Optimal Timing Of Alloplastic Cranioplasty In The Setting Of Previous Osteomyelitis
Grzegorz J. Kwiecien, MD, Rachel Aliotta, MD, Bahar Bassiri Gharb, MD, PhD, Brian Gastman, MD, James E. Zins, MD.
Cleveland Clinic, Cleveland, OH, USA.
Management of calvarial osteomyelitis is challenging and often includes debridement of infected bone and delayed alloplastic cranioplasty. However, the optimal interval between the removal of infected bone and definitive reconstruction remains controversial. We investigated the optimal time for definitive reconstruction and factors influencing cranioplasty reinfection.
A retrospective review of 111 alloplastic cranioplasties for osteomyelitis (2002-2015) were divided into four subgroups based on timing: early (<3months), early-delayed (3-6months), intermediate-delayed (6-12months), and late (>12months). Multivariate logistic regression was used to calculate probability of cranioplasty reinfection based on risk factors. Mean follow-up was 3.9±3.0years.
The combined reinfection rate was 27.2%. The reinfection rate with early reconstruction was 43.3%, early-delayed 16.7%, intermediate-delayed 14.3%, and late 0.0% (p<0.001)(Fig.1). The mean interval between the infected bone removal and cranioplasty was shorter in patients with reinfection than in patients without reinfection (2.0±3.7 vs. 6.1±8.3months; p<0.001). The strongest independent predictors of reinfection were chemotherapy (OR7.8 95%CI[2.1-29.3]), composite defect requiring scalp reconstruction (OR2.9 95%CI[1.1-7.8]), and early reconstruction. Delay of cranioplasty lowered reinfection rate (OR0.9 per each month of delay 95%CI[0.8-1.0]). Cranioplasty material was not significant.
Early alloplastic cranioplasty following osteomyelitis carries an unacceptably high risk of reinfection. This risk decreases by 10% with each month of delay. However, once the time interval between removal of infected bone and definitive reconstruction reaches 12 months, further delay does not improve the outcome.
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