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Spake CSL, Beqiri D, Rao V, Crozier JW, Svokos KA, Woo AS. Post-traumatic hydrocephalus may be associated with autologous cranioplasty failure, independent of ventriculoperitoneal shunt placement: a retrospective analysis. Br J Neurosurg 2022; 36:699-704. [PMID: 35608217 DOI: 10.1080/02688697.2022.2076808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE Decompressive craniectomy (DC) is a common procedure used for the treatment of intracranial hypertension. Once brain swelling has subsided, a cranioplasty is performed to restore cosmesis and protection to the brain. While using the patient's autologous bone flap is often the first choice in cranioplasty, this procedure is frequently complicated by bone flap resorption and infection. This study seeks to identify predictors of autologous cranioplasty failure. METHODS A retrospective analysis was conducted on patients who underwent decompressive craniectomy and autologous cranioplasty. Patient demographics and factors related to both surgeries and failure rates were recorded from patient records. Logistic regressions were conducted to determine which factors were implicated in autologous cranioplasty failure. RESULTS In our cohort, 127 patients underwent autologous cranioplasty. Overall, 18 (14.2%) patients experienced autologous cranioplasty failure. Regression analysis identified development of post-traumatic hydrocephalus (PTH) following DC (OR: 3.26, p = 0.043), presence of neurological deficits following DC (OR: 4.88, p = 0.025), and reoperation prior to CP (OR 3.0, p = 0.049) as significant predictors of autologous cranioplasty failure. Of the 16 patients who developed PTH following DC, 9 received a VP shunt. The rate of flap failure was similar across the 9 PTH patients who received a shunt and the 7 PTH patients who did not receive a shunt (33% vs. 57% failure rate, respectively, p = 0.341). CONCLUSION Autologous cranioplasty is a reasonably successful procedure with a flap failure rate of 14.2%. We identified PTH, persistent neurological deficits, and reoperation prior to cranioplasty as significant predictors of autologous cranioplasty failure. Interestingly, the presence of VP shunt did not impact the odds of flap failure.
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Soliman L, Spake C, Rao V, Sobti N, Liu P, Woo AS. Diversity and inclusion initiatives are infrequently featured among integrated plastic surgery residency program promotional YouTube videos. J Plast Reconstr Aesthet Surg 2022; 75:3877-3903. [DOI: 10.1016/j.bjps.2022.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022]
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Spake CS, Goli R, Beqiri D, Crozier JW, Cielo DJ, Klinge PM, Svokos K, Woo AS. Evidence of linear bone flap resorption in patients undergoing autologous cranioplasty following decompressive craniectomy: A 3D Slicer segmented analysis of serial CT images. World Neurosurg 2022; 164:e799-e807. [PMID: 35597539 DOI: 10.1016/j.wneu.2022.05.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Autologous cranioplasty (CP) following decompressive craniectomy (DC) carries risk of bone flap resorption (BFR). The current literature offers limited information regarding the natural progression of BFR, and the rate at which it occurs. We aim to characterize the progression of BFR over time and elucidate risk factors for accelerated BFR. METHODS A retrospective analysis was conducted on patients who underwent DC and autologous CP. Serial computed tomography (CT) images were used to quantify degree of BFR over time. Risk factors included age, diabetes, smoking status, flap fragmentation, defect size, and DC-CP time interval. Chi-square analyses and Student's t-tests were performed to examine differences between patients who experienced BFR and those who did not. RESULTS Overall, 82% of patients demonstrated evidence of clinically relevant resorption on CT. On average, the bone flap decreased in volume by 36.7% within the first year, with a linear loss in volume after multiple years of follow-up. Individuals who developed greater BFR were significantly younger (43 ± 17 vs. 56 ± 12, p=0.022), had a lower incidence of diabetes (5.9% vs. 43%, p=0.037), and had more bone flap fragments (1.4 ± 0.67 vs. 1.00 ± 0, p <0.001) than those who did not. CONCLUSION Resorption following CP with cryopreserved bone appears to progress in a fairly linear and continuous fashion over time. Using serial CT images, we found a resorption rate of 82% at our institution. We identified several possible risk factors for resorption, including flap fragmentation, younger age, and absence of diabetes.
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Basta MN, Rao V, Paiva M, Liu PY, Woo AS, Fischer JP, Breuing KH. Evaluating the Inaccuracy of the National Surgical Quality Improvement Project Surgical Risk Calculator in Plastic Surgery: A Meta-analysis of Short-Term Predicted Complications. Ann Plast Surg 2022; 88:S219-S223. [PMID: 35513323 DOI: 10.1097/sap.0000000000003189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Preoperative surgical risk assessment is a major component of clinical decision making. The ability to provide accurate, individualized risk estimates has become critical because of growing emphasis on quality metrics benchmarks. The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) Surgical Risk Calculator (SRC) was designed to quantify patient-specific risk across various surgeries. Its applicability to plastic surgery is unclear, however, with multiple studies reporting inaccuracies among certain patient populations. This study uses meta-analysis to evaluate the NSQIP SRC's ability to predict complications among patients having plastic surgery. METHODS OVID MEDLINE and PubMed were searched for all studies evaluating the predictive accuracy of the NSQIP SRC in plastic surgery, including oncologic reconstruction, ventral hernia repair, and body contouring. Only studies directly comparing SCR predicted to observed complication rates were included. The primary measure of SRC prediction accuracy, area under the curve (AUC), was assessed for each complication via DerSimonian and Laird random-effects analytic model. The I2 statistic, indicating heterogeneity, was judged low (I2 < 50%) or borderline/unacceptably high (I2 > 50%). All analyses were conducted in StataSE 16.1 (StataCorp LP, College Station, Tex). RESULTS Ten of the 296 studies screened met criteria for inclusion (2416 patients). Studies were classified as follows: (head and neck: n = 5, breast: n = 1, extremity: n = 1), open ventral hernia repair (n = 2), and panniculectomy (n = 1). Predictive accuracy was poor for medical and surgical complications (medical: pulmonary AUC = 0.67 [0.48-0.87], cardiac AUC = 0.66 [0.20-0.99], venous thromboembolism AUC = 0.55 [0.47-0.63]), (surgical: surgical site infection AUC = 0.55 [0.46-0.63], reoperation AUC = 0.54 [0.49-0.58], serious complication AUC = 0.58 [0.43-0.73], and any complication AUC = 0.60 [0.57-0.64]). Although mortality was accurately predicted in 2 studies (AUC = 0.87 [0.54-0.99]), heterogeneity was high with I2 = 68%. Otherwise, heterogeneity was minimal (I2 = 0%) or acceptably low (I2 < 50%) for all other outcomes. CONCLUSIONS The NSQIP Universal SRC, aimed at offering individualized quantifiable risk estimates for surgical complications, consistently demonstrated poor risk discrimination in this plastic surgery-focused meta-analysis. The limitations of the SRC are perhaps most pronounced where complex, multidisciplinary reconstructions are needed. Future efforts should identify targets for improving SRC reliability to better counsel patients in the perioperative setting and guide appropriate healthcare resource allocation.
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Rivera Perla KM, Tang OY, Zeyl VG, Lim R, Rao V, Toms SA, Svokos KA, Woo AS. Predicting the Impact of Race and Socioeconomic Status on Cranioplasty Materials and Outcomes. World Neurosurg 2022; 164:e463-e480. [DOI: 10.1016/j.wneu.2022.04.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
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Suskin JA, Rao V, Crozier JW, Yi T, Benz E, Woo AS. Re-evaluating the need for orthopantomography in the management of mandibular trauma: is computed tomography enough? Emerg Radiol 2022; 29:663-670. [PMID: 35426532 DOI: 10.1007/s10140-022-02049-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Mandibular fractures are frequent indications for computed tomography (CT) and orthopantomography (OPG) scans in emergency rooms. Numerous studies found CT to have higher sensitivity and enhanced accuracy compared to OPG in diagnosing mandible fractures. Controversy exists regarding additional need for OPG when evaluating dental trauma. This study investigates whether OPG adds diagnostic value to CT in mandibular trauma and whether additional OPG significantly alters management. METHODS A retrospective chart review identified 100 patients ≥ 18 years of age with known mandibular trauma who received CT and OPG in the emergency department between May 2015 and January 2020. All patients demonstrated a fracture in at least one study. CT and OPG studies were anonymized and randomized. A single attending surgeon evaluated mandible fracture and dental trauma characteristics and subsequently compared findings. RESULTS One hundred patient CT and OPG scans were reviewed. CT detected mandible fractures in all patients and OPG detected fractures in 93% (p = 0.01). Twenty-eight patients had different findings between scans. CT demonstrated 1 or more additional fracture(s) than OPG in 20 patients and dental trauma not seen on OPG in 4. OPG detected 1 fracture and no dental trauma that was not seen on CT. CT drove treatment-determining differences in 17 cases and OPG in 0 cases. CONCLUSIONS CT appears efficacious in detecting clinically significant mandible fractures and dental trauma with little additional benefit from OPG in emergency settings. Helical CT may be the only imaging necessary in evaluating patients with such trauma.
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Lerner JL, Crozier JW, Scappaticci AA, Rao V, Woo AS. Comparing diagnosis of midfacial fractures by radiologists and plastic surgeons. Emerg Radiol 2022; 29:499-505. [PMID: 35266070 DOI: 10.1007/s10140-022-02036-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinicians who manage facial fractures often rely on radiologist interpretations to help with assessment and management. Among treating physicians, facial fractures are categorized into clinically relevant patterns of injury. On the other hand, while radiologists are unsurpassed at identifying individual breaks in the bone, larger fracture patterns are not always conveyed in radiology reports. PURPOSE This study aims to assess the frequency with which the terminology describing midfacial fracture patterns is concordant among radiologists and treating clinicians. METHODS The authors identified patients with different patterns of midfacial injury including Le Fort I, Le Fort II, Le Fort III, naso-orbito-ethmoid (NOE), and zygomaticomaxillary complex (ZMC) fractures. Plastic surgery consult notes and radiological imaging reports were reviewed for concordance in documentation of injury patterns. Identification of individual fractures consistent with the diagnosed fracture pattern was also recorded. RESULTS Radiologists were noted to be highly successful in describing individual fractures of the facial bones, identifying at least two defining components of a fracture pattern in 96% of Le Fort, 88% of NOE, and 94% of ZMC injuries. However, when injury patterns were considered, only 32% of Le Fort, 28% of ZMC, and 6% of NOE fractures were explicitly identified in radiology reports. CONCLUSIONS Radiologists are highly skilled in discerning individual fractures in facial trauma cases. However, less reliability was seen in the identification of fracture patterns in midfacial injury, with particular weaknesses in descriptions of NOE and ZMC fractures. This data suggests that greater focus on patterns of midfacial injury would improve the clinical applicability of radiological reports.
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Spake CSL, Beqiri D, Rao V, Crozier JW, Svokos KA, Woo AS. Subgaleal drains may be associated with decreased infection following autologous cranioplasty: a retrospective analysis. Br J Neurosurg 2021:1-7. [PMID: 34751075 DOI: 10.1080/02688697.2021.1995588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/04/2021] [Accepted: 10/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Autologous bone is often the first choice in cranioplasty following a decompressive craniectomy. However, infection is a common complication, with reported rates up to 25%. While the incidence and management of infection are well documented, the risk factors associated with infection remain less clear. The current study aims to identify predictors of infection risk following autologous cranioplasty. METHODS A retrospective analysis was conducted on patients who underwent decompressive craniectomy and cranioplasty using cryopreserved autologous bone flaps between 2010 and 2020. Patient demographics and factors related to both surgeries and infection rates were recorded from patient records. Logistic regressions were conducted to determine which factors were implicated in the development of infection. RESULTS In our cohort, 126 patients underwent autologous cranioplasty. A total of 10 patients (7.9%) developed an infection following reconstruction, with half resulting in implant failure. We did not identify any significant risk factors for infection. Regression analysis identified placement of subgaleal drain following cranioplasty as a protective factor against the development of infection (OR: 0.16, p = 0.007). On average, drains remained in for 3 days, with no difference between the length of drains for those with infection vs. those without (p = 0.757). CONCLUSIONS The current study demonstrates an infection rate of 7.9% in patients who receive an autologous cranioplasty following decompressive craniectomy, which is consistent with previous data. Half (4%) of patients who experienced an infection ultimately required removal of the implant. While it is common practice for neurosurgeons to use drains to prevent hematomas and fluid collections, we found that subgaleal drain placement following cranioplasty was associated with decreased infection, thus demonstrating another benefit of a commonly used tool.
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Basta M, Rao V, Paiva M, Liu PY, Woo AS, Fischer JP, Breuing KH. Evaluating the Inaccuracy of the NSQIP Surgical Risk Calculator in Predicting 30-day Complications in Plastic Surgery. Plast Reconstr Surg Glob Open 2021. [PMCID: PMC9555969 DOI: 10.1097/01.gox.0000799556.45922.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kondamuri NS, Bharathi R, Woo AS, Groblewski JC. Sinonasal Myxoma With Intraorbital Expansion: A Rare Case. OTO Open 2021; 5:2473974X211045300. [PMID: 34589663 PMCID: PMC8474345 DOI: 10.1177/2473974x211045300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/12/2021] [Indexed: 12/02/2022] Open
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Basta MN, Rao V, Roussel LO, Crozier JW, Liu PY, Woo AS. Refining Indications for Orbital Floor Fracture Reconstruction: A Risk-Stratification Tool Predicting Symptom Development and Need for Surgery. Plast Reconstr Surg 2021; 148:606-615. [PMID: 34432690 DOI: 10.1097/prs.0000000000008292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Challenges in orbital floor fracture management include delayed symptom onset and controversial surgical indications based on radiographic findings. This study assessed which imaging characteristics most reliably predict symptomatology to generate a tool quantifying individual need for surgery on initial presentation. METHODS The clinical course for all patients with isolated orbital fractures at a single institution from 2015 to 2017 were reviewed. Trauma mechanism, computed tomographic scan findings, and symptoms necessitating surgery (diplopia, enophthalmos) were noted. Univariable and multivariable regression modeling was used to generate a predictive risk model for operative fractures. RESULTS One hundred twenty-one patients with isolated orbital fractures were identified. Mechanism of injury included falls (41 percent), assault (37 percent), and vehicular trauma (17 percent). Patient follow-up averaged 4.4 ± 4.8 months. Average orbital floor fracture area was 2.4 cm2 (range, 0.36 to 6.18 cm2), and orbital volume herniation averaged 0.70 cm3 (range, 0.01 to 4.23 cm3). Twenty-one patients (17.3 percent) required surgical intervention for symptomatic fractures. The strongest predictors of symptoms were orbital volume increase greater than 1.3 cm3 (OR, 10.5; p = 0.001) and inferior rectus displacement within/below the fracture line (OR, 3.7; p = 0.049). Mechanical fall was risk-reducing (OR, 0.08; p = 0.005). Symptom risk was stratified from low (3.6 percent) to high risk (71 percent) (C-statistic = 0.90). The volume of herniated orbital contents was significantly more predictive of symptoms than fracture area (C-statistic = 0.81 versus C-statistic = 0.66; p = 0.02). CONCLUSIONS The proposed risk tool allows highly accurate, early prediction of symptomatic orbital floor fractures. Findings suggest that orbital volume change, not fracture area, more reliably informs operative indications, along with inferior rectus muscle caudal malposition. A simplified stepwise decision algorithm demonstrates the potential utility of this risk-assessment tool. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Mehrzad R, Akiki R, Liu PY, Schmidt S, Woo AS. Changes in Academic Plastic Surgery Programs During the COVID-19 Pandemic. Ann Plast Surg 2021; 87:S52-S56. [PMID: 33833168 DOI: 10.1097/sap.0000000000002805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The COVID-19 pandemic has presented unprecedented challenges for surgical teaching programs, as operating rooms closed and resources were redirected for patient care. As a result, both educational challenges and opportunities emerged. The objective of this study was to assess the changes used by plastic surgery programs as a result of the pandemic. METHODS A 34-question American Council of Academic Plastic Surgeons-approved survey was distributed on April 29, 2020, to attendings in academic plastic surgery programs in the United States. Variables were controlled whenever multiple attending responses were submitted from the same program. RESULTS A total of 113 attendings, including 30 (27.8%) program directors, responded to the survey. Most respondents were located in the northeast (41.4%). The average percentage of elective case volume was 23% of pre-COVID states. Those who reported a decrease in emergent surgical case volume (55.2%) estimated it to be at an average of 45% of the normal. Almost all the respondents (95.6%) agreed that they were working fewer hours than usual, and 40.9% of those reported a decrease of more than 20 hours per week of work. Most attendings (82.1%) also reported a decrease in their monthly salary. The percentage projected current salary compared with normal was 85%. CONCLUSIONS Our survey data suggest that academic plastic surgery programs have had impactful changes to their operative and educational schedules, teaching, revenue, and patient care. The data described in this study could be used as a baseline for future pandemics affecting plastic surgery programs to help strategize their operational and educational structures.
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Pertsch NJ, Leary OP, Camara-Quintana JQ, Liu DD, Niu T, Woo AS, Ng TT, Oyelese AA, Fridley JS, Gokaslan ZL. A modern multidisciplinary approach to a large cervicothoracic chordoma using staged en bloc resection with intraoperative image-guided navigation and 3D-printed modeling: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE2023. [PMID: 36045932 PMCID: PMC9394173 DOI: 10.3171/case2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/11/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cervicothoracic junction chordomas are uncommon primary spinal tumors optimally treated with en bloc resection. Although en bloc resection is the gold standard for treatment of mobile spinal chordoma, tumor location, size, and extent of involvement frequently complicate the achievement of negative margins. In particular, chordoma involving the thoracic region can require a challenging anterior access, and en bloc resection can lead to a highly destabilized spine. OBSERVATIONS Modern technological advances make en bloc resection more technically feasible than ever before. In this case, the successful en bloc resection of a particularly complex cervicothoracic junction chordoma was facilitated by a multidisciplinary surgical approach that maximized the use of intraoperative computed tomography–guided spinal navigation and patient-specific three-dimensional–printed modeling. LESSONS The authors review the surgical planning and specific techniques that facilitated the successful en bloc resection of this right-sided chordoma via image-guided parasagittal osteotomy across 2 stages. The integration of emerging visualization technologies into complex spinal column tumor management may help to provide optimal oncological care for patients with challenging primary tumors of the mobile spine.
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Prsic A, Boyajian MK, Snapp WK, Crozier J, Woo AS. A 3-Dimensional-Printed Hand Model for Home-Based Acquisition of Fracture Fixation Skills Without Fluoroscopy. JOURNAL OF SURGICAL EDUCATION 2020; 77:1341-1344. [PMID: 32571690 PMCID: PMC7304390 DOI: 10.1016/j.jsurg.2020.05.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/19/2020] [Accepted: 05/25/2020] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To design a low cost ($40), realistic and fluoroscopy-free percutaneous Kirschner wire hand fracture fixation training instrument kit for home-based skill acquisition during the COVID-19 pandemic. DESIGN A 3D-printed hand was designed from a computed tomography scan of a healthy hand. These data were used to create replaceable hand and wrist bones and reusable silicone molds for a replica of the soft tissue envelope. The model is currently being integrated into the simulation curriculum at 2 integrated plastic surgery residency programs for training in percutaneous wire fixation of hand fractures. SETTING Brown University, Warren Alpert Medical School of Brown University. Department of Surgery, Division of Plastic and Reconstructive Surgery. Large academic quaternary referral institution. Yale University, Yale School of Medicine. Department of Surgery, Division of Plastic and Reconstructive Surgery. Large academic quaternary referral institution. PARTICIPANTS PGY 1-4 plastic surgery residents preparing to meet ACGME Accreditation for Graduate Medical Education hand surgery specific milestones. RESULTS A realistic and durable 3D model with interchangeable bones allows trainees to practice the key motor skills necessary for successful fixation of hand and wrist fractures with K-wires in a home-based setting. CONCLUSIONS A low cost, realistic and durable 3D hand model with interchangeable bones allows easy integration into any home-based hand surgery curriculum. With 3D printers and programming becoming more prevalent and affordable, such models offer a means of low-cost and safe instruction of residents in fracture fixation with no harm to patients.
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Skolnick GB, Yu JL, Patel KB, David LR, Couture DE, Smyth MD, Woo AS. Comparison of 2 Sagittal Craniosynostosis Repair Techniques: Spring-Assisted Surgery Versus Endoscope-Assisted Craniectomy With Helmet Molding Therapy. Cleft Palate Craniofac J 2020; 58:678-686. [PMID: 33094638 DOI: 10.1177/1055665620966521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION This study compares anthropometric outcomes of 2 sagittal synostosis repair techniques: spring-assisted surgery and endoscope-assisted craniectomy with molding helmet therapy. METHODS Patients undergoing spring-assisted surgery (n = 27) or endoscope-assisted craniectomy with helmet therapy (n = 40) at separate institutions were retrospectively reviewed. Pre- and 1-year postoperative computed tomography (CT) or laser scans were analyzed for traditional cranial index (CI), adjusted cranial index (aCI), and cranial vault volume (CVV). Nine patient-matched scans were analyzed for measurement consistency. RESULTS The spring-assisted group was older at both time points (P < .050) and spring-assisted group CVV was larger preoperatively and postoperatively (P < .01). However, the change in CVV did not differ between the groups (P = .210). There was no difference in preoperative CI (helmet vs spring: 70.1 vs 71.2, P = .368) between the groups. Postoperatively, helmet group CI (77.0 vs 74.3, P = .008) was greater. The helmet group also demonstrated a greater increase in CI (6.9 vs 3.1, P < .001). The proportion of patients achieving CI of 75 or greater was not significantly different between the groups (helmet vs spring: CI, 65% vs 52%, P = .370). There was no detectable bias in CI between matched CT and laser scans. Differences were identified between scan types in aCI and CVV measurements; subsequent analyses used corrected CVV and aCI measures for laser scan measures. CONCLUSIONS Both techniques had equivalent proportions of patients achieving normal CI, comparable effects on cranial volume, and similar operative characteristics. The study suggests that there may be greater improvement in CI in the helmet group. However, further research should be performed.
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Leary OP, Crozier J, Liu DD, Niu T, Pertsch NJ, Camara-Quintana JQ, Svokos KA, Syed S, Telfeian AE, Oyelese AA, Woo AS, Gokaslan ZL, Fridley JS. Three-Dimensional Printed Anatomic Modeling for Surgical Planning and Real-Time Operative Guidance in Complex Primary Spinal Column Tumors: Single-Center Experience and Case Series. World Neurosurg 2020; 145:e116-e126. [PMID: 33010507 DOI: 10.1016/j.wneu.2020.09.145] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Three-dimensional (3D) printing has emerged as a visualization tool for clinicians and patients. We sought to use patient-specific 3D-printed anatomic modeling for preoperative planning and live intraoperative guidance in a series of complex primary spine tumors. METHODS Over 9 months, patients referred to a single neurosurgical provider for complex primary spinal column tumors were included. Most recent spinal magnetic resonance and computed tomography (CT) imaging were semiautomatically segmented for relevant anatomy and models were printed using polyjet multicolor printing technology. Models were available to surgical teams before and during the operative procedure. Patients also viewed the models preoperatively during surgeon explanation of disease and surgical plan to aid in their understanding. RESULTS Tumor models were prepared for 9 patients, including 4 with chordomas, 2 with schwannomas, 1 with osteosarcoma, 1 with chondrosarcoma, and 1 with Ewing-like sarcoma. Mean age was 50.7 years (range, 15-82 years), including 6 males and 3 females. Mean tumor volume was 129.6 cm3 (range, 3.3-250.0 cm3). Lesions were located at cervical, thoracic, and sacral levels and were treated by various surgical approaches. Models were intraoperatively used as patient-specific anatomic references throughout 7 cases and were found to be technically useful by the surgical teams. CONCLUSIONS We present the largest case series of 3D-printed spine tumor models reported to date. 3D-printed models are broadly useful for operative planning and intraoperative guidance in spinal oncology surgery.
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Poggi J, Chen WS, Taylor HO, Sullivan S, Woo AS, Klinge PM. Revisiting the Resolution of Chiari Malformation in Nonsyndromic Craniosynostosis: A Case of Posterior Cranial Vault Reconstruction in Secondary Pan-Suture Synostosis. World Neurosurg 2020; 143:158-162. [PMID: 32730962 DOI: 10.1016/j.wneu.2020.07.138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND While commonly seen in syndromic craniosynostosis, the incidence of Chiari malformation (CM) in nonsyndromic craniosynostosis has been reported at 5% and there is a lack of understanding of the pathophysiology and management of CM in this patient population. CASE DESCRIPTION We present a 5-year-old male patient who underwent a sagittal craniosynostosis repair at the age of 5 months and returned at the age of 5 years with daily headaches associated with behavioral changes. He was found to have pan-synostoses and radiographic evidence of increased intracranial pressure, including a Chiari malformation. Neurologic and genetic workup was unremarkable. A cranial vault reconstruction was performed, and subsequent imaging demonstrated resolution of previously noted Chiari malformation. CONCLUSIONS In our case, we provided a unique window into the underlying pathophysiology for CM in patients with concurrent nonsyndromic craniosynostosis that we hope will add to the current foundation of literature supporting the intricate relation between cranial vault compliance and Chiari malformation or hindbrain herniation. Furthermore, we provide insight into the management of acquired CM and support isolated cranial vault reconstruction in those who do not appear to have symptomatic suboccipital compression.
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Boyajian MK, Lubner RJ, Roussel LO, Crozier JW, Ryder BA, Woo AS. A 3D printed suturing trainer for medical students. CLINICAL TEACHER 2020; 17:650-654. [PMID: 32592314 DOI: 10.1111/tct.13176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medical students must be able to suture competently upon graduation. To learn suturing technique, students must have access to practice materials. The purpose of this pilot study was to develop a novel suturing trainer and to evaluate its ability to provide realistic and accessible suturing practice. A cohort of senior students at one institution compared the device with standard suture-training media (porcine feet and sponges). METHODS Using 3D printing and silicone casting, a novel suturing trainer was developed and a cohort of senior medical students trialed the device in a standardised suturing workshop. Participants evaluated the novel suturing trainer, porcine feet and sponges for simulating human tissue with regard to: (i) tissue layers; (ii) tissue texture; (iii) ability to perform interrupted suturing; (iv) running subcuticular suturing; and (v) knot tying. RESULTS Compared with porcine feet and sponges, the suturing trainer had significantly higher mean scores (p < 0.001) for the simulation of human tissue layers and texture, as well as for the ability to facilitate the practice of interrupted suturing, running suturing and knot tying. All (n = 32) participants identified the silicone trainer as the best tool upon which to practice suturing, and 92% (n = 23) responded that their suturing skills would improve if the silicone trainer replaced porcine feet and sponges. DISCUSSION The silicone suturing device provides a more realistic and accessible suture learning experience than porcine feet and sponges. Further validation is required to assess its long-term effectiveness in medical education.
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Nissen NJ, Okhah ZI, Basta MN, Hsieh S, Crozier JW, Jehle CC, Rao V, Woo AS. Underdiagnosis of Nasoorbitoethmoid Fractures in Patients with Zygoma Injury. Plast Reconstr Surg 2020; 145:1001-1008. [PMID: 32221221 DOI: 10.1097/prs.0000000000006626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nasoorbitoethmoid fractures commonly accompany midface fractures and may be underdiagnosed, resulting in incomplete reconstruction or inadequate treatment following facial trauma. To better understand the nasoorbitoethmoid fracture diagnosis and treatment tendencies, the authors analyzed concomitant nasoorbitoethmoid injuries in the setting of zygoma fractures. METHODS The facial trauma database at a level I trauma center was evaluated. All patients with diagnosed zygoma fractures from June of 2011 to March of 2016 were assessed for a concomitant nasoorbitoethmoid injury. Documentation of these fractures in radiology, plastic surgery, and operative notes was recorded, as was the rate of nasoorbitoethmoid fracture surgical repair. RESULTS The authors identified 339 eligible patients and completed retrospective analysis of computed tomographic images for their 356 zygoma fractures. The incidence of concomitant nasoorbitoethmoid fractures was 30.6 percent (109 of 356). Documentation rates of nasoorbitoethmoid fractures were 0 percent, 3.7 percent, and 8.3 percent in radiology, plastic surgery, and operative notes, respectively. The rate of surgical correction of nasoorbitoethmoid injuries was 22.9 percent (25 of 109). Of those fractures identified, 44.9 percent (49 of 109) were minimally displaced or nondisplaced. Subset analysis of only significantly displaced fractures yielded an incidence of 16.8 percent (60 of 356). Of significantly displaced fractures, documentation rates were 0 percent, 6.7 percent, and 16.8 percent in radiology, plastic surgery, and operative notes, respectively. The surgical repair rate of significantly displaced fractures was 31.7 percent (19 of 60). CONCLUSIONS These findings suggest a high concomitance rate of nasoorbitoethmoid fractures with zygoma fractures and identify a tendency to underdocument and undertreat this injury pattern. Clinicians managing patients with midface trauma should have a high suspicion for nasoorbitoethmoid trauma. Plastic surgeons and radiologists should be better trained in identifying the nasoorbitoethmoid fracture pattern.
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Leary OP, Liu DD, Boyajian MK, Syed S, Camara-Quintana JQ, Niu T, Svokos KA, Crozier J, Oyelese AA, Liu PY, Woo AS, Gokaslan ZL, Fridley JS. Complex wound closure by plastic surgery following resection of spinal neoplasms minimizes postoperative wound complications in high-risk patients. J Neurosurg Spine 2020; 33:77-86. [PMID: 32109877 DOI: 10.3171/2019.12.spine191238] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Wound breakdown and infection are common postoperative complications following resection of spinal neoplasms. Accordingly, it has become common practice at some centers for plastic surgeons to assist with closure of large posterior defects after spine tumor resection. In this study, the authors tested the hypothesis that plastic surgery closure of complex spinal defects improves wound outcomes following resection of spinal neoplastic disease. METHODS Electronic medical records of consecutive patients who underwent resection of a spinal neoplasm between June 2015 and January 2019 were retrospectively reviewed. Patients were separated into two subpopulations based on whether the surgical wound was closed by plastic surgery or neurosurgery. Patient demographics, preoperative risk factors, surgical details, and postoperative outcomes were collected in a central database and summarized using descriptive statistics. Outcomes of interest included rates of wound complication, reoperation, and mortality. Known preoperative risk factors for wound complication in spinal oncology were identified based on literature review and grouped categorically. The presence of each category of risk factors was then compared between groups. Univariate and multivariate linear regressions were applied to define associations between individual risk factors and wound complications. RESULTS One hundred six patients met inclusion criteria, including 60 wounds primarily closed by plastic surgery and 46 by neurosurgery. The plastic surgery population included more patients with systemic metastases (58% vs 37%, p = 0.029), prior radiation (53% vs 17%, p < 0.001), prior chemotherapy (37% vs 15%, p = 0.014), and sacral region tumors (25% vs 7%, p = 0.012), and more patients who underwent procedures requiring larger incisions (7.2 ± 3.6 vs 4.5 ± 2.6 levels, p < 0.001), prolonged operative time (413 ± 161 vs 301 ± 181 minutes, p = 0.001), and greater blood loss (906 ± 1106 vs 283 ± 373 ml, p < 0.001). The average number of risk factor categories present was significantly greater in the plastic surgery group (2.57 vs 1.74, p < 0.001). Despite the higher relative risk, the plastic surgery group did not experience a significantly higher rate of wound complication (28% vs 17%, p = 0.145), reoperation (17% vs 9%, p = 0.234), or all-cause mortality (30% vs 13%, p = 0.076). One patient died from wound-related complications in each group (p = 0.851). Regression analyses identified diabetes, multilevel instrumentation, and BMI as the factors associated with the greatest wound complications. CONCLUSIONS Involving plastic surgery in the closure of spinal wounds after resection of neoplasms may ameliorate expected increases in wound complications among higher-risk patients.
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Boyajian MK, Al-Samkari H, Nguyen DC, Naidoo S, Woo AS. Partial Suture Fusion in Nonsyndromic Single-Suture Craniosynostosis. Cleft Palate Craniofac J 2020; 57:499-505. [PMID: 32013562 DOI: 10.1177/1055665620902299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Partial synostosis of cranial sutures has been shown to have clinical and diagnostic significance. However, there is limited published information about how suture fusion progresses over time. In this study, we evaluate patients with nonsyndromic single-suture synostosis. We aim to define the incidence of partial versus complete suture fusion and whether a correlation exists between the degree of suture fusion and age. METHODS Two hundred fifty-four patients with nonsyndromic single-suture synostosis were evaluated. Preoperative computed tomography (CT) scans were rendered in 3-dimensions, all sutures were visualized and assessed for patency or fusion, and length of fusion was measured. Findings were grouped according to suture type (sagittal, coronal, metopic, or lambdoid), the degree of fusion (full, >50%, or <50%), and patient age at time of CT scan (0-90, 91-180, 181-360, or >360 days). Data were analyzed to correlate patient age versus the degree of suture fusion. RESULTS For all patients, 72% had complete and 28% had partial synostosis. Ratios of full to partial fusion for each suture type were as follows: sagittal 97:36, coronal 35:22, metopic 46:4, and lambdoid 4:10. The sagittal, coronal, and metopic groups demonstrated greater probabilities of complete suture fusion as patient age increases (P = .021, P < .001, P = .001, respectively). This trend was also noted when all sutures were considered together by age-group (P < .001). CONCLUSION We note a partial suture fusion rate of 28.3%. Our analysis shows a correlation between the extent of suture synostosis and patient age. Finally, we demonstrate that different sutures display different patterns of partial and complete fusion.
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Boyajian MK, Crozier JW, Woo AS. Introduction of Medical Three-Dimensional Printing in Rhode Island. RHODE ISLAND MEDICAL JOURNAL (2013) 2019; 102:15-18. [PMID: 31398962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Since the early 2000s, three-dimensional (3D) printing has become a well-rounded, evolving technology which has begun to revolutionize healthcare. 3D printing enables rapid creation and manufacture of individual patient models from original designs or medical imaging data. These models can be used for surgical planning, procedural training for residents and medical students, and the design and manufacture of surgical instruments, implants and prostheses. Current availability of this advanced technology at the Lifespan 3D Printing Lab permits Rhode Island physicians to utilize 3D printing in multiple, diverse settings to help improve their medical practice and optimize healthcare outcomes. This article describes three case-based examples to demonstrate varies used of 3D printing in Medicine.
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Shankar VA, Snyder-Warwick A, Skolnick GB, Woo AS, Patel KB. Incidence of Palatal Fistula at Time of Secondary Alveolar Cleft Reconstruction. Cleft Palate Craniofac J 2018; 55:999-1005. [PMID: 28140667 DOI: 10.1597/16-179] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE We aim to establish consistent time points for evaluating palatal fistula incidence to standardize reporting practices and clarify prospective literature. DESIGN An institutional retrospective chart review was conducted on 76 patients with unilateral or bilateral complete cleft lip and palate who underwent secondary alveolar bone grafting between 2006 and 2015. MAIN OUTCOME MEASURES Early fistula incidence rates were reported prior to maxillary expansion, and late fistula rates were reported at the time of alveolar bone grafting. Fistula recurrence rates after primary repair were also measured. RESULTS We found an early fistula incidence rate of 20% (n = 15) and a late fistula rate of 55% (n = 42) at the time of secondary ABG. Fistulae recurred after initial repair in 43% of cases. Fistulae were classified using the Pittsburgh Classification System as type III (33%), type IV (60%), or type V (7%). The presence of a bilateral cleft ( P = 0.01) and history of early fistula repair ( P < 0.01) were associated with late fistula incidence in a univariate analysis. In a logistic regression model, only early fistula repair was associated with late fistula incidence (OR = 17.17) and overall likelihood of recurrence (OR = 70.89). CONCLUSIONS Early fistulae should be reported prior to orthodontic expansion of the maxillary arch. Late fistulae should be reported at the time of ABG, following palatal expansion. Patients who develop an early fistula after palatoplasty are likely to experience recurrent fistula formation.
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Otaify GA, Whyte MP, Gottesman GS, McAlister WH, Eric Gordon J, Hollander A, Andrews MV, El-Mofty SK, Chen WS, Veis DV, Stolina M, Woo AS, Katsonis P, Lichtarge O, Zhang F, Shinawi M. Gnathodiaphyseal dysplasia: Severe atypical presentation with novel heterozygous mutation of the anoctamin gene (ANO5). Bone 2018; 107:161-171. [PMID: 29175271 PMCID: PMC5987759 DOI: 10.1016/j.bone.2017.11.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/15/2017] [Accepted: 11/17/2017] [Indexed: 12/27/2022]
Abstract
Gnathodiaphyseal dysplasia (GDD; OMIM #166260) is an ultra-rare autosomal dominant disorder caused by heterozygous mutation in the anoctamin 5 (ANO5) gene and features fibro-osseous lesions of the jawbones, bone fragility with recurrent fractures, and bowing/sclerosis of tubular bones. The physiologic role of ANO5 is unknown. We report a 5-year-old boy with a seemingly atypical and especially severe presentation of GDD and unique ANO5 mutation. Severe osteopenia was associated with prenatal femoral fractures, recurrent postnatal fractures, and progressive bilateral enlargement of his maxilla and mandible beginning at ~2months-of-age that interfered with feeding and speech and required four debulking operations. Histopathological analysis revealed benign fibro-osseous lesions resembling cemento-ossifying fibromas of the jaw without psammomatoid bodies. A novel, de novo, heterozygous, missense mutation was identified in exon 15 of ANO5 (c.1553G>A; p.Gly518Glu). Our findings broaden the phenotypic and molecular spectra of GDD. Fractures early in life with progressive facial swelling are key features. We assessed his response to a total of 7 pamidronate infusions commencing at age 15months. Additional reports must further elucidate the phenotype, explore any genotype-phenotype correlation, and evaluate treatments.
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