A procedural step analysis of radiation exposure in fenestrated endovascular aortic repair.

OBJECTIVE: Radiation exposure during complex endovascular aortic repair may be associated with tangible adverse effects in patients and operators. This study aimed to identify the steps of highest radiation exposure during fenestrated endovascular aortic repair (FEVAR) and to investigate potential intraoperative factors affecting radiation exposure. METHODS: Prospective data of 31 consecutive patients managed exclusively with four-fenestration endografts between March 1, 2020, and July 1, 2022 were retrospectively analyzed. Leveraging the conformity of the applied technique, every FEVAR operation was considered a combination of six overall stages composed of 28 standardized steps. Intraoperative parameters, including air kerma, dose area product, fluoroscopy time, and number of digital subtraction angiographies (DSAs) and average angulations were collected and analyzed for each step. RESULTS: The mean procedure duration and fluoroscopy time was 140 minutes (standard deviation [SD], 32 minutes), and 40 minutes (SD, 9.1 minutes), respectively. The mean air kerma was 814 mGy (SD, 498 mGy), and the mean dose area product was 66.8 Gy cm2 (SD, 33 Gy cm2). The percentage of air kerma of the entire procedure was distributed throughout the following procedure stages: preparation (13.9%), main body (9.6%), target vessel cannulation (27.8%), stent deployment (29.1%), distal aortoiliac grafting (14.3%), and completion (5.3%). DSAs represented 23.0% of the total air kerma. Target vessel cannulation and stent deployment presented the highest mean lateral angulation (67 and 63 degrees, respectively). Using linear regression, each minute of continuous fluoroscopy added 18.9 mGy of air kerma (95% confidence interval, 17.6-20.2 mGy), and each DSA series added 21.1 mGy of air kerma (95% confidence interval, 17.9-24.3 mGy). Body mass index and lateral angulation were significantly associated with increased air kerma (P < .001). CONCLUSIONS: Cannulation of target vessels and bridging stent deployment are the steps requiring the highest radiation exposure during FEVAR cases. Optimized operator protection during these steps is mandatory.

Vaginal morphology and position associated with prolapse recurrence after vaginal surgery: A secondary analysis of the DEMAND study.

OBJECTIVE: To identify vaginal morphology and position factors associated with prolapse recurrence following vaginal surgery. DESIGN: Secondary analysis of magnetic resonance images (MRI) of the Defining Mechanisms of Anterior Vaginal Wall Descent cross-sectional study. SETTING: Eight clinical sites in the US Pelvic Floor Disorders Network. POPULATION OR SAMPLE: Women who underwent vaginal mesh hysteropexy (hysteropexy) with sacrospinous fixation or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy) for uterovaginal prolapse between April 2013 and February 2015. METHODS: The MRI (rest, strain) obtained 30-42 months after surgery, or earlier for participants with recurrence who desired reoperation before 30 months, were analysed. MRI-based prolapse recurrence was defined as prolapse beyond the hymen at strain on MRI. Vaginal segmentations (at rest) were used to create three-dimensional models placed in a morphometry algorithm to quantify and compare vaginal morphology (angulation, dimensions) and position. MAIN OUTCOME MEASURES: Vaginal angulation (upper, lower and upper-lower vaginal angles in the sagittal and coronal plane), dimensions (length, maximum transverse width, surface area, volume) and position (apex, mid-vagina) at rest. RESULTS: Of the 82 women analysed, 12/41 (29%) in the hysteropexy group and 22/41 (54%) in the hysterectomy group had prolapse recurrence. After hysteropexy, women with recurrence had a more laterally deviated upper vagina (p = 0.02) at rest than women with successful surgery. After hysterectomy, women with recurrence had a more inferiorly (lower) positioned vaginal apex (p = 0.01) and mid-vagina (p = 0.01) at rest than women with successful surgery. CONCLUSIONS: Vaginal angulation and position were associated with prolapse recurrence and suggestive of vaginal support mechanisms related to surgical technique and potential unaddressed anatomical defects. Future prospective studies in women before and after prolapse surgery may distinguish these two factors.

A Gaze into the Eyebrow Standards of Asian Versus Caucasian Women.

BACKGROUND: Eyebrow position affects perceived facial expression and youthfulness, and its modification is a key component of facial rejuvenation. OBJECTIVE: This investigation aimed to assess the preferred vertical eyebrow position, apex location, and eyebrow shape in Caucasian and Asian individuals and to analyze gaze patterns during aesthetic judgment using eye-tracking technology. MATERIALS AND METHODS: The study included 76 Asian and Caucasian volunteers with no medical background. Eye movements were captured with a Tobii Pro Nano eye-tracker. Participants viewed AI-generated images of Caucasian and Asian females with varied eyebrow positions (ratios 1:1.3 to 1:2.5), shapes (angles 8° to 20°), and apex positions. Aesthetic preferences were rated on a 5-point Likert scale. Eye-tracking metrics and aesthetic ratings were statistically analyzed using ANOVA and bivariate correlations. RESULTS: Both genders across ethnicities preferred a moderate eyebrow position ratio of 1:1.6. For eyebrow shapes, a 12° angle received the highest ratings, while extremes were less favored, indicating a preference for moderately curved eyebrows. The most appealing apex position was above the lateral canthus for Asians, and halfway between the lateral limbus and lateral canthus for Caucasians. Eye-tracking revealed longer fixations on unattractive features, suggesting more complex cognitive processing, while attractive features were processed more efficiently. CONCLUSION: The study revealed that aesthetic preferences for eyebrow features are influenced by both ethnic background and gender, with a general preference toward moderately curved eyebrows and subtle variations in preferred positions. These findings suggest a need for culturally sensitive approaches in facial aesthetic procedures and highlight the potential of eye-tracking technology to enhance surgical planning. Surgeons are advised to adopt a conservative, patient-centered approach when modifying eyebrow features, considering individual and cultural aesthetics to maximize patient satisfaction. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The impact of dental midline angulation towards the facial flow curve on the esthetics of an asymmetric face: Perspective of laypeople and orthodontists.

PURPOSE: The objective of the present article was to evaluate the impact of dental midline angulation in asymmetrical faces. MATERIALS AND METHODS: A full-portrait image was used to create a set of digitally modified images with a different degree of facial asymmetry, towards the right and the left side of the face respectively. Half of the images were designed with an equivalent angulation of the dental midline in respect to the curve of the lower third of the face and half of them without. Through a web survey, 250 laypeople and 250 orthodontists were asked to assess the attractiveness of each image separately. RESULTS: As the asymmetry of the face was increased, facial attractiveness was further decreased both for laypersons and orthodontists. For each one of the modified images, when the dental midline was following the curve that was formed from the inclination of the simulated asymmetry of the face, the smile attractiveness scores were significantly higher compared to a straight dental midline. CONCLUSION: Facial asymmetries derived from the inclination of the nose, the chin and the commissural line of the lips can significantly affect the smile attractiveness. An orientation of the dental midline towards the facial asymmetry in order to follow the facial curve, can be beneficial for the smile attractiveness compared to a perpendicular to the face dental midline. During the design of a smile, clinicians have to take into consideration deviations in facial midline, in order their restorations to be in harmony with the rest of the face. CLINICAL SIGNIFICANCE: During the design of a smile, clinicians have to take into consideration deviations in the facial midline, in order their restorations to be in harmony with the rest of the face.

Tip, torque and rotation of maxillary molars during distalization using Invisalign: a CBCT study.

BACKGROUND: Desirable molar distalization by bodily movement is challenging and can be difficult to achieve. This study investigated changes in molar angulation (mesiodistal tipping), molar inclination (buccolingual torque) and rotation during distalization using clear aligner therapy (CAT). MATERIALS AND METHODS: This retrospective study included 38 cone beam computed tomographic images (CBCTs) taken for patients treated with molar distalization using CAT. The study evaluated pre- (T0) and post-treatment (T1) CBCTs of 19 adult patients (36.68 ± 13.50 years) who underwent maxillary molar distalization using Invisalign® aligners (Align Technology, Inc., San José, CA, USA) with a minimum of 2 mm distalization. Changes in maxillary molar tip, torque and rotation were measured for 61 molars (183 roots). Paired t-test was used to evaluate the differences between pre- and post-treatment readings. The level of significance was set at p ≤ 0.05. The reproducibility of measurements was assessed by the intraclass correlation coefficient (ICC). RESULTS: Molar angulation did not show significant change after distalization (p = 0.158) however, there was significant increase in buccal molar inclination (p = 0.034) and mesiobuccal molar rotation (p < 0.001). CONCLUSION: Molar distalization of 2 mm did not cause significant molar tipping. Maxillary molars showed significant buccal inclination (increased torque) and mesiobuccal rotation after distalization.

Influence of screw channel angulation on reverse torque value and fracture resistance in monolithic zirconia restorations after thermomechanical cycling: an in-vitro study.

BACKGROUND: While the concept of angled screw channels has gained popularity, there remains a scarcity of research concerning the torque loss and fracture strength of monolithic zirconia restorations with various screw channel angulations when exposed to thermomechanical cycling. This in-vitro study aimed to evaluate the reverse torque value and fracture resistance of one-piece screw-retained hybrid monolithic zirconia restorations with angulated screw channels after thermomechanical cycling. METHODS: One-piece monolithic zirconia restorations, with angulated screw channels set at 0°, 15°, and 25° (n = 6 per angulation) were fabricated and bonded to titanium inserts using a dual-cure adhesive resin cement. These assemblies were then screwed to implant fixtures embedded in acrylic resin using an omnigrip screwdriver, and reverse torque values were recorded before and after thermomechanical cycles. Additionally, fracture modes were assessed subsequent to the application of compressive load. One-way ANOVA and Bonferroni post hoc test were used to compare the groups (α = 0.05). RESULTS: The study groups were significantly different regarding the fracture resistance (P = 0.0015), but only insignificantly different in the mean percentage torque loss (P = 0.4400). Specifically, the fracture resistance of the 15° group was insignificantly higher compared to the 0° group (P = 0.9037), but significantly higher compared to the 25° group (P = 0.0051). Furthermore, the fracture resistance of the 0° group was significantly higher than that of the 25° group (P = 0.0114). CONCLUSIONS: One-piece hybrid monolithic zirconia restorations with angulated screw channels can be considered an acceptable choice for angulated implants in esthetic areas, providing satisfactory fracture strength and torque loss.

Accuracy of impression methods through the comparison of 3D deviation between implant fixtures.

AIM: To compare the accuracy of three impression methods by comparing the distance between the reference points of the implant fixture, especially in curved maxillary anterior teeth. MATERIALS AND METHODS: Implant fixtures were placed in the maxillary central incisor and canine regions. A maxillary master cast was made using a model scanner and 3D printer. Ten impressions were taken from the three experimental groups constructed (group P: pick-up impression coping; group I: scan body with an intraoral scanner; group B: bite impression coping). The distance between the reference points, the angle between the scan bodies, and displacement of the 3D surface area were measured. RESULTS: The distances between the reference points were significantly different between groups I and B in the maxillary incisors, and between group P and the other two groups in the maxillary canines. Group P had the least amount of displacement in both fixtures. Both fixtures showed the highest displacement in group B. Displacement of the 3D surface area in the maxillary incisors showed no significant difference between the groups. There was a significant difference in the maxillary canines between groups P and I. CONCLUSIONS: In the present study, all three implant impression methods showed changes in the position and angle of the fixture compared with the master cast. The highest accuracy was shown by the impression method using the pick-up impression coping, but the impression method using the intraoral scanner also showed clinically acceptable accuracy. It should be noted that errors may occur when taking impressions using a bite impression coping.

Evaluation of Mesiodistal Angulation of Maxillary Anterior Teeth in Incisal View Using Manual and Digital Methods: An In Vivo Study.

AIM: The aim of the present research was to assess the mesiodistal angulation of the maxillary anterior teeth utilizing Image J computer software, a Profile projector, and a Custom-made jig. MATERIALS AND METHODS: A total of 34 subjects (17 males and 17 females) were chosen from a group of 18-30 years old with bilateral Angle Class I molars and canine relationships. One manual approach (Custom-made jig) and two digital methods (J computer software, a Profile projector) were used to record the mesiodistal angulation in incisal view. The individuals had alginate impressions made, and a facebow was used to capture the maxilla's spatial relationship with the cranium. The articulated cast with the help of mounting ring moved to the specially customized jig, then the angulations was measured in the incisal view after the casts were placed in a semi-adjustable articulator. Data were recorded and statistically analyzed. RESULTS: The mesiodistal angulation in the incisal view via three methods between the 17 males and 17 females has statistically significant different. Although the mesiodistal angulation for maxillary lateral incisor and canine did not show any statistically significant difference, the maximum and minimum values obtained were always greater in males in comparison with the females. This indicates that the positions of six maxillary anterior teeth in the males resulted in the creation of upward sweep of incisal edges of central and lateral incisors which was also referred to as "smiling line" producing masculine surface anatomy more squared and vigorous while feminine surface anatomy being more rounded, soft, and pleasant. There was no statistically significant difference between the right and left sides, indicating bilateral arch symmetry and the symmetrical place of the right teeth compared with the left side's corresponding teeth. CONCLUSION: On conclusion, according to the current study's findings, all three approaches can measure the mesiodistal angulations of maxillary anterior teeth in incisal view with clinically acceptable accuracy. The digital methods, which included using the Image J computer software and the profile projector, achieved more accurate results than the manual method. CLINICAL SIGNIFICANCE: The outcomes of this study's mesiodistal angulations can be used as a reference for placing teeth in both fully and partially edentulous conditions. This study contributes to a better understanding of the importance of achieving the ideal occlusion in the Indian population by placing the maxillary anterior teeth at the proper mesiodistal angulation. How to cite this article: Shadaksharappa SH, Lahiri B, Kamath AG, et al. Evaluation of Mesiodistal Angulation of Maxillary Anterior Teeth in Incisal View Using Manual and Digital Methods: An In Vivo Study. J Contemp Dent Pract 2024;25(4):320-325.

Early outcomes of the Conformable endograft in severe neck angulation from the Triveneto Conformable Registry.

OBJECTIVE: The study reports retrospective evaluation of early outcomes from a multicentric experience with the Excluder conformable endograft with active control system (CEXC Device) in the treatment of abdominal aortic aneurysms. Its design allows more flexibility, given by proximal unconnected stent rows and a bending wire within the delivery catheter enables control of proximal angulation. This study specifically focuses on the severe neck angulation (SNA) subgroup (≥60°). METHODS: All patients treated with CEXC Device in nine vascular surgery centers of Triveneto area (Northeast Italy) between January 2019 and July 2022 were enrolled prospectively and analyzed retrospectively. Demographic and aortic anatomical characteristics were evaluated. Endovascular aneurysm repair in SNA were selected for analysis. Major investigated outcomes were technical success, endoleaks, morbidity, mortality, and reinterventions at 30 days and during follow-up. Endograft migration and postoperative aortic neck angulation changes were also analyzed. RESULTS: A total of 129 patients were enrolled. An infrarenal angle of ≥60° was observed in 56 patients (43%) (SNA group) and their data analyzed. The mean patient age was 78.9 ± 5.9 years and median abdominal aortic aneurysm diameter 59 mm (range, 45-94 mm). Median aortic infrarenal neck length, angulation and diameter were 22 mm (range, 13-58 mm), 77° (range, 60°-150°), and 22.0 ± 3.5 mm respectively. Analysis revealed a technical success rate of 100% and perioperative major complication rate of 1.7%. Intraoperative and perioperative morbidity and mortality rates were 3.5% (one buttock claudication and one inguinal surgical cutdown) and 0%, respectively. No perioperative type I endoleaks were observed. The median follow-up was 13 months (range, 1-40 months). Five patients died during follow-up from aneurysm-unrelated causes. Two reinterventions occurred (3.5%): one conversion for a type IA endoleak and one sac embolization for a type II endoleak. Aneurysm sac shrinkage was observed in 15 patients (26%) and aneurysm stability in 35 patients (62%), respectively. Estimated freedom from reinterventions at 24 months was 92%. Aortic neck median postoperative angulation was 75° (range, 45°-139°). CONCLUSIONS: The Triveneto Conformable Registry shows good early results of the CEXC device in severely angulated aortic infrarenal necks. These data need confirmation on longer follow-up and a wider cohort of patients to further increase endovascular aneurysm repair eligibility in SNA.

Impact of coronary bifurcation angle on computed tomography derived fractional flow reserve in coronary vessels with no apparent coronary artery disease.

OBJECTIVES: Computed tomography (CT) derived fractional flow reserve (FFRCT) decreases from the proximal to the distal part due to a variety of factors. The energy loss due to the bifurcation angle may potentially contribute to a progressive decline in FFRCT. However, the association of the bifurcation angle with FFRCT is still not entirely understood. This study aimed to investigate the impact of various bifurcation angles on FFRCT decline below the clinically crucial relevance of 0.80 in vessels with no apparent coronary artery disease (CAD). METHODS: A total of 83 patients who underwent both CT angiography including FFRCT and invasive coronary angiography, exhibiting no apparent CAD were evaluated. ΔFFRCT was defined as the change in FFRCT from the proximal to the distal in the left anterior descending artery (LAD) and left circumflex artery (LCX). The bifurcation angle was calculated from three-dimensional volume rendered images. Vessel morphology and plaque characteristics were also assessed. RESULTS: ΔFFRCT significantly correlated with the bifurcation angle (LAD angle, r = 0.35, p = 0.001; LCX angle, r = 0.26, p = 0.02) and vessel length (LAD angle, r = 0.30, p = 0.005; LCX angle, r = 0.49, p < 0.0001). In LAD, vessel length was the strongest predictor for distal FFRCT of ≤ 0.80 (ß-coefficient = 0.55, p = 0.0003), immediately followed by the bifurcation angle (ß-coefficient = 0.24, p = 0.02). The bifurcation angle was a good predictor for a distal FFRCT ≤ 0.80 (LAD angle, cut-off 31.0°, AUC 0.70, sensitivity 74%, specificity 68%; LCX angle, cut-off 52.6°, AUC 0.86, sensitivity 88%, specificity 85%). CONCLUSIONS: In vessels with no apparent CAD, vessel length was the most influential factor on FFRCT, directly followed by the bifurcation angle. KEY POINTS: • Both LAD and LCX bifurcation angles are factors influencing FFR CT. • Bifurcation angle is one of the predictors of a distal FFRCT of ≤ 0.80 and an optimal cut-off value of 31.0° for the LAD and 52.6° for the LCX. • Bifurcation angle should be taken into consideration when interpreting numerical values of FFRCT.

Endovascular Treatment of Abdominal Aortic Aneurysm With Severe Angulation of Infrarenal Aortic Neck by Gore Conformable Endograft.

INTRODUCTION: The aim of the study is to report a single-center experience with the Gore Excluder conformable endograft with active control system (CEXC Device, W.L. Gore and Associates, Flagstaff, AZ, USA) in abdominal aortic aneurysms (AAAs) with severe infrarenal neck angulation. METHODS: All patients underwent EVAR with CEXC Device between September 2018 and 2020, were prospectively enrolled, and retrospectively analyzed. Anatomical details of the proximal aortic neck were evaluated. Early endpoints were the use of repositionability and angulation system, intraoperative unplanned cuff, technical success (TS), 30-day morbidity/mortality, and reintervention. Follow-up endpoints were type-I endoleaks, endograft migration, aortic neck dilatation, aneurismal sac shrinkage, survival (S), and freedom from reintervention (FFR). RESULTS: Twenty-five patients were enrolled (median age: 80 [range = 60-90] years, median AAA diameter: 60 [range = 52-90] mm). All patients had severe infrarenal neck angulation (beta angle ≧ 60°), and 11 (44%) of those had neck beta angle ≧ 90°. Median infrarenal neck angle, length, and diameter were 70° (range = 60°-90°), 22 (range = 13-42) mm and 22 (range = 18-31) mm, respectively. Endograft repositioning system was employed in 15 (60%) cases and the median number of repositioning maneuvers was 1 (range:0-4). Active angulation system was used in 17 (68%) patients. The median proximal diameter of the main-body and oversize were 28 (range = 23-36) mm and 28% (range = 21%-38%), respectively. Proximal cuff was positioned in 1 (4%) patient. Technical success was achieved in all cases. Intraoperative and perioperative morbidity and mortality were 12% and 0%, respectively. Perioperative type-I/III and II endoleaks were observed in 0 and 4 (16%) patients, respectively. The median follow-up was 12 months (range: 3-30). One patient died at 12-month for AAA-unrelated causes. Abdominal aortic aneurysm-sac shrinkage and stability were observed in 9 (36%) and 15 (60%) cases, respectively. No type-I/III endoleak and reintervention occurred during the follow-up. One persistent type-II endoleak was observed. Estimated survival at 24 months was 92%. CONCLUSION: According to the present data, the CEXC Device allows an excellent rate of TS in severe angulated aortic neck. This preliminary data, could increase the rate of patients eligible for EVAR.

Long-term Results of Angulated Versus Hyperangulated Neck in Endovascular Aneurysm Repair With Endurant Endoprosthesis.

PURPOSE: Patients with a hyperangulated (>60°) proximal aortic neck and at high risk of open surgery have been treated with endovascular aortic repair (EVAR). However, long-term outcomes are not well reported. The aim of this study is to compare the technical and clinical success of EVAR in angulated (45°-60°) and hyperangulated (>60°) proximal neck angulation. MATERIALS AND METHODS: The data of all consecutive patients undergoing EVAR treated between November 2007 and February 2020 were collected. A retrospective analysis of this prospective database was performed. The primary measure outcome was technical and clinical success. In addition, we evaluated sack evolution, type IA endoleak, secondary procedures, aneurysm rupture, mortality, aneurysm-related mortality, and migration. RESULTS: In all, 246 of 1353 EVAR patients presented with an angulation of the proximal neck >45°, 130 patients presented with an infrarenal angulation >60°, while 116 patients had an angulation between 45° and 60°. Patients with a hyperangulated infrarenal aortic neck were significantly more often women (8.6% vs 26.9%), older (73.9 vs 76.7 years), and had less often diabetes mellitus (20.7% vs 10.8%). Suprarenal neck angulation and reversed tapered neck were significantly more frequent in the hyperangulated group so that propensity scores were generated using these anatomical parameters to create a matched cohort group. No significant differences in technical (87.9% vs 94.8%) and clinical success (66.4% vs 69.8%) were observed. After a mean clinical follow-up of 58.9 months significantly more secondary procedures were performed in the hyperangulated group (23.3% vs 12.9% p=0.04); however, neck-related secondary procedures were comparable (1.7% vs 6.0%; p=0.09). Also, all-cause and aneurysm-related mortality, sack evolution, type IA endoleak, aneurysm rupture, and migration were comparable for both groups. CONCLUSION: Compared with less angulated proximal aortic neck, hyperangulated neck anatomy did not reduce the technical and clinical success of EVAR but increased the risk of secondary procedures. In patients who are not good candidates for open surgery, EVAR is a reasonable alternative.

Clinical characteristics of tetralogy of Fallot with left pulmonary artery acute angulation on computed tomography.

Left pulmonary artery (LPA) stenosis with acute angulation commonly necessitates surgical revision in the treatment of tetralogy of Fallot (TOF). We investigated the clinical characteristics of acute angulation of the LPA in patients with TOF via computed tomography (CT). Between 2011 and 2022, 160 patients were diagnosed with TOF using CT. After excluding 28 patients due to insufficient records or age, 132 patients were included in the present analysis. The patients were divided into two groups according to the presence or absence of acute angulation of the LPA: group I (TOF with an acute angle of the LPA, n = 53) and group II (TOF without an acute angle of the LPA, n = 79). We retrospectively collected clinical data from electronic medical records. T-tests were used to analyze continuous variables (i.e., age, sex, weight, right ventricular outflow tract [RVOT] pressure on echocardiography, and distance to bifurcation), and Fisher's exact and chi-square tests were used to analyze categorical data (i.e., presence of the right aortic arch, pulmonary arterial atresia/hypoplasia, atrial septal defect [ASD], patent ductus arteriosus [PDA], and pulmonary valve). The groups did not differ significantly in terms of sex, weight, presence of the right aortic arch, pulmonary arterial atresia/hypoplasia, ASD, or distance to the bifurcation. Moreover, there was no significant difference between the presence and absence of PDA (P = 0.057); however, patients in group I were significantly older (143.2 ± 97.8 days) than those in group II (91.1 ± 76.0 days, P = 0.002). Furthermore, RVOT pressure was significantly higher among patients in group I (45.1 ± 22.5 mmHg) than in group II (25.0 ± 12.4 mmHg, P < 0.001). In the current study, acute angulation of the LPA in patients with TOF, as observed on CT, was associated with older age and higher RVOT pressure on echocardiography.

Comparing left ventricular assist device inflow cannula angle between median sternotomy and thoracotomy using 3D reconstructions.

BACKGROUND: Left ventricular assist device (LVAD) implantation via thoracotomy has many potential advantages compared to conventional sternotomy, including improved inflow cannula (IFC) positioning. We compared the difference in IFC angles, postoperative, and long-term outcomes for patients with LVADs implanted via thoracotomy and sternotomy. METHODS: A single-center, retrospective analysis of 14 patients who underwent thoracotomy implantation was performed and matched with 28 patients who underwent sternotomy LVAD implantations for a total of 42 patients. Inclusion required a minimum LVAD support duration of 30 days and excluded concomitant procedures. A postoperative CT-chest was used to measure the angle the between the IFC and mitral valve in two-dimensions and results were compared with three-dimensional reconstruction using the same CT chest. Outcome data were extracted from medical records. RESULTS: There was no significant difference in gender, INTERMACS score, BMI, or age between the two groups. Median cardiopulmonary bypass time was longer in the thoracotomy group compared to the sternotomy group, 107 min (86-122) versus 76 min (56-93), p < 0.01. 3D reconstructions revealed less deviation of the IFC away from the mitral valve in devices implanted via thoracotomy compared to sternotomy, median (IQR) angle 16.3° (13.9°-21.0°) versus 23.2° (17.9°-26.4°), p < 0.01. Rates of pump thrombosis, stroke, and gastrointestinal bleeding were not significantly different. CONCLUSIONS: Devices implanted via thoracotomy demonstrated less deviation away from mitral valve. However, there was no difference in morbidity between the two approaches. 3D reconstruction of the heart is an innovative technique to measure angulation and is clinically advantageous when compared to 2D imaging.

Role of Transabdominal Ultrasonography in the Evaluation of Pediatric Patients With Daytime Wetting: A Single-Center Pilot Study.

OBJECTIVES: Urinary incontinence (UI) is a frequent cause of admission to pediatric nephrology outpatient clinics. The aim of this study was to determine whether anatomical changes in lower urinary tract structures (retrovesical angulation [RVA] and bladder neck position [BNP]) are associated with UI in pediatric patients with daytime-wetting in comparison to healthy children. METHODS: In this prospective study, patients with daytime UI diagnosed using the Dysfunctional Voiding Symptom Score of the International Children's Continence Society and 3-day-voiding/bowel diary were compared with an age- and sex-matched control group without incontinence. In addition to routine clinical evaluation, RVA and BNP were measured at rest using transabdominal ultrasound (TA-US). Intra-rater agreement was estimated. RESULTS: A total of 88 children were included in the study, with 44 children (22 boys, 22 girls) each in patient and control groups. RVA was significantly greater and BNP was significantly lower in the patient group versus control group (RVA: 134.30 ± 10.05 vs 127.94 ± 13.15, P = .013; BNP: 11.88 ± 4.53 vs 17.20 ± 5.55, P < .001, respectively). Irrespective of the presence of incontinence, girls had a significantly greater RVA than boys (P < .001). However, there was no difference between sexes in BNP values (P = .630). Intra-rater agreement was very strong for RVA (P < .001, r = .897), and strong for BNP (P < .001, r = .774). CONCLUSIONS: TA-US imaging is a non-invasive and practical procedure routinely performed in pediatric patients presenting with UI complaints. Our study demonstrated anatomical changes in lower urinary tract structures in pediatric patients with UI. These changes should be considered in the diagnosis, follow-up, and treatment of patients with UI.

Angulation error assessment for the trajectory in the anteroposterior and lateral fluoroscopic views during percutaneous endoscopic transforaminal lumbar discectomy.

BACKGROUND: Anteroposterior (AP) and lateral fluoroscopies are often used to evaluate the intraoperative location and angulation of the trajectory in percutaneous endoscopic transforaminal lumbar discectomy (PETLD). Although the location of the trajectory shown in fluoroscopy is absolutely accurate, the angulation is not always reliable. This study aimed to evaluate the accuracy of the angle shown in the AP and lateral fluoroscopic views. METHODS: A technical study was performed to assess the angulation errors of PETLD trajectories shown in AP and lateral fluoroscopic views. After reconstructing a lumbar CT image, a virtual trajectory was placed into the intervertebral foramen with gradient-changing coronal angulations of the cephalad angle plane (CACAP). For each angulation, virtual AP and lateral fluoroscopies were taken, and the cephalad angles (CA) of the trajectory shown in the AP and lateral fluoroscopic views, which indicated the coronal CA and the sagittal CA, respectively, were measured. The angular relationships among the real CA, CACAP, coronal CA, and sagittal CA were further demonstrated with formulae. RESULTS: In PETLD, the coronal CA is approximately equal to the real CA, with a small angle difference and percentage error, whereas the sagittal CA shows a rather large angle difference and percentage error. CONCLUSION: The AP view is more reliable than the lateral view in determining the CA of the PETLD trajectory.

The biomechanical effects of acromial fracture angulation in reverse total shoulder arthroplasty.

BACKGROUND: The biomechanical changes and treatment guidelines on acromial fracture after reverse shoulder arthroplasty (RSA) are still not well understood. The purpose of our study was to analyze the biomechanical changes with respect to acromial fracture angulation in RSA. METHODS: RSA was performed on 9 fresh-frozen cadaveric shoulders. An acromial osteotomy was performed on the plane extending from the glenoid surface to simulate an acromion fracture. Four conditions of acromial fracture inferior angulation were evaluated (0°, 10°, 20°, and 30° angulation). The middle deltoid muscle loading origin position was adjusted based on the position of each acromial fracture. The impingement-free angle and capability of the deltoid to produce movement in the abduction and forward flexion planes were measured. The length of the anterior, middle, and posterior deltoid was also analyzed for each acromial fracture angulation. RESULTS: There was no significant difference in the abduction impingement angle between 0° (61.8° ± 2.9°) and 10° angulation (55.9° ± 2.8°); however, the abduction impingement angle of 20° (49.3° ± 2.9°) significantly decreased from 0° and 30° angulation (44.2° ± 4.6°), and 30° angulation significantly differed from 0° and 10° (P < .01). On forward flexion, 10° (75.6° ± 2.7°), 20° (67.9° ± 3.2°), and 30° angulation (59.8° ± 4.0°) had a significantly decreased impingement-free angle than 0° (84.2° ± 4.3°; P < .01), and 30° angulation had a significantly decreased impingement-free angle than 10°. On analysis of glenohumeral abduction capability, 0° significantly differed (at 12.5, 15.0, 17.5, and 20.0N) from 20° and 30°. For forward flexion capability, 30° angulation showed a significantly smaller value than 0° (15N vs. 20N). As acromial fracture angulation increased, the middle and posterior deltoid muscles of 10°, 20°, and 30° became shorter than those of 0°; however, no significant change was found in the anterior deltoid length. CONCLUSIONS: In acromial fractures at the plane of glenoid surface, 10° inferior angulation of the acromion did not interfere with abduction and abduction capability. However, 20° and 30° of inferior angulation caused prominent impingement in abduction and forward flexion and reduced abduction capability. In addition, there was a significant difference between 20° and 30°, suggesting that not only the location of the acromion fracture after RSA but also the degree of angulation are important factors for shoulder biomechanics.

Demographic heterogeneity in valgus angulation of the proximal ulnar canal in relation to the flexion-extension axis.

BACKGROUND: The long-term outcome of total elbow arthroplasty remains unsatisfactory because of loosening and polyethylene wear, which could be caused by malpositioning of the ulnar component. When introducing an ulnar component, 2 different angles should be considered in the coronal plane: the valgus angulation of the proximal ulna in relation to the flexion-extension axis (FE-axis) and the intramedullary varus angulation in relation to the FE-axis. Currently, available TEA designs may not always be able to reconstruct the FE-axis because of the morphologic variability of the ulna. HYPOTHESIS: This study aimed to determine the demographic variability of the ulna and the relation between the 2 angulations in the frontal plane based on 3-dimentional computed tomography (CT) reconstructions of the elbow joint of healthy volunteers. METHODS: Computed tomography scans of 36 left elbows of healthy volunteers were obtained (20 men and 16 women). The scans were segmented and analyzed using the Mimics Research 20.0 software. A local coordinate system was created based on the FE-axis of the elbow and the ulna's longitudinal axis. The measurements were conducted using the 3-Matic Research 12.0 software. RESULTS: The valgus angulation of the proximal medullary canal was on average 16° in men but 12° in women and ranged between 5° and 21°. The varus angulation of the medullary cavity could be determined at 57 mm in men and 64 mm in women from the FE-axis. This angulation was on average 10° in men and 7° in women. There was no significant correlation between this angle and the length of the ulna or the point of varus angulation. CONCLUSION: This study found a wide range of valgus angulation of the proximal ulnar canal in relation to the FE-axis. The available elbow implant designs are discordant with the mean valgus angulation of the proximal ulna found in this study, and the valgus laxity of the implants does not cover the variability in the population.

The Comprehensive Evaluation of the Pinch Deformity due to Concave Alar Cartilages and Its Management.

INTRODUCTION: Acute angle between dome and ala causes alar concavity/pinch deformity. Breathing problems may accompany pinching. Here, pinch deformities were classified according to their severity and treatment modalities discussed. MATERIALS AND METHODS: Rhinoplasty patients with pinch deformities were included in study. Pinching without external nasal valve blockage (ENVB) was classified mild, pinching with ENVB was classified moderate, and extreme pinching and ENVB were classified severe deformity. In mild deformity, cephalic resection of ala was performed or cephalic resection was combined with onlay graft over ala. In moderate deformity, cephalic part was bent and sutured over lower ala. In severe deformity, cephalic part was bent, and lateral strut graft was inserted between lower and cephalic ala. In pinch deformities combined with hypertrophic lower lateral cartilage (LLC), medial crural overlay preceded above-mentioned treatment modalities. RESULTS: Thirty-eight patients (22 female, 16 male) with pinch deformities underwent rhinoplasty between January 2017 and December 2022. Mean age was 27 years. Mean follow-up was 32 months. Fifteen patients had mild deformities. Cephalic resection was enough in four patients. Camouflage grafts were settled over ala in eleven patients. Twenty patients had moderate deformities; cephalic ala was bent over lower part and sutured. Two patients had severe deformities; lateral strut graft was settled between lower and bent cephalic alar parts. One patient had LLC hypertrophy/pinch deformity. LLC hypertrophy was corrected by medial crural overlay, and concavity was corrected with cephalic resection. Satisfactory shape, better valve passage obtained in all cases. CONCLUSION: Pinch deformity could be classified according to its severity and appropriate treatment options could be determined for each class. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/journal/00266 .

A CBCT Based Assessment of Canine Eruption and Development Following Alveolar Bone Grafting in Patients Born With Unilateral Cleft lip and/or Palate.

To three-dimensionally assess and visualize the eruption path and development of the maxillary canine following alveolar bone grafting in patients born with cleft lip and palate. A further objective of this analysis was to assess how the presence of the lateral incisor impacts the eruption path of the canine.Observational follow-up study.Stockholm Craniofacial Team, Karolinska University Hospital, Sweden.Thirty children born with non-syndromic unilateral cleft lip with or without palate were consecutively included.CBCT scans of the maxilla were taken six months before and six months after the alveolar bone-grafting surgery for each patient.Canine eruption (angulation and vertical movement) and canine development (length and volume).There was a significant difference pre- and post-operatively of the canine angulation between the cleft and non-cleft sides. The mean angulation on the cleft side was 14.7° (SD = 11.1°) while on the non-cleft side, it was 4.9° (SD = 9.2°). No significant differences were noted between cleft-side and non-cleft side canines in terms of amount of vertical eruption and volumetric development. Absence of the lateral incisor did not significantly contribute to either canine angulation or its vertical eruption on the cleft-side.Higher angulation of the canine on the cleft side indicates a higher risk of future canine impaction. Presence or absence of the lateral incisor did not significantly affect canine angulation or its vertical eruption. Increased age and children born with total cleft lip and palate imply a higher risk of angulated canines on the cleft side.