The Timing of Alloplastic Cranioplasty in the Setting of Previous Osteomyelitis

Abstract

Background: Management of cranial osteomyelitis is challenging and often includes débridement of infected bone and delayed alloplastic cranioplasty. However, the optimal interval between the removal of infected bone and definitive reconstruction remains controversial. The authors investigated the optimal time for definitive reconstruction and factors influencing cranioplasty reinfection. Methods: A retrospective review of 111 alloplastic cranioplasties for osteomyelitis between 2002 and 2015 was performed. Patients were divided into four subgroups based on timing of reconstruction: group 1, less than 3 months; group 2, 3 to 6 months; group 3, 6 to 12 months; and group 4, more than 12 months. Multivariate logistic regression was used to calculate the probability of cranioplasty reinfection based on risk factors. Median follow-up was 45.9 months (range, 12.4 to 136.9 months). Results: The combined reinfection rate was 23.4 percent. The reinfection rate in group 1 was 39.6 percent; group 2, 12.5 percent; group 3, 8.0 percent; and group 4, 0.0 percent (p < 0.001). The mean interval between the infected bone removal and cranioplasty was shorter in patients with reinfection than in patients without reinfection (2.2 ± 3.9 months versus 6.1 ± 8.3 months; p < 0.001). The strongest independent predictors of reinfection were chemotherapy (OR, 10.1; 95 percent CI, 2.9 to 35.2), composite defect requiring scalp reconstruction at the time of cranioplasty (OR, 3.3; 95 percent CI, 1.2 to 8.9), and early reconstruction. Each month of delay in reconstruction reduced the reinfection rate by 10 percent (OR, 0.9 per each month of delay; 95 percent CI, 0.8 to 1.0). Cranioplasty material was not significant. Conclusions: Early alloplastic cranioplasty following osteomyelitis carries an unacceptably high risk of reinfection. This risk decreases by 10 percent with each month of delay. The authors’ regression model can be used to predict the probability of reinfection for all time periods. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Cranioplasty

“…Kwiecen et al report a 10% risk reduction for reinfection with every month cranioplasty was delayed. 25 Other studies have reported lower infection rates with earlier reconstruction (4% incidence with reconstruction as early as 3 months) in smaller adult cohorts (n ¼ 25). 26 Further discussion regarding the treatment of perioperative surgical site infection is beyond the scope of this article; however, infection at the craniotomy site should prompt a infectious disease consultation and delay of reconstruction.…”

Prognosis-Guided Reconstruction of Scalp and Skull Defects in Neurosurgical Patients

“…7 It has been repeatedly documented in the literature that frontal defects are associated with an increased risk of complications and reoperation after cranioplasty compared with all other locations due to higher likelihood of frontal sinus involvement and resulting greater chance for chronic infection, which aligned with the findings in our study (OR, 1.59 for major complications; P = 0.026). 5,8,9 Subgroup analyses stratified by etiology of defect in combination with data on mortality allows us to make informed recommendations regarding reconstructive approach dependent on the unique preoperative conditions of different patients. The majority of patients presenting with malignant intracranial neoplasms (68.4%), most commonly represented by glioblastoma multiforme, ultimately passed within a short period (median, 4.3 months [1.9-8.4 months] postoperatively, Table 5).…”

“…However, 2 of the patients had persistent infections, 2 others developed delayed wound healing problems, one died due to unrelated airway obstruction. Management of calvarial osteomyelitis most often entails delayed replacement of the infected bone with alloplastic material; in a retrospective study of 111 alloplastic cranioplasties, Kwiecien et al 5 found that the risk of reinfection decreased by 10% each month cranioplasty was delayed. Preoperative chemotherapy (OR 10.05, P < 0.01) and the presence of a composite scalp and calvarial defect (OR 3.25, P < 0.05) were identified as independent predictors of cranioplasty reinfection.…”

Reconstruction of Chronic Wounds Secondary to Injectable Drug Use with a Biodegradable Temporizing Matrix

“…Successful reconstruction of chronic, infected soft-tissue defects with underlying osteomyelitis requires serial debridement of all nonviable tissues before reconstruction. 9 , 10 Here, we present two patients with extensive bilateral forearm soft-tissue defects and osteomyelitis secondary to IDU successfully treated with IV antibiotics, debridement and staged reconstruction using BTM and STSG.…”