Transsutural distraction osteogenesis for 285 children with craniosynostosis: a single-institution experience

Hemi one-piece distraction osteogenesis for unilateral coronal craniosynostosis

INTRODUCTION

It was the aim of the study to assess the efficacy of the hemi one-piece distraction osteogenesis and to compare it to the traditional one-piece distraction osteogenesis technique.

METHODS

Two different surgical techniques were used; the one-piece distraction and the hemi one-piece distraction. The principal distinction between the two techniques is that in the hemi style approach, the intact sutures on the contralateral side were left undisturbed, with no osteotomy performed.

RESULTS

The hemi one-piece group had a significantly lower median value of plastic surgery time, total operation time, and transfusion rate (plastic surgery time 69 min (range 65-120) vs. 20 min (range 17-32.5), p < 0.001; transfusion 80 mL (range 0-150) vs. 0 mL (0-60), p = 0.1. Nasofrontal advancement was successful with no major complications. Median endocranial angulation improved (one-piece: 166.1°-176.0°, hemi: 162.9°-173.0°, p = 0.023 & p = 0.012 respectively).

CONCLUSION

This study reveals less invasive, highly effective techniques for craniosynostosis treatment, notably a unilateral osteotomy with distraction method. Nevertheless, to confirm their long-term efficacy and durability, more studies with longer follow-ups are essential.

One-piece fronto-orbital distraction osteogenesis without bandeau in patients with coronal craniosynostosis: A five-year follow-up retrospective study of 45 consecutive patients

This study aimed to review the surgical outcomes, complications, and long-term relapses in patients with unilateral or bilateral coronal craniosynostosis, who underwent one-piece fronto-orbital distraction osteogenesis (FODO) without bandeau. The cephalic index, frontal angle, and supraorbital symmetry ratio were measured on the initial and follow-up computed tomography images. Esthetic outcomes were evaluated using the Whitaker classification. 45 patients were included in this study. The average follow-up interval was 5.4 ± 1.1 years (range 2.5-8.5 years). In patients with bilateral coronal craniosynostosis, the frontal angle decreased with a relapse ratio of -2.8 ± 4.3% during long-term follow-up compared with that during short-term follow-up (p = 0.028). In patients with unilateral coronal craniosynostosis, the supraorbital symmetry ratio decreased slightly, with a relapse ratio of -3.8 ± 2.6% during long-term follow-up (p = 0.017). Complications included dural tears during osteotomy (n = 2), early distractor removal (n = 2), and wound problems (n = 3). Within the limitations of the study it seems that one-piece fronto-orbital distraction osteogenesis (FODO) generates successful and sustainable results even in the long term. Therefore, this treatment option should be considered for patients with unilateral and bilateral coronal craniosynostoses whenever appropriate.

Management of Lambdoid Craniosynostosis: A Comprehensive and Systematic Review

BACKGROUND

Craniosynostosis is a condition characterized by the premature fusion of 2 or more skull bones. Craniosynostosis of the lambdoid suture is one of the rarest forms, accounting for 1-4% of all craniosynostoses. Documented cases are separated into simple (single suture), complex (bilateral), and associated with adjacent synostoses ("Mercedes Benz" Pattern) or syndromes (i.e., Crouzon, Sathre-Chotzen, Antley-Bixler). This condition can manifest phenotypic deformities and neurological sequelae that can lead to impaired cognitive function if improperly treated or left undiagnosed. Preferred surgical techniques have varied over time but all maintain the common goals of establishing proper head shape and preventing of complications that could contribute to aforementioned sequelae.

SUMMARY

This comprehensive review highlights demographic distributions, embryological development, pathogenesis, clinical presentation, neurological sequelae, radiologic findings, surgical techniques, surgical outcomes, and postoperative considerations of patients with lambdoid craniosynostosis presentation. In addition, a systematic review was conducted to explore the operative management of lambdoid craniosynostosis using PubMed, Embase, and Scopus databases, with 38 articles included after screening. Key Messages: Due to a low volume of published cases, diagnosis and treatment can vary. Large overlap in presentation can occur in patients that display lambdoid craniosynostosis and posterior plagiocephaly, furthering the need for comprehensive analysis. Possessing the knowledge and tools to properly assess patients with lambdoid craniosynostosis will allow for more precise care and improved outcomes.

Syndromic Craniosynostosis: Objective and Parent-Reported Outcome Measurements after Cranio-Facial Remodelling Surgeries

INTRODUCTION

Syndromic craniosynostosis (SC) is a rare entity compared to the non-syndromic variant. Treatment involves a multidisciplinary approach towards a multitude of problems. Early intervention is known to be better for optimum results. We reviewed outcomes of children with SC who underwent reconstructive cranio-facial surgery.

MATERIALS AND METHODS

A retrospective study was conducted using data from hospital case files and the picture archival communication system. Objective data like the cephalic index (CI), both preoperatively and post-operatively, were compared. Subjective data for the cosmesis outcome - "Sloan and Whitaker outcome class" - following surgery were assessed. Also, parent-reported outcome measurement (PROM) was performed with various parameters to assess quality of life (QOL).

RESULTS

We had 21 operated cases of SC, with 19 needing cranio-facial remodelling. The male to female ratio was 11:10. Crouzon's syndrome was the most common syndromic association followed by Apert's syndrome. Nineteen patients underwent cranio-facial remodelling surgeries and 2 underwent the ventriculo-peritoneal shunt only - for raised intracranial pressure (ICP). Nine patients underwent cranial remodelling with fronto-orbital advancements, and 3 of these patients also received le-fort's type 3 osteotomy and advancement later. Ten patients underwent fronto-orbital advancement with parieto-occipital barrel-stave osteotomies.

OUTCOMES

Improvement in the CI was maximum at the 6-month follow-up. Six (37.5%) cases had Sloan class 1 outcome, 9 (56.25%) had class 2 outcomes, and 1 patient had a class 6 outcome. Whitaker cosmesis outcomes - 14 out of 16 cases (87.5%) had Category 1 outcomes. PROM was assessed. All parents reported at least a moderate improvement in cosmesis following surgery. Out of 15 cases, 10 (66%) reported significant improvement, while 4 (26.6%) cases reported moderate improvement with respect to eye and visual problems. Four parents reported snoring as a significant problem even after surgery. Most parents felt that the children were doing well, attending regular school, and social well-being was normal and had an overall good QOL.

CONCLUSIONS

SC cases may have a multitude of other problems like raised ICP, ophthalmological problems, poor intelligence, and cognition apart from cosmetic concerns. PROMs revealed good outcomes in terms of cosmesis, cognition, and ophthalmological and oral cavity-related problems. Significant improvement in overall QOL was seen in most patients following cranio-facial remodelling surgery.

Comparison of safety outcomes between bi-coronal and direct approaches for device removal in patients treated with distraction osteogenesis for craniosynostosis

The study aimed at comparing the safety outcomes between conventional bicoronal and direct method in device removal after cranial distraction in the treatment of craniosynostosis. This was a retrospective cohort study of patients treated with distraction osteogenesis to expand intracranial volume in the anteroposterior direction. Preoperative patient demographics, distraction protocols, and perioperative outcomes (operative time, estimated blood loss, intraoperative fluid volume, lowest hematocrit during surgery, transfusion, hospital stay, drain, postoperative complication) were collected and analyzed with the independent samples t-test. Twenty-four patients were included in the study (15 in the conventional and 9 in the direct approach group). The mean duration of surgery and intraoperative fluid volume were significantly shorter (114.56 ± 36.91 min vs. 177.20 ± 47.00 min, p = 0.003) and less (241.88 ± 194.07 ml vs. 624.00 ± 524.92 ml, p = 0.026), respectively in the direct group than in the conventional. No patients were transfused intraoperatively and admitted to the intensive care unit (ICU) postoperatively in the direct group. The mean intraoperative and total transfusion volumes were significantly greater in the conventional group (p = 0.004, 0.045, respectively). There were no significant differences in other safety outcomes. No postoperative wound complications were reported. The findings of this study indicated that the direct approach for distraction device removal in children with craniosynostosis appears to be safer than the conventional approach owing to the reduced operation time, intraoperative transfusion requirements, and ICU stay.

Distraction osteogenesis in craniosynostosis

PURPOSE OF REVIEW

Craniosynostosis, a condition of premature cranial suture fusion, can have significantly detrimental effects on development and growth due to sequelae of increased intracranial hypertension (ICP), exophthalmos, and upper airway obstruction. Evolving surgical treatments now include distraction osteogenesis (DO) due to its many benefits relative to standard cranial vault remodeling procedures. This article provides an overview and update of different surgical applications of DO for patients with craniosynostosis.

RECENT FINDINGS

DO has been utilized successfully for single and multisuture craniosynostosis with or without midface hypoplasia to increase intracranial volume, decrease ICP and improve aesthetics. It has been applied in single suture synostosis, posterior vault DO, fronto-orbital advancement, monobloc DO and Le Fort III DO. DO has been applied through modification of traditional surgical procedures with success in maintaining goals of surgery while reducing risk.

SUMMARY

DO is still a relatively new and evolving surgical technique for patients with syndromic and nonsyndromic craniosynostosis. With promising benefits, consideration for each procedure should be weighed until longer-term data is available.

Craniofacial Distraction in the Management of Anterior Plagiocephaly: A Novel Idea and a Systematic Review of the Literature

BACKGROUND

The objective of this work is to present a review of all reports involving the management of unicoronal synostosis with distraction osteogenesis (DO). Also, we have innovated a new method in the treatment of cases of anterior plagiocephaly at a young age using DO.

METHODS

We present a case in which anterior plagiocephaly was treated by DO of both metopic and hemicoronal sutures in a 4-month-old female patient. A comprehensive systematic literature review was completed using the search terms "distraction osteogenesis," "unicoronal synostosis," "anterior plagiocephaly," and "craniosynostosis." We excluded all experimental articles and reviewed clinical reports detailing the use of DO in the management of unicoronal synostosis.

RESULTS

The study sample of this review consisted of 16 reports published over a period of 17 years that were analyzed in detail. The total number of patients treated by DO was 120, and the mean age at operation was 12 months. In the case presented, successful correction of the unicoronal synostosis was achieved.

CONCLUSION

Hemicoronal and metopic suture distraction in anterior plagiocephaly achieves considerable improvement in the midline shift of the anterior cranial base and naso-orbital complex.

Distraction Osteogenesis Update: Introduction of Multidirectional Cranial Distraction Osteogenesis

In this review, we discuss in detail our current procedure for treating craniosynostosis using multidirectional cranial distraction osteogenesis (MCDO). The MCDO method allows all phenotypes of skull deformity to be reshaped by distraction osteogenesis, except in patients who are 5 months of age or younger and patients with posterior cranial vault problems. We report the results of clinical data of 36 children with craniosynostosis who underwent MCDO between 2005 and 2014 in our institute. This method has the following benefits, such as a high flexibility of reshaping, shorter treatment period and less invasive secondary intervention. We also discuss the other distraction osteogenesis techniques that are used to treat craniosynostosis and compare them with MCDO. The preferred procedure for correction of craniosynostosis may depend on the patient's age, the extent of deformity, and the extent of correction achievable by surgery. We can arrange the combinations of various methods according to the advantage and disadvantage of each technique.

Physiological Changes and Clinical Implications of Syndromic Craniosynostosis

Syndromic craniosynostosis has severe cranial stenosis and deformity, combined with hypoplastic maxillary bone and other developmental skeletal lesions. Among these various lesions, upper air way obstruction by hypoplastic maxillary bone could be the first life-threatening condition after birth. Aggressive cranial vault expansion for severely deformed cranial vaults due to multiple synostoses is necessary even in infancy, to normalize the intracranial pressure. Fronto-orbital advancement (FOA) is recommended for patients with hypoplastic anterior part of cranium induced by bicoronal and/or metopic synostoses, and posterior cranial vault expansion is recommended for those with flattening of the posterior part of the cranium by lambdoid synostosis. Although sufficient spontaneous reshaping of the cranium can be expected by expansive cranioplasty, keeping the cranial bone flap expanded sufficiently is often difficult when the initial expansion is performed during infancy. So far distraction osteogenesis (DO) is the only method to make it possible and to provide low rates of re-expansion of the cranial vault. DO is quite beneficial for both FOA and posterior cranial vault expansion, compared with the conventional methods. Associated hydrocephalus and chronic tonsillar herniation due to lambdoid synostosis can be surgically treatable. Abnormal venous drainages from the intracranial space and air way obstruction should be always considered at any surgical procedures. Neurosurgeons have to know well about the managements not only of the deformed cranial vault and the associated brain lesions but also of other multiple skeletal lesions associated with syndromic craniosynostosis, to improve treatment outcome.