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Novel Application of Antibiotic Impregnated Polymethyl-MethacrylateBone Cement for the Treatment of Infected Cranioplasties: Initial Experience
Kevin M Englar MD1, Anthony M Kordahi MD1, Michael G. Brandel, MD, MAS2, David R. Santiago-Dieppa, MD2, Arvin R. Wali, MD, MAS2, Martin Pham MD2, David Barba MD2, Joseph Ciacci MD2, Mark Rechnic MD1 1)Division of Plastic Surgery, University of California-San Diego, La Jolla, CA, USA 2)Department of Neurosurgery, University of California-San Diego, La Jolla, CA, USA

Background: Management of infected cranioplasty implants remains a challenge. Severe cases are usually treated with surgical debridement, removal of the infected implant, and prolonged antibiotic therapy. Reconstruction of the resulting defect is usually delayed for several months to years. This interval between removal and reconstruction leaves the brain vulnerable to trauma and requires an additional procedure to re-elevate the scalp flap, which can be scarred, fibrotic, and thinned, increasing the difficulty. Using antibiotic impregnated polymethyl-methacrylate (PMMA), we propose an alternative to delayed reconstruction in the face of cranioplasty infection with a dual purpose: treat the infection with a material which delivers antibiotic to the area (PMMA-antibiotic) and which functions as a temporary or permanent cranioplasty, protecting the underlying structures and preventing soft tissue contracture in the process.

Methods: We reviewed the records of three consecutive patients who presented with infected cranioplasty and underwent single-stage PMMA-antibiotic salvage cranioplasty. All patients underwent debridement and washout of the infected cranioplasty. Titanium mesh was placed over the bony defect. PMMA impregnated with vancomycin and tobramycin was then spread over the plate and defect prior to closure. Postop, patients received extended treatment with culture driven systemic antimicrobials.

Results: Case 1 A 76-year-old who presented 4.5 years after bifrontal cranioplasty with a chronic wound, purulent drainage, and exposed cranioplasty material. She refused an intervention that would leave her disfigured. Operative cultures grew Pseudomonas aeruginosa and Staph epidermidis, and she completed an eight-week antibiotic regimen. There has been no sign of recurrent infection after 13 months. Case 2 A 48-year-old, insulin dependent diabetic male presented 5 months postop from cranioplasty after trauma with a large vertex wound dehiscence with hardware exposure and drainage. This patient's socioeconomic situation left him especially vulnerable to injury without salvage cranioplasty. Operative cultures grew Pseudomonas aeruginosa, Serratia marcescens, methicillin sensitive Staph aureus. IV antibiotics were continued for six weeks. There has been no evidence of recurrent infection after nine months. Case 3 A 62-year-old woman who six weeks after status-post multiply revised hemicraniectomy and subsequent cranioplasty, developed a small dehiscence with drainage and exposed calvaria and polyether ether ketone (PEEK) prosthetic. She refused any staged procedure. Operative cultures grew Candida albicans and were treated with oral and IV antifungals. A small dehiscence occurred at two months postop at the site under maximal tension. This was surgically revised without removal of the PMMA-antibiotic cranioplasty. She is eight months postop from her salvage cranioplasty without further problem.

Conclusion: We present three cases of infected cranioplasty implants which were reconstructed in one stage using titanium mesh with PMMA-antibiotic salvage cranioplasty. Compared to a traditional staged approach, by bridging traditional implant removal and delayed reconstruction or acting as definitive reconstruction, this treatment strategy obliviates the need to leave patients deformed and calvarial contents unprotected. Furthermore, it can act as a spacer to prevent soft tissue contracture if delayed reconstruction is pursued. These results are relatively early but encouraging. Longer-term follow-up and a larger case series are needed to further delineate the role of single stage reconstruction.

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