CAD/CAM Assists Less Experienced Surgeons Achieve Equivalent Long-Term Outcomes in Cranial Vault Reconstruction
Regina S. Cho, BS, MSE1, Joseph Lopez, MD, MBA1, Leila Musavi, BS1, Bartlomiej Kachniarz, MD, MBA1, Alexandra Macmillan, MA, MBBS1, Beita Badiei2, Ricardo Bello, MD, MPH1, Amir Dorafshar, MBChB1.
1Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2University of Maryland College Park, Clarksville, MD, USA.
BACKGROUND: The purpose of this study was to assess whether long-term outcomes were equivalent between CAD/CAM-assisted cranial vault reconstruction performed by a junior surgeon with fewer years of surgical experience and traditional reconstruction performed by senior surgeons with many years of experience. Specific aims were to: 1) compare the proportions of cases requiring any revision, estimated blood loss (EBL), operative time, length of stay (LOS), post-operative complications; and 2) to examine the effect of the surgeon's experience on outcomes.
METHODS: An IRB-approved retrospective cohort study was performed for all patients with non-syndromic craniosynostosis (ages 1 month - 18 years) who received calvarial vault reconstruction at the Johns Hopkins Hospital between 1990 to 2017. Exclusion criteria: history of cranial vault remodeling, non-open reconstructive methods, or follow-up <30 days. The primary outcome variable was the Whitaker category: I for no revision required, II for minor revision, III for major revision, IV for complete reoperation. Years of surgeon experience were calculated from first year of post-craniofacial fellowship practice to year of surgery. CAD/CAM-assisted surgery was considered non-inferior if the proportion of cases requiring any revision (Whitaker II, III, or IV) was no more than 10% greater than the proportion in the traditional surgery group after multivariate logistic regression. T-tests and fisher exact tests applied as needed.
RESULTS: A total of 335 patients met inclusion/exclusion criteria, with 35 CAD/CAM cases. The traditional group had a higher proportion of cases requiring any revision (Whitaker category II, III, or IV) at 31.6% vs. 14.3% for CAD/CAM. CAD/CAM-assisted reconstruction was found to be non-inferior to traditional after accounting for patient race, sex, type of surgery, use of resorbable or non-resorbable hardware, and surgeon experience levels. CAD/CAM plastic surgeons and neurosurgeons had significantly fewer years of experience than their traditional group counterparts. Plastic surgeons had an average of 3.9 years (SD: 1.7 years) for CAD/CAM but 8.5 years (SD: 4.8 years) for traditional (p<0.01). Neurosurgeons had an average of 11.2 years (SD: 7.9 years) for CAD/CAM but 14.1 years (SD: 6.4 years) for traditional (p=0.05). Neither plastic surgeon nor neurosurgeon years of experience were significant predictors for whether a case will require revision. EBL, LOS, and postoperative complications were not significantly different between groups. CAD/CAM had significantly longer average operative times (5.7 hrs vs. 4.3 hrs, p<0.01).
CONCLUSIONS: CAD/CAM may reduce the learning curve and assist less experienced plastic surgeons in achieving equivalent long-term outcomes in craniofacial reconstruction.
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