Patellofemoral contact forces and knee gait mechanics 3 months after ACL reconstruction are associated with cartilage degradation 24 months after surgery.

OBJECTIVE: Evaluate patellofemoral cartilage health, as assessed by quantitative magnetic resonance imaging (qMRI) T2 relaxation times, 24-months after ACL reconstruction (ACLR) and determine if they were associated with patellofemoral contact forces and knee mechanics during gait 3 months after surgery. DESIGN: Thirty individuals completed motion analysis during overground walking at a self-selected speed 3 months after ACLR. An EMG-driven neuromusculoskeletal model was used to determine muscle forces, which were then used in a previously described model to estimate patellofemoral contact forces. Biomechanical variables of interest included peak patellofemoral contact force, peak knee flexion angle and moment, and walking speed. These same participants underwent a sagittal bilateral T2 mapping qMRI scan 24-months after surgery. T2 relaxation times were estimated for both patellar and trochlear cartilage. Paired t-tests were used to compare T2 relaxation times between limbs while Pearson correlations and linear regressions were utilized to assess the association between the biomechanical variables of interest and T2 relaxation times. RESULTS: Prolonged involved limb trochlear T2 relaxation times (vs uninvolved) were present 24-months after surgery, indicating worse cartilage health. No differences were detected in patellar cartilage. Significant negative associations were present within the involved limb for all the biomechanical variables of interest 3 months after ACLR and trochlear T2 relaxation times at 24-months. No associations were found in patellar cartilage or within the uninvolved limb. CONCLUSIONS: Altered involved limb trochlear cartilage health is present 24-months after ACLR and may be related to patellofemoral loading and other walking gait mechanics 3 months after surgery.

A more informed evaluation of medial compartment loading: the combined use of the knee adduction and flexor moments.

OBJECTIVE: To evaluate if the peak knee flexor moment (pKFM) provides unique and meaningful information about peak medial compartment loading above and beyond what is obtained from the peak knee adduction moment. METHODS: Standard video-based motion capture and EMG recordings were collected for 10 anterior cruciate ligament (ACL) reconstructed subjects walking at a self-selected speed. Knee joint moments were obtained using inverse dynamics and medial contact force was computed using an EMG-driven musculoskeletal model. Linear regression with the peak adductor moment entered first was implemented to isolate the unique contribution of the peak flexor moment to peak medial loading. RESULTS: Peak moments and medial contact force occurred during weight acceptance at approximately 23% of stance. The peak knee adduction moment (pKAM) was a significant predictor of peak medial loading (P = 0.004) accounting for approximately 63% of the variance. The pKFM was also a significant predictor (P = 0.009) accounting for an additional 22% of the variance. When entered together pKAM and pKFM accounted for more than 85% of the variance in peak medial compartment loading. CONCLUSION: The combined use of the peak knee flexor and adductor moments provides a significantly more accurate estimate of peak medial joint loading than the peak adduction moment alone. More accurate inferences of joint contact force will assist clinicians and researchers investigating relationships between joint loading and the onset and progression of knee osteoarthritis (OA).

Intent to quit among daily and non-daily college student smokers.

Given the high prevalence of young adult smoking, we examined (i) psychosocial factors and substance use among college students representing five smoking patterns and histories [non-smokers, quitters, native non-daily smokers (i.e. never daily smokers), converted non-daily smokers (i.e. former daily smokers) and daily smokers] and (ii) smoking category as it relates to readiness to quit among current smokers. Of the 4438 students at six Southeast colleges who completed an online survey, 69.7% (n = 3094) were non-smokers, 6.6% (n = 293) were quitters, 7.1% (n = 317) were native non-daily smokers, 6.4% (n = 283) were converted non-daily smokers and 10.2% (n = 451) were daily smokers. There were differences in sociodemographics, substance use (alcohol, marijuana, other tobacco products) in the past 30 days and psychosocial factors among these subgroups of students (P < 0.001). Among current smokers, there were differences in cigarettes smoked per day, recent quit attempts, self-identification as a smoker, self-efficacy and motivation to quit (P < 0.001). After controlling for important factors, converted non-daily smokers were more likely to be ready to quit in the next month versus native non-daily smokers (OR = 2.15, CI 1.32-3.49, P = 0.002). Understanding differences among young adults with different smoking patterns and histories is critical in developing interventions targeting psychosocial factors impacting cessation among this population.

Dynamic knee stability: current theory and implications for clinicians and scientists.

We will discuss the mechanisms by which dynamic knee stability may be achieved and relate this to issues that interest clinicians and scientists concerned with dynamic knee stability. Emphasis is placed on the neurophysiologic evidence and theory related to neuromuscular control. Specific topics discussed include the ensemble firing of peripheral mechanoreceptors, the potential for muscle stiffness modulation via force and length feedback, postural control synergies, motor programs, and the neural control of gait. Factors related to answering the difficult question of whether or not knee ligament injuries can be prevented during athletic activities are discussed. Prevention programs that train athletes to perform their sport skills in a safe fashion are put forth as the most promising prospect for injury prevention. Methods of assessing neuromuscular function are reviewed critically and the need for future research in this area is emphasized. We conclude with a brief review of the literature regarding neuromuscular training programs.

Human elbow joint torque is linearly encoded in electromyographic signals from multiple muscles.

When the central nervous system (CNS) develops a muscular activation pattern to accomplish a particular isometric task, it clearly uses information concerning the external task requirements. These task requirements serve as inputs to neural transformations that output muscular activations. However, the nature of the inputs is not exactly known. Electromyographic (EMG) signals from eight muscles spanning the human elbow, as well as the total joint torque, were collected during a submaximal isometric flexion/extension task at a single joint angle. The EMG data, without any torque information, were subjected to principal components analysis. We found that 98% of EMG data variation could be described by two principal components the first resembled the joint torque and the second resembled the sum of the EMG signals from all eight muscles. The findings suggest that the CNS encodes these two quantities during isometric tasks.

Strategies of muscular support of varus and valgus isometric loads at the human knee.

In this paper we studied how subjects activate their muscles in response to static varus and valgus loads at the knee. The muscles' contributions to the external moments were estimated using an EMG driven biomechanical model of the knee. The individual muscle activation and loading patterns were examined to identify the strategies that the nervous system uses to support varus and valgus knee moments. It was found that the (1) co-contraction of the hamstrings and quadriceps, and (2) activation of the gracilis and tensor fascia lata increased with the increasing magnitude of the varus and valgus moments. These 2 activation patterns provided positive support of valgus and varus loads at the knee The sartorius appears to be activated to provide positive support of valgus loads at the knee, whereas during varus moments this muscle increases the varus load on the knee, i.e. provides negative support. Generally, the hamstrings and quadriceps co-contraction contributed to most of the muscular support of the varus and valgus moments. In addition, co-contraction supported 11-14% of the external moment in pure varus and pure valgus respectively. It appears that there are activation strategies with the specific purpose to support varus and valgus moments, albeit small, which suggest dual goals of the neuromotor system during the support of varus and valgus moments.

Dynamic stability in the anterior cruciate ligament deficient knee.

Some individuals can stabilize their knees following anterior cruciate ligament rupture even during activities involving cutting and pivoting (copers), others have instability with daily activities (non-copers). Movement and muscle activation patterns of 11 copers, ten non-copers and ten uninjured subjects were studied during walking and jogging. Results indicate that distinct gait adaptations appeared primarily in the non-copers. Copers used joint ranges of motion, moments and muscle activation patterns similar to uninjured subjects. Non-copers reduced their knee motion, and external knee flexion moments that correlated well with quadriceps strength. Non-copers also achieved peak hamstring activity later in the weight acceptance phase and used a strategy involving more generalized co-contraction. Both copers and non-copers had high levels of quadriceps femoris muscle activity. The reduced knee moment in the involved limbs of the non-copers did not represent "quadriceps avoidance" but rather represented a strategy of general co-contraction with a greater relative contribution from the hamstring muscles.

The isometric functional capacity of muscles that cross the elbow.

We hypothesized that muscles crossing the elbow have fundamental differences in their capacity for excursion, force generation, and moment generation due to differences in their architecture, moment arm, and the combination of their architecture and moment arm. Muscle fascicle length, sarcomere length, pennation angle, mass, and tendon displacement with elbow flexion were measured for the major elbow muscles in 10 upper extremity specimens. Optimal fascicle length, physiological cross-sectional area (PCSA), moment arm, operating range on the force-length curve, and moment-generating capacity were estimated from these data. Brachioradialis and pronator teres had the longest (17.7cm) and shortest (5.5cm) fascicles, respectively. Triceps brachii (combined heads) and brachioradialis had the greatest (14.9cm(2)) and smallest (1.2cm(2)) PCSAs, respectively. Despite a comparable fascicle length, long head of biceps brachii operates over a broader range of the force-length curve (length change=56% of optimal length, 12.8cm) than the long head of triceps brachii (length change=28% of optimal length, 12. 7cm) because of its larger moment arm (4.7cm vs. 2.3cm). Although brachioradialis has a small PCSA, it has a relatively large moment-generating capacity (6.8cm(3)) due to its large moment arm (average peak=7.7cm). These results emphasize the need to consider the interplay of architecture and moment arm when evaluating the functional capabilities of a muscle.

Displacement response of juvenile arthritic wrists during grasp.

OBJECTIVE: To analyze the displacement response of juvenile arthritic wrists during grasp in order to diagnose early ligamental laxity and facilitate early splinting. METHODS: X-rays of the wrists, made under standardized conditions, of 30 children with juvenile chronic arthritis (mean age 10.4 years, range 4.5-16.9) were analyzed after being digitalized. Osseous landmarks were identified, and coordinates were calculated from measured angles and lengths with an accuracy of 0.01'. Lunate and carpal-ulnar distance were obtained according to Youm, and ulnar variance according to Häfner. RESULTS: Overall, an increase in ulnar-lunate displacement and carpal narrowing and a decrease in ulnar variance were found. However, not all wrists responded to the same extent. Radial displacement of the lunate, though slight, was found in 2 wrists and the amount of ulnar displacement varied substantially (3.1% to 22.5%). The variance in amount of displacement could suggest that juvenile wrists do not respond to increased compressive forces to the same extent. CONCLUSION: The changes found are similar to those found in the healthy wrist. Furthermore, our findings suggest that the juvenile wrist acts in accordance with the generally accepted explanation for the development of malalignment in adult wrists. It seems that laxity of ligaments can be diagnosed early by the force grip maneuver during x-ray. It would have a significant impact on the moment of orthotic intervention as well as the design of the orthotic device. Further study along this line seems justified.

Muscle activity in rapid multi-degree-of-freedom elbow movements: solutions from a musculoskeletal model.

The activity of certain muscles that cross the elbow joint complex (EJC) are affected by forearm position and forearm movement during elbow flexion/extension. To investigate whether these changes are based on the musculoskeletal geometry of the joint, a three-dimensional musculotendinoskeletal computer model of the EJC was used to estimate individual muscle activity in multi-degree-of-freedom (df) rapid (ballistic) elbow movements. It is hypothesized that this model could reproduce the major features of elbow muscle activity during multi-df elbow movements using dynamic optimal control theory, given a minimum-time performance criterion. Results from the model are presented and verified with experimental kinematic and electromyographic data from movements that involved both one-df elbow flexion/extension and two-df flexion/extension with forearm pronation/supination. The model demonstrated how the activity of particular muscles is affected by both forearm position and movement, as measured in these experiments and as previously reported by others. These changes were most evident in the flexor muscles and least evident in the extensor muscles. The model also indicated that, for specific one- and two-df movements, activating a muscle that is antagonistic or noncontributory to the movement could reduce the movement time. The major features of muscle activity in multi-df elbow movements appear to be highly dependent on the joint's musculoskeletal geometry and are not strictly based on neural influences or neuroanatomical substrates.

Laxity in healthy and osteoarthritic knees.

OBJECTIVE: Although it is a cause of osteoarthritis (OA) in animal models, laxity in human knee OA has been minimally evaluated. Ligaments become more compliant with age; whether this results in clinical laxity is not clear. In theory, laxity may predispose to OA and/or result from OA. Our goals were to examine the correlation of age and sex with knee laxity in control subjects without OA, compare laxity in uninvolved knees of OA patients with that in older control knees, and examine the relationship between specific features of OA and knee laxity. METHODS: We assessed varus-valgus and anteroposterior laxity in 25 young control subjects, 24 older control subjects without clinical OA, radiographic OA, or a history of knee injury, and 164 patients with knee OA as determined by the presence of definite osteophytes. A device was designed to assess varus-valgus laxity under a constant varus or valgus load while maintaining a fixed knee flexion angle and thigh and ankle immobilization. Radiographic evaluations utilized protocols addressing position, beam alignment, magnification, and landmark definition; the semiflexed position was used, with fluoroscopic confirmation. RESULTS: In the controls, women had greater varus-valgus laxity than did men (3.6 degrees versus 2.7 degrees; 95% confidence interval [95% CI] of difference 0.38, 1.56; P = 0.004), and laxity correlated modestly with age (r = 0.29, P = 0.04). Varus-valgus laxity was greater in the uninvolved knees of OA patients than in older control knees (4.9 degrees versus 3.4 degrees; 95% CI of difference 0.60, 2.24; P = 0.0006). In OA patients, varus-valgus laxity increased as joint space decreased (slope -0.34; 95% CI -0.48, -0.19; P < 0.0001) and was greater in knees with than in knees without bony attrition (5.3 degrees versus 4.5 degrees; 95% CI of difference 0.32, 1.27; P = 0.001). CONCLUSION: Greater varus-valgus laxity in the uninvolved knees of OA patients versus older control knees and an age-related increase in varus-valgus laxity support the concept that some portion of the increased laxity of OA may predate disease. Loss of cartilage/bone height is associated with greater varus-valgus laxity. These results raise the possibility that varus-valgus laxity may increase the risk of knee OA and cyclically contribute to progression.

Does laxity alter the relationship between strength and physical function in knee osteoarthritis?

OBJECTIVE: Since strengthening interventions have had a lower-than-expected impact on patient function in studies of knee osteoarthritis (OA) and it is known that laxity influences muscle activity, this study examined whether the relationship between strength and function is weaker in the presence of laxity. METHODS: One hundred sixty-four patients with knee OA were studied. Knee OA was defined by the presence of definite osteophytes, and patients had to have at least a little difficulty with knee-requiring activities. Tests were performed to determine quadriceps and hamstring strength, varus-valgus laxity, functional status (Western Ontario and McMaster Universities Osteoarthritis Index Physical Functioning subscale [WOMAC-PF] and chair-stand performance), body mass index, and pain. High and low laxity groups were defined as above and below the sample median, respectively. RESULTS: Strength and chair-stand rates correlated (r = 0.44 to 0.52), as did strength and the WOMAC-PF score (r = -0.21 to -0.36). In multivariate analyses, greater laxity was consistently associated with a weaker relationship between strength (quadriceps or hamstring) and physical functioning (chair-stand rate or WOMAC-PF score). CONCLUSION: Varus-valgus laxity is associated with a decrease in the magnitude of the relationship between strength and physical function in knee OA. In studies examining the functional and structural consequences of resistance exercise in knee OA, stratification of analyses by varus-valgus laxity should be considered. The effect of strengthening interventions in knee OA may be enhanced by consideration of the status of the passive restraint system.

Muscular resistance to varus and valgus loads at the elbow.

Although the contributions of passive structures to stability of the elbow have been well documented, the role of active muscular resistance of varus and valgus loads at the elbow remains unclear. We hypothesized that muscles: (1) can produce substantial varus and valgus moments about the elbow, and (2) are activated in response to sustained varus and valgus loading of the elbow. To test the first hypothesis, we developed a detailed musculoskeletal model to estimate the varus and valgus moment-generating capacity of the muscles about the elbow. To test the second hypothesis, we measured EMGs from 11 muscles in four subjects during a series of isometric tasks that included flexion, extension, varus, and valgus moments about the elbow. The EMG recordings were used as inputs to the elbow model to estimate the contributions of individual muscles to flexion-extension and varus-valgus moments. Analysis of the model revealed that nearly all of the muscles that cross the elbow are capable of producing varus or valgus moments; the capacity of the muscles to produce varus moment (34 Nm) and valgus moment (35 Nm) is roughly half of the maximum flexion moment (70 Nm). Analysis of the measured EMGs showed that the anconeus was the most significant contributor to valgus moments and the pronator teres was the largest contributor to varus moments. Although our results show that muscles were activated in response to static varus and valgus loads, their activations were modest and were not sufficient to balance the applied load.

How muscle architecture and moment arms affect wrist flexion-extension moments.

The purpose of this investigation was to determine how the moment arms and architecture of the wrist muscles influence their isometric moment-generating characteristics. A three-dimensional computer graphic model was developed that estimates the moment arms, maximum isometric forces, and maximum isometric flexion-extension moments generated by 15 muscles about the wrist over a range of wrist flexion angles. In combination with measurements of muscle strength, we used this model to answer three questions: (1) why is peak wrist flexion moment greater than peak extension moment, (2) why does flexion moment vary more with wrist flexion angle than does extension moment, and (3) why does flexion moment peak with the wrist in a flexed position? Analysis of the model revealed that the peak flexion moment is greater than the peak extension moment primarily because of the larger (110%) summed physiologic cross-sectional area of the flexors. The larger variation of flexion moment with flexion angle is caused mainly by greater variation of the moment arms of the major wrist flexors with flexion angle. The location of the peak flexion moment is determined by the wrist flexion moment arms (which tend to increase with wrist flexion) in combination with the force-length characteristics of these muscles.

Muscle activation at the human knee during isometric flexion-extension and varus-valgus loads.

We examined the role of muscles in counteracting static loads in the transverse plane at the knee to determine if (a) knee muscles are activated to counteract isometric varus or valgus loads, (b) muscle activity during varus and valgus loads changes with the angle of knee flexion, and (c) the direction of a muscle's activation can be predicted by its moment arm orientations. For seven subjects, muscle activity was recorded during isometric tasks using surface and intramuscular electrodes from 10 muscles that span the knee. A six-degree-of-freedom load cell was rigidly attached to each subject's lower leg just above the ankle, and the subjects were instructed to push against the load cell so as to produce moments in the flexion-extension-varus-valgus plane at the knee. Moments in this plane were all of equal magnitude and varied in direction the full 360 degrees in 20 degrees increments. Most muscles were not activated to stabilize the knee against varus-valgus loads, but the sartorius, gracilis, and tensor fasciae latae showed substantial electromyographic activation in these directions. The load directions where muscles were principally active were observed to be dependent on joint angle for some muscles. In particular, the principal directions of activation for these three muscles changed as the angle of knee flexion changed. Similarly, a muscle's moment arm orientation was a good predictor of direction of activation for some muscles and a poor one for others. These results suggest that different muscles may play different roles in providing joint stability and that these roles are complex functions of muscle moment arm orientations, joint angles, external load directions, and possibly other undetermined parameters.

An evaluation of optimization techniques for the prediction of muscle activation patterns during isometric tasks.

The purpose of this study was to critically evaluate the modeling potential of proposed optimization cost functions for predicting muscle forces during isometric loading. Models of the muscles about the elbow (eleven muscles) and wrist (five muscles) were constructed. The models accounted for muscle moment arms, physiological cross-sectional area, specific tension, and percent fiber type. Five nonlinear optimization cost functions, a representative sample of those proposed to date, were analyzed: minimizing the sums of muscle force2, stress2, stress3, (normalized force)2, and minimizing fatigue. Several different protocols were implemented, including elbow models which balanced combinations of flexion-extension, supination-pronation, and varus-valgus loads. Theoretical predictions were compared with EMG data of muscle activation changes as a function of load direction and muscle coactivation relationships. Results indicate a strong dependence of muscle coordination predictions on the number of degrees of freedom balanced. The choice of cost function had little influence on the results. The cost functions examined were not able to reliably estimate muscle activation as a function of load direction. Furthermore, specific synergic relationships between muscle pairs could not be accurately represented. An error analysis indicated that the discrepancies between predicted values and actual values could not be explained by errors in physiological measurements, as the differences between these two were relatively insensitive to changes in the anatomical parameters. In short, no particular cost function was found to adequately represent actual muscle activity at the elbow, although predictions at the wrist were more favorable due to differences in the degrees of freedom at the joints.

Maximum isometric moments generated by the wrist muscles in flexion-extension and radial-ulnar deviation.

Maximum isometric and passive moments about the wrist were measured for a range of flexion-extension and radial-ulnar deviation angles in 10 healthy adult males. Each subject was seated in a test apparatus with his shoulder abducted 90 degrees, elbow flexed 90 degrees, and body and forearm constrained. Peak flexion moments ranged from 5.2 to 18.7 N m (mean = 12.2, SD = 3.7), while peak extension moments ranged from 3.4 to 9.4 N m (mean = 7.1, SD = 2.1). The average flexion moment peaked at 40 degrees of flexion, whereas the average extension moment was relatively constant from 30 degrees flexion to 70 degrees extension. Peak moments generated by the radial and ulnar deviators ranged from 7.9 to 15.3 N m (mean = 11.0, SD = 2.0) and 5.9 to 11.9 N m (mean = 9.5, SD = 2.2), respectively. Passive moments in flexion-extension were near zero in the central 150 degrees of motion, but increased at the end of the range of motion. The average passive moment was 0.5 N m in 90 degrees flexion and 1.2 N m in 90 degrees extension. Average passive moments about the radial-ulnar deviation axis were near zero with the wrist radially deviated and at neutral, but increased to 0.9 N m in full ulnar deviation.

A model of load sharing between muscles and soft tissues at the human knee during static tasks.

In this study, we have subjects voluntarily generate various forces in a transverse plane just above their ankles. The contributions of their muscles and soft tissues to the support of the total external knee joint moment were determined by analyzing the experimental data using a biomechanical model of the knee. In this model, muscle forces were estimated using the recorded EMGs. To account for subject variability, various muscle parameters were adjusted using a nonlinear least-squares fit of the model's estimated flexion and extension joint moments to those recorded externally. Using the estimated muscle forces, the contributions from the muscles and other soft tissues to the total joint moment were obtained. The results showed that muscles were primarily used to support flexion and extension loads at the knee, but in so doing, were able to support some part of the varus or valgus loads. However, soft tissue loading was still required. Soft tissues supported up to an average maximum of 83 percent of the external load in pure varus and valgus. Soft tissue loading in pure varus and valgus was less than 100 percent of the external load as the muscles, on average, were able to support 17 percent of the external load. This muscle support was by virtue of muscle cocontraction and/or specific muscle activation.

Selective muscle activation following rapid varus/valgus perturbations at the knee.

Knee muscles are generally divided into groups based on their function as flexors or extensors. In this study we sought to determine if muscles were selectively activated according to their potential roles as varus or valgus stabilizers following rapid loads to the knee. While subjects were supine, varus or valgus moments were applied to the knees of 10 human subjects using a servomotor-driven perturbation device. During the experiments, electromyograms (EMG) were recorded from seven muscles, four of which had medial moment arms relative to the knee center, and three of which had lateral moment arms. It was observed that, for all medial muscles, a statistically significant increase in muscle activation followed valgus loads as compared with varus loads. All lateral muscles except the vastus lateralis showed the opposite response (as expected). These results suggest that muscles can be reflexively activated independent of their roles as flexors or extensors to provide stability to the human knee during varus or valgus loads. The timing of the reflex is consistent with that arising from joint mechanoreceptors, although polysynaptic stretch reflex may also be involved.

Selective block of the brachialis motor point. An anatomic investigation of musculocutaneous nerve branching.

BACKGROUND AND OBJECTIVES: Injections of neurolytic agents designed to block the musculocutaneous nerve often eliminate all elbow flexion movements, leaving the patient with a flail arm. In such patients, motor point blocks of the biceps brachii or brachialis muscle, or both, may be indicated. By virtue of its relative cross-section area, the brachialis is the largest contributor to elbow flexion. This factor, together with this muscle's lack of a role in supination, makes it the target of choice for controlling flexion spasticity. There are few descriptions of brachialis motor point blocks, and they fail to provide satisfactory instructions for the procedure. The goal of this study was to determine the brachialis motor point site and to quantitatively describe its location. METHODS: In this prospective, randomized study of 26 cadaver arms, the innervation site of the brachialis muscle from the musculocutaneous nerve was measured. Measurements were taken from the lateral epicondyle and were compared with the distance to the biceps motor point. These lengths were normalized across subjects by dividing by the arm length (from lateral epicondyle to the acromion). RESULTS: The brachialis was found to be innervated at approximately one third of the distance from the elbow to the acromion. This site is significantly different (P < .05) from that of the biceps brachii, which was found to be located at approximately half of the distance from the elbow to the acromion. CONCLUSIONS: An injection one third of the distance from the lateral epicondyle to the acromion along the medial aspect is recommended to provide best access to the brachialis motor point. By injecting from the medial aspect, one avoids the humerus (encountered in a lateral approach) and the need to pass through the biceps brachii (as in an anterior approach).