Simultaneous multiple vector distraction for craniosynostosis syndromes

Craniosynostosis: Posterior Cranial Vault Remodeling

Posterior cranial vault distraction osteogenesis is a powerful, reliable, low-morbidity method to achieve intracranial expansion. It is particularly useful in treating turribrachycephaly seen in syndromic craniosynostosis, allowing for gradual expansion of the bone while stretching the soft tissues over several weeks allowing greater volumetric expansion than conventional techniques. Posterior cranial vault distraction osteogenesis constitutes a more gradual remodeling modality, with infrequent complications. As a first step in intracranial expansion, it preserves the frontal cranium for future frontofacial procedures. A drawback is the need for a second surgery to remove the device, and this must be taken into account during counseling.

Cranial vault expansion by distraction osteogenesis

OBJECT

The object of this report is to present a conceptual and technical approach for expanding the cranial vault, by distraction osteogenesis, in patients with craniocephalic disproportion secondary to pancraniosynostosis and in patients with complex syndromic craniofaciosynostoses undergoing operations for aesthetic improvement.

METHODS

The clinical characteristics, techniques used, outcome and complications for all patients who underwent cranial vault expansions with distraction osteogenesis in Children's Hospital of Denver were reviewed.

RESULTS

Twenty-six cranial vault expansions were done in 24 patients. Nineteen patients presented with intracranial hypertension. Twelve of these had pancraniosynostosis and 8 had a syndromic diagnosis. Large segments of cranial bone were translated in a controlled manner for distances up to 30 mm. All but one of the patients with intracranial hypertension experienced complete resolution.

CONCLUSIONS

Cranial vault expansion by distraction osteogenesis has the great advantage, as the name implies, of generating new and vascularized autologous bone of the correct shape and in correct locations. The technique, although not simple and not risk free, is much less technically complicated and places patients at lower risk for the most serious complications than does single-stage vault expansion. Less soft tissue dissection and less devascularization of bone are required and there are no postoperative dead spaces. Distraction osteogenesis facilitates far greater vault expansions than do single-stage procedures and can be accomplished in any desired direction.

Necrotizing soft tissue infection of the scalp after fronto-facial advancement by internal distraction in a 7-year old girl with Gorlin-Chaudhry-Moss syndrome--a case report

In 1960, Gorlin, Chaudhry and Moss described a syndrome consisting of craniofacial dysostosis in association with hypertrichosis, cardiac, genital, dental and ocular anomalies. Diagnosis is based on typical clinical findings and cannot be performed by molecular genetic analysis until now. There is little in the clinical literature concerning this rare craniofacial syndrome. For functional and psychosocial reasons, surgical correction of the complex craniofacial malformation in a 7-year old Hungarian girl with Gorlin-Chaudhry-Moss syndrome was performed by fronto-facial advancement using internal distraction devices. Postoperatively necrotizing soft tissue infection of the scalp developed leading to termination of the distraction process ahead of schedule and requiring aggressive surgical management. Typical physiological and clinical characteristics were observed both during the initial craniofacial correction as well as during the management of the infectious complication suggesting that the linking of different conditions (surgical trauma plus the selection of toxic microorganisms) has caused tissue destruction rather than the syndromal disorder or the surgical technique of distraction osteogenesis. Although skeletal improvement was achieved residual damage from the infectious complication must be considered as severe.

Antley-Bixler-syndrome--staged management of craniofacial malformations from birth to adolescence--a case report

In 1975 Antley and Bixler described an unusual syndromal disorder consisting of complex craniosynostosis with midfacial hypoplasia, dysplasia of ears and nose, radiohumeral synostosis, congenital fractures of the femur and upper airway impairment in a newborn. Additional urogenital and cardiac malformations can be associated however diagnosis is based on a characteristic craniofacial deformity in association with humeroradial synostosis. Complex disturbance of craniofacial growth due to premature synostoses of the cranial base and vault results in a characteristic phenotype. Steroidogenesis due to intrinsic or extrinsic disturbance by maternal fluconazole ingestion during early pregnancy may be impaired. The mode of inheritance is supposed to be autosomal recessive. Mutations in the fibroblast growth factor receptor 2 (FGFR2) as well as mutations in the cytochrome P450 oxidoreductase (OR) gene have been verified. Like in other craniofacial dysostosis syndromes malformation of neuro- and viscerocranium is complex and requires a staged age- and growth-related interdisciplinary management with respect to the individual situation. This case report of a female patient born in 1994 suffering from that rare syndrome describes the interdisciplinary long-term management in one craniofacial centre over 16 years from birth to adolescence.

Posterior calvarial vault expansion using distraction osteogenesis

OBJECTIVES

Management of raised intracranial pressure in syndromic multi-suture craniosynostosis by cranial vault expansion can be achieved by a number of techniques. We present our initial experience in treating this group of patients with posterior calvarial distraction.

MATERIALS AND METHODS

Six patients underwent distraction osteogenesis of their posterior calvarial vault.

RESULTS

The mean period of distraction was 28 days. The mean consolidation period was 49 days. The mean distance of advancement was 24 mm. Five out of six patients completed their period of distraction and three of these cases also completed their period of consolidation. Significant calvarial expansion and improvement of head shape was achieved in all cases.

CONCLUSIONS

Posterior calvarial distraction is a safe and more efficient method of calvarial expansion than conventional techniques. These are early promising results, and future modification of the distraction devices will be needed if the effective consolidation time is to be increased.

Monoblock craniofacial internal distraction in a child with Pfeiffer syndrome: a case report

A 7-yr-old boy visited our surgical center with Pfeiffer syndrome type 1, presenting with macrocrania, broad big toe and thumb, exophthalmos, tongue protrusion, malocclusion with midfacial retrusion, mild respiratory difficulty due to minor upper airway obstruction, and developmental delay. He also exhibited anthrophobia with a passive character. The patient was treated with internal monoblock distraction osteogenesis to increase the intracranial and intraorbital volumes, and the nasal and pharyngeal airway spaces using two modular mid-facial internal distractors. For distraction, the latency period was 1 week, the daily activation of 1.0 mm was 20 days (total advancement 20 mm at the midline), and the consolidation period was 3 months. The follow-up computed tomography 12 months after surgery showed expansion of the brain and proper ossification in the distracted area. The patient also showed aesthetically good cranial contours, improved tongue and eyeball protrusion, no respiratory difficulty, and improved learning. We suggest that the internal distraction may last longer than an external type, resulting in a better bone fusion rate and successful expansion of craniofacial bones.

Do Craniosynostosis Syndrome Phenotypes with Both FGFR2 and TWIST Mutations have a Worse Clinical Outcome?

We present three cases with both FGFR2 mutations and novel TWIST sequence variants. The clinical outcome in this cohort is compared with that in individuals with a single mutation.