Correction Of Craniosynostosis Research Articles

“Long-term Outcomes of Regional Morphology in Spring-Assisted Surgery and Cranial Vault Remodeling”

Background: Spring-assisted surgery (SAS) and cranial vault remodeling (CVR) are widely used surgical techniques for correction of sagittal craniosynostosis (SC). This study evaluates changes in regional morphology of SC patients who have undergone SAS or CVR using the frontal bossing index (FBI), occipital bulleting index (OBI), vertex narrowing index (VNI), and scaphocephalic severity index (SCI) to capture differences in anterior protrusion, posterior protrusion, width restriction, and global dysmorphology, respectively. Methods: Indices were measured on CT and 3D photographs (n=788) of 257 SC patients from 2001-2022 who underwent SAS (n=177) and CVR (n=80). Short-term and long-term outcomes were evaluated. Results: Mean age at time of surgery was older in the CVR cohort (mean 22.55±16.00) than in the SAS cohort (mean 4.56±2.24; p<0.05). Pre-operatively, the SAS cohort had more severe regional dysmorphology in FBI, VNI, and SCI (p<0.05) relative to the CVR cohort. Frontal bossing consistently improved over time in both cohorts. Head width had improvement as soon as 0-6 months postoperative (p<0.05); however, it consistently regressed after the initial improvement in both cohorts. Global head shape initially improved in the CVR cohort, but over time regressed. In contrast, SAS maintained improvements in SCI over time with significantly better percent change in every age interval (p<0.05). Conclusions: The FBI, OBI, VNI, and SCI are useful tools for monitoring head shape and growth. SAS and CVR achieve similar morphologic outcomes despite more severe pre-operative morphology in the SAS group. Trending index changes with growth among the two cohorts suggests improved longevity of correction in the SAS group.

Reossification of Bone Defects After Surgical Correction of Nonsyndromic Craniosynostosis: A Review and An Original Study.

Surgical correction of nonsyndromic craniosynostosis (NSC) aims to restore cranial shape. Reossification of bone defects is paramount for the best aesthetic prognosis. However, the literature on the quantitative evaluation of bone defects after NSC surgery is scarce. This study aimed to quantify and analyze the surface area of bone defects after NSC surgery and establish a threshold value for predicting persistent defects. We conducted a systematic review and a prospective study of 28 children undergoing surgical treatment for NSC. We analyzed 426 defects on the first computed tomography scan (1 year postoperative) and 132 defects on the second computed tomography scan (4.6 years postoperative). Statistical analysis was performed using Spearman's rank correlation coefficient, Mann-Whitney-Wilcoxon rank-sum test, and Youden's J statistic. Our systematic review identified three studies reporting on bone defects' surface area and reossification rate. In our study, we found no statistically significant differences in the number or size of defects between sex or type of NSC. The threshold value for the surface area of bone defects above which there was a higher probability of persistent defects was 0.19 cm2 (Youden point), with an 89.47 % probability of persistence. Defects with a surface area below 0.19 cm2 had a considerably lower probability, only 15.07%, of persistence over time. Our study provides valuable quantitative data for managing bone defects after NSC surgery. Defects with a surface area above 0.19 cm2 should be monitored with radiological imaging because of the risk of persistence. Our findings highlight the importance of developing robust and reproducible methods for the quantitative analysis of bone defects after NSC surgery.

Factors associated with late surgical correction of craniosynostosis: A decade-long review of the United States nationwide readmission database

Late-repair craniosynostosis (LRC), defined as craniosynostosis surgery beyond 1 year of age, is often associated with increased complexity and potential complications. Our study analyzed data from the 2010–2019 Nationwide Readmissions Database to investigate patient factors related to LRC.Of 10 830 craniosynostosis repair cases, 17% were LRC. These patients were predominantly from lower-income families and had more comorbidities, indicating that socioeconomic status could be a significant contributor. LRC patients were typically treated at teaching hospitals and privately owned investment institutions. Our risk-adjusted analysis revealed that LRC patients were more likely to belong to the lowest-income quartile, receive treatment at privately owned investment hospitals, and use self-payment methods. Despite these challenges, the hospital stay duration did not significantly differ between the two groups. Interestingly, LRC patients faced a higher predicted mean total cost compared with those who had surgery before turning 1. This difference in cost did not translate to a longer length of stay, further emphasizing the complexity of managing LRC.These findings highlight the urgent need for earlier intervention in craniosynostosis cases, particularly in lower-income communities. The medical community must strive to improve early diagnosis and treatment strategies in order to mitigate the socioeconomic and health disparities observed in LRC patients.

Integrated Endoscopic Craniosynostosis Surgery and Cranial Orthosis Program

Introduction: Craniosynostosis results from premature fusion of the cranial sutures. There has been a continuous evolution of surgical correction techniques from an extensive open procedure to the minimally invasive technique. Aims and Objectives: This novel surgical technique has never been previously done in the UAE and this article documents the experience of the first team to endoscopically correct craniosynostosis with planning, surgical techniques, and customized helmet therapy. Methods: A retrospective case series of 16 nonsyndromic craniosynostosis patients with unicoronal (6), sagittal (5), bicoronal (1), frontosphenoidal (2), and metopic craniosynostoses (2) was corrected endoscopically and followed up with customized cranial helmet. Preoperative and postoperative photography, along with anthropometric measurements were taken. Results: The mean age of all patients at the time of surgery was 101 (90–117) days, mean duration of surgery was 70 minutes (38–129), mean blood loss was 120 mL (100–150), and mean duration of hospital stay 4 days (4–5). No complications and mortality were reported. Mean number of helmets was 2 (1–3). Cranial index improved in all patients with sagittal and bicoronal craniosynostosis. Close cooperation with the orthotist ensured timely helmet therapy and accurate laser scanning documentation in head molding. Conclusions: This case series has demonstrated that endoscopically craniosynostosis correction is safe, effective, and reliable and is the first reported series from the Middle East. The authors believe that every patient with nonsyndromic single‑suture craniosynostosis should be offered endoscopic correction before the age of 6 months. The orthotist forms an important part of the Multi-disciplinary team, enabling successful outcomes.

Automated surgical planning in spring-assisted sagittal craniosynostosis correction using finite element analysis and machine learning.

Sagittal synostosis is a condition caused by the fused sagittal suture and results in a narrowed skull in infants. Spring-assisted cranioplasty is a correction technique used to expand skulls with sagittal craniosynostosis by placing compressed springs on the skull before six months of age. Proposed methods for surgical planning in spring-assisted sagittal craniosynostosis correction provide information only about the skull anatomy or require iterative finite element simulations. Therefore, the selection of surgical parameters such as spring dimensions and osteotomy sizes may remain unclear and spring-assisted cranioplasty may yield sub-optimal surgical results. The aim of this study is to develop the architectural structure of an automated tool to predict post-operative surgical outcomes in sagittal craniosynostosis correction with spring-assisted cranioplasty using machine learning and finite element analyses. Six different machine learning algorithms were tested using a finite element model which simulated a combination of various mechanical and geometric properties of the calvarium, osteotomy sizes, spring characteristics, and spring implantation positions. Also, a statistical shape model representing an average sagittal craniosynostosis calvarium in 5-month-old patients was used to assess the machine learning algorithms. XGBoost algorithm predicted post-operative cephalic index in spring-assisted sagittal craniosynostosis correction with high accuracy. Finite element simulations confirmed the prediction of the XGBoost algorithm. The presented architectural structure can be used to develop a tool to predict the post-operative cephalic index in spring-assisted cranioplasty in patients with sagittal craniosynostosis can be used to automate surgical planning and improve post-operative surgical outcomes in spring-assisted cranioplasty.

Sagittal Synostectomy With Tension Band Sutures for Correction of Sagittal Craniosynostosis.

Premature fusion of the sagittal suture is the most common form of craniosynostosis and can be treated using a variety of open or endoscopic approaches. Existing approaches have varying degrees of effectiveness. Open approaches, whether performed early or late, can be associated with significant blood loss and the need for transfusion. Endoscope-assisted approaches are minimally invasive but require months of postoperative helmet therapy to help remodel the skull. Implantation of springs or distractors requires a second operation for removal of the devices. Here, we present an alternative technique for early correction of sagittal craniosynostosis combining sagittal synostectomy with tension band sutures to remodel the skull without need for transfusion or helmet therapy. We retrospectively reviewed the medical records of all patients treated for sagittal craniosynostosis using a synostectomy with tension band sutures at a single tertiary care institution. Data on patient demographics, operative factors, and postoperative course were collected. Thirty-four patients underwent the novel procedure. The median preoperative cephalic index was 68 and improved to 76 immediately postoperatively. The median blood loss was 10 mL while the operative duration was 112 minutes. No blood transfusions were needed. One small dural laceration was encountered that was promptly repaired. There were no postoperative complications. Patients presenting for follow-up visits showed continued improvement in head shape and cephalic index. A modified sagittal craniectomy with tension band sutures to remodel the skull is effective in achieving immediate correction of sagittal craniosynostosis. The correction remains durable over long-term follow-up. Importantly, the technique can be performed with minimal blood loss and reduces transfusion risk, operative time, and overall morbidity compared with traditional open approaches while avoiding the need for helmet therapy necessitated by endoscopic approaches.

Multicenter comparison of head shape outcomes for three minimally invasive strip craniectomy techniques for sagittal craniosynostosis.

A literature gap exists comparing whole head shape outcome following correction of sagittal craniosynostosis. The objective of this multicenter study was to provide an analysis of long-term results following three different endoscopic strip craniectomy techniques for correction of sagittal craniosynostosis: 1) spring-assisted strip craniectomy, 2) wide-strip craniectomy with biparietal and bitemporal barrel-stave wedge osteotomies plus helmet orthosis, and 3) narrow-strip craniectomy plus orthosis without barrel staves. Pre- and postoperative 3D stereophotogrammetric images were collected from patients who underwent craniosynostosis surgery. Procedures were divided among institutions as follows: spring-assisted strip craniectomies were performed at Atrium Health Wake Forest Baptist Hospital; narrow-strip craniectomies were performed at St. Louis Children's Hospital by one craniofacial surgeon; and wide-vertex craniectomies were performed at St. Louis Children's Hospital prior to 2010, and then continued at Children's Medical Center Dallas. Pre- and postoperative 3D whole-head composite images were generated for each procedure to visually represent outcomes at final follow-up and compared with age-matched normal controls. Patients in the spring-assisted strip craniectomy group showed normalization of frontal bossing and skull height compared with age-matched controls, whereas patients undergoing wide-strip craniectomy showed greater correction of occipital protrusion. Patients in the narrow-strip craniectomy cohort had intermediate results between these outcomes. Nested aggregate head shapes showed good correction of head shapes from all techniques. This large, retrospective, multicenter study illustrated whole head shape outcomes from three different craniectomy procedures. Although each procedure showed some differences in loci of primary correction, all three surgical methods demonstrated good correction of primary scaphocephalic deformity.

Outcomes of endoscopic treatment for early correction of craniosynostosis in children: a 26-year single-center experience.

Surgery is the cornerstone of craniosynostosis treatment. In this study, two widely accepted techniques are described: endoscope-assisted surgery (EAS) and open surgery (OS). The authors compared the perioperative and reconstructive outcomes of EAS and OS in children ≤ 6 months of age treated at the Napoleón Franco Pareja Children's Hospital (Cartagena, Colombia). According to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement, patients with defined criteria who underwent surgery to correct craniosynostosis between June 1996 and June 2022 were retrospectively enrolled. Demographic data, perioperative outcomes, and follow-up were obtained from their medical records. Student t-tests were used for significance. Cronbach's α was used to assess agreement between estimated blood loss (EBL). Spearman's correlation coefficient and the coefficient of determination were used to establish associations between the results of interest, and the odds ratio was used to calculate the risk ratio of blood product transfusion. A total of 74 patients met the inclusion criteria; 24 (32.4%) belonged to the OS group and 50 (67.6%) to the EAS group. There was a high interobserver agreement quantifying the EBL. The EBL, transfusion of blood products, surgical time, and hospital stay were shorter in the EAS group. Surgical time was positively correlated with EBL. There were no differences between the two groups in the percentage of cranial index correction at 12 months of follow-up. Surgical correction of craniosynostosis in children aged ≤ 6 months by EAS was associated with a significant decrease in EBL, transfusion requirements, surgical time, and hospital stay compared with OS. The results of cranial deformity correction in patients with scaphocephaly and acrocephaly were equivalent in both study groups.

Secondary Corrections for Single-Suture Craniosynostosis: Perioperative Outcomes and Predisposing Factors.

Many single-suture craniosynostosis corrections end up needing secondary remodeling procedures. The authors sought to determine whether these more complicated operations carry higher complication rates, and to explore potential predisposing factors. The authors performed a retrospective chart review of all patients undergoing primary and secondary remodeling corrections at a single center, between 2010 and 2020. Of 491 sequential single-suture corrections, 380 were primary procedures and 111 were secondary (89.2% initially treated elsewhere); 10.3% of primary procedures received allogeneic blood versus only 1.8% of secondary corrections ( p =0.005). Median hospital lengths of stays were similar between groups [primary, 2.0 days (interquartile range [IQR], 2 to 2); secondary, 2.0 days (IQR, 2 to 2)], as were surgical infection rates (primary, 0%; secondary, 0.9%). With respect to predisposing factors, the affected suture and presence of a genetic mutation did not appear predictive; however, the median age at primary correction was significantly younger for those needing second procedures [6.0 months (IQR, 4 to 9 months) versus 12.0 months (IQR, 11 to 16 months)]. An odds ratio estimate suggests that for every month increase in age, the odds of undergoing a reoperation drops 40%. With respect to surgical indications, concerns for raised intracranial pressure and skull defects were more commonly cited following strip craniectomies than remodeling procedures. This single-center review was unable to identify a higher risk profile for reoperations. In addition, analyses suggest that performing primary corrections at a younger age and, possibly, strip craniectomies were associated with a higher likelihood of a subsequent secondary correction. Therapeutic, III.

Demographic and Complication Profiles of Patients Receiving Craniosynostosis Repair After 18 Months of Age

Objective: Late surgical correction of craniosynostosis, defined as reconstruction after 18 months of age, poses various operative difficulties and outcome complications. Identification of patients at-risk for receiving late correction of craniosynostosis will assist in the management of these patients and may reduce overall morbidity associated with craniosynostosis surgery. The objective of this study is to identify patient populations at-risk of receiving late (> 18 months) surgical correction of craniosynostosis and the complications associated with late reconstruction. Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program pediatric database was performed from 2012 through 2019. Inclusion criteria involved patients who underwent correction of craniosynostosis determined by primary CPT codes 61550-9 between years 2012-2019. Additionally, primary CPT codes 21175, 21179, and 21180 were included if additional CPT codes 61550-9 were concurrently listed. Results: African American race, preterm birth prior to 30 weeks gestation, chronic lung disease, structural pulmonary abnormalities, prior cardiac surgery, seizure, and cerebral palsy were independently associated with increased odds of late surgical correction of craniosynostosis. Patients who received late cranial reconstruction experienced increased rates of surgical site infections (p = 0.0002), wound dehiscence (p = 0.0089), and perioperative bleeding requiring transfusion (p < 0.0001). Conclusion: Various comorbid factors increase the risk of receiving late correction of craniosynostosis. Given the increased complication profile of surgery after 18 months of age, close coordination and management of these patients is warranted. Additionally, when all comorbid factors are held statistically constant, African American patients receive craniosynostosis repair after 18 months of age 3 times more often than Caucasian patients. Future studies should focus on potential socioeconomic factors contributing to the racial disparity discovered in the timing of craniosynostosis repair. Corresponding author: Darin Patmon, 4254 Oak Forest Ct. SE Apt H8, Grand Rapids, MI 49546

Patient-specific Composite Anatomic Models: Improving the Foundation for Craniosynostosis Repair.

Preoperative surgical planning incorporating computer-aided design and manufacturing is increasingly being utilized today within the fields of craniomaxillofacial, orthopedic, and neurosurgery. Application of these techniques for craniosynostosis reconstruction can include patient-specific anatomic reference models, "normal" reference models or patient-specific cutting/marking guides based on the presurgical plan. The major challenge remains the lack of tangible means to transfer the preoperative plan to the operating table. We propose a simple solution to utilize a digitally designed, 3D-printed "composite model" as a structural template for cranial vault reconstruction. The composite model is generated by merging the abnormal patient cranial anatomy with the "dural surface topography" of an age-matched, sex-matched, and ethnicity-matched normative skull model. We illustrate the applicability of this approach in 2 divergent cases: 22-month-old African American male with sagittal synostosis and 5-month-old White male with metopic synostosis. The aim of this technical report is to describe our application of this computer-aided design and modeling workflow for the creation of practical 3D-printed skulls that can serve as intraoperative frameworks for the correction of craniosynostosis. With success in our first 2 cases, we believe this approach of a composite model is another step in reducing our reliance on subjective guesswork, and the fundamental aspect of the workflow has a wider application within the field of craniofacial surgery for both clinical patient care and education.

The Effect of Tranexamic Acid and Controlled Hypotension on Perioperative Blood Loss in Craniosynostosis Surgery.

Open cranial vault reconstruction is the standard technique of craniosynostosis correction that may cause significant blood loss. The current study aimed at comparing the effect of tranexamic acid (TXA), controlled hypotension, and their combination on perioperative blood loss and transfusion requirement in craniosynostosis surgery. The present randomized, double-blind clinical trial was conducted on 75 infants referred for craniosynostosis surgery during 2017 - 2018. Ten minutes before the start of surgery, 10 mg/kg of TXA was administered intravenously to patients in the first group (TXA group). In the second group, patients were subjected to the controlled hypotension anesthesia (CHA) using intravenous remifentanil 0.1 μ/kg (CHA group). In the third group, the patients underwent CHA similar to that of the second group, along with intravenous injection of 10 mg/kg of TXA (CHA-TXA group). Then, patients' mean arterial pressure (MAP), heart rate (HR), total blood loss, and transfusion volume were evaluated and recorded. The results of the present study revealed that although the changes in MAP and HR parameters over time (three hours after surgery) were significant in all three groups, the lowest decrease was observed in the CHA-TXA group (P-value < 0.05). In addition, the total perioperative blood loss in the CHA-TXA group with the mean of 181.20 ± 82.71 cc was significantly less than the total perioperative blood loss in the CHA and TXA groups with the means of 262.00 ± 104.04 cc and 212.80 ± 80.75 cc, respectively (P-value < 0.05). Moreover, the transfusion volume in the CHA-TXA group with the mean of 112.40 ± 53.50 cc was significantly lower than the transfusion volume in the CHA and TXA groups with the means of 174.00 ± 73.93 cc and 160.63 ± 59.35 cc, respectively (P-value < 0.05). In contrast, the total blood loss and transfusion volume were not significantly different between the CHA and TXA groups (P-value > 0.05). According to the results of the present study, although the administration of TXA alone could effectively prevent blood loss and was associated with fewer transfusion requirements, the combination of this approach with hypotensive anesthesia resulted in more reduction in perioperative blood loss and transfusion volume as well as better hemodynamic stability.

Twenty Year review of a Single Surgeon's Experience for craniosynostosis surgery

Introduction: Nonsyndromic craniosynostosis (NC) is more commonly encountered than syndromic cases in pediatric craniofacial surgery. Affected children display characteristic phenotypes according to the suture or sutures involved. This study aims to report a single surgeon experience with surgery for primary craniosynostosis correction. Methods: A retrospective review was carried out including all cases performed by the same surgeon between 2001 and 2021. The clinical data of 356 patients (371 surgeries) with primary craniosynostosis that have undergone surgery were retrospectively analyzed. Results: There were 232 (65.1%) males and 124 (34.9%) females, with most of the male preponderance occurring due to the trigonocephaly (86%) and scaphocephaly (84.5%) groups. A female predominance was observed only in brachycephaly group (64.8%). There was a statistically significant male predominance between non-syndromic versus syndromic cases (p=0.0001). The most frequent forms in non-syndromic forms were scaphocephaly in 136 (51.5%), trigonocephaly in 48 (18.1%), anterior plagiocephaly in 47 (17.8%), and brachycephaly in 35 (13.2%). A named syndrome was present in 57 (16%). Genetic syndromes presented more commonly than expected with bilateral synostosis, the Kleeblattschadel deformity, and multiple suture synostosis (p=0.001). Complications were observed in 15 (4.2%). Intraoperative hemorrhage and CSF leakage were the most common ones. Morbidity was significantly associated with monobloc fronto-facial advancement. The mean follow-up was 3.7 years (9 months to 22 years). Morphological results in NC were classified in category I in 210 (70.2%), II in 82 (27.9%), and III in 7 (1.9%) cases for NC. Conclusions: Non-syndromic craniosynostosis can be corrected with good outcomes and relatively low morbidity and mortality. For syndromic cases a multidisciplinary team is fundamental to archieve satisfactory results.

Three-Dimensional Printed Polycaprolactone Mesh in Pediatric Cranial Vault Remodeling Surgery.

The surgical management of craniosynostosis has greatly evolved with improvements in both technology and understanding of the disease process. Some drawbacks remain regarding bone regeneration within the surgical bony gaps. Generally, bony gaps improve in the 12 to 24 months after surgery, but some gaps may remain for longer and cause deformity and/or require additional bony reconstruction. These considerations make tissue-engineered bone very attractive. Novel 3-dimensional printed bioresorbable mesh implants made of Polycaprolactone (PCL) can be used to fill the surgical bony defects. The authors seek to investigate how the use of a 3-dimensional printed biodegradable PCL mesh applied to bony defects in cranial vault surgery affects bone healing. Case series analysis of 8 pediatric patients who have undergone surgical intervention using PCL mesh implants for reconstruction of bony defects during craniosynostosis correction surgery. Radiological evaluation of 3 patients at random time points between 9 and 12 months postoperative revealed persistent bony gaps in areas where PCL mesh was laid. One patient who underwent a subsequent cranial vault surgery at 9 months was found to have less bone regeneration in the defect area where PCL mesh was used when compared with an adjacent area where a particulate bone graft was used. Based on our experience, the use of PCL mesh on its own did not augment bone regeneration. It is possible that a greater amount of time or increased vascularization of the scaffold is required, which supports the concept of regenerative matching axial vascularization or the further addition of osteogenic factors to increase the rate of bone formation.

Endoscopic strip craniectomy with molding helmet therapy versus spring-assisted cranioplasty for nonsyndromic single-suture sagittal craniosynostosis: a systematic review.

Endoscopic strip craniectomy with postoperative molding helmet therapy (ESC-H) and spring-assisted cranioplasty (SAC) are commonly used minimally invasive techniques for correction of nonsyndromic sagittal craniosynostosis, but it is unclear which, if either, is superior. Therefore, the authors undertook a systematic review to compare ESC-H with SAC for the surgical management of nonsyndromic single-suture sagittal craniosynostosis. Studies were identified through a systematic and comprehensive search of four databases (Embase, MEDLINE, and two databases in the Cochrane Library). Databases were searched from inception until February 19, 2021. Pediatric patients undergoing either ESC-H or SAC for the management of nonsyndromic single-suture sagittal craniosynostosis were included. Systematic reviews and meta-analyses, single-patient case reports, mixed cohorts of nonsyndromic and syndromic patients, mixed cohorts of different craniosynostosis types, and studies in which no outcomes of interest were reported were excluded. Outcomes of interest included reoperations, blood transfusion, complications, postoperative intensive care unit (ICU) admission, operative time, estimated blood loss, length of hospital stay, and cephalic index. Pooled summary cohort characteristics were calculated for each outcome of interest. Methodological quality was assessed using the Newcastle-Ottawa Scale. The study was reported in accordance with the 2020 PRISMA statement. Twenty-two studies were eligible for inclusion in the review, including 1094 patients, of whom 605 (55.3%) underwent ESC-H and 489 (44.7%) underwent SAC for nonsyndromic sagittal craniosynostosis. There was no difference between the pooled estimates of the ESC-H and SAC groups for operative time, length of stay, estimated blood loss, and cephalic index. There was no difference between the groups for reoperation rate and complication rate. However, ESC-H was associated with a higher blood transfusion rate and higher postoperative ICU admission. The available literature does not demonstrate superiority of either ESC-H or SAC, and outcomes are broadly similar for the treatment of nonsyndromic sagittal craniosynostosis. However, the evidence is limited by single-center retrospective studies with low methodological quality. There is a need for international multicenter randomized controlled trials comparing both techniques to gain definitive and generalizable data.

Editorial introductions.

Editorial introductions.

Optimizing Blood Loss and Management in Craniosynostosis Surgery: A Systematic Review of Outcomes Over the Last 40 Years.

Surgical correction of craniosynostosis can involve significant blood loss. Rates of allogenic blood transfusion have been reported to approach 100%. Multiple interventions have been described to reduce blood loss and transfusion requirements. The aim of this study was to analyze various approaches over the last 4 decades to optimize blood loss and management during craniosynostosis surgery. PRISMA guidelines for systematic reviews were followed. PubMed and Cochrane database searches identified studies analyzing approaches to minimizing blood loss or transfusion rate in craniosynostosis surgery. Primary outcomes included rate or amount of allogenic or autologous blood transfusion, estimated blood loss (EBL), postoperative hemoglobin (Hg), or hematocrit (Hct) levels. Secondary outcomes were examined when reported. Fifty-two studies met inclusion criteria. There was marked heterogeneity regarding design, inclusion criteria, surgical intervention, and endpoints. The majority of the studies were nonrandomized and noncomparative. Four studies analyzed erythropoietin (EPO), 6 analyzed various cell-saver (CS) technologies, 18 analyzed antifibrinolytics (tranexamic acid [TXA], aminocaproic acid [ACA], and aprotinin [APO]), 8 analyzed various alternatives, and 16 analyzed multimodal pathways &amp; protocols. Some studies analyzed multiple approaches. Although the majority of studies reviewed represent level III/IV evidence, several high-quality level I studies were identified and included. Level I evidence supported an improvement in blood outcomes by utilizing EPO, CS, and TXA, individually or in concert with one another. Thus, this review suggests that a multi-prong approach may be the most effective means to optimize blood loss and transfusion outcomes in craniosynostosis surgery.

The Use of the Three-Dimensional Printed Polyether Ether Ketone Implant in Secondary Craniosynostosis Revision.

Skull deformities may be seen in patients years after craniosynostosis correction. These deformities cause psychosocial distress in affected patients. In this series, the authors describe the use of patient specific polyether ether ketone (PEEK) implants for correction of skull deformities after cranial vault remodeling for craniosynostosis. A chart review was conducted for 3 revision procedures performed by 1 plastic surgeon in collaboration with 1 neurosurgeon, both affiliated with Northwell Health. Preoperative computed tomography scans were used to design three-dimensional (3D) printed PEEK implants manufactured by KLS Martin. Implants were used to correct frontal and orbital asymmetry and skull deformities in each patient. Outcomes were assessed at 1 week, 1 month, and 3 months post-operation. Two males and 1 female, ages 13, 17, and 19, underwent revision cranioplasty or orbital rim reconstruction using a custom, single piece 3D printed PEEK implant. All 3 patients underwent cranial vault remodeling in infancy; 1 was treated for coronal craniosynostosis and 2 were treated for metopic craniosynostosis. Revision cranioplasty operative times were 90, 105, and 147 minutes, with estimated blood loss of 45 mL, 75 mL, and 150 mL, respectively. One patient went home on post op day 1 and 2 patients went home on post op day 2. All patients had an immediate improvement in structural integrity and cranial contour, and all patients were pleased with their aesthetic results. Custom 3D printed PEEK implants offer a single piece solution in revision cranioplasty surgery to correct skull deformities after cranial vault remodeling for craniosynostosis.

Review of Current Morphometric Standards in Craniosynostosis

Background/Purpose: In craniosynostosis, diagnostic imaging is crucial for identifying skull abnormalities, planning for surgical correction, and post-operative and follow-up evaluations. However, classifying postoperative corrected skull morphology is a highly subjective task for all craniofacial surgeons. Initially, many surgeons utilized the Whittaker categorization test as the post-operative outcome measure, which is based on the subjective esthetic appearance as determined by the surgeon, patient, and patient’s family. While the advancement of 3D imaging and anthropometric measurements techniques has allowed various research groups to produce normative skull models to serve as treatment guides, it is still difficult to determine the objective morphological standard. The purpose of this study is to review the current standards for classifying normal skull morphology. Methods: This paper is a review of the current surgical standards of normal cranial morphology. A systematic literature review following PRISMA guidelines was performed; all published studies over a 40-year period from 1980 to 2020 were reviewed that assessed cranial morphology of healthy pediatric samples. Results: A review of the strategies utilized by some of the major medical device manufacturers in craniosynostosis correction surgery is presented. Many of these companies have progressed to using 3D normative skull construction and 3D surface analysis to measure cranial morphology. However, many variations remain among industry standards. Conclusion: Normative head shapes and cohort data matched to similar population groups have a crucial function in the diagnosis, pre-operative planning, and post-operative evaluations in craniofacial surgery. However, industry standards for “normal head shape” utilized in surgical analysis and planning remain diverse and can be somewhat opaque to the craniofacial community. Despite the advancement of 3D imaging techniques, most reported outcomes following craniofacial surgical interventions are still subjectively defined.

Comparison of Perioperative Anesthetic Concerns in Simple and Complex Craniosynostosis Cases: A Retrospective Study

Abstract Background We compared intraoperative and postoperative anesthetic parameters between simple (S-single suture) and complex (C-more than one suture) craniosynostosis cases. Materials and Methods Data was collected from a retrospective review of anesthetic and postoperative records of patients who underwent craniosynostosis correction surgery between April 2014 and August 2019. Pearson’s chi-square and independent sample t-tests were used for analysis. Results We analyzed data of 98 patients (S-simple craniosynostosis: 40 and C-complex craniosynostosis: 58). Statistically significant differences between simple and complex cases were seen only in the incidence of difficult airway, failed extubation, and requirement of postoperative ventilation. Massive blood loss (S: 23.21 mL/kg; C: 22.71 mL/kg) and difficult airway (S: 2.04%; C: 19.39%) were the most common intraoperative adverse events encountered. Metabolic abnormalities, hemodynamic instability, and hypothermia occurred in few patients. The most common postoperative issue was pyrexia (S: 15.31%; C: 17.35%). Anemia and coagulopathy needing transfusion of blood products and vitamin K injection were seen in a significant number of cases. Three nonsyndromic patients developed seizures. Conclusion The incidence of difficult airway and failed extubation with postoperative ventilation is more frequent following surgery for complex craniosynostosis than simple craniosynostosis. Complications secondary to blood loss and airway issues were the primary cause of morbidity and mortality. A staged approach to surgical management resulted in decreased surgical blood loss among the children with complex craniosynostosis.