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      Cranioplasty with autologous cryopreserved bone after decompressive craniectomy. Complications and risk factors for developing surgical site infection

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          Abstract

          Background

          Renewed interest has developed in decompressive craniectomy, and improved survival is shown when this treatment is used after malignant middle cerebral artery infarction. The aim of this study was to investigate the frequency and possible risk factors for developing surgical site infection (SSI) after delayed cranioplasty using autologous, cryopreserved bone.

          Methods

          This retrospective study included 74 consecutive patients treated with decompressive craniectomy during the time period May 1998 to October 2010 for various non-traumatic conditions causing increased intracranial pressure due to brain swelling. Complications were registered and patient data was analyzed in a search for predictive factors.

          Results

          Fifty out of the 74 patients (67.6 %) survived and underwent delayed cranioplasty. Of these, 47 were eligible for analysis. Six patients (12.8 %) developed SSI following the replacement of autologous cryopreserved bone, whereas bone resorption occurred in two patients (4.3 %). No factors predicted a statistically significant rate of SSI, however, prolonged procedural time and cardiovascular comorbidity tended to increase the risk of SSI.

          Conclusions

          SSI and bone flap resorption are the most frequent complications associated with the reimplantation of autologous cryopreserved bone after decompressive craniectomy. Prolonged procedural time and cardiovascular comorbidity tend to increase the risk of SSI.

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          Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases.

          Cynthia Gooch, N E Gin, J German … (2009)
          Decompressive craniectomy is a potentially life-saving procedure used in the treatment of medically refractory intracranial hypertension, most commonly in the setting of trauma or cerebral infarction. Once performed, surviving patients are obligated to undergo a second procedure for cranial reconstruction. The complications following cranial reconstruction are not well described in the literature and may very well be underreported. A review of the complications would suggest measures to improve the care of these patients. A retrospective chart review was undertaken of all patients who had undergone cranioplasty during a 7-year period. Demographic data, indications for craniectomy, as well as preoperative, intraoperative, and postoperative parameters following cranioplasty, were recorded. Perioperative and postoperative complications were also recorded. Patients were classified as having no complications, any complications, and complications requiring reoperation. The groups were compared to identify risk factors predictive of poor outcomes. The authors identified 62 patients who had undergone cranioplasty. The immediate postoperative complication rate was 34%. Of these, 46 patients did not require reoperation and 16 did. Of those requiring reoperation, 7 were due to infection, 2 from wound breakdown, 2 from intracranial hemorrhage, 3 from bone resorption, and 1 from a sunken cranioplasty, and 1 patient's cranioplasty procedure was prematurely ended due to intraoperative hypotension and bradycardia. The only factor statistically associated with need for reoperation was the presence of a bifrontal cranial defect (bifrontal: 8 [67%] of 12, requiring reoperation; unilateral: 8 [16%] of 49 requiring reoperation; p < 0.01) Cranioplasty following decompressive craniectomy is associated with a high complication rate. Patients undergoing a bifrontal craniectomy are at significantly increased risk for postcranioplasty complications, including the need for reoperation.
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            Failure of autologous bone-assisted cranioplasty following decompressive craniectomy in children and adolescents.

            Kyle Grant, Craig S. Roberts, Matthew Jolley … (2004)
            The authors have routinely performed primary autologous cranioplasty to repair skull defects after decompressive craniectomy. The high rates of subsequent bone resorption occurring in children prompted this study. In an institutional review, the authors identified 40 (32 male and eight female) children and adolescents ranging from 4 months to 19 years of age in whom autologous cranioplasty was performed after decompressive craniectomy. The defect surface area ranged from 14 to 147 cm2. In all cases, the bone was fresh frozen at the time of the decompression. Symptomatic bone resorption subsequently occurred in 20 children (50%) in all of whom reoperation was required. The incidence of bone resorption significantly correlated with an increased skull defect area (p < 0.025). No significant correlation was found with age, sex, or anatomical location of the skull defect, number of fractured bone fragments, presence of a shunt, cause for decompressive craniectomy, method of duraplasty, or interval between the craniectomy and the cranioplasty. Reoperation to repair the resorbed autologous bone was performed 2 to 76 months after the initial procedure. The use of autologous bone to reconstruct skull defects in pediatric patients after decompressive craniectomy is associated with a high incidence of bone resorption. The use of autologous bone should be reevaluated in light of the high rate of reoperation in this pediatric population.
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              Analyses of the factors influencing bone graft infection after delayed cranioplasty.

              S Takanashi, A Matsuno, S Miyawaki … (2006)
              Several factors influencing bone graft infection after delayed cranioplasty are analyzed in order to reduce the occurrence of infection. For about 10 years, from March 1995 to February 2005, delayed cranioplasty was performed for 206 cases. The cases comprised 124 males and 82 females. Age distribution of the patients ranged from 6 months to 79 years old. The mean postoperative follow-up period was 1834 days. Autogenous bone, which was preserved in 100% ethanol at -20 degrees C and autoclaved before operation, was used in 54 patients. Polymethylmethacrylate (PMMA) was used in 55 patients. Custom-made PMMA was used in 3 patients. Custom-made titanium mesh was used in 77 patients. Custom-made ceramics (Alumina-ceramics 10 cases and hydroxyapatite 7 cases) was used in 17 patients. Autoclaved and autogenous bone graft and PMMA have a significantly high rate of graft infection. Titanium mesh has the significantly lowest rate of graft infection. Alumina-ceramic has a merit that it has sufficient strength, however the number of cases using custom-made ceramics including alumina-ceramic was relatively small, and thus we cannot find significant differences in infection rate compared with that of other materials. There was no statistically significant difference in the bone graft infection rate among four categories of preceding diseases; cerebrovascular diseases, head trauma, infectious diseases, and brain tumour. Autoclaved and autogenous bone grafts and PMMA have a significantly higher rate of graft infection. Titanium mesh has the significantly lowest rate of graft infection.
              Article 0 comments Cited 55 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                J. Sundseth: +47-23-074839 , +47-23-074310 , jsundset@ous-hf.no
                Journal
                Journal ID (nlm-ta): Acta Neurochir (Wien)
                Journal ID (iso-abbrev): Acta Neurochir (Wien)
                Title: Acta Neurochirurgica
                Publisher: Springer Vienna (Vienna )
                ISSN (Print): 0001-6268
                ISSN (Electronic): 0942-0940
                Publication date (Electronic): 4 February 2014
                Publication date PMC-release: 4 February 2014
                Publication date (Print): 2014
                Volume: 156
                Pages: 805-811
                Affiliations
                [ ]Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Postboks 4950, Nydalen, 0424 Oslo, Norway
                [ ]Institute of Clinical Medicine, University of Oslo, Oslo, Norway
                [ ]Department of Neurology, Medical Division, Akershus University Hospital, Lørenskog, Norway
                Article
                Publisher ID: 1992
                DOI: 10.1007/s00701-013-1992-6
                PMC ID: 3956933
                PubMed ID: 24493001
                SO-VID: 78bb1af9-5cbf-42b1-a0cf-abdf864fae8f
                Copyright © © The Author(s) 2014
                License:

                Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

                History
                Date received : 25 October 2013
                Date accepted : 30 December 2013
                Categories
                Subject: Clinical Article - Neurosurgical Techniques
                Custom metadata
                issue-copyright-statement © Springer-Verlag Wien 2014

                ScienceOpen disciplines: Surgery
                Keywords: cranioplasty,craniectomy,autologous,cryopreserved,surgical site infection,complications
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: cranioplasty, craniectomy, autologous, cryopreserved, surgical site infection, complications

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