Risk factors for bone flap resorption after autologous bone cranioplasty

Abstract Following a decompressive craniectomy, the autologous bone flap is generally considered the reconstructive material of choice in pediatric patients. Replacement of the original bone flap takes advantage of its natural biocompatibility and the associated low risk of rejection, as well as the potential to reintegrate with the adjacent bone and subsequently grow with the patient. However, despite these advantages and unlike adult patients, the replaced calvarial bone is more likely to undergo delayed bone resorption in pediatric patients, ultimately requiring revision surgery. In this review, we describe the materials that are currently available for pediatric cranioplasty, the advantages and disadvantages of autologous calvarial replacement, the incidence and classification of bone resorption, and the clinical risk factors for bone flap resorption that have been identified to date.

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Cranial autologous bone flap resorption after a cranioplasty: A case report

Surgical Neurology International ◽

10.4103/sni.sni_388_17 ◽

2018 ◽

Vol 9 (1) ◽

pp. 61 ◽

Cited By ~ 1

Author(s):

SabrinaA de França ◽

ThalesB Nepomuceno ◽

WellingsonS Paiva ◽

AlmirF Andrade ◽

ManoelJ Teixeira ◽

...

Keyword(s):

Case Report ◽

Bone Flap ◽

Bone Flap Resorption ◽

Autologous Bone

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Subcutaneous bone flap storage after emergency craniectomy: cost-effectiveness and rate of resorption

Journal of Neurosurgery ◽

10.3171/2017.6.jns17943 ◽

2018 ◽

Vol 129 (6) ◽

pp. 1604-1610 ◽

Cited By ~ 8

Author(s):

Griffin Ernst ◽

Fares Qeadan ◽

Andrew P. Carlson

Keyword(s):

Risk Factors ◽

Logistic Regression ◽

Bone Resorption ◽

Decompressive Craniectomy ◽

Significant Risk ◽

Bone Flap ◽

Type I ◽

Custom Implant ◽

Autologous Bone ◽

Clinically Significant

OBJECTIVEDecompressive craniectomy is used for uncontrolled intracranial pressure in traumatic brain injury and malignant hemispheric stroke. Subcutaneous preservation of the autologous bone flap in the abdomen is a simple, portable technique but has largely been abandoned due to perceived concerns of resorption. The authors sought to characterize their experience with subcutaneous preservation of the bone flap and cranioplasty.METHODSThe authors performed a retrospective single-institution review of subcutaneous preservation of the autologous bone flap after decompressive craniectomy from 2005 to 2015. The primary outcome was clinically significant bone resorption, defined as requiring a complete mesh implant at the time of cranioplasty, or delayed revision. The outcome also combined cases with any minor bone resorption to determine predictors of this outcome. Logistic regression modeling was used to determine the risk factors for predicting resorption. A cost comparison analysis was also used via the 2-sided t-test to compare the cost of cranioplasty using an autologous bone flap with standard custom implant costs.RESULTSA total of 193 patients with craniectomy were identified, 108 of whom received a cranioplasty. The mean time to cranioplasty was 104.31 days. Severe resorption occurred in 10 cases (9.26%): 4 were clinically significant (2 early and 2 late) and 6 demonstrated type II (severe) necrosis on CT, but did not require revision. Early resorption of any kind (mild or severe) occurred in 28 (25.93%) of 108 cases. Of the 108 patients, 26 (24.07%) required supplemental cranioplasty material. Late resorption of any kind (mild or severe) occurred in 6 (5.88%) of 102 cases. Of these, a clinically noticeable but nonoperative deformity was noted in 4 (3.92%) and minor (type I) necrosis on CT in 37 (37%) of 100. Bivariate analysis identified fragmentation of bone (OR 3.90, 95% CI 1.03–14.8), shunt-dependent hydrocephalus (OR 7.97, 95% CI 1.57–40.46), and presence of post-cranioplasty drain (OR 9.39, 95% CI 1.14–1000) to be significant risk factors for bone resorption. A binary logistic regression optimized using Fisher’s scoring determined the optimal multivariable combination of factors. Fragmentation of bone (OR 5.84, 95% CI 1.38–28.78), diabetes (OR 7.61, 95% CI 1.37–44.56), and shunt-dependent hydrocephalus (OR 9.35, 95% CI 1.64–56.21) were found to be most predictive of resorption, with a C value of 0.78. Infections occurred in the subcutaneous pocket in 5 (2.60%) of the 193 cases and after cranioplasty in 10 (9.26%) of the 108 who underwent cranioplasty. The average cost of cranioplasty with autologous bone was $2156.28 ± $1144.60 (n = 15), and of a custom implant was $35,118.60 ± $2067.51 (3 different sizes; p < 0.0001).CONCLUSIONSCraniectomy with autologous bone cranioplasty using subcutaneous pocket storage is safe and compares favorably to cryopreservation in terms of resorption and favorably to a custom synthetic implant in terms of cost. While randomized data are required to definitively prove the superiority of one method, subcutaneous preservation has enough practical advantages with low risk to warrant routine use for most patients.

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A Comparison between Pediatric and Adult Patients after Cranioplasty: Aseptic Bone Resorption Causes Earlier Revision in Children

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0039-1698391 ◽

2019 ◽

Vol 81 (03) ◽

pp. 227-232 ◽

Cited By ~ 2

Author(s):

Jennifer Göttsche ◽

Friederike Fritzsche ◽

Gertrud Kammler ◽

Thomas Sauvigny ◽

Manfred Westphal ◽

...

Keyword(s):

Risk Factor ◽

Bone Resorption ◽

Pediatric Patients ◽

Young Age ◽

Adult Patients ◽

Bone Flap ◽

Complication Rates ◽

Bone Flap Resorption ◽

Number Of Patients ◽

Autologous Bone

Abstract Background and Study Aims/Objective Cranioplasty, a common neurosurgical intervention following decompressive craniectomy (DC), is associated with high complication rates. Bone flap resorption in particular leads to a considerable number of patients requiring further surgery. The aim of this study was to investigate the frequency and time of occurrence of complications following cranioplastic procedures in children and adults. Material and Methods Data of children and adults who underwent cranioplasty between July 2010 and March 2018 were analyzed retrospectively. Clinical data, complications, and risk factors regarding aseptic bone resorption (ABR) were evaluated including patient age, occurrence of shunt-dependent hydrocephalus, and number of fragments in autologous bone flaps. Results Severe traumatic brain injury (TBI) was the leading cause for DC among children (66.7%), associated with a significantly higher number of fragments (p = 0.002). In the adult population, the most common cause was malignant infarction (55.9%) followed by TBI (24.6%). Pediatric patients in our institution received autologous bone flaps less frequently than adult patients (61.1% and 83.1%, respectively). Young age and a higher number of fragments in autologous bone flaps were associated with the occurrence of ABR. Children and adolescents showed significantly higher rates of aseptic bone necrosis (p = 0.007) and revision cranioplasty (p = 0.036). Kaplan-Meier estimates were used to further analyze bone flap resorption in children and adults, showing that revision surgery due to ABR was performed earlier in children (p = 0.001, log-rank test). Conclusion Pediatric patients demand specific care when cranioplasty is performed following DC. We identified age as an independent risk factor. The higher number of fragments appears to be a correlation due to the higher number of TBIs in children. Our data indicate that young age is the most important risk factor for the development of ABR as a frequent and early complication with a shorter revision-free time interval in children. Consequently, the uncritical use of cryopreserved autologous bone flaps should be questioned in this population.

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Predictors of primary autograft cranioplasty survival and resorption after craniectomy

Journal of Neurosurgery ◽

10.3171/2017.12.jns172013 ◽

2019 ◽

Vol 130 (5) ◽

pp. 1672-1679 ◽

Cited By ~ 12

Author(s):

Tommi K. Korhonen ◽

Sami Tetri ◽

Jukka Huttunen ◽

Antti Lindgren ◽

Jaakko M. Piitulainen ◽

...

Keyword(s):

Removal Rate ◽

Bone Flap ◽

University Hospitals ◽

Neurosurgical Procedure ◽

Factors Affecting ◽

Bone Flap Resorption ◽

Multicenter Cohort ◽

Younger Age ◽

Autologous Bone

OBJECTIVECraniectomy is a common neurosurgical procedure that reduces intracranial pressure, but survival necessitates cranioplasty at a later stage, after recovery from the primary insult. Complications such as infection and resorption of the autologous bone flap are common. The risk factors for complications and subsequent bone flap removal are unclear. The aim of this multicenter, retrospective study was to evaluate the factors affecting the outcome of primary autologous cranioplasty, with special emphasis on bone flap resorption.METHODSThe authors identified all patients who underwent primary autologous cranioplasty at 3 tertiary-level university hospitals between 2002 and 2015. Patients underwent follow-up until bone flap removal, death, or December 31, 2015.RESULTSThe cohort comprised 207 patients with a mean follow-up period of 3.7 years (SD 2.7 years). The overall complication rate was 39.6% (82/207), the bone flap removal rate was 19.3% (40/207), and 11 patients (5.3%) died during the follow-up period. Smoking (OR 3.23, 95% CI 1.50–6.95; p = 0.003) and age younger than 45 years (OR 2.29, 95% CI 1.07–4.89; p = 0.032) were found to independently predict subsequent autograft removal, while age younger than 30 years was found to independently predict clinically relevant bone flap resorption (OR 4.59, 95% CI 1.15–18.34; p = 0.03). The interval between craniectomy and cranioplasty was not found to predict either bone flap removal or resorption.CONCLUSIONSIn this large, multicenter cohort of patients with autologous cranioplasty, smoking and younger age predicted complications leading to bone flap removal. Very young age predicted bone flap resorption. The authors recommend that physicians extensively inform their patients of the pronounced risks of smoking before cranioplasty.

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Initial Dead Space and Multiplicity of Bone Flap as Strong Risk Factors for Bone Flap Resorption after Cranioplasty for Traumatic Brain Injury

Korean Journal of Neurotrauma ◽

10.13004/kjnt.2018.14.2.105 ◽

2018 ◽

Vol 14 (2) ◽

pp. 105 ◽

Cited By ~ 1

Author(s):

Jeong Kyun Joo ◽

Jong-Il Choi ◽

Chang Hyun Kim ◽

Ho Kook Lee ◽

Jae Gon Moon ◽

...

Keyword(s):

Risk Factors ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Dead Space ◽

Bone Flap ◽

Bone Flap Resorption

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Near-Total Bone Flap Resorption following Autologous Bone Cranioplasty in a Child

Pediatric Neurosurgery ◽

10.1159/000441681 ◽

2015 ◽

Vol 51 (2) ◽

pp. 109-110 ◽

Cited By ~ 4

Author(s):

Prasad Krishnan ◽

Rajaraman Kartikueyan ◽

Siddhartha Roychowdhury

Keyword(s):

Bone Flap ◽

Bone Flap Resorption ◽

Autologous Bone

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Risk factors of aseptic bone resorption: a study after autologous bone flap reinsertion due to decompressive craniotomy

Journal of Neurosurgery ◽

10.3171/2013.1.jns12860 ◽

2013 ◽

Vol 118 (5) ◽

pp. 1141-1147 ◽

Cited By ~ 56

Author(s):

Pedro Dünisch ◽

Jan Walter ◽

Yasser Sakr ◽

Rolf Kalff ◽

Albrecht Waschke ◽

...

Keyword(s):

Risk Factors ◽

Multivariate Analysis ◽

Decompressive Craniectomy ◽

Perioperative Complications ◽

Bone Flap ◽

Type Ii ◽

Flap Necrosis ◽

Bone Necrosis ◽

Increased Risk ◽

Autologous Bone

Object In patients who have undergone decompressive craniectomy, autologous bone flap reinsertion becomes necessary whenever the cerebral situation has consolidated. However, aseptic necrosis of the bone flap remains a concern. The aim of this study was to report possible perioperative complications in patients undergoing autologous bone flap reinsertion and to identify the risk factors that may predispose the bone flap to necrosis. Methods All patients admitted to the authors' neurosurgical department between September 1994 and June 2011 and who received their own cryoconserved bone flap after decompressive craniectomy were studied. The grade of the bone flap necrosis was classified into 2 types. Type II bone necrosis was characterized by aseptic resorption with circumscribed or complete lysis of tabula interna and externa requiring surgical revision. To define predisposing factors, a multivariate analysis was performed using bone necrosis as the dependent variable. Results Among the 372 patients (mean age 48.6 years, 57.4% males) who received 414 bone flaps during the observation period, 134 (36.0%) had a diffuse traumatic brain injury, 69 (18.5%) had subarachnoid hemorrhage, 58 (15.6%) had cerebral infarction, 56 (15.1%) had extraaxial bleeding, 43 (11.6%) had intracerebral bleeding, and 12 (3.2%) had a neoplasm. Surgical relevant Type II bone flap necrosis occurred in 85 patients (22.8%) and 91 bone flaps, after a median time of 15 months (interquartile range [IQR], 10–33 months). In a multivariate analysis with Type II necrosis as the dependent variable, bone flap fragmentation with 2 (OR 3.35, 95% CI 1.59–7.01, p < 0.002) or more fragments (OR 24.00, 95% CI 10.13–56.84, p < 0.001), shunt-dependent hydrocephalus (OR 1.76, 95% CI 0.99–3.12, p = 0.04), and a younger age (OR 0.98, 95% CI 0.96–0.99, p = 0.004) was associated with a higher risk for the development of an aseptic bone flap necrosis. Conclusions In patients undergoing bone flap reinsertion after craniotomy, aseptic bone necrosis is an underestimated problem during long-term follow-up. Especially in younger patients with an expected good neurological recovery and a fragmented bone flap, an initial allograft should be considered because of an increased risk for aseptic bone flap necrosis.

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