Publications
360 results found
Kazezian Z, Bull AMJ, 2021, A review of the biomarkers and in vivo models for the diagnosis and treatment of heterotopic ossification following blast and trauma-induced injuries, Bone, Vol: 143, ISSN: 1873-2763
Heterotopic ossification (HO) is the process of de novo bone formation in non-osseous tissues. HO can occur following trauma and burns and over 60% of military personnel with blast-associated amputations develop HO. This rate is far higher than in other trauma-induced HO development. This suggests that the blast effect itself is a major contributing factor, but the pathway triggering HO following blast injury specifically is not yet fully identified. Also, because of the difficulty of studying the disease using clinical data, the only sources remain the relevant in vivo models. The aim of this paper is first to review the key biomarkers and signalling pathways identified in trauma and blast induced HO in order to summarize the molecular mechanisms underlying HO development, and second to review the blast injury in vivo models developed.The literature derived from trauma-induced HO suggests that inflammatory cytokines play a key role directing different progenitor cells to transform into an osteogenic class contributing to the development of the disease. This highlights the importance of identifying the downstream biomarkers under specific signalling pathways which might trigger similar stimuli in blast to those of trauma induced formation of ectopic bone in the tissues surrounding the site of the injury. The lack of information in the literature regarding the exact biomarkers leading to blast associated HO is hampering the design of specific therapeutics. The majority of existing blast injury in vivo models do not fully replicate the combat scenario in terms of blast, fracture and amputation; these three usually happen in one insult. Hence, this paper highlights the need to replicate the full effect of the blast in preclinical models to better understand the mechanism of blast induced HO development and to enable the design of a specific therapeutic to supress the formation of ectopic bone.
Kazezian Z, Yu X, Ramette M, et al., 2020, Development of a blast injury model for investigating conditions associated with traumatic amputations, ORS 2021 Annual Meeting
INTRODUCTION: Most injuries in recent conflicts are due to blast, 70% of which are to the extremities resulting in a large number of lower limb amputations. Functional deficits due to blast induced amputation include difficulty in weight bearing and associated normal gait abnormali-ties. Significant complications following traumatic amputation are pain in the residual limb, and phantom limb pain. Heterotopic Ossification (HO) - ectopic bone formation in the soft tissues - is also highly prevalent (64%) among blast-related military amputations. The existing non-specific treatments include non-steroidal anti-inflammatory drugs (NSAID)s and low-dose radiation therapy which remain unsatisfactory leav-ing surgical bone excision the only possible curative treatment. While the prevention of HO in military amputees is the ultimate choice of treat-ment, it is yet to be identified, as the initial cause of triggering the disease is not understood. For this reason, and because studying amputation complications in humans is difficult, novel in vivo models need to be developed for further understanding of the disease mechanisms. There-fore, we hypothesised that developing a preclinical blast injury model in the hindlimb of rats which better represents the IED detonation in en-closed spaces could answer questions regarding the exact mechanism of HO and phantom limb pain. Current in vivo models exist, but none of these incorporate all blast features, that is, the blast, and the fracture in one insult. This research aims to develop a novel translational blast injury model in rats to better understand the mechanisms of phantom limb pain and HO.METHODS: This study was performed under institutional and departmental license from the Home Office UK. In line with the 3Rs principle, optimisation of the blast pressure was achieved using 34 male cadaveric Sprague-Dawley rats weighing between 285-481g to refine the experi-ments without using live animals to achieve a trans-tibial fracture at
Urbanczyk CA, Prinold JAI, Reilly P, et al., 2020, Avoiding high-risk rotator cuff loading: Muscle force during three pull-up techniques., Scandinavian Journal of Medicine and Science in Sports, Vol: 30, Pages: 2205-2214, ISSN: 0905-7188
Heavily loaded overhead training tasks, such as pull-ups are an effective strength training and rehabilitation exercise requiring high muscle forces maintained over a large range of motion. This study used experiments and computational modeling to examine loading patterns during three different pull-up variants and highlighted risks to vulnerable musculoskeletal structures. Optical motion tracking and a force platform captured kinematics and kinetics of 11 male subjects with no history of shoulder pathology, during performance of three pull-up variants-pronated front grip, pronated wide grip, and supinated reverse grip. UK National Shoulder model (UKNSM) simulated biomechanics of the shoulder girdle. Muscle forces and activation patterns were analyzed by repeated measures ANOVA with post-hoc comparisons. Motor group recruitment was similar across all pull-up techniques, with upper limb depression occurring secondary to torso elevation. Stress-time profiles show significant differences in individual muscle patterns among the three pull-up variants, with the most marked differences between wide grip and reverse grip. Comparing across techniques, latissimus dorsi was relatively more active in wide pull-ups (P < .01); front pull-ups favored activation of biceps brachii and brachialis (P < .02); reverse pull-ups displayed higher proportional rotator cuff activation (P < .01). Pull-ups promote stability of the shoulder girdle and activation of scapula stabilizers and performing pull-ups over their full range of motion is important as different techniques and phases emphasize different muscles. Shoulder rehabilitation and strength & conditioning programs should encourage incorporation of all three pull-up variants with systematic progression to provide greater global strengthening of the torso and upper limb musculature.
Bennett AN, Dyball DM, Boos CJ, et al., 2020, Study protocol for a prospective, longitudinal cohort study investigating the medical and psychosocial outcomes of UK combat casualties from the Afghanistan war: the ADVANCE Study., BMJ Open, Vol: 10, Pages: 1-11, ISSN: 2044-6055
INTRODUCTION: The Afghanistan war (2003-2014) was a unique period in military medicine. Many service personnel survived injuries of a severity that would have been fatal at any other time in history; the long-term health outcomes of such injuries are unknown. The ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) study aims to determine the long-term effects on both medical and psychosocial health of servicemen surviving this severe combat related trauma. METHODS AND ANALYSIS: ADVANCE is a prospective cohort study. 1200 Afghanistan-deployed male UK military personnel and veterans will be recruited and will be studied at 0, 3, 6, 10, 15 and 20 years. Half are personnel who sustained combat trauma; a comparison group of the same size has been frequency matched based on deployment to Afghanistan, age, sex, service, rank and role. Participants undergo a series of physical health tests and questionnaires through which information is collected on cardiovascular disease (CVD), CVD risk factors, musculoskeletal disease, mental health, functional and social outcomes, quality of life, employment and mortality. ETHICS AND DISSEMINATION: The ADVANCE Study has approval from the Ministry of Defence Research Ethics Committee (protocol no:357/PPE/12) agreed 15 January 2013. Its results will be disseminated through manuscripts in clinical/academic journals and presentations at professional conferences, and through participant and stakeholder communications. TRIAL REGISTRATION NUMBER: The ADVANCE Study is registered at ISRCTN ID: ISRCTN57285353.
Villatte G, van der Kruk E, Asim B, et al., 2020, A biomechanical confirmation of the relationship between critical shoulder angle (CSA) and articular joint loading, Journal of Shoulder and Elbow Surgery, Vol: 29, Pages: 1967-1973, ISSN: 1058-2746
Background: The Critical Shoulder Angle (CSA) has been shown to be correlated with shoulder disease states. The biomechanical hypothesis to explain this correlation is that the CSA changes the shear and compressive forces on the shoulder. The objective of this study is to test this hypothesis by use of a validated computational shoulder model. Specifically, this study assesses the impact on glenohumeral biomechanics of modifying the CSA. Methods: An inverse dynamics three-dimensional musculoskeletal model of the shoulder was used to quantify muscle forces and glenohumeral joint forces. The CSA was changed by altering the attachment point of the middle deltoid into a normal CSA (33°), a reduced CSA of 28°, and an increased CSA of 38°. Subject-specific kinematics of slow and fast speed abduction in the scapular plane, and slow and fast forward flexion measured by a 3D motion capture system were used to quantify joint reaction shear and compressive forces.Results: Increasing the CSA results in increased superior-inferior forces (shearing forces; integrated over the range of motion; p<0.05). Reducing CSA results in increased latero-medial (compressive) forces for both the maximum and integrated sum of the forces over the whole motion; p<0.01).Discussion/Conclusion: Changes in the CSA modify glenohumeral joint biomechanics with increasing CSA producing higher shear forces that would contribute to rotator cuff overuse, whereas reducing the CSA results in higher compressive forces which contribute to joint wear.
Foss L, Belli A, Brody D, et al., 2020, Setting a national consensus for managing mild and blast traumatic brain injury: post-meeting consensus report
A meeting was held on Wednesday 15 January 2020 to examine the current evidence for non-routine imaging and for neuroendocrine screening in the management of military personnel with brain injury and overlapping symptom domains. The Summit aimed to specifically address the relative utility of magnetoencephalography (MEG), diffusion tensor imaging (DTI) and susceptibility weighted imaging (SWI) in the UK context. This Consensus Report discusses points of consensus, points for further discussion/points of equipoise and recommendations that arose during, and following, the meeting.
Dimitrov H, Bull AMJ, Farina D, 2020, Real-time interface algorithm for ankle kinematics and stiffness from electromyographic signals, IEEE Transactions on Neural Systems and Rehabilitation Engineering, Vol: 28, Pages: 1416-1427, ISSN: 1534-4320
Shortcomings in capabilities of below-knee (transtibial) prostheses, compared to their biological counterparts, still cause medical complications and functional deficit to millions of amputees around the world. Although active (powered actuation) transtibial prostheses have the potential to bridge these gaps, the current control solutions limit their efficacy. Here we describe the development of a novel interface for two degrees-of-freedom position and stiffness control for below-knee amputees. The developed algorithm for the interface relies entirely on muscle electrical signals from the lower leg. The algorithm was tested for voluntary position and stiffness control in eight able-bodied and two transtibial amputees and for voluntary stiffness control with foot position estimation while walking in eight able-bodied and one transtibial amputee. The results of the voluntary control experiment demonstrated a promising target reaching success rate, higher for amputees compared to the able-bodied individuals (82.5% and 72.5% compared to 72.5% and 68.1% for the position and position and stiffness matching tasks respectively). Further, the algorithm could provide the means to control four stiffness levels during walking in both amputee and able-bodied individuals while providing estimates of foot kinematics (gait cycle cross-correlation >75% for the sagittal and >90% for the frontal plane and gait cycle root mean square error <7.5° in sagittal and <3° in frontal plane for able-bodied and amputee individuals across three walking speeds). The results from the two experiments demonstrate the feasibility of using this novel algorithm for online control of multiple degrees of freedom and of their stiffness in lower limb prostheses.
Berthaume MA, Di Federico E, Bull AMJ, 2020, The curious case of the fabella, an increasing common knee sesamoid bone, 89th Annual Meeting of the American-Association-of-Physical-Anthropologists (AAPA), Publisher: WILEY, Pages: 26-26, ISSN: 0002-9483
Nolte D, Ko S-T, Bull AMJ, et al., 2020, Reconstruction of the lower limb bones from digitised anatomical landmarks using statistical shape modelling, Gait & Posture, Vol: 77, Pages: 269-275, ISSN: 0966-6362
BackgroundBone shapes strongly influence force and moment predictions of kinematic and musculoskeletal models used in motion analysis. The precise determination of joint reference frames is essential for accurate predictions. Since clinical motion analysis typically does not include medical imaging, from which bone shapes may be obtained, scaling methods using reference subjects to create subject-specific bone geometries are widely used.Research questionThis study investigated if lower limb bone shape predictions from skin-based measurements, utilising an underlying statistical shape model (SSM) that corrects for soft tissue artefacts in digitisation, can be used to improve conventional linear scaling methods of bone geometries.MethodsSSMs created from 35 healthy adult femurs and tibiae/fibulae were used to reconstruct bone shapes by minimising the distance between anatomical landmarks on the models and those digitised in the motion laboratory or on medical images. Soft tissue artefacts were quantified from magnetic resonance images and then used to predict distances between landmarks digitised on the skin surface and bone. Reconstruction results were compared to linearly scaled models by measuring root mean squared distances to segmented surfaces, calculating differences of commonly used anatomical measures and the errors in the prediction of the hip joint centre.ResultsSSM reconstructed surface predictions from varying landmark sets from skin and bone landmarks were more accurate compared to linear scaling methods (2.60–2.95 mm vs. 3.66–3.87 mm median error; p < 0.05). No significant differences were found between SSM reconstructions from bony landmarks and SSM reconstructions from digitised landmarks obtained in the motion lab and therefore reconstructions using skin landmarks are as accurate as reconstructions from landmarks obtained from medical images.SignificanceThese results indicate that SSM reconstructions can be used to increase the accurac
Papi E, Bull AMJ, McGregor AH, 2020, Alteration of movement patterns in low back pain assessed by Statistical Parametric Mapping, Journal of Biomechanics, Vol: 100, Pages: 109597-109597, ISSN: 0021-9290
Changes in movement pattern in low back pain (LBP) groups have been analysed by reporting predefined discrete variables. However, this approach does not consider the full kinematic data waveform and its dynamic information, potentially exposing the analysis to bias. Statistical Parametric Mapping (SPM) has been introduced and applied to 1 dimensional (D) kinematic variables allowing the assessment of data over time. The aims of this study were to assess differences in 3D kinematics patterns in people with and without LBP during functional tasks by using SPM and to investigate if SPM analysis was consistent with standard 3D range of motion (RoM) assessments. 3D joints kinematics of the spine and lower limbs were compared between 20 healthy controls and 20 participants with non-specific LBP during walking, sit-to-stand and lifting. SPM analysis showed significant differences in the 3Dkinematics of the lower thoracic segment, upper and lower lumbar segment and knee joint during walking and lifting mostly observed at the beginning and/or towards the end of the tasks. ROMs differed between groups in the lower thoracic segment (walking/sit-to-stand), upper and lower lumbar segments (walking/sit-to-stand/lifting), hip and knee (sit-to-stand/lifting). Based on these results, the two approaches can yield different data interpretations. SPM analysis allows the identification of differences in movement that occur over time. This adds value to LBP movement analysis as it allows an understanding of the LBP strategies adopted during motion that may not be conveyed by simple discrete parameters such as ROMs.
Bull A, Berthaume M, 2020, Human biological variation in sesamoid bone prevalence: the curious case of the fabella, Journal of Anatomy, Vol: 236, Pages: 228-242, ISSN: 0021-8782
The fabella is a sesamoid bone located in the gastrocnemius behind the lateral femoral condyle. In humans, fabellae are 3.5 times more common today than they were 100 years ago, with prevalence rates varying between and within populations. In particular, fabellae have been assumed to be more common in Asians than non-Asians, equally common in men and women, potentially more common in older individuals, and bilateral cases (one per knee) appear to be more common than unilateral ones. The roles of genetic and environmental factors in this phenotypic variation have been hypothesized, but not rigorously investigated. Given its clinical and evolutionary significance (i.e., being associated with several knee ailments, causing medical issues on its own, interfering with medical devices, and being less common in humans compared to other mammals), it is important to comprehensively understand prevalence rate variation, and the roles of genetics and environmental factors in that variation. To address these questions, we performed a meta-analysis on data from a previously published systematic review to investigate possible variation in sexual dimorphic (n = 22 studies, 7,911 knees), ontogenetic (n = 10 studies, 4,391 knees), and global (n = 65 studies, 21,626 knees) fabella prevalence rates. In addition, we investigated what proportion of cases are bilateral (n = 37 studies, 900 individuals), and among unilateral cases (n = 20 studies, 204 individuals), if fabellae are more common in the left or right knee. Our results show that, today, fabellae are 2.47-2.60% more common in men than women, and prevalence rates increase ontogenetically into old age (i.e., 70 years old), implying that fabellae can ossify early (i.e., 12 years old) or late in life. Approximately 72.94% of cases are bilateral, and among unilateral ones, fabellae are equally common in right and left knees. There is marked regional variation in fabella prevalence rates, with rates being highest in Asia, followed by
van der Kruk E, Silverman A, Koizia L, et al., 2020, CaReMoOC: Capacity, Reserve, Movement Objectives, and Compensation. A New Framework to Describe Mechanisms of Movement Limitations, Demonstrated for Ageing, Preprints
Smith SHL, Reilly P, Bull AMJ, 2020, A musculoskeletal modelling approach to explain sit-to-stand difficulties in older people due to changes in muscle recruitment and movement strategies, Journal of Biomechanics, Vol: 98, ISSN: 0021-9290
By 2050 the proportion of over 65s is predicted to be 20% of the population. The consequences of an age-related reduction in muscle mass have not been fully investigated and, therefore, the aim of the present study was to quantify the muscle and joint contact forces using musculoskeletal modelling, during a sit-to-stand activity, to better explain difficulties in performing everyday activities for older people. A sit-to-stand activity with and without the use of arm rests was observed in ninety-five male participants, placed into groups of young (aged 18-35 years), middle-aged (aged 40-60 years) or older adults (aged 65 years and over). Older participants demonstrated significantly lower knee extensor and joint forces than the young when not using arm rests, compensating through elevated hip extensor and ankle plantarflexor muscle activity. The older group were also found to have higher shoulder joint contact forces whilst using arm rests. This tendency to reorganise muscle recruitment to include neighbouring groups or other parts of the body could make everyday activities more susceptible to age-related functional decline. Reductions in leg strength, via age- or atrophy- related means, creates increased reliance on the upper body and may result in further lower limb atrophy through disuse. The eventual decline of upper body function reduces strength reserves, leading to increased vulnerability, dependence on others and risk of institutionalisation.
Ding Z, Gudel M, Smith SHL, et al., 2019, A femoral clamp to reduce soft tissue artefact: accuracy and reliability in measuring three-dimensional knee kinematics during gait, Journal of Biomechanical Engineering, Vol: 142, Pages: 044501-1-044501-8, ISSN: 0148-0731
The accurate measurement of full sixdegrees-of-freedom(DOFs) knee joint kinematics is prohibited by soft tissue artifact (STA), which remains the greatest source of error. The purpose of this study was to present and assess a new femoral clampto reduce STA at the thigh. It was hypothesised that the device can preserve the natural knee joint kinematics pattern and outperform a conventional marker mounted rigid cluster during gait. 6Six healthy subjects were askedto walk barefoot on level ground with a cluster marker set (cluster gait) followed by a cluster-clamp-merged marker set (clamp gait) and their kinematics wasmeasured using the clustermethod in clustergait and thecluster and clamp methodssimultaneouslyin clamp gait. Two operators performed the gait measurement. A six DOFs knee joint model wasdeveloped to enable comparison withthe gold standard knee joint kinematics measured using adual fluoroscopic imaging technique. One-dimensional paired t-tests were used to compare the knee joint kinematics waveforms between cluster gait and clamp gait. The accuracy was assessed in terms of the root mean square error, coefficient of determination and Bland-Altman plots. Inter-operatorreliability was assessed15usingthe intra-class correlation coefficient.The result showed that the femoral clamp did not change the walking speed andknee joint kinematicswaveforms. Additionally, clamp gait reduced the rotationand translation errorsin the transverse plane and improved the inter-operator reliabilitywhen compared to the rigid cluster method, suggesting amore accurate and reliable measurement of knee joint kinematics.
Ding Z, Tsang C, Nolte D, et al., 2019, Improving musculoskeletal model scaling using an anatomical atlas: the importance of gender and anthropometric similarity to quantify joint reaction forces, IEEE Transactions on Biomedical Engineering, Vol: 66, Pages: 3444-3456, ISSN: 0018-9294
Objective: The accuracy of a musculoskeletal model relies heavily on the implementation of the underlying anatomical dataset. Linear scaling of a generic model, despite being time and cost-efficient, produces substantial errors as it does not account for gender differences and inter-individual anatomical variations. The hypothesis of this study is that linear scaling to a musculoskeletal model with gender and anthropometric similarity to the individual subject produces similar results to the ones that can be obtained from a subject-specific model. Methods: A lower limb musculoskeletal anatomical atlas was developed consisting of ten datasets derived from magnetic resonance imaging of healthy subjects and an additional generic dataset from the literature. Predicted muscle activation and joint reaction force were compared with electromyography and literature data. Regressions based on gender and anthropometry were used to identify the use of atlas. Results: Primary predictors of differences for the joint reaction force predictions were mass difference for the ankle (p<0.001) and length difference for the knee and hip (p≤0.017) . Gender difference accounted for an additional 3% of the variance (p≤0.039) . Joint reaction force differences at the ankle, knee and hip were reduced by between 50% and 67% (p=0.005) when using a musculoskeletal model with the same gender and similar anthropometry in comparison with a generic model. Conclusion: Linear scaling with gender and anthropometric similarity can improve joint reaction force predictions in comparison with a scaled generic model. Significance: The scaling approach and atlas presented can improve the fidelity and utility of musculoskeletal models for subject-specific applications.
Smith SHL, Reilly P, Bull AMJ, 2019, Serratus anterior weakness is a key determinant of arm-assisted standing difficulties, Medical Engineering and Physics, Vol: 74, Pages: 41-48, ISSN: 1350-4533
The ageing population has led to recent increases in musculoskeletal conditions, with muscle weakness a major contributor to functional decline. Understanding the early phases of muscle weakness will help devise treatments to extend musculoskeletal health. Little is understood of the effects of muscle weakness on everyday activities such as sit-to-stand, a determinant of mobility that, in the early stages of weakness, requires upper limb compensation. This experimental and computational modelling study investigated the effects of muscle weakness on upper-extremity muscle forces of 27 healthy adults when using arm rests. Weakness of 29 upper limb muscles was simulated by individually removing each from a musculoskeletal model. Serratus anterior weakness was highlighted as detrimental, with the model unable to fully solve the loadsharing redundancy in its absence, and forces at the elbow and glenohumeral joint and in other muscles were found to be profoundly increased. Its large number of fast-twitch muscle fibres, predisposed to atrophy with age, highlight the centrality of the serratus anterior as a key determinant of mobility in this critical task and a potential source of early immobility through its preferential loss of strength and thus point to the requirement for early clinical interventions to mitigate loss.
Ding Z, Güdel M, Smith S, et al., 2019, Measuring Three-dimensional Knee Kinematics Using a Femoral Clamp: Accuracy, Repeatability and Reproducibility in Gait., J Biomech Eng
The ability to measure full six degrees-of-freedom knee joint kinematics is critical in the diagnosis of knee pathology. Soft tissue artifact (STA) remains the greatest source of error in measurement knee kinematics. The purpose of this study is to present a new femoral clamp to reduce STA at the thigh while preserving the natural gait pattern. Knee joint kinematics during gait was measured for six healthy subjects by using the femoral clamp and a rigid cluster-based technique. Performance was assessed in terms of accuracy, repeatability and reproducibility. The result showed that the femoral clamp did not change the walking speed and the natural knee kinematics pattern of the subjects. The clamp-measured kinematics had smaller knee translation in the transverse plane and were closer to data from the literature obtained by dual fluoroscopic imaging. The clamp had improved repeatability and reproducibility compared to the rigid cluster technique, suggesting that this technology is suitable for accurate measurement of gait.
Barnes S, Clasper J, Bull A, et al., 2019, Micromotion and Push‐Out Evaluation of an Additive Manufactured Implant for Above‐the‐Knee Amputees, Journal of Orthopaedic Research, Vol: 37, Pages: 2104-2111, ISSN: 0736-0266
In comparison to through knee amputees the outcomes for above‐the‐knee amputees are relatively poor; based on this novel techniques have been developed. Most current percutaneous implant based solutions for transfemoral amputees make use of high stiffness intramedullary rods for skeletal fixation which can have risks including infection, femoral fractures and bone resorption due to stress shielding. This work details the cadaveric testing of a short, cortical bone stiffness matched subcutaneous implant, produced using additive manufacture, to determine bone implant micromotion and push out load. The results for the micromotions were all less than 20 microns and the mean push out load was 2099 Newtons. In comparison to a solid control, the stiffness matched implant exhibited significantly higher micromotion distributions and no significant difference in terms of push out load. These results suggest that, for the stiffness matched implant at time zero, osseointegration would be facilitated and that the implant would be securely anchored. For these metrics, this provides justification for the use of a short stem implant for transfemoral amputees in this subcutaneous application.
Milwood Hargrave J, Pearce P, Mayhew E, et al., 2019, Blast injuries in children: a mixed-methods narrative review., BMJ Paediatrics Open, Vol: 3, ISSN: 2399-9772
Background and significance. Blast injuries arising from high explosive weaponry iscommon in conflict areas. While blast injury characteristics are well recognised in the adults,there is a lack of consensus as to whether these characteristics translate to the paediatricpopulation. Understanding blast injury patterns in this cohort is essential for providingappropriate provision of services and care for this vulnerable cohort.Methods. In this mixed-method review, original papers were screened for data pertaining topaediatric injuries following blasts. Information on demographics, morbidity and mortality andservice requirements were evaluated. The papers were written and published in English from a range of international specialists in the field. Patient and public involvementstatement: No patients or members of the public were involved in this review.Results. Children affected by blast injuries are predominantly male and their injuries arisefrom explosive remnants of war, particularly unexploded ordinance. Blasts show increasedmorbidity and mortality in younger children, while older children have injury patterns similarto adults. Head and burn injuries represent a significant cause of mortality in young children,while lower limb morbidity is reduced compared to adults. Children have a disproportionaterequirement for both operative and non-operative service resources, and provisions for thisburden are essential.Conclusions. Certain characteristics of paediatric injuries arising from blasts are distinctfrom that of the adult cohort, while the intensive demands on services highlights theimportance of understanding the diverse injury patterns in order to optimise future serviceprovisions in caring for this the child blast survivor.
Majed A, Thangarajah T, Southgate DFL, et al., 2019, The biomechanics of proximal humeral fractures: Injury mechanism and cortical morphology, Shoulder & Elbow, Vol: 11, Pages: 247-255, ISSN: 1758-5732
BackgroundThe aim of this study was to examine the effect of arm position on proximal humerus fracture configuration and to determine whether cortical thinning would predispose to fracture propagation and more complex patterns of injury.MethodsA drop test rig was designed to simulate falls onto an outstretched arm (‘parachute reflex’). Thirty-one cadaveric specimens underwent computer tomography scanning and cortical thicknesses mapping. Humeri were fractured according to one of the two injury mechanisms and filmed using a high-speed camera. Anatomical descriptions of the injuries were made. Areas of thinning were measured and correlated with zones of fracture propagation.ResultsDirect impact simulation resulted in undisplaced humeral head split fractures in 53% of cases, with the remainder involving disruption to the articular margin and valgus impaction. Alternatively, the ‘parachute reflex’ predominantly produced shield-type injuries (38%) and displaced greater tuberosity fractures (19%). A strong correlation was demonstrated between cortical thinning and the occurrence of fracture (odds ratio = 7.766, 95% confidence interval from 4.760 to 12.669, p<0.0001).ConclusionThis study has shown that arm position during a fall influences fracture configuration of the proximal humerus. Correlating fracture pattern and mechanism of injury will allow more appropriate fracture reduction techniques to be devised.
Ahmadzadeh SMH, Chen X, Hagemann H, et al., 2019, Developing and using fast shear wave elastography to quantify physiologically-relevant tendon forces, Medical Engineering and Physics, Vol: 69, Pages: 116-122, ISSN: 1350-4533
Direct quantification of physiologically-relevant tendon forces can be used in a wide range of clinical applications. However, tendon forces have usually been estimated either indirectly by computational models or invasively using force transducers, and direct non-invasive measurement of forces remains a big challenge. The aim of this study was to investigate the feasibility of using Shear Wave Elastography (SWE) for quantifying human tendon forces at physiological levels. An experimental protocol was developed to measure Shear Wave Speed (SWS) and tensile force in a human patellar tendon using SWE and conventional tensile testing to quantify the correlation between SWS and load. The SWE system was customised to allow imaging of fast shear waves expected in human tendons under physiological loading which is outside the normal range of the existing SWE systems. SWS increased from 10.8 m/s to 36.1 m/s with the increasing tensile load from 8 N to 935 N and a strong linear correlation between SWS and load (r = 0.99, p < 0.01) was observed. The findings in this study suggest that SWE can be used as a potential non-invasive method for direct quantification of physiologically-relevant tendon forces, as well as for validating the estimated forces from other methods such as computational models.
Berthaume MA, Di Federico E, Bull AMJ, 2019, Fabella prevalence rate increases over 150 years, and rates of other sesamoid bones remain constant: a systematic review, Journal of Anatomy, Vol: 235, Pages: 67-79, ISSN: 1469-7580
The fabella is a sesamoid bone located behind the lateral femoral condyle. It is common in non-human mammals, but the prevalence rates in humans vary from 3 to 87%. Here, we calculate the prevalence of the fabella in a Korean population and investigate possible temporal shifts in prevalence rate. A total of 52.83% of our individuals and 44.34% of our knees had fabellae detectable by computed tomography scanning. Men and women were equally likely to have a fabella, and bilateral cases (67.86%) were more common than unilateral ones (32.14%). Fabella presence was not correlated with height or age, although our sample did not include skeletally immature individuals. Our systematic review yielded 58 studies on fabella prevalence rate from 1875-2018 which met our inclusion criteria, one of which was an outlier. Intriguingly, a Bayesian mixed effects generalized linear model revealed a temporal shift in prevalence rates, with the median prevalence rate in 2000 (31.00%) being ~ 3.5 times higher than that in 1900 (7.64%). In all four countries with studies before and after 1960, higher rates were always found after 1960. Using data from two other systematic reviews, we found no increase in prevalence rates of 10 other sesamoid bones in the human body, indicating that the increase in fabella prevalence rate is unique. Fabella presence/absence is due to a combination of genetic and environmental factors: as the prevalence rates of other sesamoid bones have not changed in the last 100 years, we postulate the increase in fabella prevalence rate is due to an environmental factor. Namely, the global increase in human height and weight (due to improved nutrition) may have increased human tibial length and muscle mass. Increases in tibial length could lead to a larger moment arm acting on the knee and on the tendons crossing it. Coupled with the increased force from a larger gastrocnemius, this could produce the mechanical stimuli necessary to initiate fabella formation an
Sivapuratharasu B, Bull AMJ, McGregor AH, 2019, Understanding low back pain in traumatic lower limb amputees: a systematic review, Archives of Rehabilitation Research and Clinical Translation, Vol: 1, ISSN: 2590-1095
Objective: This systematic review aims to evaluate current literature for the prevalence, causes and effect of low back pain (LBP) in traumatic lower limb amputees, specifically its association with the kinematics and kinetics of the lumbar spine and lower extremities. Data Sources: Databases (EMBASE, MEDLINE, Scopus, CINAHL, and PsycINFO) were searched systematically for eligible studies from inception to January 2018. Study Selection: The inclusion terms were synonyms of ‘low back pain’, ‘lower limb amputation’, and ‘trauma’, whilst studies involving non-traumatic amputee populations, single cases or reviews were excluded. 1822 studies were initially identified, of which 44 progressed to full-text reading, and 11 studies were included in the review.Data Extraction: Two independent reviewers reviewed the included studies, which were evaluated using a quality assessment tool and the GRADE system for risk of bias, prior to analysing results and conclusions. Data Synthesis: There was a LBP prevalence of 52–64% in traumatic amputees, compared to the 48–77% in the general amputee population (predominantly vascular, tumour and trauma), attributed to a mixture of biomechanical, psycho-social and personal factors. These factors determined the presence, frequency and severity of the pain in the amputees, significantly impacting on their quality of life. However, little evidence was available on causality. Conclusion: The high prevalence of LBP in traumatic amputees highlights the necessity to advance research into the underlying mechanics behind LBP, specifically the spinal kinematics and kinetics. This may facilitate improvements in rehabilitation, with the potential to improve quality of life in traumatic amputees.
Thompson SM, Prinold JAI, Hill AM, et al., 2019, The influence of full-thickness supraspinatus tears on abduction moments: the importance of the central tendon, Shoulder and Elbow, Vol: 11, Pages: 19-25, ISSN: 1758-5740
Background: Detachment of the central tendon of the supraspinatus from its insertion is considered to be crucial to functional deficit. The aim of the present study was to assess the function of the supraspinatus in terms of abduction moments by introducing different tear configurations to assess the functional effect of the central tendon insertion. Methods: Ten fresh frozen shoulders from five cadavers were prepared for testing. A testing protocol was established to measure the abduction moment of the supraspinatus under physiological loading tailored to the anthropometrics of each specimen. Four conditions were tested: intact supraspinatus; complete detachment of portion of the supraspinatus tendon anterior to the main central tendon; detachment of the main central tendon; and detachment of the region of the supraspinatus posterior to the main central tendon. Results: There was a significant and large reduction in abduction moment when the central tendon was sectioned (p < 0.05). A smaller reduction in abduction moment was found when the regions anterior and posterior to the main central tendon were sectioned (p < 0.05). Conclusions: The central tendon is vital in the role of functional arm abduction through force transmission through the intact rotator cuff. Reinsertion of the central tendon in the correct anatomical location is desirable to optimize functional outcome of surgery.
Nolte D, Bull AMJ, 2019, Femur finite element model instantiation from partial anatomies using statistical shape and appearance models, Medical Engineering and Physics, Vol: 67, Pages: 55-65, ISSN: 1350-4533
Accurate models of bone shapes are essential for orthopaedic reconstructions. The commonly used methods of using the contralateral side requires an intact bone and anatomical symmetry. Recent studies have shown that statistical shape and appearance models (SSAMs) as an alternative can predict accurate geometric models, but the accuracy of the mechanical property prediction is typically not addressed. This study compares stress and strain differences under identical loading conditions for reconstructions from partial anatomies.SSAMs representing shape and grey values were created using 40 female cadaveric X-ray computed tomography scans. Finite element models were created for shape reconstructions from partial bone of various lengths with boundary conditions obtained from musculoskeletal simulations. Commonly used anatomical measures, measures of the surface deviations and maximal stresses and strains were used to compare the reconstruction accuracy to the contralateral side.Surface errors were smaller compared to the contralateral side for reconstructions with 90% of the bone and slightly bigger when less bone was available. Anatomical measures were comparable. The contralateral side showed slightly smaller relative errors for strains of up to 6% on average.This study has shown that SSAM reconstructions using partial bone geometry are a possible alternative to the contralateral side.
Klemt C, Nolte D, Ding Z, et al., 2019, Anthropometric scaling of anatomical datasets for subject-specific musculoskeletal modelling of the shoulder, Annals of Biomedical Engineering, Vol: 47, Pages: 924-936, ISSN: 0090-6964
Linear scaling of generic shoulder models leads to substantial errors in model predictions. Customisation of shoulder modelling through magnetic resonance imaging (MRI) improves modelling outcomes, but model development is time and technology intensive. This study aims to validate 10 MRI-based shoulder models, identify the best combinations of anthropometric parameters for model scaling, and quantify the improvement in model predictions of glenohumeral loading through anthropometric scaling from this anatomical atlas. The shoulder anatomy was modelled using a validated musculoskeletal model (UKNSM). Ten subject-specific models were developed through manual digitisation of model parameters from high-resolution MRI. Kinematic data of 16 functional daily activities were collected using a 10-camera optical motion capture system. Subject-specific model predictions were validated with measured muscle activations. The MRI-based shoulder models show good agreement with measured muscle activations. A tenfold cross-validation using the validated personalised shoulder models demonstrates that linear scaling of anthropometric datasets with the most similar ratio of body height to shoulder width and from the same gender (p < 0.04) yields best modelling outcomes in glenohumeral loading. The improvement in model reliability is significant (p < 0.02) when compared to the linearly scaled-generic UKNSM. This study may facilitate the clinical application of musculoskeletal shoulder modelling to aid surgical decision-making.
Majed A, Thangarajah T, Southgate D, et al., 2019, Cortical thickness analysis of the proximal humerus., Shoulder Elbow, Vol: 11, Pages: 87-93, ISSN: 1758-5732
BACKGROUND: Structural changes within the proximal humerus influence the mechanical properties of the entire bone and predispose to low-energy fractures with complex patterns. The aim of the present study was to measure the cortical thickness in different regions of the proximal humerus. METHODS: Thirty-seven proximal humeri were analyzed using novel engineering software to determine cortical thickness in 10 distinct anatomical zones. RESULTS: The cortical thickness values ranged from 0.33 mm to 3.5 mm. Fifteen specimens demonstrated a consistent pattern of progressive cortical thinning that increased between the bicipital groove (thickest), the lesser tuberosity and the greater tuberosity (thinnest). Fifteen humeri were characterized by a progressive increase in cortical thickness between the greater tuberosity (thinnest), the bicipital groove and lesser tuberosity (thickest). The diaphysis exhibited the thickest cortical zone in 27 specimens, whereas the articular surface possessed the thinnest cortex in 18 cases. CONCLUSIONS: In conclusion, this is the first study to comprehensively assess cortical thickness of the humeral head. Our findings suggest that proximal humeral fractures occur along lines of cortical thinning and are displaced by the hard glenoid bone. The identification of specific areas of thick cortices may improve pre-operative planning and optimize fracture fixation.
Rane L, Ding Z, McGregor AH, et al., 2019, Deep learning for musculoskeletal force prediction, Annals of Biomedical Engineering, Vol: 47, Pages: 778-789, ISSN: 0090-6964
Musculoskeletal models permit the determination of internal forces acting during dynamic movement, which is clinically useful, but traditional methods may suffer from slowness and a need for extensive input data. Recently, there has been interest in the use of supervised learning to build approximate models for computationally demanding processes, with benefits in speed and flexibility. Here, we use a deep neural network to learn the mapping from movement space to muscle space. Trained on a set of kinematic, kinetic and electromyographic measurements from 156 subjects during gait, the network’s predictions of internal force magnitudes show good concordance with those derived by musculoskeletal modelling. In a separate set of experiments, training on data from the most widely known benchmarks of modelling performance, the international Grand Challenge competitions, generates predictions that better those of the winning submissions in four of the six competitions. Computational speedup facilitates incorporation into a lab-based system permitting real-time estimation of forces, and interrogation of the trained neural networks provides novel insights into population-level relationships between kinematic and kinetic factors.
Xu R, Ming D, Ding Z, et al., 2019, Extra Excitation of Biceps Femoris during NMES Reduces Knee Medial Loading, Royal Society Open Science, Vol: 6, ISSN: 2054-5703
Experimental data.
Ding Z, Azmi NL, Bull AMJ, 2019, Validation and use of a musculoskeletal gait model to study the role of functional electrical stimulation, IEEE Transactions on Biomedical Engineering, Vol: 66, Pages: 892-897, ISSN: 0018-9294
Objective: Musculoskeletal modeling has been used to predict the effect of functional electrical stimulation (FES) on the mechanics of the musculoskeletal system. However, validation of the resulting muscle activations due to FES is challenging as conventional electromyography (EMG) recording of signals from the stimulated muscle is affected by stimulation artefacts. A validation approach using a combination of musculoskeletal modeling and EMG was proposed, whereby the effect on nonstimulated muscles is assessed using both techniques. The aim is to quantify the effect of FES on biceps femoris long head (BFLH) and validate this directly against EMG of gluteus maximus (GMAX). The hypotheses are that GMAX activation correlates with BFLH activation; and the muscle activation during FES gait can be predicted using musculoskeletal modeling. Methods: Kinematics, kinetics, and EMG of healthy subjects were measured under four walking conditions (normal walking followed by FES walking with three levels of BFLH stimulation). Measured kinematics and kinetics served as inputs to the musculoskeletal model. Results: Strong positive correlations were found between GMAX activation and BFLH activation in early stance peak (R = 0.78, p = 0.002) and impulse (R = 0.63, p = 0.021). The modeled peak and impulse of GMAX activation increased with EMG peak (p <; 0.001) and impulse (p = 0.021). Conclusion: Musculoskeletal modeling can be used reliably to quantify the effect of FES in a healthy gait. Significance: The validation approach using EMG and musculoskeletal modeling developed and tested can potentially be applied to the use of FES for other muscles and activities.
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