title: When the bone flap hits the floor.
abstract: OBJECTIVE
  There is no published data in the neurosurgical literature describing the incidence, treatment, or outcome of contaminating a bone flap. We reviewed our departmental experience to determine methods of prevention and assess our treatment strategies.
  
  
  METHODS
  We retrospectively reviewed all incidents of dropped bone flaps during a craniotomy at a single medical center during a 16-year period. In addition, a questionnaire was mailed to neurosurgeons in the United States and abroad asking their own experience and method of management.
  
  
  RESULTS
  Fourteen incidents of dropped bone flaps occurred during a 16-year period. Follow-up varied from 2 to 176 months. The bone flap was dropped while elevating the bone (n = 4), when handing the bone off the field (n = 4), and during plating (n = 4). The context was unknown in two cases. Management included soaking the flap in betadine and/or antibiotic solution (n = 8), autoclaving (n = 2), or discarding the bone flap and replacing with a mesh cranioplasty (n = 3). The treatment remains unknown in one case. No instances of infection were noted in follow-up. In response to the survey, 66% (33 out of 50) of the polled neurosurgeons had experienced this complication during their practice, and 83% would replace the bone flap after disinfection.
  
  
  CONCLUSIONS
  Dropping a bone flap during neurosurgery remains an uncommon but preventable complication. Treatment options include discarding the bone followed by cranioplasty versus replacing the bone after treatment with antibiotic irrigation, betadine, and/or autoclaving. Replacement after disinfection is an appropriate option for contaminated bone flaps that avoids the expense and time of cranioplasty.
authors.affiliation: Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
authors.forename: Brian T
authors.initials: BT
authors.lastname: Jankowitz
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Kondziolka
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D002648:Child; D003399:Craniotomy / Q000009:adverse effects / Q000706:statistics & numerical data; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D019300:Medical Errors; D008875:Middle Aged; D012189:Retrospective Studies; D012886:Skull / Q000187:drug effects / Q000382:microbiology / Q000601:surgery; D013524:Surgical Flaps / Q000382:microbiology; D013530:Surgical Wound Infection / Q000188:drug therapy / Q000453:epidemiology*
chemical_list: D000900:Anti-Bacterial Agents