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Belza CC, Sheahan L, Blum J, Becker M, Oca M, Lopes K, Gosman AA. Geospatial and Socioeconomic Disparities Influencing the Management of Craniosynostosis. Ann Plast Surg 2024; 92:S345-S351. [PMID: 38689417 DOI: 10.1097/sap.0000000000003800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Various social determinants of health have been described as predictors of clinical outcomes for the craniosynostosis population. However, literature lacks a granular depiction of socioeconomic factors that impact these outcomes, and little is known about the relationship between patients' proximity to the care center and management of the condition. METHODS/DESIGN This study retrospectively evaluated patients with craniosynostosis who presented to a tertiary children's hospital between 2000 and 2019. Outcomes of interest included age at presentation for surgery, incidence of reoperation, and length of follow-up. Patient addresses were geocoded and plotted on two separate shapefiles containing block group information within San Diego County. The shapefiles included percent parental educational attainment (bachelor's degree or higher) and median household income from 2010. The year 2010 was chosen for the shapefiles because it is the median year of data collection for this study. Multivariate linear, logistic, and polynomial regression models were used to analyze the relationship between geospatial and socioeconomic predictors and clinical outcomes. RESULTS There were 574 patients with craniosynostosis included in this study. The mean ± SD Haversine distance from the patient's home coordinates to the hospital coordinates was 107.2 ± 321.2 miles. After adjusting for the suture fused and insurance coverage, there was a significant positive correlation between distance to the hospital and age at index surgery (P = 0.018). There was no correlation between distance and incidence of reoperation (P = 0.266) or distance and duration of follow-up (P = 0.369). Using the same statistical adjustments, lower parental percent educational attainment and lower median household income correlated with older age at index surgery (P = 0.008 and P = 0.0066, respectively) but were not correlated with reoperation (P = 0.986 and P = 0.813, respectively) or duration of follow-up (P = 0.107 and P = 0.984, respectively). CONCLUSIONS The results offer evidence that living a greater distance from the hospital and socioeconomic disparities including parental education and median household income may serve as barriers to prompt recognition of diagnosis and timely care in this population. However, the geospatial and socioeconomic factors studied do not seem to hinder incidence of reoperation or length of follow-up, suggesting that, once care has been initiated, longitudinal outcomes may be less impacted.
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Affiliation(s)
- Caitlyn C Belza
- From the Division of Plastic Surgery, Department of Surgery, University of California San Diego, School of Medicine, La Jolla, CA
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Ng JJ, Blum JD, Cheung L, Cho DY, Romeo DJ, Kalmar CL, Villavisanis DF, Bartlett SP, Taylor JA, Swanson JW. Autologous Cranioplasty Using a Dental SafeScraper Device. Plast Reconstr Surg 2024; 153:612e-616e. [PMID: 37053449 DOI: 10.1097/prs.0000000000010550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
SUMMARY Conventional methods to reconstruct cortical bone defects introduced by pediatric cranial vault remodeling (CVR) procedures have shortcomings. Use of bone burr shavings as graft material leads to variable ossification, and harvesting split-thickness cortical grafts is time-intensive and often not possible in thin infant calvaria. Since 2013, the authors' team has used the SafeScraper, originally developed as a dental instrument, to harvest cortical and cancellous bone grafts during CVR. The authors assessed the effectiveness of this technique by analyzing postoperative ossification using computed tomography scans of 52 patients, comparing cohorts treated with the SafeScraper versus those who received conventional methods of cranioplasty during fronto-orbital advancement. The SafeScraper cohort had a greater reduction in total surface area of all defects (-83.1% ± 14.9 versus -68.9% ± 29.8; P = 0.034), demonstrating a greater and more consistent degree of cranial defect ossification compared with conventional methods of cranioplasty, suggesting potential adaptability of this tool. This is the first study that describes the technique and efficacy of the SafeScraper in reducing cranial defects in CVR. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Jinggang J Ng
- From the Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia
- Perelman School of Medicine at the University of Pennsylvania
| | - Jessica D Blum
- From the Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia
| | - Liana Cheung
- From the Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia
| | - Daniel Y Cho
- From the Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia
| | - Dominic J Romeo
- From the Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia
- Perelman School of Medicine at the University of Pennsylvania
| | - Christopher L Kalmar
- From the Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia
| | - Dillan F Villavisanis
- From the Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia
| | - Scott P Bartlett
- From the Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia
| | - Jesse A Taylor
- From the Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia
| | - Jordan W Swanson
- From the Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia
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Li B, Li J, Li B, Ouchi T, Li L, Li Y, Zhao Z. A single-cell transcriptomic atlas characterizes age-related changes of murine cranial stem cell niches. Aging Cell 2023; 22:e13980. [PMID: 37681346 PMCID: PMC10652347 DOI: 10.1111/acel.13980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 09/09/2023] Open
Abstract
The craniofacial bones provide structural support for the skull and accommodate the vulnerable brain tissue with a protective cavity. The bone tissue undergoes constant turnover, which relies on skeletal stem cells (SSCs) and/or mesenchymal stem cells (MSCs) and their niches. SSCs/MSCs and their perivascular niche within the bone marrow are well characterized in long bones. As for cranial bones, besides bone marrow, the suture mesenchyme has been identified as a unique niche for SSCs/MSCs of craniofacial bones. However, a comprehensive study of the two different cranial stem cell niches at single-cell resolution is still lacking. In addition, during the progression of aging, age-associated changes in cranial stem cell niches and resident cells remain uncovered. In this study, we investigated age-related changes in cranial stem cell niches via single-cell RNA sequencing (scRNA-seq). The transcriptomic profiles and cellular compositions have been delineated, indicating alterations of the cranial bone marrow microenvironment influenced by inflammaging. Moreover, we identified a senescent mesenchymal cell subcluster and several age-related immune cell subclusters by reclustering and pseudotime trajectory analysis, which might be closely linked to inflammaging. Finally, differentially expressed genes (DEGs) and cell-cell communications were analyzed during aging, revealing potential regulatory factors. Overall, this work highlights the age-related changes in cranial stem cell niches, which deepens the current understanding of cranial bone and suture biology and may provide therapeutic targets for antiaging and regenerative medicine.
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Affiliation(s)
- Bo Li
- State Key Laboratory of Oral Diseases, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Department of Orthodontics, West China Hospital of StomatologySichuan UniversitySichuanChengduChina
| | - Jingya Li
- State Key Laboratory of Oral Diseases, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of StomatologySichuan UniversitySichuanChengduChina
| | - Bingzhi Li
- State Key Laboratory of Oral Diseases, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of StomatologySichuan UniversitySichuanChengduChina
| | | | - Longjiang Li
- State Key Laboratory of Oral Diseases, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of StomatologySichuan UniversitySichuanChengduChina
| | - Yu Li
- State Key Laboratory of Oral Diseases, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Department of Orthodontics, West China Hospital of StomatologySichuan UniversitySichuanChengduChina
| | - Zhihe Zhao
- State Key Laboratory of Oral Diseases, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Department of Orthodontics, West China Hospital of StomatologySichuan UniversitySichuanChengduChina
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Lake IV, Lopez CD, Karius AK, Niknahad A, Khoo KH, Girard AO, Yusuf CT, Hopkins E, Lopez J, Redett RJ, Yang R. Treatment Delays in Nonsyndromic Craniosynostosis: A 30-Year Retrospective Case-Control Analysis of the Impact of Socioeconomic and Family Status on Access to Care. Ann Plast Surg 2023; 90:S499-S508. [PMID: 37399479 DOI: 10.1097/sap.0000000000003519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND Patients with nonsyndromic craniosynostosis (NSC) generally undergo corrective surgery before 1 year of age to the mitigate morbidities and risks of delayed repair. The cohort of patients who receive primary corrective surgery after 1 year and factors associated with their gaps to care is poorly characterized in literature. METHODS A nested case-control study was conducted for NSC patients who underwent primary corrective surgery at our institution and affiliates between 1992 and 2022. Patients whose surgery occurred after 1 year of age were identified and matched 1:1 by surgical date to standard-care control subjects. Chart review was conducted to gather patient data regarding care timeline and sociodemographic characteristics. RESULTS Odds of surgery after 1 year of age were increased in Black patients (odds ratio, 3.94; P < 0.001) and those insured by Medicaid (2.57, P = 0.018), with single caregivers (4.96, P = 0.002), and from lower-income areas (+1% per $1000 income decrease, P = 0.001). Delays associated with socioeconomic status primarily impacted timely access to a craniofacial provider, whereas caregiver status was associated with subspecialty level delays. These disparities were exacerbated in patients with sagittal and metopic synostosis, respectively. Patients with multisuture synostosis were susceptible to significant delays related to familial strain (foster status, insurer, and English proficiency). CONCLUSIONS Patients from socioeconomically strained households face systemic barriers to accessing optimal NSC care; disparities may be exacerbated by the diagnostic/treatment complexities of specific types of craniosynostosis. Interventions at primary care and craniofacial specialist levels can decrease health care gaps and optimize outcomes for vulnerable patients.
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Affiliation(s)
- Isabel V Lake
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher D Lopez
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexander K Karius
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ava Niknahad
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kimberly H Khoo
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alisa O Girard
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cynthia T Yusuf
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elizabeth Hopkins
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Richard J Redett
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robin Yang
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Evaluation of Complications and Outcomes in Craniosynostosis by Age of Operation: Analysis of the National Surgical Quality Improvement Program-Pediatric. J Craniofac Surg 2023; 34:29-33. [PMID: 35949013 DOI: 10.1097/scs.0000000000008872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/20/2022] [Indexed: 01/11/2023] Open
Abstract
Considerable controversy exists around the optimal age on which to operate for craniosynostosis. This study aims to use data from the American College of Surgeons National Surgical Quality Improvement Program-Pediatric to assess the impact of operative age on hospital stay and outcomes. After excluding patients who underwent endoscopic cranial vault remodeling, a total of 3292 patients met inclusion criteria in the National Surgical Quality Improvement Program-Pediatric between 2012 and 2019. Median age at surgery was 300 days (interquartile range: 204-494). Patients between 0 and 6 months underwent the highest proportion of complex cranial vault remodeling, Current Procedural Terminology 61,558 ( n =44, 7.7%) and Current Procedural Terminology 61,559 ( n =317, 55.1%). White blood cell counts peaked in the 12 to 18 months group, and were lowest in the 24± months group. Hematocrit was lowest in the 0 to 6 months group and rose steadily to the 24± months group; the inverse pattern was found in platelet concentration, which was highest in the youngest patients and lowest in the oldest. Prothrombin time, international normalized ratio, and partial thromboplastin time were relatively consistent across all age groups. Younger patients had significantly shorter operating room times, which increased with patient age ( P <0.001). Younger patients also had significantly shorter length of stay ( P =0.009), though length of stay peaked between 12 and 18 months. There was a significantly lower rate of surgical site infection in younger patients, which occurred in 0.7% of patients 0 to 12 months and 1.0 to 3.0% in patients over 12 to 24± months. There was no significant difference in the average number of transfusions required in any age group ( P =0.961).
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Three-Dimensional Printed Polycaprolactone Mesh in Pediatric Cranial Vault Remodeling Surgery. J Craniofac Surg 2022:00001665-990000000-00486. [PMID: 36730495 DOI: 10.1097/scs.0000000000009133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/15/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The surgical management of craniosynostosis has greatly evolved with improvements in both technology and understanding of the disease process. Some drawbacks remain regarding bone regeneration within the surgical bony gaps. Generally, bony gaps improve in the 12 to 24 months after surgery, but some gaps may remain for longer and cause deformity and/or require additional bony reconstruction. These considerations make tissue-engineered bone very attractive. Novel 3-dimensional printed bioresorbable mesh implants made of Polycaprolactone (PCL) can be used to fill the surgical bony defects. OBJECTIVES The authors seek to investigate how the use of a 3-dimensional printed biodegradable PCL mesh applied to bony defects in cranial vault surgery affects bone healing. METHODS Case series analysis of 8 pediatric patients who have undergone surgical intervention using PCL mesh implants for reconstruction of bony defects during craniosynostosis correction surgery. FINDINGS Radiological evaluation of 3 patients at random time points between 9 and 12 months postoperative revealed persistent bony gaps in areas where PCL mesh was laid. One patient who underwent a subsequent cranial vault surgery at 9 months was found to have less bone regeneration in the defect area where PCL mesh was used when compared with an adjacent area where a particulate bone graft was used. CONCLUSIONS Based on our experience, the use of PCL mesh on its own did not augment bone regeneration. It is possible that a greater amount of time or increased vascularization of the scaffold is required, which supports the concept of regenerative matching axial vascularization or the further addition of osteogenic factors to increase the rate of bone formation.
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Shakir S, Roy M, Lee A, Birgfeld CB. Management of Sagittal and Lambdoid Craniosynostosis: Minimally Invasive Approaches. Oral Maxillofac Surg Clin North Am 2022; 34:421-433. [PMID: 35871864 DOI: 10.1016/j.coms.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The resurgence of strip craniectomies began in the mid-1990s with advances in surgical technique and anesthesia coupled with the critical observation that earlier interventions benefitted from an easily molded skull. Jimenez and Barone's pioneering introduction of endoscopic approaches to strip craniectomies coupled with postoperative helmeting in newborns and young infants and Claes Lauritzen's introduction of spring-mediated cranioplasty began the era of minimally invasive approaches in the surgical correction of craniosynostosis. This article provides technical descriptions of these treatment modalities, a comparative literature review, and our institutional algorithms for the correction of sagittal craniosynostosis and unilambdoid craniosynostosis.
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Affiliation(s)
- Sameer Shakir
- University of Washington, Seattle Children's Hospital, 4800 Sand Point Way, Seattle, WA 98105, USA
| | - Melissa Roy
- University of Washington, Seattle Children's Hospital, 4800 Sand Point Way, Seattle, WA 98105, USA
| | - Amy Lee
- University of Washington, Seattle Children's Hospital, 4800 Sand Point Way, Seattle, WA 98105, USA
| | - Craig B Birgfeld
- University of Washington, Seattle Children's Hospital, 4800 Sand Point Way, Seattle, WA 98105, USA.
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Modified endoscopic strip craniectomy technique for sagittal craniosynostosis: provides comparable results and avoids bony defects. Childs Nerv Syst 2022; 38:1173-1180. [PMID: 35022854 DOI: 10.1007/s00381-021-05429-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 11/30/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE This study describes a modified technique addressing bony defects and incomplete ossification after endoscopic strip craniectomy (ESC) for SC followed by postoperative helmet therapy (PHT). The study aims to delineate quantitative and qualitative outcomes of this modified ESC technique followed by PHT and discern the optimal duration of PHT following ESC. A secondary aim is to address the effects of the technique on bony defects. METHODS Patients undergoing ESC followed by PHT between 2017 and 2021 were included. Patient sex, age at surgery, duration of surgery, red blood cell transfusion, length of hospital stay, PHT duration, cephalic index (CI) at multiple time points, and bony defect information were collected. Descriptive and correlative analysis was done. RESULTS Thirty-one patients (25 male, 6 female) were operated in study period. Mean age at surgery was 12.81 weeks, mean duration of surgery was 57.50 min, average transfused RBC volume was 32 cc, mean length of hospital stay was 1.84 days, mean PHT duration was 33.16 weeks, and mean follow-up time was 63.42 weeks. Mean preoperative CI was 70.6, and mean CI at the end of PHT was significantly higher, being 77.1. Maximum improvement in CI (CImax) took place at week 22.97. PHT duration did not have a correlation with CI at last follow up. There were no bony defects. CONCLUSION Modified ESC technique is effective in successful correction of sagittal craniosynostosis. CImax already takes place, while PHT is continuing, but there is no certain time point for dishelmeting. The technique avoided bony defects and incomplete ossification.
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Wong A, Lance SH, Gosman AA. Treatment of Unicoronal Craniosynostosis by Rotational Flap Technique Preserves Blood Supply to the Frontal Bone Flap. Ann Plast Surg 2022; 88:S348-S350. [PMID: 35180749 DOI: 10.1097/sap.0000000000003080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgical correction of unicoronal craniosynostosis (UCS) remains a challenging problem. Long-term results are often unsatisfactory secondary to recurrence of the original deformity, requiring secondary operations such as fat grafting or complete revision of the calvarial remodeling. Distraction osteogenesis (DO) has recently emerged as a new modality for treatment of UCS, with promising results and decreased rates of reoperation compared with open cranial vault remodeling. A theoretical benefit of DO is preservation of blood supply to the frontal bone following osteotomy, as the frontal bone can be retained in situ compared with the complete removal and reshaping of the frontal bone during traditional fronto-orbital advancement. Preservation of blood supply to the frontal bone may allow for more robust bony healing and preservation of long-term growth potential; however, the vascularity of the frontal bone flap in DO has not previously been demonstrated. Here, we demonstrate unequivocally that blood supply to the frontal bone is preserved after creation of a rotational bone flap in DO management of UCS. METHODS Frontal bone flap creation via osteotomy for DO treatment of UCS was performed via previously reported technique. Indocyanine green was injected intravenously, and bone perfusion was assessed with a fluorescence imaging system. RESULTS Four patients underwent three cranial remodeling and three distractor removal procedures. After frontal bone flap creation via osteotomy for DO, perfusion to the osteotomized portion of the frontal bone flap is preserved. Blood flow is seen crossing the midline of the frontal bone. After removal of the distractor, perfusion in the osteoid consolidate is also observed. CONCLUSIONS Preservation of blood supply has not been previously demonstrated empirically in the setting of DO treatment of UCS. We show for the first time that during frontal bone flap creation, blood flow to the osteotomized portion of the frontal bone flap is maintained. Robust blood flow to the osteoid consolidate is also demonstrated. These data support the use of DO in treatment of UCS, as preserved blood supply to the bone is more likely to support improved healing and long-term results.
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Affiliation(s)
- Alvin Wong
- From the Division of Plastic Surgery, Department of Surgery, University of California San Diego; and Rady Children's Hospital, San Diego, CA
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10
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Posterior Vault Distraction Osteogenesis. J Craniofac Surg 2022; 33:1525-1528. [DOI: 10.1097/scs.0000000000008489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/11/2022] [Indexed: 11/25/2022] Open
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Yengo-Kahn AM, Akinnusotu O, Wiseman AL, Owais Abdul Ghani M, Shannon CN, Golinko MS, Bonfield CM. Sport participation and related head injuries following craniosynostosis correction: a survey study. Neurosurg Focus 2021; 50:E15. [PMID: 33794495 DOI: 10.3171/2021.1.focus20970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/14/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Craniosynostosis (CS) affects about 1 in 2500 infants and is predominantly treated by surgical intervention in infancy. Later in childhood, many of these children wish to participate in sports. However, the safety of participation is largely anecdotal and based on surgeon experience. The objective of this survey study was to describe sport participation and sport-related head injury in CS patients. METHODS A 16-question survey related to child/parent demographics, CS surgery history, sport history, and sport-induced head injury history was made available to patients/parents in the United States through a series of synostosis organization listservs, as well as synostosis-focused Facebook groups, between October 2019 and June 2020. Sports were categorized based on the American Academy of Pediatrics groupings. Pearson's chi-square test, Fisher's exact test, and the independent-samples t-test were used in the analysis. RESULTS Overall, 187 CS patients were described as 63% male, 89% White, and 88% non-Hispanic, and 89% underwent surgery at 1 year or younger. The majority (74%) had participated in sports starting at an average age of 5 years (SD 2.2). Of those participating in sports, contact/collision sport participation was most common (77%), and 71% participated in multiple sports. Those that played sports were less frequently Hispanic (2.2% vs 22.9%, p < 0.001) and more frequently had undergone a second surgery (44% vs 25%, p = 0.021). Only 9 of 139 (6.5%) sport-participating CS patients suffered head injuries; 6 (67%) were concussions and the remaining 3 were nondescript but did not mention any surgical needs. CONCLUSIONS In this nationwide survey of postsurgical CS patients and parents, sport participation was exceedingly common, with contact sports being the most common sport category. Few head injuries (mostly concussions) were reported as related to sport participation. Although this is a selective sample of CS patients, the initial data suggest that sport participation, even in contact sports, and typically beginning a few years after CS correction, is safe and commonplace.
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Affiliation(s)
- Aaron M Yengo-Kahn
- Departments of1Neurological Surgery and.,2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University; and
| | - Oluwatoyin Akinnusotu
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University; and.,3Meharry Medical College School of Medicine, Nashville, Tennessee
| | - Alyssa L Wiseman
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University; and
| | - Muhammad Owais Abdul Ghani
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University; and.,4Plastic Surgery, Vanderbilt University Medical Center
| | - Chevis N Shannon
- Departments of1Neurological Surgery and.,2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University; and
| | | | - Christopher M Bonfield
- Departments of1Neurological Surgery and.,2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University; and
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Mohanty A, Frank TS, Mohamed S, Godwin K, Malkani GG. Ultra-early synostectomy and cranial remodeling orthoses in the management of craniosynostoses. Neurosurg Focus 2021; 50:E8. [PMID: 33794492 DOI: 10.3171/2021.1.focus201014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 01/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The advent of endoscopic synostectomy has enabled early surgery for infants with craniosynostosis. Even though diagnosis is often made at birth, endoscopic synostectomy has traditionally been delayed until the infant is 3 months of age. There have been very few published reports of this procedure being performed in the early neonatal period. The authors discuss their experience with ultra-early endoscopic synostectomy, defined as an operation for infants aged 8 weeks or younger. METHODS A retrospective analysis of infants who underwent operations at or before 8 weeks of age between 2011 and 2020 was done. RESULTS Twenty-five infants underwent operations: 11 were 2 weeks of age or younger, 8 were between 3 and 4 weeks of age, and 6 were between 5 and 8 weeks of age. The infants weighed between 2.25 and 4.8 kg. Eighteen had single-suture synostosis, and 7 had multiple sutures involved. Of these 7, 4 had syndromic craniosynostosis. The average operative time was 35 minutes, and it was less than 40 minutes in 19 cases. The estimated operative blood loss was 25 ml or less in 19 cases; 5 infants required an intraoperative blood transfusion. In 1 child with syndromic multisuture craniosynostosis, the surgery was staged due to blood loss. Two children experienced complications related to the procedure: one had an incidental durotomy with skin infection, and the other had postoperative kernicterus. All infants were fitted for cranial remodeling orthoses following surgery. Three of the 25 infants required reoperations, with 2 patients with syndromic craniosynostosis needing repeat surgery for cranial volume expansion and cosmetic appearance. Another child with syndromic craniosynostosis is awaiting cranial expansion surgery. Follow-up varied between 6 months and 8 years. CONCLUSIONS The data show that ultra-early synostectomy is safe and not associated with increased complications compared with surgery performed between 3 and 6 months of age. Infants with multisuture synostosis had increased operative time, required blood transfusion, and were more likely to require a second operation.
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Affiliation(s)
| | | | - Sharif Mohamed
- 2Anesthesiology, University of Texas Medical Branch at Galveston; and
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Clinical Practice Patterns in Nonsyndromic Craniosynostosis: A Review of Continuous Certification Tracer Data From the American Board of Plastic Surgery. J Craniofac Surg 2021; 32:2029-2034. [PMID: 33654035 DOI: 10.1097/scs.0000000000007592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Szathmari A, Morgado A, Beuriat P, Petrescu P, Di Rocco F, Mottolese C. Cranioplasty for bone defects after craniosynostosis surgery. Case series with literature review. Neurochirurgie 2020; 66:97-101. [DOI: 10.1016/j.neuchi.2019.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 10/02/2019] [Accepted: 10/13/2019] [Indexed: 10/24/2022]
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Persad A, Aronyk K, Beaudoin W, Mehta V. Long-term 3D CT follow-up after endoscopic sagittal craniosynostosis repair. J Neurosurg Pediatr 2019; 25:291-297. [PMID: 31860808 DOI: 10.3171/2019.10.peds19297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/21/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical treatment of sagittal synostosis involves various surgical modalities. Long-term follow-up issues include increased intracranial pressure, secondary sutural fusion, incomplete reossification, and suboptimal cosmetic appearance. The authors' objective in this study was to review their long-term endoscopic surgical results in children with sagittal synostosis using 3D CT. METHODS The authors reviewed the long-term results of their first 38 patients who underwent endoscopic sagittal synostosis repair at age 16 weeks or younger. A standard vertex craniectomy with biparietal wedges was done in each case. After surgery, the children were fitted with a helmet, which they wore until 8 months of age. Patients were followed up for 5 years or longer, at which point a 3D CT scan was obtained. The authors examined data on the cranial index, area of bony defect, presence or absence of secondary sutural fusion, neosuture formation, and scalloping of the inner table of the skull. RESULTS Thirty-two of 38 children met inclusion criteria. There was a small but significant recession of the cranial index after the completion of helmeting (from 0.772 after completion of helmeting to 0.755 at 5 years). Of 32 children, 14 had a bony defect area > 4 cm2. Three children had secondary sutural fusion (two unilateral coronal, one bicoronal). Ten of 32 patients had partial neosuture formation. CONCLUSIONS The authors report their experience with 32 of their first 38 children who underwent endoscopic sagittal synostosis repair at 16 weeks of age or younger. With a minimum duration of 5 years, this is the longest clinicoradiological follow-up utilizing 3D CT to date in children with sagittal synostosis treated with endoscopic surgery. The authors report detailed measurements of bony loss, adjacent sutural fusion, and neosuture formation.
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Affiliation(s)
- Amit Persad
- 1Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Royal University Hospital, Saskatoon, Saskatchewan; and
| | - Keith Aronyk
- 2Division of Neurosurgery, Department of Surgery, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Wendy Beaudoin
- 2Division of Neurosurgery, Department of Surgery, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Vivek Mehta
- 2Division of Neurosurgery, Department of Surgery, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
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Wang MM, Flores RL, Witek L, Torroni A, Ibrahim A, Wang Z, Liss HA, Cronstein BN, Lopez CD, Maliha SG, Coelho PG. Dipyridamole-loaded 3D-printed bioceramic scaffolds stimulate pediatric bone regeneration in vivo without disruption of craniofacial growth through facial maturity. Sci Rep 2019; 9:18439. [PMID: 31804544 PMCID: PMC6895073 DOI: 10.1038/s41598-019-54726-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/12/2019] [Indexed: 02/08/2023] Open
Abstract
This study investigates a comprehensive model of bone regeneration capacity of dypiridamole-loaded 3D-printed bioceramic (DIPY-3DPBC) scaffolds composed of 100% beta-tricalcium phosphate (β -TCP) in an immature rabbit model through the time of facial maturity. The efficacy of this construct was compared to autologous bone graft, the clinical standard of care in pediatric craniofacial reconstruction, with attention paid to volume of regenerated bone by 3D reconstruction, histologic and mechanical properties of regenerated bone, and long-term safety regarding potential craniofacial growth restriction. Additionally, long-term degradation of scaffold constructs was evaluated. At 24 weeks in vivo, DIPY-3DPBC scaffolds demonstrated volumetrically significant osteogenic regeneration of calvarial and alveolar defects comparable to autogenous bone graft with favorable biodegradation of the bioactive ceramic component in vivo. Characterization of regenerated bone reveals osteogenesis of organized, vascularized bone with histologic and mechanical characteristics comparable to native bone. Radiographic and histologic analyses were consistent with patent craniofacial sutures. Lastly, through application of 3D morphometric facial surface analysis, our results support that DIPY-3DPBC scaffolds do not cause premature closure of sutures and preserve normal craniofacial growth. Based on this novel evaluation model, this DIPY-3DPBC scaffold strategy is a promising candidate as a safe, efficacious pediatric bone tissue engineering strategy.
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Affiliation(s)
- Maxime M Wang
- Department of Biomaterials & Biomimetics, NYU College of Dentistry, 433 1st Avenue, New York, NY, 10010, USA.
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, 307 E 33rd St, New York, NY, 10016, USA.
| | - Roberto L Flores
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, 307 E 33rd St, New York, NY, 10016, USA
| | - Lukasz Witek
- Department of Biomaterials & Biomimetics, NYU College of Dentistry, 433 1st Avenue, New York, NY, 10010, USA
| | - Andrea Torroni
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, 307 E 33rd St, New York, NY, 10016, USA
| | - Amel Ibrahim
- Department of Biomaterials & Biomimetics, NYU College of Dentistry, 433 1st Avenue, New York, NY, 10010, USA
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, 307 E 33rd St, New York, NY, 10016, USA
| | - Zhong Wang
- Department of Biomaterials & Biomimetics, NYU College of Dentistry, 433 1st Avenue, New York, NY, 10010, USA
| | - Hannah A Liss
- Department of Biomaterials & Biomimetics, NYU College of Dentistry, 433 1st Avenue, New York, NY, 10010, USA
| | - Bruce N Cronstein
- Department of Medicine, NYU Langone Health, 550 1st Avenue, New York, NY, 10016, USA
| | - Christopher D Lopez
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, 601 N Caroline St, Baltimore, MD, 21205, USA
| | - Samantha G Maliha
- Department of Plastic Surgery, University of Pittsburgh Medical Center, 3601 Fifth Ave, Pittsburgh, PA, 15213, USA
| | - Paulo G Coelho
- Department of Biomaterials & Biomimetics, NYU College of Dentistry, 433 1st Avenue, New York, NY, 10010, USA
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, 307 E 33rd St, New York, NY, 10016, USA
- Department of Mechanical Engineering, NYU Tandon School of Engineering, 6 MetroTech Center, Brooklyn, NY, 11201, USA
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Demineralized Bone Matrix and Resorbable Mesh Bilaminate Cranioplasty Is Ineffective for Secondary Reconstruction of Large Pediatric Cranial Defects. Plast Reconstr Surg 2019; 145:137e-141e. [PMID: 31592945 DOI: 10.1097/prs.0000000000006386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Replacement of the autologous bone flap after decompressive craniectomy can be complicated by significant osteolysis or infection with large defects over scarred dura. Demineralized bone matrix is an alternative to autologous reconstruction, effective when reconstructing large defects using a resorbable mesh bilaminate technique in primary cranioplasty, but this technique has not been studied for revision cranioplasty and the setting of scarred dura. Retrospective review was performed of patients receiving demineralized bone matrix and resorbable mesh bilaminate cranioplasty for postdecompressive craniectomy defects. Seven patients (mean age, 4.2 years) were identified with a mean follow-up of 4.0 years. Computed tomography before the demineralized bone matrix and resorbable mesh bilaminate cranioplasty and at least 1 year postoperatively were compared. Defects were characterized and need for revision was assessed. All patients had craniectomy with associated hemidural scarring. Five patients had autologous bone flap cranioplasty associated with nearly total osteolysis, and two patients had deferral of bone flap before demineralized bone matrix and resorbable mesh bilaminate cranioplasty. Demineralized bone matrix and resorbable mesh bilaminate cranioplasty demonstrated unpredictable and poor ossification, with bony coverage unchanged at postoperative follow-up. All patients required major revision cranioplasty at a mean time of 2.5 years. Porous polyethylene was successfully used in six of the revisions, whereas exchange cranioplasty was used in the remaining patient, with a mean follow-up of 1.4 years. Although demineralized bone matrix and resorbable mesh bilaminate is appropriate for primary cranioplasty, it should be avoided in the setting of scarred or infected dura in favor of synthetic materials or exchange cranioplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.
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Role of Autologous Fat Injection in Neglected Patients With Anterior Plagiocephaly. J Craniofac Surg 2019; 30:e637-e639. [DOI: 10.1097/scs.0000000000005662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Sakamoto Y, Miwa T, Yoshida K, Kishi K. Reossification of the skull base after fronto-orbital advancement for craniosynostosis. J Plast Reconstr Aesthet Surg 2019; 72:1700-1738. [PMID: 31439526 DOI: 10.1016/j.bjps.2019.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 05/16/2019] [Accepted: 07/27/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Yoshiaki Sakamoto
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ward, Tokyo 160-8582, Japan.
| | - Tomoru Miwa
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ward, Tokyo 160-8582, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ward, Tokyo 160-8582, Japan
| | - Kazuo Kishi
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ward, Tokyo 160-8582, Japan
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Interleukin-10 Does Not Augment Osseous Regeneration in the Scarred Calvarial Defect Achieved with Low-Dose Biopatterned BMP2. Plast Reconstr Surg 2019; 143:1215e-1223e. [PMID: 31136482 DOI: 10.1097/prs.0000000000005640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Large calvarial defects represent a major reconstructive challenge, as they do not heal spontaneously. Infection causes inflammation and scarring, further reducing the healing capacity of the calvaria. Bone morphogenetic protein-2 (BMP2) has been shown to stimulate osteogenesis but has significant side effects in high doses. BMP2 has not been tested in combination with antiinflammatory cytokines such as interleukin-10. METHODS Sixteen New Zealand White rabbits underwent 15 × 15-mm flap calvarectomies. The flap was incubated in Staphylococcus aureus and replaced, and infection and scarring were allowed to develop. The flap was subsequently removed and the wound débrided. A 15 × 15-mm square of acellular dermal matrix biopatterned with low-dose BMP2, interleukin-10, or a combination was implanted. Computed tomographic scans were taken over 42 days. Rabbits were then killed and histology was performed. RESULTS Defects treated with BMP2 showed significantly (p < 0.05) greater osseous regeneration than untreated controls. Interleukin-10 did not significantly augment the healing achieved with BMP2, and interleukin-10 alone did not significantly increase healing compared with controls. Histology showed evidence of bone formation in defects treated with BMP2. Untreated controls and defects treated with interleukin-10 alone showed only fibrous tissue in the defect site. CONCLUSIONS Low-dose BMP2 delivered directly to the scarred calvarial defect augments bony healing. Interleukin-10 at the dose applied did not significantly augment healing alone or in combination with BMP2. Healing had not finished at 42 days and analysis at later time points or the use of higher doses of BMP2 may yield greater healing.
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Long-Term Characterization of Cranial Defects After Surgical Correction for Single-Suture Craniosynostosis. Ann Plast Surg 2019; 82:679-685. [PMID: 31082848 DOI: 10.1097/sap.0000000000001906] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Craniosynostosis is typically corrected surgically within the first year of life through cranial vault reconstruction. These procedures often leave open calvarial defects at the time of surgery, which are anticipated to close over time in a large proportion of cases. However, residual calvarial defects may result as long-term sequelae from cranial vault remodeling. When larger defects are present, they may necessitate further reconstruction for closure.Better understanding of the calvarial osseous healing process may help to identify which defects will resolve or shrink to acceptable size and which will require further surgery. Our study aims to assess the long-term changes in defect size after cranial vault reconstruction for craniosynostosis. METHODS One-year postoperative and long-term computed tomography scans were retrieved from the craniofacial anomalies archive. Analysis used custom software. All defects above the size of 1 cm were analyzed and tracked for calvarial location, surface area, and circularity. Monte Carlo simulation was performed to model the effect of initial defect size on the rate of defect closure. RESULTS We analyzed a total of 74 defects. The mean ± SD initial defect surface area was 3.27 ± 3.40 cm. The mean ± SD final defect surface area was 1.71 ± 2.54 cm. The mean ± SD percent decrease was 55.06% ± 28.99%. There was a significant difference in the percentage decrease of defects in the parietal and frontoparietal locations: 68.4% and 43.7%, respectively (P = 0.001). Monte Carlo simulation results suggest that less than 10% of defects above the size of 9 cm will close to the size of 2.5 cm or less. CONCLUSIONS We describe and make available a novel validated method of measuring cranial defects. We find that the large majority of initial defects greater than 9 cm remain at least 1 in in size (2.5 cm) 1 year postoperatively. In addition, there appear to be regional differences in closure rates across the cranium, with frontoparietal defects closing more slowly than those in the parietal region. This information will aid surgeons in the decision-making process regarding cranioplasty after craniosynostosis correction.
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Reconstruction of a Calvarial Wound Complicated by Infection: Comparing the Effects of Biopatterned Bone Morphogenetic Protein 2 and Vascular Endothelial Growth Factor. J Craniofac Surg 2019; 30:260-264. [PMID: 30339591 DOI: 10.1097/scs.0000000000004779] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Bone morphogenetic protein 2 (BMP2) bioprinted on biological matrix induces osseous regeneration in large calvarial defects in rabbits, both uncomplicated and scarred. Healing in unfavorable defects scarred from previous infection is decreased due in part to the lack of vascularity. This impedes the access of mesenchymal stem cells, key to osseous regeneration and the efficacy of BMP2, to the wound bed. The authors hypothesized that bioprinted vascular endothelial growth factor (VEGF) would augment the osseous regeneration achieved with low dose biopatterned BMP2 alone. Thirteen New Zealand white rabbits underwent subtotal calvariectomy using a dental cutting burr. Care was taken to preserve the underlying dura. A 15 mm × 15 mm flap of bone was cut away and incubated in a 1 × 108 cfu/mL planktonic solution of S aureus before reimplantation. After 2 weeks of subsequent infection the flap was removed and the surgical wound debrided followed by 10 days of antibiotic treatment. On postoperative day 42 the calvarial defects were treated with acellular dermal matrix bioprinted with nothing (control), VEGF, BMP2, BMP2/VEGF combined. Bone growth was analyzed with serial CT and postmortem histology. Defects treated with BMP2 (BMP2 alone and BMP2/VEGF combination) showed significantly greater healing than control and VEGF treated defect (P < 0.5). Vascular endothelial growth factor treated defect demonstrated less healing than control and VEGF/BMP2 combination treatments achieved less healing than BMP2 alone though these differences were nonsignificant. Low dose BMP2-patterned acellular dermal matrix improves healing of scarred calvarial defects. Vascular endothelial growth factor at the doses applied in this study failed to increase healing.
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Anterior Cranial Vault Reconstruction With Distraction for Primary and Secondary Craniosynostosis Repair. J Craniofac Surg 2019; 30:e109-e112. [DOI: 10.1097/scs.0000000000005011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
PURPOSE To evaluate the utility and efficacy of bioabsorbable hydroxyapatite and collagen complex (HA/Col) for cranioplasty repair of cranial bone defects in children. METHODS Two patients (a 6-year-old male and 11-year-old female) with Treacher Collins syndrome received zygoma and orbital floor reconstruction using a full thickness of parietal bone. The bone grafts were taken from each patient's parietal cranium. The right parietal cranial defect was repaired with autologous bone dust, and the left side was repaired with HA/Col in each patient. Computed tomography scans were taken immediately after and at 12 months following surgery. The osteosynthesis areas and thicknesses were measured using computer-aided engineering. RESULTS Both patients experienced no complications, including infection. In the 6- and 11-year-old patients, the extent of osteosynthesis for HA/Col was 92.2% and 89.4%, respectively; and for the autologous bone dust was 78.5% and 53.2%, respectively. Because of the small sample size, a significant difference could not be calculated; however, the percentage of osteosynthesis for HA/Col was higher than for the autologous bone dust. CONCLUSION This study showed that HA/Col can be effectively used in cranial defects and can be considered an alternative graft material for cranial reconstruction.
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Homologous Banked Bone Grafts for the Reconstruction of Large Cranial Defects in Pediatric Patients. J Craniofac Surg 2018; 29:2038-2042. [DOI: 10.1097/scs.0000000000004716] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Custom CAD/CAM implants for complex craniofacial reconstruction in children: Our experience based on 136 cases✰. J Plast Reconstr Aesthet Surg 2018; 71:1609-1617. [DOI: 10.1016/j.bjps.2018.07.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 05/22/2018] [Accepted: 07/27/2018] [Indexed: 11/23/2022]
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Thenier-Villa JL, Sanromán-Álvarez P, Miranda-Lloret P, Plaza Ramírez ME. Incomplete reossification after craniosynostosis surgery-incidence and analysis of risk factors: a clinical-radiological assessment study. J Neurosurg Pediatr 2018; 22:120-127. [PMID: 29799353 DOI: 10.3171/2018.2.peds17717] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE One of the principles of the surgical treatment of craniosynostosis includes the release of fused bone plates to prevent recurrence. Such bone defects require a reossification process after surgery to prevent a cosmetic problem or brain vulnerability to damage. The objective of this study is to describe and analyze the radiological and clinical evolution of bone defects after craniosynostosis. METHODS From January 2005 to May 2016, 248 infants underwent surgical correction of craniosynostosis at HUiP La Fe Valencia; the authors analyzed data from 216 of these cases that met the inclusion criteria for this study. Various surgical techniques were used according to the age of the patient and severity of the case, including endoscopic-assisted suturectomy, open suturectomy, fronto-orbital advancement, and cranial vault remodeling. Clinical follow-up and radiological quantitative measurements in 2 periods-12-24 months and 2 years after surgery-were analyzed; 94 patients had a postoperative CT scan and were included in the radiological analysis. RESULTS At the end of the follow-up period, 92 of 216 patients (42.59%) showed complete closure of the bone defect, 112 patients (51.85%) had minor bone defects, and 12 patients (5.56%) had significant bone defects that required surgical intervention. In the multivariate analysis, age at first surgery was not significantly associated with incomplete reossification (p = 0.15), nor was surgical site infection (p = 0.75). Multivariate analysis identified area of cranial defect greater than 5 cm2 in the first CT scan as predictive of incomplete reossification (p = 0.04). The mean area of cranial defect in the first CT scan (12-24 months after surgery) was 3.69 cm2 in patients treated with open surgery and 7.13 cm2 in those treated with endoscopic-assisted procedures; in the multivariate analysis, type of procedure was not related to incomplete reossification (p = 0.46). The positive predictive value of palpation as evaluation of bone cranial defects was 50% for significant defects and 71% for minor defects. CONCLUSIONS The incidence of cranial defects due to incomplete reossification requiring cranioplasty was 5.56% in our series. Defects greater than 5 cm2 in the first postoperative CT scan showed a positive association with incomplete reossification. Patients treated with endoscope-assisted procedures had larger defects in the initial follow-up, but the final incidence of cranial defects was not significantly different in the endoscope-assisted surgery group from that in the open surgery group.
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Affiliation(s)
- José Luis Thenier-Villa
- 1Department of Neurological Surgery, HUiP La Fe, Valencia; and.,2Department of Neurosurgery, University Hospital Complex of Vigo, Vigo, Spain
| | - Pablo Sanromán-Álvarez
- 1Department of Neurological Surgery, HUiP La Fe, Valencia; and.,2Department of Neurosurgery, University Hospital Complex of Vigo, Vigo, Spain
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Virtual Surgical Planning for Correction of Delayed Presentation Scaphocephaly Using a Modified Melbourne Technique. J Craniofac Surg 2018; 29:914-919. [DOI: 10.1097/scs.0000000000004290] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Surgical Outcome After Less “Rigid” Fixation in Open Cranial Vault Remodeling for Craniosynostosis. J Craniofac Surg 2018; 29:861-867. [DOI: 10.1097/scs.0000000000004347] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Power-Assisted Particulate Bone Grafting Effectively Prevents Osseous Defects After Cranial Vault Reconstruction. J Craniofac Surg 2018; 29:547-552. [PMID: 29438208 DOI: 10.1097/scs.0000000000004207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Cranial vault reconstruction (CVR) is the gold standard in the operative treatment of craniosynostosis. Full thickness osseous defects (FTOD) of the calvaria have been observed in 5% to 15% patients after CVR, with higher rates cited in the fronto-orbital advancement (FOA) subset. Particulate bone graft (PBG) harvested manually has been shown to decrease FTOD after FOA from 24% to 5.5%. The authors used a modified technique using a powered craniotome, with the hypothesis that the technique would also improve outcomes. METHODS A retrospective review was performed of patients who underwent CVR for craniosynostosis between 2004 and 2014. Patient demographics, diagnosis, age, operative details, and postoperative care were reviewed in detail. Categorical, nonparametric variables were compared by Fisher exact tests. RESULTS A total of 135 patients met inclusion criteria. The most common diagnoses were metopic (n = 41), sagittal (n = 33), and unilateral coronal craniosynostosis (n = 31); 65% (n = 88) underwent FOA, 29% (n = 39) underwent single-stage total vault reconstruction, and 6% (n = 8) had a posterior vault reconstruction. CVR was performed without PBG in 95 patients and with PBG in 40 patients. Without PBG, FTOD were discovered on clinical examination in 18% of patients (n=17): 11 presented with subcentimeter defects, while 6 had larger defects requiring revision cranioplasty (6% operative revision rate). Among those receiving PBG, 1 patient presented a subcentimeter FTOD (2.5% FTOD incidence and 0% operative revision rate). CONCLUSION Particulate bone graft harvested with a powered device decreases the rate of FTOD and reoperation rate after CVR for craniosynostosis.
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Mittermiller PA, Yeom KW, Menard RM. Isolated Intraorbital Frontosphenoidal Synostosis. J Craniofac Surg 2017; 29:82-87. [PMID: 29068968 DOI: 10.1097/scs.0000000000004074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Unilateral anterior plagiocephaly is most commonly the result of deformational plagiocephaly or unilateral coronal synostosis, a premature fusion of the frontoparietal suture. However, other sutures within the coronal ring have been implicated in producing anterior cranial asymmetries. These fusions can occur in isolation or in concert with adjacent sutures. The frontosphenoidal suture is one such suture within the coronal ring that has been involved both concomitantly with and independently of frontoparietal suture fusion. Although isolated frontosphenoidal synostosis has been presented previously in the literature, these reports include patients with fusion of the extraorbital portion of the frontosphenoidal suture. This clinical report presents the first clearly documented patient of isolated frontosphenoidal synostosis that occurs entirely within the intraorbital region.The patient presented to Plastic Surgery Clinic at 3 months of age with left frontal flattening, supraorbital rim retrusion, and temporal bulging that was noted soon after birth. Computed tomography analysis revealed an isolated fusion of the greater and lesser wings of the sphenoid bone to the frontal bone on the left side. The patient had no family history of cranial anomalies and genetic testing was negative for mutations. The infant was treated with a cranial orthotic for 3 months, underwent open fronto-orbital advancement and cranial vault remodeling at 6 months, and continued wearing a cranial orthotic for another 4.5 months. Following surgical and orthotic treatment, the patient achieved a satisfactory result.
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Affiliation(s)
- Paul A Mittermiller
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford Hospital and Clinics
| | - Kristen W Yeom
- Department of Radiology, Lucile Packard Children's Hospital at Stanford and Stanford Hospital and Clinics, Palo Alto
| | - Robert M Menard
- Department of Plastic Surgery, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
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An Outcomes Comparison Between Autologous and Alloplastic Cranioplasty in the Pediatric Population. J Craniofac Surg 2017; 27:593-7. [PMID: 27035597 DOI: 10.1097/scs.0000000000002491] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The use of alloplastic material in cranial reconstruction has been well described in the adult population, especially when a paucity of autologous tissue exists. In children it is unknown how long-term growth, however, may be affected by the implantation of nonexpansible alloplastic material. Therefore, the authors sought to compare the outcomes of pediatric patients undergoing alloplastic versus autologous cranial reconstruction. METHODS To assess the safety and long-term outcomes of alloplastic cranioplasty in children, an institutional review board-approved, retrospective, single institution review of pediatric patients undergoing cranioplasty was performed from 2000 to 2014. The age at surgery, cause of the cranial defect, defect size, time since initial surgery to reconstruction, implant type, and complications were assessed. Postreconstruction imaging was reviewed if available. RESULTS A reconstructive cranioplasty was performed in 41 pediatric patients (ages 1-19 years, average 7.35 years). Thirty patients underwent alloplastic reconstruction (age 4.37 ± 5.57 years), and 11 underwent autologous reconstruction (age 2.00 ± 3.74 years). The size of the cranial defects was 144.01 ± 393.04 cm for autologous and 405.31 ± 572.96 cm for alloplastic reconstructions. Follow-up for all patients was an average of 2.33 ± 2.76 years (0.1-9 years). No patients in either group showed evidence of elevated intracranial pressure after cranioplasty. In long-term follow-up, none of the implants were exposed or lost because of infection. Computed tomography and physical examination demonstrated that there was no skull growth restriction in either group. CONCLUSIONS Our data show that alloplastic cranioplasty in the pediatric population is a safe alternative, when autologous cranial bone is not available.
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Utria AF, Lopez J, Cho RS, Mundinger GS, Jallo GI, Ahn ES, Kolk CV, Dorafshar AH. Timing of cranial vault remodeling in nonsyndromic craniosynostosis: a single-institution 30-year experience. J Neurosurg Pediatr 2016; 18:629-634. [PMID: 27503248 DOI: 10.3171/2016.5.peds1663] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Due to the changing properties of the infant skull, there is still no clear consensus on the ideal time to surgically intervene in cases of nonsyndromic craniosynostosis (NSC). This study aims to shed light on how patient age at the time of surgery may affect surgical outcomes and the subsequent need for reoperation. METHODS A retrospective cohort review was conducted for patients with NSC who underwent primary cranial vault remodeling between 1990 and 2013. Patients' demographic and clinical characteristics and surgical interventions were recorded. Postoperative outcomes were assessed by assigning each procedure to a Whitaker category. Multivariate logistic regression analysis was performed to determine the relationship between age at surgery and need for minor (Whitaker I or II) versus major (Whitaker III or IV) reoperation. Odds ratios (ORs) for Whitaker category by age at surgery were assigned. RESULTS A total of 413 unique patients underwent cranial vault remodeling procedures for NSC during the study period. Multivariate logistic regression demonstrated increased odds of requiring major surgical revisions (Whitaker III or IV) in patients younger than 6 months of age (OR 2.49, 95% CI 1.05-5.93), and increased odds of requiring minimal surgical revisions (Whitaker I or II) in patients older than 6 months of age (OR 2.72, 95% CI 1.16-6.41). CONCLUSIONS Timing, as a proxy for the changing properties of the infant skull, is an important factor to consider when planning vault reconstruction in NSC. The data presented in this study demonstrate that patients operated on before 6 months of age had increased odds of requiring major surgical revisions.
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Affiliation(s)
- Alan F Utria
- Departments of 1 Plastic and Reconstructive Surgery and
| | - Joseph Lopez
- Departments of 1 Plastic and Reconstructive Surgery and
| | - Regina S Cho
- Departments of 1 Plastic and Reconstructive Surgery and
| | | | | | | | - Craig Vander Kolk
- Departments of 1 Plastic and Reconstructive Surgery and.,Division of Plastic Surgery, Mercy Medical Center, Baltimore, Maryland
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Advantages of Calvarial Vault Distraction for the Late Treatment of Cephalocranial Disproportion. J Craniofac Surg 2016; 27:1501-5. [PMID: 27428903 DOI: 10.1097/scs.0000000000002875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Cephalocranial disproportion is a symptomatic condition related to a volume discrepancy between the calvarial vault and the brain. Traditional expansion techniques are unfavorable in older children due to inadequate dural ossification, lack of bone pliability, and limited future growth potential. The authors review their experience using distraction to close bone defects in this setting. METHODS A retrospective analysis was performed of all patients treated using distraction in this setting by a single surgeon. Demographic and outcomes data were collected. The efficacy of ossification of bone defects after expansion by distraction was measured using volume analysis of three-dimensional computed tomography (CT) scans. This required a CT scan at the completion of device activation and a follow-up CT scan 6 months or more beyond activation. RESULTS Sixteen patients (17 distractions) met the imaging-based inclusion criteria. The average age at surgery was 3.97 (2.14-6.89) years. The mean initial bone defect volume after asymmetric transverse distraction was 7.26 (5.45-13.73) mL. The mean final defect volume was 2.18 (0.00-5.90) mL with a mean change of 5.08 (1.21-12.79) mL and mean interval time of 27.85 (7.13-56.39) months. This represents a mean percent defect closure of 72.30 (20.38-100.00). CONCLUSION Distraction osteogenesis is a very effective tool for treating the older child with cephalocranial disproportion. The ability to ossify the bone defects without a donor site provides a considerable advantage in these patients.
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Anterior Cranial Vault Distraction for the Treatment of Normocephalic Pancraniosynostosis. J Craniofac Surg 2016; 27:e283-8. [PMID: 27115211 DOI: 10.1097/scs.0000000000002452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Normocephalic pancraniosynostosis is a rare form of craniosynostosis that usually presents later in life secondary to a delayed onset of symptoms and the presence of a normal head shape. Since its initial description in the literature in 2010, normocephalic pancraniosynostosis remains a rare clinical entity that has only been reported in 6 patients. Surgical treatment in the 2 published reports has been by staged total calvarial reconstruction or anterior cranial vault remodeling with bilateral frontoorbital advancement. In this case report, the authors present 1 patient with normocephalic pancraniosynostosis and propose surgical treatment by anterior cranial vault expansion with distraction osteogenesis.
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Abstract
INTRODUCTION Pansynostosis can result in markedly thin calvarial bone resulting in poor quality and quantity of allograft for cranial vault expansion. Such scenarios can result in large calvarial defects and poorly stabilized constructs. Additionally, the osteoinductive properties of neonatal dura and paracranium in cranial vault reconstruction suggest the possibility of reconstructing extensive calvarial defects using minimal native calvarium given the appropriate scaffold. We report a case of subtotal cranial vault remodeling involving greater than 50% of the cranial vault using a custom poly DL lactic acid (Sonic Weld) resorbable plate construct and underlay calvarial bone grafting. METHODS A 4-month-old male infant presented with a diagnosis of Cruzon syndrome and pansynostosis. Staged reconstruction was performed with the initial stage involving the posterior and middle cranial vault. Given the severity of the deformity, the native cranial bone was thinned with multiple defects such that it could not be used to provide structural integrity or sufficient surface coverage for cranial vault reconstruction. Useable bone comprised only a fraction of the surface area required to expand the posterior and midcranium. Resorbable poly DL lactic acid (Sonic Weld) plates were used to create a custom construct for reconstruction of the posterior and middle cranial vault. The construct was then seeded with usable fragments of the native calvarium and secured to the cranial base with resorbable pins. RESULTS The construct resulted in maintained cranial shape throughout the postoperative period. Postoperative computed tomography imaging demonstrated osteogenesis throughout the construct with bridging of the fragmented calvarial grafts. Examination of the construct during anterior cranial vault remodeling demonstrated near complete resorption of the construct, stable posterior cranial vault, and minimal dural adhesions to the posterior cranium. At 11 months postoperatively, the patient continues to demonstrate appropriate cranial expansion and maintenance of posterior cranial shape. CONCLUSIONS Fully resorbable constructs can provide effective structural support and a scaffold for osteogenisis in conjunction with minimal native calvarial bone grafts during reconstruction of large cranial vault defects in the infantile period.
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Safety and efficacy of recombinant human bone morphogenetic protein 2 on cranial defect closure in the pediatric population. J Craniofac Surg 2015; 24:917-22. [PMID: 23714911 DOI: 10.1097/scs.0b013e318256657c] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Traditional reconstructive options for cranial defects include autogenous bone graft, bone substitutes, and synthetic materials. The established standard for repairing cranial defects is autogenous bone. However, young children do not have abundant donor sites for bone harvest, which leads to challenges in closing calvarial defects. Synthetic materials are not ideal alternatives because they require subsequent retrieval and are prone to infection. Their long-term effects on growth of the skull are also not well studied. Bone morphogenetic protein 2 (BMP-2), are shown to positively affect closure of cranial defects in animal models. We present a study comparing the efficacy and safety of closure of cranial defect with bone graft augmented with recombinant human BMP-2 (rhBMP-2) and compared with a series of patients treated with bone graft alone. METHODS This study is a retrospective multicenter evaluation of 36 patients spanning 5 years. Twenty-one patients undergoing cranial defect closure augmented with rhBMP-2 were compared with 15 patients who underwent cranial defect closure using cranial bone shavings alone. We measured preoperative and postoperative defect size on volumetric computed tomographic scan reconstructions to compare defect sizes. RESULTS The rhBMP-2 group had slightly increased proportional closure compared with the control group, 86% versus 76% (P < 0.018), respectively. Two patients in the rhBMP-2 group had postoperative fusion of a suture that was known to be patent at the time of cranial defect closure. No instances of brain edema, herniation, airway compromise, or other adverse effects directly attributable to rhBMP-2 were observed. CONCLUSIONS Bone morphogenetic protein 2 may increase the amplitude and uptake of cranial bone grafts in cranial defect closure. This study shows that defect sizes of up to 16 cm can be reliably closed using this technique. Postoperative fusion of uninvolved sutures in 2 patients indicates that rhBMP-2 may have unreported adverse effects; consideration of this finding should be weighed against the benefit of improved closure of calvarial defects.
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Exchange hybrid cranioplasty using particulate bone graft and demineralized bone matrix: the best of both worlds. J Craniofac Surg 2015; 25:451-4. [PMID: 24531249 DOI: 10.1097/scs.0000000000000491] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Reconstruction of craniofacial defects in children presents several challenges that are not encountered in the adult population. Autologous bone grafts have long been the criterion standard for repairing these defects. Recently, several new materials and techniques have expanded our arsenal of reconstructive options. In this clinical report, we describe the use of both particulate bone grafting and demineralized bone matrix together to repair craniofacial defects encountered in pediatric patients.
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Distraction Osteogenesis Technique for the Treatment of Nonsyndromic Sagittal Synostosis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e474. [PMID: 26301163 PMCID: PMC4527648 DOI: 10.1097/gox.0000000000000442] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/09/2015] [Indexed: 11/25/2022]
Abstract
Background Historically, surgical treatment of children with a delayed presentation of cranial synostosis required complex cranial vault reconstruction. Recently, less invasive options for surgical correction, such as internal distraction osteogenesis, have been explored. In this study, we describe the successful management of delayed presentation of sagittal synostosis using distraction osteogenesis. Methods A bicoronal incision was made and 2 large rectangular osteotomies were performed bilaterally, involving the frontal, parietal, temporal and occipital bones. A 2 cm strut of bone over the sagittal sinus was preserved, creating bilateral free-floating bone segments. Two pairs of distractors were placed transversely, along the midline strut of bone, providing lateral distraction of these segments. This placement allowed maximum displacement at the apex of the cranial vault. Distraction was performed differentially at 1 mm per day anteriorly and 2 mm per day posteriorly, for a total of 17 days, allowing for a greater degree of expansion of the posterior vault. The consolidation phase lasted for 10 weeks. The distractors were removed via the same bicoronal incision and cranioplasty was performed to smooth prominent ridging at the margins of the distracted segments. Results The child’s cranial index improved from 0.67 preoperatively to 0.76 postoperatively. The overall vault contour was smooth with no bony defects. There was a significant cosmetic improvement of the child’s head shape. No major complications requiring reoperation or rehospitalization were encountered. Conclusion The use of distraction osteogenesis to laterally expand the cranial vault is a useful alternative in the treatment of delayed presentation, nonsyndromic, sagittal synostosis.
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The Importance of Timing in Optimizing Cranial Vault Remodeling in Syndromic Craniosynostosis. Plast Reconstr Surg 2015; 135:1077-1084. [DOI: 10.1097/prs.0000000000001058] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
UNLABELLED Craniosynostosis is typically treated in the first year of life, when osteogenic potential is high and residual obligate skull defects heal. Delayed reconstruction can result in persistent skull defects because of diminished osteogenic potential. Adequately expanding the cranium yet minimizing residual skull defects in older patients presents a conundrum. Although secondary cranioplasty can be performed, primary cortical bone coverage is preferred. The authors present a technique of cranial expansion by sliding stairstep osteotomies, thus preventing residual skull defects when treating craniosynostosis at an advanced age. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Muzaffar AR, Nguyen TB, Baker L, Warren AJ. Does the Use of Particulate Bone Graft Increase the Incidence of Postoperative Infection in Surgery for Craniosynostosis? Cleft Palate Craniofac J 2015; 52:e14-7. [DOI: 10.1597/14-016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The use of particulate bone graft (PBG) has become an accepted technique for filling cranial defects created during cranial vault expansion for craniosynostosis. However, the use of PBG may be a risk factor for postoperative infection. The aim of this study was to compare the rate of postoperative infection in patients who received particulate bone graft (PBG+) with that in patients who did not (PBG–). Design An Institutional Review Board–approved, retrospective, cohort study of consecutive patients was performed. Twenty-seven consecutive patients in the PBG– group were compared with 21 consecutive patients in the PBG+ group. The two cohorts were assessed for incidence of surgical-site infection. Results Statistical analysis was performed using the Fisher exact probability test. Surgical site infection occurred in none of the PBG– patients (0%) versus one of the PBG+ patients (4.76%). This difference in infection rates between the two cohorts was not statistically significant ( P = .4375). Conclusions Although there may be concern that PBG could serve as a facilitative medium for bacterial growth, this study demonstrates no statistically significant increase in infection rates with its use. Particulate bone grafting of cranial defects resulting from cranial vault expansion in craniosynostosis remains a useful and valuable technique.
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Affiliation(s)
| | - Thuan B. Nguyen
- Division of Plastic Surgery, University of Missouri, Columbia, Missouri
| | - Lynette Baker
- Division of Plastic Surgery, University of Missouri, Columbia, Missouri
| | - Abby J. Warren
- University of Missouri Medical School, Columbia, Missouri
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Phillips BZ, Taylor HO, Klinge PM, Sullivan SR. Piezoelectric technology for pediatric autologous cranioplasty. Cleft Palate Craniofac J 2013; 51:361-4. [PMID: 23902268 DOI: 10.1597/13-083] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective : Pediatric patients with skull defects larger than available sources for splitting bicortical bone have limited options for autogenous cortical bone cranioplasty. Piezoelectric instruments allow donor bone to be chosen based on the best possible contour rather than the presence of bicortical bone. We present the use of piezoelectric technology to split thin unicortical calvarium for autogenous cranioplasty in a series of pediatric patients. Design : Retrospective review of a series of pediatric patients requiring reconstruction for skull defects. Patients/Intervention : Our series included a 2-year-old with a parietal skull tumor and resultant 3 × 3-cm defect after craniectomy, a 2-year-old with a 3 × 3-cm defect after excision of an occipital skull tumor, a 10-year-old with a 4 × 5-cm skull defect after excision of an occipital skull tumor, and a 13-year-old who suffered a gunshot to the forehead with a 12 × 7-cm frontal skull defect. We used a piezoelectric saw to precisely and safely split unicortical and bicortical cranium that ranged from 1 to 3 mm in thickness. The inner layer was used to reconstruct the donor site; whereas, the outer layer was used for the craniectomy defect. Conclusion : The piezoelectric saw allows unicortical bone to be split and used for cortical bone cranioplasty. This technology allows choice of donor site based on the best contour rather than the presence of bicortical bone. This technique expands the possibilities of autogenous cranioplasty and enables primary repair of cranial defects that would otherwise require secondary cranioplasty with remote donor sites, foreign materials, or unstable particulate cranioplasty.
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Abstract
Although most cases of craniosynostosis are nonsyndromic, craniosynostosis is known to occur in conjunction with other anomalies in well-defined patterns that make up clinically recognized syndromes. Patients with syndromic craniosynostoses are much more complicated to care for, requiring a multidisciplinary approach to address all of their needs effectively. This review describes the most common craniosynostosis syndromes, their characteristic features and syndrome-specific functional issues, and new modalities utilized in their management. General principles including skull development, the risk of developing increased intracranial pressure in craniosynostosis syndromes, and techniques to measure intracranial pressure are discussed. Evolving techniques of the established operative management of craniosynostosis are discussed together with more recent techniques including spring cranioplasty and posterior cranial vault distraction osteogenesis.
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Affiliation(s)
- Christopher Derderian
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Subtotal cranial vault remodelling in anterior sagittal suture closure: impact of age on surgical outcome. Int J Oral Maxillofac Surg 2012; 41:1232-7. [DOI: 10.1016/j.ijom.2012.05.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 03/11/2012] [Accepted: 05/24/2012] [Indexed: 10/28/2022]
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Does the incidence of traumatic brain injury in children increase after craniofrontal surgery? J Craniofac Surg 2011; 22:1284-6. [PMID: 21772197 DOI: 10.1097/scs.0b013e31821c6b2d] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Craniofrontal reshaping (CR) for the treatment of craniosynostosis results in a temporary cranial defect due to the advancement and/or expansion of the supraorbital and frontal bones. The goal of the present study was to determine whether the incidence traumatic brain injury (TBI) was increased in patients after CR as a result of this breach in skull integrity. METHODS We performed a retrospective chart review of all patients with a diagnosis of craniosynostosis who underwent CR between 1997 and 2007 at our institution. The incidence of TBI (defined as a computed tomography-documented brain or skull injury or loss of consciousness) was determined during a 2-year postoperative follow-up period. Patients older than 1 year at the time of surgery, or those with less than 2 years of follow-up after surgery, were excluded. RESULTS A total of 396 patients met the inclusion criteria. The incidence of TBI was zero (95% confidence interval, 0-760/100,000). CONCLUSIONS The estimated incidence of TBI after CR surgery is between 0 and 760 per 100,000 patients in our clinic population. These data indicate that although CR may be associated with a slightly increased risk of TBI while the skull is healing, the absolute incidence of such injury remains extremely rare.
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