Predictive Factors of Cranioplasty Infection: Results From a Contemporary Level I Trauma Center Cohort

Cranioplasty restores skull integrity after decompressive craniectomy but carries a risk of surgical site infection that may necessitate implant removal and prolonged antimicrobial therapy. We performed a retrospective study of adult patients who underwent cranioplasty between 2014 and 2022 at a single level 1 trauma center to identify predictors of postoperative infection. Demographic, clinical, and operative variables were abstracted from the electronic medical record. The primary outcome was surgical site infection. Associations were assessed using univariate testing, multivariable logistic regression, and Cox proportional hazards modeling. Among 142 patients (median age 45.5 y; 31.7% female), the most common indication for craniectomy was trauma (63.4%). The median interval between craniectomy and cranioplasty was 124 days. Custom implants were used in all cases, most commonly polyetheretherketone (90.8%). Surgical site infection occurred in 14 patients (9.9%) at a median of 146.5 days after reconstruction. On univariate analysis, polymethylmethacrylate implants, reconstruction within 90 days of craniectomy, and postoperative wound dehiscence were associated with infection. In multivariable logistic regression, wound dehiscence (OR=24.6; 95% CI: 4.4-138.1) and polymethylmethacrylate implants (OR=6.99; 95% CI: 1.14-42.69) remained independently associated with infection. In time-to-event analysis, wound dehiscence was the only independent predictor (HR=6.8; 95% CI: 2.2-21.5). The postoperative wound integrity was the strongest determinant of infection risk after cranioplasty in this cohort.