Predictors of infection after 754 cranioplasty operations and the value of intraoperative cultures for cryopreserved bone flaps

Abstract

Predictors of infection afterobJective The authors' aim was to report the largest study on predictors of infection after cranioplasty and to assess the predictive value of intraoperative bone flap cultures before cryopreservation. methods They retrospectively examined all cranioplasties performed between March 2004 and November 2014. Throughout this study period, the standard protocol during initial craniectomy was to obtain a culture swab of the extracted autologous bone flap (ABF)-prior to its placement in cytostorage-to screen for microbial contamination. Two consecutive protocols were employed for the use and interpretation of the intraoperative swab culture results: A) From March 2004 through June 2013, any culture-positive ABF (+ABF) was discarded and a custom synthetic prosthesis was implanted at the time of cranioplasty. B) From July 2013 through November 2014, any ABF with a skin flora organism was not discarded. Instead, cryopreservation was maintained and the +ABF was re-implanted after a 10-minute soak in bacitracin irrigation as well as a 3-minute soak in betadine. results Over the 10.75-year period, 754 cranioplasty procedures were performed. The median time from craniectomy to cranioplasty was 123 days. Median follow-up after cranioplasty was 237 days for protocol A and 225 days for protocol B. The overall infection rate after cranioplasty was 6.6% (50 cases) occurring at a median postoperative Day 31. Staphylococcus spp. were involved as the causative organisms in 60% of cases. Culture swabs taken at the time of initial craniectomy were available for 640 ABFs as 114 ABFs were not salvageable. One hundred twenty-six (20%) were culture positive. Eighty-nine +ABFs occurred during protocol A and were discarded in favor of a synthetic prosthesis at the time of cranioplasty, whereas 37 +ABFs occurred under protocol B and were reimplanted at the time of cranioplasty. Cranioplasty material did not affect the postcranioplasty infection rate. There was no significant difference in the infection rate among sterile ABFs (7%), +ABFs (8%), and synthetic prostheses (5.5%; p = 0.425). All 3 +ABF infections under protocol B were caused by organisms that differed from those in the original intraoperative bone culture from the initial craniectomy. A cranioplasty procedure ≤ 14 days after initial craniectomy was the only significant predictor of postcranioplasty infection (p = 0.007, HR 3.62). coNclusioNs Cranioplasty procedures should be performed at least 14 days after initial craniectomy to minimize infection risk. Obtaining intraoperative bone cultures at the time of craniectomy in the absence of clinical infection should be discontinued as the culture results were not a useful predictor of postcranioplasty infection and led to the unnecessary use of synthetic prostheses and increased health care costs.

Comparison between subcutaneous pocket and cryopreservation method for storing autologous bone flaps in developing bone flap infection after cranioplasty, a prospective observational multi-center study of 100 cases

“…In review of literature bone ap infection rate after cranioplasty ranges from 5.9%-22%.in review of literature, Post-operative infection after CP method is stated to be 2-25.9% and SP method 2.3-18% (8,9,10,11,12).…”

“…Post-cranioplasty bone ap infection is a clinical serious condition due to its consequences, including meningitis, brain abscess formation, encephalitis, system in ammation and sepsis. Thus, high index of suspicion and low diagnostic-threshold would be rational (8).…”

“…SSI after every procedure and most importantly craniotomy and cranioplasty has major impacts on the patient, hospitalization duration, morbidities and health-service costs. If bone ap after cranioplasty is deemed to be infected, it must be removed, the wound should be irrigated and debrided, antibiotics via intra-venous route should be administered and at least after a 4-6 weeks the patient should be followed up until any evidence of infection resolves and proper time for the second cranioplasty could be determined (3,8).…”

Cryopreservation Versus Intracorporeal Preservation of Cranial Bone Flaps; A Comprehensive Review of Literature

“…13 Although, this method has many advantages but it is also followed by some major post operative complications and in some cases requiring the need of reoperation. In a study, one case was found where there was mild resorption of bone flaps although there was no infection or a need for reoperation for the complications during the follow-up periods.…”

The role of the microbiota in surgical recovery

“…Although intraoperative spillage of the intestinal contents and intra-operative contamination from the environment clearly predispose to surgical site infections, intraoperative wound cultures have been shown not to be useful predictors of post-operative wound infections. (21,22) Wound infections that occur in the absence of intestinal content spillage, intestinal manipulation or intra-operative contamination are common. As an example, Methicillin resistant Staphylococcus aureus (MRSA) wound infections continue to occur even with strict adherence to pre-operative screening, intranasal decolonization and targeted parenteral antibiotic prophylaxis.…”