Evoking natural thermal perceptions using a thin-film thermoelectric device with high cooling power density and speed.

Multimodal sensory feedback from upper-limb prostheses can increase their function and usability. Here we show that intuitive thermal perceptions during cold-object grasping with a prosthesis can be restored in a phantom hand through targeted nerve stimulation via a wearable thin-film thermoelectric device with high cooling power density and speed. We found that specific regions of the residual limb, when thermally stimulated, elicited thermal sensations in the phantom hand that remained stable beyond 48 weeks. We also found stimulation sites that selectively elicited sensations of temperature, touch or both, depending on whether the stimulation was thermal or mechanical. In closed-loop functional tasks involving the identification of cold objects by amputees and by non-amputee participants, and compared with traditional bulk thermoelectric devices, the wearable thin-film device reliably elicited cooling sensations that were up to 8 times faster and up to 3 times greater in intensity while using half the energy and 1/600th the mass of active thermoelectric material. Wearable thin-film thermoelectric devices may allow for the non-invasive restoration of thermal perceptions during touch.

Monitoring at-home prosthesis control improvements through real-time data logging.

Objective.Validating the ability for advanced prostheses to improve function beyond the laboratory remains a critical step in enabling long-term benefits for prosthetic limb users.Approach.A nine week take-home case study was completed with a single participant with upper limb amputation and osseointegration to better understand how an advanced prosthesis is used during daily activities. The participant was already an expert prosthesis user and used the Modular Prosthetic Limb (MPL) at home during the study. The MPL was controlled using wireless electromyography (EMG) pattern recognition-based movement decoding. Clinical assessments were performed before and after the take-home portion of the study. Data was recorded using an onboard data log in order to measure daily prosthesis usage, sensor data, and EMG data.Main results.The participant's continuous prosthesis usage steadily increased (p= 0.04, max = 5.5 h) over time and over 30% of the total time was spent actively controlling the prosthesis. The duration of prosthesis usage after each pattern recognition training session also increased over time (p= 0.04), resulting in up to 5.4 h of usage before retraining the movement decoding algorithm. Pattern recognition control accuracy improved (1.2% per week,p< 0.001) with a maximum number of ten classes trained at once and the transitions between different degrees of freedom increased as the study progressed, indicating smooth and efficient control of the advanced prosthesis. Variability of decoding accuracy also decreased with prosthesis usage (p< 0.001) and 30% of the time was spent performing a prosthesis movement. During clinical evaluations, Box and Blocks and the Assessment of the Capacity for Myoelectric Control scores increased by 43% and 6.2%, respectively, demonstrating prosthesis functionality and the NASA Task Load Index scores decreased, on average, by 25% across assessments, indicating reduced cognitive workload while using the MPL, over the nine week study.Significance. In this case study, we demonstrate that an onboard system to monitor prosthesis usage enables better understanding of how prostheses are incorporated into daily life. That knowledge can support the long-term goal of completely restoring independence and quality of life to individuals living with upper limb amputation.

Extended home use of an advanced osseointegrated prosthetic arm improves function, performance, and control efficiency.

Objective.Full restoration of arm function using a prosthesis remains a grand challenge; however, advances in robotic hardware, surgical interventions, and machine learning are bringing seamless human-machine interfacing closer to reality.Approach.Through extensive data logging over 1 year, we monitored at-home use of the dexterous Modular Prosthetic Limb controlled through pattern recognition of electromyography (EMG) by an individual with a transhumeral amputation, targeted muscle reinnervation, and osseointegration (OI).Main results.Throughout the study, continuous prosthesis usage increased (1% per week,p< 0.001) and functional metrics improved up to 26% on control assessments and 76% on perceived workload evaluations. We observed increases in torque loading on the OI implant (up to 12.5% every month,p< 0.001) and prosthesis control performance (0.5% every month,p< 0.005), indicating enhanced user integration, acceptance, and proficiency. More importantly, the EMG signal magnitude necessary for prosthesis control decreased, up to 34.7% (p< 0.001), over time without degrading performance, demonstrating improved control efficiency with a machine learning-based myoelectric pattern recognition algorithm. The participant controlled the prosthesis up to one month without updating the pattern recognition algorithm. The participant customized prosthesis movements to perform specific tasks, such as individual finger control for piano playing and hand gestures for communication, which likely contributed to continued usage.Significance.This work demonstrates, in a single participant, the functional benefit of unconstrained use of a highly anthropomorphic prosthetic limb over an extended period. While hurdles remain for widespread use, including device reliability, results replication, and technical maturity beyond a prototype, this study offers insight as an example of the impact of advanced prosthesis technology for rehabilitation outside the laboratory.

Clinical evaluation of the revolutionizing prosthetics modular prosthetic limb system for upper extremity amputees.

Individuals with upper extremity (UE) amputation abandon prostheses due to challenges with significant device weight-particularly among myoelectric prostheses-and limited device dexterity, durability, and reliability among both myoelectric and body-powered prostheses. The Modular Prosthetic Limb (MPL) system couples an advanced UE prosthesis with a pattern recognition paradigm for intuitive, non-invasive prosthetic control. Pattern recognition accuracy and functional assessment-Box & Blocks (BB), Jebsen-Taylor Hand Function Test (JHFT), and Assessment of Capacity for Myoelectric Control (ACMC)-scores comprised the main outcomes. 10 participants were included in analyses, including seven individuals with traumatic amputation, two individuals with congenital limb absence, and one with amputation secondary to malignancy. The average (SD) time since limb loss, excluding congenital participants, was 85.9 (59.5) months. Participants controlled an average of eight motion classes compared to three with their conventional prostheses. All participants made continuous improvements in motion classifier accuracy, pathway completion efficiency, and MPL manipulation. BB and JHFT improvements were not statistically significant. ACMC performance improved for all participants, with mean (SD) scores of 162.6 (105.3), 213.4 (196.2), and 383.2 (154.3), p = 0.02 between the baseline, midpoint, and exit assessments, respectively. Feedback included lengthening the training period to further improve motion classifier accuracy and MPL control. The MPL has potential to restore functionality to individuals with acquired or congenital UE loss.

Sensory stimulation enhances phantom limb perception and movement decoding.

OBJECTIVE: A major challenge for controlling a prosthetic arm is communication between the device and the user's phantom limb. We show the ability to enhance phantom limb perception and improve movement decoding through targeted transcutaneous electrical nerve stimulation in individuals with an arm amputation. APPROACH: Transcutaneous nerve stimulation experiments were performed with four participants with arm amputation to map phantom limb perception. We measured myoelectric signals during phantom hand movements before and after participants received sensory stimulation. Using electroencephalogram (EEG) monitoring, we measured the neural activity in sensorimotor regions during phantom movements and stimulation. In one participant, we also tracked sensory mapping over 2 years and movement decoding performance over 1 year. MAIN RESULTS: Results show improvements in the participants' ability to perceive and move the phantom hand as a result of sensory stimulation, which leads to improved movement decoding. In the extended study with one participant, we found that sensory mapping remains stable over 2 years. Sensory stimulation improves within-day movement decoding while performance remains stable over 1 year. From the EEG, we observed cortical correlates of sensorimotor integration and increased motor-related neural activity as a result of enhanced phantom limb perception. SIGNIFICANCE: This work demonstrates that phantom limb perception influences prosthesis control and can benefit from targeted nerve stimulation. These findings have implications for improving prosthesis usability and function due to a heightened sense of the phantom hand.

Mechanism of posterior malleolar fracture of the ankle: A cadaveric study.

OBJECTIVES: Ankle fracture treatment involves reduction of the bone fragments and stabilization of the joint by reversing the mechanics of injury. For posterior malleolar fracture however, the true mechanism is not understood, leading to a lack of consistent guidance on how to best treat this injury. METHODS: Fifteen cadaver ankles were subjected to fracture loading that replicated the Lauge-Hansen pronation-external rotation mechanism. An axial load was applied to each specimen, which was mounted on a materials testing machine, and the foot was rotated externally to failure. Digital video cameras recorded the failure sequence of specific anatomic structures. RESULTS: Posterior malleolar fracture occurred in 7 specimens. Of these, 1 was an intra-articular fracture, another was a fracture involving the entire posterior tibial margin consisting of 2 fragments: that of the posterior tubercle and that of the posteromedial margin of the tibial plafond, with the former judged to be a consequence of avulsion by the posterior inferior tibiofibular ligament and the latter a consequence of axial loading from the talus. In the remaining 5 specimens, the posterior malleolar fracture was a small extra-articular avulsion fracture. CONCLUSIONS: Fractures at the posterolateral corner of the distal tibia were shown to be avulsion fractures attributed to the posterior inferior tibiofibular ligament and produced by external rotation of the talus. A fracture involving the entire posterior tibial margin consisting of 2 fragments can be produced by a combination of avulsion by the posterior inferior tibiofibular ligament and axial loading from the talus.

Virtual Integration Environment as an Advanced Prosthetic Limb Training Platform.

Background: Despite advances in prosthetic development and neurorehabilitation, individuals with upper extremity (UE) loss continue to face functional and psychosocial challenges following amputation. Recent advanced myoelectric prostheses offer intuitive control over multiple, simultaneous degrees of motion and promise sensory feedback integration, but require complex training to effectively manipulate. We explored whether a virtual reality simulator could be used to teach dexterous prosthetic control paradigms to individuals with UE loss. Methods: Thirteen active-duty military personnel with UE loss (14 limbs) completed twenty, 30-min passive motor training sessions over 1-2 months. Participants were asked to follow the motions of a virtual avatar using residual and phantom limbs, and electrical activity from the residual limb was recorded using surface electromyography. Eight participants (nine limbs), also completed twenty, 30-min active motor training sessions. Participants controlled a virtual avatar through three motion sets of increasing complexity (Basic, Advanced, and Digit) and were scored on how accurately they performed requested motions. Score trajectory was assessed as a function of time using longitudinal mixed effects linear regression. Results: Mean classification accuracy for passive motor training was 43.8 ± 10.7% (14 limbs, 277 passive sessions). In active motor sessions, >95% classification accuracy (which we used as the threshold for prosthetic acceptance) was achieved by all participants for Basic sets and by 50% of participants in Advanced and Digit sets. Significant improvement in active motor scores over time was observed in Basic and Advanced sets (per additional session: ß-coefficient 0.125, p = 0.022; ß-coefficient 0.45, p = 0.001, respectively), and trended toward significance for Digit sets (ß-coefficient 0.594, p = 0.077). Conclusions: These results offer robust evidence that a virtual reality training platform can be used to quickly and efficiently train individuals with UE loss to operate advanced prosthetic control paradigms. Participants can be trained to generate muscle contraction patterns in residual limbs that are interpreted with high accuracy by computer software as distinct active motion commands. These results support the potential viability of advanced myoelectric prostheses relying on pattern recognition feedback or similar controls systems.

Clinical Trial of the Virtual Integration Environment to Treat Phantom Limb Pain With Upper Extremity Amputation.

Background: Phantom limb pain (PLP) is commonly seen following upper extremity (UE) amputation. Use of both mirror therapy, which utilizes limb reflection in a mirror, and virtual reality therapy, which utilizes computer limb simulation, has been used to relieve PLP. We explored whether the Virtual Integration Environment (VIE), a virtual reality UE simulator, could be used as a therapy device to effectively treat PLP in individuals with UE amputation. Methods: Participants with UE amputation and PLP were recruited at Walter Reed National Military Medical Center (WRNMMC) and instructed to follow the limb movements of a virtual avatar within the VIE system across a series of study sessions. At the end of each session, participants drove virtual avatar limb movements during a period of "free-play" utilizing surface electromyography recordings collected from their residual limbs. PLP and phantom limb sensations were assessed at baseline and following each session using the Visual Analog Scale (VAS) and Short Form McGill Pain Questionnaire (SF-MPQ), respectively. In addition, both measures were used to assess residual limb pain (RLP) at baseline and at each study session. In total, 14 male, active duty military personnel were recruited for the study. Results: Of the 14 individuals recruited to the study, nine reported PLP at the time of screening. Eight of these individuals completed the study, while one withdrew after three sessions and thus is not included in the final analysis. Five of these eight individuals noted RLP at baseline. Participants completed an average of 18, 30-min sessions with the VIE leading to a significant reduction in PLP in seven of the eight (88%) affected limbs and a reduction in RLP in four of the five (80%) affected limbs. The same user reported an increase in PLP and RLP across sessions. All participants who denied RLP at baseline (n = 3) continued to deny RLP at each study session. Conclusions: Success with the VIE system confirms its application as a non-invasive and low-cost therapy option for PLP and phantom limb symptoms for individuals with upper limb loss.

Initial Clinical Evaluation of the Modular Prosthetic Limb.

The Modular Prosthetic Limb (MPL) was examined for its feasibility and usability as an advanced, dexterous upper extremity prosthesis with surface electromyography (sEMG) control in with two individuals with below-elbow amputations. Compared to currently marketed prostheses, the MPL has a greater number of sequential and simultaneous degrees of motion, as well as wrist modularity, haptic feedback, and individual digit control. The MPL was successfully fit to a 33-year-old with a trans-radial amputation (TR01) and a 30-year-old with a wrist disarticulation amputation (TR02). To preserve anatomical limb length, we adjusted the powered degrees of freedom of wrist motion between users. Motor training began with practicing sEMG and pattern recognition control within the virtual integration environment (VIE). Prosthetic training sessions then allowed participants to complete a variety of activities of daily living with the MPL. Training and Motion Control Accuracy scores quantified their ability to consistently train and execute unique muscle-to-motion contraction patterns. Each user also completed one prosthetic functional metric-the Southampton Hand Assessment Procedure (SHAP) for TR01 and the Jebsen-Taylor Hand Function Test (JHFT) for TR02. Haptic feedback capabilities were integrated for TR01. TR01 achieved 95% accuracy at 84% of his VIE sessions. He demonstrated improved scores over a year of prosthetic training sessions, ultimately achieving simultaneous control of 13 of the 17 (76%) attempted motions. His performance on the SHAP improved from baseline to final assessment with an increase in number of tasks achieved. TR01 also used vibrotactile sensors to successfully discriminate between hard and soft objects being grasped by the MPL hand. TR02 demonstrated 95% accuracy at 79% of his VIE sessions. He demonstrated improved scores over months of prosthetic training sessions, however there was a significant drop in scores initially following a mid-study pause in testing. He ultimately achieved simultaneous control of all 13 attempted powered motions, and both attempted passive motions. He completed 5 of the 7 (71%) JHFT tasks within the testing time limit. These case studies confirm that it is possible to use non-invasive motor control to increase functional outcomes with individuals with below-elbow amputation and will help to guide future myoelectric prosthetic studies.

Clinical evaluation of a biomechanical guidance system for periacetabular osteotomy.

BACKGROUND: Populations suffering from developmental dysplasia of the hip typically have reduced femoral coverage and experience joint pain while walking. Periacetabular osteotomy (PAO) is one surgical solution that realigns the acetabular fragment. This challenging surgery has a steep learning curve. Existing navigation systems for computer-assisted PAO neither track the released fragment nor offer the means to assess fragment location. An intraoperative workstation--the biomechanical guidance system (BGS)--developed for PAO incorporates intraoperative fragment tracking and acetabular characterization through radiographic angles and joint biomechanics. In this paper, we investigate the accuracy and effectiveness of the BGS for bone fragment tracking and acetabular characterization in clinical settings as compared to conventional techniques and postoperative assessments. We also report the issues encountered and our remedies when using the BGS in the clinical setting. METHODS: Eleven consecutive patients (aged 22-48, mean 34, years) underwent 12 PAO surgeries (one bilateral surgery) where the BGS collected information on acetabular positioning. These measurements were compared with postoperative CT data and manual measurements made intraoperatively. RESULTS: No complications were reported during surgery, with surgical time-95-210 (mean 175) minutes-comparable to reported data for the conventional approach. The BGS-measured acetabular positioning showed strong agreement with postoperative CT measurements (-0.3-9.2, mean 3.7, degrees), whereas larger differences occurred between the surgeon's intraoperative manual measurements and postoperative CT measurements (-2.8-21.3, mean 10.5, degrees). CONCLUSIONS: The BGS successfully tracked the acetabular fragment in a clinical environment without introducing complications to the surgical workflow. Accurate 3D positioning of the acetabulum may provide more information intraoperatively (e.g., anatomical angles and biomechanics) without adversely impacting the surgery to better understand potential patient outcomes.

Development of a biomechanical guidance system for periacetabular osteotomy.

PURPOSE: This paper presents and validates a computer-navigated system for performing periacetabular osteotomy (PAO) to treat developmental dysplasia of the hip. The main motivation of the biomechanical guidance system (BGS) is to plan and track the osteotomy fragment in real time during PAO while simplifying the procedure for less-experienced surgeons. The BGS aims at developing a platform for comparing biomechanical states of the joint with the current gold standard geometric assessment of anatomical angles. The purpose of this study was to (1) determine the accuracy with which the BGS tracks the hip joint through repositioning and (2) identify improvements to the workflow. METHODS: Nineteen cadaveric validation studies quantified system accuracy, verified system application, and helped to refine surgical protocol. In two surgeries, navigation and registration accuracy were computed by affixing fiducials to two cadavers prior to surgery. All scenarios compared anatomical angle measurements and joint positioning as measured intraoperatively to postoperatively. RESULTS: In the two cases with fiducials, computed fragment transformations deviated from measured fiducial transformations by 1.4 and 1.8 mm in translation and 1.0° and 2.2° in rotation, respectively. The additional seventeen surgeries showed strong agreement between intraoperative and postoperative anatomical angles, helped to refine the surgical protocol, and demonstrated system robustness. CONCLUSION: Estimated accuracy with BGS appeared acceptable for future surgical applications. Several major system requirements were identified and addressed, improving the BGS and making it feasible for clinical studies.

Patient-specific finite element modeling for femoral bone augmentation.

The aim of this study was to provide a fast and accurate finite element (FE) modeling scheme for predicting bone stiffness and strength suitable for use within the framework of a computer-assisted osteoporotic femoral bone augmentation surgery system. The key parts of the system, i.e. preoperative planning and intraoperative assessment of the augmentation, demand the finite element model to be solved and analyzed rapidly. Available CT scans and mechanical testing results from nine pairs of osteoporotic femur bones, with one specimen from each pair augmented by polymethylmethacrylate (PMMA) bone cement, were used to create FE models and compare the results with experiments. Correlation values of R(2)=0.72-0.95 were observed between the experiments and FEA results which, combined with the fast model convergence (~3 min for ~250,000 degrees of freedom), makes the presented modeling approach a promising candidate for the intended application of preoperative planning and intraoperative assessment of bone augmentation surgery.

Biomechanical factors in planning of periacetabular osteotomy.

OBJECTIVE: This study addresses the effects of cartilage thickness distribution and compressive properties in the context of optimal alignment planning for periacetabular osteotomy (PAO). BACKGROUND: The Biomechanical Guidance System (BGS) is a computer-assisted surgical suite assisting surgeon's in determining the most beneficial new alignment of a patient's acetabulum. The BGS uses biomechanical analysis of the hip to find this optimal alignment. Articular cartilage is an essential component of this analysis and its physical properties can affect contact pressure outcomes. METHODS: Patient-specific hip joint models created from CT scans of a cohort of 29 dysplastic subjects were tested with four different cartilage thickness profiles (one uniform and three non-uniform) and two sets of compressive characteristics. For each combination of thickness distribution and compressive properties, the optimal alignment of the acetabulum was found; the resultant geometric and biomechanical characterization of the hip were compared among the optimal alignments. RESULTS: There was an average decrease of 49.2 ± 22.27% in peak contact pressure from the preoperative to the optimal alignment over all patients. We observed an average increase of 19 ± 7.7° in center-edge angle and an average decrease of 19.5 ± 8.4° in acetabular index angle from the preoperative case to the optimized plan. The optimal alignment increased the lateral coverage of the femoral head and decreased the obliqueness of the acetabular roof in all patients. These anatomical observations were independent of the choice for either cartilage thickness profile, or compressive properties. CONCLUSION: While patient-specific acetabular morphology is essential for surgeons in planning PAO, the predicted optimal alignment of the acetabulum was not significantly sensitive to the choice of cartilage thickness distribution over the acetabulum. However, in all groups the biomechanically predicted optimal alignment resulted in decreased joint contact pressure and improved acetabular coverage.

Use of a virtual integrated environment in prosthetic limb development and phantom limb pain.

Patients face two major difficulties following limb loss: phantom limb pain (PLP) in the residual limb and limited functionality in the prosthetic limb. Many studies have focused on decreasing PLP with mirror therapy, yet few have examined the same visual ameliorating effect with a virtual or prosthetic limb. Our study addresses the following key questions: (1) does PLP decrease through observation of a 3D limb in a virtual integration environment (VIE) and (2) can consistent surface electromyography (sEMG) signals from the VIE drive an advanced modular prosthetic limb (MPL)? Recorded signals from the residual limb were correlated to the desired motion of the phantom limb, and changes in PLP were scored during each VIE session. Preliminary results show an overall reduction in PLP and a trend toward improvement in signal-to-motion accuracy over time. These signals allowed MPL users to perform a wide range of hand motions.

Response of individual thoracolumbar spine ligaments under high-rate deformation.

Under-Body Blast (UBB) has emerged as the predominant threat to ground vehicles and Warfighter survivability. The force transference from the vehicle structure to the human body has resulted in serious injuries, with the thoracolumbar spine frequently damaged. Computational models of the human body are being generated to model human response and develop injury mitigation strategies. To effectively model the spine mechanics, the thoracolumbar ligaments, which serve varying roles in contributing to spine stability, must be characterized at relevant strains and strain rates. Adaptation of cervical spine testing methods has allowed for testing of isolated spinal ligaments including the Anterior Longitudinal Ligament (ALL), Posterior Longitudinal Ligament (PLL), and Ligamentum Flavum (LF). A high-rate servo-hydraulic test machine was used to execute a tensile test protocol for 24 complexes with loading rates ranging from 240 - 2800 mm/s and displacements of 25%, 50%, 75%, 100%, and 300% of the measured ligament length. Non-contact strain field measurements were recorded to produce a three dimensional strain field of the ligament surface. In order to provide the ligament data in a form which can be incorporated in the human computational models, analytical methods for modeling the ligament response are being investigated. Ultimately, this model will be optimized to be utilized in computational models of the lumbar spine.

Method for obtaining simple shear material properties of the intervertebral disc under high strain rates.

Predicting spinal injury under high rates of vertical loading is of interest, but the success of computational models in modeling this type of loading scenario is highly dependent on the material models employed. Understanding the response of these biological materials at high strain rates is critical to accurately model mechanical response of tissue and predict injury. While data exists at lower strain rates, there is a lack of the high strain rate material data that are needed to develop constitutive models. The Split Hopkinson Pressure Bar (SHPB) has been used for many years to obtain properties of various materials at high strain rates. However, this apparatus has mainly been used for characterizing metals and ceramics and is difficult to apply to softer materials such as biological tissue. Recently, studies have shown that modifications to the traditional SHPB setup allow for the successful characterization of mechanical properties of biological materials at strain rates and peak strain values that exceed alternate soft tissue testing techniques. In this paper, the previously-reported modified SHPB technique is applied to characterize human intervertebral disc material under simple shear. The strain rates achieved range from 5 to 250 strain s-1. The results demonstrate the sensitivity to the disc composition and structure, with the nucleus pulposus and annulus fibrosus exhibiting different behavior under shear loading. Shear tangent moduli are approximated at varying strain levels from 5 to 20% strain. This data and technique facilitates determination of mechanical properties of intervertebral disc materials under shear loading, for eventual use in constitutive models.

Intraoperative image-based multiview 2D/3D registration for image-guided orthopaedic surgery: incorporation of fiducial-based C-arm tracking and GPU-acceleration.

Intraoperative patient registration may significantly affect the outcome of image-guided surgery (IGS). Image-based registration approaches have several advantages over the currently dominant point-based direct contact methods and are used in some industry solutions in image-guided radiation therapy with fixed X-ray gantries. However, technical challenges including geometric calibration and computational cost have precluded their use with mobile C-arms for IGS. We propose a 2D/3D registration framework for intraoperative patient registration using a conventional mobile X-ray imager combining fiducial-based C-arm tracking and graphics processing unit (GPU)-acceleration. The two-stage framework 1) acquires X-ray images and estimates relative pose between the images using a custom-made in-image fiducial, and 2) estimates the patient pose using intensity-based 2D/3D registration. Experimental validations using a publicly available gold standard dataset, a plastic bone phantom and cadaveric specimens have been conducted. The mean target registration error (mTRE) was 0.34 ± 0.04 mm (success rate: 100%, registration time: 14.2 s) for the phantom with two images 90° apart, and 0.99 ± 0.41 mm (81%, 16.3 s) for the cadaveric specimen with images 58.5° apart. The experimental results showed the feasibility of the proposed registration framework as a practical alternative for IGS routines.

Using a virtual integration environment in treating phantom limb pain.

The Revolutionizing Prosthetics 2009 program conducted by the Defense Advanced Research Projects Agency (DARPA) has resulted in a Virtual Integration Environment (VIE) that provides a common development platform for researchers and clinicians that design, model and build prosthetic limbs and then integrate and test them with patients. One clinical need that arose during the VIE development was a feature to easily create and model animations that represent patient activities of daily living (ADLs) and simultaneously capture real-time surface EMG activity from the residual limb corresponding to the ADLs. An application of this feature is being made by the Walter Reed Military Amputee Research Program (MARP) where they are utilizing the VIE to investigate methods of reducing upper extremity amputee phantom limb pain (PLP).

Three-dimensional mechanical evaluation of joint contact pressure in 12 periacetabular osteotomy patients with 10-year follow-up.

BACKGROUND AND PURPOSE: Because of the varying structure of dysplastic hips, the optimal realignment of the joint during periacetabular osteotomy (PAO) may differ between patients. Three-dimensional (3D) mechanical and radiological analysis possibly accounts better for patient-specific morphology, and may improve and automate optimal joint realignment. PATIENTS AND METHODS: We evaluated the 10-year outcomes of 12 patients following PAO. We compared 3D mechanical analysis results to both radiological and clinical measurements. A 3D discrete-element analysis algorithm was used to calculate the pre- and postoperative contact pressure profile within the hip. Radiological angles describing the coverage of the joint were measured using a computerized approach at actual and theoretical orientations of the acetabular cup. Quantitative results were compared using postoperative clinical evaluation scores (Harris score), and patient-completed outcome surveys (q-score) done at 2 and 10 years. RESULTS: The 3D mechanical analysis indicated that peak joint contact pressure was reduced by an average factor of 1.7 subsequent to PAO. Lateral coverage of the femoral head increased in all patients; however, it did not proportionally reduce the maximum contact pressure and, in 1 case, the pressure increased. This patient had the lowest 10-year q-score (70 out of 100) of the cohort. Another hip was converted to hip arthroplasty after 3 years because of increasing osteoarthritis. INTERPRETATION: The 3D analysis showed that a reduction in contact pressure was theoretically possible for all patients in this cohort, but this could not be achieved in every case during surgery. While intraoperative factors may affect the actual surgical outcome, the results show that 3D contact pressure analysis is consistent with traditional PAO planning techniques (more so than 2D analysis) and may be a valuable addition to preoperative planning and intraoperative assessment of joint realignment.

A new interpretation of the mechanism of ankle fracture.

BACKGROUND: Researchers have found it difficult to recreate a Lauge-Hansen supination-external rotation-type ankle fracture in experimental settings. We hypothesized that a pronation-external rotation mechanism could cause both distal, short oblique and high fibular fractures and that the fracture type would be affected by associated, laterally directed forces applied to the foot. Methlods: Twenty-three cadaver ankles were subjected to fracture loading that replicated the Lauge-Hansen pronation-external rotation mechanism with or without applying an external lateral force. In Phase I, an axial load was applied to fifteen specimens mounted on a materials testing machine. Each foot was rotated externally to failure. In Phase II, eight specimens were tested according to the Phase-I protocol, but external forces were applied laterally at the foot to increase the abduction moment at the ankle. Load and position versus time curves were recorded and were correlated with video image data to establish the sequence of failure of specific anatomic structures. RESULTS: Eight specimens tested in Phase I sustained an oblique fracture of the distal end of the fibula with both medial and posterior injuries that occurred after the fibular fracture. Increasing the external lateral force and hence the abduction moment within the ankle (Phase II) resulted in three of eight specimens sustaining a high fibular fracture with a reversed fracture line (anterosuperior to posteroinferior) and/or a comminuted high fibular fracture. The distribution of traditional pronation-external rotation-type fractures differed significantly between Phase I and Phase II (p=0.032). CONCLUSIONS: This study generated counterexamples to the Lauge-Hansen classification system by showing that a short oblique fracture of the distal end of the fibula can occur with the foot in the pronated position. Furthermore, a high fibular fracture was recreated by increasing the abduction moment at the ankle.