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Calvarial Vault Reconstruction For Sagittal Craniosynostosis After One Year Of Age
David Chi, MD, PhD1, Austin Y. Ha, MD1, Dennis C. Nguyen, MD1, Gary B. Skolnick, BS1, Sybill D. Naidoo, PhD, RN1, Matthew D. Smyth, MD2, Kamlesh B. Patel, MD1.
1Washington University Division of Plastic and Reconstructive Surgery, Saint Louis, MO, USA, 2Washington University Department of Neurosurgery, Saint Louis, MO, USA.

BACKGROUND:The reconstructive goals in sagittal craniosynostosis are to relieve growth restriction and improve biparietal narrowing and frontooccipital bossing. Repair is more challenging in older patients due to thicker bone and decreased growth potential requiring more extensive remodeling. The aim of this study is to assess the safety and efficacy of four different open repair techniques in patients over 1 year of age.
METHODS: Retrospective chart review was performed of open repairs for nonsyndromic sagittal craniosynostosis between 2004-2016 (N = 170). Inclusion criteria required primary calvarial vault remodeling (CVR) performed after 1 year of age (N = 20). Length of stay (LOS), estimated blood loss (EBL), transfusion rates, operating room (OR) times, cephalic indices (CI), point of maximum width (PMW), vertical point of maximum width (V-PMW), and complications were reviewed. Measurements were taken from preoperative and 1-year postoperative 3D reconstructed CT scans.
RESULTS: Patients' mean age ( SD) at surgery was 31 17 months. Seven were treated by barrel stave osteotomy, 3 by barrel staves extending to the posterior vault, 7 by clamshell osteotomy, and 3 by parietal craniotomy. As a cohort, OR time was 265 50 minutes; EBL was 328 206 ml; and LOS was 3.8 0.8 days. Seventeen (85%) patients required intraoperative transfusions while 8 (40%) required postoperative transfusions. Within the first 30 postoperative days there were no readmissions, complications, additional surgery, or mortality. Cranial index was significantly improved by 5.8 (p < 0.001). Surgical outcomes by technique were not statistically significantly different (p > 0.08). Postoperative CI for 13 of the 20 patients (65%) remained below normal range. Age at surgery did not have an effect on improvement in CI (p = 0.55).
CONCLUSION: Calvarial vault reconstruction is a safe method to treat sagittal craniosynostosis in older children, but later surgical intervention after the age of one often results in suboptimal correction of CI regardless of technique. This retrospective comparative analysis of four different open repair techniques demonstrates no significant differences in the morphologic outcome. Additional investigation is needed to characterize effective strategies in treating older patients.


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