Mixed Reality in the Operating Room: An Initial Use in Frontal Sinus Setback in Gender-affirming Facial Surgery.

Demand for gender-affirming facial surgery is growing rapidly. Frontal sinus setback, one of the key procedures used in gender-affirming facial surgery, has a particularly high impact on gender perception. Mixed reality (MR) allows a user to view and virtually overlay three-dimensional imaging on the patient and interact with it in real time. We used the Medivis's SurgicalAR system in conjunction with the Microsoft HoloLens Lucille2 (Microsoft). Computed tomography imaging was uploaded to SurgicalAR, and a three-dimensional (3D) hologram was projected onto the display of the HoloLens. The hologram was registered and matched to the patient, allowing the surgeon to view bony anatomy and underlying structures in real time on the patient. The surgeon was able to outline the patient's frontal sinuses using the hologram as guidance. A 3D printed cutting guide was used for comparison. Negligible difference between the mixed reality-based outline and 3D-printed outline was seen. The process of loading the hologram and marking the frontal sinus outline lasted less than 10 minutes. The workflow and usage described here demonstrate significant promise for the use of mixed reality as imaging and surgical guidance technology in gender-affirming facial surgery.

Evolution of the meta-neurosurgeon: A systematic review of the current technical capabilities, limitations, and applications of augmented reality in neurosurgery.

Background: Augmented reality (AR) applications in neurosurgery have expanded over the past decade with the introduction of headset-based platforms. Many studies have focused on either preoperative planning to tailor the approach to the patient's anatomy and pathology or intraoperative surgical navigation, primarily realized as AR navigation through microscope oculars. Additional efforts have been made to validate AR in trainee and patient education and to investigate novel surgical approaches. Our objective was to provide a systematic overview of AR in neurosurgery, provide current limitations of this technology, as well as highlight several applications of AR in neurosurgery. Methods: We performed a literature search in PubMed/Medline to identify papers that addressed the use of AR in neurosurgery. The authors screened three hundred and seventy-five papers, and 57 papers were selected, analyzed, and included in this systematic review. Results: AR has made significant inroads in neurosurgery, particularly in neuronavigation. In spinal neurosurgery, this primarily has been used for pedicle screw placement. AR-based neuronavigation also has significant applications in cranial neurosurgery, including neurovascular, neurosurgical oncology, and skull base neurosurgery. Other potential applications include operating room streamlining, trainee and patient education, and telecommunications. Conclusion: AR has already made a significant impact in neurosurgery in the above domains and has the potential to be a paradigm-altering technology. Future development in AR should focus on both validating these applications and extending the role of AR.

Feasibility and Usability of Augmented Reality Technology in the Orthopaedic Operating Room.

PURPOSE OF REVIEW: Augmented reality (AR) has gained popularity in various sectors, including gaming, entertainment, and healthcare. The desire for improved surgical navigation within orthopaedic surgery has led to the evaluation of the feasibility and usability of AR in the operating room (OR). However, the safe and effective use of AR technology in the OR necessitates a proper understanding of its capabilities and limitations. This review aims to describe the fundamental elements of AR, highlight limitations for use within the field of orthopaedic surgery, and discuss potential areas for development. RECENT FINDINGS: To date, studies have demonstrated evidence that AR technology can be used to enhance navigation and performance in orthopaedic procedures. General hardware and software limitations of the technology include the registration process, ergonomics, and battery life. Other limitations are related to the human response factors such as inattentional blindness, which may lead to the inability to see complications within the surgical field. Furthermore, the prolonged use of AR can cause eye strain and headache due to phenomena such as the vergence-convergence conflict. AR technology may prove to be a better alternative to current orthopaedic surgery navigation systems. However, the current limitations should be mitigated to further improve the feasibility and usability of AR in the OR setting. It is important for both non-clinicians and clinicians to work in conjunction to guide the development of future iterations of AR technology and its implementation into the OR workflow.

Single institution series describing external ventricular drain (EVD) placement and short- and long-term complications related to placement accuracy.

Background: The placement of an external ventricular drain (EVD) for the treatment of acute hydrocephalus is one of the most common life-saving procedures that neurosurgeons perform worldwide. There are many well-known complications associated with EVD placement, including tract hemorrhages, intra-parenchymal and subdural hemorrhages, infection, and catheter misplacement. Given the variety of complications associated with EVD placement and the inconsistent findings on the relationship of accuracy to complications, the present study reviewed short- and long-term complications related to EVD placement at our institution. Methods: A retrospective review was conducted for all consecutive patients who underwent bedside EVD placement for any indication between December 2020 and December 2021. Collected variables included demographic information, etiology of disease state, pre-and post-operative head computed tomography measurements, and post-procedural metrics (immediate and delayed complications). Results: A total of 124 patients qualified for inclusion in our study. EVDs that were non-functioning/exchanged were not significantly related to age, accuracy, ventriculomegaly, sex, disposition, laterality, type of EVD used, intraventricular hemorrhage (IVH), etiology, or Kakarla Grade (KG) (all P > 0.17). The need for a second EVD was similarly not related to age, accuracy, ventriculomegaly, sex, disposition, location, laterality, type of EVD used, IVH, etiology, or KG (all P > 0.130). Patients who died, however, were significantly more likely to have a second contralateral EVD placed (18.2% vs. 4.9% P = 0.029). We also found that left-sided EVDs were significantly more likely to fail within seven days of placement (29.4% vs 13.3%, P = 0.037; relative risk (RR) 1.93, 95% confidence interval: 1.09-3.43), unrelated to age, sex, etiology, type of EVD, IVH, location of the procedure, or accuracy (all P > 0.07). This remained significant when using a binary logistic regression to control for ventriculomegaly, accuracy, mortality, age, sex, and etiology (P = 0.021, B = 3.43). Conclusion: In our cohort, although a clear relationship between inaccuracy and complication rates was not found, our data did demonstrate that left-sided EVDs were more likely to fail within the immediate postoperative time point, and patients who died were more likely to have a second, contralateral EVD placed.

Reliability and Discriminant Validity of a Checklist for Surgical Scrubbing, Gowning and Gloving.

Background: Surgical scrubbing, gowning, and gloving is challenging for medical trainees to learn in the operating room environment. Currently, there are few reliable or valid tools to evaluate a trainee's ability to scrub, gown and glove. The objective of this study is to test the reliability and validity of a checklist that evaluates the technique of surgical scrubbing, gowning and gloving (SGG). Methods: This Institutional Review Board-approved study recruited medical students, residents, and fellows from an academic, tertiary care institution. Trainees were stratified based upon prior surgical experience as novices, intermediates, or experts. Participants were instructed to scrub, gown and glove in a staged operating room while being video-recorded. Two blinded raters scored the videos according to the SGG checklist. Reliability was assessed using the intraclass correlation coefficient for total scores and Cohen's kappa for item completion. The internal consistency and discriminant validity of the SGG checklist were assessed using Cronbach alpha and the Wilcoxon rank sum test, respectively. Results: 56 participants were recruited (18 novices, 19 intermediates, 19 experts). The intraclass correlation coefficient demonstrated excellent inter-rater reliability for the overall checklist (0.990), and the Cohen's kappa ranged from 0.598 to 1.00. The checklist also had excellent internal consistency (Cronbach's alpha 0.950). A significant difference in scores was observed between all groups (p < 0.001). Conclusion: This checklist demonstrates a high inter-rater reliability, discriminant validity, and internal consistency. It has the potential to enhance medical education curricula.

Comparison of Screw Quantity and Placement of Metacarpal Fracture Fixation: A Biomechanical Study.

BACKGROUND: It is recommended to have 6 bicortical screws for plate fixation of long bone fractures; however, many metacarpal fractures do not allow 6 screws due to size limitations and proximity of crucial anatomical structures. The purpose of this biomechanical study was to determine whether the mechanical properties of a 4-screw nonlocking construct are noninferior to those of a 6-screw nonlocking construct. METHODS: Metacarpal sawbones were used to simulate a midshaft, transverse fracture. Nonlocking bicortical screws were placed in the 6-hole plate, and the metacarpals were randomly assigned to 2 equal study groups: (1) 4 screws, 2 on either side of the fracture (4S); and (2) 6 screws, 3 on either side of the fracture (6S). The metacarpals were tested in a cyclic loading mode and load to failure in a cantilever bending mode. RESULTS: Maximum deflection was significantly higher for 4S compared with 6S. Cyclic root mean square (RMS) was also significantly greater for 4S at 70 and 100 N. There were no statistically significant differences observed between the 2 constructs for maximum bending load, bending stiffness, and cyclic RMS at 40 N. The maximum bending load in 4S and 6S was 245.6 ± 37.9 N and 230.8 ± 41.9 N, respectively; 4S was noninferior and not superior to 6S. Noninferiority testing was inconclusive for bending stiffness. CONCLUSIONS: A 4-screw bicortical nonlocking construct is noninferior to a 6-screw bicortical nonlocking construct for fixation of metacarpal fractures, which may be advantageous to minimize disruption of soft tissues while maintaining sufficient construct stability.

Syndesmosis Repair Affects in Vivo Distal Interosseous Tibiofibular Ligament Elongation Under Static Loads and During Dynamic Activities.

BACKGROUND: Ligamentous ankle injuries are the most common injuries sustained by athletes and by the general population, with an incidence of approximately 2 million per year in the U.S. Injuries to the ankle syndesmosis (i.e., "high ankle sprains") are generally treated operatively. Although cadaveric studies can evaluate syndesmosis fixation strength, they cannot predict how healing, neuromuscular adaptation, or dynamic loading will affect in vivo biomechanics. Using dynamic biplane radiography (DBR), we tested the hypothesis that syndesmosis repair would restore ankle kinematics and ligament elongation during static and dynamic loading. METHODS: A convenience sample of 6 male patients who had undergone fixation (2 screw, 3 suspensory, 1 hybrid) of syndesmosis injury were assessed with use of DBR during forward running, backpedaling, a 45° angled single-leg hop, and 1 static standing trial at 2 to 4.5 years postoperatively. Three-dimensional ankle kinematics and elongation of the distal interosseous ligament, anterior inferior tibiofibular ligament, and the posterior inferior tibiofibular ligament were measured bilaterally. Comparisons were made between the operative and uninjured sides. Clinical outcomes were evaluated with use of the Foot and Ankle Ability Measure. RESULTS: Static load increased the lengths of the distal interosseous ligament (p = 0.02 to 0.05) and middle segment of the anterior inferior tibiofibular ligament (p = 0.02) in the operative ankle. The distal syndesmosis length was greater on the operative side during the static unloaded and loaded conditions (p = 0.02). Length of the distal syndesmosis on the operative side was greater than the corresponding healthy syndesmosis length during all 3 dynamic activities. On average, the operative ankle was in less dorsiflexion over the support phase of the angled hop (p = 0.05) and running (p < 0.01). The average Foot and Ankle Ability Measure Activities of Daily Living and Sports subscale scores were 95 and 88, respectively. CONCLUSIONS: This study provides the first in vivo evidence of post-fixation changes in biomechanics after syndesmosis repair. Syndesmosis repair fails to restore healthy static and dynamic distal tibiofibular anatomy, even in patients who report good to excellent clinical outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Automatic Detection of Thyroid and Adrenal Incidentals Using Radiology Reports and Deep Learning.

BACKGROUND: Computed tomography (CT) is commonly performed when evaluating trauma patients with up to 55% showing incidental findings. Current workflows to identify and inform patients are time-consuming and prone to error. Our objective was to automatically identify thyroid and adrenal lesions in radiology reports using deep learning. MATERIALS AND METHODS: All trauma patients who presented to an accredited Level 1 Trauma Center between January 2008 and January 2019 were included. Radiology reports of CT scans that included either a thyroid or adrenal gland were obtained. Preprocessing included word tokenization, removal of stop words, removal of punctuation, and replacement of misspellings. A word2vec model was trained using 1.4 million radiology reports. Both training and testing reports were selected at random, manually reviewed, and were considered the gold standard. True positive cases were defined as any lesions in the thyroid or adrenal gland, respectively. Training data was used to create models that would identify reports that contained either thyroid or adrenal lesions. Our primary outcomes were sensitivity and specificity of the models using predetermined thresholds on a separate testing dataset. RESULTS: A total of 51,771 reports were identified on 35,859 trauma patients. A total of 1,789 reports were annotated for training and 500 for testing. The thyroid model predictions resulted in a 90.0% sensitivity and 95.3% specificity. The adrenal model predictions resulted in a 92.3% sensitivity and a 91.1% specificity. A total of 240 reports were confirmed to have thyroid incidentals (mean age 69.1 yrs ± 18.9, 35% M) and 214 reports with adrenal incidentals (mean age 68.7 yrs ± 16.9, 50.5% M). CONCLUSIONS: Both the thyroid and adrenal models have excellent performance with sensitivities and specificities in the 90s. Our deep learning model has the potential to reduce administrative costs and improve the process of informing patients.

Lactate as a mediator of prehospital plasma mortality reduction in hemorrhagic shock.

BACKGROUND: Prehospital plasma transfusion in trauma reduces mortality. However, the underlying mechanism remains unclear. Reduction in shock severity may play a role. Lactate correlates with physiologic shock severity and mortality after injury. Our objective was to determine if prehospital plasma reduces lactate and if this contributes to the mortality benefit of plasma. METHODS: Patients in the Prehospital Air Medical Plasma trial in the upper quartile of injury severity (Injury Severity Score, >30) were included to capture severe shock. Trial patients were randomized to prehospital plasma or standard care resuscitation (crystalloid ± packed red blood cells). Regression determined the associations between admission lactate, 30-day mortality, and plasma while adjusting for demographics, prehospital crystalloid, time, mechanism, and injury characteristics. Causal mediation analysis determined what proportion of the effect of plasma on mortality is mediated by lactate reduction. RESULTS: A total of 125 patients were included. The plasma group had a lower adjusted admission lactate than standard of care group (coefficient, -1.64; 95% confidence interval [CI], -2.96 to -0.31; p = 0.02). Plasma was associated with lower odds of 30-day mortality (odds ratio [OR], 0.27; 95% CI, 0.08-0.90; p = 0.03). When adding lactate to this model, the effect of plasma on 30-day mortality was no longer significant (OR, 0.36; 95% CI, 0.07-1.88; p = 0.23), while lactate was associated with mortality (OR, 1.74 per 1 mmol/L increase; 95% CI, 1.10-2.73; p = 0.01). Causal mediation demonstrated 35.1% of the total effect of plasma on 30-day mortality was mediated by the reduction in lactate among plasma patients. CONCLUSION: Prehospital plasma is associated with reduced 30-day mortality and lactate in severely injured patients. More than one third of the effect of plasma on mortality is mediated by a reduction in lactate. Thus, reducing the severity of hemorrhagic shock appears to be one mechanism of prehospital plasma benefit. Further study should elucidate other mechanisms and if a dose response exists. LEVEL OF EVIDENCE: Therapeutic, level II.

Healthy ankle and hindfoot kinematics during gait: Sex differences, asymmetry and coupled motion revealed through dynamic biplane radiography.

The aims of this study were to compare male versus female and dominant versus non-dominant kinematics in the ankle and hindfoot, and to characterize coupled motion between the subtalar and tibiotalar joints during the support phase of gait. Twenty healthy adults walked on a laboratory walkway while synchronized biplane radiographs of the ankle and hindfoot were collected at 100 frames/s. A validated tracking technique was used to measure tibiotalar and subtalar kinematics. Differences between male and female range of motion (ROM) were observed only in tibiotalar (AP and ML) and subtalar (ML) translation (all differences<1 mm and all p < 0.04). Statistical parametric mapping identified differences between kinematics waveforms of males and females in tibiotalar translation (AP and ML) and eversion, and subtalar ML translation. No differences between dominant and non-dominant sides were observed in ROM or kinematics waveforms. The average absolute side-to-side difference in the kinematics waveforms was 4.1° and 1.5 mm or less for all rotations and translations, respectively. Tibiotalar plantarflexion was coupled to subtalar inversion and eversion during the impact and push-off phases of stance (r = 0.90 and r = 0.87, respectively). This data may serve as a guide for evaluating ankle kinematics waveforms, ROM, symmetry, and restoration of healthy coupled motion after surgical intervention or rehabilitation. The observed kinematics differences between males and females may predispose females to higher rates of ankle and knee injury and suggest sex-dependent ankle reconstruction techniques may be beneficial.

Biologic therapies for foot and ankle injuries.

Introduction: The use of orthobiologics as supplemental treatment for foot and ankle pathologies have increased in the past decades. They have been used to improve the healing of bone and soft tissue injuries. There have been several studies that examined the use of biologics for knee and hip pathologies but the foot and ankle construct has unique features that must be considered.Areas covered: The biologics for foot and ankle injuries that are covered in this review are platelet-rich plasma (PRP), stem cells, growth factors, hyaluronic acid, bone grafts, bone substitutes, and scaffolds. These modalities are used in the treatment of pathologies related to tendon and soft tissue as well as cartilage.Expert opinion: The utilization of biological adjuncts for improved repair and regeneration of ankle injuries represents a promising future in our efforts to address difficult clinical problems. The application of concentrated bone marrow and PRP each represents the most widely studied and commonly used injection therapies with early clinical studies demonstrating promising results, research is also being done using other potential therapies such as stem cells and growth factors; further investigation and outcome data are still needed.

In Vivo Ankle Kinematics Revealed Through Biplane Radiography: Current Concepts, Recent Literature, and Future Directions.

PURPOSE OF REVIEW: Lateral ligament repair, specifically the modified Broström-Gould (BG) procedure, has been described for patients with chronic ankle instability (CAI) after failure of nonoperative management. However, there is minimal data about native in vivo ankle bone kinematics and how repairs such as the BG procedure affect the kinematics. The objective of this review is to appraise existing literature that used biplane radiography to measure in vivo kinematics of the ankle in healthy, CAI, and BG populations. RECENT FINDINGS: Results showed that the tibiotalar joint contributes more to dorsi/plantarflexion, the subtalar joint contributes more to inversion/eversion and internal/external rotation, and that both joints are capable of complex three-dimensional (3D) motion. Preliminary data suggests that demanding activities (as opposed to walking) are necessary to elicit kinematic differences between healthy and CAI populations. Results also indicate that the BG procedure restores static kinematics and range of motion. All but one of the studies identified in this review collected static, quasi-stance, or partial gait capture data. The strength of our current knowledge is low given the small sample sizes, exploratory nature of previous work, and lack of rigorous experimental design in previous studies. Future directions include development of an improved protocol for establishing coordinate systems in the ankle bones, continued development of a database of normal kinematics during a variety of activities, and large-scale, longitudinal studies of CAI and BG patients.

Ultrasound-Guided Ankle Lateral Ligament Stabilization.

PURPOSE OF REVIEW: Ultrasound (US) is an increasingly popular imaging modality currently used both in clinics and operating rooms. The purpose of this review is to appraise literature describing traditional lateral ankle stabilization techniques and discuss potential advantages of US-guided ankle lateral ligament stabilization. In addition, albeit limited, we will describe our experiences in perfecting this technique. RECENT FINDINGS: To date, the modified open Broström-Gould technique remains as the gold standard surgical treatment for chronic ankle instability (CAI). In the past decade, modifications of this technique have been done, from a combination of arthroscopic and open procedure to an all-inside arthroscopic technique with a goal of minimizing wound complications, better outcomes, and earlier return to activity. Recently, the use of US as an adjunct to surgical procedures has gained popularity and several novel techniques have been described. The use of US in lateral ankle stabilization could allow accurate placement of the suture anchor at the anatomical attachment of the anterior talofibular ligament (ATFL) without iatrogenic damage to the neurovascular structures such as anterolateral malleolar artery, superficial peroneal nerve, and sural nerve. In summary, the use of US in ankle lateral ligament stabilization is a promising new micro-invasive technique. The theoretical advantages of US-guided ankle lateral ligament stabilization include direct visualization of desired anatomical landmarks and structures which could increase accuracy, decrease iatrogenic neurovascular damage, minimize wound complications, and improve outcomes.

Active and passive contributions to arm swing: Implications of the restriction of pelvis motion during human locomotion.

Current research has yet to determine how passive dynamics and active neural control contribute to upper limb swing during human locomotion. The present study aimed to investigate these contributions by restricting pelvis motion during walking, thereby altering the upward energy transfer from the swinging lower limbs. Ten healthy individuals walked freely on a treadmill (CON) and with an apparatus that reduced pelvis motion (PR) at three walking speeds (0.9, 1.3, and 1.8m/s). Spatiotemporal characteristics of limb movement and muscle activation were recorded and analyzed. When wearing the apparatus, the ranges of the sagittal and transverse rotations of the trunk and shoulders, as well as vertical trunk center of mass movement all decreased. At higher treadmill speeds, the movement amplitudes of the upper and lower limbs increased. This increase was less pronounced in the upper limbs when the apparatus reduced pelvis motion. However, this decrease in arm swing was accompanied with a preservation of upper and lower limb muscle activity amplitudes. The temporal coordination between upper and lower limbs was also conserved irrespective of the PR or CON conditions. Relating shoulder muscle activities to upper limb kinematics suggested these muscles mainly acted eccentrically, providing evidence that passive elements are a significant factor in arm swing control. However, the conserved muscle activity patterns and temporal coupling of limb movements when pelvis motion was reduced are suggestive of an underlying active maintenance of the locomotor pattern via linked upper and lower limb neural networks.

Application of Empirical Mode Decomposition Combined With Notch Filtering for Interpretation of Surface Electromyograms During Functional Electrical Stimulation.

The goal of this paper is to demonstrate a novel approach that combines Empirical Mode Decomposition (EMD) with Notch filtering to remove the electrical stimulation (ES) artifact from surface electromyogram (EMG) data for interpretation of muscle responses during functional electrical stimulation (FES) experiments. FES was applied to the rectus femoris (RF) muscle unilaterally of six able bodied (AB) and one individual with spinal cord injury (SCI). Each trial consisted of three repetitions of ES. We hypothesized that the EMD algorithm provides a suitable platform for decomposing the EMG signal into physically meaningful intrinsic mode functions (IMFs) which can be further used to isolate electrical stimulation (ES) artifact. A basic EMD algorithm was used to decompose the EMG signals collected during FES into IMFs for each repetition separately. IMFs most contaminated by ES were identified based on the standard deviation (SD) of each IMF. Each artifact IMF was Notch filtered to filter ES harmonics and added to remaining IMFs containing pure EMG data to get a version of a filtered EMG signal. Of all such versions of filtered signals generated from each artifact IMF, the one with maximum signal to noise ratio (SNR) was chosen as the final output. The validity of the filtered signal was assessed by quantitative metrics, 1) root mean squared error (RMSE) and signal to noise (SNR) ratio values obtained by comparing a clean EMG and EMD-Notch filtered signal from the combination of simulated ES and clean EMG and, 2) using EMG-force correlation analysis on the data collected from AB individuals. Finally, the potential applicability of this algorithm on a neurologically impaired population was shown by applying the algorithm on EMG data collected from an individual with SCI. EMD combined with Notch filtering successfully extracted the EMG signal buried under ES artifact. Filtering performance was validated by smaller RMSE values and greater SNR post filtering. The amplitude values of the filtered EMG signal were seen to be consistent for three repetitions of ES and there was no significant difference among the repetition for all subjects. For the individual with a SCI the algorithm was shown to successfully isolate the underlying bursts of muscle activations during FES. The data driven nature of EMD algorithm and its ability to act as a filter bank at different bandwidths make this method extremely suitable for dissecting ES induced EMG into IMFs. Such IMFs clearly show the presence of ES artifact at different intensities as well as pure artifact free EMG. This allows the application of Notch filters to IMFs containing ES artifact to further isolate the EMG. As a result of such stepwise approach, the extraction of EMG is achieved with minimal data loss. This study provides a unique approach to dissect and interpret the EMG signal during FES applications.

Neuromotor response of the leg muscles following a supine, stand retraining with/without neuromuscular electrical stimulation training intervention for individuals with SCI: A case series.

The goal of this paper is to study the effects of supine and stand retraining (SRT) interventions with and without multi muscle neuromuscular electrical stimulation (NMES) on the neuromuscular EMG responses of the leg muscles for individuals with motor complete SCI during walking on a body-weight support (BWS) treadmill. The main outcome variables were EMG amplitude, integrated EMG and co-contraction indices (co-excitation and co-activation) collected during a 10-minute walking treadmill trial. Data was analyzed for the first, fifth and tenth minute of walking. Results showed that both Supine+NMES and SRT+NMES interventions increased spatial-temporal aspects of muscle activity (mean EMG amplitude and integrated EMG) of lower limb muscles. SRT+NMES (loading) showed greater gains in the proximal anterior leg compartments. On the contrary, SRT without NMES (SRT only) exhibited deterioration of activity within the same muscle groups. Co-contraction indices increased for both post-NMES interventions suggesting that task-specificity of training is important to achieve the fundamental reciprocal firing known to able-bodied gait. These results show that combination of NMES+loading during passive rhythmic gait will induce neuroplasticity in the lower limbs that ultimately provides a potential effective means to recover gait in individuals with SCI.

Effects of lower limb electrical stimulation on trunk stability in persons with SCI during walking: a case series.

The purpose of the present case series was to investigate whether three lower limb rehabilitation training approaches have any effects on trunk stability of persons with motor complete SCI during a 10-minute assisted walk. These trainings included electrical stimulation (ES), standing retraining (SRT), and a novel multi-modality approach that combined ES with SRT. We observed that multi-muscle ES directed at the lower limbs had a prominent, indirect effect on the upper and lower muscles of the trunk. More specifically, trunk muscle activations of the ES+SRT subject increased after training for the more distal muscles of the trunk. This study provides preliminary evidence that combining lower limb ES with SRT may provide beneficial effects in improving trunk control and stability.

Regenerative medicine approach to reconstruction of the equine upper airway.

Airway obstruction is a common cause of poor performance in horses. Structural abnormalities (insufficient length, rigidity) can be a cause for the obstruction. Currently, there are a few effective clinical options for reconstruction of the equine larynx. A regenerative medicine approach to reconstruction may provide the capability to stabilize laryngeal structures and to encourage restoration of site-appropriate, functional, and host-derived tissue. The purpose of this study was the histopathological evaluation of (1) decellularization of equine (horse) laryngeal cartilages (epiglottis and arytenoids); (2) the host response to decellularized laryngeal cartilages implanted subcutaneously in a donkey model as a test of biocompatibility; and (3) the use of decellularized laryngeal cartilages in a clinically relevant pilot study in the horse larynx. Equine laryngeal cartilages were found to be sufficiently decellularized and were subsequently implanted subcutaneously in donkeys to test biocompatibility. After 4 weeks, the implanted cartilage was harvested. In the subcutaneous model, the samples did not elicit a rejection or foreign body type reaction and were judged suitable for implantation in a clinically relevant equine model. Implants were placed in the upper airway (arytenoids and epiglottis) of one horse. At 4 weeks, the implants were observed to remodel rapidly and were replaced by dense connective tissue with signs of new hyaline cartilage formation in the arytenoids and by connective tissue containing glandular structures and an epithelial covering in the epiglottis. The results of the present study demonstrate the feasibility of a scaffold-based regenerative medicine approach to reconstruction of the equine upper airway; however, further studies investigating long-term integration, formation of new cartilage, and mechanical properties are needed.