Reinsertion Versus Replacement for Contaminated or Postoperatively Infected Bone Flaps: Findings From the Largest Individual-Patient Analysis to Date
Published research co-authored by Mr Gordan Grahovac
This page summarises a peer-reviewed publication co-authored by Mr Gordan Grahovac. The paper reviews the management of bone flaps that are either contaminated during cranial surgery or become infected after surgery.
The aim of this summary is to make the research easier to understand for patients, families and referring clinicians, while linking directly to the original published work.
Research snapshot
Article title: Reinsertion Versus Replacement for Contaminated or Postoperatively Infected Bone Flaps: Findings From the Largest Individual-Patient Analysis to Date
Authors: Asfand Baig Mirza, Pak Yin Lam, Sara Ahmad, Tony Harshan Linton-Jude, Soniya Chauhan, Wajiha Rauf, Feras Fayez, Ariadni Georgiannakis, Amisha Vastani, Gordan Grahovac, Varinder Singh Alg, Taofiq Desmond Sanusi, Babak Arvin, Ahmed-Ramadan Sadek, Jose Pedro Lavrador
Publication year: 2026
PMID: 42080538
DOI: 10.1227/neu.0000000000004060
Study type: Systematic review and individual-patient data analysis
Mr Grahovac’s involvement: Listed author on the publication
Original publication: View the original publication on PubMed
What this paper looked at
Bone flap infection and contamination are recognised complications of cranial surgery. However, the most appropriate way to manage a contaminated or infected bone flap can vary depending on the clinical situation.
This publication reviewed outcomes from studies comparing two broad approaches:
Preserving the bone flap through decontamination and reinsertion
Discarding the bone flap and replacing it with another material
The review included patients whose bone flaps were contaminated during surgery, as well as patients who developed postoperative bone flap infections.
Key points from the publication
The review included 70 studies and 621 patients.
Three studies reported intraoperative contamination from dropped bone flaps, while 67 studies reported postoperative bone flap infections.
The paper reported that both decontamination with reinsertion and replacement could provide satisfactory cosmetic and neurological outcomes in many patients.
However, in patients with postoperatively infected bone flaps, preserving and reinserting the bone flap was associated with a higher risk of reoperation compared with replacement.
The authors also reported that certain patient factors, including radiotherapy, immunosuppression, diabetes and high body mass index, may influence reoperation risk.
Clinical relevance
This research is relevant to the management of complications after cranial surgery.
When a bone flap is contaminated or infected, the surgical team may need to decide whether it can be safely preserved or whether replacement is the more appropriate option.
The findings suggest that reinsertion may be safe in selected situations, particularly where contamination occurs during surgery. However, when a bone flap becomes infected after surgery, a more cautious, risk-stratified approach may be needed.
What this means in context
This publication does not suggest that one approach is right for every patient.
Decisions around bone flap preservation or replacement depend on several factors, including:
Whether the issue is contamination or established infection
The presence and severity of infection
The organism involved
Whether there is purulence
The patient’s general health
Relevant comorbidities
Previous treatment, such as radiotherapy
The patient’s individual surgical risk
Research of this kind helps inform surgical decision-making, guideline development and discussions around patient safety in cranial surgery.
View published abstract
The following abstract is reproduced from the original publication and is provided for reference. It may include technical terminology intended for clinical or academic audiences.
Background and objectives: Bone flap infection and contamination are feared complications of cranial surgery, yet optimal management remains controversial. The aim of this review was to determine comparative outcomes of preservation with decontamination and reinsertion vs discard and replacement after intraoperatively contaminated or postoperatively infected bone flaps.
Methods: We systematically reviewed 70 studies (621 patients) reporting either intraoperatively contaminated or postoperatively infected flaps (PROSPERO: CRD420251041697). Patient demographics, decontamination protocols, replacement materials, and outcomes were extracted and synthesized.
Results: Three studies (49 patients) reported intraoperative contamination from dropped flaps, whereas 67 studies (572 patients) reported postoperative flap infections. Decontamination methods involved washing, scrubbing, and soaking with saline, povidone-iodine, peroxide or an antibiotic/antiseptic agent, and/or autoclaving, while replacement materials included titanium, polymethyl methacrylate, polyether ether ketone, or hydroxyapatite. Most patients achieved satisfactory cosmetic and neurological outcomes, with comparably low complication rates. None of the intraoperatively contaminated flaps developed postoperative infections after either approach. Preserved flaps carried significantly higher reoperation risk (absolute risk ratio 6.68%, odds ratio 2.948, 95% CI 1.450-5.993, P = .006). This means for every 15 patients treated with decontamination rather than replacement, one extra reoperation occurs. All reoperations occurred in patients with postoperatively infected flaps, most commonly because of severe recurrent infection. Comorbidities, for example, radiotherapy, immunosuppression, diabetes, and high body mass index, also emerged as a significant predictor of reoperation risk in logistic regression analysis (adjusted odds ratio 44.2, 95% CI 1.17-436, P = .0012).
Conclusion: This is the largest pooled individual-patient data synthesis to date on management of contaminated or infected bone flaps. Both decontamination and replacement provide good outcomes and are safe and effective for intraoperatively contaminated flaps. However, decontamination with reinsertion carries higher reoperation risk compared with flap replacement among patients with postoperatively infected flaps. Flap preservation should therefore be undertaken selectively considering organism virulence, presence of purulence, and comorbidities. These results inform development of standardized risk-stratified guidelines and cost-effectiveness evaluation for bone flap management in cranial surgery.
Keywords: Bone flap; Cranioplasty; Decontamination; Individual patient data; Reinsertion; Reoperation; Systematic review.
View the original publication on PubMed
About Mr Gordan Grahovac
Mr Gordan Grahovac is a Consultant Neurosurgeon and Complex Spinal Surgeon in London and Kent with expertise in managing complex spinal and neurosurgical conditions.
His work includes the assessment and treatment of patients with degenerative spinal conditions, spinal cord compression, spinal tumours, complex spinal pathology and conditions requiring specialist neurosurgical input.
His approach focuses on careful diagnosis, appropriate treatment planning and helping patients understand their options clearly.
Important note
This page is for educational purposes only and should not be taken as individual medical advice.
If you are experiencing symptoms after cranial or spinal surgery, or if you have concerns about infection, wound healing, neurological symptoms, weakness, numbness, worsening pain or changes in your recovery, you should seek advice from an appropriately qualified medical specialist.
