Sensor-to-Bone Calibration with the Fusion of IMU and Bi-Plane X-rays.

Inertial measurement units (IMUs) need sensor-to-segment calibration to measure human kinematics. Multiple methods exist, but, when assessing populations with locomotor function pathologies, multiple limitations arise, including holding postures (limited by joint pain and stiffness), performing specific tasks (limited by lack of selectivity) or hypothesis on limb alignment (limited by bone deformity and joint stiffness). We propose a sensor-to-bone calibration based on bi-plane X-rays and a specifically designed fusion box to measure IMU orientation with respect to underlying bones. Eight patients undergoing total hip arthroplasty with bi-plane X-rays in their clinical pathway participated in the study. Patients underwent bi-plane X-rays with fusion box and skin markers followed by a gait analysis with IMUs and a marker-based method. The validity of the pelvis, thigh and hip kinematics measured with a conventional sensor-to-segment calibration and with the sensor-to-bone calibration were compared. Results showed (1) the feasibility of the fusion of bi-plane X-rays and IMUs in measuring the orientation of anatomical axes, and (2) higher validity of the sensor-to-bone calibration for the pelvic tilt and similar validity for other degrees of freedom. The main strength of this novel calibration is to remove conventional hypotheses on joint and segment orientations that are frequently violated in pathological populations.

Attenuating intrathoracic pressure swings decreases cardiac output at different intensities of exercise.

Intrathoracic pressure (ITP) swings that permit spontaneous ventilation have physiological implications for the heart. We sought to determine the effect of respiration on cardiac output ( Q ̇ $\dot Q$ ) during semi-supine cycle exercise using a proportional assist ventilator to minimize ITP changes and lower the work of breathing (Wb ). Twenty-four participants (12 females) completed three exercise trials at 30%, 60% and 80% peak power (Wmax ) with unloaded (using a proportional assist ventilator, PAV) and spontaneous breathing. Intrathoracic and intraabdominal pressures were measured with balloon catheters placed in the oesophagus and stomach. Left ventricular (LV) volumes and Q ̇ $\dot Q$ were determined via echocardiography. Heart rate (HR) was measured with electrocardiogram and a customized metabolic cart measured oxygen uptake ( V ̇ O 2 ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}}}$ ). Oesophageal pressure swings decreased from spontaneous to PAV breathing by -2.8 ± 3.1, -4.9 ± 5.7 and -8.1 ± 7.7 cmH2 O at 30%, 60% and 80% Wmax , respectively (P = 0.01). However, the decreases in Wb were similar across exercise intensities (27 ± 42 vs. 35 ± 24 vs. 41 ± 22%, respectively, P = 0.156). During PAV breathing compared to spontaneous breathing, Q ̇ $\dot Q$ decreased by -1.0 ± 1.3 vs. -1.4 ± 1.4 vs. -1.5 ± 1.9 l min-1 (all P < 0.05) and stroke volume decreased during PAV breathing by -11 ± 12 vs. -9 ± 10 vs. -7 ± 11 ml from spontaneous breathing at 30%, 60% and 80% Wmax , respectively (all P < 0.05). HR was lower during PAV breathing by -5 ± 4 beats min-1 at 80% Wmax (P < 0.0001). Oxygen uptake decreased by 100 ml min-1 during PAV breathing compared to spontaneous breathing at 80% Wmax (P < 0.0001). Overall, attenuating ITPs mitigated LV preload and ejection, thereby suggesting that the ITPs associated with spontaneous respiration impact cardiac function during exercise. KEY POINTS: Pulmonary ventilation is accomplished by alterations in intrathoracic pressure (ITP), which have physiological implications on the heart and dynamically influence the loading parameters of the heart. Proportional assist ventilation was used to attenuate ITP changes and decrease the work of breathing during exercise to examine its effects on left ventricular (LV) function. Proportional assist ventilation with progressive exercise intensities (30%, 60% and 80% Wmax ) led to reductions in cardiac output at all intensities, primarily through reductions in stroke volume. Decreases in LV end-diastolic volume (30% and 60% Wmax ) and increases in LV end-systolic volume (80% Wmax ) were responsible for the reduction in stroke volume. The relationship between cardiac output and oxygen uptake is disrupted during respiratory muscle unloading.

Symmetry in knee arthrokinematics in healthy collegiate athletes during fast running and drop jump revealed through dynamic biplane radiography.

OBJECTIVE: Changes in cartilage contact area and/or contact location after knee injury can initiate and exacerbate cartilage degeneration. Typically, the contralateral knee is used as a surrogate for native cartilage contact patterns on the injured knee. However, symmetry in cartilage contact patterns between healthy knees during high-impact activities is unknown. METHOD: Tibiofemoral kinematics were measured on 19 collegiate athletes during fast running and drop jump using dynamic biplane radiography and a validated registration process that matched computed tomography (CT)-based bone models to the biplane radiographs. Cartilage contact area and location were measured with participant-specific magnetic resonance imaging (MRI)-based cartilage models superimposed on the CT-based bone models. Symmetry in cartilage contact area and location was assessed by the absolute side-to-side differences (SSD) within participants. RESULTS: The SSD in contact area during running (7.7 ± 6.1% and 8.0 ± 4.6% in the medial and lateral compartments, respectively) was greater than during drop jump (4.2 ± 3.7% and 5.7 ± 2.6%, respectively) (95% CI of the difference: medial [2.4%, 6.6%], lateral [1.5%, 4.9%]). The average SSD in contact location was 3.5 mm or less in the anterior-posterior (AP) direction and 2.1 mm or less in the medial-lateral (ML) direction on the femur and tibia for both activities. The SSD in AP contact location on the femur was greater during running than during drop jump (95% CI of the difference: medial [1.6 mm, 3.6 mm], lateral [0.6 mm, 1.9 mm]). CONCLUSION: This study provides context for interpreting results from previous studies on tibiofemoral arthrokinematics. Previously reported differences between ligament-repaired and contralateral knee arthrokinematics fall within the range of typical SSDs observed in healthy athletes. Previously reported arthrokinematics differences that exceed SSDs found in these healthy athletes occur only in the presence of anterior cruciate ligament (ACL) deficiency or meniscectomy.

Monoplane versus biplane fluoroscopy in patients undergoing fenestrated/branched endovascular aortic repair.

OBJECTIVE: Endovascular aortic repair (EVAR) with fenestrated (F-EVAR) or branched (B-EVAR) endografts represents an indispensable tool of modern patient care in vascular surgery. The purpose of this retrospective study was to evaluate the center's initial experience of F/B-EVAR procedures performed under biplane angiography guidance compared with a historical control group. METHODS: From January 2020 to March 2022, 80 consecutive patients underwent F/B-EVAR under general anesthesia at a single institution. As from January 2021, the deployment of complex stent grafts was performed using an alternative intraoperative imaging modality-a biplane fluoroscopy and angiography. The cohort was divided into monoplane (MPA) and biplane (BPA) groups according to the imaging modality applied. The end points were operation time, fluoroscopy time, radiation exposure, dose of contrast agent, and technical success. RESULTS: The MPA group included 59 patients (78% male; median age; 74 years; interquartile range [IQR], 66-78 years) and the BPA group 21 patients (85.7% males; median age, 75 years; IQR, 69-79 years). Operation time (median, 320 minutes; IQR, 266-376 minutes) versus (median, 275 minutes; IQR, 216-333 minutes) was significantly lower in the BPA group (P = .006). The median fluoroscopy time (median, 82 minutes; IQR, 57-110 minutes vs median, 68 minutes; IQR, 54-92 minutes), contrast agent volume applied (median, 220 mL; IQR, 179-250 mL vs median, 200 mL; IQR, 170-250 mL), and radiation dose (dose-area product, median, 413 Gy × cm2; IQR, 249-736 Gy × cm2; vs median, 542 Gy × cm2; IQR, 196-789 Gy × cm2) were similar in both groups. Technical success of 96.6% (57/59 cases) versus 100% (21/21 cases) could be achieved in MPA and BPA group, respectively. CONCLUSIONS: F/B-EVAR procedures performed under BPA guidance were associated with a significant decrease in operation time.

Value of biplane transrectal ultrasonography plus micro-flow imaging in preoperative T staging and rectal cancer diagnosis in combination with CEA/CA199 and MRI.

BACKGROUND: Rectal cancer is one of the most common malignant tumors and has a high incidence rate and fatality rate. Accurate preoperative T staging of rectal cancer is critical for the selection of appropriate rectal cancer treatment. Various pre-operative imaging methods are available, and the identification of the most accurate method for clinical use is essential for patient care. We investigated the value of biplane transrectal ultrasonography (TRUS) combined with MFI in preoperative staging of rectal cancer and explored the value of combining TRUS plus MFI with CEA/CA199 and MRI. METHODS: A total of 87 patients from Daping Hospital with rectal cancer who underwent TRUS examination plus MFI were included. Grades of MFI were determined by Alder classification. Among the total patients, 64 underwent MRI and serum CEA/CA199 tests additionally within one week of TRUS. Pathological results were used as the gold standard for cancer staging. Concordance rates between TRUS, MRI, and CEA/CA199 for tumors at different stages were compared. RESULTS: There were no significant differences between the Alder classification and pathological T staging. The concordance rate of TRUS and MFI for rectal cancer T staging was 72.4% (K = 0.615, p < 0.001). Serum CEA and CA199 levels were significantly different in tumors at different stages and increased progressively by pathological stage (p < 0.001); the accuracy rate was 71.88% (K = 0.599, p < 0.001), while that of MRI was 51.56% (K = 0.303, p < 0.001), indicating that TRUS had higher consistency in the preoperative T staging of rectal cancer. The combination of TRUS, MRI, and CEA/CA199 yielded an accuracy rate of 90.6%, which was higher than that of any method alone. CONCLUSIONS: Preoperative T staging of rectal cancer from biplane TRUS plus MFI was highly consistent with postoperative pathological T staging. TRUS combined with MRI and serum CEA/CA199 had a greater value in the diagnosis of rectal cancer and a higher diagnostic rate than any examination alone.

Single-plane versus real-time biplane approaches for ultrasound-guided central venous catheterization in critical care patients: a randomized controlled trial.

BACKGROUND: Critical care patients often require central venous cannulation (CVC). We hypothesized that real-time biplane ultrasound-guided CVC would improve first-puncture success rate and reduce mechanical complications. The purpose of this study was to compare the success rate and safety of single-plane and real-time biplane approaches for ultrasound-guided CVC. METHODS: From October 2022 to March 2023, 256 participants with critical illness requiring CVC were randomized to either the single-plane (n = 128) or biplane (n = 128) ultrasound-guided cannulation groups. The success rate, number of punctures, procedure duration, incidence of catheterization-related complications, and confidence score of operators were documented. RESULTS: The central vein was successfully cannulated in all 256 participants (163 [64%] man and 93 [36%] women; mean age 69 ± 19 [range 13-104 years]), including 182 and 74 who underwent internal jugular vein cannulation (IJVC) and femoral vein cannulation (FVC), respectively. The incidence of successful puncture on the first attempt was higher in the biplane group than that in the single-plane group (91.6% vs. 74.7%; relative risk (RR), 1.226; 95% confidence interval (CI), 1.069-1.405; P = 0.002 for the IJVC and 90.9% vs. 68.3%; RR, 1.331; 95% CI, 1.053-1.684; P = 0.019 for the FVC). The biplane group was also associated with a higher first-puncture single-pass catheterization success rate (87.4% vs. 69.0% and 90.9% vs. 68.3%), fewer undesired punctures (1[1-1(1-2)] vs. 1[1-2(1-4)] and 1[1-1(1-3)] vs. 1[1-2(1-4)]), shorter cannulation time (205 s [162-283 (66-1,526)] vs. 311 s [243-401 (136-1,223)] and 228 s [193-306 (66-1,669)] vs. 340 s [246-499 (130-944)]), and fewer immediate complications (10.5% vs. 28.7% and 9.1% vs. 34.1%) for both IJVC and FVC (all P < 0.05). CONCLUSION: Real-time biplane imaging of ultrasound-guided CVCs offers advantages over the single-plane approach for critically ill patients. TRIAL REGISTRATION: This prospective RCT was registered at Chinese Clinical Trial Registry (ChiCTR2200064843). Registered 19 October 2022.

Mono- and bi-plane sonographic approach for difficult accesses in the emergency department - A randomized trial.

BACKGROUND: The insertion of peripheral intravenous (PIV) catheters is one of the most performed invasive procedures in acute healthcare settings. However, peripheral difficult vascular access (PDVA) is not uncommon and can lead to delays in administering essential medications. Ultrasound (US) has emerged as a valuable tool for facilitating PIV cannulation. Advancements in technology have introduced a technique known as bi-plane imaging, allowing the simultaneous display of both longitudinal and transverse views of vessels. We aimed to investigate whether the utilization of bi-plane imaging, as opposed to the single-plane approach, would yield superior results for PDVA in the emergency department (ED). METHODS: This study was a single-center randomized controlled trial. We included adult patients admitted to the ED who required PIV cannulation. Patients were randomly assigned to undergo cannulation using either the mono-plane or bi-plane approach, both performed by skilled providers. The primary outcome of the study was to compare the first attempt success rates between the two techniques. RESULTS: A total of 442 patients were enrolled, with 221 undergoing cannulation attempts using the mono-plane approach. Successful placement of a functioning PIV catheter was achieved in a single attempt for 313 out of 442 patients (70.8%). There was no significant difference in the success rates between the two study groups: 68.3% in the mono-plane group and 73.3% in the bi-plane group (p = 0.395). The median time required for a successful attempt differed between the groups, with 45 s (range 18-600) in the mono-plane group and 35 s (range 20-600) in the bi-plane group (p = 0.03). CONCLUSIONS: Our study confirms that US is a highly effective tool for facilitating PIV cannulation in patients with PDVA presenting to the ED. However, our investigation into the use of bi-plane imaging did not reveal a significant improvement when compared to mono-plane imaging.

Bone morphology features associated with knee kinematics may not be predictive of ACL elongation during high-demand activities.

PURPOSE: Bony morphology has been proposed as a potential risk factor for anterior cruciate ligament (ACL) injury. The relationship between bony morphology, knee kinematics, and ACL elongation during high-demand activities remains unclear. The purpose of this study was to determine if bone morphology features that have been associated with ACL injury risk and knee kinematics are also predictive of ACL elongation during fast running and double-legged drop jump. METHODS: Nineteen healthy athletes performed fast running and double-legged drop jump within a biplane radiography imaging system. Knee kinematics and ACL elongation were measured bilaterally after using a validated registration process to track bone motion in the radiographs and after identifying ACL attachment sites on magnetic resonance imaging (MRI). Bony morphological features of lateral posterior tibial slope (LPTS), medial tibial plateau (MTP) depth, and lateral femoral condyle anteroposterior width (LCAP)/lateral tibial plateau anteroposterior width (TPAP) were measured on MRI. Relationships between bony morphology and knee kinematics or ACL elongation were identified using multiple linear regression analysis. RESULTS: No associations between bony morphology and knee kinematics or ACL elongation were observed during fast running. During double-legged drop jump, a greater range of tibiofemoral rotation was associated with a steeper LPTS (ß = 0.382, p = 0.012) and a deeper MTP depth (ß = 0.331, p = 0.028), and a greater range of anterior tibial translation was associated with a shallower MTP depth (ß = - 0.352, p = 0.018) and a larger LCAP/ TPAP (ß = 0.441, p = 0.005); however, greater ACL elongation was only associated with a deeper MTP depth (ß = 0.456, p = 0.006) at toe-off. CONCLUSION: These findings indicate that observed relationships between bony morphology and kinematics should not be extrapolated to imply a relationship also exists between those bone morphology features and ACL elongation during high-demand activities. These new findings deepen our understanding of the relationship between bony morphology and ACL elongation during high-demand activities. This knowledge can help identify high-risk patients for whom additional procedures during ACL reconstruction are most appropriate.

Additional anteromedial staple fixation prevents changes in the posterior tibial slope in retrotuberosity bi-planar open-wedge high tibial osteotomy.

PURPOSE: To compare the changes in posterior tibial slope (PTS) between retrotuberosity biplane open-wedge high tibial osteotomies (RT-OWHTOs) with and without additional anteromedial staple fixation. METHODS: Seventy-nine and 77 cases of RT-OWHTOs without (Group N) and with (Group S) additional staple fixation, respectively, were retrospectively reviewed. All procedures were performed using a locking spacer plate. Demographics and preoperative knee condition were similar between the groups. Clinically, the Western Ontario and McMaster Universities Arthritis Index and range of motion were evaluated preoperatively and 2 years postoperatively. Radiographically, the mechanical axis (MA), medial proximal tibial angle (MPTA), and PTS were evaluated preoperatively and within 2 years postoperatively. Hinge fractures were investigated using computed tomography at 2 weeks postoperatively. PTS loss was defined as the difference between the corresponding values at 2 weeks and 2 years postoperatively. The incidence of PTS failure (PTS loss ≥ ± 3°) was also investigated. RESULTS: The clinical results were not significantly different between groups N and S preoperatively and 2 years postoperatively. There were no significant differences in the MA, MPTA, and PTS between the groups preoperatively and 2 weeks postoperatively; changes in these variables did not differ significantly between the groups. The incidence of hinge fractures, all of which were categorized as Takeuchi type 1, did not differ significantly. PTS loss within 2 years postoperatively was significantly greater in group N than in group S (1.0° vs. 0.1°; p < 0.01). The incidence of the PTS failure was 16.5% (13/79) and 2.6% (2/77) in groups N and S, respectively (p < 0.01). CONCLUSION: Additional anteromedial staple fixation could prevent changes in the PTS in RT-OWHTO. It is a simple method for preventing an increase in the PTS after RT-OWHTO. LEVEL OF EVIDENCE: III.

Posterior tibial slope and meniscal slope correlate with in vivo tibial internal rotation during running and drop jump.

PURPOSE: The relationship between tibial bony and meniscus anatomy and knee kinematics during in vivo, high-impact activities remains unclear. This study aimed to determine if the posterior tibial slope (PTS) and meniscal slope (MS) are associated with in vivo anterior-posterior translation and internal tibia rotation during running and double-leg drop jumps in healthy knees. METHODS: Nineteen collegiate athletes performed fast running at 5.0 m/s on an instrumented treadmill and double-leg drop jump from a 60 cm platform while biplane radiographs of the knee were acquired at 150 Hz. Tibiofemoral kinematics were determined using a validated model-based tracking process. Medial and lateral PTS and MS were measured using magnetic resonance imaging (MRI). RESULTS: In fast running, more internal tibia rotation was associated with greater PTS (ρ = 0.336, P = 0.039) and MS (ρ = 0.405, P = 0.012) in the medial knee compartment. In the double-leg drop jump, more internal tibia rotation was associated with greater PTS (ρ = 0.431, P = 0.007) and MS (ρ = 0.323, P = 0.005) in the medial knee compartment, as well as a greater PTS in the lateral knee compartment (ρ = 0.445, P = 0.005). CONCLUSION: These findings suggest that the medial and lateral PTS and medial MS are associated with the amount of knee rotation during high-impact activities. These in vivo findings improve our understanding of ACL injury risk by linking bone and meniscus morphology to dynamic kinematics.

4D-foot analysis on effect of arch support on ankle, subtalar, and talonavicular joint kinematics.

BACKGROUND: It has been difficult to study the effects of arch support on multiple joints simultaneously. Herein, we evaluated foot and ankle kinematics using a fully automated analysis system, "4D-Foot," consisting of a biplane X-ray imager and two-dimensional‒three-dimensional registration, with automated image segmentation and landmark detection tools. METHODS: We evaluated the effect of arch support on ankle, subtalar, and talonavicular joint kinematics in five healthy female volunteers without a clinical history of foot and ankle disorders. Computed tomography images of the foot and ankle and X-ray videos of walking barefoot and with arch support were acquired. A kinematic analysis using the "4D-Foot" system was performed. The ankle, subtalar, and talonavicular joint kinematics were quantified from heel-strike to foot-off, with and without arch support. RESULTS: For the ankle joint, significant differences were observed in dorsi/plantarflexion, inversion/eversion, and internal/external rotation in the late midstance phase. The dorsi/plantarflexion and inversion/eversion motions were smaller with arch support. For the subtalar joint, a significant difference was observed in all the dynamic motions in the heel-strike and late midstance phases. For the talonavicular joint, significant differences were observed in inversion/eversion and internal/external rotation in heel-strike and the late midstance phases. For the subtalar and talonavicular joints, the motion was larger with arch support. An extremely strong correlation was observed when the motion of the subtalar and talonavicular joints was compared for each condition and motion. CONCLUSIONS: The results indicated that the arch support decreased the ankle motion and increased the subtalar and talonavicular joint motions. Additionally, our study demonstrated that the in vivo subtalar and talonavicular joints revealed a strong correlation, suggesting that the navicular and calcaneal bones were moving similarly to the talus and that the arch support stabilizes the ankle joint and compensatively increases the subtalar and talonavicular joint motions.

Biplane mode for more precise intrauterine procedures.

The evolution of ultrasound and the introduction of 3- and 4-dimensional ultrasound techniques led to a shift in the perception and usage of ultrasound in fetal medicine. The biplane mode might help in multiple fetal procedures, including but not limited to basic intrauterine thoracocentesis, thoracoamniotic shunting, amnioreduction, amnioinfusion, cordocentesis, intraumbilical infusion, and umbilical cord coagulation, with a possible reduction in the complication rate. Despite its theoretical usefulness, more studies are required to assess the clinical importance of this technique.

Safety and Effectiveness of Mechanical Thrombectomy for Acute Ischemic Stroke Using Single Plane Angiography.

OBJECTIVES: Nearly all data on mechanical thrombectomy for acute ischemic stroke is based on procedures performed on biplane angiography systems. However, thrombectomy may be performed on single-plane systems in situations of triage or limited resources. We present the first US study comparing the safety and effectiveness of mechanical thrombectomy performed on single-plane vs. biplane systems. METHODS AND METHODS: A retrospective review of a prospectively maintained database identified all patients treated with thrombectomy between July 2020 and July 2021 by a high-volume practice. Patients were dichotomized into those treated on single plane and biplane systems. Demographic, procedural, clinical and follow-up characteristics were compared. RESULTS: Of the 246 patients treated with mechanical thrombectomy, 70 (33%) and 141 (66%) patients were treated on SP and BP systems, respectively. No significant differences were detected in follow-up 'good functional outcome' (mRS ≤ 2; SP 51% vs BP 43%, p = 0.14), successful recanalization (SP 87% vs BP 88%, p = 0.72), intra-procedural vascular injury (SP 3% vs BP 2%, p = 0.96), or time from groin puncture to reperfusion (SP 24 min vs BP 26 min, p = 0.58). Additionally, no significant differences were detected in peri-procedural complications, fluoroscopy times or total radiation. Patients treated on single plane systems required significantly more contrast. CONCLUSIONS: Mechanical thrombectomy for acute ischemic stroke performed on single plane angiography systems is as safe and efficacious as when performed on biplane systems. Our results may have implications for increasing stroke care access, both domestically in underserved/rural areas and internationally when considering requirements for stroke care in lower-income countries.

Atri-U: assisted image analysis in routine cardiovascular magnetic resonance volumetry of the left atrium.

BACKGROUND: Artificial intelligence can assist in cardiac image interpretation. Here, we achieved a substantial reduction in time required to read a cardiovascular magnetic resonance (CMR) study to estimate left atrial volume without compromising accuracy or reliability. Rather than deploying a fully automatic black-box, we propose to incorporate the automated LA volumetry into a human-centric interactive image-analysis process. METHODS AND RESULTS: Atri-U, an automated data analysis pipeline for long-axis cardiac cine images, computes the atrial volume by: (i) detecting the end-systolic frame, (ii) outlining the endocardial borders of the LA, (iii) localizing the mitral annular hinge points and constructing the longitudinal atrial diameters, equivalent to the usual workup done by clinicians. In every step human interaction is possible, such that the results provided by the algorithm can be accepted, corrected, or re-done from scratch. Atri-U was trained and evaluated retrospectively on a sample of 300 patients and then applied to a consecutive clinical sample of 150 patients with various heart conditions. The agreement of the indexed LA volume between Atri-U and two experts was similar to the inter-rater agreement between clinicians (average overestimation of 0.8 mL/m2 with upper and lower limits of agreement of - 7.5 and 5.8 mL/m2, respectively). An expert cardiologist blinded to the origin of the annotations rated the outputs produced by Atri-U as acceptable in 97% of cases for step (i), 94% for step (ii) and 95% for step (iii), which was slightly lower than the acceptance rate of the outputs produced by a human expert radiologist in the same cases (92%, 100% and 100%, respectively). The assistance of Atri-U lead to an expected reduction in reading time of 66%-from 105 to 34 s, in our in-house clinical setting. CONCLUSIONS: Our proposal enables automated calculation of the maximum LA volume approaching human accuracy and precision. The optional user interaction is possible at each processing step. As such, the assisted process sped up the routine CMR workflow by providing accurate, precise, and validated measurement results.

Internal Jugular Vein Cannulation Using a 3-Dimensional Ultrasound Probe in Patients Undergoing Cardiac Surgery: Comparison Between Biplane View and Short-Axis View.

OBJECTIVE: To compare the clinical performance in terms of procedure time, success rate, and cannulation attempts between ultrasound biplane view (BPX) and short-axis (SAX) view for internal jugular vein cannulation (IJV) in patients undergoing cardiac surgery. DESIGN: Prospective, observational pilot study. SETTING: University level tertiary referral hospital. PATIENTS: The study comprised 100 patients between ages 18 and 75 years undergoing elective cardiac surgery. INTERVENTIONS: One hundred patients were divided into 2 groups of 50 (BPX group and SAX group) by assigning the study participants alternatively to each group. IJV cannulation was performed using a 3-dimensional ultrasound probe in all patients with either BPX view (BPX group, n = 50) or the SAX view (SAX group, n = 50) by an experienced anesthesiologist. MEASUREMENTS AND MAIN RESULTS: Time required for imaging, time for IJV puncture, time for guidewire confirmation, number of needle punctures and needle redirections, and incidence of posterior wall puncture were noted in both groups. In addition, the quality of needle visualization and the incidence of complications were recorded. The time taken for imaging was significantly greater in the BPX group than in the SAX group (9.52 ± 2.69 s v 7.94 ± 2.55 s; p = 0.0034), whereas the time taken for IJV puncture (10.39 ± 2.33 s v 23.7 ± 2.46 s; p < 0.0001), time taken for confirmation of guidewire (32.94 ± 4.50 s v 57.64 ± 7.14 s; p < 0.0001), and the incidence of posterior wall puncture (4% v 26%; p = 0.0022) were significantly less in the BPX group than in the SAX group. The total number of attempts taken to puncture the IJV was fewer in the BPX group than in the SAX group (55 v 78). Successful puncture of the IJV occurred on the first attempt in 90% of patients in the BPX group, whereas it was only 50% in the SAX group (p < 0.0001). The quality of needle visualization was good in 90% of patients in the BPX group, whereas it was only 6% in the SAX group. The number of needle redirections for IJV puncture was less in the BPX group than in the SAX group (48 v 116). The incidence of complications was not significant between the 2 groups. CONCLUSION: The results suggested that the BPX view may be a safer, feasible and more reliable method than the SAX view for IJV cannulation in cardiac surgical patients.

ACL deficiency influences medio-lateral tibial alignment and knee varus-valgus during in vivo activities.

PURPOSE: The role of the anterior cruciate ligament (ACL) in knee biomechanics in vivo and under weight-bearing is still unclear. The purpose of this study was to compare the tibiofemoral kinematics of ACL-deficient knees to healthy contralateral ones during the execution of weight-bearing activities. METHODS: Eight patients with isolated ACL injury and healthy contralateral knees were included in the study. Patients were asked to perform a single step forward and a single leg squat first with the injured knee and then with the contralateral one. Knee motion was determined using a validated model-based tracking process that matched subject-specific MRI bone models to dynamic biplane radiographic images, under the principles of Roentgen stereophotogrammetric analysis (RSA). Data processing was performed in a specific software developed in Matlab. RESULTS: Statistically significant differences (p < 0.05) were found for single leg squat along the frontal plane: ACL-deficient knees showed a more varus angle, especially at the highest knee flexion angles (40°-50° on average), compared to the contralateral knees. Furthermore, ACL-deficient knees showed tibial medialization along the entire task, while contralateral knees were always laterally aligned. This difference became statistically relevant (p < 0.05) for knee flexion angles included between 0° and about 30°. CONCLUSION: ACL-deficient knees showed an abnormal tibial medialization and increased varus angle during single leg squat when compared to the contralateral knees. These biomechanical anomalies could cause a different force distribution on tibial plateau, explaining the higher risk of early osteoarthritis in ACL deficiency. The clinical relevance of this study is that also safe activities used in ACL rehabilitation protocols are significantly altered in ACL deficiency. LEVEL OF EVIDENCE: III.

Graft healing does not influence subjective outcomes and shoulder kinematics after superior capsule reconstruction: a prospective in vivo kinematic study.

BACKGROUND: A viable treatment option for young patients with massive, irreparable rotator cuff tears is arthroscopic superior capsule reconstruction (SCR). SCR theoretically improves shoulder stability and function and decreases pain. However, no prospective studies to date have correlated magnetic resonance imaging (MRI) healing with in vivo kinematic data. The purpose of this study was to evaluate the association between graft healing and in vivo kinematics, range of motion (ROM), strength, and patient-reported outcomes (PROs). METHODS: Ten patients (8 men and 2 women; mean age, 63 ± 7 years) with irreparable rotator cuff tears underwent arthroscopic SCR with dermal allograft. Strength was measured with isometric internal rotation and external rotation (ER) at 0° of abduction, ER at 90° of abduction, and scapular-plane abduction, whereas ROM was measured during shoulder flexion, abduction, and ER and internal rotation at 90° of abduction both before and 1 year after SCR. PROs included American Shoulder and Elbow Surgeons, Western Ontario Rotator Cuff Index, and Disabilities of the Arm, Shoulder and Hand surveys that were collected before and 1 year after SCR. Synchronized biplane radiographs were collected at 50 images/s before and 1 year after SCR while patients performed 3 trials of scapular-plane abduction. A validated volumetric tracking technique with submillimeter accuracy determined 6-df glenohumeral and scapular kinematics. The acromiohumeral distance (AHD), humeral head translation, and scapulohumeral rhythm (SHR) were calculated from the in vivo kinematics. Healing at 5 locations was evaluated on 1-year postoperative MRI scans: anterior and posterior glenoid, anterior and posterior humerus, and posteriorly along the infraspinatus. Each subject was given a score from 0 to 5 based on number of sites healed. RESULTS: Of the 10 patients, 9 (90%) had complete (n = 4) or partial (n = 5) healing of the graft whereas 1 (10%) had complete failure at the glenoid. No correlation existed between MRI healing and the AHD, SHR, strength, ROM, or PROs. American Shoulder and Elbow Surgeons, Western Ontario Rotator Cuff Index, and Disabilities of the Arm, Shoulder and Hand scores all significantly improved from before to 1 year after SCR regardless of graft healing. CONCLUSIONS: The rate of complete or partial graft healing on MRI mimics findings of prior reports in the literature. MRI healing was correlated with humeral head anterior-posterior translation but not with the static and dynamic AHDs, SHR, humeral head superior-inferior translation, ROM, strength, or PROs 1 year after SCR. All PROs improved significantly from before to 1 year after SCR regardless of graft status on MRI. In vivo kinematic changes were small after SCR and not clinically significant, and the data suggest that improvements in clinical and functional outcomes may occur in the absence of full graft healing.

Biplane transrectal ultrasonography plus ultrasonic elastosonography and contrast-enhanced ultrasonography in T staging of rectal cancer.

BACKGROUND: The aim of this study is to assess biplane transrectal ultrasonography (TRUS) plus ultrasonic elastosonography (UE) and contrast-enhanced ultrasonography (CEUS) in T staging of rectal cancer. METHODS: Between March 2016 and January 2019, 66 rectal cancer patients who completed biplane TRUS plus UE and CEUS for preoperative workup and were treated by primary total mesorectal excision (TME) were retrospectively analyzed. RESULTS: The accuracy of TRUS plus UE and CEUS in all T staging of rectal cancer was 69.7%. The highest accuracy was achieved in the T3 stage (87.5%), while it was 71.4 and 50.0% in the T1 and T2 stage, respectively. The mean sizes of uT1-T2 lesions and uT3-T4 lesions were 30.0 ± 10.6 mm (range, 10.0-55.0) and 40.2 ± 11.2 mm (range, 14.0-57.0), respectively (p < 0.001). According to the receiver operating characteristic (ROC) curve to predict pT stages (pT1,2 vs. pT3), the optimal cut-off value of lesions in greatest dimension was 28.5 mm by TRUS with areas under the curve (AUC) of 0.769, and the optimal cut-off values of peak systolic velocity (PSV) and resistive index (RI) were 18.8 cm/sec and 0.645, respectively. The AUCs of PSV and RI were 0.588 and 0.555, respectively. CONCLUSIONS: Diagnostic accuracy of TRUS plus UE and CEUS in T staging of rectal cancer does not reach the excellent published study results, especially for patients with early rectal cancer. Tumor sizes, PSV and RI are useful additions for TRUS in T staging of rectal cancer.

Uniplane medial opening wedge high tibial osteotomy relative to a biplane osteotomy can reduce the incidence of lateral-hinge fracture.

PURPOSE: With surgical modifications reflecting plate design differences of the specific rigid locking plate adding a metal wedge, uniplane high tibial osteotomy (HTO) has fewer lateral-hinge fractures and fewer plate irritations than biplane HTO. METHODS: Uniplane HTO with a rigid locking plate adding a metal wedge was compared with biplane HTO with a rigid locking plate including a proximal D-hole. For comparison, the HTO patients' medical records and radiological results in a single institution were retrospectively reviewed. The Oxford knee score 2 years post-operation, CT scan at post-operative day 2 and serial standing long-bone scanography were reviewed to evaluate clinical outcome and radiological results, including the incidence of lateral-hinge fracture, plate irritation and correction loss to varus alignment. RESULTS: A total of 103 knees, including 59 uniplane HTO and 44 biplane HTO, were enrolled. The Oxford scores were 38.1 ± 7.8 in the uniplane group and 35.9 ± 8.3 in the biplane group (ns). On CT scans, more lateral-hinge fractures developed in the biplane group, and seven knees (12%) of the uniplane group and 12 knees (27%) of the biplane group had Takeuchi type I stable hinge fracture (p < 0.05); unstable fracture was not noted in either group. Plate irritation occurred in nine knees (19%) of the uniplane group and in 14 knees (32%) of the biplane group, and the difference was statistically significant (p < 0.05). CONCLUSION: In clinical situations including the use of surgical modifications reflecting plate design differences, fewer lateral-hinge fractures developed after uniplane medial opening-wedge HTO compared with biplane HTO. Uniplane HTO potentially represents a better option than biplane HTO for the prevention of lateral-hinge fracture. LEVEL OF EVIDENCE: IV.

Recent Development in Three and Four Dimension Fetal Echocardiography.

Since its introduction >15 years ago, the use of spatial and temporal image correlation (STIC) technology has contributed substantially to fetal echocardiography. Moreover, significant advances have occurred in 3- and 4-dimensional (3D/4D) echocardiography over the past several years including the matrix probe along with advances in gray scale and color Doppler post processing, resulting in improved display of ultrasound images. In this article, we provide examples to show these recent developments including the use of color Doppler with STIC in the glass-body mode and the matrix probe thus enabling the demonstration of cardiac anomalies of the 4-chamber-view and great arteries. The use of the matrix probe allows the examination of cardiac structures in 2 orthogonal planes simultaneously, which can help in display of anatomy side by side (Biplane mode). In addition, the rapid image reconstruction of the matrix probe allows for the display of live 4D and the rapid acquisition of a STIC volume. The display of multiplanar images of the heart in 3D/4D has also been used to automate the display of ultrasound images, resulting in standardization of the image display and thus minimizing the operation dependency of the ultrasound examination. Future addition of image recognition software can also provide assistance in image review.