Preoperative Computed Tomography Scans Research Articles

Intraoperative Ultrasonography for Surgery of Cranial Traumatic Acute Subdural Hematoma: Technical Note

Intraoperative ultrasonography (IOUS) in traumatic brain injury is a fast, easy, and low-cost technique that has been poorly investigated so far even though it could potentially answer many of the intraoperative needs of the surgeon. The aim of this study was to investigate the role of IOUS in patients undergoing surgery for traumatic acute subdural hematoma (aSDH), focusing on its influence on intraoperative surgical strategy, particularly regarding the management of intracerebral contusions (ICCs) associated with aSDH. Data of patients who consecutively underwent surgical evacuation of traumatic aSDH with IOUS assistance at our institution from May 2017 to December 2020 were retrospectively analyzed. Patients were dichotomized into an ICC group (ICCs associated with aSDH on preoperative computed tomography scan) and no ICC group (no ICCs associated with aSDH on preoperative computed tomography scan). The study included 41 patients. Before aSDH evacuation, IOUS findings were similar to preoperative computed tomography data. After aSDH evacuation, IOUS detected a new-onset ICC in 13% of patients in the no ICC group and a volume increase of the known ICCs in 22% of patients in the ICC group. Therefore, IOUS made it possible to evacuate these new-onset or expanding hematomas in the same operation, changing our surgical strategy and avoiding a delayed reintervention. Our study suggests that IOUS in patients undergoing surgery for traumatic aSDH can promptly identify possible evolution of a primary head injury, leading to early and effective treatment.

Multicenter Observational Study to Evaluate the Diagnostic Value of Sonography in Patients with Chronic Rhinosinusitis.

(1) Background: Computed tomography (CT) is considered mandatory for assessing the extent of pathologies in the paranasal sinuses (PNS) in chronic rhinosinusitis (CRS). However, there are few evidence-based data on the value of ultrasound (US) in CRS. This multicenter approach aimed to compare diagnostic imaging modalities in relation to findings during surgery. (2) Methods: 127 patients with CRS were included in this prospective multicenter study. Patients received preoperative US and CT scans. The sensitivity and specificity of CT and US were extrapolated from intraoperative data. (3) Results: CT scans showed the highest sensitivity (97%) and specificity (67%) in assessing CRS. Sensitivities of B-scan US were significantly lower regarding the maxillary sinus (88%), the ethmoid sinus (53%), and the frontal sinus (45%). The highest overall sensitivity was observed for assessing the pathology of the maxillary sinus. (4) Conclusions: We observed high accuracy with CT, confirming its importance in preoperative imaging in CRS. Despite the high US expertise of all investigators and a standardized examination protocol, the validity of CT was significantly higher than US. Ultrasound of the PNS sinuses is applicable in everyday clinical practice but lacks diagnostic accuracy. Nevertheless, it might serve as a complementary hands-on screening tool to directly correlate the clinical findings in patients with PNS disease.

Computed tomography-based paravertebral muscle density predicts subsequent vertebral fracture risks independently of bone mineral density in postmenopausal women following percutaneous vertebral augmentation.

The risk of subsequent vertebral fractures (SVF) after the primary vertebral fracture cannot be explained by lower bone mineral density (BMD) alone. Computed tomography (CT) measurements of paravertebral muscle density (PMD) are recognized radiographic markers used to predict physical function, fragile fractures. This study aims to investigate the relationship between PMD and the risk of SVF in cohorts of postmenopausal women, and to determine if combining both PMD and BMD measures derived from CT can improve the accuracy of predicting SVF. This study enrolled 305 postmenopausal women between the ages of 50 and 88 for 3years of follow-up studies. Trabecular attenuation (Hounsfield units, HU) was measured at L1 level and muscle attenuation of paravertebral muscle at L3 level on preoperative lumbar CT scans to determine the L1 BMD and L3 PMD. Kaplan-Meier analysis was applied to evaluate SVF-free survival. The hazard ratios (HRs) of PMD for SVF events were estimated with the Cox proportional hazards model. The predictive values of L1 BMD and L3 PMD for SVF were quantified using the Receiver-Operating Characteristic (ROC) curve. During the 3years of follow-up studies, 88 patients (28.9%) suffered an SVF. ROC curve analysis demonstrated that an L3 PMD threshold of 32 HU had a sensitivity of 89.8% and a specificity of 62% for the prediction of SVF. Kaplan-Meier analysis showed that L3 PMD ≤ 32 HU was significantly associated with lower SVF-free survival (p < 0.001; log-rank test). After adjusting for age, BMI, diabetes, postoperative osteoporosis treatment, handgrip strength, L1 BMD, multivariate analyses also indicated a persistent modest effect of L3 PMD on SVF-free survival. The area under the ROC curve of L3 PMD and L1 BMD, combined to predict the risk of SVF, was 0.790, which was significantly higher than the value for L1 BMD alone (0.735). L3 PMD and L1 BMD significantly improved the accuracy of SVF risk prediction compared with L1 BMD alone, which was confirmed by reclassification improvement measures. The inclusion of handgrip strength and postoperative osteoporosis treatment in the model further improved SVF prediction accuracy, and PMD remained significant in the model. Decreased L3 PMD is an independent risk predictor of SVF. Combined CT-based L1 BMD and L3 PMD can significantly improve the accuracy of predicting the risk of SVF in postmenopausal women who have suffered prior osteoporotic vertebral fractures.

Radiological evaluation of temporal bone surgical landmarks for a transcanal transpromontorial approach to the internal auditory canal using three-dimensional computed tomography.

This study aimed to analyse a three-dimensional transcanal transpromontorial approach to the internal auditory canal using three-dimensional computed tomography. This study was a retrospective investigation of 48 ears of 24 patients using three-dimensional reconstruction data from normal temporal bone computed tomography. The inner structures of the temporal bone were three-dimensionally reconstructed. Eight points were marked in the three-dimensional object with reference to the axial, coronal and sagittal plane images of the computed tomography scans. Distances and angles to each point were measured from the oval and round windows. The point of the facial nerve from the internal auditory canal to the labyrinthine segment could be traced between the cochlear apex and the geniculate ganglion based on the oval window. This technique helps with identifying the locations of important surgical landmarks using three-dimensional reconstructions of pre-operative computed tomography scans and to identify the facial nerve from the internal auditory canal during surgery.

Quality of superior mesenteric and hepatic artery dissection in robotic pancreatoduodenectomy for pancreatic cancer.

This video manuscript by Ikoma and colleagues demonstrates their approach to the superior mesenteric artery and hepatic artery periadventitial dissection. The quality of superior mesenteric artery and hepatic artery dissections should be maintained in robotic pancreatoduodenectomy when performed for pancreatic cancer, to provide the best possible oncological outcomes.

Prospective assessment of osteoporosis in total shoulder arthroplasty

HypothesisThe risks of shoulder arthroplasty in those with osteopenia and osteoporosis are not fully understood. The purpose of this study was to prospectively evaluate intraoperative complications in those undergoing shoulder arthroplasty with low bone mineral density (BMD). MethodsWe prospectively enrolled consecutive patients undergoing shoulder arthroplasty with a preoperative computed tomography (CT) scan from January to July 2021. Exclusion criteria included age <50 years, revision surgery, fracture, diagnosis of inflammatory arthropathy, or active infection. An intraoperative survey assessing bone quality and complications was collected. A blinded reviewer then measured bone quality based on preoperative CT scan using a previously validated method. Subjects were then divided between normal and low BMD groups with low BMD including both osteopenia and osteoporosis. ResultsWe enrolled 75 consecutive patients who met all inclusion criteria. Nine patients were excluded due to incomplete imaging leaving a final cohort of 66 patients. The average age was 69.2 years (50.4-88.5 years), with 41 males (62.1%) and 25 females (37.9%). There were 33 anatomic total shoulder arthroplasties and 33 reverse shoulder arthroplasties. Surgeons were very accurate in identifying normal bone intraoperatively (95.5% correct) but less accurate in identifying poor bone quality (45.5% correct). Surgeons reported making changes to their plan or technique in 8 cases (12%), with 7 (87.5%) of these changes occurring in those with poor bone quality. The lesser tuberosity was damaged with posterior retraction in 16 cases (24.2%), with 13 (81.3%) of those being in patients with poor bone quality. There was 1 intraoperative glenoid rim fracture, which occurred in a patient with low bone density. ConclusionThe prevalence of osteoporosis in the population undergoing shoulder arthroplasty is high. Performing shoulder arthroplasty on those with poor bone quality presents multiple challenges, which are underappreciated. Being able to better predict bone quality based on preoperative CT imaging can alert the surgeon to potential intraoperative complications.

Comparison of Acetabular Morphology Changes After Pediatric Pelvic Osteotomies Using Patient-Specific 3-D Models

Background: Surgical management to improve hip joint morphology in immature patients with acetabular dysplasia includes Pemberton, Dega, San Diego, and Salter acetabular osteotomies. This study evaluates acetabular morphology between these osteotomies using patient-specific 3-D printing technology. Methods: Preoperative computed tomography scans (CTs) from patients with acetabular dysplasia were rendered into 3-D printable formats. Quadruplicate pelvis models for each patient received Pemberton, Dega, San Diego, and Salter osteotomies. CTs were obtained of each model before and after osteotomy. Acetabular volume and regional coverage angles were computed and compared before and after each osteotomy. Results: Fourteen hips (14 patients) were included; 1 male, 13 female; age 5.4±1.3 years (3.9-7.5 years). Acetabular volume decreased following each osteotomy (Pemberton by 14%, Dega by 19%, San Diego by 19%, and Salter by 6%), with smaller volume reduction for Salter than the others (p&lt;0.05). Volume change was similar between Pemberton, Dega, and San Diego (p=0.32). Pemberton increased coverage in Superior and Anterior regions, Dega increased coverage in Superior, Superior-Anterior, and Anterior regions, San Diego increased coverage in Posterior, Superior-Posterior, and Superior regions, and Salter increased coverage in Superior region (p&lt;0.05). Conclusions: Acetabular volume changes found in this study support the convention that redirectional osteotomies such as Salter are more volume neutral than incomplete osteotomies such as Pemberton, Dega, and San Diego. However, even the Salter decreased acetabular volume. This study re-demonstrated that each osteotomy studied changes acetabular coverage in different regions. Based on this, a surgeon’s osteotomy decision should be based on the dysplastic acetabulum morphology.

Effect of Aortic Angulation on Outcomes in Transcatheter Aortic Valve Implantation with the Self-Expanding Portico Valve

Introduction: Aortic angulation (AA), defined as the angle between the aortic annulus plane and the horizontal plane, may result in failed prosthesis positioning. The effect of AA on the procedural and short-term outcomes with the portico valves for transcatheter aortic valve implantation (TAVI) has not been fully investigated. The present study aimed to evaluate the impact of AA on device success and early outcomes of TAVI using a selfexpanding portico valve. Patients and Methods: Preoperative computed tomography scans of 121 consecutive patients treated with the portico valve were analyzed. TAVI device success and outcomes were determined according to VARC-3 definitions. Patients were divided into two groups based on mean AA. Results: The mean AA was 48.7 ± 8.9°. There were no differences in technical success (92.2 vs 89.5%, p= 0.604), device success (81.2% vs 77.2%, p= 0.582), and early safety endpoints (68.8% vs 61.4%, p= 0.397) between the AA≤ 48° and AA&gt;48° groups. The frequency and severity of paravalvular aortic regurgitation (PAR) was statistically higher in patients with AA&gt; 48° (p= 0.028). Moreover, an increased AA was also associated with valve malposition (12.3% vs. 1.6%, p= 0.018), prolonged procedure time (85 ± 26 vs. 75 ± 20 minutes, p= 0.028), and greater Δimplantation depth (2.2 ± 0.5 vs. 0.8 ± 0.1 mm; p&lt;0.001). Conclusion: Despite comparable device success and early outcomes rates, increased AA is associated with higher rates of PAR and valve malposition, with the self-expanding portico valve.

Risk Factors for Incomplete Aortic Remodeling With Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair for Complicated Aortic Dissection: Results of a Multicenter Study

Purpose: The STABILISE technique has extended the treatment of aortic dissection to the thoracoabdominal aorta to achieve complete aortic remodeling. The aim of this multicenter study was to analyze the short- and midterm anatomical results of the STABILISE technique. Materials and Methods: We retrospectively analyzed patients treated with the STABILISE technique for complicated aortic dissection at 3 French academic centers. The aortic diameter at different levels was measured preoperatively, postoperatively, and at 1 year. Results: Between 2018 and 2020, 58 patients, including 47 men (average patient age: 60±11 years), were treated for type B aortic dissection in 34 cases and residual aortic dissection after type A repair in 24 cases. Three (5.2%) patients died postoperatively. Complete aortic remodeling (false lumen thrombosis and complete reapposition of the intimal flap) was achieved in 45/55 patients (81.8%), and false lumen thrombosis in the thoracic aorta was achieved in 52/55 patients (94.5%). At 1 year, with a computed tomographic (CT) scan available for 98.2% (54/55) of patients, we observed a significant decrease in the maximal thoracic aortic diameter and a significant increase in the aortic diameter at the bare-stent level compared with the preoperative CT scan. Severe aortic angulation (p=0.024) was a risk factor for incomplete aortic remodeling and significantly increased the aortic diameter (p=0.032). Chronic aortic dissection was associated with an increased risk of incomplete aortic remodeling (p=0.002). Conclusions: STABILISE for complicated aortic dissection results in false lumen thrombosis, complete reapposition of the intimal flap, and a decrease in the maximum aortic diameter in most cases. Incomplete reapposition of the intimal flap, which is more frequent in cases of chronic aortic dissection and severe aortic angulation, is a risk factor for a significant increase in the aortic diameter at the bare-stent level, and this risk justifies close follow-up and better patient selection. Clinical impact STABILISE technique for complicated aortic dissection results in false lumen thrombosis, complete aortic remodeling and a decrease in the maximum aortic diameter in most cases. At the bare-stent level, incomplete reapposition of the intimal flap, more frequent in chronic aortic dissection and severe aortic angulation, is a risk factor for an increased aortic diameter. This finding justifies close follow-up and better patient selection; thus, the STABILISE technique should be used with care in chronic aortic dissection and severe aortic angulation.

Effects of body fat components on early renal functions of individuals following kidney donation

Objective: Obesity stands as a risk factor for the chronic kidney disease. The objective of this study was to investigate the relationship between early renal function following kidney donation and the measurements of body fat components. Methods: In total, 86 donors followed up for at least 6 months postoperatively were included. Height and weight measurements and results of laboratory analysis of all donors were recorded retrospectively. Visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), hepatic fat (HF), pancreatic fat (PF) and splenic fat (SF) measurements were performed, and pancreatic splenic fat fraction difference (P−S) and pancreatic splenic fat fraction ratio (P/S) were calculated by a radiologist using the records of preoperative computed tomography scans of donors. Results: The estimated glomerular filtration rate (eGFR), serum creatinine and spot urinary microalbumin/creatinine ratio values of the donors at the sixth month postoperatively were statistically different from those of the preoperative values ( p &lt; 0.001). In addition, the individuals were divided into two categories based on the postoperative eGFR: ⩾ 60 mL/min/1.73 m2 and &lt; 60 mL/min/1.73 m2. Age, low-density lipoprotein (LDL) level and VAT/SAT ratio were lower in group eGFR: ⩾ 60 ( p &lt; 0.001, p = 0.03, p = 0.007, respectively). Age and VAT/SAT ratio were the parameters found to be affecting the eGFR significantly, and VAT/SAT ratio (0.729, 95% CI: 0.602–0.856, p = 0.007) had higher predictive value in receiver operating characteristic curve (ROC). Conclusion: Preoperative measurements of body fat components may provide significant information to predict postoperative renal functions of kidney donor candidates. Level of evidence: Not applicable.

Preoperative Computed Tomography Morphological Features Indicative of Incisional Hernia Formation After Abdominal Surgery.

To investigate key morphometric features identifiable on routine preoperative computed tomography (CT) imaging indicative of incisional hernia (IH) formation following abdominal surgery. IH is a pervasive surgical disease that impacts all surgical disciplines operating in the abdominopelvic region and affecting 13% of patients undergoing abdominal surgery. Despite the significant costs and disability associated with IH, there is an incomplete understanding of the pathophysiology of hernia. A cohort of patients (n=21,501) that underwent colorectal surgery was identified, and clinical data and demographics were extracted, with a primary outcome of IH. Two datasets of case-control matched pairs were created for feature measurement, classification, and testing. Morphometric linear and volumetric measurements were extracted as features from anonymized preoperative abdominopelvic CT scans. Multivariate Pearson testing was performed to assess correlations among features. Each feature's ability to discriminate between classes was evaluated using 2-sided paired t testing. A support vector machine was implemented to determine the predictive accuracy of the features individually and in combination. Two hundred and twelve patients were analyzed (106 matched pairs). Of 117 features measured, 21 features were capable of discriminating between IH and non-IH patients. These features are categorized into three key pathophysiologic domains: 1) structural widening of the rectus complex, 2) increased visceral volume, 3) atrophy of abdominopelvic skeletal muscle. Individual prediction accuracy ranged from 0.69 to 0.78 for the top 3 features among 117. Three morphometric domains identifiable on routine preoperative CT imaging were associated with hernia: widening of the rectus complex, increased visceral volume, and body wall skeletal muscle atrophy. This work highlights an innovative pathophysiologic mechanism for IH formation hallmarked by increased intra-abdominal pressure and compromise of the rectus complex and abdominopelvic skeletal musculature.

Robotically assisted augmented reality system for identification of targeted lymph nodes in laparoscopic gynecological surgery: a first step toward the identification of sentinel node : Augmented reality in gynecological surgery.

To prove feasibility of multimodal and temporal fusion of laparoscopic images with preoperative computed tomography scans for a real-time in vivo-targeted lymph node (TLN) detection during minimally invasive pelvic lymphadenectomy and to validate and enable such guidance for safe and accurate sentinel lymph node dissection, including anatomical landmarks in an experimental model. A measurement campaign determined the most accurate tracking system (UR5-Cobot versus NDI Polaris). The subsequent interventions on two pigs consisted of an identification of artificial TLN and anatomical landmarks without and with augmented reality (AR) assistance. The AR overlay on target structures was quantitatively evaluated. The clinical relevance of our system was assessed via a questionnaire completed by experienced and trainee surgeons. An AR-based robotic assistance system that performed real-time multimodal and temporal fusion of laparoscopic images with preoperative medical images was developed and tested. It enabled the detection of TLN and their surrounding anatomical structures during pelvic lymphadenectomy. Accuracy of the CT overlay was > 90%, with overflow rates < 6%. When comparing AR to direct vision, we found that scores were significatively higher in AR for all target structures. AR aided both experienced surgeons and trainees, whether it was for TLN, ureter, or vessel identification. This computer-assisted system was reliable, safe, and accurate, and the present achievements represent a first step toward a clinical study.

Impact of Thrombocytopenia on Preoperative Hematoma Expansion for Acute Traumatic Subdural Hematoma

Acute subdural hematoma is a neurosurgical emergency. Thrombocytopenia poses a management challenge for these patients. We aimed to determine the impact of thrombocytopenia on preoperative hemorrhage expansion and postoperative outcomes. This retrospective study evaluated patients presenting at our institution with acute subdural hematoma between 2009 and 2019. Patients who underwent surgery, had thrombocytopenia (platelets <150,000/μL), and had multiple preoperative computed tomography scans were included. Case control 1:1 matching was performed to generate a matched cohort with no thrombocytopenia. Univariate analyses were conducted to determine changes in subdural thickness and midline shift, postoperative Glasgow Coma Scale score, mortality, length of stay, and readmission rates. We identified 19 patients with both thrombocytopenia and multiple preoperative computed tomography scans. Median platelet count was 112,000/μL (Q1 69,000, Q3 127,000). Comparing the thrombocytopenia cohort with the control group, there was a statistically significant difference in change in subdural thickness (median 5 mm [Q1 2, Q3 7.4] vs. 0 mm [Q1 0, Q3 1.5]; P=0.001) and change in midline shift (median 3 mm [Q1 0, Q3 9.5] vs. median 0.5 mm [Q1 0, Q3 1.5]; P= 0.018). The thrombocytopenia cohort had higher in-hospital mortality (10 [52.6%] vs. 2 [10.5%]; P= 0.003). No significant differences were found in postoperative Glasgow Coma Scale score, length of stay, number of readmissions, and number of reoperations. Thrombocytopenia is significantly associated with expansion of hematoma preoperatively in patients with acute subdural hematoma. While the benefit of early platelet correction cannot be determined from this study, patients who present with thrombocytopenia will benefit from close monitoring, a low threshold to obtain repeat imaging, and anticipating early surgical evacuation after platelet optimization.

Paper 47: Clinical Outcomes in Patients with Femoral Acetabular Impingement Syndrome and Acetabular Retroversion: A 3D Analysis

Objectives:To use computed tomography (CT)-based three-dimensional (3D) bone models to (1) quantify acetabular version in patients with femoroacetabular impingement syndrome (FAIS) and (2) explore the relationship between the magnitude of acetabular version and clinical outcomes following hip arthroscopy.Methods:Preoperative CT scans were acquired in 105 consecutive patients prior to hip arthroscopy for FAIS, of which 84 (80.0%) completed minimum two-year patient reported outcomes. 3D models of the pelvis and femur were generated by semi-automated segmentation, and aligned to a standard coordinate system. Acetabular version was quantified at the 12, 2, and 3 o’clock position. (Figure I) Acetabular version classifications were based on the version at the 3 o’clock position, and were defined as follows: acetabular retroversion (AR [<15°]), normal acetabular version (NV [15°-25°]), and acetabular anteversion (AA [>25°]). Patient demographic characteristics and clinical outcomes including the Hip Outcome Score – Activities of Daily Living (HOS-ADL), Hip Outcome Score – Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), and Visual Analog Scale (VAS) for pain and satisfaction were analyzed.Results:Mean age and body mass index (BMI) of patients was 33.9±12.6 years and 26.0±5.4 kg/m2, respectively, while 70.2% were female. The average acetabular version at 12, 2, and 3 o’clock for the study cohort was 9.3° ± 9.3°, 12.3° ± 7.4°, and 20.9° ± 5.7°, respectively (Figure II). After stratification based on the magnitude of acetabular anteversion at the 3 o’clock position, the number of patients and the average torsion within each group were as follows: AR (n=12; 11.3°±2.7°), NT (n=56; 20.7°±2.9°), AA (n=16; 28.5°±2.7°) (Figure III). At minimum two-year follow-up, significant between group differences in mHHS, iHOT-12, VAS for pain and satisfaction (P < 0.05) were appreciated (Table I). Post hoc analysis with Bonferroni correction (P < 0.0167) found lower scores on mHHS, iHOT-12, VAS for pain and satisfaction in patients with AR compared to NV (Table I). Lower VAS for satisfaction scores were reported in patients with AR when compared to AA (P = 0.006), but not mHHS (0.023), iHOT-12 (0.032), or VAS for pain (0.072) (Table I).Conclusions:Patients with AR reported inferior outcomes when compared to patients with NV and AA following hip arthroscopy for FAIS.

Accuracy of Chest Computed Tomography in Distinguishing Cystic Pleuropulmonary Blastoma From Benign Congenital Lung Malformations in Children

The ability of computed tomography (CT) to distinguish between benign congenital lung malformations and malignant cystic pleuropulmonary blastomas (PPBs) is unclear. To assess whether chest CT can detect malignant tumors among postnatally detected lung lesions in children. This retrospective multicenter case-control study used a consortium database of 521 pathologically confirmed primary lung lesions from January 1, 2009, through December 31, 2015, to assess diagnostic accuracy. Preoperative CT scans of children with cystic PPB (cases) were selected and age-matched with CT scans from patients with postnatally detected congenital lung malformations (controls). Statistical analysis was performed from January 18 to September 6, 2020. Preoperative CT scans were interpreted independently by 9 experienced pediatric radiologists in a blinded fashion and analyzed from January 24, 2019, to September 6, 2020. Accuracy, sensitivity, and specificity of CT in correctly identifying children with malignant tumors. Among 477 CT scans identified (282 boys [59%]; median age at CT, 3.6 months [IQR, 1.2-7.2 months]; median age at resection, 6.9 months [IQR, 4.2-12.8 months]), 40 cases were extensively reviewed; 9 cases (23%) had pathologically confirmed cystic PPB. The median age at CT was 7.3 months (IQR, 2.9-22.4 months), and median age at resection was 8.7 months (IQR, 5.0-24.4 months). The sensitivity of CT for detecting PPB was 58%, and the specificity was 83%. High suspicion for malignancy correlated with PPB pathology (odds ratio, 13.5; 95% CI, 2.7-67.3; P = .002). There was poor interrater reliability (κ = 0.36 [range, 0.06-0.64]; P < .001) and no significant difference in specific imaging characteristics between PPB and benign cystic lesions. The overall accuracy rate for distinguishing benign vs malignant lesions was 81%. This study suggests that chest CT, the current criterion standard imaging modality to assess the lung parenchyma, may not accurately and reliably distinguish PPB from benign congenital lung malformations in children. In any cystic lung lesion without a prenatal diagnosis, operative management to confirm pathologic diagnosis is warranted.

The Use of the Three-Dimensional Printed Polyether Ether Ketone Implant in Secondary Craniosynostosis Revision.

Skull deformities may be seen in patients years after craniosynostosis correction. These deformities cause psychosocial distress in affected patients. In this series, the authors describe the use of patient specific polyether ether ketone (PEEK) implants for correction of skull deformities after cranial vault remodeling for craniosynostosis. A chart review was conducted for 3 revision procedures performed by 1 plastic surgeon in collaboration with 1 neurosurgeon, both affiliated with Northwell Health. Preoperative computed tomography scans were used to design three-dimensional (3D) printed PEEK implants manufactured by KLS Martin. Implants were used to correct frontal and orbital asymmetry and skull deformities in each patient. Outcomes were assessed at 1 week, 1 month, and 3 months post-operation. Two males and 1 female, ages 13, 17, and 19, underwent revision cranioplasty or orbital rim reconstruction using a custom, single piece 3D printed PEEK implant. All 3 patients underwent cranial vault remodeling in infancy; 1 was treated for coronal craniosynostosis and 2 were treated for metopic craniosynostosis. Revision cranioplasty operative times were 90, 105, and 147 minutes, with estimated blood loss of 45 mL, 75 mL, and 150 mL, respectively. One patient went home on post op day 1 and 2 patients went home on post op day 2. All patients had an immediate improvement in structural integrity and cranial contour, and all patients were pleased with their aesthetic results. Custom 3D printed PEEK implants offer a single piece solution in revision cranioplasty surgery to correct skull deformities after cranial vault remodeling for craniosynostosis.

The influence of preoperative CT imaging on surgical delay in patients with acutely symptomatic abdominal wall hernias.

Abdominal wall hernias are common in the UK and many present in an emergent fashion. The widespread introduction of computed tomography (CT) imaging has transformed surgical practice but out of hours access can be limited by hospital resources and introduce delays. We investigated the influence of preoperative CT imaging in acutely symptomatic hernia and the association with surgical delay and risks of bowel ischemia. A retrospective analysis of patients undergoing emergency hernia surgery between 2013 and 2021 in a busy UK district general hospital. We evaluated the role of preoperative CT and its influence on timing of surgery, postoperative complications, critical care admission and hospital length of stay. Five hundred and five patients were studied. Of these, 191 had a preoperative CT scan. Sites of hernia included inguinal in 164 patients (33%); umbilical in 164 (33%); femoral in 69 (14%); incisional in 69 (14%); epigastric in 30 (6%) and Spigelian hernia 9 (2%). Preoperative CT imaging was associated with surgical delay (22.0h vs 13.0h, p < 0.001) and an increased need for bowel resection (12% vs 6%, p = 0.027). Delay in surgery was not associated with increased postoperative complications (5% vs 4%, p = 0.474) but was associated with increased critical care admission (11.0% vs 4.8%, p = 0.014). Preoperative CT scan for emergent hernias can delay often inevitable surgery and is associated with an increasing need for more complex, resectional surgery .

Variability of the retrotympanum and its association with mastoid pneumatization in cholesteatoma patients

PurposeThis study aimed to investigate the variability of the retrotympanum in patients undergoing surgical treatment for cholesteatoma.MethodsWe included 59 ears of patients undergoing middle ear surgery for cholesteatoma who had preoperative computed tomography scans. A retrospective analysis of the medical records was conducted. The sinus tympani (ST), subtympanic sinus (STS) and facial recess (FR) were classified into types A–C based on the relationship of their extension to the facial nerve. The mastoid and petrous apex were assessed and categorized as normal pneumatized or sclerotic.ResultsType A extension was the most frequently found in all sinuses (ST 64%, FR 77%, STS 69%), Type B extension was found more often in ST (34%) and STS (24%) than in FR (15%). A very deep extension was found only rarely (ST 2%, FR 8%, STS 7%). A sclerotic mastoid was found in 67% of cases. Those cases showed a statistically significant difference regarding retrotympanum pneumatization when compared with normal mastoid.ConclusionThe most frequent variant of retrotympanic pneumatization in relation to the facial nerve was type A in all subsites in cholesteatoma patients. The variability among patients with cholesteatoma is different to previously published results in healthy subjects. Moreover, the pneumatization of the retrotympanum is associated with mastoid pneumatization.

Reverse shoulder arthroplasty with metallic augments to preserve bone and restore joint line in patients with glenoid bone loss

BackgroundGlenoid bone loss poses significant challenges for reverse shoulder arthroplasty. In these patients, excess reaming can lead to further bone loss and medialization of the joint line. Metallic augments have been described as a technique for addressing this issue. However, there are currently no studies evaluating the effect of metallic augments on anatomic outcomes. This study evaluates the effect of metallic augments on the glenohumeral joint line and bone preservation. We hypothesize that metallic augments can preserve bone while preventing further medialization of the joint line in patients with preoperative glenoid bone loss. MethodsA prospective single-center, 2-surgeon consecutive case series was evaluated with postoperative computed tomography scans. Three-dimensional reconstruction was used to create models of the scapula and humerus. Comparisons were made with preoperative computed tomography scans using volumetric analysis to evaluate bone loss. The base of the coracoid was used as a constant landmark to assess the joint line position and, by proxy, the center of rotation. Further evaluation of the glenoid version and inclination was measured on the reconstructed models through standardized techniques. ResultsFifteen patients (16 implants) underwent preoperative planning and reverse shoulder arthroplasty with metallic augments from January 1, 2018, to January 1, 2021. The mean follow-up time was 13.1 months. Analysis revealed that augments prevented further medialization of the joint line and corrected the deficit on average by 10.2 mm (range 6.9-14.3; standard deviation 2.0). The mean bone volume removed during surgery was 1292 mm3 (range 525-2256; standard deviation 527), with this value inclusive of the baseplate post volume (∼800 mm3). Inclination and version were restored to acceptable limits in all cases. ConclusionsReverse shoulder arthroplasty with metallic augments reliably preserves bone and prevents medialization of the joint line in patients with preoperative glenoid bone loss. Further research is required to assess the long-term and functional outcomes of this technique.

CT based bone mineral density as a predictor of proximal junctional fractures

BackgroundProximal junctional fractures (PJFr) can be a catastrophic complication associated with adult spinal deformity surgery. Osteoporosis can be a major risk factor for the cause of PJFr. Recent studies suggest using surrogate computed tomography (CT) scans in place of spinal dual-energy x-ray absorptiometry (DEXA) scores for bone mineral density (BMD). Investigate the feasibility of using preoperative CT based bone mineral density at upper instrumented vertebrae (UIV) and one level proximally (UIV+1) and distally (UIV-1) to predict the possibility of PJFr risk. MethodsRetrospective two-academic center case-controlled study, reviewed consecutive adult spinal deformity surgeries; included constructs encompassing at least five fusion levels and fusions to pelvis. Examined demographic, surgical, and radiographic data preoperatively, postoperatively, and final follow-up. Formed groups based on type of proximal junctional deformity (PJD): Control (no PJD), proximal junctional kyphosis (PJK) and PJFr. Preoperative CT BMD values measured in Hounsfield units (HU) for sagittal and axial planes at UIV, UIV+1, and UIV-1 and compared between groups. ResultsN=92 patients. Preoperative CT scan BMD values were significantly lower in PJFr vs. control at: UIV+1 in sagittal (p=0.007), axial (p=0.02) planes; UIV sagittal (p=0.04) and axial (p=0.03) planes; and UIV-1 sagittal (p=0.05) plane. Similarly, lower CT scan BMD values noted in PJFr vs. PJK at: UIV+1 in sagittal (p=0.04) and axial (p=0.03) planes. Trend seen with lower CT scan BMD values at UIV+1 level in PJFr vs. PJK in sagittal (p=0.12) and axial (p=0.10) planes. Preoperative global sagittal imbalance measurements significantly lower in control, but comparable between PJK and PJFr. ConclusionsHigher preoperative global sagittal imbalance with lower preoperative CT BMD values at UIV and UIV+1 vertebral body may increase the risk of proximal junctional fractures after adult spine deformity surgery. Proximal junctional hooks may supplement the pathogenesis. Readers should note the small sample size.Level of Evidence: 3