temperature (37°C) for a minimum of 1
hour prior to the simulated procedure. Each neurosurgeon
fixated a total of 4 flaps (flap sizes 1 through 4). They fix-
ated flap sizes 1 and 2 using adhesive alone. Flap sizes
3 and 4 were first fixated using metallic hardware (TPS)
alone and subsequently fixated using adhesive alone after
testing of the TPS-fixated flaps and removal of hardware.
The specimens were divided into 5 test groups with differ-
ent mechanical testing approaches for each.
The adhesive was used by all surgeons as per the in-
structions for use. A combination of 3 to 4 intraoperative
fixation aids provided in the kit was used to provisionally
Smith et al.
hold the cranial flap in its anatomical position for adhesive
application. Next, the first dose of the adhesive (4 cm3) pro-
vided in the kit was mixed and applied to the kerf spaces
via a syringe with the provided cannula tip (outer diameter
4.1 mm) to mitigate adhesive over-penetration through the
kerf space. At 4.5 minutes, the fixation aids were removed.
For flap sizes 1 and 2, the adhesive from the first mix was
also used to prepare burr hole plugs that were fabricated
using the provided mold from the kit. For these same flaps,
the second dose of adhesive (4 cm3) provided in the kit
was applied to fill the residual gaps around the burr hole
plugs and kerf spaces to provide a watertight seal and to
demonstrate optimal cosmesis.
CT was used to measure several geometrical parame-
ters related to the shape of the specimen, the penetration of
adhesive in the kerf space, and any elevation or depression
of the fixated flap relative to the surrounding skull. The
entire process was automatic and coded in Python (ver-
sion 3.9.2). All specimens were scanned using cone-beam
CT (Imaging Sciences International i-CAT 17–19, 0.25-
mm resolution) at 3 time points each. They were scanned
before craniotomy in their native condition (pretreatment),
immediately after craniotomy in the cut condition with the
flap removed (resected), and when possible, after adhesive
fixation (posttreatment). Specimens that were impacted to
failure immediately after fixation were not scanned after
fixation with adhesive.
The 3-dimensional coordinates of each fiducial steel
ball in each CT data set were automatically obtained us-
ing Python. The interfiducial distance was used to register
the 3 fiducials between the 3 data sets. This information
was then used to establish coordinate systems in each
data set, and rotation matrices were calculated to trans-
form coordinates from 1 data set to another. Radial slice
images from identical locations on each specimen were
then generated in each of the 3 data sets, at 1° increments
around the entire circumference of the kerf, utilizing the
rotation matrices. The distribution of density within the
cut flap was obtained by subtracting the density distribu-
tion of the resected data set from the pretreatment data
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TABLE 2. Description of CT measurements

Measurements on Slice i* Description

Kerf location, 3-dimensional coordinates of kerf

i

Circumference, S| − | Total length of kerf around circumference

i+1

Kerf cut angle Angle of kerf cut relative to specimen axis; averaged around circumference
Kerf depth, t bi Distance along depth of kerf occupied by native bone
   Kerf interface area, S( − i)t bi Total area of kerf
i+1

Adhesive thickness, t ai Distance along depth of kerf occupied by adhesive; averaged around circumference
   Adhesive interface area, S( − i)t ai Total area of kerf occupied by adhesive
i+1

Outer overfill Distance along depth of kerf occupied by adhesive in excess of native bone on the outer side of speci-
men; max around circumference
Inner overfill Distance along depth of kerf occupied by adhesive in excess of native bone on the inner side of speci-
men; max around circumference
Bone curvature angle Angle perpendicular to bone outer surface relative to specimen axis; averaged around circumference
Flap thickness Thickness of native bone perpendicular to bone outer surface; averaged around circumference
Flap elevation Distance perpendicular to bone outer surface that the flap was elevated/depressed; max absolute
value around circumference
* i = 0–359 for each slice image. Indentation indicates the derivation hierarchy.

set. The fifth percentile density of the cut flap, inclusive of leaked from the specimen was recorded. Because there
bone and pore contents, was used as the threshold density was a visible gap around the circumference on the TPS-
for analyzing the slice images. The measurements listed fixated specimens, pressurized CSF leak testing was not
in Table 2 were obtained automatically for each specimen attempted on them.
using Python. Afterward, these specimens were returned to the bio-
A typical slice image with the analyzed parameters mechanical testing facility, in a refrigerated state, for qua-
is shown in Supplemental Table 2. The kerf midline axis sistatic compression until failure of the adhesive fixation
for each radial slice was established 1 mm away from the within 10 days of the simulated procedure. Testing was
peripheral bone margin. The inner and outer surfaces of
bone and adhesive were identified by traversing the kerf
midline axis in the pretreatment and posttreatment slice
images, respectively. The resulting kerf depth and adhe-
sive thickness were also used to obtain kerf interface and
adhesive interface areas, respectively. Adhesive overfill/
underfill, when it occurred, was quantified on both inner
and outer surfaces.
The bone normal angle was representative of the curva-
ture of the skull segment. The thickness of the bone along
this axis was measured. The elevation of the flap relative
to native bone was evaluated along the bone normal di-
rection, 10 mm from the kerf, as shown in Supplemental
Table 2.
Flap sizes 1 and 2 (n = 32) were used for leak test-
ing and quasistatic compression testing. They were fix-
ated by different neurosurgeons at each test site, who
applied adhesive around the entire kerf circumference.
Half these flaps (n = 16, consisting of 9 size 1 flaps and
7 pterional size 2 flaps) were tested for leak resistance
10 minutes after the last batch of adhesive used to fix-
ate the flap was mixed. The specimens were maintained
hydrated and at physiological temperature (37°C) during
this interval. The previously described pressure testing
setup was used to leak test the fixated flaps. Hydrostatic
pressure was increased from 5 to 40 mm Hg, at steps of
5 mm Hg, with pressure held for 5 seconds at each step.
The water was maintained at physiological temperature FIG. 2. A–B: Quasistatic compression test setup. C: Typical cranial
(37°C) throughout the test. The pressure at which water flaps before and after testing.

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FIG. 3. A–D: Impact test setup. E: Typical cranial flaps before and after testing. PVC = polyvinyl chloride.
done at room temperature (20°C). After failure, the ad-
hesive was removed from the flap and peripheral bone,
and the flaps were fixated using TPS as per each surgeon’s
recommendation. The same specimens were then tested
again under quasistatic compression.
The quasistatic compression test setup, including im-
ages of specimens before and after testing, is shown in
Fig. 2. The specimens were compressed at a rate of 1 mm/
min using a servohydraulic load frame (Instron 8501). A
3/4-inch cylindrical actuator was used on flap size 1 and a
3-pronged actuator was used for flap size 2.
The test endpoint was reached when 4 mm of total dis-
placement occurred or a force of 10% less than the peak
value was reached, whichever occurred earlier. Peak force,
force at 1 mm of displacement, and stiffness were ana-
lyzed. Stiffness—or slope of the force versus displacement
data—was determined by using unconstrained linear re-
gression of the data between 25% and 75% of peak force.
Flap sizes 3 and 4 (n = 32) were used for impact testing.
They were fixated by the different neurosurgeons at each
test site using titanium hardware (Stryker Universal Neuro
III 1.5 mm cranial fixation system) placed according to the
surgeons’ clinical preference. The mechanical compliance
of these specimens was tested at a subthreshold impact en-
ergy of 6 J. The metallic hardware was then removed, and
the same flaps were fixated by the same neurosurgeons
Smith et al.
using adhesive alone that was applied partially around the
kerf circumference. The newly fixated flaps were again
tested at subthreshold impact energies of 6 J and 12 J, 20
minutes after the last batch of adhesive used to fixate the
flap had been mixed. The specimen was maintained hy-
drated and at physiological temperature (37°C) through-
out this interval.
Afterward, the specimens were either immediately
tested to failure under impact at the test site, or they were
returned to the biomechanical testing facility in refriger-
ated condition for impact to failure testing within 10 days.
This testing was done at room temperature (20°C).
The impact test setup is shown in Fig. 3. An impactor
with adjustable weight was dropped from different heights
to deliver impact energies up to 60 J. The impactor had
a 1-inch diameter polyvinyl chloride (PVC) tip and was
equipped with a load cell (Loadstar RSB6) to measure the
impact force. A linear variable differential transformer
(LORD S-LVDT-4) probe was affixed to the inner surface
of each flap with cyano-acrylate to measure the displace-
ment of the flap. Impact energy was increased from 6 J,
at steps of 6 J, until the specimen failed. At each impact
energy level, peak force, maximum deflection, and plas-
tic deflection were recorded. A specimen was considered
failed if deflection at the center was greater than 3.9 mm
or if it was fractured at either the bone or adhesive.
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Smith et al.

TABLE 3. CT measurements of the different flap sizes

Flap Size
Characteristic 1 2 3 4
Circumference, mm 157 ± 14 (14)* 247 ± 23 (15)* 233 ± 17 (15)* 300 ± 22 (14)*
Flap thickness, mm 7.02 ± 1.86 (14)* 5.91 ± 0.64 (15) 6.39 ± 1.02 (15)* 5.81 ± 0.97 (14)*
Angle relative to axis over circumference, °
Kerf cut 27 ± 7 (14)* 30 ± 3 (15) 32 ± 3 (15)* 37 ± 4 (14)*
Bone normal 21 ± 4 (14)* 23 ± 2 (15) 26 ± 3 (15)* 33 ± 3 (14)*
Adhesive fill, %
Over circumference 99 ± 2 (14)* 99 ± 2 (15)* 71 ± 9 (10) 72 ± 9 (10)*
Over interface area 70 ± 18 (14)* 81 ± 18 (15)* 45 ± 17 (10) 53 ± 18 (10)
Over kerf depth 71 ± 18 (14)* 82 ± 19 (15) 54 ± 15 (10)* 58 ± 17 (10)
Thickness along depth of kerf, mm
Full kerf 7.25 ± 1.47 (14)* 5.68 ± 1.02 (15)* 6.83 ± 0.74 (10) 5.96 ± 0.99 (10)*
Adhesive 5.03 ± 1.15 (14)* 4.61 ± 1.11 (15) 3.64 ± 1.01 (15)* 3.45 ± 1.00 (14)*
Total interface area, mm2
Full kerf 1141 ± 269 (14)* 1405 ± 286 (15)* 1598 ± 176 (10) 1793 ± 315 (10)
Adhesive 777 ± 180 (14)* 1122 ± 284 (15)* 697 ± 218 (10)* 928 ± 250 (10)*
Alignment
Flap elevation, mm 1.17 ± 0.51 (14)* 2.00 ± 0.93 (15) 1.02 ± 0.29 (10)* 1.00 ± 0.53 (10)*
Peak overfill, mm
Outer 1.26 ± 0.93 (14)* 1.86 ± 0.69 (15) 1.34 ± 0.89 (10) 1.04 ± 0.44 (10)
Inner 1.12 ± 0.98 (9) 2.99 ± 1.39 (14)* 1.91 ± 1.00 (6) 2.23 ± 1.40 (9)
Values are shown as number or mean ± SD (sample size) unless indicated otherwise.
* Measurement was significantly different from the flap size (a = 0.05, linear model).

Some specimens were reserved in the intact condition
to test the mechanical response of the native skull. No cra-
niotomy or fixation was performed. A total of 8 specimens
(n = 8) with flap sizes 1 and 2 were tested under the same
quasistatic compression protocol as the resected and fix-
ated specimens. A total of 6 specimens (n = 6) with flap
sizes 3 and 4 were tested using the impact protocol.
All statistical analysis was done using R (version 4.1.1).
Statistical significance was tested at α = 0.05.
Results
Of the 36 intact (native) skull specimens tested, 18
(50%) were found to leak at a pressure of 30 mm Hg held
for 5 seconds. The native leak test results did not correlate
with donor anthropometry or a pathological condition.
Video 1 shows the typical sequence of adhesive appli-
cation on a cranial flap.
VIDEO 1. Typical mixing and application of bone adhesive
(Tetranite, RevBio Inc.) for cranial flap fixation. © RevBio Inc, pub-
lished with permission. Click here to view.
The mean ± SD time from mixing the adhesive until the
flaps were ready for closure without sealing was 265 ± 24
seconds (n = 66), and the time until full sealing and con-
touring was 544 ± 85 seconds (n = 30). In comparison,
the time taken for fixation with hardware was 293 ± 69
seconds (n = 27).
Table 3 shows the CT measurements grouped by flap
size. All measurements varied significantly with flap size
522 J Neurosurg Volume 139 • August 2023
with some exceptions. Average flap thickness was not sig-
nificantly different between flap sizes 1 and 3. Peak flap
elevation was not significantly different between flap sizes
1, 3, and 4 but was significantly higher for flap size 2. Aver-
age kerf angle and bone normal angle (curvature) were not
significantly different between flap sizes 1 and 2. Adhesive
interface area was not significantly different between flap
sizes 1, 3, and 4 but was significantly higher for flap size
2. Adhesive percent fill over kerf circumference, as well as
over total interface area, was significantly lower for flap
sizes 3 and 4. Inner and outer overfills have been reported
as the peak values around the circumference of each flap.
Peak outer overfill did not vary significantly with flap size.
On the outer surface, overfill occurred in all specimens
of flap sizes 1 and 2, with peak protrusion between 1 and
2 mm. It occurred in 69% of specimens with flap sizes 3
and 4. Peak inner overfill was significantly higher for flap
size 2 compared with the other flap sizes. On the inner
surface, overfill occurred in nearly all specimens with flap
size 2 (pterional flaps) with an average peak protrusion of
3 mm. Among the rest (flap sizes 1, 3, and 4), inner over-
fill occurred in 56% of specimens with peak protrusion of
1 to 2 mm. An average of 33% to 61% of the kerf depth
was filled with adhesive. There was no significant correla-
tion between flap elevation and outer or inner overfill with
flap thickness, kerf angle, or bone angle, except peak in-
ner overfill was correlated with flap thickness (p = 0.001,
linear model).
Of the 16 adhesive-fixated craniotomy specimens tested

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TABLE 4. Mechanical test groups and test results by flap size

Flap Size
Characteristic 1 2 3 4
Sample size
Total 21 20 18 19
Mechanical testing group
  Quasistatic testing
    ≤10 days after fixation 16 17
   Native specimens 5 3
  Impact testing
    ≤10 days after fixation 10 9
    20 mins after fixation 6 6
   Native specimens 2 4
Quasistatic test results
Peak force, N
  Adhesive 5125 ± 2248 (16) 5694 ± 1528 (17)
  TPS 113 ± 104 (15) 116 ± 78 (16)
  Native 7171 ± 2303 (5) 5383 ± 1775 (3)
Stiffness, N/mm
  Adhesive 4771 ± 1912 (16) 3679 ± 761 (17)
  TPS 58 ± 44 (15) 147 ± 86 (16)
  Native 4719 ± 2419 (5) 2528 ± 982 (3)
Force at 1 mm, N
  Adhesive 3314 ± 1861 (16) 3074 ± 850 (17)
  TPS 50 ± 29 (15) 90 ± 35 (16)
  Native 3285 ± 2267 (5) 2094 ± 668 (3)
6-J impact test results
Total deflection, mm
  Adhesive 248 ± 58 (16) 234 ± 74 (15)
  TPS 3114 ± 823 (16) 2762 ± 790 (15)
  Native 298 ± 53 (2) 364 ± 131 (4)
Plastic deflection, mm
  Adhesive 64 ± 46 (16) 61 ± 39 (15)
  TPS 1731 ± 1061 (15) 1648 ± 819 (15)
  Native 143 ± 29 (2) 184 ± 75 (4)
Peak force, N
  Adhesive 481 ± 379 (16) 331 ± 329 (15)
  TPS 746 ± 916 (16) 377 ± 226 (15)
  Native 389 ± 172 (2) 683 ± 438 (4)
12-J impact test results
Total deflection, mm
  Adhesive 438 ± 301 (16) 425 ± 272 (15)
  Native 187 ± 21 (2) 329 ± 155 (4)
Plastic deflection, mm
  Adhesive 188 ± 207 (16) 150 ± 90 (15)
  Native 181 ± 12 (2) 363 ± 155 (4)
Peak force, N
  Adhesive 771 ± 523 (16) 666 ± 628 (15)
  Native 535 ± 52 (2) 903 ± 433 (4)
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» CONTINUED FROM PAGE 523
TABLE 4. Mechanical test groups and test results by flap size
Characteristic 1 2
Staircase impact to failure results
Prefailure deflection, mm
  Adhesive
  Native
Failure force, N
  Adhesive
  Native
Failure energy, J
  Adhesive
  Native
Sustained energy, J
  Adhesive
  Native
Values are shown as number or mean ± SD (sample size) unless indicated otherwise.
(9 flaps were size 1 and 7 flaps were size 2), 14 (88%) did
not leak during testing up to 40 mm Hg. Both specimens
that leaked were flap size 2. One specimen leaked at 25
mm Hg and the other leaked at 40 mm Hg.
The distribution of the different flap sizes into the dif-
ferent mechanical test groups and the corresponding me-
chanical test results are shown in Table 4.
The distribution of the quasistatic mechanical response
values by fixation type are shown in Fig. 4A. The results
for the native skulls are also shown. The Student t-test was
used to compare the 2 fixation types and native skull. All
3 parameters (peak force, stiffness, and force at 1 mm)
were statistically significantly different between adhesive
and TPS fixation, as well as between native and TPS fixa-
tion (Video 2).
VIDEO 2. Quasistatic compression response of the adhesive-fixated
(left) and TPS-fixated (right) bone flaps. Force versus displacement
data of the 2 flaps were plotted. © RevBio Inc, published with permis-
sion. Click here to view.
None of the parameters were significantly different be-
tween adhesive fixation and native skull. Thus, adhesive
fixation of the bone flaps was mechanically superior to
TPS fixation and statistically equivalent to native skull.
Linear regression indicated the correlation of all the
quasistatic response parameters of the adhesive-fixated
specimens with average flap thickness. Peak force in
adhesive-fixated specimens also correlated with adhe-
sive fill area and kerf interface area. Only the quasistatic
force response at 1 mm of deflection of the TPS-fixated
specimens correlated with the bone angle (curvature of
the bone flap).
The distribution of the subthreshold impact response
values by fixation type are shown in Fig. 4B. The results
for native skull are also shown. The Student t-test was used
to compare the 2 fixation types and native skull. Total and
plastic deflection under 6-J impact were significantly less
524 J Neurosurg Volume 139 • August 2023
Flap Size
3 4
703 ± 412 (5) 1552 ± 968 (15)
1976 ± 788 (2) 1742 ± 425 (4)
1053 ± 351 (16) 1109 ± 464 (15)
1574 ± 421 (2) 1790 ± 147 (4)
24 ± 11 (16) 32 ± 14 (14)
42 ± 15 (4)
19 ± 10 (15) 28 ± 16 (15)
48 ± 17 (2) 36 ± 15 (4)
for adhesive-fixated flaps compared with TPS-fixated
specimens. They were also significantly less for the native
specimens compared with TPS (Video 3).
VIDEO 3. Impact response of TPS-fixated (left) and adhesive-
fixated (center and right) bone flaps at impact energies of 6, 6, and
12 J, respectively. Peak total deflection, residual plastic deformation,
and impact force were charted for the 3 flaps. The video has been
paused at time points corresponding to peak deflection and end
of elastic recovery. © RevBio Inc, published with permission. Click
here to view.
There was no significant difference in any subthresh-
old impact metric between adhesive-fixated and native
specimens at both impact energy levels, with 1 exception.
Plastic deflection at 6-J impact was significantly less in
adhesive-fixated flaps than native specimens. Peak force
was not significantly different between adhesive-fixated,
TPS-fixated, and native specimens at both energy levels.
The distributions of staircase impact to failure mea-
surements for adhesive-fixated flaps and native specimens
are shown in Fig. 4C. The Student t-test was used to com-
pare adhesive-fixated flaps and native skull. All metrics
except failure energy were significantly different.
Use of the t-test showed that the results of the staircase
impact to failure tests on adhesive-fixated flaps were not
significantly different between those tested 20 minutes af-
ter fixation and those tested 10 days later (p > 0.05).
Linear regression revealed the correlation of total de-
flection of TPS-fixated flaps under 6-J impact with bone
normal angle (flap curvature). Plastic deflection of TPS-
fixated flaps under 6-J impact correlated with total kerf
interface area, while total deflection of adhesive-fixated
flaps under 12-J impact correlated with bone normal angle
(flap curvature). None of the staircase impact to failure
measurements correlated significantly with CT measure-
ments.
One each of the adhesive-fixated and native specimens
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 Smith et al.

FIG. 4. Correlation of quasistatic (A), subfailure impact (B), and staircase to failure impact (C) mechanical parameters with fixation
type. Asterisks indicate a statistically significant difference (α = 0.05, t-test; p values indicating significant differences are shown).
The labels show the average value and sample size.

did not fail at an impact energy up to 60 J. In the majority Discussion

of adhesive-fixated flaps, both adhesive and bone broke. This article presents data from craniotomy test speci-
Only bone broke in 1 case and only adhesive broke in 7 mens that were fixated in a simulated surgical environ-
cases. ment by 16 neurosurgeons. Although identical instructions
J Neurosurg Volume 139 • August 2023 525

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Smith et al.
for use of the adhesive were provided to each surgeon, they
had no prior experience with the material. Therefore, the
spectrum of outcomes represents a worst-case scenario.
Leakage of CSF reportedly occurs in 4.6% of cranioto-
mies in general15 and ranges as high as 13% in posterior
fossa surgery.16 Many studies also reported that the use of
dural sealants did not change the CSF leakage rate.7,15,17
Using a novel test apparatus, seepage of fluid through the
natural vasculature of native skull bone was discovered,
with 50% of intact skull specimens leaking at a pressure
of 30 mm Hg held for 5 seconds. In total, 88% of the adhe-
sive-fixated craniotomy specimens resisted leakage under
40 mm Hg pressure, indicating that the adhesive can serve
as a secondary barrier to CSF leakage. This could poten-
tially reduce the likelihood of infection.
Wang et al.18 previously tested cranial flaps under qua-
sistatic compression. They reported peak forces of 83 ±
9, 333 ± 53, and 385 ± 63 N for flaps fixated using suture,
wire, and titanium clamps, respectively. In this study, ad-
hesive fixation was much stronger (5418 ± 1902 N) than
hardware fixation (115 ± 90 N); in fact, it produced bone
flap strength comparable to intact skull (6501 ± 2188 N).
The superior strength of adhesive fixation relative to hard-
ware fixation under impact-type loading and its compara-
bility to intact skull were also demonstrated, despite the
kerf in these specimens being only partially filled (72% ±
9%) around the circumference. Reoperations necessitated
by bone flap depression have been reported in 3% of pa-
tients who underwent craniotomy.19 Greater mechanical
fixation strength could minimize or even eliminate bone
flap depression. In fact, in this study, all the quasistatic
strength parameters and impact failure energies were sta-
tistically indistinguishable when adhesive-fixated cranial
bone flaps were compared with native skull. This may
allow patients with adhesive-fixated bone flaps to return
sooner to vigorous activity (e.g., sports).
Spetzler6 and Di Lorenzo et al.5 have written that even
low-profile miniplates can disfigure the contour of the skin
in patients with thin scalp. Patients frequently palpate the
skull hardware and cause skin irritation. In this study, we
used CT to accurately measure flap elevation and adhesive
overfill. Median flap elevation and outer overfill were 1.24
mm and 1.33 mm, respectively. Although this overfill is
comparable to the thickness of miniplates (1.5 mm),1 the
adhesive is spread over a greater distance with a shallow
ramp leading up to the peak and thus has a smooth contour
without the step-off that can be palpated at the edge of a
plate. For this reason, the adhesive should be inconspicu-
ous to the patient.
Measurements from CT also demonstrated the efficacy
of the adhesive and delivery system design (cannula size
and viscosity) to mitigate adhesive overfill and extravasa-
tion beneath the skull. Peak inner overfill (maximum pro-
trusion of adhesive around the entire circumference of the
kerf on the inner surface) was 2.20 mm. In the flaps where
the entire circumference of the bone flaps had been filled,
the adhesive penetrated only 71% to 82% of the kerf depth
on average but penetrated only 54% to 58% of the kerf
depth in the others.
The adhesive can be drilled/cut using standard neuro-
surgical tools, even at advanced time points. In cases of
526 J Neurosurg Volume 139 • August 2023
reoperation and need for emergency decompression, the
adhered flap can be removed by drilling the original kerf.
Although we attempted to simulate full in vivo con-
ditions, including temperature, wet bone, and CSF pres-
surization after fixation, a limitation of this study was the
absence of active bleeding at the surgery site. The lack of
the dura, brain, and scalp in our specimens was another
deviation from in vivo conditions and may be another
limitation. This was considered a worst-case scenario for
testing resistance to CSF leakage, resistance to fracture
under impact loading, and adhesive overfill on the inner
surface of the skull. Because we tested cadaver tissue, ad-
hesive material resorption and bone remodeling were ab-
sent. Therefore, the measurement of mechanical strength
and stiffness of our specimens, particularly at 10 days after
flap fixation, may differ from in vivo strength. The fact
that the same adhesive was tested in vivo in a sheep cra-
niotomy model and showed significantly greater bone flap
mechanical strength at 1 year postoperatively compared
with adhesive-fixated flaps at 12 weeks after surgery is a
manifestation of the osteoconductive properties of the ma-
terial in a living recipient.8
Conclusions
In this laboratory study that compared the use of stan-
dard TPS with an osteoconductive, bioresorbable, miner-
al-organic bone adhesive for human cranial bone flap fixa-
tion, the bone adhesive was biomechanically superior. In
fact, adhesive-fixated flaps were comparable in strength to
the intact skull itself. Additionally, the adhesive sealed the
kerfs around the bone flaps and mitigated simulated fluid
leakage. This novel material has the potential to improve
cranial bone flap fixation biomechanically, cosmetically,
and hydrostatically.
Acknowledgments
Research reported in this publication was supported by the
National Institute of Neurological Disorders and Stroke of the
National Institutes of Health (award no. R44NS115386). The
content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes
of Health. The following surgeons contributed to this study by
conducting fixation on the cranial bone flaps: Mohammad A.
Aziz-Sultan, Michael Anthony Mooney, Nirav Patel, and Alaa
Montaser at Brigham and Women’s Hospital Study Group,
Boston, MA; Sanjay Konakondla, Michel Lacroix, Edward
Monaco, Clemens M. Schirmer, and Cameron J. Brimley at
Geisinger Medical Center Study Group, Danville, PA; and
Frederick Boop, Madison Michael, Kenan Arnautovic, Frank
Farokhi, Vincent Nguyen, and Daniel Hoit at Semmes-Murphey
Clinic Study Group, Memphis, TN.
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Disclosures
Dr. Smith is a consultant for RevBio, Inc. Dr. Foley is a
consultant for Medtronic; owns stock in Accelus, DiscGenics,
DuraStat, Medtronic, NuVasive, RevBio, Spine Wave, Tissue
Differentiation Intelligence, True Digital Surgery, and Vori
Smith et al.
Health; holds patents with DiscGenics, Medtronic, and NuVasive;
receives royalties from Medtronic; and serves on the board of
directors of DiscGenics, DuraStat, RevBio, Tissue Differentiation
Intelligence, and True Digital Surgery. Dr. Boruah is an employee
of RevBio, Inc. Dr. Slotkin owns stock in RevBio. Dr. Woodard
is a consultant for RevBio and Vallum, Inc.; and owns stock in
Medtronic. Dr. Lazor owns stock in Clozex and received study-
related clinical or research support from RevBio. Mr. Brown
owns stock in RevBio; is an employee of RevBio; and holds
patents with RevBio. Ms. McDonough is an employee of RevBio.
Mr. Hess owns stock in RevBio; is an employee of RevBio; and
holds patents with RevBio. Dr. Citters received study-related
clinical or research support from RevBio; and receives non–study-
related clinical or research support from DePuy Synthes Joint
Reconstruction, Medacta, and ConforMIS.
Supplemental Information
Videos
Video 1. https://vimeo.com/765639554.
Video 2. https://vimeo.com/765641722.
Video 3. https://vimeo.com/765642278.
Online-Only Content
Supplemental material is available with the online version of the
article.
Supplemental Tables 1 and 2. https://thejns.org/doi/suppl/​
10.3171/2022.10.JNS221657.
Previous Presentations
Podium presentation (Smith T, Foley K, Slotkin J, et al. Novel
osteoconductive, bioresorbable bone adhesive provides superior
cranial flap fixation strength and reduced CSF leak potential in
a cadaver model) at the Congress of Neurosurgeons 2021 Annual
Meeting, Austin, TX, October 20, 2021.
Author Contributions
Conception and design: Boruah, Smith, Foley, Cavaleri, Brown,
McDonough, Hess, Van Citters. Acquisition of data: Boruah,
Smith, Foley, Slotkin, Woodard, Lazor, Cavaleri, McDonough,
Van Citters. Analysis and interpretation of data: Boruah, Cavaleri,
Van Citters. Drafting the article: Boruah, Foley. Critically revising
the article: Boruah, Smith, Foley, Slotkin, Lazor, Cavaleri, Brown,
McDonough, Hess, Van Citters. Reviewed submitted version of
manuscript: Boruah, Smith, Foley, Slotkin, Lazor, McDonough,
Van Citters. Approved the final version of the manuscript on
behalf of all authors: Boruah. Statistical analysis: Boruah.
Administrative/technical/material support: Smith, Foley, Slotkin,
Woodard, Lazor, Cavaleri, Brown, McDonough, Hess, Van
Citters. Study supervision: Smith, Brown, Hess, Van Citters.
Correspondence
Sourabh Boruah: Thayer School of Engineering, Dartmouth
College, Hanover, NH. sourabhboruah@gmail.com.
J Neurosurg Volume 139 • August 2023 527
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