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Hammad M, Oktarina A, Suhardi VJ, Thomson A, Li Q, Döring K, Augustin EJ, Ivashkiv LB, Carli AV, Bostrom MPG, Yang X. Effects of antiseptic irrigation solutions on osseointegration in a cementless tibial implantation mouse model. J Orthop Res 2024. [PMID: 39017392 DOI: 10.1002/jor.25937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 06/29/2024] [Indexed: 07/18/2024]
Abstract
Despite the success of standard antiseptic irrigation solutions in reducing periprosthetic joint infection (PJI) rates, there is still a need for more effective solutions. Synergistic use of povidone-iodine (PI) and hydrogen peroxide (H2O2) has shown promising results; however, the optimal solution concentration balancing bactericidal activity and osseointegration remains unknown. This study aims to evaluate the impact of these antiseptic irrigation solutions on osseointegration and the bone-implant interface strength in vivo. Forty C57BL/6 mice underwent bilateral tibial implantation surgery and were randomly allocated into three groups receiving 0.3% PI, 10% PI mixed with 3% H2O2, or saline as irrigation solutions intraoperatively. Assessments were performed on postoperative Days 1 and 28, including plain radiographs, microcomputed tomography (microCT) evaluation, histological analysis, immunohistochemistry, and biomechanical pull-out testing. No wound complications were observed. MicroCT scans revealed no differences in peri-implant trabecular bone parameters. Biomechanical pull-out testing showed no differences in the bone-implant interface strength across groups. Histological analysis indicated no differences in bone and bone marrow percentage areas among treatment groups. Immunohistochemical analysis demonstrated no differences among groups in peri-implant osteocalcin, osterix, or endomucin-positive cells. In conclusion, using either antiseptic irrigation solution showed no differences in osseointegration parameters compared to the control group, demonstrating safety and the absence of toxicity. CLINICAL RELEVANCE: Dilute 0.3% povidone-iodine and a 1:1 combination of 10% povidone-iodine mixed with 3% hydrogen peroxide can be safely used during primary and revision total joint arthroplasty without compromising osseointegration or causing wound complications.
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Affiliation(s)
- Mohammed Hammad
- Research Institute, Hospital for Special Surgery, New York, New York, USA
| | - Anastasia Oktarina
- Research Institute, Hospital for Special Surgery, New York, New York, USA
| | - Vincentius J Suhardi
- Research Institute, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, USA
| | - Andrew Thomson
- Research Institute, Hospital for Special Surgery, New York, New York, USA
| | - Qingdian Li
- Research Institute, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopaedic Surgery, Weill Cornell Medicine, New York, USA
| | - Kevin Döring
- Research Institute, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Edouard J Augustin
- Research Institute, Hospital for Special Surgery, New York, New York, USA
| | - Lionel B Ivashkiv
- Research Institute, Hospital for Special Surgery, New York, New York, USA
| | - Alberto V Carli
- Research Institute, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, USA
- Department of Orthopedics, Guangdong Provincial People's Hospital, Southern Medical University, Guangzhou, China
| | - Mathias P G Bostrom
- Research Institute, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, USA
- Department of Orthopedics, Guangdong Provincial People's Hospital, Southern Medical University, Guangzhou, China
| | - Xu Yang
- Research Institute, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, USA
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Jiang X, Zhijian T, Min C, Rong Y, Xinghui T, Gong X. Basic study on cryopreservation of rat calvarial osteoblasts with different cryoprotectants. Cell Tissue Bank 2024:10.1007/s10561-024-10142-3. [PMID: 38976150 DOI: 10.1007/s10561-024-10142-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 05/25/2024] [Indexed: 07/09/2024]
Abstract
Cryopreservation is a method adopted for storage of autologous skulls. Herein, this current research sought to explore the effects of different cryoprotectants on the biological characteristics of rat calvarial osteoblasts after cryopreservation. Neonatal Sprague-Dawley rats were selected and their skull tissues were isolated. The skull tissues were allocated into the refrigerating-3M, refrigerating-6M, M199-3M, M199-6M, povidone iodine-3M, and povidone iodine-6M groups according to the usage of cryoprotectants and treatment time (month) and the fresh group. Osteoblasts were isolated from skull tissues in each group through digestion. The histomorphology of the skull was evaluated by H&E staining and cell morphology was observed by microscopy. The viability, proliferation, apoptosis, and osteogenic activity of osteoblasts were assessed by trypan blue staining, MTT, flow cytometry, and alkaline phosphatase (ALP) staining. The skull histomorphology and osteoblast morphology were similar between the fresh and refrigerating groups. Osteoblast viability was weakened after cryopreservation. The longer the refrigeration time, the lower the number of living cells and the higher the apoptosis rate. However, cryopreservation using different cryoprotectants did not evidently affect osteoblast proliferation and ALP activity. Different cryoprotectants show no apparent effect on the osteogenic activity of rat calvarial osteoblasts after cryopreservation.
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Affiliation(s)
- Xu Jiang
- Department of Neurosurgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, No. 61, West Jiefang Road, Furong District, Changsha, 410005, Hunan, People's Republic of China
| | - Tan Zhijian
- Department of Neurosurgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, No. 61, West Jiefang Road, Furong District, Changsha, 410005, Hunan, People's Republic of China
| | - Cao Min
- Research and Development Center, Hunan Chuang He Biotechnology Limited Company, Changsha, 410205, Hunan, People's Republic of China
| | - Yu Rong
- Research and Development Center, Hunan Chuang He Biotechnology Limited Company, Changsha, 410205, Hunan, People's Republic of China
| | - Tan Xinghui
- Research and Development Center, Hunan Chuang He Biotechnology Limited Company, Changsha, 410205, Hunan, People's Republic of China.
| | - Xin Gong
- Department of Neurosurgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, No. 61, West Jiefang Road, Furong District, Changsha, 410005, Hunan, People's Republic of China.
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Kubon S, Lawson McLean A, Eckardt N, Neumeister A, Dinc N, Senft C, Schwarz F. Early detection of aseptic bone necrosis post-cranioplasty: A retrospective CT analysis using Hounsfield units. J Craniomaxillofac Surg 2024; 52:484-490. [PMID: 38368206 DOI: 10.1016/j.jcms.2024.02.001] [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: 07/17/2023] [Revised: 10/12/2023] [Accepted: 02/01/2024] [Indexed: 02/19/2024] Open
Abstract
This study examined the efficacy of computed tomography (CT)-based Hounsfield units (HU) as early predictors of aseptic bone necrosis, a serious post-cranioplasty complication after autologous cranioplasty. In total, 100 patients who underwent decompressive craniectomy and subsequent autologous cranioplasty were included. The radiodensity of the bone flap was evaluated in HU from CT scans at five follow-up timepoints. HU thresholds were established to predict the development of aseptic bone necrosis. HU demonstrated a declining trend throughout the follow-up period in all patients. Necrosis type I patients showed significant differences at all timepoints from 3 months post-procedure onwards, while necrosis type II patients displayed a significant decline in HU at every follow-up. Optimal thresholds with cut-off A (91.23% of initial HU) and cut-off B (78.73% of initial HU) were established to predict the occurrence of bone necrosis and the need for artificial bone replacement, respectively. Our findings demonstrated the utility of CT-based HU measurements as a simple, non-invasive tool for the early prediction of aseptic bone necrosis following autologous cranioplasty. By delineating specific HU thresholds, our study offers a valuable guide for orchestrating timely follow-ups and advising patients on the necessity of proactive interventions.
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Affiliation(s)
- Sophie Kubon
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany.
| | - Aaron Lawson McLean
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Nicklas Eckardt
- Institute of Diagnostic and Interventional Radiology, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Anne Neumeister
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Nazife Dinc
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Christian Senft
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Falko Schwarz
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
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Ten-Year Institutional Experience to Predict Risk of Calvarial Bone Flap Loss Using Long-Term Outcome Data. J Craniofac Surg 2022; 33:2394-2399. [PMID: 35859273 DOI: 10.1097/scs.0000000000008784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/11/2022] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Calvarial bone flap (CBF) loss is a common complication following craniotomy and subsequent skull reconstruction can be challenging. Defining predictors of CBF failure not only improves patient outcomes but reduces the need for complex reconstruction often requiring plastic surgery consultation. As CBF failure can occur many years following craniotomy, this study aimed to determine risk factors of CBF loss using long-term follow-up. MATERIALS AND METHODS This retrospective study included patients who underwent craniotomy with CBF reinsertion between 2003 and 2013 at a tertiary academic institution. Patients were included if demographics, comorbidities, and long-term outcomes were available. Multivariable logistic regression modeled the odds of CBF failure, defined as permanent removal for bone flap-related issues. The median follow-up was 6.9 years (interquartile range: 1.8-10.8 y). RESULTS There were 222 patients who met inclusion criteria and underwent craniotomy with CBF reinsertion, primarily for tumor resection or intracranial pressure relief. CBF failure occurred in 76 (34.2%) patients. Up to 4 CBF reinsertions were performed in both failure and nonfailure groups. The risks of CBF loss increased with each additional CBF elevation by 17-fold (P<0.001), male sex by 3-fold (P=0.005), and tumor etiology by 3-fold (P=0.033) (C-index=0.942). CONCLUSIONS Each CBF reinsertion dramatically increases the risk of CBF loss. This finding may optimize patient selection and surgical planning. Early multidisciplinary discussions between plastic surgeons and neurosurgeons may avoid multiple CBF elevations and prevent the adverse sequela of high-risk calvarial reconstruction efforts.
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Signorelli F, Giordano M, Caccavella VM, Ioannoni E, Gelormini C, Caricato A, Olivi A, Montano N. A systematic review and meta-analysis of factors involved in bone flap resorption after decompressive craniectomy. Neurosurg Rev 2022; 45:1915-1922. [PMID: 35061139 DOI: 10.1007/s10143-022-01737-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 10/18/2021] [Accepted: 01/11/2022] [Indexed: 02/02/2023]
Abstract
Decompressive craniectomy (DC) is effective in controlling increasing intracranial pressure determined by a wide range of conditions, mainly traumatic brain injury (TBI) and stroke, and the subsequent cranioplasty (CP) displays potential therapeutic benefit in terms of overall neurological function. While autologous bone flap (ABF) harvested at the time of DC is the ideal material for skull defect reconstruction, it carries several risks. Aseptic bone flap resorption (BFR) is one of the most common complications, often leading to surgical failure. The aim of our study was to systematically review the literature and carry out a meta-analysis of possible factors involved in BFR in patients undergoing ABF cranioplasty after DC. A systematic review and meta-analysis was performed in accordance with the PRISMA guidelines. Different medical databases (PubMed, Embase, and Scopus) were screened for eligible scientific reports until April 30th 2021. The following data were collected for meta-analysis to assess their role in BFR: sex, age, the interval time between DC and CP, the presence of systemic factors, the etiology determining the DC, CP surgical time, CP features, VP shunt placement, CP infection. Studies including pediatric patients or with less than 50 patients were excluded. Fifteen studies were included. There was a statistically significant increased incidence of BFR in patients with CPF > 2 compared to patients with CPF ≤ 2 (54.50% and 22.76% respectively, p = 0.010). TBI was a significantly more frequent etiology in the BFR group compared to patients without BFR (61.95% and 47.58% respectively, p < 0.001). Finally, patients with BFR were significantly younger than patients without BFR (39.12 ± 15.36 years and 47.31 ± 14.78 years, respectively, p < 0.001). The funnel plots were largely symmetrical for all the studied factors. Bone flap fragmentation, TBI etiology, and young age significantly increase the risk of bone resorption. Further studies are needed to strengthen our results and to clarify if, in those cases, a synthetic implant for primary CP should be recommended.
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Affiliation(s)
- Francesco Signorelli
- Depatment of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Martina Giordano
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valerio Maria Caccavella
- Depatment of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, 00168, Rome, Italy. .,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Eleonora Ioannoni
- Neurosurgical Intensive Care Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Camilla Gelormini
- Neurosurgical Intensive Care Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Anselmo Caricato
- Neurosurgical Intensive Care Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Olivi
- Depatment of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, 00168, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola Montano
- Depatment of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, 00168, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
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Efficacy of autogenous bone grafts preserved in 80% ethanol solution for preventing surgical site infection after cranioplasty: A retrospective cohort study. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Favourable long-term recovery after decompressive craniectomy: the Northern Finland experience with a predominantly adolescent patient cohort. Childs Nerv Syst 2022; 38:1763-1772. [PMID: 35739289 PMCID: PMC9463249 DOI: 10.1007/s00381-022-05568-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/20/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE Decompressive craniectomy (DC) is an effective treatment of intracranial hypertension. Correspondingly, the procedure is increasingly utilised worldwide. The number of patients rendered vegetative following surgery has been a concern-a matter especially important in children, due to long anticipated lifetime. Here, we report the long-term outcomes of all paediatric DC patients from an 11-year period in a tertiary-level centre that geographically serves half of Finland. METHODS We identified all patients younger than 18 years who underwent DC in the Oulu University Hospital between the years 2009 and 2019. Outcomes and clinicoradiological variables were extracted from the patient records. RESULTS Mean yearly prevalence of brain injury requiring DC was 1.34/100 000 children-twenty-four patients underwent DC during the study period and 21 (88%) survived. The median age of the patients was 16.0 years, and the median preoperative GCS was 5.0 (IQR 5.0). Fifteen patients (63%) had made a good recovery (Extended Glasgow Outcome Scale ≥ 7). Of the surviving patients, two (9.5%) had not returned to school. After traumatic brain injury (n = 20), the Rotterdam CT score (mean 3.0, range 1 to 5) was not associated with mortality, poor recovery or inability to continue school (p = 0.13, p = 0.41, p = 0.43, respectively). Absent basal cisterns were associated with mortality (p = 0.005), but not with poor recovery if the patient survived DC (p = 0.81). Hydrocephalus was associated with poor recovery and inability to continue school (p = 0.01 and p = 0.03, respectively). CONCLUSION Most of our patients made a favourable recovery and were able to continue school. No late mortality was observed. Thus, even in clinically and radiologically severely brain-injured children, decompressive craniectomy appears to yield favourable outcomes.
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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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Sengupta SK, Kumar AN, Maurya V, Bajaj H, Yadav KK, G. AK, Faujdar DS. Bony Union and Flap Resorption in Cranioplasty with Autologous Subcutaneous Pocket Preserved Bone Flap: Early Report on an Ambidirectional CT Scan-Based Study. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0040-1714317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Introduction Absence of sufficient number of prospective randomized controlled studies and comparatively small sample size and short follow-up period of most of the studies, available so far, have left ambiguity and lack of standardization of different aspects of cranioplasty.
Materials and Methods This is an early report of a computed tomography scan image-based ambidirectional study on cranioplasties performed with autologous subcutaneous pocket preserved bone flaps. Retrospective arm compared bony union and factors influencing it between cranioplasties and craniotomies. Patients with poor bony union and aseptic resorption were followed up in the prospective arm.
Results Retrospective arm of the study, followed up for five years (mean 32.2 months), comprised 42 patients as cases (Group 1) and 29 as controls (Group 2). Twenty-seven individuals (64.3%) in Group 1 had good bony union, as compared with 20 (68.9%) good unions in Group 2 out of the 29 patients. Four patients (9.5%) in Group 1 showed evidence of flap resorption, a finding absent in any patient in Group 2. Age, sex, smoking habits, superficial skin infection, and method of fixation did not appear to have any implication on bony union. Craniotomies done using Gigli saws fared better as compared with those done with pneumatic saw with lesser flap size–craniectomy size discrepancy, though it was not statistically significant. Fifteen patients have been included in the Prospective arm at the time of submission of this article.
Conclusion Ours is a study with a small sample size, unable to put its weight on any side, but can surely add some more data to help the Neurosurgeons in choosing the best for their patients.
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Affiliation(s)
- Sudip Kumar Sengupta
- Department of Neurosurgery, Command Hospital (Southern Command), Pune, Maharashtra, India
| | - Andrews Navin Kumar
- Department of Maxillofacial Surgery, Command Medical Dental Centre (Eastern Command), Kolkata, West Bengal, India
| | - Vinay Maurya
- Department of Radiodiagnosis, Base Hospital Delhi Cantonment, New Delhi, India
| | - Harish Bajaj
- Department of Neurosurgery, Command Hospital (Eastern Command), Kolkata, West Bengal, India
| | - Krishan Kumar Yadav
- Department of Neurosurgery, Command Hospital (Eastern Command), Kolkata, West Bengal, India
| | - Ashwath K. G.
- Department of Neurosurgery, Command Hospital (Eastern Command), Kolkata, West Bengal, India
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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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Hamböck M, Hosmann A, Seemann R, Wolf H, Schachinger F, Hajdu S, Widhalm H. The impact of implant material and patient age on the long-term outcome of secondary cranioplasty following decompressive craniectomy for severe traumatic brain injury. Acta Neurochir (Wien) 2020; 162:745-753. [PMID: 32025876 PMCID: PMC7066309 DOI: 10.1007/s00701-020-04243-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/23/2020] [Indexed: 12/17/2022]
Abstract
Background Secondary cranioplasty (CP) is considered to support the neurological recovery of patients after decompressive craniectomy (DC), but the treatment success might be limited by complications associated to confounders, which are not yet fully characterized. The aim of this study was to identify the most relevant factors based on the necessity to perform revision surgeries. Methods Data from 156 patients who received secondary CP following DC for severe traumatic brain injury (TBI) between 1984 and 2015 have been retrospectively analyzed and arranged into cohorts according to the occurrence of complications requiring surgical intervention. Results Cox regression analysis revealed a lower revision rate in patients with polymethylmethacrylate (PMMA) implants than in patients with autologous calvarial bone (ACB) implants (HR 0.2, 95% CI 0.1 to 1.0, p = 0.04). A similar effect could be observed in the population of patients aged between 18 and 65 years, who had a lower risk to suffer complications requiring surgical treatment than individuals aged under 18 or over 65 years (HR 0.4, 95% CI 0.2 to 0.9, p = 0.02). Revision rates were not influenced by the gender (p = 0.88), timing of the CP (p = 0.53), the severity of the TBI (p = 0.86), or the size of the cranial defect (p = 0.16). Conclusions In this study, the implant material and patient age were identified as the most relevant parameters independently predicting the long-term outcome of secondary CP. The use of PMMA was associated with lower revision rates than ACB and might provide a therapeutic benefit for selected patients with traumatic cranial defects. Electronic supplementary material The online version of this article (10.1007/s00701-020-04243-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martina Hamböck
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Rudolf Seemann
- Department of Cranio-Maxillofacial and Oral Surgery, Medical University of Vienna, Vienna, Austria
| | - Harald Wolf
- Department of Orthopedics and Traumatology, Clinical Division of Traumatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Florian Schachinger
- Department of Orthopedics and Traumatology, Clinical Division of Traumatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stefan Hajdu
- Department of Orthopedics and Traumatology, Clinical Division of Traumatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Harald Widhalm
- Department of Orthopedics and Traumatology, Clinical Division of Traumatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Rashidi A, Sandalcioglu IE, Luchtmann M. Aseptic bone-flap resorption after cranioplasty - incidence and risk factors. PLoS One 2020; 15:e0228009. [PMID: 31999739 PMCID: PMC6992164 DOI: 10.1371/journal.pone.0228009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 01/05/2020] [Indexed: 11/22/2022] Open
Abstract
Objective One of the common complications occurring after cranioplasty (CP) is aseptic bone-flap resorption (ABFR). Reoperation necessary because of the development of ABFR can lead to unfavorable complications during subsequent surgery using a synthetic skull implant, and also necessarily leads to higher costs. The aim of this study is to identify prognostic factors that may help to predict the development of ABFR. Methods In this study, 303 CP surgeries performed between 2002 and 2017 were examined retrospectively to identify factors predicting the occurrence of ABFR. A number of these factors (e.g., time lapse between decompressive craniectomy (DC) and CP, bone-flap size, specific laboratory signs, and the reason for the original DC) were analyzed as possibly influencing the risk of developing ABFR. Results ABFR of an autologous bone flap that subsequently required a CP with synthetic skull implants occurred in 10 of 303 patients (3.0%). CP timing and patients' Karnofsky Performance Scores (KPS) (p = 0.008; p = 0.012) were identified as significant factors with an impact on the development of ABRF. Age did not reveal a significant value, but statistical analysis shows a clear trend. The younger the age, the more likely it was that an ABFR would develop. Conclusion The risk of ABFR lessens the longer the period of time elapsed between DC and CP. Age does not reveal a significant value, but statistical analysis shows that there is a clear trend.
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Affiliation(s)
- Ali Rashidi
- Department of Neurosurgery, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - I. Erol Sandalcioglu
- Department of Neurosurgery, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Michael Luchtmann
- Department of Neurosurgery, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- * E-mail:
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13
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Cranioplasty With Autogenous Frozen and Autoclaved Bone: Management and Treatment Outcomes. J Craniofac Surg 2019; 30:2069-2072. [PMID: 31490439 DOI: 10.1097/scs.0000000000005951] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cranioplasty is a widely employed procedure for restoration of calvarial form and shape. The use of autogenous bone flap offers biological reconstruction with minimal donor site morbidity. One of the options to re-use bone autograft is low temperature preservation followed by autoclaving during cranioplasty. A retrospective evaluation of 12 patients with a mean age of 32.58 ± 10.04 years who underwent frozen autogenous autoclaved bone cranioplasty was done. Cranial bone flaps were removed during the initial craniectomy and stored at 4°C for 20 minutes followed by preservation at -40°C in the deep freezer of the blood bank. Cranioplasty subsequently was performed at a mean time period of 172.17 ± 26.20 days by thawing the bone at room temperature followed by autoclaving at 121°C under 15 psi for 40 minutes. Data regarding patients' characteristics and complications were recorded. Clinical outcomes based on skull shape and symmetry, cosmesis and scars were analyzed by a panel of 4 raters, including 3 doctors and 1 patient. Radiological outcomes were analyzed based on remaining bone thickness and bone gap widening. The present study revealed functionally, structurally, and cosmetically satisfying results. All the cases had satisfactory healing and no incidence of bone graft infection. The skull shape and symmetry, cosmesis and scars revealed excellent to moderate improvement in three-fourth of the patients. Radiological outcomes revealed none of the patients had severe resorption requiring surgical revision with excellent to good implant alignment in 92% of cases. It was concluded that frozen autogenous cranial bone flaps sterilized by autoclaving is safe and effective material for cranioplasty.
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Anto D, Manjooran RP, Aravindakshan R, Lakshman K, Morris R. Cranioplasty Using Autoclaved Autologous Skull Bone Flaps Preserved at Ambient Temperature. J Neurosci Rural Pract 2019; 8:595-600. [PMID: 29204021 PMCID: PMC5709884 DOI: 10.4103/jnrp.jnrp_270_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context Decompressive craniectomy followed by cranioplasty (CP) uses autologous craniectomy flaps or synthetic materials like titanium. Sterilization and preservation methods for the autologous bone flaps continue to be the surgeon's choice. Aim This study aimed to assess the short-term as well as long-term clinical outcomes of CP using autoclaved autologous bone grafts. Settings and Design This retrospective observational study was performed on patients admitted in a tertiary care teaching neurosurgery department. Patients and Methods Seventy-two patients who underwent CP with autoclaved autologous skull flaps preserved under ambient conditions with strict aseptic precautions were included in the study. Statistical Analysis Used Frequencies and percentages of the various characteristics before and after the surgery were tabulated. Continuous variables were summarized as means and standard deviations. Results The primary CP had a satisfactory clinical outcome in 62 cases (86.11%). Osteomyelitis was observed in four patients (5.56%) nearly 2 months after the surgery. Radiologically significant bone resorption was noted in a single patient (1.39%) after 1 year. Five patients (6.94%) developed bone fragmentation or fracture, and the mean time taken for this was about 36 months. In all these ten cases, secondary CP was successfully done using a prefabricated, patient-specific titanium mesh. Conclusions The efficacy and safety of the studied craniectomy flaps used for cranial reconstruction showed a good patient outcome. Further retrospective studies with larger cohorts and prospective case-control studies are essential so as to issue standard guidelines for sterilization and preservation of autologous bone flaps.
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Affiliation(s)
- Dominic Anto
- Department of Community Medicine, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India
| | - Raju Paul Manjooran
- Department of Community Medicine, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India
| | - Rajeev Aravindakshan
- Department of Neurosurgery, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India
| | - Kumar Lakshman
- Department of Community Medicine, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India
| | - Raymond Morris
- Department of Community Medicine, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India
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Korhonen TK, Salokorpi N, Ohtonen P, Lehenkari P, Serlo W, Niinimäki J, Tetri S. Classification of bone flap resorption after cranioplasty: a proposal for a computed tomography-based scoring system. Acta Neurochir (Wien) 2019; 161:473-481. [PMID: 30644012 PMCID: PMC6407745 DOI: 10.1007/s00701-018-03791-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 12/24/2018] [Indexed: 11/25/2022]
Abstract
Background Bone flap resorption (BFR) is the most prevalent complication resulting in autologous cranioplasty failure, but no consensus on the definition of BFR or between the radiological signs and relevance of BFR has been established. We set out to develop an easy-to-use scoring system intended to standardize the interpretation of radiological BFR findings. Methods All 45 autologous cranioplasty patients operated on at Oulu University Hospital from 2004 to 2014 were identified, and the bone flap status of all the available patients was evaluated using the new scoring system. Derived from previous literature, a three-variable score for the detection of BFR changes is proposed. The variables “Extent” (estimated remaining bone volume), “Severity” (possible perforations and their measured diameter), and “Focus” (the number of BFR foci within the flap) are scored from 0 to 3 individually. Using the sum of these scores, a score of 0–9 is assigned to describe the degree of BFR. Additionally, independent neurosurgeons assessed the presence and relevance of BFR from the same data set. These assessments were compared to the BFR scores in order to find a score limit for relevant BFR. Results BFR was considered relevant by the neurosurgeons in 11 (26.8%) cases. The agreement on the relevance of BFR demonstrated substantial strength (κ 0.64, 95%CI 0.36 to 0.91). The minimum resorption score in cases of relevant BFR was 5. Thus, BFR with a resorption score ≥ 5 was defined relevant (grades II and III). With this definition, grade II or III BFR was found in 15 (36.6%) of our patients. No risk factors were found to predict relevant BFR. Conclusions The score was proven to be easy to use and we recommend that only cases with grades II and III BFR undergo neurosurgical consultation. However, general applicability can only be claimed after validation in independent cohorts.
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Affiliation(s)
- Tommi K Korhonen
- Department of Neurosurgery, Oulu University Hospital, Kajaanintie 52, 90029, Oulu, Finland.
- Research Unit of Clinical Neuroscience, Neurosurgery, University of Oulu, Oulu, Finland.
| | - Niina Salokorpi
- Department of Neurosurgery, Oulu University Hospital, Kajaanintie 52, 90029, Oulu, Finland
- Research Unit of Clinical Neuroscience, Neurosurgery, University of Oulu, Oulu, Finland
| | - Pasi Ohtonen
- Division of Operative Care, Oulu University Hospital, Oulu, Finland
| | - Petri Lehenkari
- Department of Anatomy and Cell Biology and Department of Surgery, MRC Oulu, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Willy Serlo
- PEDEGO Research Unit, MRC Oulu, University of Oulu, and Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Jaakko Niinimäki
- Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland
| | - Sami Tetri
- Department of Neurosurgery, Oulu University Hospital, Kajaanintie 52, 90029, Oulu, Finland
- Research Unit of Clinical Neuroscience, Neurosurgery, University of Oulu, Oulu, Finland
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Barzaghi LR, Parisi V, Gigliotti CR, Giudice L, Snider S, Dell'Acqua A, Del Vecchio A, Mortini P. Bone resorption in autologous cryopreserved cranioplasty: quantitative evaluation, semiquantitative score and clinical significance. Acta Neurochir (Wien) 2019; 161:483-491. [PMID: 30617716 DOI: 10.1007/s00701-018-03789-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/24/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Changes after reimplantation of the autologous bone have been largely described. However, the rate and the extent of resorption in cranial grafts have not been clearly defined. Aim of our study is to evaluate the bone flap resorption (BFR) after cryopreservation. METHODS We retrospectively reviewed 27 patients, aged 18 years or older, subjected to cranioplasty (CP) adopting autologous cryopreserved flap. The BFR was derived from the percentage of decrease in flap volume (BFR%), comparing the first post-operative computed tomography (CT) and the last one available (performed at least 1 year after surgery). We also proposed a semiquantitative scoring system, based on CT, to define a clinically workable BFR classification. RESULTS After a mean ± SE follow-up of 32.5 ± 2.4 months, the bone flap volume decreased significantly (p < 0.0001). The mean BFR% was 31.7 ± 3.8% and correlated with CT-score (p < 0.001). Three BFR classes were described: mild (14.8% of cases) consisting in minimal bone remodelling, CT-score ≤ 6, mean BFR% = 3.5 ± 0.7%; moderate (51.9% of cases) corresponding to satisfactory cerebral protection, CT-score < 13, mean BFR% = 25.6 ± 2.2%; severe (33.3% of cases) consisting in loss of cerebral protection, CT-score ≥ 13, mean BFR% = 54.2 ± 3.9%. Females had higher BFR% than males (p = 0.022). BFR classes and new reconstructive surgery were not related (p = 0.58). CONCLUSIONS BFR was moderate or severe in 85.2% of re-implanted cryopreserved flaps. The proposed CT-score is an easy and reproducible tool to define resorption extent.
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Affiliation(s)
- Lina Raffaella Barzaghi
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy.
| | - Veronica Parisi
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | - Carmen Rosaria Gigliotti
- Department of Medical Physics, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Lodoviga Giudice
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | - Silvia Snider
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | - Antonio Dell'Acqua
- Department of Neurocritical Care, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Antonella Del Vecchio
- Department of Medical Physics, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
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Kim JH, Kim JH, Kwon TH, Chong K, Hwang SY, Yoon WK. Aseptic Bone Flap Resorption after Cranioplasty with Autologous Bone: Incidence, Risk Factors, and Clinical Implications. World Neurosurg 2018; 115:e111-e118. [PMID: 29626687 DOI: 10.1016/j.wneu.2018.03.197] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/27/2018] [Accepted: 03/27/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Aseptic bone flap resorption (ABFR) is a known complication of cranioplasty (CP) with an autologous bone flap. The incidence of ABFR has been reported to be as high as 34.2% in the literature; however, it is underestimated in clinical fields. We retrospectively reviewed 13 years of clinical cases of patients who underwent CP after decompressive craniectomy (DC) to investigate the incidence and risk factors of ABFR. METHODS Ninety-one patients who underwent DC and CP in Guro Hospital, Korea University Medical Center, were enrolled. ABFR was defined using serial brain computed tomography. To identify possible risk factors for ABFR, univariate and multivariate Cox regression and receiver operating characteristic curve analyses were performed. RESULTS Of the 91 patients enrolled, ABFR was diagnosed in 32 patients (35.1%). Bone flap size, existence of a shunting system, and the DC-CP interval were significant in the univariate analysis. Bone flap size was statistically significant in the multivariate analysis (P = 0.0189). The cutoff points of the DC-CP interval and bone flap size were 44 days and 110 cm2, respectively. CONCLUSIONS The incidence of ABFR was remarkably high. Bone flap size, the existence of a shunting system, and the DC-CP interval were shown to be potential risk factors of ABFR after CP.
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Affiliation(s)
- Jang Hun Kim
- Department of Neurosurgery, Guro Hospital, Seoul, Republic of Korea; Focused Training Center for Trauma, Guro Hospital, Seoul, Republic of Korea
| | - Jong Hyun Kim
- Department of Neurosurgery, Guro Hospital, Seoul, Republic of Korea
| | - Taek-Hyun Kwon
- Department of Neurosurgery, Guro Hospital, Seoul, Republic of Korea
| | - Kyuha Chong
- Department of Neurosurgery, Guro Hospital, Seoul, Republic of Korea
| | - Soon-Young Hwang
- Biostatistical Consulting Laboratory, Medical Science Research Center, Korea University College of Medicine, Seoul, Republic of Korea
| | - Won Ki Yoon
- Department of Neurosurgery, Guro Hospital, Seoul, Republic of Korea.
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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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