Joseph E. Langenderfer

Development of subject-specific and statistical shape models of the knee using an efficient segmentation and mesh-morphing approach

Subject-specific finite element models developed from imaging data provide functional representation of anatomical structures and have been used to evaluate healthy and pathologic knee mechanics. The creation of subject-specific models is a time-consuming process when considering manual segmentation and hexahedral (hex) meshing of the articular surfaces to ensure accurate contact assessment. Previous studies have emphasized automated mesh mapping to bone geometry from computed tomography (CT) scans, but have not considered cartilage and soft tissue structures. Statistical shape modeling has been proposed as an alternative approach to develop a population of subject models, but still requires manual segmentation and registration of a training set. Accordingly, the aim of the current study was to develop an efficient, integrated mesh-morphing-based segmentation approach to create hex meshes of subject-specific geometries from scan data, to apply the approach to natural femoral, tibial, and patellar cartilage from magnetic resonance (MR) images, and to demonstrate the creation of a statistical shape model of the knee characterizing the modes of variation using principal component analysis. The platform was demonstrated on MR scans from 10 knees and enabled hex mesh generation of the knee articular structures in approximately 1.5h per subject. In a subset of geometries, average root mean square geometric differences were 0.54 mm for all structures and in quasi-static analyses over a range of flexion angles, differences in predicted peak contact pressures were less than 5.3% between the semi-automated and manually generated models. The integrated segmentation, mesh-morphing approach was employed in the efficient development of subject-specific models and a statistical shape model, where populations of subject-specific models have application to implant design evaluation or surgical planning.

A stochastic analysis of glenoid inclination angle and superior migration of the humeral head

BACKGROUND Superior glenoid inclination, which is a relatively upward facing of the glenoid in the plane of the scapula, has been associated with rotator cuff pathology. Increased glenoid inclination may cause superior humeral head migration, which can cause impingement of the supraspinatus tendon. The purpose of this study was to test the hypothesis that inclination angle affects the probability of superior humeral head migration. METHODS A three-dimensional model of the glenohumeral joint was developed in which muscle forces were modeled as random variables. Monte Carlo simulation was used to compute the probability that the glenohumeral reaction force was directed such that superior humeral head migration should occur. An electromyogram-driven model was used to estimate shoulder muscle forces in healthy volunteers performing arm elevation. FINDINGS The model predicted that the probability of superior humeral head migration increased as glenoid inclination angle was increased. This finding was independent of the assumed shape of the muscle force probability distributions. INTERPRETATION The results support the theory that glenoid inclination may be a risk factor for rotator cuff pathology.

An Efficient Probabilistic Methodology for Incorporating Uncertainty in Body Segment Parameters and Anatomical Landmarks in Joint Loadings Estimated From Inverse Dynamics

Inverse dynamics is a standard approach for estimating joint loadings in the lower extremity from kinematic and ground reaction data for use in clinical and research gait studies. Variability in estimating body segment parameters and uncertainty in defining anatomical landmarks have the potential to impact predicted joint loading. This study demonstrates the application of efficient probabilistic methods to quantify the effect of uncertainty in these parameters and landmarks on joint loading in an inverse-dynamics model, and identifies the relative importance of the parameters and landmarks to the predicted joint loading. The inverse-dynamics analysis used a benchmark data set of lower-extremity kinematics and ground reaction data during the stance phase of gait to predict the three-dimensional intersegmental forces and moments. The probabilistic analysis predicted the 1-99 percentile ranges of intersegmental forces and moments at the hip, knee, and ankle. Variabilities, in forces and moments of up to 56% and 156% of the mean values were predicted based on coefficients of variation less than 0.20 for the body segment parameters and standard deviations of 2 mm for the anatomical landmarks. Sensitivity factors identified the important parameters for the specific joint and component directions. Anatomical landmarks affected moments to a larger extent than body segment parameters. Additionally, for forces, anatomical landmarks had a larger effect than body segment parameters, with the exception of segment masses, which were important to the proximal-distal joint forces. The probabilistic modeling approach predicted the range of possible joint loading, which has implications in gait studies, clinical assessments, and implant design evaluations.

A multi-subject evaluation of uncertainty in anatomical landmark location on shoulder kinematic description.

An accurate assessment of shoulder kinematics is useful for understanding healthy normal and pathological mechanics. Small variability in identifying and locating anatomical landmarks (ALs) has potential to affect reported shoulder kinematics. The objectives of this study were to quantify the effect of landmark location variability on scapular and humeral kinematic descriptions for multiple subjects using probabilistic analysis methods, and to evaluate the consistency in results across multiple subjects. Data from 11 healthy subjects performing humeral elevation in the scapular plane were used to calculate Euler angles describing humeral and scapular kinematics. Probabilistic analyses were performed for each subject to simulate uncertainty in the locations of 13 upper-extremity ALs. For standard deviations of 4 mm in landmark location, the analysis predicted Euler angle envelopes between the 1 and 99 percentile bounds of up to 16.6°. While absolute kinematics varied with the subject, the average 1–99% kinematic ranges for the motion were consistent across subjects and sensitivity factors showed no statistically significant differences between subjects. The description of humeral kinematics was most sensitive to the location of landmarks on the thorax, while landmarks on the scapula had the greatest effect on the description of scapular elevation. The findings of this study can provide a better understanding of kinematic variability, which can aid in making accurate clinical diagnoses and refining kinematic measurement techniques.

A Probabilistic Model of Glenohumeral External Rotation Strength for Healthy Normals and Rotator Cuff Tear Cases

The reigning paradigm of musculoskeletal modeling is to construct deterministic models from parameters of an “average” subject and make predictions for muscle forces and joint torques with this model. This approach is limited because it does not perform well for outliers, and it does not model the effects of population parameter variability. The purpose of this study was to simulate variability in musculoskeletal parameters on glenohumeral external rotation strength in healthy normals, and in rotator cuff tear case using a Monte Carlo model. The goal was to determine if variability in musculoskeletal parameters could quantifiably explain variability in glenohumeral external rotation strength. Multivariate Gamma distributions for musculoskeletal architecture and moment arm were constructed from empirical data. Gamma distributions of measured joint strength were constructed. Parameters were sampled from the distributions and input to the model to predict muscle forces and joint torques. The model predicted measured joint torques for healthy normals, subjects with supraspinatus tears, and subjects with infraspinatus–supraspinatus tears with small error. Muscle forces for the three conditions were predicted and compared. Variability in measured torques can be explained by differences in parameter variability.

Postural stabilization by gripping a stick with different force levels

Hand contact with a stationary surface reduces postural sway in healthy individuals even when the level of force applied is mechanically insufficient. To make this phenomenon more applicable to a real-life situation, where a stationary support is not available, a mobile stick was used to measure and control grip force. The effect of a supra-postural task of stick gripping on stability was tested in 18 healthy individuals during quiet standing, standing in semi-tandem, and with eyes closed. Subjects stood either holding no haptic stick, or gripping with one of six force levels ranging from 1 to 9N and a self-selected force in the same range. The path length and velocity of the center of pressure (COP) were measured and compared within and between experimental conditions. Gripping the stick reduced the COP path length and velocity by up to 23% and 25%, respectively, and postural stability was increased at all force levels, including self-selected. The results confirmed the stabilizing effects of gripping an external portable object regardless of the amount of force applied. This knowledge may be useful for counseling people on prevention of stability loss in real life situations where balance is challenged.

The influence of cycle time on shoulder fatigue responses for a fixed total overhead workload

The relationship between overhead work and musculoskeletal health depends on multiple task and individual factors. Knowledge gaps persist, despite examination of many of these factors individually and in combination. This investigation targeted task variation, as parameterized by cycle time within a fixed overall workload. Participants performed an intermittent overhead pressing task with four different cycle time conditions while overall workload and duty cycle was held constant. Several manifestations of fatigue were monitored during task performance. Endurance time was influenced by cycle time with shorter cycle times having endurance times up to 25% higher than longer cycle times. Surface electromyography (sEMG) results were mixed, with two muscles demonstrating amplitude increases (middle deltoid and upper trapezius) that varied with cycle time. sEMG frequency was not influenced by cycle time for any muscle monitored, despite decreases for several cycle times. Trends existed for the influence of cycle time on time-varying reported discomfort (p=0.056) and static strength (p=0.055); large effect sizes were present (ηp(2)=0.31 and 0.27, respectively). The equivocal association of fatigue indicators and cycle time is analogous to the influence of other factors implicated in overhead work musculoskeletal risk, and probabilistic modeling offers a compelling avenue for integration of the known variation in the many factors that combine to inform this risk.

The effect of actual and imaginary handgrip on postural stability during different balance conditions

The stabilizing effect of holding an object on upright posture has been demonstrated in a variety of settings. The mechanism of this effect is unknown but could be attributed to either additional sensorimotor activity triggered by a hand contact or cognitive efforts related to performance of a supra-postural task. A potential mechanism was investigated by comparing postural stability in young healthy individuals while gripping a custom instrumented wooden stick with a 5N force and while imagining holding the same stick in the hand. Twenty subjects were tested during three standing balance conditions: on a stationary surface, on a freely moving rockerboard, and with an unexpected perturbation of 10° forward rockerboard tipping. Postural stability was evaluated as velocity of the center of mass (COM) and center of pressure (COP) compared across all experimental conditions. COM and COP velocities were equally reduced when subjects gripped the stick and imagined gripping while standing stationary and on the rockerboard. When perturbed, subjects failed to show any postural stability improvements regardless of handgrip task. Results indicate a stabilizing effect of focusing attention on motor task performance. This cognitive strategy does not appear to contribute any additional stabilization when subjects are perturbed. This study adds to the current understanding of postural stabilization strategies.

A stochastic model of elbow flexion strength for subjects with and without long head biceps tear.

The classical approach of musculoskeletal modeling is to predict muscle forces and joint torques with a deterministic model constructed from parameters of an average subject. However, this type of model does not perform well for outliers, and does not model the effects of parameter variability. In this study, a Monte-Carlo model was used to stochastically simulate the effects of variability in musculoskeletal parameters on elbow flexion strength in healthy normals, and in subjects with long head biceps (LHB) rupture. The goal was to determine if variability in elbow flexion strength could be quantifiably explained with variability in musculoskeletal parameters. Parameter distributions were constructed from data in the literature. Parameters were sampled from these distributions and used to predict muscle forces and joint torques. The median and distribution of measured joint torque was predicted with small errors ( < 5%). Muscle forces for both cases were predicted and compared. In order to predict measured torques for the case of LHB rupture, the median force and mean cross-sectional area in the remaining elbow flexor muscles is greater than in healthy normals. The probabilities that muscle forces for the Tear case exceed median muscle forces for the No-Tear case are 0.98, 0.99 and 0.79 for SH Biceps, brachialis and brachioradialis, respectively. Differences in variability of measured torques for the two cases are explained by differences in parameter variability.

A probabilistic orthopaedic population model to predict fatigue-related subacromial geometric variability.

Fatigue-related glenohumeral and scapulothoracic kinematic relationships, in addition to morphological characteristics of the scapula and humerus, affect the dimensions of the subacromial space. Each exhibits considerable interpersonal variability, which if only considering the mean, can lead to misleading population estimations of subacromial impingement risk, particularly for outliers. Additionally, the relative influence of each parameter on subacromial space variability is unclear. Applying empirically-derived morphological and kinematic distributions (n=31), this research used Advanced Mean Value and Monte Carlo probabilistic modeling approaches to predict the distribution of the minimum subacromial space width (SAS) and establish which parameters contributed more to modulating the SAS. The predicted SAS differed by 8mm between 1% and 99% confidence intervals. While the SAS was not influenced by muscle fatigue, the space reduced with arm elevation to magnitudes between 4.5 and 5mm. This reduction resulted in an estimated 65-75% of the population at risk for tissue compression at elevation angles≥90° when considering the interposed tissue thickness. Morphological parameters, notably glenoid inclination, showed higher relative importance for modulating the predicted SAS across conditions, while kinematic parameters (humeral head translation, scapular orientation), which differed by elevation angle and fatigue state, demonstrated less consistent importance levels across experimental conditions. Overall, the findings reinforce the shoulder health risks related to overhead activities, as they pose an increased likelihood of mechanical rotator cuff tendon compression. Further, probabilistic methods are highly innovative, in that they are capable of determining relative parameter importance and subsequently identifying key injury risk factors. As glenoid inclination is difficult to diagnose and treat, and is associated with superior humeral head translation, interventions to improve rotator cuff strength and glenohumeral stability are recommended, particularly in populations exposed to overhead postures.