Reuse or replacement of incidentally dropped craniotomy bone flap: An institutional perspective and literature review

Incidental dropout of the craniotomy bone flap (ID-CBF) following craniotomy is a rare and unexpected occurrence in neurosurgery. Consequently, there is scant evidence to direct the surgeon on the most effective management of these events. Any strategy must strike a balance between under-treatment, which carries the risk of infection, and overly aggressive sterilization, which may increase the incidence of bone resorption. The objective of this study is to conduct a comprehensive review of our experience and evaluate it within the context of the extant literature.

A single-center, retrospective study was conducted to review the electronic records pertaining to operative reports of craniotomies. The objective of this study was to identify instances where bone flaps were inadvertently dropped during surgical procedures. In addition, we conducted a comprehensive review of the extant literature pertaining to the management of ID-CBF.

During the study period, our Institutional Review Committee identified three instances of ID-CBF. One case occurred when the bone flap was inadvertently dropped during elevation, and two cases occurred when it was transferred to the scrubbed nurse. In this specific instance, the bone flap was inadvertently dropped to the ground and was subsequently promptly collected for the purpose of sterilization. The bone flaps underwent a meticulous chemical decontamination protocol. This protocol involved successive copious washing with normal saline, followed by immersion in 50% diluted hydrogen peroxide for a 15 min interval. Subsequently, the flaps were immersed in 10% betadine solution for another 15 min. Finally, they were soaked in normal saline containing gentamicin. Following the surgical procedure, the bone flaps were secured using miniplates and screws at the surgical incision. Subsequently, patients underwent a minimum of 2 years of follow-up care. No clinical, laboratory, or imaging evidence of surgical site infection was observed.

Our series and literature review demonstrate that, in the majority of cases, the bone flap can be reused after undergoing chemical sterilization. Patients require meticulous monitoring to identify early or late surgical site infections. Nevertheless, prevention remains the most effective strategy.