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Orthopedic Research

Multigenerational growth approach to incorporate residual stress in an intervertebral disc finite element model with validation in multi-axial loading

Residual stresses are known to exist in human intervertebral discs but have not been incorporated in finite element models. A multigeneration model was applied to the annulus fibrosus of the intervertebral disc to simulate residual stresses arising from growth and remodeling. The intervertebral disc shape and compressive creep were used to verify that the multigeneration approach generates realistic values of residual stress. The model was then validated by comparing its 6 degree-of-freedom mechanical response to experimental data. Human intervertebral discs were tested in a custom-built hexapod in all 6 degrees-of-freedom (lateral shear, anterior-posterior shear, torsion, bending, flexion, and compression). Incorporating residual stresses resulted in a finite element model which can predict 4 degrees-of-freedom while excluding residual stresses produces a finite element model that can only predict 2 degrees-of-freedom.
Listed In: Biomechanical Engineering, Biomechanics, Orthopedic Research


Measuring Soft Tissue Contributions to Elbow Joint Motion and Virtual Ligament Modelling An In-Vitro Study

Knowledge of ligamentous contributions to joint stability is essential to restore normal joint range of motion and functionality through reconstruction procedures. Although, there has been numerous studies on the pathomechanics of the elbow joint, there have been very few rigorous and systematic attempts to characterize the roles of soft tissues during clinically relevant motions. Five fresh frozen cadaveric elbows from three male subjects were used for this study. In-vitro simulations were performed using a VIVO six degree-of-freedom (6-DOF) joint motion simulator (AMTI, Watertown, MA) capable of virtually simulating the effects of soft tissue constraints (virtual ligaments). This study introduces a unique, hybrid experimental-computational technique for measuring and simulating the biomechanical contributions of ligaments to elbow joint kinematics and stability. In vitro testing of cadaveric joints is enhanced by the incorporation of fully parametric virtual ligaments, which are used in place of the native joint stabilizers to characterize the contribution of elbow ligaments during simple flexion-extension motions using the principle of superposition. our results demonstrate the importance of AMCL and RCL structures as primary stabilizers under valgus and varus loading respectively. Virtual ligaments demonstrate the ability to restore the VV stability of the joint in the absence of any soft tissues attached to the osseous structures. This demonstrates the effectiveness of “virtual” ligaments for in vitro testing of elbow joint biomechanics, with applications in pre-clinical assessment of elbow implants.
Listed In: Biomechanical Engineering, Biomechanics, Mechanical Engineering, Orthopedic Research


Examining Postural Control With and Without Visual Feedback in Individuals with history of Ankle Sprain

Lateral ankle sprains are common orthopedic injuries and often result in chronic ankle instability (CAI). Studies have shown that the CAI population typically has decreased ankle proprioception and possibly a greater reliance on visual feedback when compared to healthy controls. However, little is known about how the postural control characteristics change in those with and without CAI when external visual feedback is manipulated. Purpose: To compare postural control characteristics of persons with CAI, Copers and healthy adults when performing a single leg balance test with and without external feedback. Method: The definition for CAI used for this study includes persons who have experienced recurrent ankle sprains, in addition to self-reported “feelings of instability” and “giving way,” and a score on the Identification of Functional Ankle Instability (IdFAI) of 11 or greater. 18 participants with CAI, 15 Copers, and 18 healthy controls (mean age of all groups: 22 years) performed the Athlete Single Leg Test on the Biodex Balance System (BBS) at Level 4 which involved a high degree of platform instability. All participants completed 2 trials without and with feedback in that order. Center of pressure position was recorded and the two trial mean was used for further analysis. Overall stability index (OSI) defined as the mean distance of the center of pressure from the center of the platform was obtained from the system. Sway area was calculated using custom Matlab script. Separate 3 (Group) x 2 (Feedback) mixed ANOVAs were run using overall stability index (OSI), and sway area as dependent variables. Results: Significant feedback main effect showed participants had significantly lower (better) OSI value with feedback (1.4±0.1) compared to without feedback (2.6±0.2; P < 0.001) but sway area with feedback (8.61±2.33cm2) was similar to without feedback (10.94±2.43 cm2). There was no significant group main effect or interaction observed for either of the variables. Conclusion: Results suggest that external visual feedback may not play a significant role in helping persons with CAI improve their postural control.
Listed In: Orthopedic Research, Physical Therapy


Does Corrective Surgery in Femoroacetabular Impingement Improve Joint Kinematics During Squatting?

INTRODUCTION: Cam femoroacetabular impingement (FAI) is characterized by an osseous overgrowth on the femoral head-neck junction [1], leading to pain and limited range of motion (ROM) during daily life activities [2]. Corrective surgery is highly recommended and performed in order to reduce or eliminate pain and further development of osteoarthritis (OA). However, it is still unclear whether it would lead to improved functional mobility. The purpose was to compare kinematic variables of the operated limb between FAI patients when performing a squat task pre-surgery and at around 2-year follow-up. A secondary objective consisted of express the results in a biomechanical functional score to quantify the joint kinematics of FAI patients compared to healthy control (CTRL) participants. METHODS: Eleven male patients (7 arthroplasty: 34.6±8.1 years, 25.7±3.2 kg/m2; 4 open: 33.3±7.1 years, 24.9±1.9 kg/m2) and 21 CTRL (2F/19M, 33.4±6.7 years, 25.4±3.3 kg/m2) participants were recruited from the orthopaedic surgeon’s clinical practice. Patients were assigned to either an arthroplasty or open FAI surgery correction. The participants signed prior to their participation a consent form approved by the hospital and university ethics board. Patients agreed to undergo motion analysis prior to and 2 years after the surgery. The CTRL were selected based on similar age and BMI as the FAI group and underwent the same motion analysis protocol. At the local hospital, CT scan was performed in all participants to confirm an alpha-angle higher than 55º and also establish their pelvic and knee bony landmarks. At the motion laboratory, the participants were outfitted with 45 reflective markers and performed a minimum of five trials of deep squat at a self-selected pace. Three-dimensional joint kinematics (200 Hz) of the lower limbs were captured using a ten-camera motion analysis system (Vicon, UK). Kinematics data were processed in Nexus 1.8.3 (Vicon, UK) using a modified Plug-In-Gait model and exported with a custom MATLAB script (Mathworks, USA) to calculate group averages and extract relevant variables. All trials were time-normalized based on a full squat cycle (descent and ascent phases) and individual averages for each participant were calculated across the trials. Four kinematic variables were included in the analysis: pelvis, hip, knee, and ankle sagittal angles. The normalized root-mean-square deviation (nRMSD) was calculated between the FAI and the CTRL groups for both pre- and post-surgery conditions, expressed by
Listed In: Biomechanical Engineering, Biomechanics, Orthopedic Research


Bilateral assessment of cartilage with UTE-T2* quantitative MRI and associations with knee center of rotation following anterior cruciate ligament reconstruction

Purpose: Anterior cruciate ligament (ACL) tear greatly increases the risk of knee osteoarthritis (OA), even when patients undergo ACL reconstruction surgery (ACLR). Changes to walking kinematics following ACLR have been suggested to play a role in this degenerative path to post-traumatic OA by shifting the location of repetitive joint contact loads that occur during walking to regions of cartilage not conditioned for altered loads. Recent work has shown that changes to the average knee center of rotation during walking (KCOR) between 2 and 4 years after ACLR are associated with long term changes in patient reported outcomes at 8 years. Changes to KCOR result in changes to contact patterns between the femur and the tibial plateau. However, it is unknown if changes to this kinematic measure are reflected by changes to cartilage as early as 2 years after surgery. Ultrashort TE-enhanced T2* (UTE-T2*) mapping has been shown to be sensitive to subsurface changes occurring in deep articular cartilage early after ACL injury and over 2 years after ACLR that were not detectable by standard morphological MRI. Thus, the purpose of this study was to test the hypothesis that side to side differences in KCOR correlate with side to side differences in UTE-T2* quantitative MRI (qMRI) in the central weight bearing regions of the medial and lateral tibial plateaus at 2 years following ACLR. Methods: Thirty-five human participants (18F, Age: 33.8±10.5 yrs, BMI: 24.1±3.3) with a history of unilateral ACL reconstruction (2.19±0.22 yrs post-surgery) and no other history of serious lower limb injury received bilateral examinations on a 3T MRI scanner. UTE-T2* maps were calculated via mono-exponential fitting on a series of T2*-weighted MR images acquired at eight TEs (32μs -16 ms, non-uniform echo spacing) using a radial out 3D cones acquisition. All subjects completed bilateral gait analysis. Medial-lateral (ML) and anterior-posterior (AP) coordinates of average KCOR during stance of walking were calculated for both knees. Side to side differences in KCOR were tested for correlations with side to side differences in mean full thickness UTE-T2* quantitative values in the central weight bearing regions of the medial and lateral tibial plateau using Pearson correlation coefficients. Results: There was a distribution in UTE-T2* values, with some subjects having higher UTE-T2* and some lower in the ACLR knee relative to the contralateral knee. A significant correlation (R=0.407, p=0.015, Figure 1A) was observed between UTE-T2* and the ML KCOR with a more lateral KCOR corresponding to higher values of UTE-T2* for the medial tibia. Similarly, for the lateral tibia, a lower UTE-T2* was correlated with a more posterior KCOR (R=0.363, p=0.032, Figure 1B). Significant correlations were not observed for UTE-T2* in the lateral tibia with the ML position of KCOR or for UTE-T2* in the medial tibia with the AP position of KCOR. Conclusions: The results of this study support the hypothesis that side to side differences in mean full thickness UTE-T2* qMRI correlate with side to side differences in knee kinematics at 2 years after ACLR. The finding that a more lateral KCOR in the ACLR knee correlates with UTE T2* values in the medial tibia that were higher than the contralateral side suggests that this kinematic change, which has been previously shown to result in more relative motion between the femur and tibia in the medial compartment, could be affecting subsurface matrix integrity, inducing changes detectable by UTE-T2* mapping. Additionally, the finding that a more posterior KCOR in the ACLR knee correlated with UTE-T2* values in the lateral tibia that were lower than the contralateral knee further suggests that the UTE-T2* metric may reflect early changes in cartilage health. When interpreted within the context of prior work showing that a posterior shift in KCOR from 2 to 4 years post-surgery correlated with improved clinical outcomes at 8 years, the observed lower UTE-T2* with a more posterior KCOR, which is reflective of improved quadriceps recruitment, suggests positive cartilage matrix properties. In spite of the limitations of this cross-sectional and exploratory study, and the difficulty accounting for changes in the contralateral knee, these results support future studies of the relationship between UTE-T2* and KCOR to provide new insight into predicting the risk for OA after ACLR.
Listed In: Biomechanical Engineering, Biomechanics, Gait, Mechanical Engineering, Orthopedic Research, Sports Science


Effects of Total Knee Replacement Material Pairing on Implant Kinematics and Stability

Physical testing of TKR systems to assess stability is an important aspect in screening candidate TKR designs which can be expensive and time consuming. Costs can be reduced by utilizing 3D printed plastic components. The objective is to compare the kinematics and intrinsic constraint of metal-on-plastic (M-P) and plastic-on-plastic (P-P) implants under physiologically relevant loading, with and without simulated ligament contributions, in order to elucidate the effects of material pairings. A cruciate retaining TKR implant was created by combining a 3D printed ABS plastic tibial component with the standard cobalt chrome femoral component, as well as a 3D printed ABS plastic replica femoral component. This results in both M-P and P-P articulations that were mounted to a VIVO 6-DOF joint motion simulator (AMTI, Watertown, MA), which was used for in vitro constraint testing using functional laxity tests. Anterior-posterior (AP) and internal-external (IE) constraint was measured based on resulting deviations from the normal path when superimposed AP and IE loads were applied. Ligaments were simulated as tension-only point-to-point springs using the soft tissue modelling capabilities of the VIVO. Different kinematics were observed between the M-P and P-P implants which could be the result of different initial implant positioning on the joint motion simulator or due to “stiction” of the P-P implant. The functional laxity of the implant system tested appears to be relatively insensitive to the material pairing and ligament presence. These relationships are complex and hard to predict, which underscores the importance of pre-clinical in vitro testing.
Listed In: Biomechanical Engineering, Biomechanics, Gait, Mechanical Engineering, Orthopedic Research


Effects of an 8-week cadence gait training program on knee loading in individuals following ACL reconstruction

While normalization of gait is a primary goal of early rehabilitation, between limb asymmetries in knee extensor moment can persist 6-24 months later and previous literature assessing gait interventions is limited. The purpose of this study was to assess the influence of subject-specific cadence gait training program on knee loading mechanics following ACLr. Nine individuals completed an 8-week cadence training program (20min, 3x/week; Table1) and nine sex- and surgery-matched individuals served as controls. All eighteen participants received standard physical therapy and were tested at 1 and 3 months post-op. Kinematic and kinetic data were collected during walking at a self-selected speed. Repeated measures ANOVAs were used for comparisons; significance α≤0.05. Main effects of limb and time were observed: knee ROM (kROM;p<0.001;p=0.044;Fig.1) and knee extensor moment (kEXT;p=0.003;p=0.002) in the cadence and control groups, respectively. No main effects of group for kROM (p=0.136) or kEXT (p=0.229) were found. A trend toward a significant group x time x limb interaction was observed in kEXT (p=0.092), but not kROM (p=0.412). Post-hoc analyses of kEXT (Fig.2) revealed a significant time x limb interaction for the cadence group (p=0.053) but not the control group (p=0.884). In the cadence group, the time x limb interaction was driven by a 131% increase in kEXT in the surgical limb versus a 42% increase in the non-surgical limb between T1 and T2. Consistent with previous findings, these pilot data show promising results as the cadence intervention resulted in improvements in sagittal plane knee loading compared to controls.


Listed In: Biomechanics, Gait, Orthopedic Research, Physical Therapy, Sports Science


Elasto-Plastic Computational Modelling of Damage Mechanisms in Total Elbow Replacements

As a treatment for end-stage elbow joint arthritis, total elbow replacement (TER) results in joint motions similar to the intact joint; however, bearing wear, excessive deformations and/or early fracture may necessitate early revision of failed implant components. A finite element model of a TER assembly was developed based on measurements from a Coonrad-Morrey implant (Zimmer, Inc., Warsaw, IN) using nonlinear elasto-plastic UHMWPE material properties and a frictional penalty contact formulation. The loading scenario applied to the model includes a flexion-extension motion, a joint force reaction with variable magnitude and direction and a time varying varus-valgus (VV) moment with a maximum magnitude of 13 N.m, simulating a chair-rise scenario as an extreme loading condition. Model results were compared directly with corresponding experimental data. Experimental wear tests were performed on the abovementioned implants using a VIVO (AMTI, Watertown, MA) six degree-of-freedom (6-DOF) joint motion simulator apparatus. The worn TER bushings were scanned after the test using micro computed tomography (μCT) imaging techniques, and reconstructed as 3D models. Contact pressure distributions on the humeral and ulnar bushings correlate with the sites of damage as represented by the μCT data and gross observation of clinical retrievals. The results demonstrate UHMWPE bushing damage due to different loading protocols. Numerical results demonstrate strong agreement with experimental data based on the location of deformation and creep on bushings and exhibit promising capabilities for predicting the damage and failure mechanisms of TER implants.
Listed In: Biomechanical Engineering, Biomechanics, Biotribology, Mechanical Engineering, Orthopedic Research


Sensitivity to Marker Placement in the TSRHC Foot Model

Multi-segmented foot and ankle (FandA) models provide more information regarding intrinsic foot motion compared to rigid-body models due to additional markers on bony landmarks of the foot. Marker placement sensitivity is a concern, especially in patients with bony abnormalities, because kinematics vary with marker placement deviations. PURPOSE: Assess kinematic changes due to marker placement error using the TSRHC multi-segmented FandA model. METHODS: Our participant was an 18yo female lacking any prior orthopedic conditions. The Plug-in-Gait model was used with the TSRHC model. An experienced clinician executed all marker placements, systematically moving each marker approximately 2.5mm within two planes. Three dynamic trials were collected for each condition, and static trials were used to calculate exact distances markers moved. Six force plates (AMTI) were utilized to confirm a consistent walking pattern. Graphs analyzed included: 1)PIG–ankle dorsiflexion, foot rotation, foot progression angle, 2)TSRHC–hindfoot, forefoot, FF-tibia. For each condition, the peaks of affected kinematic graphs were compared to assess correlations. Intra-trial error was determined by the maximum difference across walking trials. CONCLUSION: The hindfoot was most sensitive to transverse plane marker placement errors. Markers on metatarsals periodically rose vertically when moved laterally due to foot curvature causing errors in the sagittal plane as well. The forefoot also had transverse plane errors when metatarsal markers were moved. This case study illustrates the importance of proper marker placement training when utilizing a multi-segmented foot model. A thorough understanding of a utilized model is imperative, including how sensitive the model is to marker placement.
Listed In: Biomechanics, Gait, Orthopedic Research


Nucleotomy Alters Internal Strain Distribution of the Human Lumbar Intervertebral Disc

Nucleotomy is a surgical procedure following herniation and also simulates the reduced nucleus pulpousus (NP) pressure that occurs with disc degeneration. Internal disc strains are an important factor in disc function, yet it is unclear how internal strains are affected by nucleotomy. Grade II L3-L4 human cadaveric discs (n=6) were analyzed intact and after a partial nucleotomy that removed 30-50% of the NP through a left posterolateral incision (incision) while the contralateral side remained intact (uninjured). Two cycles of stress-relaxation testing were performed for reference (50N) and loaded (0.70MPa) configurations. After each 8hour equilibration period, the reference and loaded discs were imaged separately in a 7T MRI scanner (0.3mm isotropic resolution). The reference and loaded images were registered to calculate internal strain within the annulus fibrosus (AF) lamellae and discs were averaged to create anatomical templates. Circumferential, radial, and axial strains for each disc were transformed to the average templates, effectively normalizing the strains. Five circumferential regions were defined within the mid-third of the templates. Nucleotomy altered disc strains on both the incision and uninjured sides from the intact state. Strain fields were inhomogeneous through the five regions. Mean circumferential strain was unaffected by nucleotomy on the uninjured side, but decreased with incision, showing hoop strains through the AF were disrupted. Mean compressive axial strains were higher after nucleotomy, effectively reducing AF stiffness, and mean radial strains were unaltered after partial nucleotomy. These findings are important to address etiology and progression of degeneration, and to develop and evaluate therapeutic interventions.
Listed In: Biomechanical Engineering, Biomechanics, Orthopedic Research