Decompressive hemicraniectomy and cranioplasty using subcutaneously preserved autologous bone flaps versus synthetic implants: perioperative outcomes and cost analysis

Ehsan DowlatiDepartment of Neurosurgery, MedStar Georgetown University Hospital, and

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Kory B. Dylan PaskoGeorgetown University School of Medicine,

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Esteban A. MolinaGeorgetown University School of Medicine,

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Daniel R. FelbaumDepartment of Neurosurgery, MedStar Georgetown University Hospital, and
Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC

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R. Bryan MasonDepartment of Neurosurgery, MedStar Washington Hospital Center, Washington, DC

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Jeffrey C. MaiDepartment of Neurosurgery, MedStar Georgetown University Hospital, and
Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC

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M. Nathan NairDepartment of Neurosurgery, MedStar Georgetown University Hospital, and

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Edward F. AulisiDepartment of Neurosurgery, MedStar Washington Hospital Center, Washington, DC

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Rocco A. ArmondaDepartment of Neurosurgery, MedStar Georgetown University Hospital, and
Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC

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OBJECTIVE

It has not been well-elucidated whether there are advantages to preserving bone flaps in abdominal subcutaneous (SQ) tissue after decompressive hemicraniectomy (DHC), compared to discarding bone flaps. The authors aimed to compare perioperative outcomes and costs for patients undergoing autologous cranioplasty (AC) after DHC with the bone flap preserved in abdominal SQ tissue, and for patients undergoing synthetic cranioplasty (SC).

METHODS

A retrospective review was performed of all patients undergoing DHC procedures between January 2017 and July 2021 at two tertiary care institutions. Patients were divided into two groups: those with flaps preserved in SQ tissue (SQ group), and those with the flap discarded (discarded group). Additional analysis was performed between patients undergoing AC versus SC. Primary end points included postoperative and surgical site complications. Secondary endpoints included operative costs, length of stay, and blood loss.

RESULTS

A total of 248 patients who underwent DHC were included in the study, with 155 patients (62.5%) in the SQ group and 93 (37.5%) in the discarded group. Patients in the discarded group were more likely to have a diagnosis of severe TBI (57.0%), while the most prevalent diagnosis in the SQ group was malignant stroke (35.5%, p < 0.05). There were 8 (5.2%) abdominal surgical site infections and 9 (5.8%) abdominal hematomas. The AC group had a significantly higher reoperation rate (23.2% vs 12.9%, p = 0.046), with 11% attributable to abdominal reoperations. The average cost of a reoperation for an abdominal complication was $40,408.75 ± $2273. When comparing the AC group to the SC group after cranioplasty, there were no significant differences in complications or surgical site infections. There were 6 cases of significant bone resorption requiring cement supplementation or discarding of the bone flap. Increased mean operative charges were found for the SC group compared to the AC group ($72,362 vs $59,726, p < 0.001).

CONCLUSIONS

Autologous bone flaps may offer a cost-effective option compared to synthetic flaps. However, when preserved in abdominal SQ tissue, they pose the risk of resorption over time as well as abdominal surgical site complications with increased reoperation rates. Further studies and methodologies such as cryopreservation of the bone flap may be beneficial to reduce costs and eliminate complications associated with abdominal SQ storage.

ABBREVIATIONS

AC = autologous cranioplasty; DHC = decompressive hemicraniectomy; PEEK = polyetheretherketone; PMMA = polymethylmethacrylate; pRBC = packed red blood cell; SC = synthetic cranioplasty; SQ = subcutaneous; TBI = traumatic brain injury.
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Figure from Kim et al. (pp 1601–1609).

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