Scleral contact lenses for the management of complicated ptosis

PURPOSE

To present the management of three patients suffering from ptosis of various etiologies, with scleral contact lenses.

MATERIAL AND METHODS

Three patients (five eyes) with ptosis resulting from levator dehiscence due to long-term rigid gas permeable contact lens wear for keratoconus, phthisis bulbi, and myopathy due to Kearns-Sayre syndrome were identified during a 2-year period. They were fitted with scleral contact lenses in order to provide cosmesis by lifting the upper eyelid with the bulk of the lens, and simultaneously provide vision correction where applicable.

RESULTS

The scleral contact lenses provided comfortable wear, significantly improved cosmesis as both palpebral aperture and marginal reflex distance were increased, and visual acuity was also subjectively and objectively improved. Two of the patients opted for the scleral contact lenses, whereas the parents of the third patient, a 10-year-old girl with Kearns-Sayre syndrome, chose to undergo ptosis surgery due to handling issues of the scleral contact lenses.

CONCLUSION

Scleral contact lenses can be a useful addition to the treatment option for patients with complicated ptosis.

A numeric approach for anatomic plate design

Osteosynthesis plate designs with high levels of anatomical compliance have been demonstrated to have numerous clinical benefits. The purpose of this paper is to introduce a systematic numeric approach for anatomic plate design on the example of the distal medial tibia. The advantage of using numeric approaches for plate design is to gain objective and complete anatomical input as opposed to cadaveric investigations with limited sample sizes. A recent development in this area is a proprietary technology called SOMA which is based on a large database of 3D bone models generated from thin-slice computer tomographic scans plus associated software tools. In this paper, one of these associated software tools is described which automatically assesses the anatomic fit of osteosynthesis plates based on a large database of bone models. As an example, this tool was applied to assess the mean plate to bone distance of distal medial tibia plates, when fitted onto 444 Caucasian and 310 Asian 3D bone models respectively. The analyses revealed differences in the anatomical compliance of plates from different generations and manufacturers. The anatomical compliance of SOMA designed plates was statistically significantly better compared to all other plates in all groups "Short", "Intermediate" and "Long" and for both ethnicities "Caucasian" and "Asian" (P<0.001). The study has shown that using an underlying database with accompanying computational tools such as SOMA can be a powerful and efficient approach towards the development and advancement of osteosynthesis plates in trauma surgery, ultimately resulting in plates with high levels of anatomical compliance and potential clinical benefits.

Crestal Bone Loss around Dental Implants: Platform Switching vs Platform Matching-A Retrospective Study

AIM

The objective of this study was to determine the vertical and horizontal marginal bone levels in platform-switched and platform-matched dental implants.

MATERIALS AND METHODS

In the present study, 50 dental implants were placed in 50 patients over a 1-year period. Measurement was performed from the implant shoulder to the most apical and horizontal marginal defect by periapical radiographs to examine the changes of peri-implant alveolar bone before and 12 months after prosthodontic restoration delivery.

RESULTS

These marginal bone measurements showed a bone gain of 0.53 ± 0.98 mm in the vertical gap and 0.52 ± 0.93 mm in the horizontal gap of the platform matching, while in the platform switching, a bone gain of 1.33 ± 1 mm in the vertical gap (p < 0.05) and 1.60 ± 0.56 mm in the horizontal gap was found. Statistically significant difference was found for bone regeneration in the vertical gap between the two groups (p < 0.05) using t-test with Statistical Package for the Social Sciences (SPSS) statistical test version 17.

CONCLUSION

The crestal bone around the implants can be preserved with platform-switching concept and it can be applied in clinical condition.

CLINICAL SIGNIFICANCE

The crestal bone around the implants can be preserved with platform-switching concept.

Posterior cornea and thickness changes after scleral lens wear in keratoconus patients

PURPOSE

To evaluate the changes in the corneal thickness, anterior chamber depth and posterior corneal curvature and aberrations after scleral lens wear in keratoconus patients with and without intrastromal corneal ring segments (ICRS).

METHODS

Twenty-six keratoconus subjects (36.95 ± 8.95 years) were evaluated after 8 h of scleral lens wear. The subjects were divided into two groups: those with ICRS (ICRS group) and without ICRS (KC group). The study variables evaluated before and immediately after scleral lens wear included corneal thickness evaluated in different quadrants, posterior corneal curvature at 2, 4, 6 and 8 mm of corneal diameter, posterior corneal aberrations for 4, 6 and 8 mm of pupil size and anterior chamber depth.

RESULTS

There was a statistically significant corneal thinning (p < 0.05) in the inferior region of the KC group and in the superior region of the ICRS group. No change (p > 0.05) in the anterior chamber depth was found. The KC group showed a steepening (p < 0.05) in the temporal quadrant and a flattening that mainly affected to the superior-nasal quadrant. The ICRS group showed a steepening (p < 0.05) that mainly affected to the superior-nasal quadrant. Regarding posterior corneal aberrations, only changes (p < 0.05) in Z4 for 8 mm and Z8 for 4 mm were found in the KC group.

CONCLUSIONS

Short-term scleral lens wear showed a thinning of the cornea and changes in the posterior corneal curvature affects different regions in keratoconus patients with and without ICRS.

Survey of Current Practice in the Fitting and Fine-Tuning of Common Signal-Processing Features in Hearing Aids for Adults

BACKGROUND

Current guidelines for adult hearing aid fittings recommend the use of a prescriptive fitting rationale with real-ear verification that considers the audiogram for the determination of frequency-specific gain and ratios for wide dynamic range compression. However, the guidelines lack recommendations for how other common signal-processing features (e.g., noise reduction, frequency lowering, directional microphones) should be considered during the provision of hearing aid fittings and fine-tunings for adult patients.

PURPOSE

The purpose of this survey was to identify how audiologists make clinical decisions regarding common signal-processing features for hearing aid provision in adults.

RESEARCH DESIGN

An online survey was sent to audiologists across the United States. The 22 survey questions addressed four primary topics including demographics of the responding audiologists, factors affecting selection of hearing aid devices, the approaches used in the fitting of signal-processing features, and the strategies used in the fine-tuning of these features.

STUDY SAMPLE

A total of 251 audiologists who provide hearing aid fittings to adults completed the electronically distributed survey. The respondents worked in a variety of settings including private practice, physician offices, university clinics, and hospitals/medical centers.

DATA COLLECTION AND ANALYSIS

Data analysis was based on a qualitative analysis of the question responses. The survey results for each of the four topic areas (demographics, device selection, hearing aid fitting, and hearing aid fine-tuning) are summarized descriptively.

RESULTS

Survey responses indicate that audiologists vary in the procedures they use in fitting and fine-tuning based on the specific feature, such that the approaches used for the fitting of frequency-specific gain differ from other types of features (i.e., compression time constants, frequency lowering parameters, noise reduction strength, directional microphones, feedback management). Audiologists commonly rely on prescriptive fitting formulas and probe microphone measures for the fitting of frequency-specific gain and rely on manufacturers' default settings and recommendations for both the initial fitting and the fine-tuning of signal-processing features other than frequency-specific gain.

CONCLUSIONS

The survey results are consistent with a lack of published protocols and guidelines for fitting and adjusting signal-processing features beyond frequency-specific gain. To streamline current practice, a transparent evidence-based tool that enables clinicians to prescribe the setting of other features from individual patient characteristics would be desirable.

Patient Impressions of Possible Catastrophic Outcomes after Diabetic Foot Ulceration

BACKGROUND

Diabetes Mellitus (DM) and its complications are well studied; patients with diabetes may suffer from neuropathy and vascular issues, and associated with these, lower extremity ulceration. Ulcers are often refractory to treatment, and can be difficult for both patients and clinicians to manage. Such complications may lead to amputations, which in turn are a risk factor for death. However, in certain situations amputation may be the only option available, and may be used as reconstructive surgery, restoring function. The impacts of ulceration, amputation, use of prostheses, and other complications of diabetes on Quality of Life (QOL) are well studied. Similarly, the impact of QOL on overall health has been studied in some detail.

OBJECTIVE

Not as well understood are patient expectations regarding amputation and ulceration, and patient knowledge of these outcomes. Specifically, it is not fully understood how patients view these complications prior to their occurrence. In this review we survey the literature for studies discussing these attitudes. Our objective was to perform a systematic review of the medical literature to understand how patients understand and anticipate the potential negative outcomes of ulceration and amputation. We also aimed to identify areas where there are gaps in patient knowledge, which could be addressed by clinicians.

RESULTS

Our study yielded articles regarding impressions of patients with diabetes about their general health and outcomes. However, we did not discover much literature directly concerning attitudes toward catastrophic lower extremity outcomes before they occurred. We also identified that patients lack knowledge of management and complications of diabetes; both of these gaps provide an opportunity to better direct care for such patients.

Application of Data Mining to a Large Hearing-Aid Manufacturer's Dataset to Identify Possible Benefits for Clinicians, Manufacturers, and Users

Modern hearing instruments contain logging technology to record data, such as the acoustic environments in which the device is being used and how the signal processing is consequently operating. Combined with patient data, such as the audiogram, this information gives a more comprehensive picture of the user and their relationship with the aid. Here, a relatively large, anonymized dataset (>300,000 devices, >150,000 wearers) from a hearing-aid manufacturer was data mined for connections between subsets of the logged varieties of data. Apart from replicating links that have previously been reported in labor-intensive studies, a link between device style (in-the-ear/behind-the-ear) and the sound levels of encountered environments was demonstrated, suggesting that some device types are more successful from a lifestyle perspective. Furthermore, the data also suggested links between the audiogram and the sound environments in which the aid was operated. Modeling the expected link between the environment and the microphone directionality settings revealed patterns of either abnormal fitting or where the aid was not operating correctly-factors that may indicate a failed fitting. Given the necessarily redacted nature of the dataset, the reported findings represent a proof-of-concept of the use of relatively large-scale data mining to guide and assess hearing-aid fitting procedures for possible benefits to the clinician, manufacturer, and patient.

Evaluation of Auditory Functioning and Rehabilitation Using Patient-Reported Outcome Measures

There is lack of a systematic approach concerning how to select an adequate hearing aid and how to evaluate its efficacy with respect to the personal needs of rehabilitation. The goal of this study was to examine the applicability and added value of two widely used self-reporting questionnaires in relation to the evaluation of hearing aid fitting. We analyzed responses, pre- and postfitting, from 1,319 subjects who completed the Client Oriented Scale of Improvement (COSI) and a slightly adapted version of the Amsterdam Inventory for Auditory Disability and Handicap (in Dutch: AVAB). Most COSI responses were at or near the maximum possible score. Results show a close relation between COSI's degree of change and final ability (Spearman's rho = 0.71). Both AVAB and COSI showed a significant effect of hearing aid experience, but-in contrast to AVAB-COSI did not show a significant effect of the degree of hearing loss. In addition, a Friedman test showed significant differences between six dimensions of auditory functioning for both AVAB and COSI, although post hoc analysis revealed that for COSI, the dimension speech in quiet explained most variation between dimensions. In conclusion, the effects of hearing loss were more salient in AVAB, while both AVAB and COSI showed differences regarding hearing aid experience. Combining the advantages of both methods results in a detailed evaluation of hearing aid rehabilitation. Our results therefore suggest that both methods should be used in a complementary manner, rather than separately.

Influence of the Quantity of Aortic Valve Calcium on the Agreement Between Automated 3-Dimensional Transesophageal Echocardiography and Multidetector Row Computed Tomography for Aortic Annulus Sizing

Accurate aortic annulus sizing is key for selection of appropriate transcatheter aortic valve implantation (TAVI) prosthesis size. The present study compared novel automated 3-dimensional (3D) transesophageal echocardiography (TEE) software and multidetector row computed tomography (MDCT) for aortic annulus sizing and investigated the influence of the quantity of aortic valve calcium (AVC) on the selection of TAVI prosthesis size. A total of 83 patients with severe aortic stenosis undergoing TAVI were evaluated. Maximal and minimal aortic annulus diameter, perimeter, and area were measured. AVC was assessed with computed tomography. The low and high AVC burden groups were defined according to the median AVC score. Overall, 3D TEE measurements slightly underestimated the aortic annulus dimensions as compared with MDCT (mean differences between maximum, minimum diameter, perimeter, and area: -1.7 mm, 0.5 mm, -2.7 mm, and -13 mm², respectively). The agreement between 3D TEE and MDCT on aortic annulus dimensions was superior among patients with low AVC burden (<3,025 arbitrary units) compared with patients with high AVC burden (≥3,025 arbitrary units). The interobserver variability was excellent for both methods. 3D TEE and MDCT led to the same prosthesis size selection in 88%, 95%, and 81% of patients in the total population, the low, and the high AVC burden group, respectively. In conclusion, the novel automated 3D TEE imaging software allows accurate and highly reproducible measurements of the aortic annulus dimensions and shows excellent agreement with MDCT to determine the TAVI prosthesis size, particularly in patients with low AVC burden.

Clinical accuracy of a novel open-lattice-frame implant positioning system: A case series

OBJECTIVE

The purpose of the study was to assess the clinical accuracy of a novel open-lattice-frame implant positioning system by evaluating the deviation between planned and actual implant positions on pre- and postoperative cone beam computed tomography (CBCT) images of patients treated with dental implants. Secondary aims were to record surgical time from first incision to end of implant surgery and start of suturing, and to record patient and surgeon satisfaction from the implant surgical procedure. Pre- and postoperative CBCT of 10 patients receiving 18 dental implants were used to generate implant angular deviations and implant shoulder and apex deviations. Mean angular deviation was 2.96 ± 1.31 degrees (range 0.75 to 5.60 degrees). Mean shoulder and apex deviations were 1.07 ± 0.49 mm (range 0.38 to 1.85 mm) and 1.35 ± 0.57 mm (range 0.52 to 2.19 mm), respectively. Mean time from first incision to start of suturing was 24 ± 7 minutes. Patient satisfaction ranged between 8 and 10, and surgeon satisfaction regarding the procedure ranged between 9 and 10, on a scale of 1 to 10. The open-lattice-frame implant positioning system provided adequate accuracy, and may aid in improving patient-related and surgeon-related outcomes by improving surgical accuracy and shortening surgical treatment duration.

Digital evaluation of the fit of zirconia-reinforced lithium silicate crowns with a new three-dimensional approach

OBJECTIVE

Several methods for the evaluation of fit of computer-aided design/computer-assisted manufacture (CAD/CAM)-fabricated restorations have been described. In the study, digital models were recorded with an intraoral scanning device and were measured using a new three-dimensional (3D) computer technique to evaluate restoration internal fit. The aim of the study was to evaluate the internal adaptation and fit of chairside CAD/CAM-fabricated zirconia-reinforced lithium silicate ceramic crowns fabricated with different post-milling protocols. The null hypothesis was that different post-milling protocols did not influence the fitting accuracy of zirconia-reinforced lithium silicate restorations.

METHOD AND MATERIALS

A master all-ceramic crown preparation was completed on a maxillary right first molar on a typodont. Twenty zirconia-reinforced lithium silicate ceramic crowns (Celtra Duo, Dentsply Sirona) were designed and milled using a chairside CAD/CAM system (CEREC Omnicam, Dentsply Sirona). The 20 crowns were randomly divided into two groups based on post-milling protocols: no manipulation after milling (Group MI) and oven fired-glazing after milling (Group FG). A 3D computer method was used to evaluate the internal adaptation of the crowns. This was based on a subtractive analysis of a digital scan of the crown preparation and a digital scan of the thickness of the cement space over the crown preparation as recorded by a polyvinylsiloxane (PVS) impression material. The preparation scan and PVS scan were matched in 3D and a 3D difference analysis was performed with a software program (OraCheck, Cyfex). Three areas of internal adaptation and fit were selected for analysis: margin (MA), axial wall (AX), and occlusal surface (OC). Statistical analysis was performed using 80% percentile and one-way ANOVA with post-hoc Scheffé test (P = .05).

RESULTS

The closest internal adaptation of the crowns was measured at the axial wall with 102.0 ± 11.7 µm for group MI-AX and 106.3 ± 29.3 µm for group FG-AX. The largest internal adaptation of the crowns was measured for the occlusal surface with 258.9 ± 39.2 µm for group MI-OC and 260.6 ± 55.0 µm for group FG-OC. No statistically significant differences were found for the post-milling protocols (P > .05). The 3D difference pattern was visually analyzed for each area with a color-coded scheme.

CONCLUSION

Post-milling processing did not affect the internal adaptation of zirconia-reinforced lithium silicate crowns fabricated with a chairside CAD/CAM technique. The new 3D computer technique for the evaluation of fit of restorations may be highly promising and has the opportunity to be applied to clinical studies.

When to biomechanically examine a lower-limb amputee: A systematic review of accommodation times

BACKGROUND

Hundreds of investigations examining biomechanical outcomes of various prostheses have been completed, but one question remains unanswered: how much time should an amputee be given to accommodate to a new prosthesis prior to biomechanical testing?

OBJECTIVE

To examine the literature for accommodation time given during biomechanical investigations to determine whether consensus exists.

STUDY DESIGN

Systematic review.

METHODS

A systematic search was completed on 7 January 2016 using PubMed and Scopus.

RESULTS

The search resulted in 156 investigations. Twenty-eight studies did not provide an accommodation or were unclear (e.g. provided a "break in period"), 5 studies tested their participants more than once, 25 tested only once and on the same day participants received a new prosthesis (median (range): above-knee: 60 (10-300) min; below-knee: 18 (5-300) min), and 98 tested once and gave a minimum of 1 day for accommodation (hip: 77 (60-180) days; above-knee: 42 (1-540) days; below-knee: 21 (1-475) days).

CONCLUSION

The lack of research specifically examining accommodation and the high variability in this review's results indicates that it remains undecided how much accommodation is necessary. There is a need for longitudinal biomechanical investigations to determine how outcomes change as amputees accommodate to a new prosthesis. Clinical relevance The results of this review indicate that little research has been done regarding lower-limb amputees accommodating to a new prosthesis. Improper accommodation could lead to increased variability in results, results that are not reflective of long-term use, and could cause clinicians to make inappropriate decisions regarding a prosthesis.

Dynamic elasticity measurement for prosthetic socket design

The paper proposes a novel apparatus to measure the dynamic elasticity of human limb in order to help the design and fabrication of the personalized prosthetic socket. To take measurements of the dynamic elasticity, the desired force generated as an exponential chirp signal in which the frequency increases and amplitude is maintained according to time progress is applied to human limb and then the skin deformation is recorded, ultimately, to obtain the frequency response of its elasticity. It is referred to as a Dynamic Elasticity Measurement Apparatus (DEMA) in the paper. It has three core components such as linear motor to provide the desired force, loadcell to implement the force feedback control, and potentiometer to record the skin deformation. After measuring the force/deformation and calculating the dynamic elasticity of the limb, it is visualized as 3D color map model of the limb so that the entire dynamic elasticity can be shown at a glance according to the locations and frequencies. For the visualization, the dynamic elasticities measured at specific locations and frequencies are embodied using the color map into 3D limb model acquired by using 3D scanner. To demonstrate the effectiveness, the visualized dynamic elasticities are suggested as outcome of the proposed system, although we do not have any opportunity to apply the proposed system to the amputees. Ultimately, it is expected that the proposed system can be utilized to design and fabricate the personalized prosthetic socket in order for releasing the wearing pain caused by the conventional prosthetic socket.

Effects of image and education on the precision of the measurement method for evaluating prosthesis misfit

STATEMENT OF PROBLEM

Various methods for measuring prosthesis misfit have been suggested. Although the cross-sectional images between the crown and abutment are used to evaluate the misfit, the effects of the image and the observer's knowledge on the precision of measurement are unknown.

PURPOSE

The purpose of this in vitro study was to investigate the effects of the image and of education on the precision of prosthesis misfit measurement methods using inter- and intraobserver variability analyses.

MATERIAL AND METHODS

The cross-sectional images in the margin were obtained using the computer-aided replica technique (CART), silicone replica technique (RT), and sectioning technique (ST). Twenty-five observers measured the absolute marginal discrepancy values in the images obtained from each group 4 times at an interval of 2 weeks; the observers went through different education sessions regarding the selection of the measurement points. The precision of measurement was determined and compared using the likelihood-ratio test statistic (α=.05) and the intraclass correlation coefficient with the linear mixed-effects model.

RESULTS

The CART group exhibited the smallest deviations in the measurement variations, followed by the ST and RT groups (P<.001). Additional education on misfit measurements generally decreased the deviation values in all the groups, but without any significant differences.

CONCLUSIONS

The cross-sectional image obtained from the measurement methods and education on the evaluation method affected the precision of the prosthesis misfit measurement. Digital methods might be a useful tool to significantly enhance the precision of the measurements.

Rewriting the tip apex distance for the proximal femoral nail anti-rotation

INTRODUCTION

The proximal femur nail anti-rotation (PFNA-II) (Synthes GmbH, Oberdorf, Switzerland) is the most commonly used implant for intramedullary nailing of unstable intertrochanteric fractures in our centre. However, mechanical failure of the bone with respect to the implant is a cause of concern due to its significant morbidity especially in the elderly. To date, factors for fixation failures are not well defined in the literature. This study aims to evaluate the factors that predispose to cut out of the PFNA implant and to provide a guide for surgical fixation.

PATIENTS AND METHODS

This study was a retrospective analysis of 340 patients who underwent PFNA-II insertion from 2011 to 2013 in our centre. Intraoperative image intensifier images were used for calculation of tip apex distance, neck shaft angles, determination of Cleveland zones. Demographic data was collected on patients age and gender. The fractures were classified based on AO-OTA classification (Marsh et al., 2007) [1]. Patients were followed up for a minimum of 4 months and union of the fracture or until a complication occurred. Risk ratio for cut out was also compared with each statistically significant variable to determine the cut-off point.

RESULTS

The incidence of cut out was 6.7% Tip apex distance, neck shaft angles and female gender were statistically significant for cut out. The study found that tip apex distance beyond 27mm increased the risk of cut out. Neck shaft angles less than 128° also increased the risk of cut out. Posterior and superior blade position in the femoral head and AO 31A3 fractures trended towards significance for cut out but were not statistically significant.

CONCLUSION

To avoid cut out, one should aim for a tip apex distance of not more than 27mm and preserve a neck shaft angle of more than 128°. Risk stratification of the patient allows the surgeon to take greater caution in the post-operative period to detect early cut out.

Use of Intraoral Welding to Increase the Predictability of Immediately Loaded Computer-Guided Implants

Inaccuracy of computer-guided implant placement may lead to complications when combined with an immediately loaded prefabricated prosthesis. The aim of this case series was to describe the use of an intraoral welding technique to increase the predictability of immediately loaded implants supporting a fixed full-arch prosthesis after computer-guided flapless implant placement. A total of 60 Ankylos plus implants (Dentsply) with a width of 3.5 mm and a length of 8 to 14 mm were placed consecutively in 10 patients. The implants were functionally loaded using the intraoral welding technique on the day of surgery. The accuracy of guided implant placement was assessed by matching the planning cone beam computed tomography (CBCT) scans with postoperative CBCT scans. No mechanical or biologic complications were registered at the 1-year follow-up. The global coronal deviation of implant placement from the guide plan ranged from 0.25 to 2.84 mm (SD: 0.6 mm), with a mean of 1.28 mm. Average angle deviation was 3.42 degrees (range 0.38-7.82 degrees; SD: 1.52 degrees). The global apical deviation ranged between 0.36 and 3.85 mm (SD: 0.71 mm), with a mean of 1.65 mm. Despite the inaccuracy registered, this guided-welded approach allowed successful achievement of a passive fit of the full-arch prosthesis on the inserted implants the same day of the surgery and provided a high implant and prosthetic survival rate at the 1-year follow-up.

Medical 3-D Printing

Three-dimensional printing is used in the manufacturing industry, medical and pharmaceutical research, drug production, clinical medicine, and dentistry, with implications for precision and personalized medicine. This technology is advancing the development of patient-specific prosthetics, stents, splints, and fixation devices and is changing medical education, treatment decision making, and surgical planning. Diagnostic imaging modalities play a fundamental role in the creation of 3-D printed models. Although most 3-D printed objects are rigid, flexible soft-tissue-like prosthetics also can be produced.

Role of Cortical Auditory Evoked Potentials in Reducing the Age at Hearing Aid Fitting in Children With Hearing Loss Identified by Newborn Hearing Screening

Recording of free-field cortical auditory evoked potential (CAEP) responses to speech tokens was introduced into the audiology management for infants with a permanent childhood hearing impairment (PCHI) during 2011-2015 at a U.K. service. Children with bilateral PCHI were studied from two sequential cohorts. Thirty-four children had followed an audiology pathway prior to CAEP introduction, and 44 children followed a pathway after the introduction of CAEP and were tested with unaided and aided CAEP responses. Data analysis explored the age of diagnosis, hearing aid fitting, and referral for cochlear implant (CI) assessment for each of these groups. CAEP offered a novel educative process for the parents and audiologists supporting decision-making for hearing aid fitting and CI referral. Delays in hearing aid fitting and CI referral were categorized as being due to the audiologist's recommendation or parental choice. Results showed that the median age of hearing aid fitting prior to CAEP introduction was 9.2 months. After the inclusion of CAEP recording in the infant pathways, it was 3.9 months. This reduction was attributable to earlier fitting of hearing aids for children with mild and moderate hearing losses, for which the median age fell from 19 to 5 months. Children with profound hearing loss were referred for CI assessment at a significantly earlier age following the introduction of CAEP. Although there has also been a national trend for earlier hearing aid fitting in children, the current study demonstrates that the inclusion of CAEP recording in the pathway facilitated earlier hearing aid fitting for milder impairments.

Misfit of implant prostheses and its impact on clinical outcomes. Definition, assessment and a systematic review of the literature

BACKGROUND AND AIM

Compromised fit between the contact surfaces of screw-retained implant-supported fixed dentures (IFDs) is thought to create uncontrolled strains in the prosthetic components and peri-implant tissues, thus evoking biological and technical complications such as bone loss, screw loosening, component fractures and, at worst, loss of implants or prostheses. The aim of this systematic review was to evaluate the impact of marginal misfit on the clinical outcomes of IFDs, and to elucidate definition and assessment methods for passive fit.

MATERIALS AND METHODS

A systematic review of the literature was conducted with a PICO question: "For partially or complete edentulous subjects with screw-retained IFDs, does the marginal misfit at the implant-prosthesis interfaces have an impact on the clinical outcomes?". A literature search was performed electronically in PubMed (MEDLINE) with the help of Boolean operators to combine key words, and by hand search in relevant journals. English written in vivo studies published before August 31, 2016 that reported on both clinical outcome and related implant prosthesis misfit (gap, strains, torque) were selected using predetermined inclusion criteria.

RESULTS

The initial search yielded 2626 records. After screening and a subsequent filtering process, five human and five animal studies were included in the descriptive analysis. The selected studies used different methods to assess misfit (linear distortion, vertical gap, strains, screw torque). While two human studies evaluated the biological response and technical complications prospectively over 6 and 12 months, the animal studies had an observation period < 12 weeks. Four human studies analysed retrospectively the 3 to 32 years' outcomes. Screw-related complications were observed, but biological sequelae could not be confirmed. Although the animal studies had different designs, bone adaptation and implant displacement was found in histological analyses. Due to the small number of studies and the heterogenic designs and misfit assessment methods, no meta-analysis of the data could be performed.

CONCLUSIONS

The current literature provides insufficient evidence as to the effect of misfit at the prosthesis-implant interface on clinical outcomes of screw-retained implant-supported fixed dentures. Marginal gaps and static strains due to screw tightening were not found to have negative effects on initial osseointegration or peri-implant bone stability over time. Based on two clinical studies, the risk for technical screw-related complications was slightly higher. While the degree of tolerable misfit remains a matter of debate, the present data do not imply that clinicians neglect good fit, but aim to achieve the least misfit possible. Conflict of interest statement: The authors declare no conflict of interest. The review was conducted as part of the 2016 Foundation of Oral Rehabilitation Consensus Conference on "Prosthetic Protocols in Implant-based Oral Rehabilitation".

Analysis of clinically important factors on the performance of advanced hydraulic, microprocessor-controlled exo-prosthetic knee joints based on 899 trial fittings

The objective of this work is to evaluate whether clinically important factors may predict an individual's capability to utilize the functional benefits provided by an advanced hydraulic, microprocessor-controlled exo-prosthetic knee component.This retrospective cross-sectional cohort analysis investigated the data of above knee amputees captured during routine trial fittings. Prosthetists rated the performance indicators showing the functional benefits of the advanced maneuvering capabilities of the device. Subjects were asked to rate their perception. Simple and multiple linear and logistic regression was applied.Data from 899 subjects with demographics typical for the population were evaluated. Ability to vary gait speed, perform toileting, and ascend stairs were identified as the most sensitive performance predictors. Prior C-Leg users showed benefits during advanced maneuvering. Variables showed plausible and meaningful effects, however, could not claim predictive power. Mobility grade showed the largest effect but also failed to be predictive.Clinical parameters such as etiology, age, mobility grade, and others analyzed here do not suffice to predict individual potential. Daily walking distance may pose a threshold value and be part of a predictive instrument. Decisions based solely on single parameters such as mobility grade rating or walking distance seem to be questionable.

Digital templating for THA: a simple computer-assisted application for complex hip arthritis cases

INTRODUCTION

Total hip arthroplasty (THA) is the standard procedure for end-stage arthritis of the hip. Its technical success relies on preoperative planning of the surgical procedure and virtual setup of the operative performance. Digital hip templating is one methodology of preoperative planning for THA which requires a digital preoperative radiograph and a computer with special software.

PATIENTS AND METHODS

This is a prospective study involving 23 patients (25 hips) who were candidates for complex THA surgery (unilateral or bilateral). Digital templating is done by radiographic assessment using radiographic magnification correction, leg length discrepancy and correction measurements, acetabular component and femoral component templating as well as neck resection measurement.

RESULTS

The overall accuracy for templating the stem implant's exact size is 81%. This percentage increased to 94% when considering sizing within 1 size.

CONCLUSION

Digital templating has proven effective, reliable and essential technique for preoperative planning and accurate prediction of THA sizing and alignment.

Intraoperative factors affecting conversion from cruciate retaining to cruciate substituting in total knee arthroplasty

PURPOSE

The purpose of this study was to analyse the factors affecting the conversion from posterior cruciate ligament (PCL)-retaining (CR) to PCL-substituting (PS) prostheses during total knee arthroplasty (TKA).

METHODS

A total of 920 TKAs, which had been preoperatively planned to undergo implantation of CR-type prostheses, were reviewed retrospectively. Of these, 83 knees (9.0 %) were converted intraoperatively to PS prostheses. The clinical and radiological factors of the non-converted (CR) and converted (PS) groups were compared. Clinically, age, gender, body mass index, angle of flexion contracture, size of the femoral component, and thickness of the polyethylene insert were compared between the CR and PS groups. Radiologically, the severity of the varus deformity and the posterior tibial slope angle (PSA) were compared between the CR and PS groups.

RESULTS

No significant differences in age, gender, body mass index, range of motion, thickness of the polyethylene insert, or severity of varus deformity were identified. The average preoperative angle of flexion contracture was 5.9° ± 7.4° in the CR group and 8.1° ± 9.1° in the PS group (p = 0.002). The average preoperative PSA was 9.6° ± 4.0° in the CR group and 11.0° ± 5.0° in the PS group (p = 0.018). The conversion rates to a PS-type femoral component of size C, D, and E were 13.1, 7.0, and 6.3 %, respectively (p = 0.004).

CONCLUSION

The conversion rate from CR- to PS-type prostheses was high in patients with severe flexion contracture, steep posterior slope, and a small femoral component size. These factors should be carefully considered for appropriate selection of prosthesis type.

LEVEL OF EVIDENCE

IV.

Long-term mortality after lower-limb amputation

BACKGROUND

Mortality after amputation is known to be extremely high and is associated with a number of patient features. We wished to calculate this mortality after first-time lower-limb amputation and investigate whether any population or treatment factors are associated with worse mortality.

OBJECTIVE

To follow up individuals after lower limb amputation and ascertain the mortality rate as well as population or treatment features associated with mortality.

STUDY DESIGN

A prospective cohort study.

METHODS

Prospective lower-limb amputations over 1 year (N = 105) at a Regional Rehabilitation Centre were followed up for 3 years.

RESULTS

After 3 years, 35 individuals in the cohort had died, representing a mortality of 33%. On initial univariate analysis, those who died were more likely to have diabetes mellitus (χ(2) = 7.16, df = 1, p = 0.007) and less likely to have been fitted with a prosthesis (χ(2) = 5.84, df = 1, p = 0.016). There was no association with age, gender, level of amputation, social isolation, significant medical co-morbidity other than diabetes or presence of mood disorders. A multi-variable logistic regression (backward step) confirmed that diabetes (odds ratio = 3.04, confidence intervals = 1.25-7.40, p = 0.014) and absence of prosthesis-fitting (odds ratio = 2.60, confidence interval = 1.16-6.25, p = 0.028) were independent predictors of mortality.

CONCLUSION

Mortality after amputation is extremely high and is increased in individuals with diabetes or in those who are not fitted with a prosthesis after amputation.

CLINICAL RELEVANCE

The link between diabetes and mortality after amputation has been noted by others, but this is the first study to find an effect from prosthetic limb-wearing. This requires further investigation to ascertain why the wearing of a prosthetic limb, confers an independent survival benefit that is not related to the presence of medical co-morbidity.