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Clinical Practice Patterns And Evidence-based Medicine In Non-syndromic Craniosynostosis: A Sixteen-year Review Of Maintenance Of Certification Tracer Data From The American Board Of Plastic Surgery
Selcen S. Yuksel, BS1, Aaron M. Kearney, MD2, Arun K. Gosain, MD3.
1Northwestern University Feinberg School of Medicine, Chicago, IL, USA, 2McGaw Medical Center, Northwestern University, Chicago, IL, USA, 3Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.

PURPOSE: Since 2003, the American Board of Plastic Surgery (ABPS) has been collecting data on 20 plastic surgery operations as part of the Maintenance of Certification (MOC) process. These data provide a valuable tool to track national trends in clinical practice. The goal of this study was to describe national trends in craniosynostosis repair as they relate to Evidence-Based Medicine (EBM) articles published during this timeframe.
METHODS: Cumulative tracer data for non-syndromic craniosynostosis was reviewed as of April 2014 and September 2019 and compared with EBM articles published in Plastic and Reconstructive Surgery. Topics were placed into three categories: (1) pearls, topics addressed in both the tracer data and EBM articles, (2) topics addressed in EBM articles but not collected in tracer data, and (3) topics addressed in tracer data but not EBM articles.
RESULTS: As of September 2019, 900 cases of non-syndromic craniosynostosis had been entered. The median age at time of surgery was 8 months (range, 1-204 months). The most common surgical technique used was anterior regional cranioplasty (Table 1). 89% of patients had no complications. The most common complication was dural tear (1%). 2% of patients required transfusion of at least 2 units of packed red blood cells. The incidences of infection (1.2%) and CSF leak (0.4%) were relatively low, and intracranial hypertension was observed in 7% of patients. There were no significant changes in these statistics between cumulative data in 2014 and 2019. Differences from 2014 to 2019 consisted of an increase in patients with asymptomatic clinical presentation (27% vs 36%, p = 0.001) and presentation with papilledema (1% vs 2%, p = 0.036). Topics addressed in EBM articles but not tracer data included administration of erythropoietin and other blood-loss prevention techniques.
Pearls were identified concerning preoperative evaluation, surgical technique, and postoperative management. The use of preoperative MRI significantly increased (1% vs 4%, p = 0.014) while use of CT remained stable (90% vs 92%, p = 0.178). Concerning surgical technique, the use of internal distraction cranioplasty (0% vs 1%, p = 0.012) significantly increased, while use of other surgical techniques remained stable. Significant changes were also noted in the methods of fixation used (Table 2). Helmet therapy was used post-operatively in 21% cases in both years (p = 0.869).
CONCLUSION:
By examining ABPS tracer data, we are able to describe national trends in non-syndromic craniosynostosis repair over a 16-year period. Contrary to EBM, the use of pre-operative CT scans remains stable, although the use of MRI has increased. Internal distraction cranioplasty is also being used with increased frequency. Analysis of these and other accumulated MOC tracer data highlights important trends in clinical practice over the last 16 years.

Table 1.
Surgical technique2014 (n = 430)2019 (n = 900)p
Regional cranioplasty anterior179 (42%)336 (37%)0.133
Orbital rim advancement149 (35%)323 (36%)0.659
Whole vault cranioplasty117 (27%)241 (27%)0.868
Regional cranioplasty posterior54 (13%)105 (12%)0.639
Endoscopic cranioplasty49 (11%)112 (12%)0.301
Linear craniectomy18 (4%)47 (5%)0.412
Distraction cranioplasty internal0 (0%)13 (1%)0.012
Distraction cranioplasty spring0 (0%)3 (0%)0.230
Other56 (13%)123 (14%)0.747

Table 2.
Fixation method2014 (n = 430)2019 (n = 900)p
Resorbable plates/screws292 (68%)585 (65%)0.295
Resobable suture212 (49%)433 (48%)0.6843
Ultrasonic welding101 (23%)142 (16%)0.001
Wire43 (10%)60 (7%)0.033
Metallic plates/screws6 (1%)15 (2%)0.710
None of the above57 (13%)158 (18%)0.046
Other16 (4%)26 (3%)0.417


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