Posterior cranial vault expansion via distraction osteogenesis: an update and critical evaluation
Ian Hoppe, Rosaline Zhang, Lawrence Lin, Kate Magoon, Jordan Swanson, Scott Bartlett, Jesse Taylor.
Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
Background: Many craniofacial centers have adopted posterior vault distraction osteogenesis (PVDO) as a first-line treatment to increase intracranial volume in the management of complex, multisuture craniosynostosis due to its ability to produce greater intracranial volume expansion and delay of fronto-orbital advancement. Our center has performed PVDO for these patients for approximately 9 years, and the purpose of this study is to evaluate our “lessons learned” during that time period.
Methods: 87 patients underwent PVDO during the time period, and all were included. Demographic information, intraoperative details, distraction protocol, and selected postoperative outcomes (need for reoperation related to PVDO, need for secondary PVDO, concern for infection during distraction, the presence of an occipital step off noted on postoperative imaging and subsequent cranial procedures performed) were collected. Two time periods were identified based on our use of PVDO, early (2009 – 2013) and late (2014 – 2018), in order to elucidate the effect of changes made during the evolution of this procedure at our institution. Statistical analyses were performed using student's t-test and chi-square analysis.
Results: Of the 87 patients reviewed, 31 patients underwent PVDO in the early time period compared to 56 in the late. Procedures performed in the early time period experienced a significantly increased volume of estimated blood loss (EBL) at distractor placement, blood replacement at distractor placement, and EBL at distractor removal. Plating of the lambdoids was significantly associated with the need for a secondary PVDO (p < 0.01). The presence of a postoperative occipital step-off on imaging was associated with performing a postero-inferior osteotomy above the estimated level of the torcula (p = 0.02). In contrast, performing occipital barrel staves was protective with regards to the development of an occipital step-off on postoperative imaging (p = 0.04).
Conclusion: This study evaluates the evolution of the use of PVDO to treat complex, multisuture craniosyostosis at our institution. Like other procedures, there appears to be a learning curve, with our “late” group demonstrating improved trans-operative and post-operative outcomes. Important technical aspects of performing the procedure include vector selection and occipital barrel stave osteotomies to provide a gradual transition between the transport segment and cranial base.
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