Lower limb alignment becomes more varus and hyperextended from supine to bipedal stance in asymptomatic, osteoarthritic and prosthetic neutral or varus knees.

PURPOSE: Knee alignment is a fundamental measurement in the assessment, monitoring and surgical management of patients with osteoarthritis. There is a lack of data regarding how static tibiofemoral alignment varies between supine and standing conditions. This study aimed to quantify the relationship between supine and standing lower limb alignment in asymptomatic, osteoarthritic (OA) and prosthetic (TKA) knees. METHODS: A non-invasive position capture system was used to assess knee alignment for 30 asymptomatic controls and 31 patients with OA both before and after TKA. Coronal and sagittal mechanical femorotibial angles were measured supine with the lower limb in extension and in bipedal stance. Changes between conditions were analysed using paired ttests. Vector plots of ankle centre displacement relative to the knee centre from supine to standing were produced to allow three-dimensional visualisation. RESULTS: All groups showed a trend towards varus and extension when going from supine to standing. Mean change for asymptomatic knees was 1.2° more varus (p = 0.001) and 3.8° more extended (p < 0.001). For OA knees this was 1.1° more varus (p = 0.009) and 5.9° more extended (p < 0.001) and TKA knees 1.9° more varus (p < 0.001) and 5.6° more extended (p < 0.001). CONCLUSION: The observed consistent changes in lower limb alignment between supine and standing positions across knee types suggests the soft tissue envelope restraining the knee may have a greater influence on dynamic alignment changes than the underlying bony deformity. This highlights the importance of quantifying soft tissue behaviour when planning, performing and evaluating alignment dependent surgical interventions of the knee. When routinely assessing any type of knee, clinicians should be aware that subtle consistent alignment changes occur under weightbearing conditions and tailor their treatments accordingly. LEVEL OF EVIDENCE: II.

Thermal Damage Done to Bone by Burring and Sawing With and Without Irrigation in Knee Arthroplasty.

BACKGROUND: Heat from bone resecting tools used in knee surgery can induce thermal osteonecrosis, potentially causing aseptic implant loosening. This study compared oscillating saws to burrs in terms of temperature generation and histologic damage. Use of irrigation to reduce bone temperature was also investigated. METHODS: Temperatures were recorded during sawing and burring with or without irrigation (uncooled or cooled). Histologic analyses were then carried out. Differences between groups were tested statistically (α = 0.05). RESULTS: On average, burring produced higher temperatures than sawing (P < .001). When uncooled irrigation was used, bone temperatures were significantly lower in sawed bone than in burred bone (P < .001). Irrigation lowered temperatures and thermal damage depths and increased osteocyte viability (P < .001). CONCLUSION: These results suggest that irrigating bone during resection could prevent osteonecrosis onset.

High degree of accuracy of a novel image-free handheld robot for unicondylar knee arthroplasty in a cadaveric study.

BACKGROUND: Surgical robotics has been shown to improve the accuracy of bone preparation and soft tissue balance in unicondylar knee arthroplasty (UKA). However, although extensive data have emerged with regard to a CT scan-based haptically constrained robotic arm, little is known about the accuracy of a newer alternative, an imageless robotic system. QUESTIONS/PURPOSES: We assessed the accuracy of a novel imageless semiautonomous freehand robotic sculpting system in performing bone resection and preparation in UKA using cadaveric specimens. METHODS: In this controlled study, we compared the planned and final implant placement in 25 cadaveric specimens undergoing UKA using the new tool. A quantitative analysis was performed to determine the translational, angular, and rotational differences between the planned and achieved positions of the implants. RESULTS: The femoral implant rotational mean error was 1.04° to 1.88° and mean translational error was 0.72 to 1.29 mm across the three planes. The tibial implant rotational mean error was 1.48° to 1.98° and the mean translational error was 0.79 to 1.27 mm across the three planes. CONCLUSIONS: The image-free robotic sculpting tool achieved accurate implementation of the surgical plan with small errors in implant placement. The next step will be to determine whether accurate implant placement translates into a clinical and functional benefit for the patient.

Research synthesis of recommended acetabular cup orientations for total hip arthroplasty.

Total hip arthroplasty (THA) is regarded as one of the most successful surgical procedures of modern times yet continues to be associated with a small but significant complication rate. Many early failures may be associated with poor component positioning with, in particular, acetabular component orientation dependent on the subjective judgement of the surgeon. In this paper, we compare the manufacturers' instructions on acetabular cup orientation with the literature-based recommended safety zones and surgical technique, by transforming them onto a single, clinically-relevant framework in which the different reference systems, safety guidelines and current instrumentation surgical techniques can be evaluated. The observed limited consensus between results reflects ongoing uncertainty regarding the optimum acetabular component positioning. As malpositioning of the acetabular cup increases the risk of revision surgery, any ambiguity over the correct position can have a causal effect. Our analysis highlights the need for a surgical reference system which can be used to describe the position of the acetabular cup intra-operatively.

Validity and reliability of an alternative method for measuring power output during six-second all-out cycling.

In a laboratory setting where both a mechanically-braked cycling ergometer and a motion analysis (MA) system are available, flywheel angular displacement can be estimated by using MA. The purpose of this investigation was to assess the validity and reliability of a MA method for measuring maximal power output (Pmax) in comparison with a force transducer (FT) method. Eight males and eight females undertook three identical sessions, separated by 4 to 6 days; the first being a familiarization session. Individuals performed three 6-second sprints against 50% of the maximal resistance to complete two pedal revolutions with a 3-minute rest between trials. Power was determined independently using both MA and FT analyses. Validity: MA recorded significantly higher Pmax than FT (P < .05). Bland-Altman plots showed that there was a systematic bias in the difference between the measures of the two systems. This difference increased as power increased. Repeatability: Intraclass correlation coefficients were on average 0.90 ± 0.05 in males and 0.85 ± 0.08 in females. Measuring Pmax by MA, therefore, is as appropriate for use in exercise physiology research as Pmax measured by FT, provided that a bias between these measurements methods is allowed for.

Exploiting light-based 3D-printing for the fabrication of mechanically enhanced, patient-specific aortic grafts.

Despite polyester vascular grafts being routinely used in life-saving aortic aneurysm surgeries, they are less compliant than the healthy, native human aorta. This mismatch in mechanical behaviour has been associated with disruption of haemodynamics contributing to several long-term cardiovascular complications. Moreover, current fabrication approaches mean that opportunities to personalise grafts to the individual anatomical features are limited. Various modifications to graft design have been investigated to overcome such limitations; yet optimal graft functionality remains to be achieved. This study reports on the development and characterisation of an alternative vascular graft material. An alginate:PEGDA (AL:PE) interpenetrating polymer network (IPN) hydrogel has been produced with uniaxial tensile tests revealing similar strength and stiffness (0.39 ± 0.05 MPa and 1.61 ± 0.19 MPa, respectively) to the human aorta. Moreover, AL:PE tubular conduits of similar geometrical dimensions to segments of the aorta were produced, either via conventional moulding methods or stereolithography (SLA) 3D-printing. While both fabrication methods successfully demonstrated AL:PE hydrogel production, SLA 3D-printing was more easily adaptable to the fabrication of complex structures without the need of specific moulds or further post-processing. Additionally, most 3D-printed AL:PE hydrogel tubular conduits sustained, without failure, compression up to 50% their outer diameter and returned to their original shape upon load removal, thereby exhibiting promising behaviour that could withstand pulsatile pressure in vivo. Overall, these results suggest that this AL:PE IPN hydrogel formulation in combination with 3D-printing, has great potential for accelerating progress towards personalised and mechanically-matched aortic grafts.

Comparison of power and EMG during 6-s all-out cycling between young and older women.

To investigate the effects of ageing on the neural control strategies governing sprint cycling on a friction-loaded cycle-ergometer, 10 older (aged 70-83 yr) and 8 young (aged 19-35 yr) healthy women completed seven 6-s all-out cycling trials against varying loads. Root mean square (RMS), median frequency and muscle fibre conduction velocity were determined from the vastus lateralis of the dominant limb during each pedal stroke. Peak power was 43% lower in the older group compared to the younger (p < 0.001) and was accompanied by a significantly lower RMS (p < 0.05). No differences were observed in the other electromyography (EMG) parameters between the groups (p > 0.05). ΔRMS from the first to the sixth second during each trial was found to increase significantly with the development of power output in both groups (p < 0.05). For the first time during an all-out 6-s cycle trial, it has been demonstrated that older women's lower mechanical power output was accompanied by a significantly lower RMS, which indicates a decline in either the number of active of motor units or a reduced discharge rate. Hence, changes in motor units can be regarded as a contributory factor to the decline of muscle power with advancing age. Overall, though, similar neural strategies are adopted in both younger and older populations.

Standardising the clinical assessment of coronal knee laxity.

Clinical laxity tests are used for assessing knee ligament injuries and for soft tissue balancing in total knee arthroplasty. This study reports the development and validation of a quantitative technique of assessing collateral knee laxity through accurate measurement of potential variables during routine clinical examination. The hypothesis was that standardisation of a clinical stress test would result in a repeatable range of laxity measurements. Non-invasive infrared tracking technology with kinematic registration of joint centres gave real-time measurement of both coronal and sagittal mechanical tibiofemoral alignment Knee flexion, moment arm and magnitude of the applied force were all measured and standardised. Three clinicians then performed six knee laxity examinations on a single volunteer using a target moment of 18 Nm. Standardised laxity measurements had small standard deviations (within 1. 1 degree) for each clinician and similar mean values between clinicians, with the valgus laxity assessment (mean of 3 degrees) being slightly more consistent than varus (means of 4 degrees or 5 degrees). The manual technique of coronal knee laxity assessment was successfully quantified and standardised, leading to a narrow range of measurements (within the accuracy of the measurement system). Minimising the subjective variables of clinical examination could improve current knowledge of soft tissue knee behaviour.

The assessment of instability in the osteoarthritic knee.

Patient-reported instability is a common complaint amongst those with knee arthritis.Much research has examined the assessment of self-reported instability in the knee; however, no definitive quantitative measure of instability has been developed.This review focuses on the current literature investigating the nature of self-reported instability in the arthritic knee and discusses the possibilities of further investigation. Cite this article: EFORT Open Rev 2019;4:70-76. DOI: 10.1302/2058-5241.4.170079.

On the relationships between applied force, photography technique, and the quantification of bruise appearance.

Bruising is an injury commonly observed within suspect cases of assault or abuse, yet how a blunt impact initiates bruising and influences its severity is not fully understood. Furthermore, the standard method of documenting a bruise with colour photography is known to have limitations which influence the already subjective analysis of a bruise. This research investigated bruising using a standardised blunt impact, delivered to 18 volunteers. The resulting bruise was imaged using colour, cross polarised (CP) and infrared photography. Timelines of the L*a*b* colour space were determined from both colour and CP images for up to 3 weeks. Overall, no single photographic technique out-performed the others, however CP did provide greater contrast than colour photography. L*a*b* colour space timelines were not attributable any physiological characteristics. Whilst impact force negatively correlated with BMI (R2 = 0.321), neither were associated with any measure of bruise appearance. Due to the inter-subject variability in the bruise response to a controlled infliction, none of the methods in the current study could be used to reliably predict the age of a bruise or the severity of force used in creating a bruise. A more comprehensive approach combining impact characteristics, tissue mechanics, enhanced localised physiological measures and improvements in quantifying bruise appearance is likely to be essential in removing subjectivity from their interpretation.

Computer assisted orthopaedic surgery: Past, present and future.

Computer technology is ubiquitous and relied upon in virtually all professional activities including neurosurgery, which is why it is surprising that it is not the case for orthopaedic surgery with fewer than 5% of surgeons using available computer technology in their procedures. In this review, we explore the evolution and background of Computer Assisted Orthopaedic Surgery (CAOS), delving into the basic principles behind the technology and the changes in the discussion on the subject throughout the years and the impact these discussions had on the field. We found evidence that industry had an important role in driving the discussion at least in knee arthroplasty-a leading field of CAOS-with the ratio between patents and publications increased from approximately 1:10 in 2004 to almost 1:3 in 2014. The adoption of CAOS is largely restrained by economics and ergonomics with sceptics challenging the accuracy and precision of navigation during the early years of CAOS moving to patient functional improvements and long term survivorship. Nevertheless, the future of CAOS remains positive with the prospect of new technologies such as improvements in image-guided surgery, enhanced navigation systems, robotics and artificial intelligence.

Determination of the strain-dependent hydraulic permeability of the compressed bovine nucleus pulposus.

The hydraulic permeability, k, of the nucleus pulposus (NP) is crucial, both in withstanding compressive stress and for convective transport of nutrients within the disc. Permeability has previously been determined using biphasic mathematical models, but has not been found by direct permeation experiments, which is the objective of this study. Bovine coccygeal nucleus samples (n=64), phi10mm and thickness 683+/-49microm (mean+/-S.D.) were compressed axially to one of lambda=1.0, 0.9, 0.8, 0.7, 0.6, 0.5, 0.4 or 0.3, where lambda is the stretch ratio. Ringer's solution was permeated through the sample, with an o-ring ensuring axial flow. During stress equilibrium, k was determined and fitted to four permeability-strain equations. Permeability decreased exponentially with compression, and was best described by Values of k were comparable to those arising from mathematical models, lending confidence to permeability being determined from such models.

The strain-dependent osmotic pressure and stiffness of the bovine nucleus pulposus apportioned into ionic and non-ionic contributors.

Elucidation of the load-bearing mechanism of the nucleus pulposus (NP) facilitates understanding of the mechanical and metabolic functioning of the intervertebral disc and provides key data for mathematical models. Negatively charged proteoglycans in the NP generate an ionic osmotic pressure, pi(i), which contributes to the tissue's resistance to load and, moreover, is the main mechanism by which the unloaded disc rehydrates. Functionally important, pi(i) has seldom been investigated in situ and, crucially, its variation with strain has not been reported. In a confined compression apparatus, we aimed to apportion the strain-dependent load-bearing mechanism of the NP at equilibrium to the tissue matrix and ionic osmotic pressure; and to determine whether any proteoglycan loss occurs during confined compression testing. Forty-eight confined compression experiments were conducted in isotonic (0.15M NaCl) and hypertonic (3.0 and 6.1M NaCl) external solutions in single and multiple step-strain protocols. The 6.1M NaCl external solution was needed to eliminate as much of the ionic effects as possible. The ionic osmotic pressure was well described by pi(i)=19.1lambda(-1.58) (R(2)=0.992), and was approximately 70% of the applied load at equilibrium, independent of lambda. The effective aggregate modulus, H(A)(eff), also increased with strain: H(A)(eff)=59.0lambda(-2.18). Concentrations of sulphated glycosaminoglycans were obtained for the samples tested in isotonic NaCl with no proteoglycan loss detected from the confined compression tests. These results highlight the non-linearity of the stress-strain response of NP tissue and the necessity to include a non-linear function for osmotic pressure in mathematical models of this tissue.

Inertial properties of the German Shepherd Dog.

One of the most popular dog breeds deployed by both the police and military has been the German Shepherd yet little is known about the morphology or body segment parameters of this breed. Such measures are essential for developing biomechanical models which, in turn, may guide clinicians in developing surgical interventions, injury treatment and prevention procedures. This paper provides a complete set of body segment parameters and inertial properties for the German Shepherd. Morphometric measures and 3-dimensional inertial properties, including mass, centre of mass, moment of inertia and volume, were measured from 17 segments from 6 German Shepherd police service dog cadavers. Using whole body mass and geometric modelling, 11 regression equations were developed for predicting segment masses, and 33 equations were developed for predicting moments of inertia. Using these data, inverse dynamic analyses may be applied in future investigations of canine mechanics, guiding surgical procedures, rehabilitation and training especially for the German Shepherd breed but potentially for other breeds too.

Moderate alterations in lower limbs muscle temperature do not affect postural stability during quiet standing in both young and older women.

Older adults demonstrate increased amounts of postural sway, which may ultimately lead to falls. Temperature is known to have a profound effect on the performance of the neuromuscular system which could have important implications on motor control. It is, therefore, of interest to investigate if the age-related decline in postural stability could be affected by changes in local limbs temperature. The present study investigated the effects of localized warming and cooling on postural sway in nine young (22+/-3 years) and nine older (73+/-3 years) women. Postural sway was assessed, using a single force platform, during quiet standing at three muscle temperature conditions: control (34.2+/-0.2 degrees C), cold (31.3+/-0.3 degrees C) and warm (37.0+/-0.1 degrees C). Two stances were evaluated, the Romberg (large support base) and modified Tandem (narrow support base), under both eyes-open and eyes-closed conditions. Root mean square (RMS), mean velocity (MV), sway area (SA) and mean power frequency (MPF) were calculated from the centre of pressure (COP) displacement. Neither warming nor cooling significantly affected any of the postural parameters which were, however, all higher (P<0.05) in the older group than the young group in all conditions. This study demonstrated that, in quiet standing conditions, a moderate variation (+/-3 degrees C) in lower limbs temperature does not affect postural steadiness in either young or older women.

Lower limb alignment and laxity measures before, during and after total knee arthroplasty: A prospective cohort study.

BACKGROUND: This study compared knee alignment and laxity in patients before, during and after total knee arthroplasty, using methodologically similar procedures, with an aim to help inform pre-operative planning. METHODS: Eighteen male and 13 female patients were recruited, mean age 66years (51-82) and mean body mass index of 33 (23-43). All were assessed pre- and postoperatively using a non-invasive infrared position capture system and all underwent total knee arthroplasty using a navigation system. Knee kinematic data were collected and comparisons made between preoperative clinical and intraoperative measurements for osteoarthritic knees, and between postoperative clinical and intraoperative measurements for prosthetic knees. FINDINGS: There was no difference in unstressed coronal mechanical femoral-tibial angles for either osteoarthritic or prosthetic knees. However, for sagittal alignment the knees were in greater extension intraoperatively (osteoarthritic 5.2° p<0.001, prosthetic 7.2° p<0.001). For osteoarthritic knees, both varus and valgus stress manoeuvres had greater angular displacements intraoperatively by a mean value of 1.5° for varus (p=0.002) and 1.6° for valgus (p<0.001). For prosthetic knees, only valgus angular displacement was greater intraoperatively (0.9°, p=0.002). INTERPRETATION: Surgeons performing total knee arthroplasties should be aware of potential differences in alignment and laxity measured under different conditions to facilitate more accurate operative planning and follow-up.

Tensile properties of the transverse carpal ligament and carpal tunnel complex.

BACKGROUND: A new sophisticated method that uses video analysis techniques together with a Maillon Rapide Delta to determine the tensile properties of the transverse carpal ligament-carpal tunnel complex has been developed. METHODS: Six embalmed cadaveric specimens amputated at the mid-forearm and aged (mean (SD)): 82 (6.29) years were tested. The six hands were from three males (four hands) and one female (two hands). Using trigonometry and geometry the elongation and strain of the transverse carpal ligament and carpal arch were calculated. The cross-sectional area of the transverse carpal ligament was determined. Tensile properties of the transverse carpal ligament-carpal tunnel complex and Load-Displacement data were also obtained. Descriptive statistics, one-way ANOVA together with a post-hoc analysis (Tukey) and t-tests were incorporated. FINDINGS: A transverse carpal ligament-carpal tunnel complex novel testing method has been developed. The results suggest that there were no significant differences between the original transverse carpal ligament width and transverse carpal ligament at peak elongation (P=0.108). There were significant differences between the original carpal arch width and carpal arch width at peak elongation (P=0.002). The transverse carpal ligament failed either at the mid-substance or at their bony attachments. At maximum deformation the peak load and maximum transverse carpal ligament displacements ranged from 285.74N to 1369.66N and 7.09mm to 18.55mm respectively. The transverse carpal ligament cross-sectional area mean (SD) was 27.21 (3.41)mm(2). INTERPRETATION: Using this method the results provide useful biomechanical information and data about the tensile properties of the transverse carpal ligament-carpal tunnel complex.

Accuracy of a freehand sculpting tool for unicondylar knee replacement.

BACKGROUND: Unicondylar knee replacement is technically challenging and malalignment of the implant components is one of the factors that results in high failure rates. Surgical robotics with navigation is emerging as a potential solution to improve the accuracy of implant placement. METHODS: The accuracy of performing unicondylar knee replacement using a freehand sculpting, semi-active robotic tool was investigated using 20 synthetic femurs and tibia. Resultant femoral and tibial implant placement was compared to the planned implant position. RESULTS: The maximum rotational error was 3.2(o) and RMS angular error was 1.46(o) across all orientations, for both the tibia and femoral implants. The maximum translational error was 1.18 mm and the RMS translational error across all directions was 0.61 mm. CONCLUSIONS: The freehand sculpting tool produced accurate implant placement with small errors comparable to those reported by other robotic-assistive devices on the market for unicondylar knee replacement.

Confined compression of collagen hydrogels.

Reconstituted collagen hydrogels are often used for in vitro studies of cell-matrix interaction and as scaffolds for tissue engineering. Understanding the mechanical and transport behaviours of collagen hydrogels is therefore extremely important, albeit difficult due to their very high water content (typically >99.5%). In the present study the mechanical behaviour of collagen hydrogels in confined compression was investigated using biphasic theory (J Biomechemical Engineering 102 (1980) 73), to ascertain whether the technique is sufficiently sensitive to determine differences in the characteristics of hydrogels of between 0.2% and 0.4% collagen. Peak stress, equilibrium stress, aggregate modulus and hydraulic permeability of the hydrogels exhibited sensitivity to collagen content, demonstrating that the technique is clearly able to discriminate between hydrogels with small differences in collagen content and may also be sensitive to factors that affect matrix remodelling. The results also offer additional insight into the deformation-dependent permeability of collagen hydrogels. This study suggests that confined compression, together with biphasic theory, is a suitable technique for assessing the mechanical properties of collagen hydrogels.

Sensitivity analysis of permeability parameters of bovine nucleus pulposus obtained through inverse fitting of the nonlinear biphasic equation: effect of sampling strategy.

Permeability controls the fluid flow into and out of soft tissue, and plays an important role in maintaining the health status of such tissue. Accurate determination of the parameters that define permeability is important for the interpretation of models that incorporate such processes. This paper describes the determination of strain-dependent permeability parameters from the nonlinear biphasic equation from experimental data of different sampling frequencies using the Nelder-Mead simplex method. The ability of this method to determine the global optimum was assessed by constructing the whole manifold arising from possible parameter combinations. Many parameter combinations yielded similar fits with the Nelder-Mead algorithm able to identify the global maximum within the resolution of the manifold. Furthermore, the sampling strategy affected the optimum values of the permeability parameters. Therefore, permeability parameter estimations arising from inverse methods should be utilised with the knowledge that they come with large confidence intervals.