Impact of severity and therapy onset on helmet therapy in positional plagiocephaly.

Although helmet therapy is a widely established method in the treatment of positional plagiocephaly, therapeutic regimens remain contentious, especially regarding starting age. Hence, this study investigated the impact of starting age and severity on the effectiveness of helmet therapy. A total of 213 pediatric patients treated for positional plagiocephaly with an orthotic device were enrolled in this study. Pre- and post-treatment calvarial asymmetry was measured according to the Cranial Vault Asymmetry Index (CVAI) using 3D-Photogrammetry. Patients were classified by age at which treatment was started: Group 1 was comprised of patients younger than 24 weeks (n = 82); Group 2, those aged 24-32 weeks (n = 75); Group 3, those aged >32 weeks (n = 56). Additionally, groups were categorized by severity (mild: CVAI 3-7%; moderate: CVAI 7-12%; severe: CVAI > 12%). Mean initial CVAI was 9.8%, which reduced to 5.4% after helmet treatment. Group 1 (<24 weeks) showed the highest absolute and relative rate of correction. Within the groups, severity correlated positively with relative and absolute reduction of the asymmetry. A significant difference in the reduction of the CVAI depending on age was only seen in moderate and severe cases of plagiocephaly- but not in mild plagiocephaly. The present study confirms the effectiveness of helmet therapy for positional plagiocephaly. The use of an orthotic device is an appropriate treatment option particularly in infants with severe plagiocephaly and a start of helmet therapy before the age of 6 month is advisable.

The value of tranexamic acid during fronto-orbital advancement in isolated metopic craniosynostosis.

Craniofacial surgery in infants still harbors the risk of significant blood loss and the need for red blood cell (RBC) transfusion. Hence, the aim of the present study was to investigate the antifibrinolytic effect of tranexamic acid (TXA) on intraoperative blood loss and RBC transfusion rates during fronto-orbital advancement (FOA) in isolated metopic synostosis. A total of 33 children with metopic synostosis were operated on using standardized FOA, of which 16 patients (48.5%) were treated without intraoperative TXA (non-TXA group) and 17 patients (51.5%) received TXA intraoperatively (TXA group). To accurately evaluate the calculated blood loss (CBL) we analyzed the values for pre- and postoperative hematocrit and the volume of the RBC transfusion. The mean CBL and the mean weight-adjusted CBL was significantly lower for patients receiving TXA compared with the non-TXA group (158.8 ml vs. 198.5 ml, p = 0.0001; and 19.1 ml/kg vs. 22.3 ml/kg, p = 0.0293, respectively). In addition, the mean RBC transfusion and the mean weight-adjusted RBC transfusion was significantly lower for the TXA group (252.2 ml vs. 280.0 ml, p = 0.0001; and 27.9 ml/kg vs. 31.3 ml/kg, p = 0.0345, respectively). The mean duration of the surgical procedure did not differ statistically between the groups (132 min vs. 136 min, p = 0.4081), hence the lower CBL in the TXA-group was not related to a shorter cutting-suture time. As the use of intraoperative TXA minimizes blood transfusion volumes in children who undergo FOA, antifibrinolytics, such as TXA, should be considered for routine use in pediatric craniofacial surgery.

The Incidence of Complications Associated With Molding Helmet Therapy: An Avoidable Risk in the Treatment of Positional Head Deformities?

Molding helmet therapy using an individual head orthosis presents a widely accepted treatment option for children with positional head deformities; however, studies addressing the incidence of complications during helmet therapy are rare. The current study evaluates the incidence of complications in 205 children with positional head deformity undergoing molding helmet therapy. Children were classified according to the severity of their deformity as presented by the Cranial Vault Asymmetry Index (CVAI) and the Cephalic Index (CI). Fifty-nine (28.8%) of our patients presented a moderate and 146 (71.2%) a severe form of a positional head deformity. Of these children, 166 (81.0%) were diagnosed for plagiocephaly, 19 (9.3%) were brachycephalic, and 20 (9.7%) showed a combination of plagiocephaly and brachycephaly. Overall, 54 children (26.3%) showed minor complications during their helmet molding including pressure sores (13.7%), ethanol erythema (2.9%), skin erosions/skin infections (4.3%), or deficient fitting (5.4%). Children with a combination of plagiocephaly and brachycephaly (n = 20) showed the highest risk for complications, which was significantly higher compared with children with plagiocephaly (50% vs 22.3%; P = 0.012). Irrespective of the type of positional head deformity, no statistical difference was revealed between the moderate and the severe form. Minor complications are a relatively frequent event during helmet molding therapy. Especially children with a combination of plagiocephaly-brachycephaly are at high risk for complications. A reduction of this rate might be reached by a close follow-up for a short period between helmet manufacturing adjustments.