Deep Learning-Based Diagnostic System for Velopharyngeal Insufficiency Based on Videofluoroscopy in Patients With Repaired Cleft Palates.

Velopharyngeal insufficiency (VPI), which is the incomplete closure of the velopharyngeal valve during speech, is a typical poor outcome that should be evaluated after cleft palate repair. The interpretation of VPI considering both imaging analysis and perceptual evaluation is essential for further management. The authors retrospectively reviewed patients with repaired cleft palates who underwent assessment for velopharyngeal function, including both videofluoroscopic imaging and perceptual speech evaluation. The final diagnosis of VPI was made by plastic surgeons based on both assessment modalities. Deep learning techniques were applied for the diagnosis of VPI and compared with the human experts' diagnostic results of videofluoroscopic imaging. In addition, the results of the deep learning techniques were compared with a speech pathologist's diagnosis of perceptual evaluation to assess consistency with clinical symptoms. A total of 714 cases from January 2010 to June 2019 were reviewed. Six deep learning algorithms (VGGNet, ResNet, Xception, ResNext, DenseNet, and SENet) were trained using the obtained dataset. The area under the receiver operating characteristic curve of the algorithms ranged between 0.8758 and 0.9468 in the hold-out method and between 0.7992 and 0.8574 in the 5-fold cross-validation. Our findings demonstrated the deep learning algorithms performed comparable to experienced plastic surgeons in the diagnosis of VPI based on videofluoroscopic velopharyngeal imaging.

Subchondral insufficiency fracture is a predictive factor of osteoarthritis progression and conversion to arthroplasty in non-surgically treated medial meniscus root tear.

PURPOSE: To investigate the radiographic and clinical outcomes of non-surgical treatment for medial meniscus posterior root tear (MMPRT), and prognostic factors for osteoarthritis (OA) progression and clinical failure. METHODS: A prospectively collected database was retrospectively reviewed for patients who were diagnosed with acute medial meniscus posterior root tear (MMPRT) between 2013 and 2021 and treated non-surgically for more than 2 years. Patient demographic characteristics and clinical outcomes including pain numeric rating scale (NRS), International Knee Documentation Committee (IKDC) subjective score, Lysholm score, and Tegner activity scale were evaluated. For radiographic evaluation, knee radiographs were obtained to assess the angle of knee alignment and Kellgren-Lawrence (K-L) grade during the first and annually follow-up visits. Baseline magnetic resonance (MR) images were reviewed for the presence of medial meniscus extrusion, bone marrow edema, subchondral insufficiency fracture of medial femoral condyle, and cartilage lesion. The OA progression group was defined as patients who experienced a worsening of one or more grades in the K-L classification system. Prognostic factors were evaluated for OA progression and conversion to total knee arthroplasty (TKA). RESULTS: Ninety-four patients (90 female and 4 male) with a mean age of 67.0 ± 7.3 years (range, 53-83 years) were followed for a mean of 46.1 ± 22.1 months (range, 24.1-170.5). During the follow-up period, no significant differences in clinical scores were observed, and there were also no significant differences between the groups with and without OA progression. Overall, 12 patients (13%) underwent TKA at a mean of 20.7 ± 16.5 months (range, 8-69 months) and 34 patients (36%) demonstrated OA progression at a mean time of 24 ± 15 months (range, 12-62). The subchondral insufficiency fracture was a prognostic factor for OA progression (p = 0.045 for knee radiograph and p = 0.019 for MR) and conversion to TKA (RR, 4.08 [95% CI 1.23-13.57]; p = 0.022). CONCLUSIONS: Non-surgical treatment for acute medial meniscus posterior root tear did not result in any significant change in clinical outcomes from the initial to the final follow-up. The rate of conversion to arthroplasty was 13%, and the rate of osteoarthritis progression was 36%. Furthermore, subchondral insufficiency fracture was found to be a concomitant prognostic factor correlated with OA progression and conversion to arthroplasty. This information can provide insights for physicians when discussing treatment options with patients, particularly regarding the use of non-surgical treatment and may contribute as a source for future studies of medial meniscus posterior root tear. LEVEL OF EVIDENCE: IV.

Nanopore 16S amplicon sequencing enables rapid detection of pathogen in knee periprosthetic joint infection.

OBJECTIVES: We investigated whether nanopore 16S amplicon sequencing is capable of bacterial identification in patients with knee prosthetic joint infection (PJI), and we compared its efficacy with conventional culture studies. METHODS: In total, 36 patients who had clinical manifestation suspected of PJI were enrolled in this study. To begin, synovial fluids were aspirated from the affected knee using aseptic technique and tissues specimens were obtained during the surgery. Next, DNA was extracted from the synovial fluid or tissues, and 16S rDNA PCR was performed. In PCR positive cases, nanopore amplicon sequencing was then performed for up to 3 h. The results of amplicon sequencing were compared to those of conventional culture studies. RESULTS: Of the 36 patients enrolled, 22 were classified as true infections according to the MSIS criteria whereas 14 were considered uninfected. Among the 22 PJI cases, 19 cases were culture positive (CP-PJI) while three cases were culture negative (CN-PJI). In 14 of 19 (73.7 %) CP- PJI cases, 16S sequencing identified concordant bacteria with conventional culture studies with a significantly shorter turnaround time. In some cases, nanopore 16S sequencing was superior to culture studies in the species-level identification of pathogen and detection of polymicrobial infections. Altogether, in the majority of PJI candidate patients (32 of 36, 88.9 %), 16S sequencing achieved identical results to cultures studies with a significantly reduced turnaround time (100.9 ± 32.5 h vs. 10.8 ± 7.7 h, p < 0.001). CONCLUSIONS: Nanopore 16S sequencing was found to be particularly useful for pathogen identification in knee PJI. Although the sensitivity was not superior to culture studies, the nanopore 16S sequencing was much faster, and species-level identification and detection of polymicrobial infections were superior to culture studies.

The Effect of Position on Radiographic Angle Measurements of the Lower Extremities.

Purpose: Accurately measuring an angle on a lower extremity X-ray is essential for the diagnosis and treatment of knee osteoarthritis (KOA). However, the angle is often affected by position, especially with flexion contracture and rotation. To date, there have been no quantitative analyses examining the relationship between lower extremity angle and patient position and no studies targeting patients with deformities. The aim of this study is to quantify the effect of position on angle measurements in lower extremity X-rays and to compare the effect in patients with different deformities. Methods: Computed tomography (CT) data of 131 patients with knee pain were retrospectively analyzed. The subjects were categorized into the following groups: neutral (hip-knee-ankle angle (HKAA) between 175 and 185°), varus (HKAA less than 175°), valgus (HKAA more than 185°), and flexion (flexion contracture more than 10°). CT images were digitally reconstructed to anterior-posterior X-ray images using an average intensity projection algorithm. The process was then repeated while rotating the reconstruction plane from internal 9° to external 9°. In this manner, X-ray images were reconstructed in different rotational states. The following angles were measured from reconstructed X-ray images: HKAA, lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), and femoral valgus angle (FVA). The measurements were then compared according to the degree of rotation. Results: FVA significantly differed according to rotation in all groups (P < 0.001), with a difference of 1.3° (±0.4°). HKAA significantly changed only in the flexion contracture group (P < 0.001), which showed a difference of 1.0° (±0.7°). However, HKAA in the other groups, LDFA, and MPTA did not significantly differ depending on rotation. Conclusions: Radiographic measurement of FVA is subject to change according to rotation. HKAA significantly changed only in the flexion contracture group, so more care should be taken while obtaining X-rays of patients with flexion contracture.

Early Prediction of the Need for Orthognathic Surgery in Patients With Repaired Unilateral Cleft Lip and Palate Using Machine Learning and Longitudinal Lateral Cephalometric Analysis Data.

ABSTRACT: The purpose of this study was to determine the cephalometric predictors of the future need for orthognathic surgery in patients with repaired unilateral cleft lip and palate (UCLP) using machine learning. This study included 56 Korean patients with UCLP, who were treated by a single surgeon and a single orthodontist with the same treatment protocol. Lateral cephalograms were obtained before the commencement of orthodontic/orthopedic treatment (T0; mean age, 6.3 years) and at at least of 15 years of age (T1; mean age, 16.7 years). 38 cephalometric variables were measured. At T1 stage, 3 cephalometric criteria (ANB ≤ -3°; Wits appraisal ≤ -5 mm; Harvold unit difference ≥34 mm for surgery group) were used to classify the subjects into the surgery group (n = 10, 17.9%) and non-surgery group (n = 46, 82.1%). Independent t-test was used for statistical analyses. The Boruta method and XGBoost algorithm were used to determine the cephalometric variables for the prediction model. At T0 stage, 2 variables exhibited a significant intergroup difference (ANB and facial convexity angle [FCA], all P < 0.05). However, 18 cephalometric variables at the T1 stage and 14 variables in the amount of change (ΔT1-T0) exhibited significant intergroup differences (all, more significant than P < 0.05). At T0 stage, the ANB, PP-FH, combination factor, and FCA were selected as predictive parameters with a cross-validation accuracy of 87.4%. It was possible to predict the future need for surgery to correct sagittal skeletal discrepancy in UCLP patients at the age of 6 years.

Custom-Made Nasal Retainer Using Latex Nelaton Urine Catheter After the Cheiloplasty.

Nasal retainers are common tools used in managing patients with cleft lip. The significance of nasal retainer in preventing nostril collapse or stenosis to maintain a symmetrical nose after the surgical procedures is already well known. We came up with a way to create a nasal retainer using a latex nelaton catheter. Custom-made nasal retainer using latex nelaton catheter was used postoperatively on a 10-month-old infant with median cleft lip after cheiloplasty. In postoperative day 7, her nostrils were large enough for premade silicone nasal retainer to fit. She was discharged with instructions given to use the retainer for 6 months. Custom-made nasal retainer can be used as an alternative to premade nasal retainers for patients with wide columella or small nostril cavities, or who cannot afford premade retainers.

Effect of collagen matrix on postoperative palatal fistula in cleft palate repair.

Palatal fistula is a challenging complication following cleft palate repair. We investigated the usefulness of collagen matrix in the prevention of postoperative fistula. We performed a retrospective cohort study of patients with cleft palate who underwent primary palatoplasty (Furlow's double opposing z-plasty) in Seoul National University Children's Hospital. Collagen Graft and Collagen Membrane (Genoss, Suwon, Republic of Korea) were selectively used in patients who failed complete two-layer closure. The effect of collagen matrix on fistula formation was evaluated according to palatal ratio (cleft width to total palatal width) and cleft width. A total of 244 patients (male, 92 and female, 152; median age, 18 months) were analyzed. The average cleft width was 7.0 mm, and the average palatal ratio was 0.21. The overall fistula rate was 3.6% (9/244). Palatal ratio (p = 0.014) and cleft width (p = 0.004) were independent factors impacting the incidence of postoperative fistula. Receiver operating characteristic curve analysis showed that the cutoff values in terms of screening for developing postoperative fistula were a palatal ratio of 0.285 and a cleft width of 9.25 mm. Among nonsyndromic patients with values above those cutoffs, the rates of fistula development were 0/5, 1/6 (16.7%), and 4/22 (18.2%) for those who received Collagen Graft, Collagen Membrane, and no collagen, respectively. Collagen matrix may serve as an effective tool for the prevention of palatal fistula when complete two-layer closure fails, especially in wide palatal clefts. The benefit was most evident in Collagen Graft with thick and porous structure.

The Reconstruction of the Central Tubercle in Bilateral Cleft Lips: Bilateral Lateral Mucosal Advancement Flap With Reinforcement of the Orbicularis Oris Muscle.

BACKGROUND: There are various methods to correct the whistle deformity in bilateral cleft lip. In case of the central deficiency with concomitant lateral excess, local tissue rearrangement can be used to reposition the lateral tissue. We designed bilateral lateral advancement flap with reinforcement of the orbicularis oris muscle. METHOD: Thirteen bilateral cleft lip patients with whistling lip deformity from July 2009 to February 2017 underwent our method of tubercle formation. Vertical upper lip measurements of upper lip were recorded. Augmentation percentage was documented using follow-up measurements compared with preoperative measurements. The average follow-up period was 16.2 months (range, 9-26 months). The axis of the flap and central incision were placed on the red line (wet-dry vermilion border). Dissection was performed through the submucosal plane. After entire dissection, inter-orbicularis oris muscle suture on both medial edge of the flap was performed. In case it was necessary, back-cutting incision on both curvature of the central orbicularis oris could facilitate central augmentation. Elevated superior and inferior trap-door flaps were trimmed to make natural central lip line along with the lateral mucosal flaps. Both lateral parts of vermilions were closed in V-Y advancement fashion. RESULT: The vertical height of central tubercle (T) had a mean increase of 136.9%, which was significantly different from preoperative measurement (P < 0.05). There were no surgical complications. CONCLUSIONS: Our surgical method is safe, useful, and effective to correct the whistle deformity of the central deficiency with concomitant lateral excess.

Correlation Between Speech Outcomes and the Amount of Maxillary Advancement After Orthognathic Surgery (Le Fort I Conventional Osteotomy and Distraction Osteogenesis) in Patients With Cleft Lip and Palate.

BACKGROUND: The purpose of this study is to evaluate the factors affecting the speech outcome following Le fort I conventional osteotomy(CO) or Le Fort I distraction osteogenesis(DO) in patients with cleft lip and palate at a single institution. METHOD: Records of cleft lip and palate patients who underwent orthognathic surgery between 2010 and 2015 were reviewed. Data included age at orthognathic surgery, sex, cleft lip and palate type, type of orthognathic surgery, the amount of maxillary advancement, and speech assessment. Speech outcomes were classified into 2 categories. Compared with the pre and post-operative Pittsburgh Weighted speech scale scores, in case that the post-operative total score is increased the authors define it as "Speech deterioration" and if not, the authors define it as "Speech preservation." RESULT: The 44 patients were identified, 33 patients underwent CO and 11 patients underwent DO. The mean age was 19.4 ±â€Š1.4. The mean period time of speech evaluation after orthognathic surgery was 1.0 ±â€Š0.46 year. The mean amount of maxillary advancement was 7.2 ±â€Š3.2 mm and show significant correlation with speech outcomes. (P = 0.012) . In CO group, the patients who had the maxilla 1∼5 mm advancement maintained their speech completely and 44% of patients with 6∼8 mm deteriorated their speech. In DO group, patients with 9∼10 mm maintained their speech completely, 50% of patients with 11∼12 mm deteriorated their speech and 100% of patients with 13∼16 mm deteriorated their speech. According to the relationship between the amount of maxillary advancement and speech outcomes, there was a statistically significant correlation in both CO and DO groups. (P = 0.04, 0.029). CONCLUSION: It was found that speech of the patients with more amount of maxillary advancement tended to get worse. Also, it was observed that there exist some stable ranges of maxillary advancement for speech safety which does not effect on speech. (1∼5 mm in CO group and 9∼10 mm in DO group).

Hyaluronic acid-cross-linked filler stimulates collagen type 1 and elastic fiber synthesis in skin through the TGF-ß/Smad signaling pathway in a nude mouse model.

Compared to pure hyaluronic acid filler, cross-linked hyaluronic acid (HAc) exhibits superior biocompatibility and longevity as a dermal filler. We previously developed composite HAc-hydroxyapatite (HAp) fillers. Herein, we systematically compared the protein-level increase and gene expression between HAc-micro-HAp and HAc-nano-HAp in mice and determined the mechanisms underlying the biological responses to HAc and HAp. Five-week-old female BALB/c-nude mice were classified into five groups: normal skin, Radiesse, Restylane, HAc-nano-HAp, and HAc-micro-HAp. Fillers (200 µl) were injected to evenly fill the back of mice. Skin biopsies were performed to investigate collagen and elastic fiber synthesis after filler injections. Western blot analysis, real-time polymerase chain reaction analysis, and immunohistochemistry were performed to investigate protein and gene expression changes. Organ (liver, lung, spleen, and kidney) toxicity of HAc-nano-HAp was determined by hematoxylin and eosin staining after 12 weeks. Protein and gene expression analyses indicated that, compared with pure fillers, HAc-nano-HAp and HAc-micro-HAp hydrogels preferentially promoted collagen and elastic fiber formation through the TGF-ß pathway. The composite fillers also exhibited no evidence of organ toxicity. HAc-HAp filler might play an important role in collagen and elastic fiber regeneration. HAc filler stimulates collagen type 1 and elastic fiber synthesis through the TGF-ß/Smad pathway. The role of HAc-HAp composite fillers in photoaging in animal models and their effects on skin, including elasticity and tensile strength, should be investigated.

Non-vascularized iliac bone grafting for scaphoid nonunion with avascular necrosis.

We present the surgical outcomes of non-vascularized bone grafting taken from the iliac crest in 24 patients with scaphoid nonunion and avascular necrosis. The Fisk-Fernandez technique was used in 11 patients, and cancellous bone grafting was used in 13 patients. Bony union was achieved in 22 of the 24 patients. Non-vascularized iliac bone grafting can be used for the surgical management of scaphoid nonunion with avascular necrosis. Although revascularization of the proximal fragment after surgery was not evaluated, bony union was confirmed in nearly all patients. LEVEL OF EVIDENCE: IV.

Effectiveness of autologous serum as an alternative to fetal bovine serum in adipose-derived stem cell engineering.

In cell culture, medium supplemented with fetal bovine serum is commonly used, and it is widely known that fetal bovine serum supplies an adequate environment for culture and differentiation of stem cells. Nevertheless, the use of xenogeneic serum can cause several problems. We compared the effects of four different concentrations of autologous serum (1, 2, 5, and 10%) on expansion and adipogenic differentiation of adipose-derived stem cells using 10% fetal bovine serum as a control. The stem cells were grafted on nude mice and the in vivo differentiation capacity was evaluated. The isolation of adipose-derived stem cells was successful irrespective of the culture medium. The proliferation potential was statistically significant at passage 2, as follows: 10% autologous serum > 10% fetal bovine serum = 5% autologous serum > 2% autologous serum = 1% autologous serum. The differentiation capacity appeared statistically significant at passage 4, as follows: 10% fetal bovine serum > 10% autologous serum = 5% autologous serum > 2% autologous serum = 1% autologous serum. Ten percent autologous serum and 10% fetal bovine serum had greater differentiation capacity than 1 and 2% autologous serum in vivo, and no significant difference was observed between the groups at ≥ 5% concentration at 14 weeks. In conclusion, 10% autologous serum was at least as effective as 10% fetal bovine serum with respect to the number of adipose-derived stem cells at the end of both isolation and expansion, whereas 1 and 2% autologous serum was inferior.

The use of botulinum toxin type A in aesthetic mandibular contouring.

The lower third of Asian faces is wider than that of Caucasians and it is determined by the size and width of the mandibular bone and the thickness of muscles and subcutaneous fat tissues surrounding it. Efforts to create an aesthetically slim and smooth facial contour line in nonobese people have led the authors to focus on two approaches: surgical resection of the masseteric muscle and modeling ostectomy of the square-angled mandibular bone. Because these procedures present some problems, the authors adopted a nonsurgical concept that chemically denervates muscles and reduces the bulk of the muscle. The authors have conducted a total of 1021 clinical cases from March of 2001 through September of 2002, in which patients were treated with botulinum toxin type A (Dysport; Ipsen Ltd, Slough, United Kingdom) for remodeling the lower facial contour line; 383 of those cases were followed up for at least 3 months after the initial injection. A database was made by measuring the change in the thickness of the injected muscle with an ultrasonogram. Eleven patients underwent resection of the mandibular angle before injection. The preinjection ostectomy group was involved in the study as a result of their dissatisfaction with the surgical results; they had a rather thick masseter muscle and not a bone problem. Some had both bone problems and a thick masseter muscle. Three months after the botulinum toxin injection, the thickness of the muscle was reduced by 31 percent on average. The atrophic effect of injection was observed after 2 to 4 weeks for most patients. Seventy percent of the 383 patients tracked were greatly satisfied with the result, with another 23 percent generally satisfied. No long-term side effects were reported. Masseteric hypertrophy is frequent in Asians because of racial characteristics and dietary habits. Botulinum toxin type A has made a new epoch in facial contouring for Asians. Considering that Asians have a prominent malar and a prominent mandible angle, the reduction in the thickness of the masseter can provoke relative prominence of the malar and mandible angle. Therefore, precise indication and anatomy of the facial muscle should be thoroughly understood, which will decrease the incidence of side effects and problems. Botulinum toxin type A (Dysport) injection is simple in technique, has few side effects, and promises a rapid return to daily life. The authors conclude that the injection of botulinum toxin type A can replace surgical masseter resection.