Salvage of an exposed cranial prosthetic implant using a transposition flap with an indwelling antibiotic irrigation system

Abstract

Cranial implant removal is recommended if implants become exposed owing to scalp necrosis after cranioplasty. However, it carries the risk of extensive bleeding, and the resultant cranial defects can cause both aesthetic and functional problems. We present a case of a scalp defect exposing a cranial prosthetic implant that was reconstructed with a local flap and salvaged using an indwelling antibiotic irrigation system. A 73-year-old man presented with scalp necrosis after undergoing cranioplasty due to intracranial hemorrhage. The cranial implant was exposed through the scalp defect. Methicillin-resistant Staphylococcus aureus was detected in the culture from the open wound. After debridement of the necrotic tissue and burring of the superficial layer of the implant, a transposition flap was used to cover the defect and an indwelling antibiotic irrigation system was installed. Continuous irrigation with vancomycin was conducted for 5 days, and intravenous vancomycin was continued for 4 weeks. The flap was in good condition at 4 months postoperatively, with no infection. The convex contour of the scalp was well maintained. The patient's neurological status was stable. Exposed cranial implants can be salvaged with continuous antibiotic irrigation as an alternative to implant removal; thus, the risk of bleeding and possible disfigurement may be avoided.

Healing Exposed Calvarial Hardware Using Negative-Pressure Wound Therapy and Vashe Wound Solution: Case Report

“…All 11 patients salvaged their implants and had no recurrence of infection for 2 to 6 years postoperation 9 . Hwang and Chang 15 describe a patient with scalp necrosis and implant exposure postcranioplasty who underwent debridement and a transposition flap followed by an indwelling antibiotic irrigation system for 5 days and IV vancomycin for 4 weeks 15 . The flap survived, and the patient had no reinfection at 4 months postoperatively 15 .…”

“…Hwang and Chang 15 describe a patient with scalp necrosis and implant exposure postcranioplasty who underwent debridement and a transposition flap followed by an indwelling antibiotic irrigation system for 5 days and IV vancomycin for 4 weeks 15 . The flap survived, and the patient had no reinfection at 4 months postoperatively 15 . In the article by Huang et al, 14 21 patients with implant infection and titanium mesh exposure received U-shaped surgical debridement and either total removal (n = 4), partial removal (n = 3), or retention of titanium implant (n = 14) followed by immediate negative-pressure wound therapy (NPWT) with chymotrypsin irrigation for 5 days 14 .…”

“…Chen et al 9 used an antibiotic irrigation system to successfully treat 11 patients with infection under the skin flap and no exposed hardware after titanium mesh cranioplasty without removal of bone flaps and hardware. Similarly, Hwang and Chang 15 salvaged a cranioplasty implant in a patient with scalp necrosis, exposed implant, and infection after undergoing cranioplasty by installing an indwelling antibiotic irrigation system after debriding devitalized skin and covering the defect with a transposition flap.…”

Antibacterial Designs for Implantable Medical Devices: Evolutions and Challenges

“…Antibiotic resistance in bacteria even multidrug-resistant (MDR) bacteria is now a worldwide challenge [ 91 ]. Antibiotic-resistant infections were frequently reported all over the world, including in both developing and developed countries ( Table 4 ) [ 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 ]. During an infection, Staphylococcus aureus ( S. aureus ) often forms biofilms on implantable devices, which dramatically increases the ability of the species to acquire resistance via horizontal plasmid transfer [ 111 ].…”

“…This is why S. aureus has high rates of resistance. As shown by the typical cases reported in recent years ( Table 4 ), MRSA has become the most common strain causing infections of various implantable medical devices, including cardiac devices [ 93 , 95 , 99 , 103 , 106 ], orthopedic prosthetics [ 96 , 97 ], cochlear implants [ 98 ], breast implants [ 100 ], laryngeal implants [ 101 ], and stent grafts [ 109 ]. In addition, there is an alarming increase in antibiotic resistance in other strains, such as Acinetobacter baumannii [ 92 ], Mycobacterium chelonae [ 94 ], Enterobacter cloacae complex [ 102 ], S. epidermidis [ 104 , 110 ], Klebsiella pneumoniae [ 105 ], Staphylococcus haemolyticus [ 107 ], and Staphylococcal endophthalmitis [ 108 ], are also involved in various resistant DAIs.…”