Carolyn Anglin

A functional task analysis and motion simulation for the development of a powered upper-limb orthosis

Describes research work directed towards the development and application of a design methodology to determine the optimal configuration of a powered upper-limb orthosis. The design objective was to minimize the orthosis complexity, defined as the number of degrees of freedom, while maintaining the ability to perform specific tasks. This objective was achieved in three stages. First, potential users of a powered orthosis were interviewed to determine their priority tasks. Secondly, the natural arm motions of able-bodied individuals performing the priority tasks were profiled using a video tracking system. Finally, a kinematic simulation algorithm was developed and employed in order to evaluate whether a proposed orthosis configuration could perform the priority tasks. The research results indicate that task functionality is overly compromised for orthosis configurations with less than five degrees of freedom, plus prehension. Acceptable task performance, based on the specific priority tasks considered, was achieved in the simulations of two different orthosis configurations with five degrees of freedom. In the first design option, elevation (rotation about a horizontal axis through the shoulder) and radial/ulnar deviation are fixed, while in the second option wrist flexion and radial/ulnar deviation are fixed. A prototype orthosis is currently being developed using the first design option. >

Effect of Calibration Method on Tekscan Sensor Accuracy

Tekscan pressure sensors are used in biomechanics research to measure joint contact loads. While the overall accuracy of these sensors has been reported previously, the effects of different calibration algorithms on sensor accuracy have not been compared. The objectives of this validation study were to determine the most appropriate calibration method supplied in the Tekscan program software and to compare its accuracy to the accuracy obtained with two user-defined calibration protocols. We evaluated the calibration accuracies for test loads within the low range, high range, and full range of the sensor. Our experimental setup used materials representing those found in standard prosthetic joints, i.e., metal against plastic. The Tekscan power calibration was the most accurate of the algorithms provided with the system software, with an overall rms error of 2.7% of the tested sensor range, whereas the linear calibrations resulted in an overall rms error of up to 24% of the tested range. The user-defined ten-point cubic calibration was almost five times more accurate, on average, than the power calibration over the full range, with an overall rms error of 0.6% of the tested range. The user-defined three-point quadratic calibration was almost twice as accurate as the Tekscan power calibration, but was sensitive to the calibration loads used. We recommend that investigators design their own calibration curves not only to improve accuracy but also to understand the range(s) of highest error and to choose the optimal points within the expected sensing range for calibration. Since output and sensor nonlinearity depend on the experimental protocol (sensor type, interface shape and materials, sensor range in use, loading method, etc.), sensor behavior should be investigated for each different application.

Hip resurfacing femoral neck fracture influenced by valgus placement.

Femoral neck fracture is the most common short-term concern after hip resurfacing arthroplasty. Currently, there is little basis to decide between neutral and valgus placement. We loaded 10 notched cadaveric femur pairs to failure; one side was implanted at 0° relative to the femoral neck and the other at 10° valgus. All 20 were dual-energy xray absorptiometry-scanned. Failure load correlated with bone mineral density. Valgus placement increased the fracture load by an average of 28% over neutral for specimens with normal bone mineral density but had no effect on fracture load in specimens with low bone mineral density. For specimens with normal bone mineral density (typical of patients undergoing resurfacing arthroplasty), neutral-valgus placement had a greater effect than bone mineral density, explaining 54% of the fracture load variance. Component placement greater than 10° valgus is likely undesirable because this can lead to an increase in component size and a greater likelihood of notching. To reduce fracture risk, we recommend placing the femoral component in valgus and selecting patients with higher bone mineral density.

To Resurface or Not to Resurface the Patella in Total Knee Arthroplasty

AbstractThe management of the patellar articular surface at the time of primary total knee arthroplasty (TKA) is controversial. We used expected-value decision analysis to determine whether the patella should be resurfaced in TKA, and also whether secondary resurfacing on an unresurfaced patella is worthwhile. Outcome probabilities and utility values were derived from randomized controlled trials only. A decision tree was constructed and fold-back analysis was performed to ascertain the best treatment path. Sensitivity analyses were performed to determine the effect on decision-making of varying outcome probabilities and utilities. Our model showed patellar resurfacing is the best management strategy for the patella at the time of primary TKA. This decision is robust to changes in the specific data: the best path would remain the same as long as the incidence of persistent anterior knee pain (AKP) with resurfacing remains less than 29% (current mean, 12%) or the incidence of AKP after nonresurfacing falls below 12% (current mean, 26%). Delayed (ie, secondary) patellar resurfacing for ongoing patellar pain provides inferior results for the majority of patients. Level of Evidence: Level II, decision analysis. See the Guidelines for Authors for a complete description of levels of evidence.

Determinants of patellar tracking in total knee arthroplasty

BACKGROUND Optimizing patellar tracking in total knee arthroplasty is a surgical priority. Despite this, a comparison of the effects of different component placements on patellar tracking is not available; the biomechanical impact of the patellar resection angle has not been studied; and the similarity between intraoperative and postoperative effects, fundamental to improving patellar tracking, is unknown. Our objective was to compare the impact of the major controllable femoral, tibial and patellar component positions on patellar kinematics during both passive and loaded flexion. METHODS We tested eight cadaveric knee specimens in two rigs, simulating intraoperative and weightbearing flexion. Optoelectronic marker arrays were attached to the femur, tibia and patella to record kinematics throughout the range of motion. We modified posterior-stabilized fixed-bearing knee components to allow for five types of variations in component placement in addition to the neutral position: femoral component rotation, tibial component rotation, patellar resection angle, patellar component medialization and additional patellar thickness, for a total of 11 individual variations. FINDINGS The major determinants of patellar tilt and shift were patellar component medialization, patellar resection angle and femoral component rotation. The relative order of these variables depended on the structure (bone or component), kinematic parameter (tilt or shift) and flexion angle (early or late flexion). Effects of component changes were consistent between the intraoperative and weightbearing rigs. INTERPRETATION To improve patellar tracking, and thereby the clinical outcome, surgeons should focus on patellar component medialization, patellar resection angle and femoral component rotation. These have been linked with anterior knee pain as well. Neither tibial component rotation nor patellar thickness should be adjusted to improve patellar tracking.

Computer-assisted femoral head resurfacing

Femoral head resurfacing is re-emerging as a surgical option for younger patients who are not yet candidates for total hip replacement. However, this procedure is more difficult than total hip replacement, and the mechanical jigs typically used to align the implant produce significant variability in implant placement and take a significant amount of time to position properly. We propose that a computer-assisted surgical (CAS) technique could reduce implant variability with little or no increase in operative time. We describe a new CAS technique for this procedure and demonstrate in a cadaver study of five paired femurs that the CAS technique in the hands of a novice surgeon markedly reduced the varus/valgus variability of the implant relative to the pre-operative plan (2° standard deviation for CAS versus 5° for a mechanical jig operated by an expert surgeon). We also show that the mechanical jig resulted in significantly retroverted implant placement. There was no significant difference in operative time between the two techniques.

In vivo patellar kinematics during total knee arthroplasty

Patellar maltracking after total knee arthroplasty often results in complications, including anterior knee pain, instability and impingement, and is therefore better resolved intraoperatively. Many factors can affect patellar kinematics during knee replacement, including component position, implant design, joint alignment, and soft tissue tensions. However, to our knowledge, the impact of arthroplasty on patellar kinematics has not been previously reported in vivo. A computer-assisted surgery (CAS) system was developed to measure the pre-arthroplasty patellar kinematics, display the distance between this path and the surface of the planned femoral component, and compare the post-arthroplasty path to the pre-arthroplasty path. Three surgeons from three centers used this CAS system to measure the in vivo pre- and post-arthroplasty kinematics of 18 patients. There was a small, but consistent, proximal shift in the tibial joint lines (mean: 4.2 mm), resulting in pseudo patella-baja, i.e., relatively more distal contact of the patella on the femoral component. This led to significant changes in proximodistal and anteroposterior patellar positioning as well as patellar flexion following arthroplasty (p < 0.008). Mediolateral shift, tilt and internal/external spin had the greatest magnitudes of change (mean: 4.1 mm, 4.6° and 4.6°, respectively) relative to their mean pre-arthroplasty ranges (averaging 2.1 mm, 5.8° and 5.8°, respectively); however, these changes were distributed almost equally medially and laterally, indicating no surgical bias in any one direction. Female patients had more lateral tilt on average than male patients throughout flexion (p < 0.004 post-arthroplasty, p < 0.03 pre-arthroplasty, in later flexion), as well as other kinematic differences; there may therefore be potential for improving overall kinematic results by focusing on gender differences during research, design and surgery. This study demonstrated the feasibility of using a CAS system to measure patellofemoral kinematics. Intraoperative awareness of patellar tracking, including knowledge of the tibiofemoral joint line, could have an impact on the surgical plan and thereby improve the postoperative outcome.

Biomechanical Consequences of Patellar Component Medialization in Total Knee Arthroplasty

The optimal amount of patellar component medialization in knee arthroplasty is unknown. We measured the impact, on patellofemoral kinematics and contact force distribution, of 0.0-, 2.5-, and 5.0-mm patellar component medialization in 7 cadaveric specimens implanted with knee arthroplasty components. The knees were flexed dynamically in a weight-bearing rig. Medialization led to lateral shift of the patellar bone, slight medial shift of the patellar component in the femoral groove, lateral tilt of the patella, reduced patellofemoral contact force in later flexion, and lateral shift of the center of pressure in early flexion. Effects on shift and tilt were proportional to the amount of medialization. As a result of this investigation, we recommend medializing the patellar component slightly-on the order of 2.5 mm.

Radiological method for measuring patellofemoral tracking and tibiofemoral kinematics before and after total knee replacement

Objectives Numerous complications following total knee replacement (TKR) relate to the patellofemoral (PF) joint, including pain and patellar maltracking, yet the options for in vivo imaging of the PF joint are limited, especially after TKR. We propose a novel sequential biplane radiological method that permits accurate tracking of the PF and tibiofemoral (TF) joints throughout the range of movement under weightbearing, and test it in knees pre- and post-arthroplasty. Methods A total of three knees with end-stage osteoarthritis and three knees that had undergone TKR at more than one year’s follow-up were investigated. In each knee, sequential biplane radiological images were acquired from the sagittal direction (i.e. horizontal X-ray source and 10° below horizontal) for a sequence of eight flexion angles. Three-dimensional implant or bone models were matched to the biplane images to compute the six degrees of freedom of PF tracking and TF kinematics, and other clinical measures. Results The mean and standard deviation for the six degrees of freedom of PF tracking and TF kinematics were computed. TF and PF kinematics were highly accurate (< 0.9 mm, < 0.6°) and repeatable. Conclusions The developed method permitted measuring of in vivo PF tracking and TF kinematics before and after TKR throughout the range of movement. This method could be a useful tool for investigating differences between cohorts of patients (e.g., with and without pain) impacting clinical decision-making regarding surgical technique, revision surgery or implant design.

Healthy vs. osteoarthritic hips: A comparison of hip, pelvis and femoral parameters and relationships using the EOS® system

BACKGROUND Osteoarthritis is a debilitating disease, for which the development path is unknown. Hip, pelvis and femoral morphological and positional parameters relate either to individual differences or to changes in the disease state, both of which should be taken into account when diagnosing and treating patients. These have not yet been comprehensively quantified. Previous imaging studies have been limited by a number of factors: supine rather than standing measurements; high radiation dose; a limited field of view; and 2D rather than 3D measurements. EOS®, a new radiographic imaging modality that acquires simultaneous frontal and lateral (sagittal) X-ray images of the full body, allows 3D reconstruction of the hip, pelvis and lower limb. The aim of the study was to explore similarities and differences between healthy and osteoarthritis groups. METHODS Two groups of subjects, 30 healthy and 30 with hip osteoarthritis, were assessed and compared for pelvic, acetabular and femoral parameters in the standing position. FINDINGS There were not only significant differences between groups but also considerable overlap amongst the individuals. Sacral slope, acetabular angle of Idelberger and Frank, femoral mechanical angle and femoral head eccentricity as well as right-left asymmetries in centre-edge acetabular angle and femoral head diameter were higher on average in osteoarthritic patients compared to healthy subjects, whereas acetabular abduction was lower in the osteoarthritic group (P<0.05). Correlations were identified between key parameters in both groups. INTERPRETATION Differences between the groups suggest either degenerative changes over time or inherent differences between individuals that may contribute to the disease progression. These data provide a basis for longitudinal and post-surgery studies. Due to the considerable variability amongst individuals and the considerable overlap between groups, patients should be evaluated individually and at multiple joints when planning hip, knee and spine surgery.