Plastic Surgery Research Council
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PSRC 60th Annual Meeting

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The Role Of Distraction Osteogenesis In The Surgical Management Of Craniosynostosis: A Systematic Review
Owen Johnson, III, MD, FACS, Anne Tong, MBBS, Christopher Wallner, BS, Amir H. Dorafshar, MBChB.
Johns Hopkins University School of Medicine, Baltimore, MD, USA.

PURPOSE: Distraction osteogenesis (DO) has been proposed as an alternative to cranial remodeling surgery (CRS) for craniosynostosis, but technique descriptions and outcome analyses are limited to small case series. This systematic review summarizes operative characteristics and outcomes of DO for craniosynostosis. A secondary aim is to identify advantages and disadvantages of this approach and formulate guidelines for recommending its use over CRS.
METHODS: Two independent assessors undertook a systematic review of the literature using Cochrane, PubMed, Scopus, Google Scholar, and Web of Science databases. Studies that reported descriptive analysis, operative technical data, outcomes, or post-operative complications of DO for craniosynostosis were included. Studies that reported concomitant midface or mandibular distraction were excluded.
RESULTS: Twenty-two eligible manuscripts, totaling 292 cases, were identified. In 267 cases DO was the primary procedure while 25 had previous operations. There were 93 cases of syndromic craniosynostosis, most frequently Apert (38) and Crouzon (21) syndromes. The remaining 199 were nonsyndromic, the most common deformities being plagiocephaly (56), scaphocephaly (40), and brachycephaly (23). All comparison studies found mean operative time, blood loss, and intensive care unit (ICU) length of stay to be less than CRS, some with statistical significance. Only 19 patients (6.5%) required any blood transfusion whereas in CRS transfusion is almost universal. Treatment protocols included: latency period of 4.7 ± 1.6 d, distraction rate of 1 millimeter/d, distraction period of 20.4 ± 6.1 d, and consolidation period of 59.6 ± 22.8 d. Final distraction length was 22.9 ± 9.7 millimeters. There were complications in 46 (16%) cases, but most of these were minor, such as superficial infections, cerebrospinal fluid leaks requiring no intervention, or hardware issues. Footplate loosening or hardware malposition was highly variable and dependent on surgical technique. There were no post-operative deaths. Serious complications associated with CRS such as meningitis, epidural abscess, or significant resorption were not observed after DO. With reasonable follow-up (23.6 ± 21.6 months, range 6 to 130), there have been zero reports of bony relapse, including when DO was used to treat relapse after CRS. DO required at least two surgeries, and prolonged in-patient hospitalization was sometimes employed to manage the distraction process. In 291 cases, post-operative improvement was observed in the form of decreased intracranial pressure, resolved headache or papilledema, improved aesthetic appearance, increased cranial volume, or other measurements of endocranial angulation or proportion. In one case intracranial hypertension failed to completely resolve.
CONCLUSIONS: DO is a useful adjunct to treat craniosynostosis with low morbidity and durable results. Compared to CRS, DO is performed with decreased operative time, blood loss, need for transfusion, and need for intensive care. While DO can be labor-intensive and requires at least two procedures, its efficacy and safety profile suggest it can be considered an efficacious alternative method for the treatment of craniosynostosis. DO may be particularly advantageous in posterior vault expansion or to salvage cases of previous failure/relapse following CRS.


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