Reconstruction of skull defects following decompressive craniectomy is associated with a high rate of complications. Implantation of autologous cryopreserved bone has been associated with infection rates of up to 33%, resulting in considerable patient morbidity. Predisposing factors for infection and other complications are poorly understood. Patients undergoing cranioplasty between 1999 and 2009 were identified from a prospectively maintained database. Records and imaging were reviewed retrospectively. Demographics, the initial craniectomy and subsequent cranioplasty surgeries, complications, and outcomes were recorded. A total of 187 patients underwent delayed cranioplasty using autologous bone flaps cryopreserved at −30°C following decompressive craniectomy. Indications for craniectomy were trauma (77.0%), stroke (16.0%), subarachnoid hemorrhage (2.67%), tumor (2.14%), and infection (2.14%). There were 64 complications overall (34.2%), the most common being infection (11.2%) and bone resorption (5.35%). After multivariate analysis, intraoperative cerebrospinal fluid (CSF) leak was significantly associated with infection, whereas longer duration of surgery and unilateral site were associated with resorption. Cranioplasty using frozen autologous bone is associated with a high rate of infective complications. Intraoperative CSF leak is a potentially modifiable risk factor. Meticulous dissection during cranioplasty surgery to minimize the chance of breaching the dural or pseudodural plane may reduce the chance of bone flap.
ChibbaroSTacconiLRole of decompressive craniectomy in the management of severe head injury with refractory cerebral edema and intractable intracranial pressure. Our experience with 48 casesSurg Neurol2007686632–638
2.
AarabiBHesdorfferDCAhnESArescoCScaleaTMEisenbergHMOutcome following decompressive craniectomy for malignant swelling due to severe head injuryJ Neurosurg20061044469–479
3.
HowardJLCipolleMDAndersonM, et al. Outcome after decompressive craniectomy for the treatment of severe traumatic brain injuryJ Trauma2008652380–385, discussion 385–386
4.
ArticoMFerranteLPastoreFS, et al. Bone autografting of the calvaria and craniofacial skeleton: historical background, surgical results in a series of 15 patients, and review of the literatureSurg Neurol200360171–79
5.
SultanSMDavidsonEHButalaP, et al. Interval cranioplasty: comparison of current standardsPlast Reconstr Surg201112751855–1864
6.
R Core TeamR: A Language and Environment for Statistical ComputingR Foundation for Statistical ComputingVienna, Austria2012
7.
ChangV, et al. Outcomes of cranial repair after craniectomyJ Neurosurg201011251120–1124
8.
Moreira-GonzalezAJacksonITMiyawakiTBarakatKDiNickVClinical outcome in cranioplasty: critical review in long-term follow-upJ Craniofac Surg2003142144–153
9.
NagayamaKYoshikawaGSomekawaK, et al. Cranioplasty using the patient's autogenous bone preserved by freezing–an examination of post-operative infection rates [in Japanese]No Shinkei Geka2002302165–169
10.
MatsunoATanakaHIwamuroH, et al. Analyses of the factors influencing bone graft infection after delayed cranioplastyActa Neurochir (Wien)20061485535–540, discussion 540
11.
GoochMRGinGEKenningTJGermanJWComplications of cranioplasty following decompressive craniectomy: analysis of 62 casesNeurosurg Focus2009266E9
12.
MansonPNCrawleyWAHoopesJEFrontal cranioplasty: risk factors and choice of cranial vault reconstructive materialPlast Reconstr Surg1986776888–904
13.
ChengYKWengHHYangJTLeeMHWangTCChangCNFactors affecting graft infection after cranioplastyJ Clin Neurosci200815101115–1119
14.
LiangWXiaofengYWeiguoL, et al. Cranioplasty of large cranial defect at an early stage after decompressive craniectomy performed for severe head traumaJ Craniofac Surg2007183526–532
15.
AsanoYRyukeYHasuoMSimosawaSCranioplasty using cryopreserved autogenous bone [in Japanese]No To Shinkei199345121145–1150
16.
ProloDJBurresKPMcLaughlinWTChristensenAHAutogenous skull cranioplasty: fresh and preserved (frozen), with consideration of the cellular responseNeurosurgery19794118–29
17.
OsawaMHaraHIchinoseYKoyamaTKobayashiSSugitaYCranioplasty with a frozen and autoclaved bone flapActa Neurochir (Wien)19901021-238–41
18.
BhaskarIPZawNNZhengMLeeGYBone flap storage following craniectomy: a survey of practices in major Australian neurosurgical centresANZ J Surg2011813137–141
19.
OhJHZöllerJEKüblerAA new bone banking technique to maintain osteoblast viability in frozen human iliac cancellous boneCryobiology2002443279–287
20.
ReutherTKochelMMueller-RichterU, et al. Cryopreservation of autologous bone grafts: an experimental study on a sheep animal modelCells Tissues Organs20101915394–400
21.
ProloDJOklundSAThe use of bone grafts and alloplastic materials in cranioplastyClin Orthop Relat Res1991268270–278
22.
IwamaTYamadaJImaiSShinodaJFunakoshiTSakaiNThe use of frozen autogenous bone flaps in delayed cranioplasty revisitedNeurosurgery2003523591–596, discussion 595–596
23.
FlanneryTMcConnellRSCranioplasty: why throw the bone flap out?Br J Neurosurg2001156518–520
24.
ShoakazemiAFlanneryTMcConnellRSLong-term outcome of subcutaneously preserved autologous cranioplastyNeurosurgery2009653505–510, discussion 510
25.
MovassaghiKVer HalenJGanchiPAmin-HanjaniSMesaJYaremchukMJCranioplasty with subcutaneously preserved autologous bone graftsPlast Reconstr Surg20061171202–206
26.
InamasuJKuramaeTNakatsukasaMDoes difference in the storage method of bone flaps after decompressive craniectomy affect the incidence of surgical site infection after cranioplasty? Comparison between subcutaneous pocket and cryopreservationJ Trauma2010681183–187, discussion 187
27.
PaşaoğluAKurtsoyAKocRK, et al. Cranioplasty with bone flaps preserved under the scalpNeurosurg Rev1996193153–156
28.
HäuptliJSegantiniPNew tissue preservation method for bone flaps following decompressive craniotomy [in German]Helv Chir Acta1980471-2121–124
29.
MorinaAKelmendiFMorinaQ, et al. Cranioplasty with subcutaneously preserved autologous bone grafts in abdominal wall-Experience with 75 cases in a post-war country KosovaSurg Neurol Int2011272
30.
YanoHTanakaKMatsuoTTsudaMAkitaSHiranoACranioplasty with auto-purified bone flap after infectionJ Craniofac Surg20061761076–1079
31.
MorenoJForriolFEffects of preservation on the mechanical strength and chemical composition of cortical bone: an experimental study in sheep femoraBiomaterials200223122615–2619
32.
ZingaleAAlbaneseVCryopreservation of autogeneous bone flap in cranial surgical practice: what is the future? A grade B and evidence level 4 meta-analytic studyJ Neurosurg Sci2003473137–139
33.
YadlaSCampbellPGChitaleRMaltenfortMGJabbourPSharanADEffect of early surgery, material, and method of flap preservation on cranioplasty infections: a systematic reviewNeurosurgery20116841124–1129, discussion 1130
34.
GrossmanNShemesh-JanHSMerkinVGideonMCohenADeep-freeze preservation of cranial bones for future cranioplasty: nine years of experience in Soroka University Medical CenterCell Tissue Bank200783243–246
35.
LeeCHChungYSLeeSHYangHJSonYJAnalysis of the factors influencing bone graft infection after cranioplastyJ Trauma Acute Care Surg2012731255–260
36.
SchussPVatterHMarquardtG, et al. Cranioplasty after decompressive craniectomy: the effect of timing on postoperative complicationsJ Neurotrauma20122961090–1095
37.
LuYHuiGLiuFWangZTangYGaoSSurvival and regeneration of deep-freeze preserved autologous cranial bones after cranioplastyBr J Neurosurg2012262216–221
38.
SobaniZAShamimMSZafarSN, et al. Cranioplasty after decompressive craniectomy: An institutional audit and analysis of factors related to complicationsSurg Neurol Int20112123
39.
ShimizuSMorikawaAKugaYMouriGMurataTCranioplasty using autogenous bone cryopreserved with dimethylsulfoxide (DMSO) [in Japanese]No Shinkei Geka2002305479–485
40.
ImSHJangDKHanYMKimJTChungDSParkYSLong-term incidence and predicting factors of cranioplasty infection after decompressive craniectomyJ Korean Neurosurg Soc2012524396–403
41.
JosanVASgourosSWalshARDoverMSNishikawaHHockleyADCranioplasty in childrenChilds Nerv Syst2005213200–204
42.
LeeSCWuCTLeeSTChenPJCranioplasty using polymethyl methacrylate prosthesesJ Clin Neurosci200916156–63
43.
TokoroKChibaYTsuboneKLate infection after cranioplasty—review of 14 casesNeurol Med Chir (Tokyo)1989293196–201
44.
ArchavlisECarvi Y NievasMThe impact of timing of cranioplasty in patients with large cranial defects after decompressive hemicraniectomyActa Neurochir (Wien)201215461055–1062
45.
De BonisPFrassanitoPMangiolaANucciCGAnileCPompucciACranial repair: how complicated is filling a “hole”?J Neurotrauma20122961071–1076
46.
BeauchampKMKashukJMooreEE, et al. Cranioplasty after postinjury decompressive craniectomy: is timing of the essence?J Trauma2010692270–274
