Evaluation of parental and surgeon stressors and perceptions of distraction osteogenesis in pediatric craniofacial patients: a cross-sectional survey study

Posterior cranial vault distraction in children with syndromic craniosynostosis: the era of biodegradable materials-a comprehensive review of the literature and proposed novel global application

Distraction osteogenesis is utilized to increase intracranial volume in the treatment of restrictive pathologies, most commonly syndromic synostosis. Children too young for open calvarial vault expansion or other systemic or local contraindications to a direct reconstructive approach benefit greatly from distraction osteogenesis, typically addressing posterior vault expansion. Wound infection, cerebrospinal fluid (CSF) leak, device failure, need for a second surgery for removal, and cost, are issues that can limit the use of this approach. These challenges are more pronounced in low- and middle-income countries (LMICs) due to lack of access to the device, the financial burden of the need for a second surgery, and the severity of the implications of infection and CSF leak. Over the last five decades, there has been an increased acceptance of bioresorbable instrumentation in craniofacial surgery. Poly L-lactic acid, polyglycolic acid, and polydioxanone are the most commonly used polymers. New resorbable fixation tools such as ultrasound-activated pins and heat-activated pins are superior to conventional bioresorbable screws in allowing attachment to thinner bone plates. In this paper, we present a review of the literature on cranial vault distraction and the use of bioresorbable materials and propose a novel design of a fully absorbable cranial distractor system using external magnetic distraction control, eliminating the need for external activation ports and a second surgery to remove the hardware. The application of this technology in LMIC settings could advance access to care and treatment options for patients with syndromic synostosis.

"Ten Years of Posterior Cranial Vault Expansion via Distraction Osteogenesis: An Update and Critical Evaluation"

PURPOSE

The goal of this study was to describe the 10-year evolution of our surgical technique and institutional perioperative outcomes using posterior vault distraction osteogenesis (PVDO) in patients with syndromic and multi-suture craniosynostosis.

METHODS

We performed a retrospective cohort study of patients who underwent PVDO for treatment of syndromic and multi-suture craniosynostosis at a single institution over a 10-year period. Demographic data, perioperative outcomes, distraction patterns, and complications were analyzed. Outcomes for patients in the first 5 years ("early cohort") were compared to those of the latter 5 years ("late cohort").

RESULTS

110 patients underwent a total of 118 PVDO procedures. Syndromic patients represented 83.6% of the cohort (n=92) and were significantly younger than non-syndromic patients at the time of first PVDO (median 14.1 [6.6, 40.1] vs 42.7 [15.2, 59.6] months, p=0.014). Mean distraction distance in the anterior-posterior direction was 30.8 mm (SD=7.4). Compared to the early cohort, PVDO in the late cohort had faster median operative times (144.0min [123.0, 189.0] vs 161.0min [138.0, 199.0], p=0.038), lower estimated blood loss as a percent of blood volume (28.5 [20.6, 45.3] vs 50.0 [31.1, 95.8], p<0.001), and lower blood replacement as percent of blood volume (39.5 [23.8, 59.1] vs 56.3 [37.8, 110.1], p=0.009).

CONCLUSIONS

Our 10-year experience with PVDO demonstrates continued overall safety and efficacy with improved perioperative outcomes over time. While it has become our first line of expansion in syndromic craniosynostosis, shortcomings such as need for device removal, infectious concerns, and potential for CSF leak merit attention by the craniofacial community.