Persistent Cranial Defects After Endoscopic Sagittal Synostosis Surgery.

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Incomplete cranial ossification is a rare complication of calvarial-vault remodeling for sagittal synostosis often requiring reoperation. Studies show an incidence ranging from 0.5% to 18%. Infants with sagittal synostosis who underwent endoscopic sagittal synostectomy and barrel stave osteotomies with postoperative orthotic helmeting between 2003 and 2021 were included with minimum follow-up until the completion of helmeting. Of 90 patients, 86 met inclusion; 3 had defects (3.5%). Patients with and without cranial defects had no difference in age of surgery (113 versus 131d), duration helmeting (6.6 versus 7.0mo), or perioperative/postoperative complications. Two underwent reoperation for recurrence. Patients with cranial defects manifested the evidence of developmental concerns more than patients without (100% versus 16.9%).The average cranial defect size was 19.33cm 2 and age at surgery 4.29 years. All were managed with cranial particulate bone grafting with addition of bone matrix and SonicWeld plate. The first had 6×6cm posterior defect requiring cranioplasty at 4.86 years with excellent healing. The second had a 3×6cm posterior and 1×1cm anterior defect, underwent cranioplasty at 4.14 years with persistent 4×6 defect, requiring repeat cranioplasty at 5.3 years. The third had a 3×5cm posterior defect and underwent cranioplasty at 3.88 years with continued defect, planning for repeat intervention. This is the largest documented series of reoperations for incomplete ossification after endoscopic sagittal synostectomy with postoperative helmet treatment. The authors report a 3.5% rate of cranial defects, managed with bone grafting, bone matrix, and absorbable plates. Patients with poor ossification may have a propensity toward developmental concerns.