Revision of 116 orthognathic surgery patients operated on with the high-oblique sagittal osteotomy (HOSO): a retrospective case series (PROCESS-compliant article).

BACKGROUND: The high-oblique sagittal osteotomy (HOSO) is an alternative to a bilateral sagittal split osteotomy (BSSO). Due to its novelty, there are no long-term studies which have focused on describing the incidence and type of complications encountered in the post-operative follow-up. The aim of this retrospective study is to analyze patients operated on with this surgical technique and the post-operative complications encountered. PATIENT AND METHODS: The electronic medical records of all patients treated with orthognathic surgery at the Department of Oral, Maxillofacial and Facial Plastic Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany, between the years 2009 and 2016 were retrospectively reviewed. RESULTS: A total of 116 patients fulfilled the inclusion criteria. The cases operated on with the standard osteosynthesis (X, Y, and straight) showed a complication rate of 36.37% (n = 4/11). The cases operated on with the HOSO-dedicated plates (HOSO-DP) showed, in total, a complication rate of 6.67% (n = 7/105). The most common post-operative complication resulting from both fixation methods was a reduction in mouth opening and TMJ pain for 4.3%. During the first years of performing the surgery (2009-211), a variety of standard plates had material failure causing non-union or pseudarthrosis. No cases of material failure were observed in the cases operated on with the HOSO-DP. The statistical results showed a highly significant dependence of a reduction in OP-time over the years, when the HOSO was performed without additional procedures (R2 > 0.83, P < 0.0015). CONCLUSION: The rate of complications in the HOSO were shown to be comparable to the rate of complications from the BSSO reported in the literature. Moreover, the use of the ramus dedicated plate appears to provide enough stability to the bone segments, making the surgery safer. CLINICAL RELEVANCE: The HOSO needs to be considered by surgeons as an alternative to BSSO. Once the use of the HOSO-DP was established, the rate of complications and the operation time reduced considerably.

Shortage of paediatric radiologists acting as an expert witness: position statement from the British Society of Paediatric Radiology (BSPR) National Working Group on Imaging in Suspected Physical Abuse (SPA).

One of the most challenging areas of radiological imaging in children is the diagnosis of physical abuse. There is a dearth of paediatric radiologists willing to act as expert witnesses, particularly in the family courts. There are a number of reasons why radiologists may not be interested or willing to put themselves forward to work as expert witnesses in this field. A group of imaging experts recently formed the "British Society of Paediatric Radiology (BSPR) Working Group on Imaging in Suspected Physical Abuse (SPA)". The group comprises radiologists and neuroradiologists with current or previous experience of providing expert witness reports to the court in cases of SPA. The group met in January 2019 to explore pragmatic solutions to the chronic inefficiencies in both medical and legal practices and the challenges that arise from working in a legal arena with different structures, goals, and assessment criteria. Key issues concerned organisational inefficiencies, variable support from National Health Service Trusts and the Royal College of Radiologists to conduct this work, and the risk/benefit of involvement. This work is important for the patient, parents, and society in general, and highly rewarding for clinical practitioners who are involved, but there are several issues with current practices that discourage active participation. With several members of the group either retired or close to retirement, the shortage of experts is becoming a pressing issue within the UK, which requires an engaged multidisciplinary group to come up with creative solutions. Here, the group provide a consensus opinion highlighting the current barriers and potential facilitators to increasing the number of radiologists willing to provide opinions to the court.

Head imaging in suspected non accidental injury in the paediatric population. In the advent of volumetric CT imaging, has the skull X-ray become redundant?

AIM: To assess whether the inclusion of skull radiography, as part of the skeletal survey performed in suspected non-accidental injury (NAI), is still justified when volume computed tomography (CT) of the head has also been performed. MATERIALS AND METHODS: This was a retrospective study which included 94 patients aged between 24 days and 23 months who presented to the Emergency Department between August 2014 to July 2016 and had subsequent investigations for suspected NAI. Patients were identified from the local radiology systems (Carestream PACS and CRIS) using strict inclusion and exclusion criteria. Inclusion criteria were any suspected NAI patient who had both unenhanced volume CT head and skull radiography during the same episode of presentation. Any child with suspected NAI who only had one of either CT or radiographs of the skull (and not both) were excluded. RESULTS: None of the cases reviewed demonstrated additional findings on skull X-rays that were not demonstrated on the CT head. Due to the starkness of this result, the confidence interval is 0-3.9%. In two cases, additional bony findings were demonstrated on the CT head which were not evident on the skull X-rays. CONCLUSION: Skull X-rays could be excluded from the NAI skeletal survey without missing intracranial injuries or skull fractures in cases where a contemporaneous volumetric CT head is also performed.

Soft-tissue evidence of head injury in infants and young children: is CT head examination justified?

AIM: To determine whether it is justified to undertake a computed tomography (CT) examination of the head in children under 1 year of age who present with a bruise, swelling, or laceration of >5 cm following head injury in children presenting to a paediatric accident and emergency (A&E) department in the northwest of England. Further aims were to determine whether there was any justification for performing a CT head examination for children with soft-tissue injuries measuring <5 cm, or for children >1 year with evidence of soft-tissue injury, but without any other concerning feature. MATERIALS AND METHODS: Children <3 years of age presenting with soft-tissue evidence of head injury between May 2011 and Oct 2014 and who subsequently underwent head CT were retrospectively identified from radiology requests. The CT images and clinical notes were used to identify those with skull fracture or intracranial haemorrhage and to determine whether the child was subsequently admitted or discharged from A&E. RESULTS: Eighty-five CT head examinations met the criteria for inclusion. Of these, 45 examinations demonstrated skull fractures and four examinations identified intracranial haemorrhage. Thirty-eight requests included soft-tissue evidence of head injury as the sole reason indicated for CT head examination. Of these, 22 examinations demonstrated skull fractures and one examination identified intracranial haemorrhage. CONCLUSION: Soft-tissue evidence of head injury as the sole reason for CT head examination appears to be justified in the present patient population. Furthermore, this study suggests that CT head examination should also be considered for children with soft-tissue injuries of <5 cm and for children aged between 1 and 3 years if identification of a skull fracture would alter the child's management.

Paediatric trauma imaging: why do we need separate guidance?

It is often assumed that the pattern of injury in children mirrors that of the adult population, but children have different anatomical proportions and the relative elasticity of their tissues results in different injury patterns. The authors of this review are members of the British Society of Paediatric Radiologists subgroup and developed the recently published(47) paediatric trauma protocols for imaging children involved in major blunt trauma. The following article has been written to bring these guidelines to the attention of the wider community of UK radiologists, and explain the rationale behind the recommendations.

Diagnosis and assessment of disease activity in takayasu arteritis: a childhood case illustrating the challenge.

Takayasu Arteritis (TA) is a rare, debilitating large vessel vasculitis occurring in patients of all ages, including infants, but the disease most commonly presents in the third decade. Diagnosis is often delayed and consequently TA is associated with significant morbidity and mortality. Accurate methods of monitoring disease activity or damage are lacking and currently rely on a combination of clinical features, blood inflammatory markers, and imaging modalities. In this report we describe a case of a 14-year-old boy with childhood-onset TA who, despite extensive negative investigations, did indeed have on-going active large vessel vasculitis with fatal outcome. Postmortem analysis demonstrated more extensive and active disease than originally identified. This report illustrates and discusses the limitations of current modalities for the detection and monitoring of disease activity and damage in large vessel vasculitis. Clinicians must be aware of these limitations and challenges if we are to strive for better outcomes in TA.

On the pH-responsive, charge-selective, polymer-brush-mediated transport probed by traditional and scanning fluorescence correlation spectroscopy.

The complete and reversible charge-selective sequestration of fluorophores by a weak polyelectrolyte brush, poly(2-(dimethylamino)ethylmethacrylate) (PDMAEMA) was demonstrated using fluorescence correlation spectroscopy (FCS). The chemistry and thickness of the weak polyelectrolyte PDMAEMA was tuned reversibly between neutral and cationic polymer forms. Thus, by switching the pH successively, the brush architecture was tuned to selectively trap and release anionic dye probes while continuously excluding cationic molecules. In addition, line-scan FCS was implemented and applied for the first time to a synthetic polymer system and used to identify a new, slower diffusion time on the order of seconds for the sequestered anionic probe under acidic conditions. These results, which quantify the selective sequestration properties of the PDMAEMA brush, are important because they enable a better understanding of transport in polymers and establish a spectroscopic means of evaluating materials with proposed applications in separations science, charge storage/release, and environmental remediation.

Computer-assisted pre- and postoperative evaluation of surgically assisted rapid maxillary expansion.

OBJECTIVE: Computer-assisted methods were used to evaluate different variants of surgically assisted rapid maxillary expansion (SARME) in terms of bone repositioning, new bone formation in the osteotomy gap, and bone quality before and after surgery. MATERIALS AND METHODS: Twenty-nine patients (18 male, 11 female) with a mean age of 29 years (16 to 44 years) were included in the study. Surgically assisted rapid maxillary expansion with Le Fort I osteotomy was performed in all patients studied. High-resolution computed tomography (CT) was carried out directly before and 6 to 8 weeks after surgery. After registration of the preoperative CT data on the postoperative data, 3D models were constructed and superimposed. New bone formation in the osteotomy gap was visualized by means of a visualization procedure developed specifically for this purpose. Bone quality was analyzed by dividing the models into different anatomical segments. A qualitative comparison of the data was accomplished using a direct volume rendering procedure with a special transfer function. A quantitative comparison was carried out based on the pre- and postoperative histograms of each region. RESULTS: Maxillary widening was confirmed in all patients by computer-assisted analysis. Four patients exhibited significant maxillary asymmetry after surgery. New bone formation within the osteotomy gap was irregular along the osteotomy lines but often symmetrical on both sides. The more symmetrical the osteotomy, the more symmetrical the new bone formation proved to be. In all but two cases, the postoperative qualitative and quantitative analyses showed a significant decrease in Hounsfield units, particularly in the vestibular bone. CONCLUSION: The differences in new bone formation in the osteotomy gap suggest that the type of surgical technique and distractor used influence the outcome. Our results indicate that SAME results in a decrease in bone quality, particularly in the vestibular bone. Computer-assisted analysis clearly results in an information gain.

[A long-term 3D cast model analysis focusing bone-borne vs. tooth-borne SARME].

UNLABELLED: This retrospective study evaluated 34 patients pre- and ~20.5 months post expansion 3D scanned cast models with tooth-borne (ТВ, n1=16) and bone-borne (BB, n2=18) devices. Measurements were performed for transverse skeletal/dental maxillary widening, dental tipping and dental attachment loss. RESULTS: T-Test in long-term effects: BB: bigger, symmetric transverse widening along the dental arch; bigger attachment loss in the frontal teeth, canines, 2nd premolars. molars; bigger dental tipping in the canines and 2nd molars; ТВ: asymmetric transverse widening along the dental arch; bigger attachment loss in the 1st premolars: bigger dental tipping in the premolars and 1st molars. CONCLUSION: BB should be used whenever bigger transverse maxillary expansion is required, new distractor designs may reduce segmental inclination and initial expansion asymmetries, consequently, eliminating the related attachment loss from secondary orthodontic tooth movements for arch alignment. ТВ devices showed minor expansion with good periodontal attachment, yet attachment loss in the first premolars must be critically seen in bigger expansion distances.

Palatal piezosurgical window osteotomy for maxillary sinus augmentation.

This technical note describes a new surgical technique for a palatal approach to the maxillary sinus for a vertical augmentation prior to dental implant placement. In 12 fully or partially edentulous patients (seven women, five men), 16 palatal sinus elevations were performed. After elevation of palatal full-thickness flap a rectangular access window was cut with a piezosurgical device. The raised sinus cavity was augmented with a synthetic nano-structured hydroxyapatite-based graft material. No harm occurred to the greater palatine artery or the sinus membrane. The vestibular and periimplant gingiva were preserved and there was no disharmonious soft tissue distortion or massive scar formation. Swelling and bleeding were minimal. Primary stability was achieved for all but one implant. This technique may be an alternative to other sinus augmentation approaches in cases where enough transversal width of the posterior alveolar crest is available.

Fixation of mandibular fractures with plates or miniplates: prospective study.

AIM: The choice of a more adequate internal fixation system in the treatment of mandibular fractures still originates controversy in the literature. The purpose of this study was to evaluate the effectiveness of internal fixation systems in the fixation of mandibular fractures, comparing indications and postoperative results between 2.4-mm plates and 2.0-mm miniplates. METHODS: A total of 42 consecutive patients with 71 mandibular fractures that had undergone either 2.4-mm plates (N.=20) or 2.0-mm miniplates (N.=22) were prospectively analyzed. Patients had a minimum follow-up of 6 months. Statistical analyses were made in the comparison between systems. RESULTS: There was no significant difference in the choice of systems as to age and characteristics of the fractures, but in patients with systemic diseases or chronic substance abuse, as well as in exposed fractures, with more frequency of 2.4-mm plates. 2.0-mm miniplates presented better recovery of jaw opening in the postoperative period. Temporary facial nerve deficit was observed exclusively in the case of extraoral approach. Both systems presented low rate of complications which required reoperation, however 2.0-mm miniplates presented better efficacy when compared to 2.4-mm plates. CONCLUSION: In conclusion, 2.0-mm miniplates should be always used when possible in the fixation of mandibular fractures, respecting their contraindications.

Finite element simulation of skeletal muscular structures obtained from images of histological serial sections.

In this study, we present a method for the three-dimensional reconstruction of objects obtained from histological serial sections (exemplified by those of a pennate striated skeletal muscle) and its application to the finite element method. A hyperelastic material model is used for modeling biological soft tissue. The reconstruction process relies on the direct construction of a volumetric mesh using an octree approach which leads to a stable finite element method. Stability can be expressed in the spectral matrix condition number. To visualize stress patterns within the underlying anatomy the simulation results are projected onto images of the histological scenario.

Computation of a tetrahedral mesh for striated muscle deformation simulation.

Competing concepts exist regarding surgery for instance of the cleft lip and palate to date. Morphology-based simulations at histological scale may one day be used to help the surgeon predict the possible outcome of a variety of approaches. It however can be a challenge to generate volume meshes that are applicable to the mathematical modelling of three-dimensional spatial modifications. Computation of surface meshes may be considered less delicate. The aim of this study is to design and evaluate a novel algorithm that supports finite element methods. Images of histological serial sections of a striated muscle were segmented. Results of the three-dimensional reconstruction of multiple layers of the polygonal segmentation data characterized the hull of the muscle. The corresponding surface mesh was then converted into a tetrahedral mesh to generate volume. This was achieved by mapping multiple template types onto neighbouring intersection polygons. Muscle contraction was subsequently simulated by mesh deformation. The technique successfully generated volumes and was able to provide data on contraction directions. The mesh supported a novel approach to simulate representations of contraction. However, several drawbacks were evident. Mathematical modelling of scenarios with more than one striated muscle will require considerable modification of the currently presented approach. Future studies need to then evaluate the applicability of volume meshes to represent arrays of three-dimensional biological objects. Surface mesh based mathematical modelling of cleft lip and palate surgery and its results are therefore not yet in reach.

Are UK radiologists satisfied with the training and support received in suspected child abuse?

AIM: To determine current practice and perceptions of the adequacy of training and support received for the reporting of skeletal surveys in suspected physical child abuse. MATERIALS AND METHODS: A list of telephone numbers of UK hospitals with a radiology department was obtained from the Royal College of Radiologists. One hundred hospitals were then randomly selected for inclusion in the survey. An 18-item questionnaire was successfully administered to consultant radiologists from 84 departments. RESULTS: Sixty-one percent of departments had a named radiologist to report their skeletal surveys, 16% assigned surveys to a random radiologist, and 23% referred them elsewhere. Only 52% of departments had a dedicated paediatric radiologist, thus in a significant proportion of departments (25%) initial reports on skeletal surveys for physical abuse were provided by non-paediatric radiologists. Fifteen percent did not have ready access to a paediatric radiology opinion. Sixty-one percent thought that the service could be improved. Expert evidence was provided by 5% of respondents. Seventy-three percent would never consider providing expert evidence, even if given adequate radiology and/or legal training. CONCLUSION: The survey shows significant dissatisfaction amongst consultant radiologists with the current service, confirms a low number of paediatric radiologists taking on this work, and suggests the potential to increase numbers of radiology child abuse experts by 27% if given improved training and support. Appropriate service and education strategies should be implemented.

Audit of ultrasound and decision to operate in groin pain of unknown aetiology with ultrasound technique explained.

AIM: To determine the ability of a groin ultrasound service to identify inguinal/femoral hernias in patients with groin pain and equivocal clinical signs, and to evaluate the number of positive cases undergoing surgery. METHODS AND MATERIALS: A retrospective review of 243 examinations performed during the period January 2000 to June 2004 was undertaken. The referral information, as well as details of the examination and subsequent follow-up, were obtained through our hospital/radiological information system. RESULTS: Of 243 patients, 92 (38%) were referrals from general practitioners and 151 (62%) were hospital referrals. The examinations were performed by radiology consultants or specialist registrars, the former accounting for 228 examinations (94%). The age range of the patients was 3 months to 88 years (mean age=48.7), with a male to female ratio of 3.2:1. One hundred and forty-three examinations were negative for hernias. Two of these patients underwent groin explorations and were found to be normal. The rest were discharged and none returned with related complaints. Ninety-four examinations (39%) were positive for hernias, as a result of which 62 patients underwent surgery. Of these, only four were found to be false-positives giving a positive predictive value of 94% in operated patients. Three scans were equivocal, and three were positive for other conditions. CONCLUSION: In patients with equivocal clinical signs, groin ultrasound is a useful tool for identifying hernias, and therefore, aids surgical management.

Complex facial trauma with combined surgical and orthodontic rehabilitation.

Severe panfacial trauma require broad reconstructive procedures. As in the case presented, a primary reconstruction with ideal aesthetic outcome cannot be reached in every case. If not, these cases often require further reconstructive procedures. What this can be and how long this could take, this article intends to show. This case report presents the history of a today 30 year old male patient with a severe central midfacial comminuted fracture with preexisting Angle class II and comprehensive reconstruction.

[Virtual tissue. Quaoaring]. / Virtuelles Gewebe. Quaoaring.

Virtual tissue can be generated by employing various methods. First steps en route to virtual tissue may encompass the generation of virtual cells. One such approach termed Quaoaring was applied to produce artificial erythrocytes and these were both discocyte and echinocyte in shape. The results were subsequently compared with data gleaned from scanning electron microscopy and atomic force microscopy. Quaoaring has, however, proved to be unsuccessful in creating convincing objects, particularly those which should be echinocytic in appearance.

[Analysis of histological datasets by signal processing methods]. / Signaltheoretische Analyse histologischer Daten im Ortsfrequenzraum.

In the present study, a semi-automatic segmentation and classification algorithm is proposed for the analysis of histological and cytological images. In view of the fact that histological and cytological images usually exhibit poor contrast and blurred outlines, classical segmentation algorithms often fail to detect relevant structures. A new algorithm for texture segmentation based on signal processing methods in combination with machine learning techniques was therefore developed.