Accuracy of soft tissue balancing in total knee arthroplasty using surgeon-defined assessment versus a gap-balancer or electronic sensor.

BACKGROUND: Soft tissue balancing is essential for the success of total knee arthroplasty (TKA) and is mainly dependent on surgeon-defined assessment (SDA) or a gap-balancer (GB). However, an electronic sensor has been developed to objectively measure the gap pressure. This study aimed to evaluate the accuracy of soft tissue balancing using SDA and GB compared with a sensor. METHODS: Forty-eight patients undergoing TKA (60 knees) were prospectively enrolled. Soft tissue balancing was sequentially performed using SDA, a GB, and an electronic sensor. We compared the SDA, GB, and sensor data to calculate the sensitivity, specificity, and accuracy at 0°, 45°, 90°, and 120° flexion. Cumulative summation (CUSUM) analysis was performed to assess the surgeon's performance during the sensor introductory phase. RESULTS: The sensitivity of SDA was 63.3%, 68.3%, 80.0%, and 80.0% at 0°, 45°, 90°, and 120°, respectively. The accuracy of the GB compared with sensor data was 76.7% and 71.7% at 0° and 90°, respectively. Cohen's kappa coefficient for the accuracy of the GB was 0.406 at 0° (moderate agreement) and 0.227 at 90° (fair agreement). The CUSUM 0° line achieved good prior performance at case 45, CUSUM 90° and 120° showed a trend toward good prior performance, while CUSUM 45° reached poor prior performance at case 8. CONCLUSION: SDA was a poor predictor of knee balance. GB improved the accuracy of soft tissue balancing, but was still less accurate than the sensor, particularly for unbalanced knees. SDA improved with ongoing use of the sensor, except at 45° flexion.

A microarchitectural assessment of the gluteal tuberosity suggests two possible patterns in entheseal changes.

OBJECTIVES: Macroscopic entheseal forms show two main features: predominant signs of bony formation or resorption. To understand the development of these forms, we investigated microarchitectural differences between the macroscopic proliferative and resorptive forms of the gluteus maximus enthesis. MATERIALS AND METHODS: The macromorphological analysis of entheseal changes (EC) was based on the Villotte, visual scoring system for fibrous entheses. Gluteal tuberosity specimens of different stages of Villote's system were harvested from 16 adult males derived from an archaeological context and scanned using microcomputed tomography. RESULTS: The microarchitectural analyzes of cortical bone demonstrated a trend of higher porosity in the resorptive compared to the proliferative phase in Stage B, whereas a 30% porosity reduction was detected in the resorptive compared to proliferative phase of Stage C. In terms of the trabecular bone between the resorptive and proliferative entheseal phases, there was a trend of increased connectivity density, whereas the structural model index decreased in B and increased in C. The assessment of the entire specimen showed an increase in porosity from the proliferative to the resorptive phase in the Stage B, in contrast to a decrease in the Stage C. DISCUSSION: The results suggest that from an initial flat entheses, two directions of EC development are possible: (a) a bony prominence may form and, subsequently, it is subjected to trabecularization of the cortical bone inside the prominence, such cortical trabecularization can lead to visible porosity on the cortical external surface; (b) the cortical bone defect may develop with the regular underlying cortical bone.

Cell maceration scanning electron microscopy and computer-derived porosity measurements in assessment of connective tissue microstructure changes in the canine myxomatous mitral valve.

Canine myxomatous mitral valve disease is associated with changes in the valve extracellular matrix (ECM). The aim of this study was to examine the use of cell macerated scanning electron microscopy (CMSEM) in evaluating ECM changes in a small sample of valves and to quantify these changes using computer-aided image analysis of sample porosity (a measure of structural disorganisation and collagen loss). The distinct layered structure of the de-cellularised matrix could be seen in the normal valve and there were marked changes in layers and ECM organisation as the disease progressed. Clearly visible and quantifiable, statistically significant changes were found in valve porosity across the entire leaflet thickness and particularly in the valve mid and distal zones. All of these changes are presumed to affect the mechanical function of the valve. In conclusion, CMSEM with computed image analysis can be used to visualise and measure tissue structural changes in a quasi-3-dimensional manner in normal and diseased tissues.

Energy expenditure associated with softening and stiffening of echinoderm connective tissue.

Catch connective tissue of echinoderms at rest (in the standard state) either stiffens or softens in response to different kinds of stimulation. The energy consumption associated with the changes was estimated by measurement of the oxygen consumption rate (VO(2)) in three types of connective tissues-echinoid catch apparatus (CA), holothuroid body-wall dermis (HD), and asteroid body-wall dermis (AD). Mechanical stimulation by repetitive compression (10%-15% strain), which increased viscosity measured by creep tests, was employed for inducing the stiff state. Noradrenaline (10(-3) mol l(-1)), which decreased viscosity of CA, and static 80% compressive strain, which decreased viscosity of HD, were used to induce the soft state in the respective tissues. The VO(2) (in µl/g/h) values of the standard state were 2.91 (CA), 1.41 (HD), and 0.56 (AD), which were less than 1/4 of the VO(2) of the resting body-wall muscle of the starfish. The VO(2) of the stiff state was about 1.5 times greater than that of the standard state in all types of connective tissues. The VO(2) of the soft state was 3.4 (CA)-9.1 (HD) times greater than that of the standard state. The economical nature of catch connective tissue in posture maintenance is discussed.

Celebration of the 50th anniversary of the foundation of the French society for connective tissue research. Its short history in the frame of the origin and development of this discipline.

The science of connective tissues has (at least) a double origin. Collagen, their major constituent was first studied in conjunction with the leather industry. Acid mucopolysaccharides (now glycosaminoglycans) were characterised by (bio)-chemists interested in glycoconjugates. They joined mainly hospital-based rheumatology departments. Later started the study of elastin with the discovery of elastases and of connective tissue-born (structural) glycoproteins. Besides rhumatologists and leather-chemists mainly pathologists became involved in this type of research, followed closely by ophthalmology research. The first important meetings of these diverse specialists were organised under the auspices of NATO, first in Saint-Andrew's in GB in 1964 and a few years later (1969) in Santa Margareta, Italy. With the discovery of fibronectin, a "structural glycoprotein", started the study of cell-matrix interactions, reinforced by the identification of cell-receptors mediating them and the "cross-talk" between cells and matrix constituents. The first initiative to organise societies for this rapidly growing discipline was that of Ward Pigman in New York in 1961, restricted however to glycol-conjugates. Next year, in 1962 was founded the first European Connective Tissue Society in Paris: the "Club français du tissu conjonctif", which played a crucial role in the establishment of schools, laboratories, national and international meetings in the major cities of France: Paris, Lyon, Reims, Caen,Toulouse. A second European society was born in Great Britain, and at a joint meeting with the French society at the Paris Pasteur Institute, was founded in 1967 by these societies the Federation of European Connective Tissue Societies (FECTS). Their meetings, organised every second year, drained a wide attendance from all over the world. An increasing number of young scientists joined since then this branch of biomedical discipline with several international journals devoted to connective tissue research, to matrix biology. The increasing number and quality of the young generation of scientists engaged in research related to the extracellular matrix or better Biomatrix and cell-matrix interactions is a further guarantee for the continued interest in this crucial field of science at the interface of basic and medically oriented research.

Assessment of viscous and elastic properties of sub-wavelength layered soft tissues using shear wave spectroscopy: theoretical framework and in vitro experimental validation.

In elastography, quantitative imaging of soft tissue elastic properties is provided by local shear wave speed estimation. Shear wave imaging in a homogeneous medium thicker than the shear wavelength is eased by a simple relationship between shear wave speed and local shear modulus. In thin layered organs, the shear wave is guided and thus undergoes dispersive effects. This case is encountered in medical applications such as elastography of skin layers, corneas, or arterial walls. In this work, we proposed and validated shear wave spectroscopy as a method for elastic modulus quantification in such layered tissues. Shear wave dispersion curves in thin layers were obtained by finite-difference simulations and numerical solving of the boundary conditions. In addition, an analytical approximation of the dispersion equation was derived from the leaky Lamb wave theory. In vitro dispersion curves obtained from phantoms were consistent with numerical studies (deviation <1.4%). The least-mean-squares fitting of the dispersion curves enables a quantitative and accurate (error < 5% of the transverse speed) assessment of the elasticity. Dispersion curves were also found to be poorly influenced by shear viscosity. This phenomenon allows independent recovery of the shear modulus and the viscosity, using, respectively, the dispersion curve and the attenuation estimation along the propagation axis.

The effect of connective tissue material uncertainties on knee joint mechanics under isolated loading conditions.

Although variability in connective tissue parameters is widely reported and recognized, systematic examination of the effect of such parametric uncertainties on predictions derived from a full anatomical joint model is lacking. As such, a sensitivity analysis was performed to consider the behavior of a three-dimensional, non-linear, finite element knee model with connective tissue material parameters that varied within a given interval. The model included the coupled mechanics of the tibio-femoral and patello-femoral degrees of freedom. Seven primary connective tissues modeled as non-linear continua, articular cartilages described by a linear elastic model, and menisci modeled as transverse isotropic elastic materials were included. In this study, a multi-factorial global sensitivity analysis is proposed, which can detect the contribution of influential material parameters while maintaining the potential effect of parametric interactions. To illustrate the effect of material uncertainties on model predictions, exemplar loading conditions reported in a number of isolated experimental paradigms were used. Our findings illustrated that the inclusion of material uncertainties in a coupled tibio-femoral and patello-femoral model reveals biomechanical interactions that otherwise would remain unknown. For example, our analysis revealed that the effect of anterior cruciate ligament parameter variations on the patello-femoral kinematic and kinetic response sensitivities was significantly larger, over a range of flexion angles, when compared to variations associated with material parameters of tissues intrinsic to the patello-femoral joint. We argue that the systematic sensitivity framework presented herein will help identify key material uncertainties that merit further research and provide insight on those uncertainties that may not be as relative to a given response.

Assessment of shear modulus of tissue using ultrasound radiation force acting on a spherical acoustic inhomogeneity.

An ultrasound-based method to locally assess the shear modulus of a medium is reported. The proposed approach is based on the application of an impulse acoustic radiation force to an inhomogeneity in the medium and subsequent monitoring of the spatio-temporal response. In our experimental studies, a short pulse produced by a 1.5-MHz highly focused ultrasound transducer was used to initiate the motion of a rigid sphere embedded into an elastic medium. Another 25 MHz focused ultrasound transducer operating in pulse-echo mode was used to track the displacement of the sphere. The experiments were performed in gel phantoms with varying shear modulus to demonstrate the relationship between the displacement of the sphere and shear modulus of the surrounding medium. Because the magnitude of acoustic force applied to sphere depends on the acoustic material properties and, therefore, cannot be used to assess the absolute value of shear modulus, the temporal behavior of the displacement of the sphere was analyzed. The results of this study indicate that there is a strong correlation between the shear modulus of a medium and spatio-temporal characteristics of the motion of the rigid sphere embedded in this medium.

Non-invasive assessment of superficial soft tissue local displacements during movement: a feasibility study.

In the movement analysts community, the assessment of the displacement of skin photogrammetric markers relative to the underlying bone (soft tissue displacement, STD) is considered to be a priority. The aim of this study is to present a non-invasive method that allows for the characterization of STD for any marker location, subject, and motor task. In particular, this method provides an estimate of the STD vector in a bone-embedded frame. The body segment under analysis is endowed with the largest possible number of skin markers located over all areas of interest. Any given STD vector is observed from all the marker cluster frames that can be built by suitably combining all the available markers. A subset of the latter frames is identified that is made of frames endowed with uncorrelated local movements. The estimate of a given STD vector is determined through the coherent average of the vectors reconstructed using the above-mentioned independent frames. This estimate is affected by a 180 degrees phase indeterminacy. The proposed method and the underlying hypotheses were validated using markers located on the thighs of two female subjects treated for a total knee replacement. The relevant STD estimates, STDm, were compared with those directly observed using photogrammetry combined with 2D fluoroscopic projections and the prosthesis CAD model (STDf). Recordings were made while the volunteers performed step up/down motor tasks. The root mean square value of STDm was found in the range 2.5-23.0 mm and was consistent with the RMS values of STDf and with other results reported in the literature and obtained in similarly unconstrained conditions. Moreover, STDm and STDf showed a pattern similarity measured by a correlation coefficient equal to 0.83 (+/-0.13) and by a normalised root mean square distance equal to 27% (+/-16%). The described estimate of the STD pattern and magnitude, even with the above-mentioned indeterminacies, constitutes valuable information when aiming at optimal marker placement and is an indispensable prerequisite for bone pose estimator design and assessment.

Influence of osseointegration degree and pattern on resonance frequency in the assessment of dental implant stability using finite element analysis.

PURPOSE: Resonance frequency analysis (RFA) has been widely used to predict dental implant stability by assessing conditions surrounding the implant. The aim of this study was to investigate the influence of osseointegration degree and pattern on the resonance frequency of implant-bone structure by means of finite element analysis (FEA). MATERIALS AND METHODS: A basic FEA model was created to represent a titanium implant in a portion of the maxillary bone at the left first premolar region. This model was then used to compute the vibration behaviors for 5 osseointegration degrees and 8 osseointegration pattern models using modal and harmonic analysis. RESULTS: In the arbitrarily set osseointegration pattern models, a significant influence of osseointegration degree on the resonance frequency (P < .001) could be expressed as the linear function R2 = 0.99. No significant influence from the osseointegration pattern could be observed (P = .89). While the coronal-osseointegration model had a slightly higher resonance frequency than others and the apical-osseointegration model had the lowest, the difference between the highest and lowest value was within 5% (P = .51). In the randomly set osseointegration models, the osseointegration degree had a statistically significant influence on the resonance frequency (P < .001); the pattern of random osseointegration for a certain osseointegration degree had little influence. CONCLUSION: It seems that RFA can detect implant-stability changes related to the increase in osseointegration degree. However, careful consideration should be given to its use in predicting the stability in vivo of loss of osseointegration at the marginal bone.

Static mechanical assessment of elastic Young's modulus of tissue mimicking materials used for medical imaging.

Emerging medical imaging techniques usually provide quantitative diagnostic parameters. Since the description of a method for quantitative imaging of strain and elastic modulus distributions in soft tissues by Ophir et al. in 1991, research in elastography is progressing and experimental in vitro validation of new displacement estimators appears crucial for clinical applications. Materials mimicking biological tissues appear very useful to reach this goal. Nevertheless, correct validation necessitates knowledge of mechanical properties of the investigated material, which are often difficult to obtain. This study describes a simple method for mechanical characterization of gels used in elastography. We demonstrated the possibility to assess elasticity modulus with a reasonable reproducibility using simple tools and methods. For validation, the described method was further tested with 5 samples of Polyvinyl alcohol (PVA) cryogel having different values of elasticity. Young's moduli, from 24 to 135 kPa according to the number of freeze-thaw cycles (from 1 to 5) have been measured with a reproducibility varying from 2 to 7%, in the respect of strict measurements conditions. The method demonstrates good feasibility and acceptable reproducibility to mechanically characterize phantoms.

Mechanical property assessment of tissue-mimicking phantoms using remote palpation and optical read-out for amplitude of vibration and refractive index modulation.

A coherent light beam is used to interrogate the focal region within a tissue-mimicking phantom insonified by an ultrasound transducer. The ultrasound-tagged photons exiting from the object carry with them information on local optical path length fluctuations caused by refractive index variations and medium vibration. Through estimation of the force distribution in the focal region of the ultrasound transducer, and solving the forward elastography problem for amplitude of vibration of tissue particles, we observe that the amplitude is directed along the axis of the transducer. It is shown that the focal region interrogated by photons launched along the transducer axis carries phase fluctuations owing to both refractive index variations and particle vibration, whereas the photons launched perpendicular to the transducer axis carry phase fluctuations arising mainly from the refractive index variations, with only smaller contribution from vibration of particles. Monte-Carlo simulations and experiments done on tissue-mimicking phantoms prove that as the storage modulus of the phantom is increased, the detected modulation depth in autocorrelation is reduced, significantly for axial photons and only marginally for the transverse-directed photons. It is observed that the depth of modulation is reduced to a significantly lower and constant value as the storage modulus of the medium is increased. This constant value is found to be the same for both axial and transverse optical interrogation. This proves that the residual modulation depth is owing to refractive index fluctuations alone, which can be subtracted from the overall measured modulation depth, paving the way for a possible quantitative reconstruction of storage modulus. Moreover, since the transverse-directed photons are not significantly affected by storage modulus variations, for a quantitatively accurate read-out of absorption coefficient variation, the interrogating light should be perpendicular to the focusing ultrasound transducer axis.

Controlled Monte Carlo method for light propagation in tissue of semi-infinite geometry.

The controlled Monte Carlo method is generalized to model photon migration in turbid media of arbitrary geometries. Its implementation for the reflection geometry is exemplified in this paper. The most probable diffuse direction of light is used as the local attractive vector that serves as the basis of biased sampling of scattering angles. Consequently, path-length resolved photon trajectories can be generated with a significantly improved efficiency. We report a more than 29 times reduction in simulation time for early arriving photons in a typical configuration.

Time-domain Green functions for diffuse light in two adjoining turbid half-spaces.

Propagation of light emitted by an instantaneous source located above a plane interface between two semi-infinite turbid media is considered using the diffusion approximation. Green functions are derived for an instantaneous line source and an instantaneous point source by the method of Bellman et al. [Philos. Mag. 40, 297 (1949)], which is based on integral transforms. Both two-dimensional and three-dimensional Green functions for diffuse light have been obtained in the form of single integrals that allow for fast calculation of the specific intensity in the whole space. The influence of the optical parameters of the two media (diffusion coefficients, absorptions, and refractive indices) on the shapes of the contour lines of the specific intensity is analyzed.

Modeling low-coherence enhanced backscattering using Monte Carlo simulation.

Constructive interference between coherent waves traveling time-reversed paths in a random medium gives rise to the enhancement of light scattering observed in directions close to backscattering. This phenomenon is known as enhanced backscattering (EBS). According to diffusion theory, the angular width of an EBS cone is proportional to the ratio of the wavelength of light lambda to the transport mean-free-path length l(s)* of a random medium. In biological media a large l(s)* approximately 0.5-2 mm >> lambda results in an extremely small (approximately 0.001 degrees ) angular width of the EBS cone, making the experimental observation of such narrow peaks difficult. Recently, the feasibility of observing EBS under low spatial coherence illumination (spatial coherence length Lsc << l(s)*) was demonstrated. Low spatial coherence behaves as a spatial filter rejecting longer path lengths and thus resulting in an increase of more than 100 times in the angular width of low coherence EBS (LEBS) cones. However, a conventional diffusion approximation-based model of EBS has not been able to explain such a dramatic increase in LEBS width. We present a photon random walk model of LEBS by using Monte Carlo simulation to elucidate the mechanism accounting for the unprecedented broadening of the LEBS peaks. Typically, the exit angles of the scattered photons are not considered in modeling EBS in the diffusion regime. We show that small exit angles are highly sensitive to low-order scattering, which is crucial for accurate modeling of LEBS. Our results show that the predictions of the model are in excellent agreement with the experimental data.

Correlation transfer and diffusion of ultrasound-modulated multiply scattered light.

We develop a temporal correlation transfer equation (CTE) and a temporal correlation diffusion equation (CDE) for ultrasound-modulated multiply scattered light. These equations can be applied to an optically scattering medium with embedded optically scattering and absorbing objects to calculate the power spectrum of light modulated by a nonuniform ultrasound field. We present an analytical solution based on the CDE and Monte Carlo simulation results for light modulated by a cylinder of ultrasound in an optically scattering slab. We further validate with experimental measurements the numerical calculations for an actual ultrasound field. The CTE and CDE are valid for moderate ultrasound pressures and on a length scale comparable with the optical transport mean-free path. These equations should be applicable to a wide spectrum of conditions for ultrasound-modulated optical tomography of soft biological tissues.

Monte Carlo-based inverse model for calculating tissue optical properties. Part I: Theory and validation on synthetic phantoms.

A flexible and fast Monte Carlo-based model of diffuse reflectance has been developed for the extraction of the absorption and scattering properties of turbid media, such as human tissues. This method is valid for a wide range of optical properties and is easily adaptable to existing probe geometries, provided a single phantom calibration measurement is made. A condensed Monte Carlo method was used to speed up the forward simulations. This model was validated by use of two sets of liquid-tissue phantoms containing Nigrosin or hemoglobin as absorbers and polystyrene spheres as scatterers. The phantoms had a wide range of absorption (0-20 cm(-1)) and reduced scattering coefficients (7-33 cm(-1)). Mie theory and a spectrophotometer were used to determine the absorption and reduced scattering coefficients of the phantoms. The diffuse reflectance spectra of the phantoms were measured over a wavelength range of 350-850 nm. It was found that optical properties could be extracted from the experimentally measured diffuse reflectance spectra with an average error of 3% or less for phantoms containing hemoglobin and 12% or less for phantoms containing Nigrosin.

Assessment of 1-lead and 2-lead electrode patterns in electrical impedance endotomography.

Electrical impedance endotomography (EIE) is a modality of impedance imaging where the electrodes are located on an insulating core placed at the centre of the region of interest. The absence of a physical limit to the medium surrounding the probe enables the use of remote electrodes. The present study compares the features of 2-lead measurements, where the two pairs of electrodes are located on the probe, to 1-lead measurements, where one of the two injection electrodes and one of the two sensing electrodes are located at a distance far away from the probe. The methodology was the characterization of the sensitivity matrix under the influence of electrode pattern, reconstruction radius and mesh construction. Three mesh constructions, three values of the reconstruction radius and five electrode patterns were compared. The study was carried out in 2D using calculated data. Measurement noise was simulated by an addition of 5% Gaussian white noise. The images were reconstructed using the Tikhonov method and L-curve technique. The results show that the reconstruction mesh and the radius of the reconstruction domain have less influence on the conditioning of the sensitivity matrix than the electrode pattern. Both 1-lead and 2-lead configurations enabled the reconstruction of images of relatively similar quality. Additional selection criteria are expected from hardware considerations.

Reconstruction of optical properties of low-scattering tissue using derivative estimated through perturbation Monte-Carlo method.

An iterative method for the reconstruction of optical properties of a low-scattering object, which uses a Monte-Carlo-based forward model, is developed. A quick way to construct and update the Jacobian needed to reconstruct a discretized object, based on the perturbation Monte-Carlo (PMC) approach, is demonstrated. The projection data is handled either one view at a time, using a propagation-backpropagation (PBP) strategy where the dimension of the inverse problem and consequently the computation time are smaller, or, when this approach failed, using all the views simultaneously with a full dataset. The main observations and results are as follows. 1. Whereas the PMC gives an accurate and quick method for constructing the Jacobian the same, when adapted to update the computed projection data, the data are not accurate enough for use in the iterative reconstruction procedure leading to convergence. 2. The a priori assumption of the location of inhomogeneities in the object reduces the dimension of the problem, leading to faster convergence in all the cases considered, such as an object with multiple inhomogeneities and data handled one view at a time (i.e., the PBP approach). 3. On the other hand, without a priori knowledge of the location of inhomogeneities, the problem was too ill posed for the PBP approach to converge to meaningful reconstructions when both absorption and scattering coefficients are considered as unknowns. Finally, to bring out the effectiveness of this method for reconstructing low-scattering objects, we apply a diffusion equation-based algorithm on a dataset from one of the low-scattering objects and show that it fails to reconstruct object inhomogeneities.

Advanced modelling of optical coherence tomography systems.

Analytical and numerical models for describing and understanding the light propagation in samples imaged by optical coherence tomography (OCT) systems are presented. An analytical model for calculating the OCT signal based on the extended Huygens-Fresnel principle valid both for the single and multiple scattering regimes is reviewed. An advanced Monte Carlo model for calculating the OCT signal is also reviewed, and the validity of this model is shown through a mathematical proof based on the extended Huygens-Fresnel principle. Moreover, for the first time the model is verified experimentally. From the analytical model, an algorithm for enhancing OCT images is developed: the so-called true-reflection algorithm in which the OCT signal may be corrected for the attenuation caused by scattering. For the first time, the algorithm is demonstrated by using the Monte Carlo model as a numerical tissue phantom. Such algorithm holds promise for improving OCT imagery and to extend the possibility for functional imaging.