Successful Strategies for Dealing With Infected, Custom-Made Hydroxyapatite Cranioplasty

Abstract

When a cranioplasty implant becomes infected, standard operating procedure dictates its removal and the initiation of a long course of antibiotic therapy. However, removing such a prosthesis can have a series of adverse consequences, including delayed cognitive and motor recovery, lack of brain tissue protection, unsightly deformity, and the need for two additional surgical procedures, not to mention the additional costs involved. To maintain the advantages of cranioplasty, we opted for a conservative approach (levofloxacin and rifampicin every 24 hours for 8 weeks) in a 68-year-old woman whose custom-made porous hydroxyapatite implant, fitted following aneurysm clipping, had become infected. The tissues overlying the implant were curettaged, and the patient's clinical condition, blood markers, and infection course were continuously monitored (local monitoring was performed by single-photon emission computed tomography [SPECT]/computed tomography [CT after intravenous administration of Tc-labeled antigranulocyte antibody). Blood tests and SPECT/CT evidenced a progressive reduction in phlogosis indices and infection locus, even 1 month after antibiotic therapy was commenced, and at 2 years from cranioplasty, the same tests and clinical examination were negative. At 6-year follow-up, clinical assessment revealed nothing out of the ordinary.Hence, specific cases (hydroxyapatite prosthesis, intact dura, cranial CT and magnetic resonance imaging negative for empyema, well-vascularized scalp, antibiotic-responsive bacteria) of infected cranial implant can be treated using a conservative approach consisting of appropriate antibiotic therapy, accompanied by local debridement where necessary, and assiduous monitoring of phlogosis indices and local verification via labeled-leukocyte scintigraphy. Our report, which was compiled after a long-term follow-up period, shows that this conservative procedure appears to be a viable option in cases of infected, custom-made hydroxyapatite cranioplasty, provided that some basic rules concerning clinical and instrumental standards are adhered to, as clearly stated in our report.

Healing Exposed Calvarial Hardware Using Negative-Pressure Wound Therapy and Vashe Wound Solution: Case Report

“…As reported by Zanotti et al, 19 one patient with infection and no exposed hardware postcranioplasty underwent levofloxacin and rifampicin every 24 hours for 8 weeks followed by debridement. At 2-year follow-up, the patient remained infection-free 19 . Johnson et al 22 treated a patient with skin necrosis and exposure of hardware with IV antibiotics for 3 weeks followed by debridement, drainage of infected tissue, scalp rotation flap, and 3 more weeks of antibiotics.…”

“…The authors indicated that they could avoid prosthesis removal due to targeted antibiotic therapy, wound surgical revision, and the biomimetism of HA prosthesis. Zanotti et al 19 successfully salvaged an infected HA cranioplasty prosthesis without explantation through the use of targeted antibiotics followed by debridement. Six years after treatment, the patient revealed no problems or reinfections with the implant 19 .…”

“…Zanotti et al 19 successfully salvaged an infected HA cranioplasty prosthesis without explantation through the use of targeted antibiotics followed by debridement. Six years after treatment, the patient revealed no problems or reinfections with the implant 19 . Hu et al 16 used antibiotics and a glucocorticoid to conservatively treat a titanium implant cranioplasty without removal of the implant.…”

“…In contrast, eight studies reported on postcranioplasty conservative infection management strategies. 9,[14][15][16][17]19,21,22 In the article by Chen et al, 9 11 patients with infection under the skin flap after cranioplasty received 3 weeks of systemic IV antibiotics and 1 week of enclosed continuous irrigation and drainage. All 11 patients salvaged their implants and had no recurrence of infection for 2 to 6 years postoperation.…”

The Antibiotic Immersion of Custom-Made Porous Hydroxyapatite Cranioplasty: A Multicentric Cohort Study

“…This method allows to decrease implant-associated infection by decreasing bacterial adherence and subsequent colonization. 49 Local delivery of antibiotics allows to deliver a high, locally effective dose whereas maintaining a low plasma concentration to minimize or eliminate systemic toxicity.…”