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  • Journal article
    Iranpour F, Merican AM, Teo SH, Cobb JP, Amis AAet al., 2017,

    Femoral articular geometry and patellofemoral stability

    , KNEE, Vol: 24, Pages: 555-563, ISSN: 0968-0160

    Background:Patellofemoral instability is a major cause of anterior knee pain. The aim of this study was to examine how the medial and lateral stability of the patellofemoral joint in the normal knee changes with knee flexion and measure its relationship to differences in femoral trochlear geometry.Methods:Twelve fresh-frozen cadaveric knees were used. Five components of the quadriceps and the iliotibial band were loaded physiologically with 175 N and 30 N, respectively. The force required to displace the patella 10 mm laterally and medially at 0°, 20°, 30°, 60° and 90° knee flexion was measured. Patellofemoral contact points at these knee flexion angles were marked. The trochlea cartilage geometry at these flexion angles was visualized by Computed Tomography imaging of the femora in air with no overlying tissue. The sulcus, medial and lateral facet angles were measured. The facet angles were measured relative to the posterior condylar datum.Results:The lateral facet slope decreased progressively with flexion from 23° ± 3° (mean ± S.D.) at 0° to 17 ± 5° at 90°. While the medial facet angle increased progressively from 8° ± 8° to 36° ± 9° between 0° and 90°. Patellar lateral stability varied from 96 ± 22 N at 0°, to 77 ± 23 N at 20°, then to 101 ± 27 N at 90° knee flexion. Medial stability varied from 74 ± 20 N at 0° to 170 ± 21 N at 90°. There were significant correlations between the sulcus angle and the medial facet angle with medial stability (r = 0.78, p < 0.0001).Conclusions:These results provide objective evidence relating the changes of femoral profile geometry with knee flexion to patellofemoral stability.

  • Journal article
    Amis AA, 2017,

    Anterolateral knee biomechanics

    , KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY, Vol: 25, Pages: 1015-1023, ISSN: 0942-2056

    This article reviews the evidence for the roles of the anterolateral soft-tissue structures in rotatory stability of the knee, including their structural properties, isometry, and contributions to resisting tibial internal rotation. These data then lead to a biomechanical demonstration that the ilio-tibial band is the most important structure for the restraint of anterolateral rotatory instability.

  • Journal article
    Ma S, Goh EL, Jin A, Bhattacharya R, Boughton O, Patel B, Karunaratne A, Vo NT, Atwood R, Cobb J, Hansen U, Abel Ret al., 2017,

    Long-term effects of bisphosphonate therapy: perforations, microcracks and mechanical properties

    , Scientific Reports, Vol: 7, Pages: 1-10, ISSN: 2045-2322

    Osteoporosis is characterised by trabecular bone loss resulting from increased osteoclast activation and unbalanced coupling between resorption and formation, which induces a thinning of trabeculae and trabecular perforations. Bisphosphonates are the frontline therapy for osteoporosis, which act by reducing bone remodelling, and are thought to prevent perforations and maintain microstructure. However, bisphosphonates may oversuppress remodelling resulting in accumulation of microcracks. This paper aims to investigate the effect of bisphosphonate treatment on microstructure and mechanical strength. Assessment of microdamage within the trabecular bone core was performed using synchrotron X-ray micro-CT linked to image analysis software. Bone from bisphosphonate-treated fracture patients exhibited fewer perforations but more numerous and larger microcracks than both fracture and non-fracture controls. Furthermore, bisphosphonate-treated bone demonstrated reduced tensile strength and Young’s Modulus. These findings suggest that bisphosphonate therapy is effective at reducing perforations but may also cause microcrack accumulation, leading to a loss of microstructural integrity and consequently, reduced mechanical strength.

  • Journal article
    Amirthanayagam TD, Amis AA, Reilly P, Emery RJHet al., 2017,

    Rotator cuff-sparing approaches for glenohumeral joint access: an anatomic feasibility study

    , Journal of Shoulder and Elbow Surgery, Vol: 26, Pages: 512-520, ISSN: 1058-2746

    BackgroundThe deltopectoral approach for total shoulder arthroplasty can result in subscapularis dysfunction. In addition, glenoid wear is more prevalent posteriorly, a region difficult to access with this approach. We propose a posterior approach for access in total shoulder arthroplasty that uses the internervous interval between the infraspinatus and teres minor. This study compares this internervous posterior approach with other rotator cuff–sparing techniques, namely, the subscapularis-splitting and rotator interval approaches.MethodsThe 3 approaches were performed on 12 fresh frozen cadavers. The degree of circumferential access to the glenohumeral joint, the force exerted on the rotator cuff, the proximity of neurovascular structures, and the depth of the incisions were measured, and digital photographs of the approaches in different arm positions were analyzed.ResultsThe posterior approach permits direct linear access to 60% of the humeral and 59% of the glenoid joint circumference compared with 39% and 42% for the subscapularis-splitting approach and 37% and 28% for the rotator interval approach. The mean force of retraction on the rotator cuff was 2.76 (standard deviation [SD], 1.10) N with the posterior approach, 2.72 (SD, 1.22) N with the rotator interval, and 4.75 (SD, 2.56) N with the subscapularis-splitting approach. From the digital photographs and depth measurements, the estimated volumetric access available for instrumentation during surgery was comparable for the 3 approaches.ConclusionThe internervous posterior approach provides greater access to the shoulder joint while minimizing damage to the rotator cuff.

  • Journal article
    Colaco H, Lord BR, Back DL, Davies AJ, Amis AA, Ajuied Aet al., 2017,

    Biomechanical properties of Bovine tendon xenografts treated with a modern processing method

    , Journal of Biomechanics, Vol: 53, Pages: 144-147, ISSN: 1873-2380

    Xenograft tendons have been used in few human studies, with variable results. With the advent of novel tissue processing techniques, which may mitigate against an immune-mediated rejection response without adversely affecting mechanical properties, there maynowbe a clinical role for xenograft tendons, particularly in knee ligament reconstruction. We hypothesize that‘BioCleanse®’processed bovine extensor digitorum medialis(EDM) tendons exhibit favorable time-zero pre-implantation biomechanical characteristics when compared to both unprocessed bovine EDM tendons and BioCleanse® processed human cadaveric allograft tibialis anterior tendons.In this in vitrocase controlled laboratory study, three groups of tendons underwent a 5-stage static loading test protocol: 15 BioCleanse® bovine (BCB), 15 fresh frozen unprocessed bovine (FFB), and 12 BioCleanse® human allograft (BCA) tendons. Cross-sectional area of the grafts was measured using an alginate molding technique, and tendons were mounted within an Instron® 5565 Materials Testing System using cryogenic clamps. BCB tendons displayed a higher ultimate tensile stress (p<0.05), with equivalent ultimate failure load, creep, and modulus of elasticity when compared to the FFB tendons (p>0.05). BCB tendons had an equivalent cross-sectional area to the BCA tendons (p>0.05) whilst exhibiting a greater failure load, ultimate tensile stress, less creep and a higher modulus of elasticity (p<0.05).The BioCleanse® process didnot adversely affect the time-zero biomechanical roperties of bovine xenograft EDM tendons. BioCleanse® processed bovine xenograft EDM tendons exhibitedsuperior biomechanical characteristics when 3compared with BioCleanse® processed allograft tibialis anterior tendons

  • Conference paper
    Boughton OR, Zhao S, Arnold M, Ma S, Cobb JP, Giuliani F, Hansen U, Abel RLet al., 2017,

    Measuring bone stiffness using microindentation

    , British Orthopaedic Research Society (BORS) 2016 Conference, Publisher: British Editorial Society of Bone and Joint Surgery, Pages: 31-31, ISSN: 2049-4416
  • Journal article
    van Arkel RJ, Jeffers JRT, Amis AA, 2017,

    Editorial Commentary: Anatomical Vandalism of the Hip? Hip Capsular Repair Seems a Sound Adjunct to Hip Arthroscopic Surgery

    , ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY, Vol: 33, Pages: 314-316, ISSN: 0749-8063
  • Book chapter
    Kittl C, Inderhaug E, Stephen J, El-Daou H, Williams A, Amis AAet al., 2017,

    Scientific basis and surgical technique for iliotibial band tenodesis combined with ACL reconstruction

    , Controversies in the Technical Aspects of ACL Reconstruction: An Evidence-Based Medicine Approach, Pages: 393-404, ISBN: 9783662527405

    Anatomy: Due to the complexity of the lateral side of the knee, it may be best to describe these structures in terms of three tissue layers from superficial to deep. The distal part of the fascia lata - (1) the superficial layer of the iliotibial band (ITB) - is tethered to the distal femur by the (2) deep and capsulo-osseous fibres of the ITB. Removal of these ITB layers exposes the (3) anterolateral capsule and other deeper structures, which has been described as including the anterolateral ligament (ALL) with differing interpretations. Biomechanics: The anterior cruciate ligament (ACL) and the ITB have been shown to be the primary restraints to anterior tibial translation and internal tibial rotation, respectively. An injury of the ACL and the anterolateral structures may therefore result in a combined translatory and rotatory instability, called anterolateral rotatory instability (ALRI). As a logical rationale, a surgical intervention would include an intra-articular ACL reconstruction alongside a reconstruction of the anterolateral structures. This has been shown to restore normal knee kinematics in a simulated ALRI-injured knee. Conclusion: The anatomy of the anterolateral side is complex and yet not fully understood. Thus, there is an urgent need for a standardised nomenclature/terminology for these structures. A combined ALRI injury may be treated with an intra-articular ACL reconstruction and a nonanatomic ITB tenodesis.

  • Journal article
    Inderhaug E, Stephen JM, Williams A, Amis AAet al., 2016,

    Biomechanical Comparison of Anterolateral Procedures Combined With Anterior Cruciate Ligament Reconstruction

    , American Journal of Sports Medicine, Vol: 45, Pages: 347-354, ISSN: 0363-5465

    Background: Anterolateral soft tissue structures of the knee have a role in controlling anterolateral rotational laxity, and they maybe damaged at the time of anterior cruciate ligament (ACL) ruptures.Purpose: To compare the kinematic effects of anterolateral operative procedures in combination with intra-articular ACL reconstructionfor combined ACL plus anterolateral–injured knees.Study Design: Controlled laboratory study.Methods: Twelve cadaveric knees were tested in a 6 degrees of freedom rig using an optical tracking system to record the kinematicsthrough 0 to 90 of knee flexion with no load, anterior drawer, internal rotation, and combined loading. Testing was firstperformed in ACL-intact, ACL-deficient, and combined ACL plus anterolateral–injured (distal deep insertions of the iliotibial bandand the anterolateral ligament [ALL] and capsule cut) states. Thereafter, ACL reconstruction was performed alone and in combinationwith the following: modified MacIntosh tenodesis, modified Lemaire tenodesis passed both superficial and deep to thelateral collateral ligament, and ALL reconstruction. Anterolateral grafts were fixed at 30 of knee flexion with both 20 and 40 Nof tension. Statistical analysis used repeated-measures analyses of variance and paired t tests with Bonferroni adjustments.Results: ACL reconstruction alone failed to restore native knee kinematics in combined ACL plus anterolateral–injured knees (P\.05 for all). All combined reconstructions with 20 N of tension, except for ALL reconstruction (P 5 .002-.01), restored anteriortranslation. With 40 N of tension, the superficial Lemaire and MacIntosh procedures overconstrained the anterior laxity in deepflexion. Only the deep Lemaire and MacIntosh procedures—with 20 N of tension—restored rotational kinematics to the intactstate (P . .05 for all), while the ALL underconstrained and the superficial Lemaire overconstrained internal rotation. The sameprocedures with 40 N of tension

  • Journal article
    van Arkel RJ, Jeffers JRT, 2016,

    In vitro hip testing in the International Society of Biomechanics coordinate system

    , JOURNAL OF BIOMECHANICS, Vol: 49, Pages: 4154-4158, ISSN: 0021-9290
  • Journal article
    Athwal K, El Daou, Lord B, Davies AJ, Manning W, Rodriguez y Baena, Deehan DJ, Amiset al., 2016,

    Lateral soft-tissue structures contribute to cruciate-retaining total knee arthroplasty stability.

    , Journal of Orthopaedic Science, Vol: 35, Pages: 1902-1909, ISSN: 0949-2658

    Little information is available to surgeons regarding how the lateral structures prevent instability in the replaced knee. The aim of this study was to quantify the lateral soft‐tissue contributions to stability following cruciate‐retaining total knee arthroplasty (CR TKA). Nine cadaveric knees were tested in a robotic system at full extension, 30°, 60°, and 90° flexion angles. In both native and CR implanted states, ±90 N anterior–posterior force, ±8 Nm varus–valgus, and ±5 Nm internal–external torque were applied. The anterolateral structures (ALS, including the iliotibial band), the lateral collateral ligament (LCL), the popliteus tendon complex (Pop T), and the posterior cruciate ligament (PCL) were transected and their relative contributions to stabilizing the applied loads were quantified. The LCL was found to be the primary restraint to varus laxity (an average 56% across all flexion angles), and was significant in internal–external rotational stability (28% and 26%, respectively) and anterior drawer (16%). The ALS restrained 25% of internal rotation, while the PCL was significant in posterior drawer only at 60° and 90° flexion. The Pop T was not found to be significant in any tests. Therefore, the LCL was confirmed as the major lateral structure in CR TKA stability throughout the arc of flexion and deficiency could present a complex rotational laxity that cannot be overcome by the other passive lateral structures or the PCL. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1902–1909, 2017.

  • Journal article
    Cheong VS, Karunaratne A, Amis AA, Bull AMJet al., 2016,

    Strain rate dependency of fractures of immature bone

    , Journal of the Mechanical Behavior of Biomedical Materials, Vol: 66, Pages: 68-76, ISSN: 1751-6161

    Radiological features alone do not allow the discrimination between accidental paediatric long bone fractures or those sustained by child abuse. Therefore, there is a clinical need to elucidate the mechanisms behind each fracture to provide a forensic biomechanical tool for the vulnerable child. Four-point bending and torsional loading tests were conducted at more than one strain rate for the first time on immature bone, using a specimen-specific alignment system, to characterise structural behaviour at para-physiological strain rates. The bones behaved linearly to the point of fracture in all cases and transverse, oblique, and spiral fracture patterns were consistently reproduced. The results showed that there was a significant difference in bending stiffness between transverse and oblique fractures in four-point bending. For torsional loading, spiral fractures were produced in all cases with a significant difference in the energy and obliquity to fracture. Multiple or comminuted fractures were seen only in bones that failed at a higher stress or torque for both loading types. This demonstrates the differentiation of fracture patterns at different strain rates for the first time for immature bones, which may be used to match the case history given of a child and the fracture produced.

  • Conference paper
    Ma S, Goh EL, Patel B, Jin A, Boughton O, Cobb J, Hansen U, Abel RLet al., 2016,

    Are the cracks starting to appear in bisphosphonate therapy?

    , British Orthopaedic Research Society (BORS) 2016 Conference, Publisher: British Editorial Society of Bone and Joint Surgery, Pages: 53-53, ISSN: 2049-4416
  • Journal article
    Lord BR, El-Daou H, Sabnis BM, Gupte CM, Wilson AJ, Amis AAet al., 2016,

    Erratum to: Biomechanical comparison of graft structures in anterior cruciate ligament reconstruction (vol 25, pg 559, 2017)

    , Knee Surgery, Sports Traumatology, Arthroscopy, Vol: 25, Pages: 988-988, ISSN: 0942-2056

    Purpose: Double-bundle (DB) anterior cruciate ligament (ACL) reconstruction may offer kinematic restoration superior to anatomic single bundle (SB), but it remains technically challenging. The femoral attachment site has the most effect on ACL graft isometry, so a simplified three-socket (3S) construct which still uses two sockets to cover the femoral ACL attachment is attractive. It was hypothesised that ACL reconstruction using three- and four-socket techniques would more closely restore native knee kinematics compared to anatomic two-socket (SB) surgery.Methods: Nine cadaveric knees were used to evaluate the kinematics of ACL-intact, ACL-deficient, anatomic SB, three-socket, and DB arthroscopic ACL reconstructions. Suspensory fixation was used, and grafts were tensioned to match the anterior draw of the intact knee at 20°. A six-degree-of-freedom robotic system measured knee laxity under 90 N anterior tibial force and rotational laxity under 5 N-m torque. Combined moments were applied to simulate the pivot-shift subluxation: 4 N-m internal rotation and 8 N-m valgus.Results: Significant differences between reconstructions were not found during anterior tibial loading, apart from SB being more lax than DB at 60° flexion. All reconstructions produced comparable laxity to the intact state, apart from SB at 60°. Significant differences between reconstructions were not found at any flexion angle during tibial internal/external applied torques. Under combined loading, DB produced significantly less laxity than SB constructs apart from anterior tibial translation at 0° and internal rotation at 45°. 3S and DB were comparable to the native knee throughout.Conclusion: Although 3S restored laxities to a similar extent to DB, significant superiority over SB surgery was not observed. Although statistically significant differences were found between SB and DB surgery during anterior tibial and simulated pivot-shift loading, both remained similar to the nativ

  • Journal article
    Merican AM, Iranpour F, Amis AA, 2016,

    Iliotibial band tension reduces patellar lateral stability

    , J Orthop Res
  • Journal article
    Sopher R, Amis A, Davies D, Jeffers Jet al., 2016,

    The influence of muscle pennation angle and cross-sectional area on contact forces in the ankle joint

    , Journal of Strain Analysis for Engineering Design, Vol: 52, Pages: 12-23, ISSN: 0309-3247

    Data about a muscle’s fibre pennation angle and physiological cross-sectional area are used in musculoskeletal modelling to estimate muscle forces, which are used to calculate joint contact forces. For the leg, muscle architecture data are derived from studies that measured pennation angle at the muscle surface, but not deep within it. Musculoskeletal models developed to estimate joint contact loads have usually been based on the mean values of pennation angle and physiological cross-sectional area.Therefore, the first aim of this study was to investigate differences between superficial and deep pennation angles within each muscle acting over the ankle and predict how differences may influence muscle forces calculated in musculoskeletal modelling. The second aim was to investigate how inter-subject variability in physiological cross-sectional area and pennation angle affects calculated ankle contact forces.Eight cadaveric legs were dissected to excise the muscles acting over the ankle. The mean surface and deep pennation angles, fibre length and physiological cross-sectional area were measured. Cluster analysis was applied to group the muscles according to their architectural characteristics. A previously validated OpenSim model was used to estimate ankle muscle forces and contact loads using architecture data from all eight limbs.The mean surface pennation angle for soleus was significantly greater (54%) than the mean deep pennation angle. Cluster analysis revealed three groups of muscles with similar architecture and function: deep plantarflexors and peroneals, superficial plantarflexors and dorsiflexors. Peak ankle contact force was predicted to occur before toe-off, with magnitude greater than five times bodyweight. Inter-specimen variability in contact force was smallest at peak force.These findings will help improve the development of experimental and computational musculoskeletal models by providing data to estimate force based on both surface and deep

  • Journal article
    Lord BR, El-Daou H, Sabnis BM, Gupte CM, Wilson AM, Amis AAet al., 2016,

    Biomechanical comparison of graft structures in anterior cruciate ligament reconstruction

    , Knee Surgery Sports Traumatology Arthroscopy, Vol: 25, Pages: 559-568, ISSN: 1433-7347

    PURPOSE: Double-bundle (DB) anterior cruciate ligament (ACL) reconstruction may offer kinematic restoration superior to anatomic single bundle (SB), but it remains technically challenging. The femoral attachment site has the most effect on ACL graft isometry, so a simplified three-socket (3S) construct which still uses two sockets to cover the femoral ACL attachment is attractive. It was hypothesised that ACL reconstruction using three- and four-socket techniques would more closely restore native knee kinematics compared to anatomic two-socket (SB) surgery. METHODS: Nine cadaveric knees were used to evaluate the kinematics of ACL-intact, ACL-deficient, anatomic SB, three-socket, and DB arthroscopic ACL reconstructions. Suspensory fixation was used, and grafts were tensioned to match the anterior draw of the intact knee at 20°. A six-degree-of-freedom robotic system measured knee laxity under 90 N anterior tibial force and rotational laxity under 5 N-m torque. Combined moments were applied to simulate the pivot-shift subluxation: 4 N-m internal rotation and 8 N-m valgus. RESULTS: Significant differences between reconstructions were not found during anterior tibial loading, apart from SB being more lax than DB at 60° flexion. All reconstructions produced comparable laxity to the intact state, apart from SB at 60°. Significant differences between reconstructions were not found at any flexion angle during tibial internal/external applied torques. Under combined loading, DB produced significantly less laxity than SB constructs apart from anterior tibial translation at 0° and internal rotation at 45°. 3S and DB were comparable to the native knee throughout. CONCLUSION: Although 3S restored laxities to a similar extent to DB, significant superiority over SB surgery was not observed. Although statistically significant differences were found between SB and DB surgery during anterior tibial and simulated pivot-shift loading, both remain

  • Journal article
    Ma S, Boughton O, Karunaratne A, Jin A, Cobb JP, Hansen U, Abel RLet al., 2016,

    Synchrotron imaging assessment of bone quality

    , Clinical Reviews in Bone and Mineral Metabolism, Vol: 14, Pages: 150-160, ISSN: 1559-0119

    Bone is a complex hierarchical structure and its principal function is to resist mechanical forces and fracture. Bone strength depends not only on the quantity of bone tissue but also on the shape and hierarchical structure. The hierarchical levels are interrelated, especially the micro-architecture, collagen and mineral components; hence analysis of their specific roles in bone strength and stiffness is difficult. Synchrotron imaging technologies including micro-CT and small/wide angle X-Ray scattering/diffraction are becoming increasingly popular for studying bone because the images can resolve deformations in the micro-architecture and collagen-mineral matrix under in situ mechanical loading. Synchrotron cannot be directly applied in-vivo due to the high radiation dose but will allow researchers to carry out systematic multifaceted studies of bone ex-vivo. Identifying characteristics of aging and disease will underpin future efforts to generate novel devices and interventional therapies for assessing and promoting healthy aging. With our own research work as examples, this paper introduces how synchrotron imaging technology can be used with in-situ testing in bone research.

  • Journal article
    Hansen UN, 2016,

    Dynamic three-dimensional shoulder MRI during active motion for investigation of rotator cuff diseases

    , PLOS One, Vol: 11, ISSN: 1932-6203

    BackgroundMRI is the standard methodology in diagnosis of rotator cuff diseases. However, many patients continue to have pain despite treatment, and MRI of a static unloaded shoulder seems insufficient for best diagnosis and treatment. This study evaluated if Dynamic MRI provides novel kinematic data that can be used to improve the understanding, diagnosis and best treatment of rotator cuff diseases.MethodsDynamic MRI provided real-time 3D image series and was used to measure changes in the width of subacromial space, superior-inferior translation and anterior-posterior translation of the humeral head relative to the glenoid during active abduction. These measures were investigated for consistency with the rotator cuff diseases classifications from standard MRI.ResultsThe study included: 4 shoulders with massive rotator cuff tears, 5 shoulders with an isolated full-thickness supraspinatus tear, 5 shoulders with tendinopathy and 6 normal shoulders. A change in the width of subacromial space greater than 4mm differentiated between rotator cuff diseases with tendon tears (massive cuff tears and supraspinatus tear) and without tears (tendinopathy) (p = 0.012). The range of the superior-inferior translation was higher in the massive cuff tears group (6.4mm) than in normals (3.4mm) (p = 0.02). The range of the anterior-posterior translation was higher in the massive cuff tears (9.2 mm) and supraspinatus tear (9.3 mm) shoulders compared to normals (3.5mm) and tendinopathy (4.8mm) shoulders (p = 0.05).ConclusionThe Dynamic MRI enabled a novel measure; ‘Looseness’, i.e. the translation of the humeral head on the glenoid during an abduction cycle. Looseness was better able at differentiating different forms of rotator cuff disease than a simple static measure of relative glenohumeral position.

  • Conference paper
    Geraldes D, Hansen U, Jeffers J, Amis Aet al., 2016,

    Interference fit optimisation for small press-fitted pegs

    , International Society for Technology in Arthroplasty 2015, Publisher: BRITISH EDITORIAL SOCIETY OF BONE & JOINT SURGERY, Pages: 150-150, ISSN: 2049-4416

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