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Ye J, Wang J, Zhao J, Xia M, Wang H, Sun L, Zhang WB. RhoA/ROCK-TAZ Axis regulates bone formation within calvarial trans-sutural distraction osteogenesis. Cell Signal 2024; 121:111300. [PMID: 39004327 DOI: 10.1016/j.cellsig.2024.111300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/29/2024] [Accepted: 07/11/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Craniofacial skeletal deformities can be addressed by applying tensile force to sutures to prompt sutural bone formation. The intricate process of mechanical modulation in craniofacial sutures involves complex biomechanical signal transduction. The small GTPase Ras homolog gene family member A (RhoA) functions as a key mechanotransduction protein, orchestrating the dynamic assembly of the cytoskeleton by activating the Rho-associated coiled-coil containing protein kinase (ROCK). Transcriptional coactivator with PDZ-binding motif (TAZ) serves as a crucial mediator in the regulation of genes and the orchestration of biological functions within the mechanotransduction signaling pathway. However, the role of RhoA/ROCK-TAZ in trans-sutural distraction osteogenesis has not been reported. METHODS We utilized pre-osteoblast-specific RhoA deletion mice to establish an in vivo calvarial trans-sutural distraction model and an in vitro mechanical stretch model for pre-osteoblasts isolated from neonatal mice. Micro-CT and histological staining were utilized to detect the formation of new bone in the sagittal suture of the skull as well as the activation of RhoA, Osterix and TAZ. The activation of ROCK-limk-cofilin and the nuclear translocation of TAZ in pre-osteoblasts under mechanical tension were detected through Western blot, qRT-PCR, and immunofluorescence. RESULTS The osteogenic differentiation of pre-osteoblasts was facilitated by mechanical tension through the activation of RhoA and Rho-associated kinase (ROCK), while ablation of RhoA impaired osteogenesis by inhibiting pre-osteoblast differentiation after suture expansion. Furthermore, inhibiting RhoA expression could block tensile-stimulated nuclear translocation of TAZ by preventing F-actin assembly through ROCK-LIM-domain kinase (LIMK)-cofilin pathway. In addition, the TAZ agonist TM-25659 could attenuate impaired osteogenesis caused by ablation of RhoA in pre-osteoblasts by increasing TAZ nuclear accumulation. CONCLUSIONS This study demonstrates that mechanical stretching promotes the osteogenic differentiation of pre-osteoblasts in trans-sutural distraction osteogenesis, and this process is mediated by the RhoA/ROCK-TAZ signaling axis. Overall, our results may provide an insight for potential treatment strategies for craniosynostosis patients through trans-sutural distraction osteogenesis.
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Affiliation(s)
- Junjie Ye
- Department of Orthodontics, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing Medical University, Nanjing 210029, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing Medical University, Nanjing 210029, China
| | - Jialu Wang
- Nanjing Stomatological Hospital, Affiliated Hospital of Medical School, Institute of Stomatology, Nanjing University, Nanjing 210000, China
| | - Jing Zhao
- Department of Orthodontics, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing Medical University, Nanjing 210029, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing Medical University, Nanjing 210029, China
| | - Meng Xia
- Changsha Stomatological Hospital, Changsha, Hunan 410000, China
| | - Hua Wang
- Department of Orthodontics, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing Medical University, Nanjing 210029, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing Medical University, Nanjing 210029, China
| | - Lian Sun
- Department of Orthodontics, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing Medical University, Nanjing 210029, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing Medical University, Nanjing 210029, China.
| | - Wei-Bing Zhang
- Department of Orthodontics, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing Medical University, Nanjing 210029, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing Medical University, Nanjing 210029, China; The Fourth Affiliated Hospital of Soochow University, Medical Center of Soochow University, Suzhou 215000, China.
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Jeon S, Kwon DH, Han M, Oh AK, Chung JH, Kim S, Kim SK, Phi JH, Lee JY, Kim KH, Kim BJ. Identifying Risk Factors for Wound Complications Following Fronto-Orbital Advancement in Patients With Craniosynostosis: 3-dimensional Craniometrics Analysis. J Craniofac Surg 2024:00001665-990000000-01828. [PMID: 39178394 DOI: 10.1097/scs.0000000000010539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 06/23/2024] [Indexed: 08/25/2024] Open
Abstract
This study aims to identify 3-dimensional (3D) craniometric predictors of wound complications following fronto-orbital advancement (FOA) surgery in craniosynostosis patients. The authors conducted a retrospective review of medical records for 43 patients (25 female, 18 male) who underwent open FOA between 2006 and 2023, with an average follow-up duration of 91.8 months. The data collected included age at surgery, sex, whether the craniosynostosis was syndromic, involvement of multiple sutures, history of suturectomy, wound complications (categorized as minor or major), and preoperative and postoperative 3D CT scans. The authors quantified relative changes in intracranial volume (ICV), cranial area above the Frankfurt Horizontal plane, anteroposterior diameter (APD), and cranial height (CH) using Mimics software. A logistic regression analysis was performed to identify predictors of wound complications post-FOA. Among the 43 patients who underwent FOA, 10 experienced postoperative wound complications (4 minor, 6 major), revealing significant associations with multisuture involvement and changes in △cranial area, △APD, and △CH (all P<0.05). In the multivariable analysis with backward elimination, △cranial area, and △CH were identified as significant risk factors for wound complications (OR 1.17, 95% CI: 1.01-1.36, P=0.032; and OR 0.59, 95% CI: 0.38-0.92, P=0.019, respectively). The cutoff values for △cranial area and △APD were 5.95% and 7.93%, respectively. This study identified measurable craniometric changes, especially in the cranial area, as risk factors for wound complications following FOA. It underscores the necessity for personalized surgical planning and meticulous postoperative wound care in FOA to enhance patient outcomes through risk-aware strategies.
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Affiliation(s)
- Sungmi Jeon
- Division of Pediatric Plastic Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine
| | - Dae Hyun Kwon
- Division of Pediatric Plastic Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine
| | - Mira Han
- Medical Research Collaborating Center, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Albert K Oh
- Divisions of Plastic Surgery, Children's National Medical Center, Washington, DC
| | - Jee Hyeok Chung
- Division of Pediatric Plastic Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine
| | - Sukwha Kim
- Department of Plastic Surgery, CHA Bundang Medical Center, Gyeonggi-do
- Medical Big Data Research Center, Seoul National University College of Medicine
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Byung Jun Kim
- Division of Pediatric Plastic Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine
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Santiago G, Santiago C, Nguyen A, Choudhary A, Zhao L, Alkureishi LWT, Patel PK, Purnell CA. Alterations in Sphenoid Anatomy in Craniosynostosis: Implications for Fronto-Orbital Advancement. Cleft Palate Craniofac J 2024:10556656241245514. [PMID: 38567431 DOI: 10.1177/10556656241245514] [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: 04/04/2024] Open
Abstract
OBJECTIVE Fronto-orbital advancement involves removal of the fronto-orbital bandeau. Visualization of the saw blade is lost as it passes through the fronto-orbital-sphenoid junction (FOSJ), placing the temporal lobe at risk of injury. We aim to provide a 3D analysis of the space surrounding this osteotomy to differentiate various types of craniosynostoses. DESIGN Retrospective cohort. SETTING Institutional. PATIENTS Thirty patients with isolated unicoronal synostosis, nonsyndromic bicoronal synostosis, metopic synostosis, Apert syndrome, Crouzon syndrome, and Muenke syndrome. INTERVENTIONS CT scans conducted between 2 months to 2 years of age were 3D reconstructed to compare craniometrics against normal controls. MAIN OUTCOME MEASURE(S) Craniometrics. RESULTS The mean bone thickness of the FOSJ at the level of the supraorbital rim was significantly small for the Apert, unicoronal and bicoronal groups. The mean vertical height of the middle cranial fossa from the lesser sphenoid wing was significantly greater in the unicoronal group. The mean vertical height of the tip of the temporal lobe from the lateral sphenoid ridge was greater in the unicoronal, isolated bicoronal, and Apert groups. The mean corneal protrusion beyond the lateral orbital rim was significantly greater in the Apert and unicoronal groups. The mean horizontal depth of the orbit was smallest in the Apert group. The mean vertical distance between the dacryon and the foramen cecum, and the mean volume of temporal lobe beneath the sphenoid shelf were the largest in the Apert group. CONCLUSIONS Patients with Apert syndrome have the most unfavorable morphology of the anterior and middle cranial fossae.
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Affiliation(s)
- Gaia Santiago
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Chiara Santiago
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Alvin Nguyen
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Akriti Choudhary
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Linping Zhao
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - Lee W T Alkureishi
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
- Department of Plastic and Reconstructive Surgery, Shriners Children's Hospital, Chicago, IL, USA
| | - Pravin K Patel
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
- Department of Plastic and Reconstructive Surgery, Shriners Children's Hospital, Chicago, IL, USA
| | - Chad A Purnell
- Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois College of Medicine, Chicago, IL, USA
- Department of Plastic and Reconstructive Surgery, Shriners Children's Hospital, Chicago, IL, USA
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Kalantar Hormozi A, Moradi E, Rahnama A, Noori M, Kalantar Hormozi H. Surgical Treatment of Anterior Plagiocephaly With Limited Calvarial Osteotomy. J Craniofac Surg 2024:00001665-990000000-01319. [PMID: 38315766 DOI: 10.1097/scs.0000000000009988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/14/2023] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVE Anterior plagiocephaly is a condition in which the unicoronal suture is prematurely fused and the skull shape will change due to asymmetric growth. METHODS This is a retrospective study describing the unilateral limited frontal osteotomy for remodeling deformed areas in the frontal and orbital bone and its pros and cons. RESULTS Twenty-eight patients were included in the study, with a mean age of 16.8 (±11.7) months. Mean intraoperative bleeding was 78.1 (±23.6) mL. One (3.57%) patient developed postoperative bleeding, around 200 mL. After 12 months, all patients (100%) had grade I Whitaker. CONCLUSION The described technique is safe and may have promising short-term outcomes for the correction of anterior plagiocephaly.
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Affiliation(s)
- Abdoljalil Kalantar Hormozi
- Department of Plastic and Craniofacial Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, 15 Khordad Hospital
| | - Ehsan Moradi
- Department of Pediatric Neurosurgery and Craniofacial Surgery, Mofid Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ahmad Rahnama
- Department of Plastic and Craniofacial Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, 15 Khordad Hospital
| | - Mehran Noori
- Department of Plastic and Craniofacial Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, 15 Khordad Hospital
| | - Hadis Kalantar Hormozi
- Brain Imaging Center, Douglas Mental Health University Institute; Integrated Program in Neuroscience, McGill University, Montreal, Quebec, Canada
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Bashiryan BA, Gadzhieva OA, Satanin LA, Lavrenyuk EA, Tere VA, Mazerkina NA, Sakharov AV, Getmanova IV, Roginsky VV. [Prospective analysis of inflammatory markers and perioperative clinical data in children with craniosynostosis undergoing reconstructive surgery]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2024; 88:70-78. [PMID: 38334733 DOI: 10.17116/neiro20248801170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
BACKGROUND Craniosynostosis (CS) is a group of skull malformations manifested by congenital absence or premature closure of cranial sutures. Reconstructive surgery in the second half of life is traditional approach for CS. The issues of surgical stress response after reconstructive surgery for CS in children are still unclear. OBJECTIVE To evaluate clinical and laboratory parameters in children undergoing traumatic reconstructive surgery for CS. MATERIAL AND METHODS Inclusion criteria were CS, reconstructive surgery, age <24 months, no comorbidities and available laboratory diagnostic protocol including complete blood count, biochemical blood test with analysis of C-reactive protein, procalcitonin, ferritin and presepsin. The study included 32 patients (24 (75%) boys and 8 (25%) girls) aged 10.29±4.99 months after surgery between October 2021 and June 2022. Non-syndromic and syndromic forms of CS were observed in 25 (78.1%) and 7 (21.9%) cases, respectively. RESULTS There were no infectious complications. We analyzed postoperative clinical data, fever, clinical and biochemical markers of inflammation. CONCLUSION Early postoperative period after reconstructive surgery for CS in children is accompanied by significant increase of inflammatory markers (C-reactive protein, procalcitonin, ferritin). However, these findings do not indicate infectious complications. This is a manifestation of nonspecific systemic reaction. Severity of systemic inflammatory response syndrome with increase in acute phase proteins indicates highly traumatic reconstructive surgery for CS in children. Analysis of serum presepsin allows for differential diagnosis between infectious complication and uncomplicated course of early postoperative period.
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Affiliation(s)
| | | | - L A Satanin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - V A Tere
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | - V V Roginsky
- Central Research Institute of Dental and Maxillofacial Surgery, Moscow, Russia
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Valenti AB, Asadourian P, Guadix S, Truong AY, Buontempo M, Hoffman CE, Souweidane M, Imahiyerobo TA. Management of Total Frontal Bone Loss After Surgery for Craniosynostosis: The Modified Visor Bone Flap With Brain Cage. Cleft Palate Craniofac J 2024; 61:144-149. [PMID: 36017535 DOI: 10.1177/10556656221121041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Complications after craniosynostosis surgery occur in 11% to 36% of cases and may be precipitated by poor soft tissue coverage and concomitant exposure of non-sterile regions; sequelae may result in infection, osteomyelitis, and bone loss requiring complex reconstruction. In the pediatric population, autologous cranioplasty remains the gold standard due to growth potential and a more favorable complication profile than synthetic cranioplasty. Virtual surgery planning (VSP) and computer-assisted design (CAD)/computer-assisted manufacturing (CAM) technology can be utilized to create innovative, patient-specific autologous solutions, similar to the approach with synthetic cranioplasty. A novel surgical approach using VSP was used for an 18-month-old female with near total bifrontal bone loss. Surface area measurements were used to determine the amount of bone available to replace the infected frontal bone. VSP was utilized to determine the most efficient construct configuration possible to achieve maximal coverage via calculation of cranial bone surface area measurements. Surgical reconstruction of the defect was planned as a Modified Visor Bone Flap with Posterior Brain Cage. A construct was fashioned from available cranial bone struts to obtain widespread coverage. 3D Recon images from before and after surgery demonstrate almost complete re-ossification of the cranial vault with significant resulting clinical improvement. Reconstruction of total frontal bone loss is possible by utilizing this technique. VSP can improve the safety and efficiency of complex autologous cranial bone reconstructions. We propose a treatment algorithm to address the problem of near total frontal bone loss in young children for whom alloplastic implants are not suitable.
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Affiliation(s)
- Alyssa B Valenti
- Department of Surgery, Division of Plastic Surgery, Columbia University Medical Centeragb, New York, NY, USA
- Division of Plastic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Paul Asadourian
- Division of Plastic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Sergio Guadix
- Department of Neurosurgery, Weill Cornell Medical Center, New York, NY, USA
| | - Albert Y Truong
- Department of Surgery, Division of Plastic Surgery, Columbia University Medical Centeragb, New York, NY, USA
- Division of Plastic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Michelle Buontempo
- Department of Neurosurgery, Weill Cornell Medical Center, New York, NY, USA
| | - Caitlin E Hoffman
- Department of Neurosurgery, Weill Cornell Medical Center, New York, NY, USA
| | - Mark Souweidane
- Department of Neurosurgery, Weill Cornell Medical Center, New York, NY, USA
| | - Thomas A Imahiyerobo
- Department of Surgery, Division of Plastic Surgery, Columbia University Medical Centeragb, New York, NY, USA
- Division of Plastic Surgery, Columbia University Medical Center, New York, NY, USA
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Bashiryan BA, Gadzhieva OA, Satanin LA, Mazerkina NA, Khukhlaeva EA, Lavrenyuk EA, Tere VA, Kwan OK, Roginsky VV. [Prospective assessment of surgical stress response in patients with craniosynostosis: comparison of clinical and laboratory data]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2024; 88:62-70. [PMID: 39169583 DOI: 10.17116/neiro20248804162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
BACKGROUND Highly traumatic surgical correction of craniosynostosis (CS) is usually followed by severe postoperative period and high risk of complications. Surgical stress response (SSR) is an important and often neglected cause of severe early postoperative period. OBJECTIVE To compare clinical and laboratory parameters of SSR in children who underwent various surgeries for CS. MATERIAL AND METHODS The study included 63 patients aged 7.02±4.12 months. All ones underwent surgery for CS between October 2021 and June 2022. We analyzed clinical and laboratory markers of SSR, as well as correlation with severity of surgical stress. RESULTS No surgical complications were observed. There were postoperative complications in 12 (19.0%) cases including febrile fever in 9 (14.3%) patients, severe pain and edematous syndromes with prolonged hospital-stay in 3 (4.8%) cases. Significant correlations were revealed between severity of surgical stress and certain laboratory markers (CRP, ACTH, T3, insulin, HOMA-IR). The last ones characterized SSR severity. Patients with high scores of stress response demonstrated more severe course of early postoperative period. CONCLUSION Surgical stress scale makes it possible to predict early postoperative period and optimize patient management. Lower severity of surgical stress response following endoscopic interventions is another reason for the wider use of low-traumatic surgical methods in pediatric neurosurgery.
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Affiliation(s)
| | | | - L A Satanin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | - V A Tere
- Burdenko Neurosurgical Center, Moscow, Russia
| | - O K Kwan
- Burdenko Neurosurgical Center, Moscow, Russia
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Hengartner AC, Serrato P, Sayeed S, Prassinos AJ, Alperovich M, DiLuna M, Elsamadicy AA. Associated Risk Factors for Extended Length of Stay Following Cranial Vault Remodeling for Craniosynostosis: Analysis of the 2012 to 2021 NSQIP-Pediatric Database. J Craniofac Surg 2023:00001665-990000000-01172. [PMID: 37943085 DOI: 10.1097/scs.0000000000009847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/04/2023] [Indexed: 11/10/2023] Open
Abstract
OBJECTIVES The aim of this study was to identify the factors associated with extended length of stay (LOS) for pediatric patients with craniosynostosis undergoing cranial vault remodeling (CVR). METHODS A retrospective cohort study was performed using the 2012 to 2021 American College of Surgeons National Surgical Quality Improvement Program-Pediatric database. Pediatric patients below 2 years old with craniosynostosis who underwent CVR were identified using Current Procedural Terminology and International Classification of Diseases-9/10 codes. Patients were dichotomized according to whether they encountered an extended postoperative hospital LOS, which was defined as LOS greater than the 75th percentile for the entire cohort (4 days). Patient demographics, comorbidities, intraoperative variables, postoperative adverse events, and health care resource utilization were assessed. Multivariate logistic regression analysis was utilized to identify predictors of prolonged LOS. RESULTS In our cohort of 9784 patients, 1312 (13.4%) experienced an extended LOS. The extended LOS cohort was significantly older than the normal LOS cohort (normal LOS: 225.1±141.8 d vs. extended LOS: 314.4±151.7 d, P<0.001) and had a smaller proportion of non-Hispanic white patients (normal LOS: 70.0% vs. extended LOS: 61.2%, P<0.001). Overall, comorbidities and adverse events were significantly higher in the extended LOS cohort than the normal LOS cohort. On multivariate logistic regression, independent associations of extended LOS included age, race and ethnicity, weight, American Society of Anesthesiologists classification, impaired cognitive status, structural pulmonary abnormalities, asthma, and neuromuscular disorders. CONCLUSIONS This study demonstrates that age, race, comorbidities, and perioperative complications contribute to extended LOS after CVR for craniosynostosis. Further investigations to further elucidate the risk factors of extended LOS is warranted to optimize patient outcomes.
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Affiliation(s)
| | - Paul Serrato
- Department of Neurosurgery, Yale University School of Medicine
| | - Sumaiya Sayeed
- Department of Neurosurgery, Yale University School of Medicine
| | - Alexandre J Prassinos
- Department of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT
| | - Michael Alperovich
- Department of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT
| | - Michael DiLuna
- Department of Neurosurgery, Yale University School of Medicine
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Cleft and Craniofacial Surgery. J Oral Maxillofac Surg 2023; 81:E120-E146. [PMID: 37833020 DOI: 10.1016/j.joms.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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10
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Grove AM, Kirsch HM, Kurnik NM, Bristol RE, Sitzman TJ, Pfeifer C, Singh DJ. Preoperative Frontal and Parietal Bone Thickness Assessment to Predict Blood Loss and Transfusion During Extended Suturectomy for Isolated Sagittal Craniosynostosis. Cleft Palate Craniofac J 2023:10556656231202840. [PMID: 37710993 DOI: 10.1177/10556656231202840] [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: 09/16/2023] Open
Abstract
OBJECTIVE To predict the morbidity of sagittal suturectomy using preoperative computer tomographic measurement of frontal and parietal bone thickness in osteotomy sites. DESIGN Retrospective analysis. SETTING Tertiary children's hospital. PATIENTS Fifty infants with nonsyndromic, isolated sagittal craniosynostosis who underwent extended sagittal suturectomy from 2015-2022. METHODS Mean thickness of the frontal and parietal bone in regions of osteotomies were determined for each patient from preoperative CT images obtained within 30 days prior to suturectomy. The relationship between bone thickness (mm) and estimated blood loss (mL) was evaluated using Spearman's correlation and a multivariable model that adjusted for patient weight and surgery duration. The association between bone thickness and perioperative blood transfusion was evaluated using a multivariable logistic model controlling for patient weight and surgery duration. MAIN OUTCOME MEASURES Estimated blood loss, perioperative blood transfusion. RESULTS Frontal and parietal bone thickness in the region of osteotomies were positively correlated with estimated blood loss (p < 0.01). After adjusting for patient weight and duration of operation, both parietal and frontal bone thickness were associated with intraoperative blood loss (R2 = 0.292, p = 0.002 and R2 = 0.216, p = 0.026). Thicker frontal and parietal bone in the line of osteotomies resulted in significantly higher odds of blood transfusion. Bone thickness in the line of parietal osteotomies was 76% accurate at identifying patients who would require blood transfusion (p = 0.004). CONCLUSIONS Frontal and parietal bone thickness in the line of osteotomies is associated with blood loss and perioperative blood transfusion for sagittal suturectomy operations.
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Affiliation(s)
- Austin M Grove
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix Children's Center for Cleft and Craniofacial Care, Phoenix, AZ, USA
| | - Hannah M Kirsch
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix Children's Center for Cleft and Craniofacial Care, Phoenix, AZ, USA
| | - Nicole M Kurnik
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix Children's Center for Cleft and Craniofacial Care, Phoenix, AZ, USA
| | - Ruth E Bristol
- Division of Pediatric Neurosurgery, Department of Surgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Thomas J Sitzman
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix Children's Center for Cleft and Craniofacial Care, Phoenix, AZ, USA
| | - Cory Pfeifer
- Department of Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Davinder J Singh
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix Children's Center for Cleft and Craniofacial Care, Phoenix, AZ, USA
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11
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Which centers should be authorized to treat craniosynostosis? A plea for quality and not for quantity. Arch Pediatr 2023; 30:113-117. [PMID: 36509626 DOI: 10.1016/j.arcped.2022.11.021] [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: 05/17/2022] [Accepted: 11/20/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In centers for craniosynostosis surgery, the volume of activity does not necessarily reflect the quality of the treatment. OBJECTIVE Our aim was to analyze a retrospective series of patients over a period of 6 years in a low-volume craniosynostosis surgery center, and to study indicators that reflect the quality of treatment. PATIENTS AND METHODS The analysis included all patients who underwent a craniofacial surgery for all forms of craniosynostosis during the period 2012-2017 (annual follow-up for 4 years). Data on the type of synostosis, sex, age, weight, type of surgery, duration of surgery, blood transfusion, postinterventional care, and total length of hospital stay were collected. Medical and surgical complications were recorded using the Leeds classification. RESULTS Overall, 42 patients (33 male; 23 cases of scaphocephaly, 13 cases of trigonocephaly, 4 cases of coronal plagiocephaly, 1 case of lambdoid plagiocephaly, and 1 case of brachycephaly) underwent craniofacial surgery with a median age of 7.4 months [4.8; 10.4] and a mean weight of 8.40 ± 1.92 kg at surgery. The median hospital stay was 7 days [6;7] with 1 day in the postinterventional care unit for 83% of patients. The global complication rate was 12% (95% CI: 4%-26%) with three minor cutaneous and two major (cardiovascular and septic) complications. CONCLUSION Complication rates reflect the quality of care in a center that treats craniosynostosis much more than do the number of procedures, mean hospital stay, and blood transfusion rates. It is essential to define new indicators capable of measuring the quality of life linked to surgical procedures and of using them to assess the competence of a center.
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Chowdhury AM, Patel R, Silva AHD, Dunaway DJ, Jeelani NUO, Ong J, Hayward R, James G. Sagittal synostosis: does choice of intervention and its timing affect the long-term aesthetic and neurodevelopmental outcome? A single-institution study of 167 children. J Neurosurg Pediatr 2023; 31:169-178. [PMID: 36461830 DOI: 10.3171/2022.10.peds22135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 10/21/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE Sagittal craniosynostosis (SC) is the most commonly encountered form of craniosynostosis. Despite its relative frequency, there remains significant heterogeneity in both operative management and follow-up between centers and a relative paucity of long-term outcome data in the literature. At the authors' institution, families of children presenting with SC are offered the following options: 1) conservative management with ophthalmic surveillance, 2) minimally invasive surgery at < 6 months of age (spring-assisted cranioplasty [SAC]) or 3) calvarial vault remodeling at any age (CVR). The authors reviewed outcomes for all children presenting with SC during a 5-year period, regardless of the treatment received. METHODS Consecutive children born between January 1, 2008, and December 31, 2012, presenting with SC were identified, and detailed chart reviews were undertaken. Demographic, surgical, perioperative, head shape, scar, and neurodevelopmental (behavioral, education, speech, and language) data were analyzed. The cohort was divided by type of surgery (none, SAC, or CVR) and by age at surgery (early, defined as ≤ 6 months; or late, defined as > 6 months) for comparison purposes. RESULTS A total of 167 children were identified, 129 boys and 38 girls, with a median age at presentation of 5.0 (range 0.4-135) months. Three families opted for conservative management. Of the 164 children who underwent surgery, 83 underwent SAC, 76 underwent CVR, and 5 underwent a "hybrid" procedure (CVR with springs). At a median age of 7.0 (range 0.5-12.3) years, there was no significant difference in concerns regarding head shape, scar, or neurodevelopmental outcomes between the early and late intervention groups over all procedures performed, or between the early or late SAC and CVR cohorts. There were more head shape concerns in the SAC group than in the CVR group overall (25.7% vs 11.8%, respectively; p = 0.026), although most of these concerns were minor and did not require revision. CONCLUSIONS In this cohort, regardless of operative intervention and timing of intervention, infants achieved similar neurodevelopmental outcomes. Minimally invasive surgery (SAC) appears to result in less complete correction of head shape than CVR, but this may be balanced by advantages in reduced operative time, hospitalization, and blood loss. SAC was equal to CVR in neuropsychological outcomes.
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Affiliation(s)
- Adnan-Mustafiz Chowdhury
- 1Barts and the London School of Medicine and Dentistry, Queen Mary University of London
- 2Craniofacial Unit, Great Ormond Street Hospital, London; and
| | - Ryan Patel
- 1Barts and the London School of Medicine and Dentistry, Queen Mary University of London
- 2Craniofacial Unit, Great Ormond Street Hospital, London; and
| | | | - David J Dunaway
- 2Craniofacial Unit, Great Ormond Street Hospital, London; and
- 3Great Ormond Street Institute of Child Health, University College London, United Kingdom
| | - Noor Ul Owase Jeelani
- 2Craniofacial Unit, Great Ormond Street Hospital, London; and
- 3Great Ormond Street Institute of Child Health, University College London, United Kingdom
| | - Juling Ong
- 2Craniofacial Unit, Great Ormond Street Hospital, London; and
- 3Great Ormond Street Institute of Child Health, University College London, United Kingdom
| | - Richard Hayward
- 2Craniofacial Unit, Great Ormond Street Hospital, London; and
- 3Great Ormond Street Institute of Child Health, University College London, United Kingdom
| | - Greg James
- 2Craniofacial Unit, Great Ormond Street Hospital, London; and
- 3Great Ormond Street Institute of Child Health, University College London, United Kingdom
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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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14
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Perioperative Morbidity of Secondary Frontal Orbital Advancement After Initial Frontal Orbital Advancement. J Craniofac Surg 2023; 34:173-176. [PMID: 36084230 DOI: 10.1097/scs.0000000000009002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/08/2022] [Indexed: 01/11/2023] Open
Abstract
Frontal orbital advancement (FOA) is frequently performed for patients with syndromic and/or multisuture craniosynostosis. A small proportion of patients who undergo FOA have unfavorable growth and subsequently require a second FOA later in life; however, the perioperative risks associated with this second procedure are not well studied. We report results from a retrospective review of FOAs conducted from 2007 to 2022 at a single site with the same craniofacial surgeon. A total of 33 patients were included. Perioperative outcomes were compared between primary and secondary FOA procedures. The two groups were similar in regard to suture involvement and diagnosis, although the secondary FOA group was older at the time of their FOA (1.23 versus 7.07 y, P <0.001). There was no significant difference between groups in operating time, volume of blood transfusion by weight, or in the incidence of postoperative wound complications ( P >0.05). Primary FOA procedures had significantly higher weight-adjusted blood loss (28 versus 18 mL/kg, P =0.014), with a higher proportion of patients receiving a blood transfusion (95% versus 62%, P =0.025). There was no significant difference between groups in the incidence of intraoperative dural injury (50% versus 84%, P =0.067). Our findings suggest that secondary procedures appear to impose less of a surgical risk relative to primary FOA traditionally performed in infancy, likely because of the advanced age at the time of secondary FOA.
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Stanton E, Urata M, Chen JF, Chai Y. The clinical manifestations, molecular mechanisms and treatment of craniosynostosis. Dis Model Mech 2022; 15:dmm049390. [PMID: 35451466 PMCID: PMC9044212 DOI: 10.1242/dmm.049390] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Craniosynostosis is a major congenital craniofacial disorder characterized by the premature fusion of cranial suture(s). Patients with severe craniosynostosis often have impairments in hearing, vision, intracranial pressure and/or neurocognitive functions. Craniosynostosis can result from mutations, chromosomal abnormalities or adverse environmental effects, and can occur in isolation or in association with numerous syndromes. To date, surgical correction remains the primary treatment for craniosynostosis, but it is associated with complications and with the potential for re-synostosis. There is, therefore, a strong unmet need for new therapies. Here, we provide a comprehensive review of our current understanding of craniosynostosis, including typical craniosynostosis types, their clinical manifestations, cranial suture development, and genetic and environmental causes. Based on studies from animal models, we present a framework for understanding the pathogenesis of craniosynostosis, with an emphasis on the loss of postnatal suture mesenchymal stem cells as an emerging disease-driving mechanism. We evaluate emerging treatment options and highlight the potential of mesenchymal stem cell-based suture regeneration as a therapeutic approach for craniosynostosis.
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Affiliation(s)
- Eloise Stanton
- Center for Craniofacial Molecular Biology, University of Southern California, Los Angeles, CA 90033, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Mark Urata
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA 90033, USA
| | - Jian-Fu Chen
- Center for Craniofacial Molecular Biology, University of Southern California, Los Angeles, CA 90033, USA
| | - Yang Chai
- Center for Craniofacial Molecular Biology, University of Southern California, Los Angeles, CA 90033, USA
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16
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Richardson IJ, Wager LE, Recker MJ, Reynolds R, Ruiz R, Markiewicz MR. Morbidity Associated With Anterior Versus Posterior Cranial Vault Expansion for Early Treatment of Syndromic Craniosynostosis: A Systematic Review and Meta-Analysis. J Oral Maxillofac Surg 2021; 80:651-661. [PMID: 34863645 DOI: 10.1016/j.joms.2021.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this systematic review and meta-analysis was to estimate and compare rates of unplanned reoperation and complications after undergoing either fronto-orbital advancement (anterior cranial vault expansion) or posterior cranial vault expansion as an early surgery in the management of syndromic craniosynostosis. MATERIALS AND METHODS A literature search was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant articles were identified in 2 electronic databases (PubMed and EMBASE) from the time of electronic publication to November 2020. Quality assessment and risk of bias were appraised using the Grading of Recommendations Assessment, Development and Evaluation system. A meta-analysis was performed comparing rates of reoperation and complications between participants who underwent anterior or posterior cranial vault expansion as an early surgery. RESULTS Of 1,373 screened records, 7 met inclusion criteria. Six were included in the meta-analysis. The studies that met inclusion criteria reported on 103 patients treated with anterior techniques and 72 patients treated with a posterior approach. Anterior cranial vault expansion was associated with significantly higher rates of reoperation (Peto odds ratio = 2.83; 95% confidence interval = 1.19, 6.74, P = .02) and complications (Peto odds ratio = 2.61; 95% confidence interval = 1.12, 6.12, P = .03) than posterior cranial vault expansion. CONCLUSIONS Both anterior and posterior approaches are suitable options in the treatment of syndromic craniosynostosis depending on patient-specific factors. Anterior cranial vault expansion was associated with higher rates of unplanned reoperation and complications than posterior techniques in this analysis. Because of the paucity of literature which met inclusion criteria, this study was not able to assess critical outcome variables such as distance distracted/volumetric expansion, estimated blood loss, and cost. Larger studies evaluating both techniques under multiple institutions with long-term follow-up are indicated.
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Affiliation(s)
- Ian J Richardson
- Resident, Department of Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, Louisiana State University, New Orleans, LA; Former predoctoral student, School of Dental Medicine, State University of New York at Buffalo, Buffalo, NY
| | - Lauren E Wager
- Resident, Department of Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, University of Florida, College of Medicine- Jacksonville, Jacksonville, FL; Former predoctoral student, School of Dental Medicine, State University of New York at Buffalo, Buffalo, NY
| | - Matthew J Recker
- Resident in training, Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY
| | - Renée Reynolds
- Assistant professor and Residency Program Director, Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY
| | - Ramon Ruiz
- Director, Pediatric Craniomaxillofacial Surgery, Arnold Palmer Hospital for Children, Orlando, FL
| | - Michael R Markiewicz
- Professor and Chair, Department of Oral and Maxillofacial Surgery, School of Dental Medicine, University at Buffalo, Clinical Professor, Department of Neurosurgery, Division of Pediatric Surgery, Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Attending Surgeon, Roswell Park Comprehensive Cancer Center, Co-Director, Craniofacial Center of Western New York, John Oishei Children's Hospital, Buffalo, NY.
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17
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Cranial Vault Distraction in Nonsyndromic Sagittal Synostosis. J Craniofac Surg 2021; 33:156-160. [PMID: 34519707 DOI: 10.1097/scs.0000000000008125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT A multitude of operations exists for the treatment of patients with sagittal craniosynostosis presenting after 6 months of age, of which total cranial vault remodeling now provides the most reliable aesthetic outcome. As our national craniofacial center evolved and began to develop a comprehensive multi-disciplinary team to manage complex surgical cases, we offered cranial vault distraction as an alternative to more invasive surgery for late presentation nonsyndromic scaphocephaly. The authors conducted a retrospective review of all patients undergoing this procedure.An average distraction distance of 39.4 mm was achieved in 15 patients aged 1 to 9 years. As a result, the cephalic index changed an average of 4%. The mean transfusion volume in the perioperative period was 32.47% of estimated blood volume. There were 2 complications requiring further operative intervention and distraction was stopped early in 1 patient.The authors propose that internal calvarial distraction is a viable alternative to total cranial vault remodeling for the management of late presentations of sagittal craniosynostosis.
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18
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Saponaro G, Pelo S, Gasparini G, Todaro M, Cerbellli E, Moro A, Doneddu P. Approach to Fronto-Orbital Sequelae in Anterior Synostotic Plagiocephaly: Our Flow Chart Based on Di Rocco Classification. J Craniofac Surg 2021; 32:1986-1989. [PMID: 34516067 DOI: 10.1097/scs.0000000000007389] [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: 11/26/2022] Open
Abstract
INTRODUCTION Anterior synostotic plagiocephaly recognizes the synostosis of one of the hemicoronal sutures as a cause and can manifest itself with varying degrees of severity. Clinically it presents a reduction of the sagittal growth of the affected side and flattening of the frontoparietal complex. MATERIALS AND METHODS The authors retrospectively examined our case sample dividing it into 3 groups based on the Di Rocco classification. For each category, we assessed the extent of facial alterations at the end of skeletal growth and retrospectively analyzed the surgical options aimed at correcting aesthetic and skeletal deficits. RESULTS The authors found that predictable results could be obtained by standardizing the surgical procedure based on Di Rocco's classification groups; in particular, the authors achieved satisfactory results by assigning a specific surgical procedure to each class.
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Affiliation(s)
- Gianmarco Saponaro
- Maxillo-Facial Unit, Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, Italy
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19
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Long-Term Neurocognitive Outcomes in Sagittal Synostosis: The Impact of Reoperation. J Craniofac Surg 2021; 32:58-61. [PMID: 33394632 DOI: 10.1097/scs.0000000000006909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Optimal age at surgery in nonsyndromic sagittal craniosynostosis continues to be debated. Previous reports suggest that earlier age at whole vault cranioplasty more frequently requires reoperation. It is unknown, however, whether reoperation affects neurocognitive outcome. This study examined the impact of reoperation on neurocognitive outcome in children with nonsyndromic sagittal craniosynostosis using comprehensive neurocognitive testing. METHODS Forty-seven school-age children (age 5-16 years) with nonsyndromic sagittal craniosynostosis who underwent whole-vault cranioplasty were included in this analysis. Participants were administered a battery of standardized neuropsychological testing to measure neurocognitive outcomes. RESULTS Thirteen of the 47 participants underwent reoperation (27.7%); 11 out of the 13 reoperations were minor revisions while 2 reoperations were cranioplasties. Reoperation rate was not statistically different between patients who had earlier surgery (at age ≤6 months) versus later surgery (at age >6 months) (P > 0.05). Nonreoperated patients who had only one later-in-life surgery did not perform statistically better than reoperated patients on any outcome measure of neurocognitive function, including IQ, academic achievement, visuomotor integration, executive function, and behavior. Comparing reoperated earlier surgery patients with nonreoperated later surgery patients, reoperated earlier surgery patients had higher full-scale and verbal IQ (P < 0.05), scored higher on word reading, reading comprehension, spelling, numerical operations, and visuomotor integration (P < 0.05), and had fewer indicators of suspected learning disabilities (P < 0.01) compared to nonreoperated later surgery patients. CONCLUSION Reoperation rate after whole vault cranioplasty was 27.7%, with few cases of repeat cranioplasty (4.2% of all patients). Reoperation was not associated with worse neurocognitive outcome. Reoperated earlier surgery patients in fact performed better in IQ, academic achievement and visuomotor integration when compared to nonreoperated later surgery patients.
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20
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Bautista G. Craniosynostosis: Neonatal Perspectives. Neoreviews 2021; 22:e250-e257. [PMID: 33795400 DOI: 10.1542/neo.22-4-e250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Craniosynostosis is the premature fusion of 1 or more sutures that normally separate the bony plates of an infant's skull and occurs in about 1 in 2,000 to 2,500 live births. Primary or congenital craniosynostoses represent the majority of cases and consist of single-suture and multisuture synostoses. Multisuture synostoses are typically associated with distinct craniofacial syndromes, including Muenke syndrome, Apert syndrome, Crouzon syndrome, and Pfeiffer syndrome, and are thus categorized under syndromic craniosynostoses. Secondary causes of craniosynostoses include metabolic or hematologic disorders that affect bone metabolism and typically present much later than primary synostoses. The severity of the deformity and the presence of increased intracranial pressure dictate the need for early surgical intervention, prompting the importance of early recognition and timely referral. Infants with craniosynostosis are also at increased risk for neurodevelopmental impairment and thus require close follow-up and monitoring. The early recognition and referral of craniosynostosis is imperative for the optimization of management and minimization of potential neurologic impairments that may develop.
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Affiliation(s)
- Geoanna Bautista
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Mattel Children's Hospital and the David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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21
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Pribadi C, Camp E, Cakouros D, Anderson P, Glackin C, Gronthos S. Pharmacological targeting of KDM6A and KDM6B, as a novel therapeutic strategy for treating craniosynostosis in Saethre-Chotzen syndrome. Stem Cell Res Ther 2020; 11:529. [PMID: 33298158 PMCID: PMC7726873 DOI: 10.1186/s13287-020-02051-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/26/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND During development, excessive osteogenic differentiation of mesenchymal progenitor cells (MPC) within the cranial sutures can lead to premature suture fusion or craniosynostosis, leading to craniofacial and cognitive issues. Saethre-Chotzen syndrome (SCS) is a common form of craniosynostosis, caused by TWIST-1 gene mutations. Currently, the only treatment option for craniosynostosis involves multiple invasive cranial surgeries, which can lead to serious complications. METHODS The present study utilized Twist-1 haploinsufficient (Twist-1del/+) mice as SCS mouse model to investigate the inhibition of Kdm6a and Kdm6b activity using the pharmacological inhibitor, GSK-J4, on calvarial cell osteogenic potential. RESULTS This study showed that the histone methyltransferase EZH2, an osteogenesis inhibitor, is downregulated in calvarial cells derived from Twist-1del/+ mice, whereas the counter histone demethylases, Kdm6a and Kdm6b, known promoters of osteogenesis, were upregulated. In vitro studies confirmed that siRNA-mediated inhibition of Kdm6a and Kdm6b expression suppressed osteogenic differentiation of Twist-1del/+ calvarial cells. Moreover, pharmacological targeting of Kdm6a and Kdm6b activity, with the inhibitor, GSK-J4, caused a dose-dependent suppression of osteogenic differentiation by Twist-1del/+ calvarial cells in vitro and reduced mineralized bone formation in Twist-1del/+ calvarial explant cultures. Chromatin immunoprecipitation and Western blot analyses found that GSK-J4 treatment elevated the levels of the Kdm6a and Kdm6b epigenetic target, the repressive mark of tri-methylated lysine 27 on histone 3, on osteogenic genes leading to repression of Runx2 and Alkaline Phosphatase expression. Pre-clinical in vivo studies showed that local administration of GSK-J4 to the calvaria of Twist-1del/+ mice prevented premature suture fusion and kept the sutures open up to postnatal day 20. CONCLUSION The inhibition of Kdm6a and Kdm6b activity by GSK-J4 could be used as a potential non-invasive therapeutic strategy for preventing craniosynostosis in children with SCS. Pharmacological targeting of Kdm6a/b activity can alleviate craniosynostosis in Saethre-Chotzen syndrome. Aberrant osteogenesis by Twist-1 mutant cranial suture mesenchymal progenitor cells occurs via deregulation of epigenetic modifiers Ezh2 and Kdm6a/Kdm6b. Suppression of Kdm6a- and Kdm6b-mediated osteogenesis with GSK-J4 inhibitor can prevent prefusion of cranial sutures.
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Affiliation(s)
- Clara Pribadi
- Mesenchymal Stem Cell Laboratory, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Esther Camp
- Mesenchymal Stem Cell Laboratory, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Dimitrios Cakouros
- Mesenchymal Stem Cell Laboratory, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Peter Anderson
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Craniofacial Unit, Women and Children Hospital, North Adelaide, South Australia, Australia
| | - Carlotta Glackin
- Molecular Medicine and Neurosciences, City of Hope National Medical Center and Beckman Research Institute, Duarte, CA, USA
| | - Stan Gronthos
- Mesenchymal Stem Cell Laboratory, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia. .,Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.
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22
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Hariri F, Abdullah MF, Adam KBC, Bahuri NFA, Kulasegarah J, Nathan AM, Ismail F, Khaliddin N, May CM, Chan L, Keong TM, Ganesan D, Rahman ZAA. Analysis of complications following multidisciplinary functional intervention in paediatric craniomaxillofacial deformities. Int J Oral Maxillofac Surg 2020; 50:457-462. [PMID: 32891466 DOI: 10.1016/j.ijom.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 06/20/2020] [Accepted: 08/11/2020] [Indexed: 11/24/2022]
Abstract
Paediatric craniomaxillofacial (CMF) surgery requires a multidisciplinary team approach to ensure the optimal and holistic management of children with craniofacial deformities. The aim of this retrospective study was to analyse the complications following functional interventions among 34 CMF deformity patients in a single multidisciplinary craniofacial centre. Electronic data including patient demographic characteristics and clinical entry were analysed. Inclusion criteria were all paediatric patients with CMF deformities who underwent various functional interventions. A total of 64 interventions (48 intermediate and 16 definitive) were conducted. Based on the Sharma classification of complications, 20.3% were type I, 4.7% were type II, 1.6% were type III, and 4.7% were type IV . Most complications were type I, which included local infection (3.1%) and premature opening of tarsorrhaphy (3.1%). More serious complications (types III and IV) included temporary visual loss (1.6%) and intraoperative haemorrhage (1.6%). Although a low complication rate was observed in intermediate interventions, a higher complication rate was observed in more complex definitive interventions such as monobloc distraction osteogenesis. Although most complications were manageable, effective prevention remains mandatory, as serious complications may lead to permanent damage and mortality. This analysis highlights the importance of a multidisciplinary team approach to optimize the outcomes in CMF patient management.
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Affiliation(s)
- F Hariri
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia.
| | - M F Abdullah
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia; School of Dental Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - K B C Adam
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia; Department of Oral Maxillofacial Surgery and Diagnosis, Kulliyyah of Dentistry, IIUM Kuantan Campus, Kuantan, Malaysia
| | - N F A Bahuri
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - J Kulasegarah
- Department of Otorhinolaryngology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - A M Nathan
- Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - F Ismail
- Department of Ophthalmology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - N Khaliddin
- Department of Ophthalmology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - C M May
- Department of Ophthalmology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - L Chan
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
| | - T M Keong
- Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - D Ganesan
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Z A A Rahman
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
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23
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Hope Springs Eternal: Insights Into the Durability of Springs to Provide Long-Term Correction of the Scaphocephalic Head Shape. J Craniofac Surg 2020; 31:2079-2083. [PMID: 32796307 DOI: 10.1097/scs.0000000000006815] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Spring-mediated cranial vault expansion (SMC) has become a primary treatment modality at our institution to correct scaphocephalic head shape in the setting of isolated sagittal craniosynostosis (CS). Spring-mediated cranioplasty is associated with minimal procedural morbidity and reliable clinical efficacy, although long-term outcomes are not well elucidated. Herein we describe our institutional experience and lessons learned with SMC. We hypothesize that SMC performed in young infants offers durable scaphocephalic correction as measured by cephalic index (CI) at the 1, 3, and 5-year postoperative timepoints.Patients with isolated sagittal CS who underwent SMC at our institution during an 8-year period were retrospectively studied. The primary outcome measure was long-term head shape determined by CI at the 1, 3, and 5-year postoperative timepoints. Secondary outcomes included patient and spring factors associated with change in CI, including age and spring force. All statistical tests were 2-tailed with P < 0.05 denoting significance.In total, 88 patients underwent SMC at a median age of 3.3 months with a median preoperative CI 69 (interquartile range: [66, 71]). The postoperative CI increased to 73 [71, 76] at postoperative day 1. At 1 month, the CI increased by 8.6 to 77 (P < 0.0001) and appeared to reach a plateau at 3 months (76, [74, 78]) without further improvement (P < 0.10). At 5 years, CI remained stable without relapse (76, [75, 81], demonstrating an 8.9 increase from preoperative CI. Age at time of spring placement and change in CI were inversely related (P < 0.005). Total spring force directly correlated with increased change in postoperative CI at the 6-month postoperative timepoint (P < 0.02).In summary, SMC offers durable correction of scaphocephaly as measured by CI for patients with isolated sagittal CS at the 5-year postoperative timepoint. The cranial expansion observed 1-month post-spring implantation may serve as a proxy for long-term CI.
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Zubovic E, Skolnick GB, Naidoo SD, Bellanger M, Smyth MD, Patel KB. Endoscopic treatment of combined metopic-sagittal craniosynostosis. J Neurosurg Pediatr 2020; 26:113-121. [PMID: 32302979 DOI: 10.3171/2020.2.peds2029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Combined metopic-sagittal craniosynostosis is traditionally treated with open cranial vault remodeling and fronto-orbital advancement, sometimes in multiple operations. Endoscopic treatment of this multisuture synostosis presents a complex challenge for the surgeon and orthotist. METHODS The authors retrospectively analyzed the preoperative and 1-year postoperative CT scans of 3 patients with combined metopic-sagittal synostosis, all of whom were treated with simultaneous endoscope-assisted craniectomy of the metopic and sagittal sutures followed by helmet therapy. Established anthropometric measurements were applied to assess pre- and postoperative morphology, including cranial index and interfrontal divergence angle (IFDA). Patients' measurements were compared to those obtained in 18 normal controls. RESULTS Two boys and one girl underwent endoscope-assisted craniectomy at a mean age of 81 days. The mean preoperative cranial index was 0.70 (vs control mean of 0.82, p = 0.009), corrected postoperatively to a mean of 0.82 (vs control mean of 0.80, p = 0.606). The mean preoperative IFDA was 110.4° (vs control mean of 152.6°, p = 0.017), corrected postoperatively to a mean of 139.1° (vs control mean of 140.3°, p = 0.348). The mean blood loss was 100 mL and the mean length of stay was 1.7 days. No patient underwent reoperation. The mean clinical follow-up was 3.4 years. CONCLUSIONS Endoscope-assisted craniectomy with helmet therapy is a viable single-stage treatment option for combined metopic-sagittal synostosis, providing correction of the stigmata of trigonoscaphocephaly, with normalization of the cranial index and IFDA.
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Affiliation(s)
- Ema Zubovic
- 1Division of Plastic & Reconstructive Surgery, Department of Surgery, and
| | - Gary B Skolnick
- 1Division of Plastic & Reconstructive Surgery, Department of Surgery, and
| | - Sybill D Naidoo
- 1Division of Plastic & Reconstructive Surgery, Department of Surgery, and
| | | | - Matthew D Smyth
- 2Department of Neurosurgery, Washington University School of Medicine in St. Louis; and
| | - Kamlesh B Patel
- 1Division of Plastic & Reconstructive Surgery, Department of Surgery, and
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Abstract
BACKGROUND Surgical site infection (SSI) after open cranial vault reconstruction (CVR), while relatively uncommon, has received little attention in the literature to date. Here, the authors report our institution's experience with the perioperative management of infectious complications following CVR for craniosynostosis and present the first systematic review of the literature on this topic. METHODS The authors performed a retrospective chart review for patients with syndromic and nonsyndromic craniosynostosis who underwent open CVR between 1990 and 2015 at a single institution to determine predictors of SSIs and a systematic review of studies that evaluated for SSI after CVR to ascertain the pooled incidence of SSI, common infectious organisms, and prophylactic antibiotic protocols. RESULTS Out of 548 primary and 163 secondary CVR cases at our institution, 6 primary reconstruction patients (1.09%) and 9 secondary reconstruction patients (5.52%) developed an SSI requiring extended hospital stay or readmission (P <0.001); overall infection rate was 2.11%. Streptococcus and Staphylococcus species were the most common organisms isolated. On multivariate analysis, syndromic status conferred more than 7 times greater odds of SSI (OR 7.7, P = 0.023). Pooled analysis of the literature yielded an overall SSI rate of 1.05% to 2.01%. In contrast to our institutional findings, the most common organisms reported were Candida species and Pseudomonas aeruginosa. The most common prophylactic antibiotic protocol was a first-generation cephalosporin for 24 to 72 hours post-operatively. CONCLUSIONS Patients undergoing secondary reconstruction have higher infection rates after CVR, and syndromic status is an important predictor of infection when controlling for other patient factors. Our literature review reveals nosocomial organisms to be the most commonly reported source of infection, though this is contrary to our institutional findings of skin flora being most common. Antibiotic prophylaxis varies institutionally.
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Zubovic E, Lapidus JB, Skolnick GB, Naidoo SD, Smyth MD, Patel KB. Cost comparison of surgical management of nonsagittal synostosis: traditional open versus endoscope-assisted techniques. J Neurosurg Pediatr 2020; 25:351-360. [PMID: 31923895 DOI: 10.3171/2019.11.peds19515] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Management of craniosynostosis at an early age is important for mitigating the risk of abnormal cranial development, but treatment can result in significant expenses. Previous research has shown that endoscope-assisted craniectomy (EAC) is less costly than open cranial vault remodeling (CVR) for patients with sagittal synostosis. The aim of this study was to strengthen the existing body of healthcare cost research by elucidating the charges associated with open and endoscopic treatment for patients with nonsagittal synostosis. METHODS The authors performed a retrospective analysis of data obtained in 41 patients who underwent open CVR and 38 who underwent EAC with postoperative helmet therapy for nonsagittal, single-suture craniosynostosis (metopic, coronal, and lambdoid) between 2008 and 2018. All patients were < 1 year of age at the time of surgery and had a minimum 1 year of follow-up. Inpatient charges, physician fees, helmet charges, and outpatient clinic visits in the 1st year were analyzed. RESULTS The mean ages of the children treated with EAC and open CVR were 3.5 months and 8.7 months, respectively. Patients undergoing EAC with postoperative helmet therapy required more outpatient clinic visits in the 1st year than patients undergoing CVR (4 vs 2; p < 0.001). Overall, 13% of patients in the EAC group required 1 helmet, 30% required 2 helmets, 40% required 3 helmets, and 13% required 4 or more helmets; the mean total helmeting charges were $10,072. The total charges of treatment, including inpatient charges, physician fees, outpatient clinic visit costs, and helmet charges, were significantly lower for the EAC group than they were for the open CVR group ($50,840 vs $95,588; p < 0.001). CONCLUSIONS Despite the additional charges for postoperative helmet therapy and the more frequent outpatient visits, EAC is significantly less expensive than open CVR for patients with metopic, coronal, and lambdoid craniosynostosis. In conjunction with the existing literature on clinical outcomes and perioperative resource utilization, these data support EAC as a cost-minimizing treatment for eligible patients with nonsagittal synostosis.
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Affiliation(s)
- Ema Zubovic
- 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Jodi B Lapidus
- 2Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, California; and
| | - Gary B Skolnick
- 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Sybill D Naidoo
- 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Matthew D Smyth
- 3Department of Neurosurgery, Washington University School of Medicine in St. Louis, Missouri
| | - Kamlesh B Patel
- 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, Missouri
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Robertson E, Kwan P, Louie G, Boulanger P, Aalto D. Skeletal Deformity in Patients With Unilateral Coronal Craniosynostosis: Perceptions of the General Public. Craniomaxillofac Trauma Reconstr 2020; 13:122-129. [PMID: 32642043 DOI: 10.1177/1943387520911873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Study Design A two-alternative forced choice design was used to gather perceptual data regarding unicoronal synostosis (UCS). Objective Cranial vault remodeling aims at improving the aesthetic appearance of infants with UCS by reshaping the forehead and reducing the potential for psychosocial discrimination. People's perception of craniofacial deformity plays a role in the stigma of deformity. The purpose of this study is to examine the relationship between objective skull deformity in UCS patients and laypersons' perception of skull normality. Methods Forty layperson skull raters were recruited from the general public. Skull raters were asked to categorize 45 infant skull images as normal or abnormal. Twenty-one of the images were UCS skulls, and 24 were normal skulls. Skulls were displayed briefly on a computer to simulate a first impression scenario and generate a perceptual response. A χ 2 analysis and mixed-effects regression model were used to analyze the response data. Results Members of the general public were good at distinguishing between skull groups, χ 2 (1) = 281.97, P < .001. In addition, skull raters' responses were predicted by the severity of deformity in the UCS skulls (b = -0.10, z = -2.6, P = .010, CI: -0.18, -0.02). A skull with a deformity value of 2.8 mm (CI: 1.8, 4.1) was equally likely to be rated normal or abnormal. Conclusions This is the first study to investigate the relationship between objective skull deformity in UCS and public perception. Laypersons were good at distinguishing the difference between normal and UCS skulls, and their perceptions of normality were predicted by the degree of skull deformity.
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Affiliation(s)
- Emilie Robertson
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, Canada.,Department of Communication Sciences and Disorders, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada.,Institute for Reconstructive Sciences in Medicine, Misericordia Community Hospital, Edmonton, Alberta, Canada
| | - Peter Kwan
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, Canada
| | - Gorman Louie
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, Canada
| | - Pierre Boulanger
- Department of Computing Sciences, University of Alberta, Edmonton, Canada
| | - Daniel Aalto
- Department of Communication Sciences and Disorders, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada.,Institute for Reconstructive Sciences in Medicine, Misericordia Community Hospital, Edmonton, Alberta, Canada
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Azoulay-Avinoam S, Bruun R, MacLaine J, Allareddy V, Resnick CM, Padwa BL. An Overview of Craniosynostosis Craniofacial Syndromes for Combined Orthodontic and Surgical Management. Oral Maxillofac Surg Clin North Am 2020; 32:233-247. [PMID: 32081578 DOI: 10.1016/j.coms.2020.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This article provides an overview of epidemiology, genetics, and common orofacial features of those with craniosynostosis. Patients with craniosynostosis require several surgical procedures along with continuum of care. The earliest surgical interventions are done during the first few years of life to relieve the fused sutures. Midface advancement, limited phase of orthodontic treatment, and combined orthodontics/orthognathic surgery treatment are usually required during later years. This article presents several examples of cases with outcomes associated with these procedures.
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Affiliation(s)
- Shayna Azoulay-Avinoam
- Department of Orthodontics, College of Dentistry, University of Illinois at Chicago, 801 South Paulina Street, 138AD (MC841), Chicago, IL 60612-7211, USA
| | - Richard Bruun
- Boston Children's Hospital Cleft Lip/Palate and Craniofacial Teams, Department of Dentistry, Boston Children's Hospital, Harvard School of Dental Medicine, 300 Longwood Avenue, Boston, MA 02115, USA
| | - James MacLaine
- Department of Developmental Biology, Boston Children's Hospital, Harvard School of Dental Medicine, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Veerasathpurush Allareddy
- Department of Orthodontics, College of Dentistry, University of Illinois at Chicago, 801 South Paulina Street, 138AD (MC841), Chicago, IL 60612-7211, USA.
| | - Cory M Resnick
- Oral & Maxillofacial Surgery Program, Department of Plastic & Oral Surgery, Harvard Medical School, 300 Longwood Avenue, Hunnewell, 1st Floor, Boston, MA 02115, USA
| | - Bonnie L Padwa
- Section of Oral and Maxillofacial Surgery, Department of Plastic & Oral Surgery, Harvard Medical School, 300 Longwood Avenue, Hunnewell, 1st Floor, Boston, MA 02115, USA
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Use of an Oral Device in the Stabilization of Facial Advancement after Early Removal of the Osteodistraction Device for Postoperative Sequelae. Dent J (Basel) 2020; 8:dj8010012. [PMID: 31963781 PMCID: PMC7148519 DOI: 10.3390/dj8010012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/10/2020] [Accepted: 01/17/2020] [Indexed: 11/16/2022] Open
Abstract
The aim of this study is to present an oral device that improves splanchnocranium stability after osteodistraction in children treated for correction of craniofacial malformations. When removal of the distraction device before the end of the treatment is necessary, the reposition of a new fixation system might not be possible. In these cases, regrown bone is immature, and relapse of malformation occurs frequently. We have been treating these cases by the application of an oral device named Maxillary Advancement Contention (MAC). MAC is used in every patient when any complication interrupts the protocol of osteodistraction before the end of the stabilization time. The device is placed immediately after the removal of the distraction device and left in place for at least three months. We used MAC in six children surgically treated for correction of craniosynostosis with facial or craniofacial advancement. To establish the relapse of malformation we analyzed relations Sella-Nasion-Orbitale (SNOr) and Sella-Nasion-A point (SNA) angles before application of the MAC and after one year. The analysis of stability was excellent in every patient. This device might help, with a minimally invasive procedure, to maintain the obtained advancement allowing stabilization of the regrown bone.
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Wound Healing Complications After Cranial Vault Reconstruction for Craniosynostosis. J Craniofac Surg 2019; 31:110-112. [PMID: 31652214 DOI: 10.1097/scs.0000000000005937] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Craniosynostosis is a congenital cranial malformation involving premature fusion of cranial sutures. Indications for surgical repair of craniosynostosis include elevation of intracranial pressure, which can result in impaired vision and mental disability, as well as correction of abnormal skull shape. Resorbable plating systems have become the preferred technique for bony fixation in the repair of craniosynostosis. Multiple studies demonstrate the safety and low complication rate of resorbable plating systems.However, there is no consensus on which plating system is superior for patient outcomes. This study aims to investigate how the polymer composition of resorbable plating systems utilized in cranial vault reconstruction contributes to wound healing complications. A retrospective chart review was performed at the institution between January 1, 2005 and December 31, 2015. About 202 patients who underwent surgical repair of craniosynostosis were identified. The results showed that patients receiving the Biomet Lactosorb plating system were over twice as likely to have a wound complication within a year of surgery compared to other plating systems used at the institution. Wound complications continued to occur in the Biomet Lactosorb group at ≥180 days after surgery, whereas complications among the other plating systems occurred ≤80 days postoperatively. Half of all patients with wound complications had to undergo reoperation. These data demonstrate the effect of unique polymer compositions on wound healing, and will help to guide future clinical practice and industry development of resorbable plating systems.
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Topical Vancomycin for Surgical Prophylaxis in Pediatric Craniofacial Surgeries. J Craniofac Surg 2019; 30:2163-2167. [PMID: 31261326 DOI: 10.1097/scs.0000000000005708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Topical vancomycin has been demonstrated to be safe and effective for reducing surgical site infections (SSIs) following spine surgery in both adults and children, however, there are no studies of its efficacy in reducing SSIs in craniofacial surgery. The SSIs are one of the most common complications following craniofacial surgery. The complexity of craniofacial procedures, use of grafts and implants, long operative durations and larger surgical wounds all contribute to the heightened risk of SSIs in pediatric craniofacial cases. A retrospective review of all open and endoscopic pediatric craniofacial procedures performed between May 2014 and December 2017 at a single children's hospital was conducted to examine SSI rates between patients receiving topical vancomycin and a historical control group. The treatment group received topical vancomycin irrigation before wound closure. An ad-hoc cost analysis was performed to determine the cost-savings associated with topical vancomycin use. A total of 132 craniofacial procedures were performed during the study period, with 50 cases in the control group and 82 cases in the vancomycin group. Overall, SSI rate was 3.03%. Use of topical vancomycin irrigation led to a significant reduction in SSIs (4/50 SSI or 8.0% in control group vs 0/82 or 0% in vancomycin group, P = 0.04). No adverse events were observed with topical vancomycin use. The potential cost-savings associated with the use of topical vancomycin as SSI prophylaxis in this study was $102,152. Addition of topical vancomycin irrigation as routine surgical infection prophylaxis can be an effective and low-cost method for reducing SSI in pediatric craniofacial surgery.
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Paganini A, Bhatti-Söfteland M, Fischer S, Kölby D, Hansson E, O’Hara J, Maltese G, Tarnow P, Kölby L. In search of a single standardised system for reporting complications in craniofacial surgery: a comparison of three different classifications. J Plast Surg Hand Surg 2019; 53:321-327. [DOI: 10.1080/2000656x.2019.1626736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Anna Paganini
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Madiha Bhatti-Söfteland
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sara Fischer
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Kölby
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Emma Hansson
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Justine O’Hara
- Craniofacial Surgery Department, Great Ormond Street Hospital, London, UK
| | - Giovanni Maltese
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Tarnow
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Kölby
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
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Intra- and Postoperative Blood Loss and Transfusion Requirements in Children Undergoing Craniofacial Surgery. J Craniofac Surg 2019; 30:1798-1801. [PMID: 31033756 DOI: 10.1097/scs.0000000000005492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pediatric craniosynostosis (CS) surgery is frequently associated with extensive blood loss and transfusion requirements. The aim of the study was to evaluate the authors' institutional procedure with 2-surgeon approach and early transfusion strategy on blood loss and blood product transfusions in children undergoing craniofacial surgery. A retrospective analysis of medical records was performed of pediatric CS corrections during a 15-year period. Primary endpoint was blood loss and transfusion requirement during and the following 24 hours postoperatively. Linear regression analyses were performed of associations between intra and- postoperative blood loss and blood loss and weight. A total of 276 children (median 9 months) were included. Intraoperative blood loss was 22 mL/kg (14-33 mL/kg) and postoperatively 27 mL/kg (18-37 mL/kg), with no change during the study period. Intraoperative transfusions of red blood cell and plasma were 16 mL/kg (10-24 mL/kg) and postoperative 14 mL/kg (9-21 mL/kg). Postoperative red blood cell and plasma transfusions were 2 mL/kg (0-6 mL/kg) and of 0 mL/kg, respectively. Craniosynostosis type was related to blood loss (P < 0.001). There was an association between intraoperative and postoperative blood loss (P = 0.012) and intra- and postoperative blood loss and weight (P = 0.002, P = < 0.001). Duration of surgery was 110 minutes (range 60-300 minutes).Pediatric CS surgery is associated with substantial intra- and postoperative blood loss and transfusion requirements, which did not change over a 15-year period. Blood loss was associated with type of CS. Intraoperative blood loss was correlated to postoperative blood loss and body weight.
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Steinberg B, Caccamese J, Costello BJ, Woerner J. Cleft and Craniofacial Surgery. J Oral Maxillofac Surg 2019; 75:e126-e150. [PMID: 28728728 DOI: 10.1016/j.joms.2017.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Goobie S, Zurakowski D, Isaac K, Taicher B, Fernandez P, Derderian C, Hetmaniuk M, Stricker P, Abruzzese C, Apuya J, Beethe A, Benzon H, Binstock W, Brzenski A, Budac S, Busso V, Chhabada S, Chiao F, Cladis F, Claypool D, Collins M, Dabek R, Dalesio N, Falconl R, Fernandez A, Fernandez P, Fiadjoe J, Gangadharan M, Gentry K, Glover C, Goobie SM, Gosman A, Grap S, Gries H, Griffin A, Haberkern C, Hajduk J, Hall R, Hansen J, Hetmaniuk M, Hsieh V, Huang H, Ingelmo P, Ivanova I, Jain R, Kars M, Kowalczyk-Derderian C, Kugler J, Labovsky K, Lakheeram I, Lee A, Martinez JL, Masel B, Medellin E, Meier P, Levy HM, Muhly WT, Muldowney B, Nelson J, Nicholson J, Nguyen KP, Nguyen T, Olutuye O, Owens-Stubblefield M, Parekh UR, Petersen T, Pohl V, Post J, Poteet-Schwartz K, Prozesky J, Reddy S, Reid R, Ricketts K, Rubens D, Ryan L, Skitt R, Soneru C, Spitznagel R, Stricker P, Singh D, Singhal NR, Sorial E, Staudt S, Stubbeman B, Sung W, Syed T, Szmuk P, Taicher BM, Thompson D, Tretault L, Ungar-Kastner G, Watts R, Wieser J, Wong K, Zamora L. Predictors of perioperative complications in paediatric cranial vault reconstruction surgery: a multicentre observational study from the Pediatric Craniofacial Collaborative Group. Br J Anaesth 2019; 122:215-223. [DOI: 10.1016/j.bja.2018.10.061] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/03/2018] [Accepted: 10/15/2018] [Indexed: 11/24/2022] Open
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Impact of Cardiac Risk Factors on Complications Following Cranial Vault Remodeling: Analysis of the 2012 to 2016 National Safety Quality Improvement Program-Pediatric Database. J Craniofac Surg 2019; 30:442-447. [PMID: 30615003 DOI: 10.1097/scs.0000000000005114] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Congenital cardiac malformations have been reported in 8% of patients with craniosynostosis undergoing cranial vault remodeling (CVR), but associations with surgical outcomes are unknown. This study evaluated postoperative complications in patients who underwent CVR for craniosynostosis with or without cardiac risk factors (CRF) using the National Safety Quality Improvement Program-Pediatric (NSQIP-P) database. NSQIP-P database was queried for patients <2 years with craniosynostosis who underwent CVR from 2012 to 2016 based on diagnosis and procedure codes. The primary outcome was a composite of available NSQIP-P complications. Analysis compared patients with craniosynostosis based on the presence or absence of CRF. Univariate and multiple logistic regression identified risk factors associated with postoperative complications. A total of 3293 patients met inclusion criteria (8% with CRF). Two-thirds of patients experienced at least 1 complication, though patients with CRF experienced a greater proportion (74% vs 66%, P = 0.001). Univariate analysis identified associations between post-operative complications and age, ASA class, supplemental oxygen, neuromuscular disorders, preoperative nutritional supplementation, interventricular hemorrhage, and CRF. On multivariate regression, only older age (OR 1.17, 95% CI 1.01-1.36) and longer operative duration (OR 1.01, 95% CI 1.01-1.01) were associated with greater odds of postoperative complications. The most common complication in patients with craniosynostosis who undergo CVR is bleeding requiring transfusion. Older age and longer operative duration were associated with postoperative complications. Although patients with CRF have more postoperative complications, CRF was not a risk factor on adjusted analysis.
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Goyal A, Lu VM, Yolcu YU, Elminawy M, Daniels DJ. Endoscopic versus open approach in craniosynostosis repair: a systematic review and meta-analysis of perioperative outcomes. Childs Nerv Syst 2018; 34:1627-1637. [PMID: 29961085 DOI: 10.1007/s00381-018-3852-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 05/22/2018] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Surgery for craniosynostosis remains a crucial element in successful management. Intervention by both endoscopic and open approaches has been proven effective. Given the differences in timing and indications for these procedures, differences in perioperative outcomes have yet to be thoroughly compared between the two approaches. The aim of the systematic review and meta-analysis was to assess the available evidence of perioperative outcomes between the two approaches in order to better influence the management paradigm of craniosynostosis. METHODS We followed recommended PRISMA guidelines for systematic reviews. Seven electronic databases were searched to identify all potentially relevant studies published from inception to February 2018 which were then screened against a set of selection criteria. Data were extracted and analyzed using meta-analysis of proportions. RESULTS Twelve studies satisfied all the selection criteria to be included, which described a pooled cohort involving 2064 craniosynostosis patients, with 965 (47%) and 1099 (53%) patients undergoing surgery by endoscopic and open approaches respectively. When compared to the open approach, it was found that the endoscopic approach conferred statistically significant reductions in blood loss (MD = 162.4 mL), operative time (MD = 112.38 min), length of stay (MD = 2.56 days), and rates of perioperative complications (OR = 0.58), reoperation (OR = 0.37) and transfusion (OR = 0.09), where all p < 0.001. CONCLUSION Both endoscopic and open approaches for the surgical management of craniosynostosis are viable considerations. The endoscopic approach confers a significant reduction in operative and postoperative morbidity when compared to the open approach. Given that specific indications for either approach should be considered when managing a patient, the difference in perioperative outcomes remain an important element of this paradigm. Future studies will validate the findings of this study and consider long-term outcomes, which will all contribute to rigor of craniosynostosis management.
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Affiliation(s)
- Anshit Goyal
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Victor M Lu
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Yagiz U Yolcu
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Mohamed Elminawy
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
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Gadgil N, Pan IW, Babalola S, Lam S. Evaluating the National Surgical Quality Improvement Program-Pediatric Surgical Risk Calculator for Pediatric Craniosynostosis Surgery. J Craniofac Surg 2018; 29:1546-1550. [PMID: 29877982 DOI: 10.1097/scs.0000000000004654] [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
BACKGROUND The American College of Surgeons' National Surgical Quality Improvement Program-Pediatric (NSQIP-P) risk calculator was developed based on national data. There have been no studies assessing the risk calculator's performance in pediatric neurosurgery. The authors aimed to evaluate the predictions from the risk calculator compared to our single institution experience in craniosynostosis surgery. METHODS Outcomes from craniosynostosis surgeries performed between 2012 and 2016 at our academic pediatric hospital were evaluated using the NSQIP-P risk calculator. Descriptive statistics were performed comparing predicted 30-day postoperative events and clinically observed outcomes. The performance of the calculator was evaluated using the Brier score and receiver operating characteristic curve (ROC). RESULTS A total of 202 craniosynostosis surgeries were included. Median age was 0.74 years (range 0.15-6.32); 66% were males. Blood transfusion occurred in 162/202 patients (80%). The following clinical characteristics were statistically correlated with surgical complications: American Society of Anesthesiologists physical status classification >1 (P < 0.001), central nervous system abnormality (P < 0.001), syndromic craniosynostosis (P = 0.001), and redo operations (P = 0.002). Postoperative events occurred in <3%, including hardware breakage, tracheal-cartilaginous sleeve associated with critical airway, and surgical site infection. The calculator performed well in predicting any complication (Brier = 0.067, ROC = 73.9%), and for pneumonia (Brier = 0.0049, ROC 99%). The calculator predicted a low rate of cardiac complications, venous thromboembolism, renal failure, reintubation, and death; the observed rate of these complications was 0. CONCLUSIONS The risk calculator demonstrated reasonable ability to predict the low number of perioperative complications in patients undergoing craniosynostosis surgery with a composite complications outcome. Efforts to improve the calculator may include further stratification based on procedure-specific risk factors.
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Affiliation(s)
- Nisha Gadgil
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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Predictors of Postoperative Complications of Craniosynostosis Repair in the National Inpatient Sample. Ann Plast Surg 2018; 80:S261-S266. [DOI: 10.1097/sap.0000000000001383] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Craniosynostosis and Guanine Nucleotide-binding Protein Alpha Stimulating Mutation: Risk of Bleeding Diathesis and Circulatory Collapse in Patients Undergoing Cranial Vault Reconstruction. J Craniofac Surg 2018; 28:1286-1288. [PMID: 28358762 DOI: 10.1097/scs.0000000000003592] [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
Reconstruction of the craniosynostosis deformity is a relatively safe operation with low overall complication risks. Despite expected risk of significant blood loss, life-threatening bleeding is relatively rare, and there is a low incidence of reported deaths in the literature. Several modalities have been described for perioperative mitigation of blood loss and transfusion requirements. Due to the low overall risk of life-threatening bleeding and circulatory collapse, it is judicious that any potential causes of such unusual but potentially significant fatal bleeding complication be evaluated and reported to increase awareness for craniofacial surgeons treating these conditions. In this report and literature review, the authors present a highly unusual patient with significant bone bleeding and circulatory collapse in a metopic craniosynostosis patient with guanine nucleotide-binding protein alpha stimulating (GNAS) mutation; perform a literature review regarding bleeding diathesis in craniosynostosis patients with GNAS mutations; and suggest guidelines to potentially prevent mortality in such patients.
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Anania P, Pacetti M, Ravegnani M, Pavanello M, Piatelli G, Consales A. Iatrogenic Pseudoaneurysm of Superficial Temporal Artery After Surgery for Scaphocephaly: Case Report and Review of Literature. World Neurosurg 2018; 111:60-62. [DOI: 10.1016/j.wneu.2017.12.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/05/2017] [Accepted: 12/08/2017] [Indexed: 10/18/2022]
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Arts S, Delye H, van Lindert EJ. Intraoperative and postoperative complications in the surgical treatment of craniosynostosis: minimally invasive versus open surgical procedures. J Neurosurg Pediatr 2018; 21:112-118. [PMID: 29171801 DOI: 10.3171/2017.7.peds17155] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare minimally invasive endoscopic and open surgical procedures, to improve informed consent of parents, and to establish a baseline for further targeted improvement of surgical care, this study evaluated the complication rate and blood transfusion rate of craniosynostosis surgery in our department. METHODS A prospective complication registration database that contains a consecutive cohort of all pediatric neurosurgical procedures in the authors' neurosurgical department was used. All pediatric patients who underwent neurosurgical treatment for craniosynostosis between February 2004 and December 2014 were included. In total, 187 procedures were performed, of which 121 were endoscopically assisted minimally invasive procedures (65%). Ninety-three patients were diagnosed with scaphocephaly, 50 with trigonocephaly, 26 with plagiocephaly, 3 with brachycephaly, 9 with a craniosynostosis syndrome, and 6 patients were suffering from nonsyndromic multisutural craniosynostosis. RESULTS A total of 18 complications occurred in 187 procedures (9.6%, 95% CI 6.2-15), of which 5.3% (n = 10, 95% CI 2.9-10) occurred intraoperatively and 4.2% (n = 8, 95% CI 2.2-8.2) occurred postoperatively. In the open surgical procedure group, 9 complications occurred: 6 intraoperatively and 3 postoperatively. In the endoscopically assisted procedure group, 9 complications occurred: 4 intraoperatively and 5 postoperatively. Blood transfusion was needed in 100% (n = 66) of the open surgical procedures but in only 21% (n = 26, 95% CI 15-30) of the endoscopic procedures. One patient suffered a transfusion reaction, and 6 patients suffered infections, only one of which was a surgical site infection. A dural tear was the most common intraoperative complication that occurred (n = 8), but it never led to postoperative sequelae. Intraoperative bleeding from a sagittal sinus occurred in one patient with only minimal blood loss. There were no deaths, permanent morbidity, or neurological sequelae. CONCLUSIONS Complications during craniosynostosis surgery were relatively few and minor and were without permanent sequelae in open and in minimally invasive procedures. The blood transfusion rate was significantly reduced in endoscopic procedures compared with open procedures.
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Bruce WJ, Chang V, Joyce CJ, Cobb AN, Maduekwe UI, Patel PA. Age at Time of Craniosynostosis Repair Predicts Increased Complication Rate. Cleft Palate Craniofac J 2017; 55:649-654. [PMID: 29665342 DOI: 10.1177/1055665617725215] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE This study uses administrative data to assess the optimal timing for surgical repair of craniosynostosis and to identify factors associated with risk of perioperative complications. DESIGN Statistical analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database (2006, 2009, 2012). SETTING KID-participating hospitals in 44 states. PATIENTS Children 0 to 3 years of age with ICD-9 codes for surgical correction of craniosynostosis (756 and 0124, 0125, 0201, 0203, 0204, or 0206). MAIN OUTCOME MEASURE Age-based cohorts were assessed for perioperative complications. We performed a multivariable analysis to determine characteristics associated with increased risk of complications. RESULTS 21 million admissions were screened and 8417 visits met criteria for inclusion. Seventy-five percent of procedures occurred before age 1. Complications occurred in 8.6% of patients: 6.6% of patients at age 0 to 6 months, 10.3% of patients aged 7 to 12 months, and 13.9% of patients 12 to 36 months. Patients with acrocephalosyndactyly or associated congenital anomalies experienced complications in 22.9% of cases (OR = 3.07, 95% CI = 2.33, 4.03). CONCLUSION Craniosynostosis repair is safe; however, the risk of complications increases with age at intervention. Presence of a syndromic congenital deformity at any age carries the greatest increased risk of perioperative complications. This suggests that optimal timing of intervention is within the first year of life, especially in those cases with additional factors increasing perioperative risk. These data support the importance of counseling patients of the increased risk associated with delaying craniosynostosis repair.
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Affiliation(s)
- William J Bruce
- 1 Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Victor Chang
- 1 Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Cara J Joyce
- 2 Department of Public Health Science, Loyola University Chicago, Maywood, IL, USA
| | - Adrienne N Cobb
- 3 Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Uma I Maduekwe
- 3 Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Parit A Patel
- 4 Department of Surgery, Division of Plastic and Reconstructive Surgery, Loyola University Medical Center, Maywood, IL, USA.,5 Department of Pediatrics, Loyola University Medical Center, Maywood, IL, USA
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Abstract
Craniosynostosis is the premature fusion of the calvarial sutures that is associated with a number of physical and intellectual disabilities spanning from pediatric to adult years. Over the past two decades, techniques in molecular genetics and more recently, advances in high-throughput DNA sequencing have been used to examine the underlying pathogenesis of this disease. To date, mutations in 57 genes have been identified as causing craniosynostosis and the number of newly discovered genes is growing rapidly as a result of the advances in genomic technologies. While contributions from both genetic and environmental factors in this disease are increasingly apparent, there remains a gap in knowledge that bridges the clinical characteristics and genetic markers of craniosynostosis with their signaling pathways and mechanotransduction processes. By linking genotype to phenotype, outlining the role of cell mechanics may further uncover the specific mechanotransduction pathways underlying craniosynostosis. Here, we present a brief overview of the recent findings in craniofacial genetics and cell mechanics, discussing how this information together with animal models is advancing our understanding of craniofacial development.
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Affiliation(s)
- Zeinab Al-Rekabi
- Department of Mechanical Engineering, University of Washington, 3900 E Stevens Way NE, Seattle, WA, 98195, USA
- Seattle Children’s Research Institute, Center for Developmental Biology and Regenerative Medicine, 1900 9 Ave, Seattle, WA, 98101, USA
| | - Michael L. Cunningham
- Seattle Children’s Research Institute, Center for Developmental Biology and Regenerative Medicine, 1900 9 Ave, Seattle, WA, 98101, USA
- Department of Pediatrics, Division of Craniofacial Medicine and the, University of Washington, 1959 NE Pacific St., Seattle, WA, 98195, USA
| | - Nathan J. Sniadecki
- Department of Mechanical Engineering, University of Washington, 3900 E Stevens Way NE, Seattle, WA, 98195, USA
- Department of Bioengineering, University of Washington, 3720 15 Ave NE, Seattle WA, 98105, USA
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Affiliation(s)
- Christopher R Forrest
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
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Shastin D, Peacock S, Guruswamy V, Kapetanstrataki M, Bonthron DT, Bellew M, Long V, Carter L, Smith I, Goodden J, Russell J, Liddington M, Chumas P. A proposal for a new classification of complications in craniosynostosis surgery. J Neurosurg Pediatr 2017; 19:675-683. [PMID: 28362186 DOI: 10.3171/2017.1.peds16343] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Complications have been used extensively to facilitate evaluation of craniosynostosis practice. However, description of complications tends to be nonstandardized, making comparison difficult. The authors propose a new pragmatic classification of complications that relies on prospective data collection, is geared to capture significant morbidity as well as any "near misses" in a systematic fashion, and can be used as a quality improvement tool. METHODS Data on complications for all patients undergoing surgery for nonsyndromic craniosynostosis between 2010 and 2015 were collected from a prospective craniofacial audit database maintained at the authors' institution. Information on comorbidities, details of surgery, and follow-up was extracted from medical records, anesthetic and operation charts, and electronic databases. Complications were defined as any unexpected event that resulted or could have resulted in a temporary or permanent damage to the child. RESULTS A total of 108 operations for the treatment of nonsyndromic craniosynostosis were performed in 103 patients during the 5-year study period. Complications were divided into 6 types: 0) perioperative occurrences; 1) inpatient complications; 2) outpatient complications not requiring readmission; 3) complications requiring readmission; 4) unexpected long-term deficit; and 5) mortality. These types were further subdivided according to the length of stay and time after discharge. The overall complication rate was found to be 35.9%. CONCLUSIONS The proportion of children with some sort of complication using the proposed definition was much higher than commonly reported, predominantly due to the inclusion of problems often dismissed as minor. The authors believe that these complications should be included in determining complication rates, as they will cause distress to families and may point to potential areas for improving a surgical service.
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Craniotomy of the Fused Sagittal Suture Over the Superior Sagittal Sinus Is a Safe Procedure. J Craniofac Surg 2017; 28:650-653. [DOI: 10.1097/scs.0000000000003440] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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