Objetivo: Investigar a efetividade da cirurgia de retalho faríngeo (RF) e da palatoplastia secundária com veloplastia intravelar (VI) na correção da insuficiência velofaríngea (IVF) e comparar os resultados pós-cirúrgicos de hipernasalidade, hiponasalidade, nasalância e grau de fechamento velofaríngeo entre as duas cirurgias. Material e Métodos: Estudo conduzido no Laboratório de Fisiologia do HRAC-USP, em 78 indivíduos, de ambos os sexos, com idade entre 6 e 52 anos (21±10 anos, em média), com fissura de palato±lábio, já submetidos à correção cirúrgica da IVF há 14 meses, em média, sendo 40 pacientes com RF e 38 com VI. A hipernasalidade e a hiponasalidade foram classificadas perceptivamente por três fonoaudiólogas a partir de amostra de fala gravada. A nasalância foi determinada por meio da nasometria e o fechamento velofaríngeo foi aferido a partir da medida da área do orifício velofaríngeo obtida por meio da avaliação aerodinâmica. Diferenças entre as duas técnicas foram consideradas estatisticamente significantes ao nível de 5%. Resultados: Verificou-se ausência de hipernasalidade em 35% e 70% dos casos e, presença de hiponasalidade em 10% e 25% dos pacientes com RF, de acordo com a avaliação perceptiva da fala e a nasometria, respectivamente e, fechamento velofaríngeo adequado em 80% dos casos, de acordo com a avaliação aerodinâmica. Nos pacientes com VI, ausência de hipernasalidade foi verificada em 29% e 34% e hiponasalidade foi detectada em 3% dos casos, respectivamente na avaliação perceptiva da fala e na nasometria e, fechamento velofaríngeo adequado foi observado em 50% dos pacientes. Conclusão: O retalho faríngeo foi mais eficiente que a palatoplastia secundária com veloplastia intravelar na eliminação dos sintomas da IVF. / Objective: To investigate the effectiveness of pharyngeal flap surgery (PFS) and the secondary palatoplasty with intravelar veloplasty (IV) for velopharyngeal insufficiency management (VPI) as well as to compare the postoperative outcome of hypernasality, hyponasality, nasalance and velopharyngeal closure between the two surgeries. Methods: Study conducted at the Laboratory of Physiology, HRAC-USP, on 78 individuals of both genders, aged between 6 and 52 years (21±10 years, on average), with cleft palate±lip , underwent surgical management of IVF for 14 months on average, 40 patients with RF and 38 with IV. Hypernasality and hyponasality were perceptually rated by three speech pathologists using recorded speech samples. Nasalance was determined by means of nasometry and velopharyngeal closure was assessed by means of velopharyngeal orifice area measurement provided by pressure-flow studies. Differences between the two techniques were considered statistically significant at 5%. Results: Absence of hypernasality was observed in 35% and 70% of the cases, and presence of hyponasality in 10% and 25% of the patients submitted to RF, according to the perceptual speech assessment and nasometry, respectively, and adequate velopharyngeal closure was observed in 80% of the cases, according to the aerodynamic evaluation. Absence of hypernasality in patients submitted to VI, was observed in 29% and 34%, and hyponasality was detected in 3% of the cases, respectively according to the perceptual speech assessment and nasometry, and adequate velopharyngeal closure was observed in 50% of these patients. Conclusion: The pharyngeal flap surgery was more efficient than the secondary palatoplasty with intravelar veloplasty regarding the elimination of IVF symptoms.

abstract: Minimally invasive surgery is a surgical technique that is known for its reduced patient recovery time. It is a surgical procedure done by using long reached tools and an endoscopic camera to operate on the body though small incisions made near the point of operation while viewing the live camera feed on a nearby display screen. Multiple camera views are used in various industries such as surveillance and professional gaming to allow users a spatial awareness advantage as to what is happening in the 3D space that is presented to them on 2D displays. The concept has not effectively broken into the medical industry yet. This thesis tests a multi-view camera system in which three cameras are inserted into a laparoscopic surgical training box along with two surgical instruments, to determine the system impact on spatial cognition, perceived cognitive workload, and the overall time needed to complete the task, compared to one camera viewing the traditional set up. The task is a non-medical task and is one of five typically used to train surgeons’ motor skills when initially learning minimally invasive surgical procedures. The task is a peg transfer and will be conducted by 30 people who are randomly assigned to one of two conditions; one display and three displays. The results indicated that when three displays were present the overall time initially using them to complete a task was slower; the task was perceived to be completed more easily and with less strain; and participants had a slightly higher performance rate. / Dissertation/Thesis / Masters Thesis Human Systems Engineering 2019

Robot-assisted minimally invasive surgery is used to perform intricate surgical tasks through small incisions using long, slender instruments. The miniaturization of these instruments is advantageous to both surgeon and patient because smaller instruments reduce trauma to surrounding tissue, decrease patient recovery times, and can be used in confined spaces otherwise inaccessible using larger instruments. However, miniaturization of existing designs is limited by friction between moving parts, the volume occupied by the end effector, and manufacturing and assembly constraints. The objective of this work is to develop and analyze concepts that can be used in robot-assisted needlescopic surgery. The concepts are intended for instrument shafts no larger than 3 mm in diameter. An ideal concept is one with large ranges of wrist and gripping motion. Concepts should also minimize friction and swept volume while maintaining a focus on manufacturability and ease of assembly. Multiple concepts were generated and evaluated using a tree classification scheme, proof-of-concept prototypes, and simplified mathematical models. Three unique concepts were further developed and tested—the Split CORE Grips, the Inverted Flexure Grips, and the Crossed Cylinders Wrist. The two grip concepts are instruments that incorporate one rotational degree of freedom and one gripping degree of freedom. The wrist concept incorporates two rotational degrees of freedom and could be coupled with a single DOF grip mechanism to form a functional instrument. In addition to concept development, a variety of fabrication techniques were investigated to better understand the challenges that arise when designing and fabricating devices at the 3 mm scale. To augment existing techniques, a novel fabrication technique was developed which uses layers of lithographically patterned carbon nanotube (CNT) composite material to form a 3D part. This method was used to prototype some of the designs at a 1:1 size scale.

Intra-articular fractures (IAFs) often lead to poor outcomes, despite surgeons’ best efforts at reconstructing the fractured articular surface. The objective of articular fracture reduction is to improve joint congruity thereby lower articular contact pressure and minimize the risk of post-traumatic osteoarthritis (PTOA). Surgical fracture reductions performed using less invasive approaches (i.e., percutaneously) rely heavily upon C-arm fluoroscopy to judge articular surface congruity. Based on varied outcomes, it appears that the use of 2D imaging alone for this purpose may prove inadequate. Despite this, there has been little investigation into novel metrics for assessment of reduction quality. This work first explores seven methods for assessment of reduction quality (3 2D, 3 3D, and one biomechanical). The results indicate that metrics which take 3D measurement or joint biomechanics into account when characterizing reduction quality are more strongly correlated with PTOA development. A computer assisted surgery system, which provides up-to-date 3D fracture geometry and contact stress distributions intra-operatively, was developed. Its utility was explored in a series of ten cadaveric tibial plafond fracture reductions, where contact stresses and contact areas were compared in surgeries with vs. without biomechanical guidance. The use of biomechanical guidance caused an increase in surgical time and fluoroscopy usage (39% and 17%, respectively). However, it facilitated decreases in the mean and maximum contact stress by 0.7 and 1.5 MPa, respectively. Contact areas engaged at known deleterious levels (contact stress > 4.5 MPa) were also 44% lower in cases which used guidance. The findings of this work suggest that enhanced visualization of a fracture intra-operatively may facilitate improved long-term outcomes. Further development and study of this system is warranted.

Objective: The purpose of this study was to evaluate the accuracy of surgical guides for dental implant placement fabricated by additive and subtractive techniques. Methods: A standardized mandible model (BoneModels, Castellón, Spain) was duplicated and the proposed implant position was performed from a diagnostic wax-up. An implant was placed in the printed model as a reference. Cone beam computed tomography (CBCT) was made with the radiographic surgical guide to design a surgical guide on BlueSky Plan 4 software. The .stl file of the surgical guide was exported and fabricated by two different techniques: additive (3D printing) and subtractive (milling). Fifteen surgical guides per group were used to place implants in the printed models. The angular deviations, differences in depth, coronal and apical deviations were measured using GeoMagic Control X software. Results were analyzed by Wilcoxon-Mann-Whitney (Wilcoxon Rank Sum) test and PERMANOVA (Permutational Multivariate Analysis of Variance). Intraclass correlation was used to analyze the reproducibility. A 0.05 level of significance was used, with Bonferroni multiple adjustment as needed. Results: There were no significant differences in accuracy of implant placement using additive technique vs subtractive techniques. The mean angular deviations between planned and actual position of implant in mesio-distal cross-section were 0.780±0.803 degrees for printed group and 0.772±0.724 degrees for the milled group. The analogous results in bucco-lingual cross-section were 1.601±1.223 degrees in in printed group and 1.767±0.762 degrees in the milled group. The differences in depth (mm) were measured in four aspects including mesial, distal, buccal and lingual. The mean differences in depth in the group that using printed surgical guides were 0.373±0.285 mm, 0.325±0.230 mm, 0.240±0.228 mm, and 0.247±0.168 mm in those 4 aspects, respectively. The mean differences in depth in the group that using milled surgical guides were 0.511±0.326 mm, 0.396±0.316 mm, 0.215±0.230 mm, and 0.230±0.122 mm in those four aspects, respectively. The mean coronal deviation showed 0.32 mm in the printed group and 0.27 mm in the milled group. For the apical deviation, the results of this study showed mean apical deviation 0.84 mm in the printed group and 0.80 mm in the milled group. Conclusions: No statistically significant difference was identified between the position of implant placed using surgical guide fabricated by the additive technique (3D printing) vs surgical guides fabricated by subtractive technique (milling). The 3D-printed surgical guide could be an alternative for guided-implant surgery with the benefits of high accuracy, ease of fabrication and reduction of laboratory time and materials, thereby increasing cost-effectiveness.

Highly comminuted intra-articular fractures are complex and difficult injuries to treat. Once emergent care is rendered, the definitive treatment objective is to restore the original anatomy while minimizing surgically induced trauma. Operations that use limited or percutaneous approaches help preserve tissue vitality, but reduced visibility makes reconstruction more difficult. A pre-operative plan of how comminuted fragments would best be re-positioned to restore anatomy helps in executing a successful reduction. The objective of this work was to create new virtual fracture reconstruction technologies that would deliver that information for a clinical series of severe intra-articular fractures. As a step toward clinical application, algorithmic development benefits from the availability of more precise and controlled data. Therefore, this work first developed 3D puzzle solving methods in a surrogate platform not confounded by various in vivo complexities. Typical tibial plafond fracture fragmentation/dispersal patterns were generated with five identical replicas of human distal tibia anatomy that were machined from blocks of high-density polyetherurethane foam (bone fragmentation surrogate). Replicas were fractured using an instrumented drop tower and pre- and post-fracture geometries were obtained using laser scans and CT. A semi-automatic virtual reconstruction computer program aligned fragment native surfaces to a pre-fracture template. After effective reconstruction algorithms were created for the surrogate tibias, the next aim was to develop new algorithms that would accommodate confounding biologic factors and puzzle solve clinical fracture cases. First, a novel image analysis technique was developed to segment bone geometries from pre- and post-surgical reduction CT scans using a modified 3D watershed segmentation algorithm. Next, 3D puzzle solving algorithms were advanced to obtain fracture reconstructions in a series of highly comminuted tibial plafond fracture cases. Each tibia was methodically reconstructed by matching fragment native (periosteal and articular) surfaces to an intact template that was created from a mirror image of the healthy contralateral limb. Virtual reconstructions obtained for ten tibial plafond fracture cases had average alignment errors of 0.39±0.5 mm. These novel 3D puzzle solving methods are a significant advancement toward improving treatment by providing a powerful new tool for planning the surgical reconstruction of comminuted articular fractures.

Cigarette smoking has been a public health concern for many years, and the possible impact of smoking on surgical site infection (SSI) has been studied broadly. However, a gap in understanding has persisted concerning whether there is an association between smoking tobacco and the development of SSI among patients who undergo lower extremity surgery, specifically total knee arthroplasty (TKA). The purpose of this study was to examine the association between smoking and lower extremity SSI. Andersen's behavioral model (BM) was used to understand the risk factors relevant to the interaction between smoking and SSI. Application of the BM categories of predisposing, enabling, need, and behavioral habits facilitated the discussion of surgical outcomes. A quantitative, cross-sectional approach was used to analyze data from a legacy registry of an east coast hospital. The research question addressed whether there was a relationship of the smoking status of three groups (i.e., smokers, nonsmokers, and previous smokers) and the variables in the BM categories (predisposing variables of age, gender, and body mass index [BMI]; enabling variable of health care insurance coverage; and need variables of health diagnoses, diabetes, hypertension, deficiency anemia, rheumatoid arthritis [RA]) to postoperative SSI. Multiple logistic regression test was used and no statistical association was found between smoking status and SSI; however, RA had a significant association with SSI. Positive social change may occur through the dissemination of new knowledge to reduce the financial burden of the prevalence of SSI through behavioral changes and improvements to health wellness.

Family members of surgical patients experience anxiety due to lack of consistent communication during the surgical process. Attending to the needs of the surgical patient's family members is an important factor easily forgotten in a busy clinical arena. The purpose of this project was to decrease the surgical patient's family member's anxiety by providing family members with timely and consistent information regarding the patient's progress through surgery. The theoretical foundation used was general systems theory showing that a change in one part of a system leads to change in the whole system with the use of improved communication and feedback. The key question asked was whether an electronic information system could provide additional information in conjunction with personal interaction to reduce the family member's anxiety. The project design was a prospective, randomized, posttest design in a single-center study using the State-Trait Anxiety Inventory Survey for Adults (STAI). The sample size was 80 surgical patients' family members. Results using the Wilcoxon-Rank-Sum test indicated that the addition of an electronic information display was unable to reduce STAI scores. The medians for the State portion of the survey were .823 across all categories for both the control and intervention groups. The medians for the Trait portion of the survey for both the control and intervention groups were .118 with p >05. Although the data suggests retaining the null hypothesis, a significant social change was the staff's heightened awareness of the surgical patient's family's vulnerability and the need for communication during the perioperative phase.

Articular fracture reduction is a complex surgical task that requires surgeons to be competent at multiple surgical skills to successfully complete. The list of skills needed includes the ability to use fluoroscopic images to build a 3D mental model of the fracture during reconstruction, the proper handling and use of surgical instruments, how to manipulate the fracture fragment into a reduced configuration with minimal hand motion, proper k-wire placement, and the preservation of surrounding soft tissues. Current training methodology is based on an apprenticeship model. The resident learns by watching a senior surgeon, and then preforms the procedure on live patients under the guidance of the senior surgeon to gain competence. This endangers the patient and does not provide the best outcome for either patient or resident. The work presented in this thesis is the early development of an articular fracture reduction simulator, the subsequent use of the simulator in the training of orthopaedic residents, and assessment of the improvement of residents after practice on the simulator. To date, the simulator has been tested on four different groups of residents,3 different groups from the University of Iowa and one group from the University of Minnesota. Considerable effort has been made to validate the improvement seen in resident performance through objective means. The Objective Structured Assessment of Technical Skills (OSATS) is a global rating score and procedural checklist that has been previously validated to objectively measure surgical skill. Other assessment metrics include hand motion capture to count the number of discrete actions and measure distance traveled during the surgical procedure, fluoroscopic usage and radiation exposure, articular `step-off', the surface deviation from an intact or ideal reconstruction, and contact stress exposure. The results indicate that the goals for the simulator have been met, that the simulator provides a means of training orthopaedic residents, assessing improvement, decreased the cost of training, and improved patient safety. The simulator is not without limitations including sample size, and radiation exposure. The task being trained is complex and can be broken down into basic subtasks that could be trained individually. Even with flaws, the simulator is an improvement over current training methods and is an excellent first step toward creating a surgical skills curriculum to comply with new mandates from orthopaedic surgery's governing bodies.

Coyote (Canis latrans) predation accounts for the majority of neonatal pronghorn (Antilocapra americana) mortality in many areas and may influence local population declines. Current techniques used to manage coyote predation on wildlife species generally focus on lethal control methods. However, these methods may be controversial to the general public. Coyote sterilization is an alternative predation control method which is more acceptable to the public and has been shown to be effective in reducing sheep predation. We hypothesized that surgical sterilization of coyotes may increase pronghorn fawn survival; in the same way it reduces coyote predation on domestic sheep. Sterilization reduces the energetic need to provision coyote pups, which may decrease the predation rate on fawns by sterile coyotes. We employed tubal ligation and vasectomy of captured coyotes to maintain pair bonds and territoriality. We monitored pronghorn fawns by radio telemetry for one year pre-treatment and coyotes and pronghorn fawns one year post-treatment. We also examined the effects of sterilization on coyote territorial maintenance and survival. Survival of fawns captured in sterile coyote home ranges was higher than survival of fawns captured in intact home ranges (P = 0.078). We also found that fawn survival was consistently higher in the northern part of the study site (P = 0.081). A severe winter followed by a wet spring in 2007 did not reduce fawn survival and may have increased fawn survival (P = 0.364); however, our sample sizes did not allow us to detect significance in this relationship. Our results also supported the hypothesis that sterilization, while keeping hormonal systems intact, did not change coyote territorial behaviors. Sterile coyote packs were the same size as intact packs (P = 0.554). Sterile and intact coyote packs maintained similar home range sizes in all seasons tested (P ¡Ý 0.556). We found differences between home range and core area overlap of sterile and intact packs in some seasons, but this trend appeared to exist before the coyotes were treated. Residency rates were similar for sterile and intact coyotes (P = 0.406). We recommend coyote sterilization as a tool to boost pronghorn fawn survival in areas where fawn survival is a critical factor in pronghorn population persistence. Because these techniques have been tested under few circumstances, we recommend careful monitoring in future coyote sterilization programs.