The Careful Return of Sports Medicine Procedures in the United States During COVID-19: Comparison of Utilization, Patient Demographics, and Complications.

OBJECTIVES: Sports medicine procedures encompass some of the highest-volume elective surgeries performed annually. Elective surgery was suspended because of the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic; therefore, the purpose was to compare temporal trends in procedural volume, patient demographics, and postoperative complications of elective sports medicine procedures in 2019 and 2020. METHODS: Using a multicenter, nationwide sample, a retrospective query of the 2019 to 2020 American College of Surgeon's National Surgery Quality Improvement Program database was conducted for all patients undergoing common elective sports medicine procedures. Temporal trends in utilization, demographics, and 30-day complications were compared pre-COVID (2019 and 2020Q1) with post-COVID (2020Q2-Q4). Linear regression was used to evaluate changes in procedural volume over time. A significance threshold of P < 0.05 was used. RESULTS: A total of 48,803 patients underwent elective surgery in 2019 (n = 27,883) and 2020 (n = 20,920), a 25.0% decline. Procedural utilization declined by 42.5% in 2020Q2 and never returned to prepandemic baseline in 2020Q3-Q4. The percentage decline in case volume from 2019 to 2020Q2 was greatest for meniscectomy (47.6%), rotator cuff repair (42.7%), labral repair (41.6%), biceps tenodesis (41.3%), and anterior cruciate ligament reconstruction (38.5%). Total complication rates were similar in 2019 (1.31%) versus 2020 (1.51%; P = 0.072). The 30-day readmission (0.74% versus 0.67%; P = 0.374), reoperation (0.35% versus 0.35%; P = 0.963), and mortality (0.01% versus 0.01%; P = 0.657) rates were similar between calendar years. CONCLUSIONS: Sports medicine procedures declined during the second quarter of 2020. Despite pandemic restrictions, patients who did undergo surgery did not experience increased complications. The present study may be used by surgeons, hospitals, and subspecialty societies to support the careful utilization of elective surgery during COVID-19. LEVEL OF EVIDENCE: III, prognostic study.

How does sleep apnea impact outcomes following primary total hip arthroplasty for femoral neck fractures: a matched-control analysis.

BACKGROUND: Cross-sectional studies have demonstrated that the prevalence of sleep apnea (SA) to be increasing within the United States. While studies have shown the association of SA and its association on complications following elective orthopedic procedures, well-powered studies investigating its impact in a traumatic setting are limited. The purpose of this study was to determine whether SA patients undergoing primary total hip arthroplasty (THA) for femoral neck fractures have higher rates of: (1) hospital lengths of stay (LOS); (2) readmissions; (3) complications; and (4) healthcare expenditures. METHODS: The 100% Medicare Standard Analytical Files was queried from 2005 to 2014 for patients who sustained femoral neck fractures and were treated with primary THA. The study group consisted of patients with concomitant diagnoses of SA, whereas patients without SA served as controls. Study group patients were matched to controls in a 1:5 ratio by age, sex, and various comorbid conditions. Demographics of the cohorts were compared using Pearson's chi-squared analyses, and multivariate logistic regression analyses were used to calculate the odds (OR) of the effects of SA on postoperative outcomes. A p value less than 0.006 was considered to be statistically significant. RESULTS: The final query yielded 24,936 patients within the study (n = 4166) and control (n = 20,770) cohorts. SA patients had significantly longer in-hospital LOS (6 vs. 5 days, p < 0.0001) but similar readmission rates (24.12 vs. 20.50%; OR: 1.03, p = 0.476). SA patients had significantly higher frequency and odds of developing medical complications (72.66 vs. 43.85%; OR: 1.57, p < 0.0001), and higher healthcare costs ($22,743.79 vs. $21,572.89, p < 0.0001). CONCLUSION: SA is associated with longer in-hospital LOS, higher rates of complications and healthcare expenditures. This study is vital as it can allow orthopaedists to educate patients with SA on the potential complications which may occur following their procedure. LEVEL OF EVIDENCE: III.

Anemia Severity and the Risks of Postoperative Complications and Extended Length of Stay Following Primary Total Elbow Arthroplasty.

BACKGROUND: Anemia is a modifiable risk factor that may influence postoperative complications following orthopedic surgical procedures. The objective was to determine the influence of preoperative anemia severity on postoperative complications and length of stay (LOS) following total elbow arthroplasty (TEA). METHODS: The American College of Surgeons National Surgical Quality Improvement Program registry was queried from 2006 to 2019 for patients undergoing primary TEA. Using the World Health Organization definitions of anemia, patients undergoing TEA were stratified into 3 cohorts: nonanemia (hematocrit >36% for women, >39% for men), mild anemia (hematocrit 33%-36% for women, 33%-39% for men), and moderate-to-severe anemia (hematocrit <33% for both women and men). Patient demographics, surgical time, LOS, and postoperative complications were compared between the groups. A P value <.004 was considered significant. RESULTS: After exclusion, 589 patients, of whom 369 (62.6%) did not have anemia, 129 (21.9%) had mild anemia, and 91 (15.5%) had moderate/severe anemia, were included. Increasing severity of anemia was associated with an increased average hospital LOS (2.30 vs 2.81 vs 4.91 days, P < .001). There was a statistically significant increase in blood transfusions (1.08% vs 7.75% vs 17.58%, P < .001), major complications (9.21% vs 17.83% vs 34.07%, P < .001), any complications (11.11% vs 23.26% vs 36.26%, P < .001), and extended LOS ≥6 days (6.23% vs 6.98% vs 31.87%, P < .001) with increasing severity of anemia. Multivariate analysis identified moderate-to-severe anemia was significantly associated with major complications and extended LOS (P < .001). CONCLUSIONS: Preoperative anemia is a modifiable risk factor for medical and surgical complications within 30 days of TEA.

The 5-Item Modified Frailty Index for Risk Stratification of Patients Undergoing Total Elbow Arthroplasty.

BACKGROUND: Frailty, quantified using the 5-item modified frailty index (mFI-5), has been shown to predict adverse outcomes in orthopaedic surgery. The utility in total elbow arthroplasty (TEA) patients is unclear. We evaluated if increasing frailty would correlate with worse postoperative outcomes. METHODS: A retrospective assessment of patients in the American College of Surgeons National Surgery Quality Improvement Program undergoing primary TEA was performed. The mFI-5 was calculated by assigning 1 point for each comorbidity (diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status). Poisson regression was used to evaluate mFI-5 scores on complications, length of stay (LOS), and adverse discharge. A significance threshold was at P < .05. RESULTS: In total, 609 patients were included; 34.5% (n = 210) were not frail (mFI = 0), 44.0% (n = 268) were slightly frail (mFI = 1), and 21.5% (n = 131) were frail (mFI ≥ 2). As mFI score increased from 0 to ≥ 2, the following rates increased: any complication (9.0%-19.8%), major complication (11.0%-20.6%), cardiac complication (0.0%-2.3%), hematologic complication (3.3%-9.2%), adverse discharge (2.9%-22.9%), and LOS from 2.08 to 3.97 days (all P < .048). Following adjustment, Poisson regression demonstrated patients with a mFI ≥ 2 had increased risk of major complication (risk ratio [RR]: 2.13; P = .029), any complication (RR: 2.49; P = .032), Clavien-Dindo IV complication (RR: 5.53; P = .041), and adverse discharge (RR: 5.72; P < .001). CONCLUSIONS: Frailty is not only associated with longer hospitalizations, but more major complications and non-home discharge. The mFI-5 is a useful risk stratification that may assist in decision-making for TEA.

The effects of the COVID-19 pandemic on elective unicompartmental knee arthroplasty in the USA: further evidence that outpatient arthroplasty is safe and effective.

PURPOSE: In response to COVID-19, elective surgeries including unicompartmental knee arthroplasties (UKA) decreased. We aimed to quantify and compare temporal trends in utilization and complications in the calendar year 2019 (pre-pandemic) to 2020 in the USA. METHODS: The 2019 to 2020 ACS-NSQIP database was queried for patients undergoing elective UKA. Patients prior to COVID-19 (2019 and 2020 Q1) were compared to those after (2020 Q2-Q4). Case volumes, patient demographics, complications, and lengths of stay (LOS) were compared between years. Pearson's chi-square test was used to compare patient demographics. Linear regression was conducted to evaluate the change in case volumes. P values less than 0.05 were significant. RESULTS: In total, 3361 patients underwent UKA: 1880 in 2019 and 1481 in 2020. The number of outpatient UKAs increased (56.4% vs. 65.6%; p < 0.001). There was no significant difference in the volume of cases in 2019Q1 through 2020Q1 (p = 0.424). Case volumes fell by 60% in 2020Q2 compared with the average quarterly volume in 2019. Comparing 2019 to 2020, there was no significant difference in rates of total complications (2.1% vs. 2.2%; p = 0.843), minor complications (1.2% vs. 0.9%; p = 0.529), major complications (1.1% vs. 1.4%; p = 0.447), infection complications (1.0% vs. 0.8%; p = 0.652), wound complications (0.1% vs. 0.1%; p = 1.0), cardiac complications (0.0% vs. 0.1%; p = 0.111), pulmonary complications (0.1% vs. 0.2%; p = 0.473), hematology complications (0.1% vs. 0.1%; p = 1.0), renal complications (0.1% vs. 0.0%; p = 1.0), and Clavien-Dindo IV complications (0.1% vs. 0.4%; p = 0.177). CONCLUSION: UKA case volumes declined during the second quarter of 2020. A significant proportion of surgeries were transitioned outpatient, despite no change in complication rates.

Risk factors for the development of a peri-prosthetic joint infection up to 2 Years following primary reverse shoulder arthroplasty.

Background: Reverse shoulder arthroplasty (RSA) has become commonly used to treat glenohumeral osteoarthritis (GHOA), of which complications such as peri-prosthetic joint infections (PJIs) may develop. The objective of this study was to compare patient demographics of those who did and did not develop PJIs within 2 years after primary RSA for GHOA and identify risk factors for this sequela. Methods: A nationwide database was queried from 2005 to 2014 for Medicare patients treated with primary RSA (International Classification of Disease (ICD-9) procedural code 81.88) for GHOA. Patients who developed PJIs within 2-years of primary RSA defined the study group, whereas those who were devoid of infections represented the comparison group. Our study consisted of 51,824 patients, of which 879 (1.69%) developed a PJI. Patient demographics comprising the Elixhauser comorbidity index (ECI) were compared using Chi-Square analyses. Multivariable logistic regression models were used to compute the odds-ratios (OR) of patient-specific factors associated with acquiring a PJI within 2 years after RSA. P values less than 0.002 were significant. Results: Patients developing a PJI had higher mean ECI (8 vs. 6; p < 0.0001). The greatest risk factors for developing PJIs within 2-years following RSA were male sex (OR: 2.10, 95%CI: 1.81-2.43, p < 0.0001), pathologic weight loss (OR: 1.78, 95%CI: 1.45-2.17, p < 0.0001), iron deficiency anemia (OR: 1.75, 95%CI: 1.49-2.06, p < 0.0001), morbid obesity (OR: 1.52, 95%CI: 1.21-1.88, p = 0.0001), rheumatoid arthritis (OR: 1.32, 95%CI: 1.13-1.54, p = 0.0003), arrhythmias (OR: 1.26, 95%CI 1.09-1.46, p = 0.001), and depressive disorders (OR: 1.23, 95%CI 1.06-1.43, p = 0.001). Conclusions: The greatest risk factors for PJIs within 2 years of primary RSA included male sex; additional modifiable risk factors included iron deficiency anemia, pathologic weight loss, and obesity. Preoperative screening can help to identify modifiable risk factors and alter management for high-risk patients to potentially minimize PJIs.

Resident and Fellow Participation Does Not Affect Short-Term Postoperative Complications After Distal Radius Fracture Fixation.

Background Complications after open reduction internal fixation (ORIF) for distal radius fractures (DRF) are well documented, but the impact of trainee involvement on postoperative outcomes has not been studied. Questions Does trainee involvement affect postoperative complication rates and length of hospital stay? Methods The American College of Surgeons National Surgical Quality Improvement Program was queried from 2006 to 2012 for patients undergoing DRF ORIF. A 1:1 propensity score matched resident/fellow involved cases to attending-only cases. Demographics, length of stay, and postoperative complications were compared between the two groups. Logistic regression was used to evaluate independent predictors of adverse events and to evaluate cases with and without trainee involvement. Results Overall, 3,003 patients underwent DRF ORIF from 2006 to 2012. After matching, 1,150 cases (50% with resident/fellow involvement) were included. The overall rate of adverse events was 4.4% (46/1,050). There were no significant differences in the short-term complication rate in trainee-involved (2.3%) versus attending-only cases (3.9%) ( p = 0.461). For ORIF of DRF, there were no significant differences, between attending-only cases and resident/fellow-involved cases, with regard to short-term major complications ( p = 0.720) or minor complications ( p = 0.374). Length of hospital stay was similar between cohorts (1.22 vs. 0.98 days) ( p = 0.723). On multivariate analysis, trainee involvement was not an independent predictor of minor, major, or any complication after DRF fixation after controlling for multiple independent factors (all p > 0.364). Discussion Trainee participation in DRF ORIF is not associated with increased risk of short-term (30 days) medical or surgical postoperative complications. Level of Evidence This is a Level IV case-control study.

The Effect of COVID-19 on Elective Total Knee Arthroplasty Utilization, Patient Comorbidity Burden, and Complications in the United States: A Nationwide Analysis.

INTRODUCTION: Total knee arthroplasty (TKA) is one of the highest volume elective procedures done nationwide. Elective surgery was suspended because of the COVID-19 pandemic. The utilization trends, comparison of patient demographics, and postoperative outcomes in 2020 have yet to be evaluated substantially. We compared temporal trends in procedural volume, patient demographics, and postoperative complications of elective TKA in 2019 and 2020. METHODS: Using a multicenter, nationwide representative sample, a retrospective query of the 2019 to 2020 American College of Surgeon's National Surgery Quality Improvement Program database was conducted for patients undergoing elective TKA. Temporal trends in utilization, demographics, and length of stay were compared pre-COVID-19 (2019 to 2020Q1) with post-COVID-19 (2020Q2 to Q4). Postoperative outcomes were compared by calendar year (2019 versus 2020). Linear regression was used to evaluate changes in procedural volume over time. A significance threshold of P < 0.05 was used. RESULTS: A total of 121,415 patients underwent elective TKA in 2019 (N = 72,002) and 2020 (N = 49,413), a 31.4% decline. The proportion of hospital-defined "outpatient" TKAs in 2020 was significantly greater than that in 2019 (41.5% versus 25.5%; P < 0.001). Elective TKA utilization declined by 65.1% in 2020Q2 and never returned to prepandemic baseline in 2020Q3 to Q4. The average length of stay was shorter in 2020 (1.56 versus 1.87 days; P < 0.001). The proportion of same-day discharge increased each quarter from 2019Q1 to Q4 (6.2% to 8.6%) to 2020Q1 to Q4 (8.7% to 17.1%). Total complication rates were similar in 2019 (4.84%) versus 2020 (4.75%); P = 0.430. The 30-day mortality (0.08% versus 0.07%; P = 0.858), revision surgery (1.0% versus 1.0%; P = 0.940), and readmission (2.8% versus 2.6%; P = 0.053) rates were no different between 2019 and 2020. CONCLUSION: Elective TKA declined during the second quarter of 2020. A large proportion of surgeries were transitioned to outpatient with rates of same-day discharge increasing over the study period, despite no change in complication, mortality, and readmission rates. Patient outcomes were not compromised despite pandemic restrictions for elective surgery. LEVEL OF EVIDENCE: Level III.

The combined effect of policy changes and the covid-19 pandemic on the same day discharge and complications following total hip arthroplasty: a nationwide analysis.

INTRODUCTION: As a result of the SARS-CoV-2 (COVID-19) pandemic in 2020, elective surgeries, including total joint arthroplasty (TJA), were suspended nationwide. Concurrent removal of total hip arthroplasty (THA) from the Medicare inpatient-only list posed challenges to the delivery of quality patient care with low payor cost. Therefore, the objective of this study was to compare temporal trends in patient demographics, case volumes, length of stay, and complications following elective THA in the years 2019 to 2020 in the United States. METHODS: The 2019 to 2020 ACS-NSQIP database was queried for elective THA patients. Patients Pre-COVID (2019 and 2020Q1) were compared with post-COVID (2020Q2-Q4). THA utilization, demographics, 30-day complications, and length of stay (LOS) were compared between years. Linear regression evaluated changes in case volumes over time with significance threshold of P < 0.05. RESULTS: A total of 77,797 patients underwent elective THA in 2019 (n = 43,667) and 2020 (n = 34,130), resulting in a 24.5% decline. Outpatient THA increased in 2020 (35.6%) vs. 2019 (5.7%) (P < 0.001). There was no significant difference in the volume of cases in 2019Q1 through 2019Q4 (P = 0.984). Elective THA volumes declined by 68.8% in 2020Q2, returned to pre-pandemic baseline in 2020Q3, before leveling off at 81.5% of baseline in Q4. Average LOS was significantly shorter in 2020 (1.55 days) vs. 2019 (1.78 days) (P < 0.001) and the proportion of same day discharge (SDD) increased quarterly from 2019 to 2020. There was no significant difference in the total complication rates in 2019 (6.6%) vs. 2020 (6.6%) (P = 0.831). DISCUSSION: Elective THA precipitously declined during the second quarter of 2020. The combined effect of policy changes and the COVID-19 pandemic resulted in a seven-fold increase in the number of surgeries performed in the outpatient setting in 2020. Rates of SDD doubled over the study period, despite no change in complication rates.

Comparison of patient-demographics, causes, and costs of 90-day readmissions following primary total shoulder arthroplasty for glenohumeral osteoarthritis.

Introduction: Readmissions following orthopaedic surgery are associated with worse outcomes and increased healthcare costs. Studies investigating trends, causes, and costs of readmissions following primary total shoulder arthroplasty (TSA) for the indication of glenohumeral osteoarthritis (OA) are limited. The objective was to compare: 1) patient-demographics of those readmitted and not readmitted within 90-days following primary TSA for OA; 2) causes of readmissions and 3) associated costs. Methods: A retrospective query from 2005 to 2014 was performed using a nationwide administrative claims database. The study group consisted of patients readmitted within 90-days following primary TSA for glenohumeral OA, whereas patients not readmitted served as controls. Causes of readmission were stratified into the following groups: cardiovascular, hematological, endocrine, gastrointestinal (GI), musculoskeletal (MSK), neoplastic, neurological, pulmonary, infectious, renal, and miscellaneous causes. Patient demographics were compared, in addition to the frequency of the causes of readmissions, and their associated costs. Chi-square analyses compared demographics between groups. Analysis of variance was utilized to determine differences in 90-day costs for the causes of readmission. A p-value less than 0.001 was significant. Results: The overall 90-day readmission rate was 2.4% (3432/143,878). Patients readmitted following primary TSA were more likely to be over the age of 75, female, and higher prevalence of comorbid conditions, including psychiatric and medical conditions. Readmitted patients had a higher overall comorbidity burden per mean Elixhauser-Comorbidity Index (ECI) scores (10 vs. 7,p < .0001). The leading cause of readmissions were due to MSK (17.34%), cardiac (16.28%), infectious (16.26%), and gastrointestinal (11.64%) etiologies. There were differences in the mean 90-day costs of care for the various causes of readmissions, with the leading cost of readmissions being cardiac causes ($10,913.70) and MSK ($10,590.50) etiologies. Conclusion: Patients with greater comorbidities experienced increased incidence of readmission following TSA for glenohumeral OA. Cardiac and MSK etiologies were the primary cause of readmissions. Level of evidence: III.

How Did Coronavirus-19 Impact the Expenses for Medical Students Applying to an Orthopaedic Surgery Residency in 2020 to 2021?

BACKGROUND: Orthopaedic surgery is one of the most competitive specialties for residency applicants. For the 2021 residency match, the coronavirus-19 pandemic introduced complexity for programs and applicants because away rotations were limited and in-person interviews were cancelled. This may have changed the landscape in terms of expenses for candidates in important ways, but this topic has been insufficiently studied. QUESTIONS/PURPOSES: Given that in 2021, students did not attend away rotations and all interviews were held virtually, we asked (1) What were the financial savings associated with this change? (2) Was medical school geographic region associated with differences in expenses when applying to residency? METHODS: A retrospective, cross-sectional analysis of the 2020 and 2021 Texas Seeking Transparency in Application to Residency Dashboard database was performed. The data were derived from an online survey of a nationwide pool of applicants from 87% (123 of 141) of US allopathic medical schools upon conclusion of the match. The response percentage was 29% (521 of 1794). We believe this nationwide dataset represents the largest and most current data for this applicant group. Responses from applicants applying to orthopaedic surgery residency in the year before the COVID-19 pandemic application changes (2020) and during COVID-19 (2021) were queried and compared. After the orthopaedic surgery match, the database was evaluated for individual (application costs, away rotation expenses, and interview expenses) and total expenses for medical school seniors applying to orthopaedic surgery residency. Applicant characteristics were compared between application cycles. The 2020 to 2021 Texas Seeking Transparency in Application to Residency Dashboard database had 521 responses (n = 263 in 2020 and n = 258 in 2021) from applicants applying to orthopaedic surgery residency. Demographic and applicant characteristics were comparable between application cycles. Median expenses are reported with percentile distributions and geographic comparisons. A Mann-Whitney U test or Kruskal-Wallis H test was used to determine whether there were statistically significant differences in expenses between years and between medical school regions at a p value threshold of < 0.05. RESULTS: For all applicants, the median total expenses (USD 7250 versus USD 2250), application costs (USD 2250 versus USD 1750), away rotation expenses (USD 2750 versus USD 250), and interview expenses (USD 2250 versus USD 75) declined in 2021 compared with 2020 (all p < 0.001). The median total savings in expenses for all applicants in 2021 compared with 2020 was USD 5000. In 2021, median total expenses were lower in all geographic regions with the greatest savings from applicants in the West (USD 6000); in addition, the difference in median total expenses between the geographic region with the highest total expenses and the lowest total expenses was lower in the pandemic year than it was in the year prior (USD 1000 versus USD 1500; p < 0.001). In 2021, there were differences in total expenses between the Northeast (USD 1750), West (USD 1750), and Central (USD 2750) regions (p < 0.001). From 2020 to 2021, only application fees from Northeast applicants differed (USD 2250 versus USD 1250; p < 0.001). In 2020, interview expenses were not different between all regions (USD 2250 Northeast and West versus USD 2750 Central and South; p = 0.19); similarly in 2021, interview expenses were similar between all regions (USD 75 versus USD 75; p = 0.82). Finally, in 2020, Northeast (USD 3250) and Western (USD 3250) applicants spent more for away rotations than Southern (USD 2750) and Central (USD 2250) applicants (p = 0.01). In 2021, applicants from schools in the South (USD 250) and Central (USD 250) regions spent more than their counterparts (USD 0; p = 0.028). CONCLUSION: In the COVID-19 application cycle, the median expenditures of orthopaedic residency candidates were USD 5000 lower than they were in the previous year; the difference can be attributed to the use of virtual interviews and the lack of away rotations. There are geographic implications, with applicants from Western United States medical schools potentially saving the most. Despite the financial savings during the 2021 match, further study related to the long-term success of the current application process (both for applicants and programs) is needed. The recommendation in May 2020 by the AOA Council of Orthopaedic Residency Directors (CORD) to limit the number of applications submitted by candidates with USMLE Step 1 scores greater than 235 did not result in any considerable decline in applications submitted or expenses. A better understanding of how differences in these expenses may influence our specialty's ability to attract socioeconomically diverse candidates would be important, and we need to explore perceived and actual financial obstacles to obtaining this diversity in the application process. Finally, avenues should be explored by program directors and chairpersons to reduce the expenses of the traditional application process while maintaining recruitment of top candidates. LEVEL OF EVIDENCE: Level IV, economic analysis.

Three-dimensional magnetic resonance imaging of velopharyngeal structures.

PURPOSE: To report the feasibility of using a 3-dimensional (3D) magnetic resonance imaging (MRI) protocol for examining velopharyngeal structures. Using collected 3D MRI data, the authors investigated the effect of sex on the midsagittal velopharyngeal structures and the levator veli palatini (levator) muscle configurations. METHOD: Ten Caucasian healthy adults (5 women and 5 men) participated. A whole-head 3D MRI scan was obtained while participants were at rest in the supine position. Basic anatomic parameters of the velopharynx including midsagittal velopharyngeal structures and levator muscle configurations were compared between sexes. RESULTS: Detailed information on the 3D MRI protocol and data analysis method was introduced in the study. On the basis of the data, only the length of the levator muscle showed a statistically significant sex difference: Male participants had significantly longer levator muscles than those of female participants. CONCLUSIONS: The present study successfully demonstrated the use of 3D MRI in quantifying major velopharyngeal structures and provided additional data on the anatomic variations that exist in healthy adult individuals.

Simultaneous dynamic and functional MRI scanning (SimulScan) of natural swallows.

In studies of swallowing, dynamic and functional MRI are increasingly used to observe motor oropharyngeal behaviors and identify associated brain regions. However, monitoring of motor performance during a functional examination requires disruptive monitoring sensors, visual or auditory cued tasks, and strict subject compliance to stimuli. In this work, a simultaneous acquisition (SimulScan) was developed to provide dynamic images to monitor oropharyngeal motions during swallowing (1 mid-sagittal slice at 14.5 frames per second) simultaneous with functional MRI (24 oblique-axial slices with a TR of 1.6512 s). Data were acquired while three healthy adult subjects passively viewed a movie during three 15-min scans with the purpose of covertly studying uncued natural swallows. Dynamic MR images were used to determine timing of swallow onsets for subsequent functional analysis. Resulting functional maps show significant areas of activation that agree with previous functional magnetic resonance imaging studies of cued water swallows, except for regions associated with processing the task stimulus. SimulScan may prove a useful tool in developing new techniques for studying swallowing and associated neuromuscular disorders.

Real-time magnetic resonance imaging of velopharyngeal activities with simultaneous speech recordings.

OBJECTIVE: To examine the relationships between acoustic and physiologic aspects of the velopharyngeal mechanism during acoustically nasalized segments of speech in normal individuals by combining fast magnetic resonance imaging (MRI) with simultaneous speech recordings and subsequent acoustic analyses. DESIGN: Ten normal Caucasian adult individuals participated in the study. Midsagittal dynamic magnetic resonance imaging (MRI) and simultaneous speech recordings were performed while participants were producing repetitions of two rate-controlled nonsense syllables including /zanaza/ and /zunuzu/. Acoustic features of nasalization represented as the peak amplitude and the bandwidth of the first resonant frequency (F1) were derived from speech at the rate of 30 sets per second. Physiologic information was based on velar and tongue positional changes measured from the dynamic MRI data, which were acquired at a rate of 21.4 images per second and resampled with a corresponding rate of 30 images per second. Each acoustic feature of nasalization was regressed on gender, vowel context, and velar and tongue positional variables. RESULTS: Acoustic features of nasalization represented by F1 peak amplitude and bandwidth changes were significantly influenced by the vowel context surrounding the nasal consonant, velar elevated position, and tongue height at the tip. CONCLUSIONS: Fast MRI combined with acoustic analysis was successfully applied to the investigation of acoustic-physiologic relationships of the velopharyngeal mechanism with the type of speech samples employed in the present study. Future applications are feasible to examine how anatomic and physiologic deviations of the velopharyngeal mechanism would be acoustically manifested in individuals with velopharyngeal incompetence.

Faster dynamic imaging of speech with field inhomogeneity corrected spiral fast low angle shot (FLASH) at 3 T.

PURPOSE: To evaluate the impact of magnetic field inhomogeneity correction on achievable imaging speeds for magnetic resonance imaging (MRI) of articulating oropharyngeal structures during speech and to determine if sufficient acquisition speed is available for visualizing speech structures with real-time MRI. MATERIALS AND METHODS: We designed a spiral fast low angle shot (FLASH) sequence that combines several acquisition techniques with an advanced image reconstruction approach that includes magnetic field inhomogeneity correction. A simulation study was performed to examine the interaction between imaging speed, image quality, number of spiral shots, and field inhomogeneity correction. Six volunteer subjects were scanned to demonstrate adequate visualization of articulating structures during simple speech samples. RESULTS: The simulation study confirmed that magnetic field inhomogeneity correction improves the available tradeoff between image quality and speed. Our optimized sequence co-acquires magnetic field maps for image correction and achieves a dynamic imaging rate of 21.4 frames per second, significantly faster than previous studies. Improved visualization of anatomical structures, such as the soft palate, was also seen from the field-corrected reconstructions in data acquired on volunteer subjects producing simple speech samples. CONCLUSION: Adequate temporal resolution of articulating oropharyngeal structures during speech can be obtained by combining outer volume suppression, multishot spiral imaging, and magnetic field corrected image reconstruction. Correcting for the large, dynamic magnetic field variation in the oropharyngeal cavity improves image quality and allows for higher temporal resolution.