1
|
Gold C, Kournoutas I, Seaman SC, Greenlee J. Bone flap management strategies for postcraniotomy surgical site infection. Surg Neurol Int 2021; 12:341. [PMID: 34345482 PMCID: PMC8326101 DOI: 10.25259/sni_276_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/27/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Surgical site infection (SSI) after a craniotomy is traditionally treated with wound debridement and disposal of the bone flap, followed by intravenous antibiotics. The goal of this study is to evaluate the safety of replacing the bone flap or performing immediate titanium cranioplasty. Methods: All craniotomies at single center between 2008 and 2020 were examined to identify 35 patients with postoperative SSI. Patients were grouped by bone flap management: craniectomy (22 patients), bone flap replacement (seven patients), and titanium cranioplasty (six patients). Retrospective chart review was performed to identify patient age, gender, index surgery indication and duration, diffusion restriction on MRI, presence of gross purulence, bacteria cultured, sinus involvement, implants used during surgery, and antibiotic prophylaxis/ treatment. These variables were compared to future infection recurrence and wound breakdown. Results: There was no significant difference in infection recurrence or future wound breakdown among the three bone flap management groups (P = 0.21, P = 0.25). None of the variables investigated had any significant relation to infection recurrence when all patients were included in the analysis. However, when only the bone flap replacement group was analyzed, there was significantly higher infection recurrence when there was frank purulence present (P = 0.048). Conclusion: Replacing the bone flap or performing an immediate titanium cranioplasty is safe alternatives to discarding the bone flap after postoperative craniotomy SSI. When there is gross purulence present, caution should be used in replacing the bone flap, as infection recurrence is significantly higher in this subgroup of patients.
Collapse
Affiliation(s)
- Colin Gold
- Department of Neurosurgery, University of Iowa
| | - Ioannis Kournoutas
- Carver College of Medicine, University of Iowa, Iowa City, Iowa, United States
| | | | | |
Collapse
|
2
|
Policicchio D, Casu G, Dipellegrini G, Doda A, Muggianu G, Boccaletti R. Comparison of two different titanium cranioplasty methods: Custom-made titanium prostheses versus precurved titanium mesh. Surg Neurol Int 2020; 11:148. [PMID: 32637201 PMCID: PMC7332511 DOI: 10.25259/sni_35_2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/13/2020] [Indexed: 11/16/2022] Open
Abstract
Background: The aim of this study was to compare the results of two different titanium cranioplasties for reconstructing skull defects: standard precurved mesh versus custom-made prostheses. Methods: Retrospective analysis of 23 patients submitted to titanium cranioplasty between January 2014 and January 2019. Ten patients underwent delayed cranioplasty using custom-made prostheses; and 13 patients were treated using precurved titanium mesh (ten delayed cranioplasties, and three single-stage resection- reconstructions). Demographic, clinical, and radiological data were recorded. Results and complications of the two methods were compared, including duration of surgery, cosmetic results (visual analog scale for cosmesis [VASC]), and costs of the implants. Results: Complications: one epidural hematoma in the custom-made group, one delayed failure in precurved group due to wound dehiscence with mesh exposure. There were no infections in either group. All custom-made prostheses perfectly fitted on the defect; eight of 13 precurved mesh prostheses incompletely covered the defect. Custom-made cranioplasty obtained better cosmetic results (average VASC 94 vs. 68), shorter surgical time (141min vs. 186min), and -fewer screws was needed to fix the prostheses in place (6 vs. 15). However, satisfactory results were obtained using precurved mesh in cases of small defects and in single-stage reconstruction. Precurved mesh was found to be cheaper (€1,500 vs. €5,500). Conclusion: Custom-made cranioplasty obtained better results and we would suggest that this should be a first choice, particularly for young patients with a large cranial defect. Precurved mesh was cheaper and useful for single-stage resection-reconstruction. Depending on the individual conditions, both prostheses have their place in cranioplasty therapies.
Collapse
Affiliation(s)
- Domenico Policicchio
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Via Enrico De Nicola, Sassari, Italy
| | - Gina Casu
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Via Enrico De Nicola, Sassari, Italy
| | - Giosuè Dipellegrini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Via Enrico De Nicola, Sassari, Italy
| | - Artan Doda
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Via Enrico De Nicola, Sassari, Italy
| | - Giampiero Muggianu
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Via Enrico De Nicola, Sassari, Italy
| | - Riccardo Boccaletti
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Via Enrico De Nicola, Sassari, Italy
| |
Collapse
|
3
|
Hitoshi Y, Yamashiro S, Yoshida A, Mukasa A. Cranial Reconstruction with Titanium Mesh for Open Depressed Skull Fracture in Children: Reports of Two Cases with Long-term Observation. Kurume Med J 2020; 66:77-80. [PMID: 32378531 DOI: 10.2739/kurumemedj.ms661011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In the treatment of open depressed skull fracture in pediatric cases, it is preferable to use the patient's own bone material rather than artificial material. However, there are occasions when self-material reconstruction may be impossible. In such cases the safe option is to leave the defect until future replacement of the skull becomes possible, however this often causes such children to experience severe limitations to school life. We present two thought-provoking cases in which we solved such issues by early stage cranioplasty using a titanium mesh. The first case involved a 9-year-old boy who sustained a depressed fracture in the right temporal region after falling down a riverbank. Although he underwent surgical repair, bacterial infection forced removal of the bone flap postoperatively. His school life was severely restricted and sports activities were prohibited due to the residual regional bone defect. Cranial reconstruction with a titanium mesh made it possible for him to enjoy a more active lifestyle. The second case involved a 7-year-old boy who sustained a right frontal depressed fracture in a traffic accident. The fractured skull was promptly replaced by a titanium mesh at the initial surgery due to the extreme degree of bone fragmentation. Both boys returned to school life enjoying normal activities and without any complications for up to 8 years now. The cases presented here indicate that early cranioplasty even using artificial material is not only safe but enables school age patients to participate in physical activities. From the standpoint of physical and psychological development, early stage cranioplasty with titanium mesh may be a valuable treatment option for pediatric open depressed skull fracture.
Collapse
Affiliation(s)
| | - Shigeo Yamashiro
- Division of Neurosurgery, Cerebrovascular Medicine and Surgery, Saiseikai Kumamoto Hospital
| | | | - Akitake Mukasa
- Department of Neurosurgery, Graduate School of Life Sciences, Kumamoto University
| |
Collapse
|
4
|
Di Rienzo A, Colasanti R, Gladi M, Dobran M, Della Costanza M, Capece M, Veccia S, Iacoangeli M. Timing of cranial reconstruction after cranioplasty infections: are we ready for a re-thinking? A comparative analysis of delayed versus immediate cranioplasty after debridement in a series of 48 patients. Neurosurg Rev 2020; 44:1523-1532. [PMID: 32592100 DOI: 10.1007/s10143-020-01341-z] [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: 04/13/2020] [Revised: 05/16/2020] [Accepted: 06/18/2020] [Indexed: 10/24/2022]
Abstract
The optimal management of cranioplasty infections remains a matter of debate. Most authors have suggested that the infected bone/implant removal is mandatory, combined with prolonged antibiotic therapy before reconstruction. However, failures can occur, even with 12-18-month intervals between the surgeries. Longer wait times before cranial reconstruction increase the risks of socioeconomic burdens and further complications, as observed in decompressed patients hosting shunts. In our department, we treated 48 cranioplasty infections over a period of 8 years, divided into two groups. For Group A (n = 26), the treatment consisted of cranioplasty removal and debridement, followed by a delayed reconstruction. Group B (n = 22) received 2 weeks of broad-spectrum antibiotics, followed by an "aggressive" field debridement and immediate cranioplasty. All patients received a minimum of 8 weeks of post-operative antibiotic therapy and were scheduled for clinic-radiological follow-ups for at least 36 months. Significant differences were observed between Groups A and B with respect to the number of failures (respectively 7 versus 1), the global operative time (significantly longer for Group B), germ identification (respectively 7 versus 13), and the overall length of hospital stay (on average, 61.04 days in Group A versus 47.41 days in Group B). Three shunted patients in Group A developed sinking flap syndrome. Shunt resetting allowed symptom control until cranioplasty in one subject, whereas two did not improve, even after reconstruction. In selected patients, an aggressive field debridement, followed by the immediate replacement of an infected cranioplasty, may represent a safe and valuable option.
Collapse
Affiliation(s)
| | - Roberto Colasanti
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy. .,Department of Neurosurgery, Maurizio Bufalini Hospital, AUSL della Romagna, Cesena, Italy.
| | - Maurizio Gladi
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
| | - Mauro Dobran
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
| | | | - Mara Capece
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
| | - Salvatore Veccia
- Department of Infectious Diseases, Università Politecnica delle Marche, Ancona, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
| |
Collapse
|
5
|
Moneim J, Wenlock RD, Wells AJ, Price RD, Timofeev I, Helmy A, Hutchinson PJ. Single procedure revision cranioplasty with intra-operative autoclave following titanium plate exposure. Br J Neurosurg 2019; 34:329-332. [PMID: 31736374 DOI: 10.1080/02688697.2019.1690129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Patients with titanium cranioplasties can develop skin defects and plate exposure requiring revision surgery to prevent infection. The management of these patients has historically been staged surgery to remove the exposed plate followed by re-implantation of a sterile plate at a later date.Objectives: We describe an alternative where the exposed plate is removed, sterilised by autoclaving and re-implanted, in one operation.Methods: Patients with exposed titanium cranioplasties who underwent single-stage revisions were identified over a 30-month period. All patients received antibiotics post-procedure and were followed up.Results: Between June 2015 and December 2017 four patients had five single-stage revision cranioplasties with intraoperative autoclave sterilisation (SSRC). The mean time from initial procedure to revision was 5.6years. The mean time from plate exposure to surgery was 7 days. Plate exposure recurred in 60% (3/5) of cases post-SSRC. Two of these had the plate removed. The other had a second SSRC. On average recurrent plate exposure developed 17 months after SSRC. The 2 cases who had the plate removed remained complication-free to last follow up at 25 and 52 months after SSRC.Conclusions: Single procedure revision cranioplasty with intra-operative autoclave following titanium plate exposure may be considered as an option in patients with plate exposure who do not have other evidence on infection but we found recurrent plate exposure occurred in 50%.
Collapse
Affiliation(s)
- Joseph Moneim
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Rhys D Wenlock
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Adam J Wells
- Department of Academic Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Richard D Price
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Ivan Timofeev
- Department of Academic Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Adel Helmy
- Department of Academic Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter J Hutchinson
- Department of Academic Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
6
|
Yoshioka N. Immediate Cranioplasty for Postcranioplasty Infection in Patients with Ventriculoperitoneal Shunt. World Neurosurg 2018; 119:311-314. [PMID: 30144602 DOI: 10.1016/j.wneu.2018.08.076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/06/2018] [Accepted: 08/08/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with a ventriculoperitoneal (VP) shunt tend to develop epidural fluid accumulation after cranioplasty and also have a higher frequency of syndrome of the trephined after bone flap removal. Thus treatment of patients with postcranioplasty infection and a VP shunt is often challenging. CASE DESCRIPTION We treated 2 patients with postcranioplasty infection and a VP shunt. One patient had undergone decompressive craniectomy for cerebral hemorrhage, and the other patient had a large frontal dead space following resection of a brain tumor. Both patients were treated by immediate cranioplasty with obliteration of the epidural dead space by using a vascularized free latissimus dorsi muscle flap. In both of them, the postoperative course was uneventful without any complications. CONCLUSIONS Immediate cranioplasty and obliteration of the epidural dead space with a vascularized free latissimus dorsi muscle flap is an alternative for patients with postcranioplasty infection who are unfavorable candidates for temporary bone flap removal because of the risk of neurologic deterioration.
Collapse
|
7
|
Bone flap salvage in acute surgical site infection after craniotomy for tumor resection. Neurosurg Rev 2018; 41:1071-1077. [PMID: 29428980 DOI: 10.1007/s10143-018-0955-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 01/28/2018] [Accepted: 02/01/2018] [Indexed: 10/18/2022]
Abstract
Craniotomy surgical site infections are an inherent risk and dreaded complication for the elective brain tumor patient. Sequelae can include delays in resumption in adjuvant treatments for multiple surgeries if staged cranioplasty is pursued. Here, the authors review their experience in operative debridement of surgical site infections with single-stage reimplantation of the salvaged craniotomy bone flap. A prospectively maintained database of a single surgeon's neuro-oncology patients from 2009 to 2017 (JRF) was queried to identify 11 patients with surgical site infection after craniotomy for tumor resection. All patients underwent a protocol of aggressive operative debridement including drilling the bone edges and intraoperative flap sterilization with single-stage reimplantation, followed by tailored-antibiotic therapy. Ten of the 11 patients with frankly contaminated bone flaps from surgical site infection were able to be salvaged in a single-stage procedure. Five of these patients underwent adjuvant chemotherapy and/or radiation without secondary complication. There was one treatment failure in a delayed fashion which required additional surgery for craniectomy; however, this occurred after adjuvant treatment was administered. Surgical debridement and bone flap salvage is safe and cost-effective in managing acute surgical site infections after craniotomy for tumors. Additionally, this practice is likely beneficial in expediting the resumption of cancer therapy.
Collapse
|
8
|
Lee JC, Volpicelli EJ. Bioinspired Collagen Scaffolds in Cranial Bone Regeneration: From Bedside to Bench. Adv Healthc Mater 2017; 6:10.1002/adhm.201700232. [PMID: 28585295 PMCID: PMC5831258 DOI: 10.1002/adhm.201700232] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/11/2017] [Indexed: 12/24/2022]
Abstract
Calvarial defects are common reconstructive dilemmas secondary to a variety of etiologies including traumatic brain injury, cerebrovascular disease, oncologic resection, and congenital anomalies. Reconstruction of the calvarium is generally undertaken for the purposes of cerebral protection, contour restoration for psychosocial well-being, and normalization of neurological dysfunction frequently found in patients with massive cranial defects. Current methods for reconstruction using autologous grafts, allogeneic grafts, or alloplastic materials have significant drawbacks that are unique to each material. The combination of wide medical relevance and the need for a better clinical solution render defects of the cranial skeleton an ideal target for development of regenerative strategies focused on calvarial bone. With the improved understanding of the instructive properties of tissue-specific extracellular matrices and the advent of precise nanoscale modulation in materials science, strategies in regenerative medicine have shifted in paradigm. Previously considered to be simple carriers of stem cells and growth factors, increasing evidence exists for differential materials directing lineage specific differentiation of progenitor cells and tissue regeneration. In this work, we review the clinical challenges for calvarial reconstruction, the anatomy and physiology of bone, and extracellular matrix-inspired, collagen-based materials that have been tested for in vivo cranial defect healing.
Collapse
Affiliation(s)
- Justine C Lee
- Greater Los Angeles Veterans Affairs Research Service, Los Angeles, California
- University of California Los Angeles Division of Plastic and Reconstructive Surgery, Los Angeles, California
| | - Elizabeth J Volpicelli
- Greater Los Angeles Veterans Affairs Research Service, Los Angeles, California
- University of California Los Angeles Division of Plastic and Reconstructive Surgery, Los Angeles, California
| |
Collapse
|
9
|
Sugii N, Matsuda M, Sekine T, Matsumura H, Yamamoto T, Matsumura A. Delayed Brain Edema and Swelling following Craniectomy for Evacuation of an Epidural Abscess that Improved by Cranioplasty: Case Report. J Neurol Surg Rep 2017; 78:e109-e112. [PMID: 28852606 PMCID: PMC5573553 DOI: 10.1055/s-0037-1606315] [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: 01/10/2017] [Accepted: 06/05/2017] [Indexed: 11/06/2022] Open
Abstract
We report a unique case of delayed brain swelling following craniectomy that improved rapidly after cranioplasty, and discuss the potential mechanism underlying this delayed and reversible brain swelling. A 22-year-old woman developed surgical site infection after removal of a convexity meningioma. Magnetic resonance imaging revealed an epidural abscess around the surgical site. Subsequently, the abscess was evacuated, and the bone flap was removed. Later, brain edema around the skull defect emerged and progressed gradually, despite resolution of the infection. The edematous brain developed focal swelling outward through the bone defect without ventricle dilatation. Because we suspected that the edema and swelling were caused by the state of the bone defect, we performed a cranioplasty 10 weeks after the bone flap removal, and brain edema improved rapidly. We hypothesized that the brain edema was initially caused by surgical stress and inflammation, followed by compression of cortical veins between the dural edge and brain tissue, leading to disruption of venous return and exacerbation of brain edema. When delayed focal brain edema and external swelling progress gradually after bone flap removal, after excluding other pathological conditions, cranioplasty should be considered to improve cortical venous congestion caused by postsurgical adhesion.
Collapse
Affiliation(s)
- Narushi Sugii
- Department of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Masahide Matsuda
- Department of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Tomokazu Sekine
- Department of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hideaki Matsumura
- Department of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Akira Matsumura
- Department of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| |
Collapse
|
10
|
Versatility of the Latissimus Dorsi Free Flap during the Treatment of Complex Postcraniotomy Surgical Site Infections. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1355. [PMID: 28740770 PMCID: PMC5505831 DOI: 10.1097/gox.0000000000001355] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/17/2017] [Indexed: 11/26/2022]
Abstract
Background: Some intractable cases of postcraniotomy infection, which can involve compromised skin, an open frontal air sinus, and residual epidural dead space, have been reported. In such cases, reconstructing the scalp and skull is challenging. Methods: Between 2009 and 2016, the author treated 12 patients with recalcitrant postcraniotomy surgical site infections with latissimus dorsi (LD) free flaps. The patients’ ages ranged from 37 to 79 years (mean, 63.5 years), and their underlying diseases included subarachnoid hemorrhaging (n = 5), brain tumors (n = 4), and cerebral arteriovenous malformations (n = 3). Results: The LD free flap was used for scalp reconstruction in 3 cases, scalp reconstruction and separation of the intracranial and nasal cavities in 5 cases, and the obliteration of epidural dead space in 4 cases. Debridement followed by staged cranial reconstruction was carried out in 8 cases, and single-stage cranial reconstruction was conducted in 2 cases. The bone defects of the other 2 cases, which were small, were filled with LD musculo-adipose free flaps. The postoperative local appearance of the wounds was acceptable in every case, and no complications occurred. Conclusions: The LD free flap is a versatile tool for the treatment of complex postcraniotomy surgical site infections. This vascularized muscle flap is useful for controlling local infections because of its abundant vascularity. Moreover, its variety of uses means that it can resolve several problems in cases involving complex cranial wounds.
Collapse
|
11
|
Cranioplasty and Craniofacial Reconstruction: A Review of Implant Material, Manufacturing Method and Infection Risk. APPLIED SCIENCES-BASEL 2017. [DOI: 10.3390/app7030276] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|