Rigid fixation of the calvaria in craniosynostosis without using "rigid" fixation

Early observations of intracranial translocation of metal wires, plates, and screws used for infant skull surgery have led some surgeons to investigate alternative forms of fixation. The purpose of this study was to review a series of infants and children in whom absorbable suture fixation was used as the sole method of fixation in cranial vault remodeling. Standard osteotomies were successfully modified to permit the use of this less rigid form of fixation. Over a 6-year period, 142 cranial vault procedures were performed, primarily for craniosynostosis, using absorbable sutures (2-0 polydioxanone). Patients who did not have absorbable suture fixation, or who had a combination of absorbable sutures with another form of fixation, were excluded from this review. Records were reviewed for results (assessed by both the treating surgeon and an independent anthropologist) and for complications. The average age of patients was 2 years, 7 months (range, 1 month to 16 years). The clinical results were judged as follows: grade I (excellent), 49 percent; grade II (minor imperfections), 48 percent; grade III (small surgical procedure needed), 2 percent; and grade IV (complete reoperation required), 1 percent. Anthropologic results were similarly distributed: excellent, 36 percent; good, 56 percent; fair, 8 percent; and poor, 0 percent. Those 3 to 8 percent of patients who were found to have the poorest results were all noted to have syndromes, and it appeared that an inherent lack of growth was the primary basis for the low score. There were no deaths or major complications in this series of patients. The smaller complications identified were infections [four cases (2.8 percent)] and transient cerebrospinal fluid leak [two cases (1.4 percent)]. The most important factor in determining whether absorbable suture fixation was sufficient was the size of a preexisting calvarial defect. Although concerns have been raised about a possible link between absorbable suture fixation and subsequent poor reossification, no such association was noted in this review. The primary disadvantage of using absorbable sutures was the lack of rigidity provided. Advantages included lower costs, speed of application, and the absence of observed intracranial translocation. In conclusion, the use of absorbable suture fixation (with modifications in osteotomy design) was associated with both acceptable aesthetic outcomes and low complication rates. Craniofacial surgeons may wish to consider the use of absorbable sutures as another option for bone fixation in treatment of craniosynostosis.