Exploratory analysis of spontaneous versus paced breathing on heart rate variability in veterans with combat-related traumatic injury.

BACKGROUND: Respiration is a crucial determinant of autonomic balance and heart rate variability (HRV). The comparative effect of spontaneous versus paced breathing on HRV has been almost exclusively explored in healthy adults and never been investigated in an injured military cohort. OBJECTIVE: To examine the effect of spontaneous versus paced breathing on HRV in veterans with combat-related traumatic injury (CRTI). DESIGN: Observational cohort study. SETTING: ArmeD serVices trAuma rehabilitatioN outComE (ADVANCE) study, Stanford Hall, UK. PARTICIPANTS: The sample consisted of 100 randomly selected participants who sustained CRTI (eg, amputation) during their deployment (Afghanistan 2003-2014) and were recruited into the ongoing ADVANCE prospective cohort study. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: HRV was recorded using a single-lead ECG. HRV data were acquired during a sequential protocol of 5-minute spontaneous breathing followed immediately by 5 minutes of paced breathing (six cycles/minute) among fully rested and supine participants. HRV was reported using time domain (root mean square of successive differences), frequency domain (low frequency and high frequency) and nonlinear (sample entropy) measures. The agreement between HRV during spontaneous versus paced breathing was examined using the Bland-Altman analysis. RESULTS: The mean age of participants was 36.5 ± 4.6 years. Resting respiratory rate was significantly higher with spontaneous versus paced breathing (13.4 ± 3.4 vs. 7.6 ± 2.0 breaths/minute; p < .001), respectively. Resting mean heart rate and root mean square of successive differences were significantly higher with paced breathing than spontaneous breathing (p < .001). Paced breathing significantly increased median low frequency power than spontaneous breathing (p < .001). No significant difference was found in the absolute power of high frequency between the two breathing protocols. The Bland-Altman analysis revealed poor agreement between HRV values during spontaneous and paced breathing conditions with wide limits of agreement. CONCLUSION: Slow-paced breathing leads to higher HRV than spontaneous breathing and could overestimate resting "natural-state" HRV.

The integration of ortho-plastic limb salvage teams in the humanitarian response to violence-related open tibial fractures: evaluating outcomes in the Gaza Strip.

BACKGROUND: Limb salvage by ortho-plastic teams is the standard protocol for treating open tibial fractures in high-income countries, but there's limited research on this in conflict settings like the Gaza Strip. This study assessed the clinical impact of gunshot-related open tibial fractures, compared patient management by orthopedic and ortho-plastic teams, and identified the risk factors for bone non-union in this context. METHODS: A retrospective review of medical records was conducted on Gaza Strip patients with gunshot-induced-open tibial fractures from March 2018 to October 2020. Data included patient demographics, treatments, and outcomes, with at least one year of follow-up. Primary outcomes were union, non-union, infection, and amputation. RESULTS: The study included 244 injured individuals, predominantly young adult males (99.2%) with nearly half (48.9%) having Gustilo-Anderson type IIIB fractures and more than half (66.8%) with over 1 cm of bone loss. Most patients required surgery, including rotational flaps and bone grafts with a median of 3 admissions and 9 surgeries. Ortho-plastic teams managed more severe muscle and skin injuries, cases with bone loss > 1 cm, and performed less debridement compared to other groups, though these differences were not statistically significant. Non-union occurred in 53% of the cases, with the ortho-plastic team having the highest rate at 63.6%. Infection rates were high (92.5%), but no significant differences in bone or infection outcomes were observed among the different groups. Logistic regression analysis identified bone loss > 1 cm, vascular injury, and the use of a definitive fixator at the first application as predictors of non-union. CONCLUSIONS: This study highlights the severity and complexity of such injuries, emphasizing their significant impact on patients and the healthcare system. Ortho-plastic teams appeared to play a crucial role in managing severe cases. However, further research is still needed to enhance our understanding of how to effectively manage these injuries.

Injuries in Fatalities of Dismounted Blast: Identification of Four Mechanisms of Head and Spine Injury.

Blast is the most common injury mechanism in conflicts of this century due to the widespread use of explosives, confirmed by recent conflicts such as in Ukraine. Data from conflicts in the last century such as Northern Ireland, the Falklands, and Vietnam up to the present day show that between 16% and 21% of personnel suffered a traumatic brain injury. Typical features of fatal brain injury to those outside of a vehicle (hereafter referred to as dismounted) due to blast include the presence of hemorrhagic brain injury alongside skull fractures rather than isolated penetrating injuries more typical of traditional ballistic head injuries. The heterogeneity of dismounted blast has meant that analysis from databases is limited and therefore a detailed look at the radiological aspects of injury is needed to understand the mechanism and pathology of dismounted blast brain injury. The aim of this study was to identify the head and spinal injuries in fatalities due to dismounted blast. All UK military fatalities from dismounted blast who suffered a head injury from 2007-2013 in the Iraq and Afghanistan conflicts were identified retrospectively. Postmortem computerized tomography images (CTPMs) were interrogated for injuries to the head, neck, and spine. All injuries were documented and classified using a radiology brain injury classification (BIC) tool. Chi-squared (χ2) and Fisher's exact tests were used to investigate correlations between injuries, along with odds ratios for determining the direction of correlation. The correlations were clustered. There were 71 fatalities from dismounted blast with an associated head injury with a CTPM or initial CT available for analysis. The results showed the heterogeneity of injury from dismounted blast but also some potential identifiable injury constellations. These were: intracranial haemorrhage, intracranial deep haemorrhage, spinal injury, and facial injury. These identified injury patterns can now be investigated to consider injury mechanisms and so develop mitigation strategies or clinical treatments. Level of Evidence: Observational. Study type: cohort observational.

Pain after combat injury in male UK military personnel deployed to Afghanistan.

BACKGROUND: Chronic pain after injury poses a serious health burden. As a result of advances in medical technology, ever more military personnel survive severe combat injuries, but long-term pain outcomes are unknown. We aimed to assess rates of pain in a representative sample of UK military personnel with and without combat injuries. METHODS: We used data from the ADVANCE cohort study (ISRCTN57285353). Individuals deployed as UK armed forces to Afghanistan were recruited to include those with physical combat injuries, and a frequency-matched uninjured comparison group. Participants completed self-reported questionnaires, including 'overall' pain intensity and self-assessment of post-traumatic stress disorder, anxiety, and depression. RESULTS: A total of 579 participants with combat injury, including 161 with amputations, and 565 uninjured participants were included in the analysis (median 8 yr since injury/deployment). Frequency of moderate or severe pain was 18% (n=202), and was higher in the injured group (n=140, 24%) compared with the uninjured group (n=62, 11%, relative risk: 1.1, 95% confidence interval [CI]: 1.0-1.2, P<0.001), and lower in the amputation injury subgroup (n=31, 19%) compared with the non-amputation injury subgroup (n=109, 26%, relative risk: 0.9, 95% CI: 0.9-1.0, P=0.034). Presence of at least moderate pain was associated with higher rates of post-traumatic stress (RR: 3.7, 95% CI: 2.7-5.0), anxiety (RR: 3.2, 95% CI: 2.4-4.3), and depression (RR: 3.4, 95% CI: 2.7-4.5) after accounting for injury. CONCLUSION: Combat injury, but not amputation, was associated with a higher frequency of moderate to severe pain intensity in this cohort, and pain was associated with adverse mental health outcomes.

The Influence of Physical and Mental Health Mediators on the Relationship Between Combat-Related Traumatic Injury and Ultra-Short-Term Heart Rate Variability in a U.K. Military Cohort: A Structural Equation Modeling Approach.

INTRODUCTION: Combat-related traumatic injury (CRTI) adversely affects heart rate variability (HRV). The mediating effect of mental and physical health factors on the relationship between CRTI, its severity and HRV has not been previously studied and investigated. MATERIALS AND METHODS: A cross-sectional mediation analysis of the ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) prospective cohort study was performed. The sample consisted of injured and uninjured British male servicemen who were frequency-matched based on their age, rank, role-in-theater, and deployment to Afghanistan (2003-2014). CRTI and injury severity (the New Injury Severity Scores [NISS] [NISS < 25 and NISS ≥ 25]) were included as exposure variables. HRV was quantified using the root mean square of successive differences (RMSSD) obtained using pulse waveform analysis. Depression and anxiety mediators were quantified using the Patient Health Questionnaire and Generalized Anxiety Disorder, respectively. Body mass index and the 6-minute walk test (6MWT) represented physical health measures. Two mediation pathways between exposure and outcome variables were examined in comparison with the uninjured group using structural equation modeling. RESULTS: Of 862 servicemen, 428 were injured and 434 were uninjured with the mean age at assessment of 33.9 ± 5.4 (range 23-59) years. Structural equation modeling revealed that depression, anxiety, and body mass index did not significantly mediate the relationship between injury/injury severity and RMSSD. However, the 6MWT significantly mediated the relationship between CRTI and RMSSD (27% mediation). The indirect effect of 6MWT on the relationship between injury severity (NISS ≥ 25 vs. uninjured) and RMSSD was -0.06 (95% CI: -0.12, -0.00, P < .05). CONCLUSIONS: The findings suggest that greater physical function may improve HRV following CRTI. Longitudinal studies are warranted to further validate these findings.

Hip joint and muscle loading for persons with bilateral transfemoral/through-knee amputations: biomechanical differences between full-length articulated and foreshortened non-articulated prostheses.

BACKGROUND: Currently, there is little available in-depth analysis of the biomechanical effect of different prostheses on the musculoskeletal system function and residual limb internal loading for persons with bilateral transfemoral/through-knee amputations (BTF). Commercially available prostheses for BTF include full-length articulated prostheses (microprocessor-controlled prosthetic knees with dynamic response prosthetic feet) and foreshortened non-articulated stubby prostheses. This study aims to assess and compare the BTF musculoskeletal function and loading during gait with these two types of prostheses. METHODS: Gait data were collected from four male traumatic military BTF and four able-bodied (AB) matched controls using a 10-camera motion capture system with two force plates. BTF completed level-ground walking trials with full-length articulated and foreshortened non-articulated stubby prostheses. Inverse kinematics, inverse dynamics and musculoskeletal modelling simulations were conducted. RESULTS: Full-length articulated prostheses introduced larger stride length (by 0.5 m) and walking speed (by 0.3 m/s) than stubbies. BTF with articulated prostheses showed larger peak hip extension angles (by 10.1°), flexion moment (by 1.0 Nm/kg) and second peak hip contact force (by 3.8 bodyweight) than stubbies. There was no difference in the hip joint loading profile between BTF with stubbies and AB for one gait cycle. Full-length articulated prostheses introduced higher hip flexor muscle force impulse than stubbies. CONCLUSIONS: Compared to stubbies, BTF with full-length articulated prostheses can achieve similar activity levels to persons without limb loss, but this may introduce detrimental muscle and hip joint loading, which may lead to reduced muscular endurance and joint degeneration. This study provides beneficial guidance in making informed decisions for prosthesis choice.

Relationship between combat-related traumatic injury and its severity to predicted cardiovascular disease risk: ADVANCE cohort study.

BACKGROUND: This study investigated the relationship between combat-related traumatic injury (CRTI) and its severity and predicted cardiovascular disease (CVD) risk. MATERIAL AND METHODS: This was an analysis of comparative 10-year predicted CVD risk (myocardial infarction, stroke or CVD-death) using the QRISK®3 scoring-system among adults recruited into the Armed Services Trauma Rehabilitation Outcome (ADVANCE) cohort study. Participants with CRTI were compared to uninjured servicemen frequency-matched by age, sex, rank, deployment (Afghanistan 2003-2014) and role. Injury severity was quantified using the New Injury Severity Score (NISS). RESULTS: One thousand one hundred forty four adult combat veterans were recruited, consisting of 579 injured (161 amputees) and 565 uninjured men of similar age ethnicity and time from deployment/injury. Significant mental illness (8.5% vs 4.4%; p = 0.006) and erectile dysfunction (11.6% vs 5.8%; p < 0.001) was more common, body mass index (28.1 ± 3.9 vs 27.4 ± 3.4 kg/m2; p = 0.001) higher and systolic blood pressure variability (median [IQR]) (1.7 [1.2-3.0] vs 2.1 [1.2-3.5] mmHg; p = 0.008) lower among the injured versus uninjured respectively. The relative risk (RR) of predicted CVD (versus the population expected risk) was higher (RR:1.67 [IQR 1.16-2.48]) among the injured amputees versus the injured non-amputees (RR:1.60 [1.13-2.43]) and uninjured groups (RR:1.52 [1.12-2.34]; overall p = 0.015). After adjustment for confounders CRTI, worsening injury severity (higher NISS, blast and traumatic amputation) were independently associated with QRISK®3 scores. CONCLUSION: CRTI and its worsening severity were independently associated with increased predicted 10-year CVD risk.

Developments in circular external fixators: A review.

Circular external fixators (CEFs) are successfully used in orthopedics owing to their highly favorable stiffness characteristics which promote distraction osteogenesis. Although there are different designs of external fixators, how these features produce optimal biomechanics through structural and component designs is not well known. Therefore, the aim of this study was to conduct a review on CEFs following the PRISMA statement. A search for relevant research articles was performed on Scopus and PubMed databases providing the related keywords. Furthermore, a patent search was conducted on the Google Patent database. 126 records were found to be eligible for the review. Different designs of CEFs were summarized and tabulated based on their specific features. A bibliometric analysis was also performed on the eligible research papers. Based on the findings, the developments of CEFs in terms of materials, automation, adjustment methods, component designs, wire-clamping, and performance evaluation have been extensively discussed. The trends of the CEF design and future directions are also discussed in this review. Significant research gaps include a lack of consideration towards ease of assembly, effective wire-clamping methods, and CEFs embedded with online patient-monitoring systems, among others. An apparent lack of research interest from low-middle and low-income countries was also identified.

High-density EMG, IMU, kinetic, and kinematic open-source data for comprehensive locomotion activities.

Novel sensor technology enables new insights in the neuromechanics of human locomotion that were previously not possible. Here, we provide a dataset of high-density surface electromyography (HDsEMG) and high-resolution inertial measurement unit (IMU) signals, along with motion capture and force data for the lower limb of 10 healthy adults during multiple locomotion modes. The participants performed level-ground and slope walking, as well as stairs ascent/descent, side stepping gait, and stand-to-walk and sit-to-stand-to-walk, at multiple walking speeds. These data can be used for the development and validation of locomotion mode recognition and control algorithms for prosthetics, exoskeletons, and bipedal robots, and for motor control investigations.

Developing an exercise intervention to improve bone mineral density in traumatic amputees: protocol for a Delphi study.

INTRODUCTION: Lower limb amputation results in reduced bone mineral density (BMD) on the amputated side. Exercise interventions have proven effective in improving BMD. However, such interventions have not been attempted in an amputee population. Exercises designed for people with intact limbs may not be suitable for amputees, due to joint loss and the mechanical interface between the exercise equipment and the femoral neck being mediated through a socket. Therefore, prior to intervention implementation, it would be prudent to leverage biomechanical knowledge and clinical expertise, alongside scientific evidence in related fields, to assist in intervention development. The objective of this study is to elicit expert opinion and gain consensus to define specific exercise prescription parameters to minimise/recover BMD loss in amputees. METHODS AND ANALYSIS: The Delphi technique will be used to obtain consensus among international experts; this will be conducted remotely as an e-Delphi process. 10-15 experts from ≥2 continents and ≥5 countries will be identified through published research or clinical expertise. Round 1 will consist of participants being asked to rate their level of agreement with statements related to exercise prescription to improve amputee BMD using a 5-point Likert Scale. Agreement will be deemed as ≥3 on the Likert Scale. Open feedback will be allowed in round 1 and any statement which less than 50% of the experts agree with will be excluded. Round 2 will repeat the remaining statements with the addition of any input from round 1 feedback. Round 3 will allow participants to reflect on their round 2 responses considering statistical representation of group opinion and whether they wish to alter any of their responses accordingly. Statements reaching agreement rates of 70% or above among the experts will be deemed to reach a consensus and will be implemented in a future exercise interventional trial. ETHICS AND DISSEMINATION: Ethical approval was received from Imperial College Research Ethics Committee (reference: 6463766). Delphi participants will be asked to provide digital informed consent. The findings will be disseminated through peer-reviewed publications.

The relationship between combat-related traumatic amputation and subclinical cardiovascular risk.

BACKGROUND: The relationship between acute combat-related traumatic injury (CRTI) to coronary flow reserve (CFR) and subclinical cardiovascular risk have not been examined and was the primary aim of this study. METHODS AND RESULTS: UK combat veterans from the ADVANCE cohort study (UK-Afghanistan War 2003-14) with traumatic limb amputations were compared to injured non-amputees and to a group of uninjured veterans from the same conflict. Subclinical cardiovascular risk measures included fasted blood atherogenic index of plasma (AIP), triglyceride-glucose index (TyG; insulin resistance), the neutrophil-lymphocyte ratio (NLR) and high-sensitivity C-reactive protein (hs-CRP; vascular inflammation), body mass index (BMI) and visceral fat volume (dual-energy X-ray absorptiometry) and 6-min walk distance (6MWD; physical performance). The subendocardial viability ratio (SEVR), to estimate CFR, was calculated using arterial pulse waveform analysis (Vicorder device). In total 1144 adult male combat veterans were investigated, comprising 579 injured (161 amputees, 418 non-amputees) and 565 uninjured men. AIP, TyG, NLR, hs-CRP, BMI, total body fat and visceral fat volume were significantly higher and the SEVR and 6MWD significantly lower in the amputees versus the injured-non-amputees and uninjured groups. The SEVR was lowest in those with above knee and multiple limb amputations. CRTI (ExpB 0.96; 95% CI 0.94-0.98: p < 0.0001) and amputation (ExpB 0.94: 95% CI 0.91-0.97: p < 0.0001) were independently associated with lower SEVR after adjusting for age, rank, ethnicity and time from injury. CONCLUSION: CRTI, traumatic amputation and its worsening physical deficit are associated with lower coronary flow reserve and heightened subclinical cardiovascular risk.

Bilateral Asymmetry in Knee and Hip Musculoskeletal Loading During Stair Ascending/Descending in Individuals with Unilateral Mild-to-Moderate Medial Knee Osteoarthritis.

Most cases of unilateral knee osteoarthritis (OA) progress to bilateral OA within 10 years. Biomechanical asymmetries have been implicated in contralateral OA development; however, gait analysis alone does not consistently detect asymmetries in OA patient gait. Stair ambulation is a more demanding activity that may be more suited to reveal between-leg asymmetries in OA patients. The objective of this study was to investigate the between-leg biomechanical differences in patients with unilateral mild-to-moderate knee OA. Sixteen unilateral mild-to-moderate medial knee OA patients and 16 healthy individuals underwent kinematic and kinetic analysis of stair ascent and descent. Stair ascent produced higher loading and muscle forces in the unaffected limb compared to the OA limb, and stair descent produced lower loading on the OA limb compared to healthy subjects. These biomechanical differences were apparent in the ankle, knee, and hip joints. The implications of these findings are that OA patients rely more heavily on their unaffected sides than the affected side in stair ascent, a strategy that may be detrimental to the unaffected joint health. The reduction in affected limb loading in stair descent is thought to be related to minimizing pain.

Association Between Combat-Related Traumatic Injury and Skeletal Health: Bone Mineral Density Loss Is Localized and Correlates With Altered Loading in Amputees: the Armed Services Trauma Rehabilitation Outcome (ADVANCE) Study.

The association between combat-related traumatic injury (CRTI) and bone health is uncertain. A disproportionate number of lower limb amputees from the Iraq and Afghanistan conflicts are diagnosed with osteopenia/osteoporosis, increasing lifetime risk of fragility fracture and challenging traditional osteoporosis treatment paradigms. The aim of this study is to test the hypotheses that CRTI results in a systemic reduction in bone mineral density (BMD) and that active traumatic lower limb amputees have localized BMD reduction, which is more prominent with higher level amputations. This is a cross-sectional analysis of the first phase of a cohort study comprising 575 male adult UK military personnel with CRTI (UK-Afghanistan War 2003 to 2014; including 153 lower limb amputees) who were frequency-matched to 562 uninjured men by age, service, rank, regiment, deployment period, and role-in-theatre. BMD was assessed using dual-energy X-ray absorptiometry (DXA) scanning of the hips and lumbar spine. Femoral neck BMD was lower in the CRTI than the uninjured group (T-score -0.08 versus -0.42 p = .000). Subgroup analysis revealed this reduction was significant only at the femoral neck of the amputated limb of amputees (p = 0.000), where the reduction was greater for above knee amputees than below knee amputees (p < 0.001). There were no differences in spine BMD or activity levels between amputees and controls. Changes in bone health in CRTI appear to be mechanically driven rather than systemic and are only evident in those with lower limb amputation. This may arise from altered joint and muscle loading creating a reduced mechanical stimulus to the femur resulting in localized unloading osteopenia. This suggests that interventions to stimulate bone may provide an effective management strategy. © 2023 Crown copyright and The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland.

Clinical trial of a low-cost external fixator for global surgery use.

PURPOSE: A low-cost modular external fixator for the lower limb has been developed for global surgery use. The purpose of this study is to assess outcome measures in the first clinical use of the device. METHODS: A prospective cohort study was conducted with patients recruited in two trauma hospitals. Initial clinical procedure data were collected, and patients were followed up every two weeks until 12 weeks or definitive fixation. Follow-up assessed infection, stability, and radiographic outcomes. In addition, patient-reported outcomes and surgeons' feedback on device usability were collected by questionnaires. RESULTS: The external fixator was used on 17 patients. Ten were mono-lateral, five were joint spanning, and two were delta configuration. One patient had a pin site infection at 12-week follow-up. All were stable when tested mechanically and using radiographic assessment, and 53% were converted to definitive fixation. CONCLUSION: The low-cost external fixator developed is appropriate for use in global surgery trauma centres with good clinical outcomes. PROSPECTIVE TRIAL REGISTRATION NUMBER AND DATE: SLCTR/2021/025 (06 Sep 2021).

Characterization of muscle recruitment during gait of bilateral transfemoral and through-knee persons with limb loss.

Introduction: Due to loss in musculoskeletal capacity, there is an increased burden on the residual limbs of bilateral transfemoral and through-knee persons with limb loss. This reduced capacity is associated with an increased cost of walking that is detrimental to functionality. Compensatory gait strategies are adopted by this population. However, how these strategies relate to specific muscle recruitment is not known. The primary aim of this study is to characterize muscle recruitment during gait of this population. The secondary aim is to assess whether the measured kinematics can be actuated when the endurance of specific muscles is reduced and if this is the case, which alternative muscles facilitate this. Methods: 3D gait data and high-resolution magnetic resonance images were acquired from six bilateral transfemoral and through-knee persons with limb loss. Subject-specific anatomical muscle models were developed for each participant, and a validated musculoskeletal model was used to quantify muscle forces in two conditions: during normal gait (baseline) and when muscles, which were identified as functioning above a "healthy" level at baseline, have a reduced magnitude of maximum force capacity (reduced endurance simulation). To test the hypothesis that there are differences in muscle forces between the baseline trials and the simulations with reduced muscular endurance, a Bonferroni corrected two-way ANOVA with repeated measures was completed between the two states. Results: The baseline analysis showed that the hip flexors experience relatively high muscle activations during gait. The reduced endurance simulation found two scenarios. First, for 5 out of the 12 simulations, the baseline kinematics could not be reproduced with the reduced muscular capacity. Second, for 7 out of 12 cases where the baseline kinematics were achieved, this was possible with compensatory increased activation of some muscles with similar functions (p ≤ 0.003). Discussion: Evidently, due to the loss of the ankle plantar flexors, gait imposes a high demand on the flexor muscle group of the residual limb. This study highlights how the elevated cost of gait in this population manifests in muscle recruitment. To enhance functionality, it is critical to consider the mechanical demand on the hip flexors and to develop rehabilitation interventions accordingly.

3D shape reconstruction of the femur from planar X-ray images using statistical shape and appearance models.

Major trauma is a condition that can result in severe bone damage. Customised orthopaedic reconstruction allows for limb salvage surgery and helps to restore joint alignment. For the best possible outcome three dimensional (3D) medical imaging is necessary, but its availability and access, especially in developing countries, can be challenging. In this study, 3D bone shapes of the femur reconstructed from planar radiographs representing bone defects were evaluated for use in orthopaedic surgery. Statistical shape and appearance models generated from 40 cadaveric X-ray computed tomography (CT) images were used to reconstruct 3D bone shapes. The reconstruction simulated bone defects of between 0% and 50% of the whole bone, and the prediction accuracy using anterior-posterior (AP) and anterior-posterior/medial-lateral (AP/ML) X-rays were compared. As error metrics for the comparison, measures evaluating the distance between contour lines of the projections as well as a measure comparing similarities in image intensities were used. The results were evaluated using the root-mean-square distance for surface error as well as differences in commonly used anatomical measures, including bow, femoral neck, diaphyseal-condylar and version angles between reconstructed surfaces from the shape model and the intact shape reconstructed from the CT image. The reconstructions had average surface errors between 1.59 and 3.59 mm with reconstructions using the contour error metric from the AP/ML directions being the most accurate. Predictions of bow and femoral neck angles were well below the clinical threshold accuracy of 3°, diaphyseal-condylar angles were around the threshold of 3° and only version angle predictions of between 5.3° and 9.3° were above the clinical threshold, but below the range reported in clinical practice using computer navigation (i.e., 17° internal to 15° external rotation). This study shows that the reconstructions from partly available planar images using statistical shape and appearance models had an accuracy which would support their potential use in orthopaedic reconstruction.

ADVANCE-TBI study protocol: traumatic brain injury outcomes in UK military personnel serving in Afghanistan between 2003 and 2014 - a longitudinal cohort study.

INTRODUCTION: Outcomes of traumatic brain injury (TBI) are highly variable, with cognitive and psychiatric problems often present in survivors, including an increased dementia risk in the long term. Military personnel are at an increased occupational risk of TBI, with high rates of complex polytrauma including TBI characterising the UK campaign in Afghanistan. The ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE)-TBI substudy will describe the patterns, associations and long-term outcomes of TBI in the established ADVANCE cohort. METHODS AND ANALYSIS: The ADVANCE cohort comprises 579 military personnel exposed to major battlefield trauma requiring medical evacuation, and 566 matched military personnel without major trauma. TBI exposure has been captured at baseline using a standardised interview and registry data, and will be refined at first follow-up visit with the Ohio State Method TBI interview (a National Institute of Neurological Disorders and Stroke TBI common data element). Participants will undergo blood sampling, MRI and detailed neuropsychological assessment longitudinally as part of their follow-up visits every 3-5 years over a 20-year period. Biomarkers of injury, neuroinflammation and degeneration will be quantified in blood, and polygenic risk scores calculated for neurodegeneration. Age-matched healthy volunteers will be recruited as controls for MRI analyses. We will describe TBI exposure across the cohort, and consider any relationship with advanced biomarkers of injury and clinical outcomes including cognitive performance, neuropsychiatric symptom burden and function. The influence of genotype will be assessed. This research will explore the relationship between military head injury exposure and long-term outcomes, providing insights into underlying disease mechanisms and informing prevention interventions. ETHICS AND DISSEMINATION: The ADVANCE-TBI substudy has received a favourable opinion from the Ministry of Defence Research Ethics Committee (ref: 2126/MODREC/22). Findings will be disseminated via publications in peer-reviewed journals and presentations at conferences.

The effect of muscle atrophy in people with unilateral transtibial amputation for three activities: Gait alone does not tell the whole story.

Amputation imposes significant challenges in locomotion to millions of people with limb loss worldwide. The decline in the use of the residual limb results in muscle atrophy that affects musculoskeletal dynamics in daily activities. The aim of this study was to quantify the lower limb muscle volume discrepancy based on magnetic resonance (MR) imaging and to combine this with motion analysis and musculoskeletal modelling to quantify the effects in the dynamics of key activities of daily living. Eight male participants with traumatic unilateral transtibial amputation were recruited who were at least six months after receiving their definitive prostheses. The muscle volume discrepancies were found to be largest at the knee extensors (35 %, p = 0.008), followed by the hip abductors (17 %, p = 0.008). Daily activities (level walking, standing up from a chair and ascending one step) were measured in a motion analysis laboratory and muscle and joint forces quantified using a detailed musculoskeletal model for people with unilateral transtibial amputation which was calibrated in terms of the muscle volume discrepancies post-amputation at a subject-specific level. Knee extensor muscle forces were lower at the residual limb than the intact limb for all activities (p ≤ 0.008); residual limb muscle forces of the hip abductors (p ≤ 0.031) and adductors (p ≤ 0.031) were lower for standing-up and ascending one step. While the reduced knee extensor force has been reported by other studies, our results suggest a new biomechanically-based mitigation strategy to improve functional mobility, which could be achieved through strengthening of the hip abd/adductor muscles.

The accuracy of statistical shape models in predicting bone shape: A systematic review.

BACKGROUND: This systematic review aims to ascertain how accurately 3D models can be predicted from two-dimensional (2D) imaging utilising statistical shape modelling. METHODS: A systematic search of published literature was conducted in September 2022. All papers which assessed the accuracy of 3D models predicted from 2D imaging utilising statistical shape models and which validated the models against the ground truth were eligible. RESULTS: 2127 papers were screened and a total of 34 studies were included for final data extraction. The best overall achievable accuracy was 0.45 mm (root mean square error) and 0.16 mm (average error). CONCLUSION: Statistical shape modelling can predict detailed 3D anatomical models from minimal 2D imaging. Future studies should report the intended application domain of the model, the level of accuracy required, the underlying demographics of subjects, and the method in which accuracy was calculated, with root mean square error recommended if appropriate.