Quantitative analysis of the reversibility of knee flexion contractures with time: an experimental study using the rat model.

BACKGROUND: Knee flexion contractures prevent the full extension of the knee joint and cause disability. The etiology is not well defined. Extended periods of immobilization of joints lead to contractures difficult to completely reverse by rehabilitation treatments. Recovery of the complete range of motion without intervention has not been studied but is of importance to optimize clinical management. This study was designed to quantify the spontaneous reversibility of knee flexion contractures over time. METHODS: Knee flexion contractures of increasing severities were induced by internally fixing one knee of 250 adult male rats for 6 increasing durations. The contractures were followed for four different durations of spontaneous recovery up to 48 weeks (24 groups, target n=10 per group). The angle of knee of extension at a standardized torque was measured. Contralateral knees constituted controls. RESULTS: Full reversibility characterized by knee extension similar to controls was only measured in the lowest severity group where 4 weeks of spontaneous recovery reversed early-onset contractures. Spontaneous recovery of 2, 4 and 8 weeks caused partial gain of knee extension in longer-lasting contractures (P ≤ 0.05; all 4 comparisons). Extending the durations of spontaneous recovery failed to further improve knee extension (P>0.05, all 12 comparisons). No reversal occurred in the highest severity group (32 week; P>0.05). CONCLUSIONS: Reversibility of knee flexion contractures was dependent on their severity. Full spontaneous recovery was limited to the least severe contractures. While contractures initially improved, a plateau was reached beyond which additional durations of spontaneous recovery led to no additional gain of knee extension. These results support our view that without treatment, permanent losses in knee mobility must be anticipated in immobility-induced contractures.

Knee joint stiffness following immobilization and remobilization: A study in the rat model.

Deficits in extension can limit the function and performance of the knee joint. The range of motion (ROM) deficit in knee extension is often measured and reported at a single torque value applied in the flexion-extension axis. This static measurement of ROM omits key details about the biomechanical properties of the knee, such as its mechanical stiffness. Our objectives were (1) to quantify knee extension stiffness after various periods of immobilization and remobilization, and (2) to evaluate how stiffness correlated with the length of the posterior knee capsule. Two hundred fifty-six male Sprague Dawley rats had one knee immobilized at a 45° angle in flexion using a Delrin® plate for 6 different durations ranging from 1 to 32 weeks. Remobilization was initiated by removing the plate and lasted for 0-48 weeks. The contralateral knee and unoperated age-matched rats were used as controls. An automated arthrometer extended the knee at four pre-determined torques and these data were used to calculate mechanical stiffness. The stiffness of knees immobilized for 8 or more weeks was significantly greater than controls and persisted despite remobilization (p < 0.05). Remobilization after 16 and 32 weeks of immobilization resulted in a progressive increase in mechanical stiffness (p < 0.05). The length of the posterior capsule significantly correlated with knee stiffness in extension (p < 0.05). Deficit in knee extension was characterized by increased stiffness, which was irreversible upon unassisted remobilization.

Using a Knee Arthrometer to Evaluate Tissue-specific Contributions to Knee Flexion Contracture in the Rat.

Normal knee range of motion (ROM) is critical to well-being and allows one to perform basic activities such as walking, climbing stairs and sitting. Lost ROM is called a joint contracture and results in increased morbidity. Due to the difficulty of reversing established knee contractures, early detection is important, and hence, knowing risk factors for their development is essential. The rat represents a good model with which the effect of an intervention can be studied due to the similarity of rat knee anatomy to that of humans, the rat's ability to tolerate long durations of knee immobilization in flexion, and because mechanical data can be correlated with histologic and biochemical analysis of knee tissue. Using an automated arthrometer, we demonstrate a validated, precise, reproducible, user-independent method of measuring the extension ROM of the rat knee joint at specific torques. This arthrometer can be used to determine the effects of interventions on knee joint ROM in the rat.

Quantitative and temporal differential recovery of articular and muscular limitations of knee joint contractures; results in a rat model.

Joint contractures alter the mechanical properties of articular and muscular structures. Reversibility of a contracture depends on the restoration of the elasticity of both structures. We determined the differential contribution of articular and muscular structures to knee flexion contractures during spontaneous recovery. Rats (250, divided into 24 groups) had one knee joint surgically fixed in flexion for six different durations, from 1 to 32 wk, creating joint contractures of various severities. After the fixation was removed, the animals were left to spontaneously recover for 1 to 48 wk. After the recovery periods, animals were killed and the knee extension was measured before and after division of the transarticular posterior muscles using a motorized arthrometer. No articular limitation had developed in contracture of recent onset (≤2 wk of fixation, P > 0.05); muscular limitations were responsible for the majority of the contracture (34 ± 8° and 38 ± 6°, respectively; both P < 0.05). Recovery for 1 and 8 wk reversed the muscular limitation of contractures of recent onset (1 and 2 wk of fixation, respectively). Long-lasting contractures (≥4 wk of fixation) presented articular limitations, irreversible in all 12 durations of recovery compared with controls (all 12 P < 0.05). Knee flexion contractures of recent onset were primarily due to muscular structures, and they were reversible during spontaneous recovery. Long-lasting contractures were primarily due to articular structures and were irreversible. Comprehensive temporal and quantitative data on the differential reversibility of mechanically significant alterations in articular and muscular structures represent novel evidence on which to base clinical practice.

Mechanical and biomechanical analysis of a linear piston design for angular-velocity-based orthotic control.

A linear piston hydraulic angular-velocity-based control knee joint was designed for people with knee-extensor weakness to engage knee-flexion resistance when knee-flexion angular velocity reaches a preset threshold, such as during a stumble, but to otherwise allow free knee motion. During mechanical testing at the lowest angular-velocity threshold, the device engaged within 2 degrees knee flexion and resisted moment loads of over 150 Nm. The device completed 400,000 loading cycles without mechanical failure or wear that would affect function. Gait patterns of nondisabled participants were similar to normal at walking speeds that produced below-threshold knee angular velocities. Fast walking speeds, employed purposely to attain the angular-velocity threshold and cause knee-flexion resistance, reduced maximum knee flexion by approximately 25 degrees but did not lead to unsafe gait patterns in foot ground clearance during swing. In knee collapse tests, the device successfully engaged knee-flexion resistance and stopped knee flexion with peak knee moments of up to 235.6 Nm. The outcomes from this study support the potential for the linear piston hydraulic knee joint in knee and knee-ankle-foot orthoses for people with lower-limb weakness.

Two-degree-of-freedom powered prosthetic wrist.

Prosthetic wrists need to be compact. By minimizing space requirements, a wrist unit can be made for people with long residual limbs. This prosthetic wrist uses two motors arranged across the arm within the envelope of the hand. The drive is transmitted by a differential so that it produces wrist flexion and extension, pronation and supination, or a combination of both. As a case study, it was controlled by a single-prosthesis user with pattern recognition of the myoelectric signals from the forearm. The result is a compact, two-degree-of-freedom prosthetic wrist that has the potential to improve the functionality of any prosthetic hand by creating a hand orientation that more closely matches grasp requirements.

Angular-velocity control approach for stance-control orthoses.

Currently, stance-control knee orthoses require external control mechanisms to control knee flexion during stance and allow free knee motion during the swing phase of gait. A new angular-velocity control approach that uses a rotary-hydraulic device to resist knee flexion when the knee angular velocity passes a preset threshold is presented. This angular-velocity approach for orthotic stance control is based on the premise that knee-flexion angular velocity during a knee-collapse event, such as a stumble or fall, is greater than that during walking. The new hydraulic knee-flexion control device does not require an external control mechanism to switch from free motion to stance control mode. Functional test results demonstrated that the hydraulic angular-velocity activated knee joint provided free knee motion during walking, engaged upon knee collapse, and supported body weight while the end-user recovered to a safe body position. The joint was tested to 51.6 Nm in single loading tests and passed 200,000 repeated loading cycles with a peak load of 88 Nm per cycle. The hydraulic, angular velocity activation approach has potential to improve safety and security for people with lower extremity weakness or when recovering from joint trauma.

Measurement of articular cartilage surface irregularity in rat knee contracture.

OBJECTIVE: To design novel quantitative methods to evaluate the irregularity of articular cartilage surface; and to apply these methods for assessment of surface irregularity in a rat knee contracture model. METHODS: A total of 117 rat knees were either immobilized or sham-operated and harvested after 2, 4, 8, 16, or 32 weeks, and 11 knees were not operated. Standardized histologic sections were digitized and the contours of femoral and tibial cartilage surfaces were delineated. The rates of change in cartilage contour were calculated. Rate of change above a defined threshold constituted surface irregularity. RESULTS: In non-operated knees, cartilage surface irregularity in femur and tibia amounted to 3.1 +/- 0.5%. Immobilized knees showed significantly more irregularities than the sham-operated knees at all time points (2 weeks: 5.3 +/- 0.6% vs 3.1 +/- 0.4%; 4 weeks: 10.5 +/- 0.9% vs 4.4 +/- 0.9%; 8 weeks: 12.0 +/- 1.8% vs 4.9 +/- 0.2%; 16 weeks: 13.7 +/- 2.0% vs 4.9 +/- 0.4%; and 32 weeks: 13.8 +/- 1.4% vs 3.4 +/- 0.6%; all p < 0.05). No difference was observed between sham-operated and non-operated knees. Increasing duration of immobilization in weeks (t) significantly correlated with more surface irregularity, described by the logarithmic formula: % irregularity = 6.6 + 2.1 ln (t), (F = 59.3, p < 0.001). This formula showed that irregularity progressed rapidly after immobilization and plateaued after 8 weeks. CONCLUSION: We designed methods to quantify cartilage surface irregularity and applied them to a contracture model. Cartilage surface irregularities appeared after 2 weeks of immobilization and progressed rapidly to plateau after 8 weeks. Combined with microscopic magnetic resonance imaging, this measurement of cartilage surface irregularity may constitute a sensitive tool to detect cartilage degeneration clinically.