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Youn SB, Hwang G, Kim HG, Kang JS, Kim HC, Oh SH, Kim MK, Chung BS, Rhim JK, Sheen SH. Intrawound Vancomycin Powder Application for Preventing Surgical Site Infection Following Cranioplasty. J Korean Neurosurg Soc 2023; 66:536-542. [PMID: 37032483 PMCID: PMC10483168 DOI: 10.3340/jkns.2023.0024] [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: 01/30/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 04/11/2023] Open
Abstract
OBJECTIVE Surgical site infection is the most detrimental complication following cranioplasty. In other surgical fields, intrawound vancomycin powder application has been introduced to prevent surgical site infection and is widely used based on results in multiple studies. This study evaluated the effect of intrawound vancomycin powder in cranioplasty compared with the conventional method without topical antibiotics. METHODS This retrospective study included 580 patients with skull defects who underwent cranioplasty between August 1, 1998 and December 31, 2021. The conventional method was used in 475 (81.9%; conventional group) and vancomycin powder (1 g) was applied on the dura mater and bone flap in 105 patients (18.1%; vancomycin powder group). Surgical site infection was defined as infection of the incision, organ, or space that occurred after cranioplasty. Surgical site infection within 1-year surveillance period was compared between the conventional and vancomycin powder groups with logistic regression analysis. Penalized likelihood estimation method was used in logistic regression to deal with zero events. All local and systemic adverse events associated with topical vancomycin application were also evaluated. RESULTS Surgical site infection occurred in 31 patients (5.3%) and all were observed in the conventional group. The median time between cranioplasty and detection of surgical site infection was 13 days (range, 4-333). Staphylococci were the most common organisms and identified in 25 (80.6%) of 31 cases with surgical site infections. The surgical site infection rate in the vancomycin powder group (0/105, 0.0%) was significantly lower than that in the conventional group (31/475, 6.5%; crude odds ratio [OR], 0.067; 95% confidence interval [CI], 0.006-0.762; adjusted OR, 0.068; 95% CI, 0.006-0.731; p=0.026). No adverse events associated with intrawound vancomycin powder were observed during the follow-up. CONCLUSION Intrawound vancomycin powder effectively prevented surgical site infections following cranioplasty without local or systemic adverse events. Our results suggest that intrawound vancomycin powder is an effective and safe strategy for patients undergoing cranioplasty.
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Affiliation(s)
- Seong Bin Youn
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Hyun-Gon Kim
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Jae Seong Kang
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Hyung Cheol Kim
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Sung Han Oh
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Mi-Kyung Kim
- Department of Neurosurgery, Myongji St Mary’s Hospital, Seoul, Korea
| | - Bong Sub Chung
- Department of Neurosurgery, Anyang Sam Hospital, Anyang, Korea
| | - Jong Kook Rhim
- Department of Neurosurgery, Jeju National University Hospital, Jeju, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang CHA Medical Center, CHA University, Seongnam, Korea
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Ebel F, Schön S, Sharma N, Guzman R, Mariani L, Thieringer FM, Soleman J. Clinical and patient-reported outcome after patient-specific 3D printer-assisted cranioplasty. Neurosurg Rev 2023; 46:93. [PMID: 37074490 PMCID: PMC10115682 DOI: 10.1007/s10143-023-02000-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/16/2023] [Accepted: 04/08/2023] [Indexed: 04/20/2023]
Abstract
Various cranioplasty techniques exist for the reconstruction of cranial bone defects. Patient-specific implants can be produced in-house using a recently developed 3D printer-assisted cranioplasty technique. However, the resulting cosmetic outcomes from the patient's perspective are underreported. With our case series, we aim to present the clinical outcome, morbidity rate, patient-reported cosmetic results, and cost-effectiveness of patient-specific3D printer-assisted cranioplasty technique. This is a consecutive retrospective case series of adult patients undergoing cranioplasty using the patient-specific 3D printer-assisted technique. As primary endpoint, the functional outcome based on modified Rankin scale (mRS) at discharge and follow-up was assessed. A prospective telephone survey was conducted to collect and provide patient-reported outcomes. Thirty-one patients underwent patient-specific 3D printer-assisted cranioplasty, mostly to reconstruct frontotemporoparietal (61.3%) and frontotemporal defects with orbital involvement (19.4%). Good functional outcome (mRS ≤ 2) at discharge and during the last follow-up was achieved in 54.8% (n = 17) and 58.1% (n = 18) patients. Overall, the rate of clinically relevant surgery-related complications was 35.5% (n = 11). Postoperative epidural hematoma/collection (16.1%) and infections (12.9%) were the most frequent complications. Permanent morbidity occurred in one patient (3.2%) with postoperative acute ipsilateral vision loss after frontotemporal cranioplasty with orbital involvement. No surgery-related mortality occurred. The mean patient-reported cosmetic satisfaction score was 7.8 ± 1.5, with 80% of patients reporting satisfying or very satisfying cosmetic results. No significant differences were seen between the different defect localization regarding the cosmetic outcome. The mean manufacturing costs of a patient-specific 3D printer-assisted implant ranged from 748 to 1129 USD. Based on our case series, patient-specific 3D printer-assisted cranioplasty is cost-effective and leads to satisfying cosmetic results, especially in large defects and/or defects with complex geometry.
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Affiliation(s)
- Florian Ebel
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland.
| | - Stephan Schön
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Neha Sharma
- Department of Oral & Cranio-Maxillo-Facial Surgery and 3D Print Lab, University Hospital of Basel, Basel, Switzerland
- Medical Additive Manufacturing Research Group (Swiss MAM/Smart Implants), Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Florian M Thieringer
- Department of Oral & Cranio-Maxillo-Facial Surgery and 3D Print Lab, University Hospital of Basel, Basel, Switzerland
- Medical Additive Manufacturing Research Group (Swiss MAM/Smart Implants), Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Spake CS, Goli R, Beqiri D, Crozier JW, Cielo DJ, Klinge PM, Svokos K, Woo AS. Evidence of linear bone flap resorption in patients undergoing autologous cranioplasty following decompressive craniectomy: A 3D Slicer segmented analysis of serial CT images. World Neurosurg 2022; 164:e799-e807. [PMID: 35597539 DOI: 10.1016/j.wneu.2022.05.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Autologous cranioplasty (CP) following decompressive craniectomy (DC) carries risk of bone flap resorption (BFR). The current literature offers limited information regarding the natural progression of BFR, and the rate at which it occurs. We aim to characterize the progression of BFR over time and elucidate risk factors for accelerated BFR. METHODS A retrospective analysis was conducted on patients who underwent DC and autologous CP. Serial computed tomography (CT) images were used to quantify degree of BFR over time. Risk factors included age, diabetes, smoking status, flap fragmentation, defect size, and DC-CP time interval. Chi-square analyses and Student's t-tests were performed to examine differences between patients who experienced BFR and those who did not. RESULTS Overall, 82% of patients demonstrated evidence of clinically relevant resorption on CT. On average, the bone flap decreased in volume by 36.7% within the first year, with a linear loss in volume after multiple years of follow-up. Individuals who developed greater BFR were significantly younger (43 ± 17 vs. 56 ± 12, p=0.022), had a lower incidence of diabetes (5.9% vs. 43%, p=0.037), and had more bone flap fragments (1.4 ± 0.67 vs. 1.00 ± 0, p <0.001) than those who did not. CONCLUSION Resorption following CP with cryopreserved bone appears to progress in a fairly linear and continuous fashion over time. Using serial CT images, we found a resorption rate of 82% at our institution. We identified several possible risk factors for resorption, including flap fragmentation, younger age, and absence of diabetes.
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Affiliation(s)
- Carole Sl Spake
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI.
| | - Rachna Goli
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Dardan Beqiri
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Joseph W Crozier
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Deus J Cielo
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Petra M Klinge
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Konstantina Svokos
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Albert S Woo
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
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Ortiz Torres M, Ziu E, Agunbiade S, Carr SB, Litofsky NS. Bifrontal Osteoplastic Flap: An Option to Decrease Infection in Bifrontal Craniotomies with Skull Base Osteotomies. Brain Sci 2022; 12:brainsci12020163. [PMID: 35203925 PMCID: PMC8870631 DOI: 10.3390/brainsci12020163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 02/06/2023] Open
Abstract
Infection can be a common complication following bifrontal craniotomy with skull base osteotomies given the potential violation of sinuses and entry into the nasal structures. Our objective was to examine our series of patients who underwent a bifrontal craniotomy with skull base osteotomies and describe the infection rate. We propose the bifrontal osteoplastic flap as an adjunct to infection prevention. A retrospective single-center study of a patient database was performed. Twenty patients were identified. Fifty-five percent were male. The mean age was 55.7 ± 13.9 years. The most common indications for surgery were esthesioneuroblastomas (35%) and anterior skull base meningiomas (30%). Six patients (30%) developed an infection, 1 patient (5%) developed a CSF leak, and no patients developed a mucocele. All 6 infected cases had nasal pathology with intracranial extension, they all received chemoradiation post-operatively and were all combined cases with otorhinolaryngology. Eighty-three percent of these patients required a craniectomy and all of them required long-term IV antibiotics. Infection is not uncommon after a bifrontal craniotomy with skull base osteotomies and the use of the bifrontal osteoplastic flap in cases where the risk of infection is high, i.e., esthesioneuroblastomas surgery, may help reduce said risk and lead to better patient outcomes.
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Di Rienzo A, Colasanti R, Dobran M, Formica F, Della Costanza M, Carrassi E, Aiudi D, Iacoangeli M. Management of infected hydroxyapatite cranioplasty: Is salvage feasible? BRAIN AND SPINE 2022; 2:100907. [PMID: 36248178 PMCID: PMC9560697 DOI: 10.1016/j.bas.2022.100907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/13/2022] [Accepted: 06/19/2022] [Indexed: 11/30/2022]
Abstract
Introduction The use of hydroxyapatite cranioplasties has grown progressively over the past few decades. The peculiar biological properties of this material make it particularly suitable for patients with decompressive craniectomy where bone reintegration is a primary objective. However, hydroxyapatite infection rates are similar to those of other reconstructive materials. Research question We investigated if infected hydroxyapatite implants could be saved or not. Materials and methods We present a consecutive series over a 10-year period of nine patients treated for hydroxyapatite cranioplasty infection. Clinical and radiological data from admission and follow-up, photo and video material documenting the different phases of infection assessment and treatment, and final outcomes were retrospectively reviewed in an attempt to identify the best options and possible pitfalls in a case-by-case decision-making process. Results Five unilateral and four bifrontal implants became infected. Wound rupture with cranioplasty exposure was the most common presentation. At revision, all implants were ossified, requiring a new craniotomy to clean the purulent epidural collections. The cranioplasty was fully saved in one hemispheric and 2 bifrontal implants and partially saved in the remaining 2 bifrontal implants. A complete cranioplasty removal was needed in the other 4 cases, but immediate cranial reconstruction was possible in 2. Skin defects were covered by free flaps in 3 cases. Four patients underwent adjunctive hyperbaric therapy, which was effective in one case. Discussion and conclusion In our experience, infected hydroxyapatite cranioplasty management is complex and requires a multidisciplinary approach. Salvage of a hydroxyapatite implant is possible under specific circumstances. We present a series of 9 patients treated for hydroxyapatite cranioplasty infection. One hemispheric and 2 bifrontal implants were fully saved, 2 bifrontal only partially. A complete removal was needed in 4 cases, but immediate cranial reconstruction was possible in 2. Infected hydroxyapatite cranioplasties salvage is complex, but possible under specific circumstances.
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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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Zaed I, Rossini Z, Faedo F, Fontanella MM, Cardia A, Servadei F. Long-term follow-up of custom-made porous hydroxyapatite cranioplasty in adult patients: a multicenter European study. Can we trust self-reported complications? J Neurosurg Sci 2020; 66:335-341. [PMID: 32989979 DOI: 10.23736/s0390-5616.20.05138-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cranioplasty is a surgical intervention aiming to re-establish the integrity of skull defects. Autologous bone and different heterologous materials are used for this purpose, with various reported related complications. The aim of the study was to evaluate the complication rate in a multicentric cohort of patients underwent porous hydroxyapatite (PHA) cranioplasty implantation and to assess the validity of company post-market clinical analysis. METHODS Authors analyzed a company based register of 6279 PHA cranioplasty implanted all over the world. In these adult patients only self-reported complications were available. We then obtained the data of adult patients treated with custom-made porous HA prostheses (CustomBone Service) in 20 institutions from different European countries through an on-site interview with the physicians in charge of the patients (494 patients). The endpoints were the incidence of adverse events and of related implant removal. RESULTS The groups of patients had similar demographics characteristics. The average follow-up was 26.7 months. A significantly higher number of complications was recorded in the group of patients underwent onsite interview. Thirty-nine complications were reported (7.89%) with an explantation rate of 4.25% (21 cases) in the series, compared to the data reported from the Company (complications rate of 3.3% and explantation rate of 3.1%). The most common complications were infection (4.86%), hematomas (1.22%), fractures (1.01%), mobilization (0.4%) and scar retraction (0.4%). CONCLUSIONS Our data confirm that porous HA cranioplasty is at least as effective as other heterologous materials to repair cranial defects. Another interesting finding is that self-reporting complicantions by surgeons does not give a precise picture of the real rate of complications of the devices. These data in future studies need to be re-confirmed with on-site interviews.
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Affiliation(s)
- Ismail Zaed
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy - .,Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy -
| | - Zefferino Rossini
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Francesca Faedo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Marco M Fontanella
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Cardia
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
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Liu L, Lu ST, Liu AH, Hou WB, Cao WR, Zhou C, Yin YX, Yuan KS, Liu HJ, Zhang MG, Zhang HJ. Comparison of complications in cranioplasty with various materials: a systematic review and meta-analysis. Br J Neurosurg 2020; 34:388-396. [PMID: 32233810 DOI: 10.1080/02688697.2020.1742291] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective: Meta-analysis to evaluate complications in the use of autogenous bone and bone substitutes and to compare bone substitutes, specifically HA, polyetheretherketone (PEEK) and titanium materials.Methods: Search of PubMed, Cochrane, Embase and Google scholar to identify all citations from 2010 to 2019 reporting complications regarding materials used in cranioplasty.Results: 20 of 2266 articles met the inclusion criteria, including a total of 2913 patients. The odds of overall complication were significantly higher in the autogenous bone group (n = 214/644 procedures, 33.2%) than the bone substitute groups (n = 116/436 procedures, 26.7%, CI 1.29-2.35, p < 0.05). In bone substitutes groups, there was no significant difference in overall complication rate between HA and Ti (OR, 1.2; 95% CI, 0.47-3.14, p = 0.69). PEEK has lower overall complication rates (OR, 0.51; 95% CI, 0.30-0.87, p = 0.01) and lower implant exposure rates (OR, 0.17; 95% CI, 0.06-0.53, p = 0.002) than Ti, but there was no significant difference in infection rates and postoperative hematoma rates.Conclusions: Cranioplasty is associated with high overall complication rates with the use of autologous bone grafts compared with bone substitutes. PEEK has a relatively low overall complication rates in substitutes groups, but still high infection rates and postoperative hematoma rates. Thus, autologous bone grafts should only be used selectively, and prospective long-term studies are needed to further refine a better material in cranioplasty.
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Affiliation(s)
- Liming Liu
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China
| | - Shou-Tao Lu
- Tenth People's Hospital, Tongji University, Shanghai, China
| | - Ai-Hua Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Neurointerventional Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wen-Bo Hou
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China
| | - Wen-Rui Cao
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China
| | - Chao Zhou
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China
| | - Yu-Xia Yin
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China
| | - Kun-Shan Yuan
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China
| | - Han-Jie Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming-Guang Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hai-Jun Zhang
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China.,Tenth People's Hospital, Tongji University, Shanghai, China.,Faculty of Medicine, Aalborg University, Alborg, Denmark
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Octacalcium phosphate collagen composite (OCP/Col) enhance bone regeneration in a rat model of skull defect with dural defect. Heliyon 2020; 6:e03347. [PMID: 32072051 PMCID: PMC7011046 DOI: 10.1016/j.heliyon.2020.e03347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/12/2019] [Accepted: 01/30/2020] [Indexed: 11/29/2022] Open
Abstract
Cranial bone defects are a major issue in the field of neurosurgery, and improper management of such defects can cause cosmetic issues as well as more serious infections and inflammation. Several strategies exist to manage these defects clinically, but most rely on synthetic materials that are prone to complications; thus, a bone regenerative approach would be superior. We tested a material (octacalcium phosphate collagen composite [OCP/Col]) that is known to enhance bone regeneration in a skull defect model in rats. Using a critical-sized rat skull defect model, OCP/Col was implanted in rats with an intact dura or with a partial defect of the dura. The results were compared with those in a no-treatment group over the course of 12 weeks using computed tomographic and histological analysis. OCP/Col enhanced bone regeneration, regardless of whether there was a defect of the dura. OCP/Col can be used to treat skull defects, even when the dura is injured or removed surgically, via bone regeneration with enhanced resorption of OCP/Col, thus limiting the risk of infection greatly.
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Abstract
BACKGROUND Infection may complicate the outcome of cranial repair with significant additional morbidity, related to hospitalization, surgery and long antibiotic therapy, that may become even dramatic in case of multi-resistant germs and in particular in the paediatric population. Additionally, the economic costs for the health system are obvious. Moreover, surgical decisions concerning the timing of cranioplasty and choice of the material may be strongly affected by the risk of infection. Despite, management and prevention of cranioplasty infections are not systematically treated through the literature so far. METHODS We reviewed pertinent literature dealing with cranioplasty infection starting from the diagnosis to treatment options, namely conservative versus surgical ones. Our institutional bundle, specific to the paediatric population, is also presented. This approach aims to significantly reduce the risk of infection in first-line cranioplasty and redo cranioplasty after previous infection. CONCLUSIONS A thorough knowledge and understanding of risk factors may lead to surgical strategies and bundles, aiming to reduce infectious complications of cranioplasty. Finally, innovation in materials used for cranial repair should also aim to enhance the antimicrobial properties of these inert materials.
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Wright JM, Raghavan A, Wright CH, Alonso A, Momotaz H, Sweet J, Sajatovic M, Selman W. Impact of Dual-Layer Duraplasty During Hemicraniectomy on Morbidity and Operative Metrics of Cranioplasty: A Retrospective Case-Control Study Comparing a Single-Layer with a Dual-Layer Technique. World Neurosurg 2019; 125:e1189-e1195. [DOI: 10.1016/j.wneu.2019.01.276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/27/2019] [Accepted: 01/30/2019] [Indexed: 01/31/2023]
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12
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Fricia M, Nicolosi F, Ganau M, Cebula H, Todeschi J, Santin MDN, Nannavecchia B, Morselli C, Chibbaro S. Cranioplasty with Porous Hydroxyapatite Custom-Made Bone Flap: Results from a Multicenter Study Enrolling 149 Patients Over 15 Years. World Neurosurg 2019; 121:160-165. [DOI: 10.1016/j.wneu.2018.09.199] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 01/23/2023]
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13
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Posti JP, Yli-Olli M, Heiskanen L, Aitasalo KMJ, Rinne J, Vuorinen V, Serlo W, Tenovuo O, Vallittu PK, Piitulainen JM. Cranioplasty After Severe Traumatic Brain Injury: Effects of Trauma and Patient Recovery on Cranioplasty Outcome. Front Neurol 2018; 9:223. [PMID: 29695995 PMCID: PMC5904383 DOI: 10.3389/fneur.2018.00223] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 03/22/2018] [Indexed: 11/16/2022] Open
Abstract
Background In patients with severe traumatic brain injury (sTBI) treated with decompressive craniectomy (DC), factors affecting the success of later cranioplasty are poorly known. Objective We sought to investigate if injury- and treatment-related factors, and state of recovery could predict the risk of major complications in cranioplasty requiring implant removal, and how these complications affect the outcome. Methods A retrospective cohort of 40 patients with DC following sTBI and subsequent cranioplasty was studied. Non-injury-related factors were compared with a reference population of 115 patients with DC due to other conditions. Results Outcome assessed 1 day before cranioplasty did not predict major complications leading to implant removal. Successful cranioplasty was associated with better outcome, whereas a major complication attenuates patient recovery: in patients with favorable outcome assessed 1 year after cranioplasty, major complication rate was 7%, while in patients with unfavorable outcome the rate was 42% (p = 0.003). Of patients with traumatic subarachnoid hemorrhage (tSAH) on admission imaging 30% developed a major complication, while none of patients without tSAH had a major complication (p = 0.014). Other imaging findings, age, admission Glasgow Coma Scale, extracranial injuries, length of stay at intensive care unit, cranioplasty materials, and timing of cranioplasty were not associated with major complications. Conclusion A successful cranioplasty after sTBI and DC predicts favorable outcome 1 year after cranioplasty, while stage of recovery before cranioplasty does not predict cranioplasty success or failure. tSAH on admission imaging is a major risk factor for a major complication leading to implant removal.
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Affiliation(s)
- Jussi P Posti
- Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital, Turku, Finland.,Division of Clinical Neurosciences, Turku Brain Injury Centre, Turku University Hospital, Turku, Finland.,Department of Neurology, University of Turku, Turku, Finland.,Department of Biomaterials Science and Turku Clinical Biomaterials Centre--TCBC, Institute of Dentistry, University of Turku, Turku, Finland
| | - Matias Yli-Olli
- Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital, Turku, Finland.,Division of Clinical Neurosciences, Turku Brain Injury Centre, Turku University Hospital, Turku, Finland.,Department of Neurology, University of Turku, Turku, Finland.,Department of Biomaterials Science and Turku Clinical Biomaterials Centre--TCBC, Institute of Dentistry, University of Turku, Turku, Finland
| | - Lauri Heiskanen
- Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital, Turku, Finland.,Division of Clinical Neurosciences, Turku Brain Injury Centre, Turku University Hospital, Turku, Finland.,Department of Neurology, University of Turku, Turku, Finland
| | - Kalle M J Aitasalo
- Department of Biomaterials Science and Turku Clinical Biomaterials Centre--TCBC, Institute of Dentistry, University of Turku, Turku, Finland.,Department of Otorhinolaryngology--Head and Neck Surgery, Division of Surgery and Cancer Diseases, Turku University Hospital, Turku, Finland
| | - Jaakko Rinne
- Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital, Turku, Finland.,Department of Neurology, University of Turku, Turku, Finland
| | - Ville Vuorinen
- Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital, Turku, Finland.,Department of Neurology, University of Turku, Turku, Finland
| | - Willy Serlo
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland.,MRC Oulu, PEDEGO Research Center, Oulu University, Oulu, Finland
| | - Olli Tenovuo
- Division of Clinical Neurosciences, Turku Brain Injury Centre, Turku University Hospital, Turku, Finland.,Department of Neurology, University of Turku, Turku, Finland
| | - Pekka K Vallittu
- Department of Biomaterials Science and Turku Clinical Biomaterials Centre--TCBC, Institute of Dentistry, University of Turku, Turku, Finland.,City of Turku Welfare Division, Turku, Finland
| | - Jaakko M Piitulainen
- Department of Biomaterials Science and Turku Clinical Biomaterials Centre--TCBC, Institute of Dentistry, University of Turku, Turku, Finland.,Department of Otorhinolaryngology--Head and Neck Surgery, Division of Surgery and Cancer Diseases, Turku University Hospital, Turku, Finland
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14
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Abode-Iyamah KO, Chiang HY, Winslow N, Park B, Zanaty M, Dlouhy BJ, Flouty OE, Rasmussen ZD, Herwaldt LA, Greenlee JD. Risk factors for surgical site infections and assessment of vancomycin powder as a preventive measure in patients undergoing first-time cranioplasty. J Neurosurg 2017; 128:1241-1249. [PMID: 28498056 DOI: 10.3171/2016.12.jns161967] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Craniectomy is often performed to decrease intracranial pressure following trauma and vascular injuries. The subsequent cranioplasty procedures may be complicated by surgical site infections (SSIs) due to prior trauma, foreign implants, and multiple surgeries through a common incision. Several studies have found that intrawound vancomycin powder (VP) is associated with decreased risk of SSIs after spine operations. However, no previously published study has evaluated the effectiveness of VP in cranioplasty procedures. The purpose of this study was to determine whether intrawound VP is associated with decreased risk of SSIs, to evaluate VP's safety, and to identify risk factors for SSIs after cranioplasty among patients undergoing first-time cranioplasty. METHODS The authors conducted a retrospective cohort study of adult patients undergoing first-time cranioplasty for indications other than infections from January 1, 2008, to July 31, 2014, at an academic health center. Data on demographics, possible risk factors for SSIs, and treatment with VP were collected from the patients' electronic health records. RESULTS During the study period, 258 patients underwent first-time cranioplasties, and 15 (5.8%) of these patients acquired SSIs. Ninety-two patients (35.7%) received intrawound VP (VP group) and 166 (64.3%) did not (no-VP group). Patients in the VP group and the no-VP group were similar with respect to age, sex, smoking history, body mass index, and SSI rates (VP group 6.5%, no-VP group 5.4%, p = 0.72). Patients in the VP group were less likely than those in the no-VP group to have undergone craniectomy for tumors and were more likely to have an American Society of Anesthesiologists physical status score > 2. Intrawound VP was not associated with other postoperative complications. Risk factors for SSI from the bivariable analyses were diabetes (odds ratio [OR] 3.65, 95% CI 1.07-12.44), multiple craniotomy procedures before the cranioplasty (OR 4.39, 95% CI 1.47-13.18), prior same-side craniotomy (OR 4.73, 95% CI 1.57-14.24), and prosthetic implants (OR 4.51, 95% CI 1.40-14.59). The multivariable analysis identified prior same-side craniotomy (OR 3.37, 95% CI 1.06-10.79) and prosthetic implants (OR 3.93, 95% CI 1.15-13.40) as significant risk factors for SSIs. After adjusting for potential confounders, patients with SSIs were more likely than those without SSIs to be readmitted (OR 7.28, 95% CI 2.07-25.60). CONCLUSIONS In this study, intrawound VP was not associated with a decreased risk of SSIs or with an increased risk of complications. Prior same-side craniotomy and prosthetic implants were risk factors for SSI after first-time cranioplasty.
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Affiliation(s)
| | | | | | - Brian Park
- 3The University of Iowa Carver College of Medicine
| | | | | | | | | | - Loreen A Herwaldt
- 2Internal Medicine.,5Department of Epidemiology, The University of Iowa College of Public Health, Iowa City, Iowa
| | - Jeremy D Greenlee
- Departments of1Neurosurgery and.,3The University of Iowa Carver College of Medicine
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15
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To Retain or Remove the Bone Flap During Evacuation of Acute Subdural Hematoma: Factors Associated with Perioperative Brain Edema. World Neurosurg 2016; 95:85-90. [PMID: 27476687 DOI: 10.1016/j.wneu.2016.07.067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/18/2016] [Accepted: 07/19/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND The fate of the bone flap is a significant decision during surgical treatment of acute subdural hematoma (SDH). A general guideline revolves around the surgeon's concern for brain edema. Limited studies, however, have focused on the factors that contribute to perioperative brain edema. METHODS From 2012 to 2015, 38 patients who underwent decompressive craniectomy for acute SDH were reviewed. Clinical data were extracted (age, sex, initial Glasgow Coma Scale (GCS) score, sodium level, hematocrit, and intraoperative blood loss). From the preoperative scan, SDH volume, midline shift (MLS), and volume within the skull (to estimate baseline brain volume) were measured. From the postoperative scan, brain volume (including any herniating regions) was measured. Δ% was defined as the percentage change in postoperative brain volume compared with preoperative volume. Evident contralateral injury, contusions, and intraventricular hemorrhage (IVH) were noted. RESULTS Fifteen patients demonstrated negative Δ%. Univariate analysis found significant correlations between Δ% and preoperative MLS, initial GCS, presence of IVH, and presence of contralateral injury (P < 0.05). A multiple regression for Δ% elicited a significant model (F [3, 34] = 17.387, P < 0.01) with R2 0.605, where Δ% = 16.197 - 1.246*GCS - 0.986 * MLS + 3.292 * IVH (with 0 = no IVH, 1 = presence of IVH). CONCLUSIONS A high proportion of patients can exhibit negative Δ%, or relative brain compression after decompression of SDH. For these patients, replacement of the bone flap may be reasonable to avoid obligatory interval cranioplasty. Preoperative MLS, initial GCS, and presence of IVH can help predict whether overall brain volume will swell or compress within the normal confines of the skull. This can guide the decision to retain or remove the bone flap.
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16
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Sun G, Shi L, Pan T, Li X, Zhang S. Technique of ICP Monitored Stepwise Intracranial Decompression Effectively Reduces Postoperative Complications of Severe Bifrontal Contusion. Front Neurol 2016; 7:56. [PMID: 27148158 PMCID: PMC4827019 DOI: 10.3389/fneur.2016.00056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/29/2016] [Indexed: 12/21/2022] Open
Abstract
Background Bifrontal contusion is a common clinical brain injury. In the early stage, it is often mild, but it progresses rapidly and frequently worsens suddenly. This condition can become life threatening and therefore requires surgery. Conventional decompression craniectomy is the commonly used treatment method. In this study, the effect of intracranial pressure (ICP) monitored stepwise intracranial decompression surgery on the prognosis of patients with acute severe bifrontal contusion was investigated. Method A total of 136 patients with severe bifrontal contusion combined with deteriorated intracranial hypertension admitted from March 2001 to March 2014 in our hospital were selected and randomly divided into two groups, i.e., a conventional decompression group and an ICP monitored stepwise intracranial decompression group (68 patients each), to conduct a retrospective study. The incidence rates of acute intraoperative encephalocele, delayed hematomas, and postoperative cerebral infarctions and the Glasgow outcome scores (GOSs) 6 months after the surgery were compared between the two groups. Results (1) The incidence rates of acute encephalocele and contralateral delayed epidural hematoma in the stepwise decompression surgery group were significantly lower than those in the conventional decompression group; the differences were statistically significant (P < 0.05); (2) 6 months after the surgery, the incidence of vegetative state and mortality in the stepwise decompression group were significantly lower than those in the conventional decompression group (P < 0.05); the rate of favorable prognosis in the stepwise decompression group was also significantly higher than that in the conventional decompression group (P < 0.05). Conclusion The ICP monitored stepwise intracranial decompression technique reduced the perioperative complications of traumatic brain injury through the gradual release of ICP and was beneficial to the prognosis of severe traumatic brain injury treatment.
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Affiliation(s)
- Guan Sun
- Department of Neurosurgery, Fourth Affiliated Yancheng Hospital of Nantong University , Yancheng , China
| | - Lei Shi
- Department of Neurosurgery, The First People's Hospital of Kunshan affiliated with Jiangsu University , Suzhou , China
| | - Tianhong Pan
- Department of Neurosurgery, The First People's Hospital of Kunshan affiliated with Jiangsu University , Suzhou , China
| | - Xiaoliang Li
- Department of Neurosurgery, The First People's Hospital of Kunshan affiliated with Jiangsu University , Suzhou , China
| | - Shuguang Zhang
- Department of Neurosurgery, The First People's Hospital of Kunshan affiliated with Jiangsu University , Suzhou , China
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17
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Nguyen HS, Doan N, Wolfla C, Pollock G. Fenestration of bone flap during decompressive craniotomy for subdural hematoma. Surg Neurol Int 2016; 7:16. [PMID: 26958422 PMCID: PMC4766810 DOI: 10.4103/2152-7806.175899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/05/2016] [Indexed: 11/16/2022] Open
Abstract
Background: Persistent/recurrent extra-axial hemorrhage may occur after decompression of a subdural hematoma (SDH) followed by an immediate replacement of bone flap. A fenestration of the bone flap may encourage extra-axial fluid absorption; however, the literature has not explored this technique. Methods: Forty-four consecutive patients who underwent surgical decompression of SDH with immediate replacement of bone flap were divided into two groups: Fenestration (F), n = 33, and no fenestration (NF), n = 11. Fenestration involves placement of twist drill holes 1–2 cm apart throughout the bone flap. Clinical data (age, sex, history of antiplatelet/anticoagulation [AA], and presence of drains) were collected. The size of bone flap, postoperative volume, and midline shift (MLS) were measured. A univariate analysis was performed for continuous variables; Fisher's exact test was performed for categorical variables. Results: For postoperative volume, NF group exhibited 94.4 ± 15.5 cm3, while F group exhibited 47.3 ± 15.5 cm3 (P = 0.04); no AA exhibited 62.9 ± 12.3 cm3, while AA exhibited 100.5 ± 19.0 cm3 (P = 0.07); no drains exhibited 110.1 ± 29.6 cm3, while drains exhibited 63.0 ± 9.1 cm3 (P = 0.14). For postoperative MLS, NF group exhibited 4.8 ± 1.1 mm, while F group exhibited 2.5 ± 1.1 mm (P = 0.16); no AA exhibited 2.3 ± 1.0 mm, while AA exhibited 5.8 ± 1.4 mm (P = 0.048); no drains exhibited 4.6 ± 2.2 mm, while drains exhibited 3.8 ± 0.7 mm (P = 0.70). Accounting for fenestration status and AA status: For F group, AA status did not correlate with postoperative volume or MLS significantly; for NF group, history of AA exhibited higher postoperative value 129.2 ± 26.5 cm3, compared to no history of AA at 59.5 ± 16.2 cm3 (P = 0.03). Conclusion: Our results suggest that fenestration prior to the immediate replacement of bone flap after surgical decompression of SDH has the potential to reduce extra-axial fluid accumulation.
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Affiliation(s)
- Ha Son Nguyen
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ninh Doan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Christopher Wolfla
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Glen Pollock
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
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