Halo skull pins consist of a threaded post with a tip that penetrates the skull, yet the diameter, tip design, and material varies. Historically, skull pins were made from steel or titanium. In 2003, evidence was reported of titanium halo pins burning

1
Complications Associated with Ceramic vs.
Titanium Halo Pins A Retrospective Review
Megan Zachar CO, Molly Hill MSPO, Sara Pschigoda
CO, Jeffrey Wensman CPO, Gregory Graziano MD,
Rakesh Patel MD, Claire Kalpakjian PhD
Introduction Purpose
Methods
Results
Discussion
A halo orthosis immobilizes the cervical spine to
prevent or manage spinal cord injury. Previous
studies have shown halo treatment is ultimately
successful, yet is associated with a high
complication rate including pin loosening (loss
of fixation against the skull) and pinsite
infection.1,2
Preliminary results of this retrospective review
show increased incidence of pin loosening and
infection with ceramic-tipped pins compared to
titanium pins, however it does not reach
statistical significance. The limitations of a
retrospective chart review may affect these
results, as a complication may have been missed
if it was not documented. Electronic charting
was adopted through the early years of the study
when titanium pins were used, which may result in
fewer chart notes. The ceramic pins were
adopted for safe MR imaging. If these
complication rates are verified through
prospective studies, it may lead to
recommendations for usage of ceramic-tipped pins
only in situations when the patient will undergo
MR imaging.
Ceramic TitaniumStandard TitaniumHIFix Total
Subjects (n) 71 19 72 162

Male 68 58 57 62
Female 32 42 43 38

Mean Age 52 45 51 51
Age Range 18-89 18-79 19-85 18-89

Mean Days in Halo 73 82 80 77

MRI 11 16 24 12
Halo skull pins consist of a threaded post with a
tip that penetrates the skull, yet the diameter,
tip design, and material varies. Historically,
skull pins were made from steel or titanium. In
2003, evidence was reported of titanium halo pins
burning a patients scalp during magnetic
resonance imaging.3 To eliminate the risk of pin
burning and reduce artifact, a ceramic-tipped
halo pin was developed.4 This study examines
the complication rates associated with ceramic
tipped and titanium halo skull pins.
Hypothesis Pin loosening and infection rates
associated with ceramic pins are not
significantly different from those of titanium
pins.
Conclusions
The results of this study suggest that pin type
is not associated with the incidence of
complications after placement. Although pin type
was not significant, there were a substantial
number of patients who experienced complications.
Such complications during the course of halo
treatment can cause patient discomfort and
compromise the stability of the halo. The next
step in this line of research includes
biomechanical studies on the pin/bone interface
and prospective clinical studies to increase
knowledge of factors that lead to pin
complications and help improve clinical outcomes.
A Ceramic Non-conductive, blunt tip
B Titanium Standard Sharp tip flares to a shoulder
C Titanium HIFix Cylindrical cutting tip
Chi-Square analysis was performed to assess
significant differences by pin type. There were
no statistically significant differences in
overall pin complications by pin type (?2
2.266, p 0.322). Analysis of specific
complications found no significant difference for
pin loosening (X2 1.060, p 0.589) or
infection (X2 0.440, p 0.803) between the
three pin types.

• References
• Garfin SR, Botte MJ, Waters RL, Downey, Nickel
  VL. Complications in the use of the halo fixation
  device. J Bone Joint Surg 198668-A(3)320-325.
• Bono CM. The Halo Fixator. J Am Acad Orthop Surg
  200715(12)728-737.
• Kim LJ et al. Scalp burns from halo pins
  following magnetic resonance imaging. J Neurosurg
  200399186
• Diaz FL, Tweardy L, Shellock FG. Cervical
  external immobilization devices Spine
  201035(4)411-415.

Acknowledgements This study was funded by a
grant from the Paralyzed Veterans Association,
Washington DC, with research training support
from the University of Michigan Practice-Oriented
Research Training (PORT) Program. The PORT
Program is part of the Michigan Institute for
Clinical and Health Research at the University of
Michigan and supported by a grant from the
National Institutes of Health Clinical and
Translation Sciences Award (UL1RR024986).