From the Department of Plastic Surgery, Cleveland Clinic.
Plast Reconstr Surg. 2019 Mar;143(3):853-861. doi: 10.1097/PRS.0000000000005363.
Management of cranial osteomyelitis is challenging and often includes débridement of infected bone and delayed alloplastic cranioplasty. However, the optimal interval between the removal of infected bone and definitive reconstruction remains controversial. The authors investigated the optimal time for definitive reconstruction and factors influencing cranioplasty reinfection.
A retrospective review of 111 alloplastic cranioplasties for osteomyelitis between 2002 and 2015 was performed. Patients were divided into four subgroups based on timing of reconstruction: group 1, less than 3 months; group 2, 3 to 6 months; group 3, 6 to 12 months; and group 4, more than 12 months. Multivariate logistic regression was used to calculate the probability of cranioplasty reinfection based on risk factors. Median follow-up was 45.9 months (range, 12.4 to 136.9 months).
The combined reinfection rate was 23.4 percent. The reinfection rate in group 1 was 39.6 percent; group 2, 12.5 percent; group 3, 8.0 percent; and group 4, 0.0 percent (p < 0.001). The mean interval between the infected bone removal and cranioplasty was shorter in patients with reinfection than in patients without reinfection (2.2 ± 3.9 months versus 6.1 ± 8.3 months; p < 0.001). The strongest independent predictors of reinfection were chemotherapy (OR, 10.1; 95 percent CI, 2.9 to 35.2), composite defect requiring scalp reconstruction at the time of cranioplasty (OR, 3.3; 95 percent CI, 1.2 to 8.9), and early reconstruction. Each month of delay in reconstruction reduced the reinfection rate by 10 percent (OR, 0.9 per each month of delay; 95 percent CI, 0.8 to 1.0). Cranioplasty material was not significant.
Early alloplastic cranioplasty following osteomyelitis carries an unacceptably high risk of reinfection. This risk decreases by 10 percent with each month of delay. The authors' regression model can be used to predict the probability of reinfection for all time periods.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
颅骨骨髓炎的治疗具有挑战性，通常包括感染骨的清创和延迟性异体颅骨修复。然而，去除感染骨与确定性重建之间的最佳间隔时间仍存在争议。作者研究了确定性重建的最佳时间以及影响颅骨修补再感染的因素。
回顾性分析了 2002 年至 2015 年间 111 例颅骨骨髓炎异体颅骨修复术。根据重建时间将患者分为 4 个亚组：第 1 组，少于 3 个月；第 2 组，3 至 6 个月；第 3 组，6 至 12 个月；第 4 组，超过 12 个月。采用多变量逻辑回归计算基于危险因素的颅骨修补再感染概率。中位随访时间为 45.9 个月（范围：12.4 至 136.9 个月）。
总的再感染率为 23.4%。第 1 组的再感染率为 39.6%；第 2 组为 12.5%；第 3 组为 8.0%；第 4 组为 0.0%（p < 0.001）。与无再感染的患者相比，再感染患者的感染骨切除与颅骨修补之间的平均间隔时间更短（2.2 ± 3.9 个月比 6.1 ± 8.3 个月；p < 0.001）。再感染的最强独立预测因子是化疗（OR，10.1；95%CI，2.9 至 35.2）、颅骨修补时需要头皮重建的复合缺损（OR，3.3；95%CI，1.2 至 8.9）和早期重建。重建每延迟一个月，再感染率降低 10%（OR，每延迟一个月降低 0.9；95%CI，0.8 至 1.0）。颅骨修补材料无显著意义。
骨髓炎后早期行异体颅骨修复术再感染风险极高。这种风险每延迟一个月就会降低 10%。作者的回归模型可用于预测所有时间段的再感染概率。
临床问题/证据水平：治疗，III 级。
