Presence of Propionibacterium acnes in patients with aseptic bone graft resorption after cranioplasty: preliminary evidence for low-grade infection

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OBJECTIVE

Autologous bone graft reimplantation remains the standard treatment after decompressive hemicraniectomy. Unfortunately, some patients present with signs of bone resorption without any visible signs of infection; the reasons remain unknown. Contamination with Propionibacterium acnes has been discussed as a potential source of the osteolytic process. The aim of this study was to investigate the microbial spectrum detected in samples of grafts from patients with aseptic bone resorption and compare them to septic bone graft infections in order to identify P. acnes as the specific pathogen of aseptic bone resorption.

METHODS

The authors retrospectively reviewed all patients treated for aseptic bone resorption between 2012 and 2017 in their neurosurgical department. Septic infections were used as a control group to gain information on the present bacterial spectrum. Perioperative data such as demographics, number of surgeries, and complications were assessed and compared with the microbiological analyses conducted in order to detect differences and potential sources for aseptic bone resorption and possible differences in bacterial contamination in septic and aseptic bone infection.

RESULTS

In total, 38 patients underwent surgery between 2012 and 2017 for septic bone infection—14 for aseptic bone resorption. In 100% of the septic bone infection cases in which bone flap removal was needed, bacteria could be isolated from the removed bone flap (55% Staphylococcus aureus, 13.2% Enterococcus faecalis, and 18.4% Staphylococcus epidermidis). The microbial spectrum from samples of aseptic bone flaps with resorption was examined in 10 of 14 patients and revealed contamination with P. acnes in 40% (n = 4, the other 6 bone grafts were sterile), especially in sonication analysis, whereas visible septic bone infection was mainly caused by S. aureus without detection of P. acnes.

CONCLUSIONS

Aseptic bone resorption may be caused by low-grade infections with P. acnes. However, further analysis needs to be conducted in order to understand its clinical relevance and treatment perspective.

ABBREVIATIONS SAH = subarachnoid hemorrhage; SSI = surgical site infection; TBI = traumatic brain injury.

Article Information

Correspondence Sandro M. Krieg: Technische Universität München, Germany. sandro.krieg@tum.de.

INCLUDE WHEN CITING Published online August 30, 2019; DOI: 10.3171/2019.5.JNS191200.

Disclosures Dr. Krieg is a consultant for Spineart Deutschland GmbH and Nexstim Plc and received honoraria from Medtronic and Carl Zeiss Meditec. Drs. Krieg and Meyer received research grants from and are consultants for Brainlab AG. Dr. Meyer received honoraria, consulting fees, and research grants from Medtronic, icotec ag, and Relievant Medsystemy Inc.; honoraria and research grants from Ulrich Medical; honoraria and consulting fees from Spineart Deutschland GmbH and DePuy Synthes; and royalties from Spineart Deutschland GmbH.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Causes of titanium-customized cranioplasty divided in aseptic and septic bone infections: the main reason was septic bone infection (n = 38, 73%); bone flap necrosis was accountable for 27% (n = 14).

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    Initial causes of craniotomy in patients with subsequent septic bone infections. The main diagnosis was TBI (31%), followed by recurrent meningioma surgery (21%), stroke (16%), and SAH (13%), as well as arteriovenous malformations (AVMs) and other tumors (both 8%). Figure is available in color online only.

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    Initial causes of craniotomy in patients suffering from aseptic bone resorption. The main diagnosis was SAH (43%), followed by TBI (29%), stroke (21%), and other tumors (7%).

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    Identified bacteria in microbiological analyses of septic bone grafts at the time of bone graft removal, with no evidence for the presence of P. acnes compared to patients with aseptic bone resorption.

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    Bacterial spectrum detected in samples obtained from aseptic bone resorption grafts: the only bacterium isolated (mainly in sonication analysis) was P. acnes, in 40% of the cases. The others remained without bacterial contamination.

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    Scatterplot showing the duration from initial craniotomy to septic bone infections in 38 patients, ranging from 31 days to 2459 days, with a median of 148 days.

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    Scatterplot showing duration from initial craniotomy to aseptic bone resorption in 14 patients, ranging from 349 days to 2983 days, with a median of 829 days.

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