1
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Robles LA, Morell A. Autologous Cranioplasty with Bone Flap Preserved in Conventional Freezers: An Adequate Option in Low Resource Settings. World Neurosurg 2024; 182:116-123. [PMID: 38042293 DOI: 10.1016/j.wneu.2023.11.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/26/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Autologous cranioplasty has been used for decades and is the gold standard treatment in patients who underwent decompressive craniectomy (DC). One of the most common methods to store the cranial bone flap is cryopreservation at very low temperatures (-70 to -80°). The only way to achieve these low temperatures is by using special freezers which are not always available in all medical facilities, especially in low-resource centers. This paper describes our experience with the storage of cranial bone flaps in freezers of conventional refrigerators. METHODS This retrospective study included patients treated with autologous cranioplasty, operated between 2015 and 2020. The cranial bone flap was stored at -18°C in the freezer of conventional refrigerators. Complications and outcomes were analyzed and compared with reports of patients in whom ultra-low temperature freezers were used for bone flap preservation. RESULTS Twenty-five patients were included. The average follow-up period was 33 months. Trauma was the most common cause of DC, followed by stroke. The mean age was 36.7. Aseptic bone flap resorption was observed in 4 cases (16%). No cases of infection were observed. CONCLUSIONS The use of freezers from conventional refrigerators may be an acceptable alternative for the preservation of the cranial bone flap in facilities where special freezers are not available. The rate of aseptic bone necrosis and infections observed in this paper was similar to the incidence of these complications reported in studies where ultra-low temperatures were used.
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Affiliation(s)
- Luis A Robles
- Section of Neurosurgery, Hospital CMQ, Vallarta Jalisco, Mexico.
| | - Alexis Morell
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami Florida USA
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2
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Anderson H, Hersh DS, Khan Y. The potential role of mechanotransduction in the management of pediatric calvarial bone flap repair. Biotechnol Bioeng 2024; 121:39-52. [PMID: 37668193 PMCID: PMC10841298 DOI: 10.1002/bit.28534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/30/2023] [Accepted: 08/05/2023] [Indexed: 09/06/2023]
Abstract
Pediatric patients suffering traumatic brain injuries may require a decompressive craniectomy to accommodate brain swelling by removing a portion of the skull. Once the brain swelling subsides, the preserved calvarial bone flap is ideally replaced as an autograft during a cranioplasty to restore protection of the brain, as it can reintegrate and grow with the patient during immature skeletal development. However, pediatric patients exhibit a high prevalence of calvarial bone flap resorption post-cranioplasty, causing functional and cosmetic morbidity. This review examines possible solutions for mitigating pediatric calvarial bone flap resorption by delineating methods of stimulating mechanosensitive cell populations with mechanical forces. Mechanotransduction plays a critical role in three main cell types involved with calvarial bone repair, including mesenchymal stem cells, osteoblasts, and dural cells, through mechanisms that could be exploited to promote osteogenesis. In particular, physiologically relevant mechanical forces, including substrate deformation, external forces, and ultrasound, can be used as tools to stimulate bone repair in both in vitro and in vivo systems. Ultimately, combating pediatric calvarial flap resorption may require a combinatorial approach using both cell therapy and bioengineering strategies.
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Affiliation(s)
- Hanna Anderson
- Biomedical Engineering, University of Connecticut, Storrs, Connecticut, USA
- The Cato T. Laurencin Institute for Regenerative Engineering, UConn Health, Farmington, Connecticut, USA
| | - David S Hersh
- Department of Surgery, UConn School of Medicine, Farmington, Connecticut, USA
- Division of Neurosurgery, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Yusuf Khan
- Biomedical Engineering, University of Connecticut, Storrs, Connecticut, USA
- The Cato T. Laurencin Institute for Regenerative Engineering, UConn Health, Farmington, Connecticut, USA
- Orthopaedic Surgery, UConn Health, Farmington, Connecticut, USA
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3
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Son Y, Chung J. Risk Factor Analysis of Cryopreserved Autologous Bone Flap Resorption in Adult Patients Undergoing Cranioplasty with Volumetry Measurement Using Conventional Statistics and Machine-Learning Technique. J Korean Neurosurg Soc 2024; 67:103-114. [PMID: 37709548 PMCID: PMC10788544 DOI: 10.3340/jkns.2023.0143] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/29/2023] [Accepted: 09/13/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVE Decompressive craniectomy (DC) with duroplasty is one of the common surgical treatments for life-threatening increased intracranial pressure (ICP). Once ICP is controlled, cranioplasty (CP) with reinsertion of the cryopreserved autologous bone flap or a synthetic implant is considered for protection and esthetics. Although with the risk of autologous bone flap resorption (BFR), cryopreserved autologous bone flap for CP is one of the important material due to its cost effectiveness. In this article, we performed conventional statistical analysis and the machine learning technique understand the risk factors for BFR. METHODS Patients aged >18 years who underwent autologous bone CP between January 2015 and December 2021 were reviewed. Demographic data, medical records, and volumetric measurements of the autologous bone flap volume from 94 patients were collected. BFR was defined with absolute quantitative method (BFR-A) and relative quantitative method (BFR%). Conventional statistical analysis and random forest with hyper-ensemble approach (RF with HEA) was performed. And overlapped partial dependence plots (PDP) were generated. RESULTS Conventional statistical analysis showed that only the initial autologous bone flap volume was statistically significant on BFR-A. RF with HEA showed that the initial autologous bone flap volume, interval between DC and CP, and bone quality were the factors with most contribution to BFR-A, while, trauma, bone quality, and initial autologous bone flap volume were the factors with most contribution to BFR%. Overlapped PDPs of the initial autologous bone flap volume on the BRF-A crossed at approximately 60 mL, and a relatively clear separation was found between the non-BFR and BFR groups. Therefore, the initial autologous bone flap of over 60 mL could be a possible risk factor for BFR. CONCLUSION From the present study, BFR in patients who underwent CP with autologous bone flap might be inevitable. However, the degree of BFR may differ from one to another. Therefore, considering artificial bone flaps as implants for patients with large DC could be reasonable. Still, the risk factors for BFR are not clearly understood. Therefore, chronological analysis and pathophysiologic studies are needed.
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Affiliation(s)
- Yohan Son
- Department of Neurosurgery, Dankook University Hospital, Cheonan, Korea
| | - Jaewoo Chung
- Department of Neurosurgery, Dankook University Hospital, Cheonan, Korea
- Department of Neurosurgery, College of Medicine, Dankook University, Cheonan, Korea
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4
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Gousias K, Stricker I, Hoyer A, Theocharous T, Rompf C, Pranada AB, Tannapfel A, Agrawal R, Tischoff I. Explanted Skull Flaps after Decompressive Hemicraniectomy Demonstrate Relevant Bone Avitality-Is Their Reimplantation Worth the Risk? Brain Sci 2023; 13:1277. [PMID: 37759878 PMCID: PMC10526390 DOI: 10.3390/brainsci13091277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 08/26/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Reimplantations of autologous skull flaps after decompressive hemicraniectomies (DHs) are associated with high rates of postoperative bone flap resorption (BFR). We histologically assessed the cell viability of explanted bone flaps in certain periods of time after DH, in order to conclude whether precursors of BRF may be developed during their storage. METHODS Skull bone flaps explanted during a DH between 2019 and 2020 were stored in a freezer at either -23 °C or -80 °C. After their thawing process, the skulls were collected. Parameters of bone metabolism, namely PTH1 and OPG, were analyzed via immunohistochemistry. H&E stain was used to assess the degree of avital bone tissue, whereas the repeated assays were performed after 6 months. RESULTS A total of 17 stored skull flaps (8 at -23 °C; 9 at -80 °C) were analyzed. The duration of cryopreservation varied between 2 and 17 months. A relevant degree of bone avitality was observed in all skull flaps, which significantly increased at the repeated evaluation after 6 months (p < 0.001). Preservation at -23 °C (p = 0.006) as well as longer storage times (p < 0.001) were identified as prognostic factors for higher rates of bone avitality in a linear mixed regression model. CONCLUSIONS Our novel finding shows a clear benefit from storage at -80° C, which should be carefully considered for the future management and storage of explanted skull flaps. Our analysis also further revealed a significant degree of bone avitality, a potential precursor of BFR, in skull flaps stored for several weeks. To this end, we should reconsider whether the reimplantation of autologous skull flaps instead of synthetic skull flaps is still justified.
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Affiliation(s)
- Konstantinos Gousias
- Department of Neurosurgery, Academic Hospital of University of Muenster, St. Marien Hospital Luenen, 44532 Luenen, Germany; (T.T.); (R.A.)
- Medical School, Westfaelische Wilhelms University of Muenster, 48149 Muenster, Germany
- Medical School, University of Nicosia, Nicosia 2408, Cyprus
| | - Ingo Stricker
- Institute of Pathology, Ruhr University Bochum, 44789 Bochum, Germany; (I.S.); (A.T.); (I.T.)
| | - Annika Hoyer
- Biostatistics and Medical Biometry, Medical School OWL, Bielefeld University, 33615 Bielefeld, Germany;
| | - Theocharis Theocharous
- Department of Neurosurgery, Academic Hospital of University of Muenster, St. Marien Hospital Luenen, 44532 Luenen, Germany; (T.T.); (R.A.)
| | - Csilla Rompf
- MVZ Dr. Eberhard & Partner Dortmund, 44137 Dortmund, Germany; (C.R.); (A.B.P.)
| | - Arthur B. Pranada
- MVZ Dr. Eberhard & Partner Dortmund, 44137 Dortmund, Germany; (C.R.); (A.B.P.)
| | - Andrea Tannapfel
- Institute of Pathology, Ruhr University Bochum, 44789 Bochum, Germany; (I.S.); (A.T.); (I.T.)
| | - Rachit Agrawal
- Department of Neurosurgery, Academic Hospital of University of Muenster, St. Marien Hospital Luenen, 44532 Luenen, Germany; (T.T.); (R.A.)
| | - Iris Tischoff
- Institute of Pathology, Ruhr University Bochum, 44789 Bochum, Germany; (I.S.); (A.T.); (I.T.)
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5
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Xu A, Venugopal V, Aryal MR, Alfawares Y, Matur AV, Cheng J, Kosco E, McConaha M, Ghalsasi O, Lockett D, Bal G, Andaluz N, Ngwenya LB, Anand S, Forbes J. Toward global availability of low-cost, patient-specific cranial implants: creation and validation of automated CranialRebuild freeware application. Acta Neurochir (Wien) 2023; 165:2219-2224. [PMID: 37351673 DOI: 10.1007/s00701-023-05663-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/12/2023] [Indexed: 06/24/2023]
Abstract
PURPOSE Financial restrictions limit the options for hermetically precise, patient-specific cranial implants (PSCIs) after decompressive hemicraniectomy (DHC) in low-income countries. Use of image segmentation, modeling software, and 3D printers has lowered costs associated with PSCIs. However, requirements of time and technical expertise have prevented widespread utilization. Our objective was to create a fully automated software algorithm that is able to generate a virtual model (.STL) of a negative of an implant using CT imaging following DHC. METHODS A freeware algorithm (CranialRebuild) was constructed with the following capabilities: (1) after the upload of digital imaging and communications in medicine files, the normal side is analyzed in reference to the side of DHC, (2) Boolean subtraction is used to obtain a virtual image of the desired implant, and (3) a two-piece virtual model (.STL) of the PSCI mold is generated. In four cadaveric specimens, a standard DHC was performed. Post-DHC CT imaging was used to obtain a .STL of the negative of the implant, which was then printed using poly-lactic acid (PLA). Methylmethacrylate cement was used to generate a PSCI from the mold. The PSCIs were implanted into the index specimens; cosmesis was subjectively evaluated using a 5-point Likert scale. RESULTS Two specimens were graded as 4/5, indicating that minor post-processing modification was needed for optimal cosmesis. Two specimens were graded as 3/5, indicating that optimal cosmesis could be obtained following moderate post-processing modification. CONCLUSIONS CranialRebuild can be used to create hermetically precise PSCIs at a fraction of the price of third-party vendors. Validation of this technology has significant implications for the accessibility of customized cranial implants worldwide.
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Affiliation(s)
- Alice Xu
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Vysakh Venugopal
- Center for Global Design and Manufacturing, Department of Mechanical Engineering, University of Cincinnati, Cincinnati, OH, USA
| | - Manish Raj Aryal
- Center for Global Design and Manufacturing, Department of Mechanical Engineering, University of Cincinnati, Cincinnati, OH, USA
| | - Yara Alfawares
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Abhijith V Matur
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joshua Cheng
- Department of Biomechanical Engineering, Duke University, Durham, NC, USA
| | - Ethan Kosco
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Matthew McConaha
- Center for Global Design and Manufacturing, Department of Mechanical Engineering, University of Cincinnati, Cincinnati, OH, USA
| | - Omkar Ghalsasi
- Center for Global Design and Manufacturing, Department of Mechanical Engineering, University of Cincinnati, Cincinnati, OH, USA
| | | | - Gabriella Bal
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Norberto Andaluz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Laura B Ngwenya
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sam Anand
- Center for Global Design and Manufacturing, Department of Mechanical Engineering, University of Cincinnati, Cincinnati, OH, USA
| | - Jonathan Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Two-center validation of the Oulu resorption score for bone flap resorption after autologous cranioplasty. Clin Neurol Neurosurg 2021; 212:107083. [PMID: 34896867 DOI: 10.1016/j.clineuro.2021.107083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/23/2021] [Accepted: 11/28/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Autologous bone has been the gold standard of cranioplasty materials for decades. Unique to autologous cranioplasty, bone flap resorption is a poorly understood and unclearly defined complication. Even further, it has been unclear, whether the resorption process eventually stabilizes over time. Thus, the sufficient follow-up period after autologous cranioplasty is unknown. The Oulu Resorption Score (ORS) is a straight-forward classification system for the radiological interpretation of bone flap resorption. The aims of the present study were to evaluate the reliability of the ORS using intra-class correlation coefficient (ICC) and to assess the temporal progression of the resorption process. METHODS We identified 108 consecutive autologous cranioplasty patients treated between 2005 and 2018 in two tertiary referral centers. All 365 head CT scans the patients had undergone were evaluated using the ORS in a blinded, independent two-center setting. Intra- and inter-observer reliabilities were calculated. The ORS was applied to study the temporal progression of the resorption process. RESULTS The intra-observer reliability of the ORS was excellent (ICC 0.94, 95%CI 0.93-0.95). Inter-observer reliability was good-to-excellent (ICCs 0.87 and 0.89, 95%CIs 0.84-0.89 and 0.87-0.91, respectively). In scatterplot smoothing analyses, the progression of bone flap resorption appeared to stabilize 12-24 months after cranioplasty. CONCLUSIONS ORS is the only validated radiological tool for the standardized analysis of bone flap resorption after autologous cranioplasty. Evaluated using the ORS, the resorption process seemed to stabilize during the first two postoperative years after cranioplasty, suggesting that the sufficient follow-up time after autologous cranioplasty is two years.
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7
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Meyer H, Khalid SI, Dorafshar AH, Byrne RW. The Materials Utilized in Cranial Reconstruction: Past, Current, and Future. Plast Surg (Oakv) 2021; 29:184-196. [PMID: 34568234 PMCID: PMC8436325 DOI: 10.1177/2292550320928560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Cranioplasty (CP) is associated with high complication rates compared to other common neurosurgical procedures. Several graft materials are used for CP, which may contribute to the high complication rates, but data in the literature regarding the influence of graft material on post-CP outcomes are inconsistent making it difficult to determine if, when, and to what extent the graft material impacts the rate of perioperative complications. There is an increased demand to identify and develop superior graft materials. OBJECTIVE To review and compare the indications, risks, complications, and patient results associated with the use of different graft materials for cranial reconstructions. DESIGN A search through EBSCOhost was conducted using the keywords "craniectomy" or "decompressive craniectomy," "cranioplasty," and "materials." The search was limited to literature published in the English language from 2005 until the present. Ultimately, 69 articles were included in this review. Due to the heterogeneity of the study populations, results, statistical analyses, and collecting methods, no statistical analyses could be performed. CONCLUSIONS Several graft materials have been adapted for use in cranial reconstructions with inconsistent results making it unclear if or when one material may be indicated over others. Advances in computer-aided design have led to improved patient-specific implants, but the ideal graft material is still being sought after in ongoing research efforts. Reviewing materials currently available, as well as those in clinical trials, is important to identify the limitations associated with different implants and to guide future research.
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Affiliation(s)
- Haley Meyer
- Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, IL, USA
| | - Syed I. Khalid
- Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, IL, USA
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Amir H. Dorafshar
- Department of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL
| | - Richard W. Byrne
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL
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8
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Hersh DS, Anderson HJ, Woodworth GF, Martin JE, Khan YM. Bone Flap Resorption in Pediatric Patients Following Autologous Cranioplasty. Oper Neurosurg (Hagerstown) 2021; 20:436-443. [PMID: 33469664 DOI: 10.1093/ons/opaa452] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/06/2020] [Indexed: 01/31/2023] Open
Abstract
Following a decompressive craniectomy, the autologous bone flap is generally considered the reconstructive material of choice in pediatric patients. Replacement of the original bone flap takes advantage of its natural biocompatibility and the associated low risk of rejection, as well as the potential to reintegrate with the adjacent bone and subsequently grow with the patient. However, despite these advantages and unlike adult patients, the replaced calvarial bone is more likely to undergo delayed bone resorption in pediatric patients, ultimately requiring revision surgery. In this review, we describe the materials that are currently available for pediatric cranioplasty, the advantages and disadvantages of autologous calvarial replacement, the incidence and classification of bone resorption, and the clinical risk factors for bone flap resorption that have been identified to date.
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Affiliation(s)
- David S Hersh
- Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut.,Department of Surgery, UConn School of Medicine, Farmington, Connecticut.,Department of Pediatrics, UConn School of Medicine, Farmington, Connecticut
| | - Hanna J Anderson
- Connecticut Convergence Institute for Translation in Regenerative Engineering, UConn Health, Farmington, Connecticut.,Department of Biomedical Engineering, University of Connecticut School of Engineering, Storrs, Connecticut
| | - Graeme F Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan E Martin
- Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut.,Department of Surgery, UConn School of Medicine, Farmington, Connecticut
| | - Yusuf M Khan
- Connecticut Convergence Institute for Translation in Regenerative Engineering, UConn Health, Farmington, Connecticut.,Department of Biomedical Engineering, University of Connecticut School of Engineering, Storrs, Connecticut.,Department of Orthopedic Surgery, UConn School of Medicine, Farmington, Connecticut
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9
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Mirabet V, García D, Roca A, Quiroz AR, Antón J, Rodríguez-Cadarso M, Ocete D, Aranda L, Melero A, Guillot AJ, Yagüe N, Guillén I, Botella C. Cranioplasty with Autologous Bone Flaps Cryopreserved with Dimethylsulphoxide: Does Tissue Processing Matter. World Neurosurg 2021; 149:e582-e591. [PMID: 33556597 DOI: 10.1016/j.wneu.2021.01.131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this article was to study the outcome of patients who underwent cranioplasty with cryopreserved autologous bone after decompressive craniectomy. METHODS Data from 74 patients were retrospectively analyzed. They were divided into groups according to the storage time and the age at cranioplasty. To assess the predictive potential for complication, factors were related to successive stages (preoperative, craniectomy, tissue processing, cranioplasty, and postoperative). Cooling and warming rates applied on bone flap were calculated. The ability to inhibit microbial growth was determined exposing bone fragments to a panel of microorganisms. The concentration of antibiotics eluted from the bone was also determined. A bone explant culture method was used to detect living cells in the thawed cranial bone. RESULTS Hydrocephalus was significantly more frequent in pediatric patients (26.7%) than in adults (5.1%). The overall rate of bone flap resorption was 21.6% (43.7% of which required reoperation). Surgical site infection after cranioplasty was detected in 6.8% of patients. There was no correlation between infection as a postoperative complication and previous microbiological-positive culture during processing. The cause of craniectomy did not influence the risk of bone flap contamination. Vancomycin was the only antibiotic detected in the supernatant where the bone was incubated. Outgrowth from bone explants was observed in 36.8% of thawed skulls. An early start of bone flap processing at the tissue bank had a positive effect on cell viability. CONCLUSIONS The outcome after autologous cranioplasty is a multifactorial process, which is modulated by patient-related, surgery-related, and bone-related factors.
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Affiliation(s)
- Vicente Mirabet
- Cell and Tissue Bank, Centro de Transfusión de la Comunidad Valenciana, Valencia, Spain.
| | - Daniel García
- Cell and Tissue Bank, Centro de Transfusión de la Comunidad Valenciana, Valencia, Spain
| | - Amparo Roca
- Cell and Tissue Bank, Centro de Transfusión de la Comunidad Valenciana, Valencia, Spain
| | - Arnold R Quiroz
- Cell and Tissue Bank, Centro de Transfusión de la Comunidad Valenciana, Valencia, Spain
| | - Joan Antón
- Cell and Tissue Bank, Centro de Transfusión de la Comunidad Valenciana, Valencia, Spain
| | | | - Dolores Ocete
- Service of Microbiology, Consorcio Hospital General Universitario, Valencia, Spain
| | - Lucas Aranda
- Service of Microbiology, Consorcio Hospital General Universitario, Valencia, Spain
| | - Ana Melero
- Department of Pharmacy, Pharmaceutical Technology and Parasitology, Universitat de València, Valencia, Spain
| | - Antonio J Guillot
- Department of Pharmacy, Pharmaceutical Technology and Parasitology, Universitat de València, Valencia, Spain
| | - Nuria Yagüe
- Cell and Tissue Bank, Centro de Transfusión de la Comunidad Valenciana, Valencia, Spain
| | - Isabel Guillén
- Department of Pharmacy, Faculty of Health Sciences, Universidad Cardenal Herrera-CEU, Valencia, Spain
| | - Carlos Botella
- Cell and Tissue Bank, Centro de Transfusión de la Comunidad Valenciana, Valencia, Spain
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10
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Padalhin A, Ventura R, Kim B, Sultana T, Park CM, Lee BT. Boosting osteogenic potential and bone regeneration by co-cultured cell derived extracellular matrix incorporated porous electrospun scaffold. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2021; 32:779-798. [PMID: 33375905 DOI: 10.1080/09205063.2020.1869879] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Implants for bone regeneration to remedy segmental bone defects, osteomyelitis, necrotic bone tissue and non-union fractures have worldwide appeal. Although biomaterials offer most of the advantages by improving tissue growth but developments are more commonly achieved via biologically derived molecules. To aid site specific bone tissue regeneration by synthetic scaffold, cell derived extracellular matrix (ECM) can be a crucial component. In this study, co-cultured bone marrow mesenchymal stem cell and osteoblastic cells derived ECM incorporated electrospun polycaprolactone (PCL) membranes were assessed for bone tissue engineering application. The preliminary experimental details indicated that, co-culture of cells supported enhanced in vitro ECM synthesis followed by successful deposition of osteoblastic ECM into electrospun membranes. The acellular samples revealed retention of ECM related biomacromolecules (collagen, glycosaminoglycan) and partial recovery of pores after decellularization. In vitro biocompatibility tests ensured improvement of proliferation and osteoblastic differentiation of MC3T3-E1 cells in decellularized ECM containing membrane (PCL-ECM) compared to bare membrane (PCL-B) which was further confirmed by osteogenic marker proteins expression analysis. The decellularized PCL-ECM membrane allowed great improvement of bone regeneration over the bare membrane (PCL-B) in 8 mm size critical sized rat skull defects at 2 months of post implantation. In short, the outcome of this study could be impactful in development and application of cell derived ECM based synthetic electrospun templates for bone tissue engineering application.[Formula: see text].
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Affiliation(s)
- Andrew Padalhin
- Department of Regenerative Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Reiza Ventura
- Department of Regenerative Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Boram Kim
- Department of Regenerative Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Tamanna Sultana
- Department of Regenerative Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea.,Institute of Tissue Regeneration, Soonchunhyang University, Cheonan, Republic of Korea
| | - Chan Mi Park
- Institute of Tissue Regeneration, Soonchunhyang University, Cheonan, Republic of Korea
| | - Byong-Taek Lee
- Department of Regenerative Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea.,Institute of Tissue Regeneration, Soonchunhyang University, Cheonan, Republic of Korea
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11
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The storage of skull bone flaps for autologous cranioplasty: literature review. Cell Tissue Bank 2021; 22:355-367. [PMID: 33423107 DOI: 10.1007/s10561-020-09897-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 12/27/2020] [Indexed: 01/10/2023]
Abstract
The use of autologous bone flap for cranioplasty after decompressive craniectomy is a widely used strategy that allows alleviating health expenses. When the patient has recovered from the primary insult, the cranioplasty restores protection and cosmesis, recovering fluid dynamics and improving neurological status. During this time, the bone flap must be stored, but there is a lack of standardization of tissue banking practices for this aim. In this work, we have reviewed the literature on tissue processing and storage practices. Most of the published articles are focused from a strictly clinical and surgical point of view, paying less attention to issues related to tissue manipulation. When bone resorption is avoided and the risk of infection is controlled, the autograft represents the most efficient choice, with the lowest risk of complication. Otherwise, depending on the degree of involvement, the patient may have to undergo new surgery, assuming further risks and higher healthcare costs. Therefore, tissue banks must implement protocols to provide products with the highest possible clinical effectiveness, without compromising safety. With a centralised management of tissue banking practices there may be a more uniform approach, thus facilitating the standardization of procedures and guidelines.
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12
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Lai Q, Ge Y. Letter to the Editor. An altered posterior question-mark incision. J Neurosurg 2020; 134:1349-1350. [PMID: 32947254 DOI: 10.3171/2020.7.jns202703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Qingjia Lai
- 1The Second Affiliated Hospital of Chengdu Medical College & Nuclear Industry 416 Hospital, Chengdu, China and
| | - Yuanhong Ge
- 2The Second People's Hospital of Chengdu, Chengdu, China
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13
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Jeon JP, Heo Y, Kang SH, Yang JS, Choi HJ, Cho YJ. Retrospective Chronologic Computed Tomography Analysis of Bone Flap Fusion and Resorption After Craniotomy and Autologous Cryopreserved Cranioplasty. World Neurosurg 2019; 129:e900-e906. [PMID: 31229749 DOI: 10.1016/j.wneu.2019.06.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND In open brain surgery, fixation of the bone flap is the final procedure. The bone flaps then fuse naturally. The objective of this study was to investigate the chronological process of bone fusion after craniotomy and autologous cranioplasty. METHODS Retrospective data were collected from patients who underwent craniotomy or cranioplasty after August 2004 and had at least 1 computed tomography (CT) scan at 3 months postsurgery. The patients were divided into a craniotomy group and a cranioplasty group. Head CT scans were analyzed to evaluate bone fusion and resorption. RESULTS Records from 978 patients who underwent craniotomy or cranioplasty between September 2004 and November 2015 were reviewed; 369 patients were eligible for the final analysis (craniotomy, n = 276; cranioplasty, n = 93). The mean cryopreservation period for the bone flap in the cranioplasty group was 49.3 days. The mean patient age was 51.4 ± 18.1 years in the craniotomy group and 51.6 ± 17.1 years in the cranioplasty group. Head CT scans showed bone fusion rates of 76.6% in the craniotomy group and 53.3% in the cranioplasty group at 6 months postsurgery (P = 0.015) and 78.6% and 78.1%, respectively, at 1 year postsurgery (P = 0.951). There was also a significant difference in the bone flap resorption rate between the 2 groups. CONCLUSIONS Bone flap fusion rates after craniotomy and cranioplasty were significantly different before 12 months, but not significantly different thereafter. Bone resorption occurred more frequently in the cranioplasty group over time.
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Affiliation(s)
- Jin Pyeong Jeon
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Chuncheon-si, Gangwon-do, Korea
| | - Yunsuk Heo
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Chuncheon-si, Gangwon-do, Korea
| | - Suk-Hyung Kang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Chuncheon-si, Gangwon-do, Korea.
| | - Jin Seo Yang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Chuncheon-si, Gangwon-do, Korea
| | - Hyuk Jai Choi
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Chuncheon-si, Gangwon-do, Korea
| | - Yong-Jun Cho
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Chuncheon-si, Gangwon-do, Korea
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14
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Korhonen TK, Tetri S, Huttunen J, Lindgren A, Piitulainen JM, Serlo W, Vallittu PK, Posti JP. Predictors of primary autograft cranioplasty survival and resorption after craniectomy. J Neurosurg 2018; 130:1672-1679. [PMID: 29749908 DOI: 10.3171/2017.12.jns172013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 12/19/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Craniectomy is a common neurosurgical procedure that reduces intracranial pressure, but survival necessitates cranioplasty at a later stage, after recovery from the primary insult. Complications such as infection and resorption of the autologous bone flap are common. The risk factors for complications and subsequent bone flap removal are unclear. The aim of this multicenter, retrospective study was to evaluate the factors affecting the outcome of primary autologous cranioplasty, with special emphasis on bone flap resorption. METHODS The authors identified all patients who underwent primary autologous cranioplasty at 3 tertiary-level university hospitals between 2002 and 2015. Patients underwent follow-up until bone flap removal, death, or December 31, 2015. RESULTS The cohort comprised 207 patients with a mean follow-up period of 3.7 years (SD 2.7 years). The overall complication rate was 39.6% (82/207), the bone flap removal rate was 19.3% (40/207), and 11 patients (5.3%) died during the follow-up period. Smoking (OR 3.23, 95% CI 1.50-6.95; p = 0.003) and age younger than 45 years (OR 2.29, 95% CI 1.07-4.89; p = 0.032) were found to independently predict subsequent autograft removal, while age younger than 30 years was found to independently predict clinically relevant bone flap resorption (OR 4.59, 95% CI 1.15-18.34; p = 0.03). The interval between craniectomy and cranioplasty was not found to predict either bone flap removal or resorption. CONCLUSIONS In this large, multicenter cohort of patients with autologous cranioplasty, smoking and younger age predicted complications leading to bone flap removal. Very young age predicted bone flap resorption. The authors recommend that physicians extensively inform their patients of the pronounced risks of smoking before cranioplasty.
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Affiliation(s)
- Tommi K Korhonen
- 1Department of Neurosurgery, Oulu University Hospital, Oulu
- 2Research Unit of Clinical Neuroscience, Neurosurgery, Oulu University Hospital and University of Oulu
| | - Sami Tetri
- 1Department of Neurosurgery, Oulu University Hospital, Oulu
- 2Research Unit of Clinical Neuroscience, Neurosurgery, Oulu University Hospital and University of Oulu
| | - Jukka Huttunen
- 3Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio
| | - Antti Lindgren
- 3Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio
| | - Jaakko M Piitulainen
- 4Division of Surgery and Cancer Diseases, Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Hospital, Turku Finland and University of Turku
| | - Willy Serlo
- 5PEDEGO Research Unit, University of Oulu, MRC Oulu, and Department of Children and Adolescents, Oulu University Hospital, Oulu
| | - Pekka K Vallittu
- 6Department of Biomaterials Science, Institute of Dentistry, University of Turku and City of Turku, Welfare Division, Turku
| | - Jussi P Posti
- 6Department of Biomaterials Science, Institute of Dentistry, University of Turku and City of Turku, Welfare Division, Turku
- 7Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital, Turku; and
- 8Department of Neurology, University of Turku, Finland
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15
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Classification of the Residual Cranial Defects and Selection of Reconstruction Materials. J Craniofac Surg 2018; 28:1694-1701. [PMID: 28806376 DOI: 10.1097/scs.0000000000003752] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The cranial defects are complex in nature and are due to various causes. Therefore, there is a need for a common term of reference to these defects. This requirement stood as a prime reason for proposing a classification system for cranial defects. The classification is based on 2 decades of experience in cranioplasty. This efficient and simple way of representation would fill the existing lacunae for a systematic communication on cranial defects. Over the ages the evolution of reconstruction and grafting had undergone a massive progress. Therefore, it is essential to enumerate all available graft and bio-materials for restoring the cranial defects. The aetiology for these defects, age and sex of the patient, site and size of the defect, associated systemic conditions, cost factor, and operator's choice are the factors that play key role in the selection of the reconstructive material. This article discusses on these factors in cranioplasty. High success rate with excellent function and cosmetic outcome in using a variety of materials, as shared in this article. The advantages of autografts cannot be matched by any existing alloplast. However, in case of larger defects, for a better cosmetic outcome and to reduce the donor site morbidity, alloplasts are the most widely preferred material of choice.
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16
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Korhonen TK, Salokorpi N, Niinimäki J, Serlo W, Lehenkari P, Tetri S. Quantitative and qualitative analysis of bone flap resorption in patients undergoing cranioplasty after decompressive craniectomy. J Neurosurg 2018; 130:312-321. [DOI: 10.3171/2017.8.jns171857] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 08/21/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAutologous bone cranioplasty after decompressive craniectomy entails a notable burden of difficult postoperative complications, such as infection and bone flap resorption (BFR), leading to mechanical failure. The prevalence and significance of asymptomatic BFR is currently unclear. The aim of this study was to radiologically monitor the long-term bone flap survival and bone quality change in patients undergoing autologous cranioplasty.METHODSThe authors identified all 45 patients who underwent autologous cranioplasty at Oulu University Hospital, Finland, between January 2004 and December 2014. Using perioperative and follow-up CT scans, the volumes and radiodensities of the intact bone flap prior to surgery and at follow-up were calculated. Relative changes in bone flap volume and radiodensity were then determined to assess cranioplasty survival. Sufficient CT scans were obtainable from 41 (91.1%) of the 45 patients.RESULTSThe 41 patients were followed up for a median duration of 3.79 years (25th and 75th percentiles = 1.55 and 6.66). Thirty-seven (90.2%) of the 41 patients had some degree of BFR and 13 (31.7%) had a remaining bone flap volume of less than 80%. Patients younger than 30 years of age had a mean decrease of 15.8% in bone flap volume compared with the rest of the cohort. Bone flap volume was not found to decrease linearly with the passing of time, however. The effects of lifestyle factors and comorbidities on BFR were nonsignificant.CONCLUSIONSIn this study BFR was a very common phenomenon, occurring at least to some degree in 90% of the patients. Decreases in bone volume were especially prominent in patients younger than 30 years of age. Because the progression of resorption during follow-up was nonlinear, routine follow-up CT scans appear unnecessary in monitoring the progression of BFR; instead, clinical follow-up with mechanical stability assessment is advised. Partial resorption is most likely a normal physiological phenomenon during the bone revitalization process.
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Affiliation(s)
| | | | | | - Willy Serlo
- 3PEDEGO Research Unit; and
- 5Department of Children and Adolescents, Oulu University Hospital, MRC Oulu, Finland
| | - Petri Lehenkari
- 4Department of Anatomy and Cell Biology, University of Oulu; and
| | - Sami Tetri
- 1Department of Neurosurgery, Oulu University Hospital
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Fan MC, Wang QL, Sun P, Zhan SH, Guo P, Deng WS, Dong Q. Cryopreservation of Autologous Cranial Bone Flaps for Cranioplasty: A Large Sample Retrospective Study. World Neurosurg 2017; 109:e853-e859. [PMID: 29107719 DOI: 10.1016/j.wneu.2017.10.112] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/17/2017] [Accepted: 10/20/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To clarify the clinical outcomes of cranioplasty with cryopreserved bone flaps and identify risk factors related to bone flap infection and resorption after cranioplasty with cryopreserved bone flaps. METHODS A total of 946 patients (989 bone flaps) underwent decompressive craniectomy and delayed cranioplasty via the use of cryopreserved autogenous cranial bone flaps. Cranial bone flaps were removed during the initial craniectomy and reserved in liquid nitrogen (-196°C) with dimethyl sulfoxide as a cryoprotectant. Cranioplasty subsequently was performed once the brain injury had healed. Data regarding complications and clinical outcomes were recorded and the potential risk factors were analyzed. RESULTS Data from 960 flaps were available for analysis. The overall complication rate was 15.83% (152 of 960). Bone resorption occurred in 42 flaps in 37 patients (4.38%). The bone flaps resorption rate was greater in patients ≤18 years than in patients >18 years (9.38% vs. 3.61%, P < 0.05). Cryopreservation for more than 365 days tended to result in a greater bone resorption rate (6.88% vs. 2.92%, P < 0.01). Skull bone grafts infection occurred in 39 flaps in 34 patients (4.06%). The bone graft infection rate was greater in emergency craniectomy cases (8.81% vs. 2.59%, P < 0.01) and in patients with diabetes (10.53% vs. 3.07%, P < 0.01). CONCLUSIONS Cryopreservation of autologous cranial bone flaps is safe and effective for cranioplasty. Cranioplasty with cryopreserved autologous cranial bone flaps should be performed no more than 1 year after craniectomy. Emergency craniectomy and patients with diabetes require special attention.
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Affiliation(s)
- Ming-Chao Fan
- Neurosurgical Intensive Care Unit, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qiao-Ling Wang
- Community Medical Service Center of Zhenjiang Street, North City District, Qingdao, China
| | - Peng Sun
- Department of Neurosurgery, the Affiliated Hospital of Qingdao University, Qingdao, China.
| | - Shu-Hua Zhan
- Department of Neurosurgery, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Pin Guo
- Department of Neurosurgery, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wen-Shuai Deng
- Neurosurgical Intensive Care Unit, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qian Dong
- Department of Pediatric Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China.
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18
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Cho TG, Kang SH, Cho YJ, Choi HJ, Jeon JP, Yang JS. Osteoblast and Bacterial Culture from Cryopreserved Skull Flap after Craniectomy: Laboratory Study. J Korean Neurosurg Soc 2017; 60:397-403. [PMID: 28689388 PMCID: PMC5544374 DOI: 10.3340/jkns.2017.0101.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/24/2017] [Accepted: 05/04/2017] [Indexed: 11/27/2022] Open
Abstract
Objective Cranioplasty using a cryopreserved skull flap is a wide spread practice. The most well-known complications of cranioplasty are postoperative surgical infections and bone flap resorption. In order to find biological evidence of cryopreserved cranioplasty, we investigated microorganism contamination of cryopreserved skulls and cultured osteoblasts from cryopreserved skulls. Methods Cryopreserved skull flaps of expired patients stored in a bone bank were used. Cryopreserved skulls were packaged in a plastic bag and wrapped with cotton cloth twice. After being crushed by a hammer, cancellous bone between the inner and outer table was obtained. The cancellous bone chips were thawed in a water bath of 30°C rapidly. After this, osteoblast culture and general microorganism culture were executed. Osteoblast cultures were done for 3 weeks. Microorganism cultures were done for 72 hours. Results A total of 47 cryopreserved skull flaps obtained from craniectomy was enrolled. Of the sample, 11 people were women, and the average age of patients was 55.8 years. Twenty four people had traumatic brain injuries, and 23 people had vascular diseases. Among the patients with traumatic brain injuries, two had fracture compound comminuted depressed. The duration of cryopreservation was, on average, 83.2 months (9 to 161 months). No cultured osteoblast was observed. No microorganisms were cultured. Conclusion In this study, neither microorganisms nor osteoblasts were cultured. The biological validity of cryopreserved skulls cranioplasty was considered low. However, the usage of cryopreserved skulls for cranioplasty is worthy of further investigation in the aspect of cost-effectiveness and risk-benefit of post-cranioplasty infection.
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Affiliation(s)
- Tack Geun Cho
- Department of Neurosurgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Suk Hyung Kang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Yong Jun Cho
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Hyuk Jai Choi
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Jin Pyeong Jeon
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Jin Seo Yang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
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19
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Cho YJ, Kang SH. Review of Cranioplasty after Decompressive Craniectomy. Korean J Neurotrauma 2017; 13:9-14. [PMID: 28512612 PMCID: PMC5432454 DOI: 10.13004/kjnt.2017.13.1.9] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 04/17/2017] [Accepted: 04/19/2017] [Indexed: 12/18/2022] Open
Abstract
Cranioplasty is an in evitable operation conducted after decompressive craniectomy (DC). The primary goals of cranioplasty after DC are to protect the brain, achieve a natural appearance and prevent sinking skin flap syndrome (or syndrome of the trephined). Furthermore, restoring patients' functional outcome and supplementing external defects helps patients improve their self-esteem. Although early cranioplasty is preferred in recent year, optimal timing for cranioplasty remains a controversial topic. Autologous bone flaps are the most ideal substitute for cranioplasty. Complications associated with cranioplasty are also variable, however, post-surgical infection is most common. Many new materials and techniques for cranioplasty are introduced. Cost-benefit analysis of these new materials and techniques can result in different outcomes from different healthcare systems.
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Affiliation(s)
- Yong Jun Cho
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Suk Hyung Kang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
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20
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Chan DYC, Mok YT, Lam PK, Tong CSW, Ng SCP, Sun TFD, Poon WS. Cryostored autologous skull bone for cranioplasty? A study on cranial bone flaps' viability and microbial contamination after deep-frozen storage at -80°C. J Clin Neurosci 2017; 42:81-83. [PMID: 28431953 DOI: 10.1016/j.jocn.2017.04.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 04/03/2017] [Indexed: 11/15/2022]
Abstract
Craniectomy is a life-saving procedure. Subsequent cranioplasty with autologous skull bone has a bone resorption rate from 4% to 22.8% and an infection rate from 3.3% to 26%. There are concerns with their viability and the potential microbial contamination as they were explanted for a long period of time. Eighteen cranial bone flaps stored at Prince of Wales Hospital Skull Bone Bank during the period from June 2011 to March 2016 were identified. Ethics approval was obtained. Bone chips and deep bone swabs were collected for osteoblast culture and microbial culture. Skull Bone Bank was kept at -80°C under strict aseptic technique during the study period. The storage period ranged from 4months to 55months. For the osteoblast culture, all eighteen bone flaps had no viable osteoblast growth. For the bacterial culture, five had positive bacteria growth (27.8%). Three were Pasteurella multocida and two were Methicillin-resistant Staphylococcus aureus. The mean duration of storage of the infected bone flap was 32.9months (±15.1months) versus 19.9months (±17.9months) of those bone flaps with no bacterial growth (p=0.1716). The mean size of the infected versus non-infected bone flaps was 117.7cm2 (±44.96cm2) versus 76.8cm2 (±50.24cm2) respectively (p=0.1318). Although in this study statistical significance was not reached, it was postulated that infected bone flaps tended to be larger in size and had a longer duration of storage. In conclusion, cryostored skull bone flaps beyond four months showed no viable osteoblasts. Bacterial contamination rate of bone flaps was 27.8% in this study.
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Affiliation(s)
- David Yuen Chung Chan
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
| | - Yi Tan Mok
- Operating Theatre, Prince of Wales Hospital, Hong Kong.
| | - Ping Kuen Lam
- Chow Tai Fook - Cheung Yu Tung Surgical Stem Cell Research Centre, The Chinese University of Hong Kong, Hong Kong.
| | - Cindy See Wai Tong
- Chow Tai Fook - Cheung Yu Tung Surgical Stem Cell Research Centre, The Chinese University of Hong Kong, Hong Kong.
| | - Stephanie Chi Ping Ng
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
| | - Tin Fung David Sun
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
| | - Wai Sang Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Chow Tai Fook - Cheung Yu Tung Surgical Stem Cell Research Centre, The Chinese University of Hong Kong, Hong Kong.
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21
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Wui SH, Kim KM, Ryu YJ, Kim I, Lee SJ, Kim J, Kim C, Park S. The Autoclaving of Autologous Bone is a Risk Factor for Surgical Site Infection After Cranioplasty. World Neurosurg 2016; 91:43-9. [PMID: 27032525 DOI: 10.1016/j.wneu.2016.03.066] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND This retrospective study was designed to evaluate the effectiveness of autoclaving for the prevention of surgical site infection (SSI) after cranioplasty. METHODS Patients who underwent cranioplasty with autologous bone were enrolled. SSI was defined as an infection requiring bone flap removal. Risk factors of SSI, as reported by other researchers, and microbiologic features of SSI were analyzed. All bone flaps were preserved in a deep freezer (-70°C). Autoclaving of the preserved autologous bone flap before cranioplasty was performed for 5 minutes at 135°C in the 26 patients. RESULTS Eighty patients were enrolled. The mean age was 53.3 years and the male/female ratio was 3:2. Causes of craniectomy included trauma (n = 37) and nontrauma (n = 43). The mean time interval between craniectomy and cranioplasty was 49.7 days. The SSI rate after cranioplasty with autologous bone was 17.5% (n = 14). In univariate analysis, the cranioplasty operation time (P = 0.09) and the use of autoclaved bone (P = 0.00) were supposed to be risk factors for SSI. The use of autoclaved autologous bone was found to be the only risk factor of SSI (P = 0.01; hazard ratio = 8.88) in binary logistic regression analysis. Non-methicillin-resistant Staphylococcus aureus (MRSA) causes were more frequent in the autoclaved group (MRSA, 30%; non-MRSA, 70%) compared with the nonautoclaved group (MRSA, 100%) (P = 0.07). A microscopic examination showed that autoclaving after long-term cryopreservation may result in a loss of bone viability. CONCLUSIONS Autoclaving of autologous bone causes SSI after cranioplasty and it seems to increase the risk of non-MRSA infection by normal skin flora.
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Affiliation(s)
- Seong-Hyun Wui
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Kang Min Kim
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon-si, Gangwon-do, Republic of Korea.
| | - Young-Joon Ryu
- Department of Pathology, Kangwon National University Hospital, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Inkyeong Kim
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Seung Jin Lee
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Jiha Kim
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Choonghyo Kim
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Seoungwoo Park
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon-si, Gangwon-do, Republic of Korea
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22
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Tan ETW, Ling JM, Dinesh SK. The feasibility of producing patient-specific acrylic cranioplasty implants with a low-cost 3D printer. J Neurosurg 2015; 124:1531-7. [PMID: 26566203 DOI: 10.3171/2015.5.jns15119] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Commercially available, preformed patient-specific cranioplasty implants are anatomically accurate but costly. Acrylic bone cement is a commonly used alternative. However, the manual shaping of the bone cement is difficult and may not lead to a satisfactory implant in some cases. The object of this study was to determine the feasibility of fabricating molds using a commercial low-cost 3D printer for the purpose of producing patient-specific acrylic cranioplasty implants. METHODS Using data from a high-resolution brain CT scan of a patient with a calvarial defect posthemicraniectomy, a skull phantom and a mold were generated with computer software and fabricated with the 3D printer using the fused deposition modeling method. The mold was used as a template to shape the acrylic implant, which was formed via a polymerization reaction. The resulting implant was fitted to the skull phantom and the cranial index of symmetry was determined. RESULTS The skull phantom and mold were successfully fabricated with the 3D printer. The application of acrylic bone cement to the mold was simple and straightforward. The resulting implant did not require further adjustment or drilling prior to being fitted to the skull phantom. The cranial index of symmetry was 96.2% (the cranial index of symmetry is 100% for a perfectly symmetrical skull). CONCLUSIONS This study showed that it is feasible to produce patient-specific acrylic cranioplasty implants with a low-cost 3D printer. Further studies are required to determine applicability in the clinical setting. This promising technique has the potential to bring personalized medicine to more patients around the world.
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Affiliation(s)
- Eddie T W Tan
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Ji Min Ling
- Department of Neurosurgery, National Neuroscience Institute, Singapore
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23
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Singla N, Parkinson Singh S, Gupta SK, Karthigeyan M, Radotra BD. Histopathology of subcutaneously preserved autologous bone flap after decompressive craniectomy: a prospective study. Acta Neurochir (Wien) 2014; 156:1369-73. [PMID: 24752721 DOI: 10.1007/s00701-014-2071-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 03/14/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Limited reports are available regarding the viability of subcutaneously preserved autologous bone flaps after decompressive craniectomy. The present study was undertaken to evaluate the histopathological changes in these autologous bone flaps. METHODS Between January 2011 and July 2012, 50 patients were prospectively studied at the time of cranioplasty. Bone flap retrieved from the abdominal wall was subjected to histopathological examination to look for mononuclear cell infiltration into the Haversian system, presence of osteocytes, osteoblastic activity, angiogenesis and new bone formation. Microbiological culture of bone specimens was also done. RESULTS Of the 50 patients, there were 40 cases of trauma, 6 of aneurysmal bleed, 2 of tumor, and a single case of intracerebral hemorrhage and middle cerebral artery infarct, respectively. Mean age of the patients was 35.8 years (range, 10-64 years). Histopathological examination revealed the presence of osteocytes in 86 %, which indicates the viability of bone flaps. Osteoblastic activity was noted in 38 % and angiogenesis in 14 % of bone flaps, respectively. New bone formation was found in 6 %, and all had underlying osteoblastic activity. No significant correlation was found between the presence of osteocytes, osteoblasts, angiogenesis and duration of preservation of bone flaps. Acinetobacter species were cultured in a single patient. However, there was no evidence of clinical infection. CONCLUSIONS Subcutaneously preserved bone flap in the anterior abdominal wall remains viable and retains its osteogenic potential, and it is a simple, cost-effective option for storage of bone flaps during decompressive craniotomy. It has a negligible infection rate.
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Affiliation(s)
- Navneet Singla
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India,
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Tahir MZ, Shamim MS, Sobani ZA, Zafar SN, Qadeer M, Bari ME. Safety of untreated autologous cranioplasty after extracorporeal storage at − 26 degree celsius. Br J Neurosurg 2013; 27:479-82. [DOI: 10.3109/02688697.2012.757291] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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