Integration of statistical shape modeling and alternating interpolation-based model tracking technique for measuring knee kinematics in vivo using clinical interleaved bi-plane fluoroscopy.

Background: A 2D fluoroscopy/3D model-based registration with statistical shape modeling (SSM)-reconstructed subject-specific bone models will help reduce radiation exposure for 3D kinematic measurements of the knee using clinical alternating bi-plane fluoroscopy systems. The current study aimed to develop such an approach and evaluate in vivo its accuracy and identify the effects of the accuracy of SSM models on the kinematic measurements. Methods: An alternating interpolation-based model tracking (AIMT) approach with SSM-reconstructed subject-specific bone models was used for measuring 3D knee kinematics from dynamic alternating bi-plane fluoroscopy images. A two-phase optimization scheme was used to reconstruct subject-specific knee models from a CT-based SSM database of 60 knees using one, two, or three pairs of fluoroscopy images. Using the CT-reconstructed model as a benchmark, the performance of the AIMT with SSM-reconstructed models in measuring bone and joint kinematics during dynamic activity was evaluated in terms of mean target registration errors (mmTRE) for registered bone poses and the mean absolute differences (MAD) for each motion component of the joint poses. Results: The mmTRE of the femur and tibia for one image pair were significantly greater than those for two and three image pairs without significant differences between two and three image pairs. The MAD was 1.16 to 1.22° for rotations and 1.18 to 1.22 mm for translations using one image pair. The corresponding values for two and three image pairs were 0.75 to 0.89° and 0.75 to 0.79 mm; and 0.57 to 0.79° and 0.6 to 0.69 mm, respectively. The MAD values for one image pair were significantly greater than those for two and three image pairs without significant differences between two and three image pairs. Conclusions: An AIMT approach with SSM-reconstructed models was developed, enabling the registration of interleaved fluoroscopy images and SSM-reconstructed models from more than one asynchronous fluoroscopy image pair. This new approach had sub-millimeter and sub-degree measurement accuracy when using more than one image pair, comparable to the accuracy of CT-based methods. This approach will be helpful for future kinematic measurements of the knee with reduced radiation exposure using 3D fluoroscopy with clinically alternating bi-plane fluoroscopy systems.

Effects of lateral instability on ankle coupled motions in vivo using 3D fluoroscopy.

Lateral ankle instability (LAI) compromises the normal kinematics of the ankle, affecting activities of daily living. In vitro kinematics of ankles with LAI during single-plane motions are available, but the active control stability of these motions remains unclear. The current study measured the 3D ankle kinematics during unresisted single-plane motion tests using a bi-plane fluoroscope with a CT model-based 2D/3D registration method in 12 patients with LAI and 14 healthy peers. The coupling of the kinematic components at the talocrural and subtalar joints was quantified by the path difference between the forward and return paths of the coupled motion. Significantly increased path differences were found in the subtalar dorsiflexion/plantarflexion and inversion/eversion components during internal/external rotation tests (p < 0.05). During inversion/eversion, significantly reduced tibiocalcaneal ranges of motion and the path differences in the talocrural and subtalar dorsiflexion/plantarflexion components were noted (p < 0.05). The current results suggest that chronic LAI had compromised control stability at the subtalar joint during internal/external rotation tests and a conservative motion control strategy with significantly reduced ranges of motion to maintain good control of out-of-plane motion components in response to direct challenges of the anterior talofibular ligament during inversion/eversion tests. The current results also suggest that, compared to kinematic patterns of individual components, the path difference of the coupled motion may serve as a better measure of the motion control stability of the ankle in differentiating LAI from healthy controls.

Efficacy and Optimal Dose of Botulinum Toxin A in Post-Stroke Lower Extremity Spasticity: A Systematic Review and Meta-Analysis.

Post-stroke spasticity impedes patients' rehabilitation progress. Contradictory evidence has been reported in using Botulinum Neurotoxin type A (BoNT-A) to manage post-stroke lower extremity spasticity (PLES); furthermore, an optimum dose of BoNT-A for PLES has not yet been established. Therefore, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to identify the efficacy and optimal dose of BoNT-A on PLES. "Meta" and "Metafor" packages in R were used to analyze the data. Hedges' g statistic and random effect model were used to calculate and pool effect sizes. Twelve RCTs met the eligibility criteria. Muscle tone significantly improved in week four, week eight, and maintained to week twelve after BoNT-A injection. Improvements in functional outcomes were found, some inconsistencies among included studies were noticed. Dosage analysis from eight studies using Botox® and three studies using Dysport® indicated that the optimum dose for the commonest pattern of PLES (spastic plantar flexors) is medium-dose (approximately 300U Botox® or 1000 U Dysport®). BoNT-A should be regarded as part of a rehabilitation program for PLES. Furthermore, an optimal rehabilitation program combined with BoNT-A management needs to be established. Further studies should also focus on functional improvement by BoNT-A management in the early stage of stroke.

A model-based tracking method for measuring 3D dynamic joint motion using an alternating biplane x-ray imaging system.

PURPOSES: To propose a new model-based tracking method for measuring three-dimensional (3D) dynamic joint kinematics using a clinical alternating biplane x-ray imaging system; and to quantify in vitro its errors in measuring ankle and knee motions at different motion speeds. METHODS: A new model-based tracking method based on motion component partition and interpolation (MCPI) was developed for measuring 3D dynamic joint kinematics based on a clinical alternating biplane x-ray imaging system. Two detectors of the biplane imaging system placed perpendicular to each other were operated to collect alternating fluoroscopic images of the targeted joint during tasks. The CT data of the joint were also acquired for the reconstruction of volumetric and surface models of each of the associated bones. The CT-based models of the bones were first registered to the alternating images using a model-to-single-plane fluoroscopic image registration method, and the resulting bone poses were then refined using a two-level optimization with motion component partition and model vertex trajectory interpolation. The MCPI method was evaluated in vitro for measurement errors for an ankle and a knee specimen moving at different speeds against a standard reference provided by a highly accurate motion capture system. The positional and rotational errors of the measured bone poses were quantified in terms of the bias, precision, and root-mean-squared errors (RMSE), as well as the mean target registration error (mTRE), a final mTRE less than 2.5 mm indicating a successful registration. RESULTS: The new method was found to have RMSE of bone pose measurements of less than 0.18 mm for translations and 0.72° for rotations for the ankle, and 0.33 mm and 0.74° for the knee with a high successful registration rate (>97%), and did not appear to be affected by joint motion speeds. Given the same alternating fluoroscopic images, the MCPI method outperformed the typical biplane analysis method assuming zero time offset between the two fluoroscopic views. The differences in performance between the methods were increased with increased joint motion speed. With the accurate bone pose data, the new method enabled talocrural, subtalar, and tibiofemoral kinematics measurements with submillimeter and subdegree accuracy, except for an RMSE of 1.04° for the internal/external rotation of the talocrural joint. CONCLUSIONS: A new model-based tracking method based on MCPI has been developed for measuring dynamic joint motions using an alternating biplane x-ray imaging system widely available in medical centers. The MCPI method has been demonstrated in vitro to be highly accurate in determining the 3D kinematics of the bones of both the ankle joint complex and the knee. The current results suggest that the MCPI method would be an effective approach for measuring in vivo 3D kinematics of dynamic joint motion in a clinical setting equipped with an alternating biplane x-ray imaging system.

Effects of gait speed on the body's center of mass motion relative to the center of pressure during over-ground walking.

Preferred walking speed (PWS) reflects the integrated performance of the relevant physiological sub-systems, including energy expenditure. It remains unclear whether the PWS during over-ground walking is chosen to optimize one's balance control because studies on the effects of speed on the body's balance control have been limited. The current study aimed to bridge the gap by quantifying the effects of the walking speed on the body's center of mass (COM) motion relative to the center of pressure (COP) in terms of the changes and directness of the COM-COP inclination angle (IA) and its rate of change (RCIA). Data of the COM and COP were measured from fifteen young healthy males at three walking speeds including PWS using a motion capture system. The values of IAs and RCIAs at key gait events and their average values over gait phases were compared between speeds using one-way repeated measures ANOVA. With increasing walking speed, most of the IA and RCIA related variables were significantly increased (p<0.05) but not for those of the frontal IA. Significant quadratic trends (p<0.05) with highest directness at PWS were found in IA during single-limb support, and in RCIA during single-limb and double-limb support. The results suggest that walking at PWS corresponded to the COM-COP control maximizing the directness of the RCIAs over the gait cycle, a compromise between the effects of walking speed and the speed of weight transfer. The data of IA and RCIA at PWS may be used in future assessment of balance control ability in people with different levels of balance impairments.

Kinematic strategies for obstacle-crossing in patients with isolated posterior cruciate ligament deficiency.

The posterior cruciate ligament (PCL) plays an important role in the structural stability and sensory feedback at the knee. Altered structural and proprioceptive function at the PCL-deficient knee may affect the joint motions and the end-point control during functional activities. The current study identified the effects of unilateral PCL deficiency (PCLD) on the end-point control and joint kinematics of the lower limbs during obstacle-crossing. Eighteen patients with unilateral PCLD and eighteen healthy controls were each asked to walk and cross obstacles of heights of 10%, 20% and 30% of their leg lengths, with the affected and the unaffected limb leading, while their kinematic data were measured. Patients with PCLD were found to cross obstacles with significantly increased toe-clearance (p<0.01), increased trailing toe-obstacle distance (p<0.05) and reduced crossing speed (p<0.01) when compared to the controls. Similar end-point control was observed in the PCLD group whether leading with the affected or unaffected limb, which appears to be as a result of bilateral kinematic accommodation to reduce the risk of tripping. To achieve similar toe-clearances, crossing strategies with the unaffected limb leading involved angular changes at more joints than those with the affected limb leading. The PCLD group appeared to adopt a conservative strategy to reduce the risk of tripping over the obstacle during obstacle-crossing, using different joint kinematic changes depending on whether the affected or unaffected limb was leading. It is suggested that monitoring of the kinematic strategies adopted by patients with PCLD during obstacle-crossing may be needed in future rehabilitation programs with the aim of reducing tripping risks during obstacle-crossing.

Soft tissue artefacts of skin markers on the lower limb during cycling: Effects of joint angles and pedal resistance.

Soft tissue artefacts (STA) are a major error source in skin marker-based measurement of human movement, and are difficult to eliminate non-invasively. The current study quantified in vivo the STA of skin markers on the thigh and shank during cycling, and studied the effects of knee angles and pedal resistance by using integrated 3D fluoroscopy and stereophotogrammetry. Fifteen young healthy adults performed stationary cycling with and without pedal resistance, while the marker data were measured using a motion capture system, and the motions of the femur and tibia/fibula were recorded using a bi-plane fluoroscopy-to-CT registration method. The STAs with respect to crank and knee angles over the pedaling cycle, as well as the within-cycle variations, were obtained and compared between resistance conditions. The thigh markers showed greater STA than the shank ones, the latter varying linearly with adjacent joint angles, the former non-linearly with greater within-cycle variability. Both STA magnitudes and within-cycle variability were significantly affected by pedal resistance (p<0.05). The STAs appeared to be composed of one component providing the stable and consistent STA patterns and another causing their variations. Mid-segment markers experienced smaller STA ranges than those closer to a joint, but tended to have greater variations primarily associated with pedal resistance and muscle contractions. The current data will be helpful for a better choice of marker positions for data collection, and for developing methods to compensate for both stable and variation components of the STA.

Validity and reliability of ankle morphological measurements on computerized tomography-synthesized planar radiographs.

BACKGROUND: Clinical success of total ankle arthroplasty depends heavily on the available information on the morphology of the bones, often obtained from measurements on planar radiographs. The current study aimed to evaluate the intra-rater, inter-rater and inter-session reliability and the validity of radiograph-based measurements of ankle morphology, and to quantify the effects of examiner experience on these measurements. METHODS: Twenty-four fresh frozen ankle specimens were CT scanned, data of which were used to reconstruct 3D volumetric bone models for synthesizing 2D radiographs. Two orthopaedic surgeons with different levels of clinical experience identified twenty landmarks five times on each of the synthesized sagittal and coronal radiographs and repeated the test on a subsequent day within 5 days. The landmarks were used to calculate fourteen morphological parameters. The two-way mixed-effects (ICC3,1), two-way random-effects (ICC2,k) and two-way random-effects (ICC3,k) models were used, respectively, to assess the intra-rater, inter-rater and inter-session reliability of measurements. The validity of the measurements for each examiner was assessed by comparing them with gold standard values obtained from the 2D radiographs projected from the 3D volumetric models using Pearson's correlation analysis and Bland and Altman plots, and the differences were defined as the measurement errors. RESULTS: Most of the morphological parameters were of good to very good intra-rater, inter-session and inter-rater reliability for both examiners (ICC > 0.61). Experience appeared to affect the inter-rater and inter-session reliability, the senior examiner showing greater inter-session ICC values than the junior examiner. Most of the tibial parameters had moderate to excellent correlations with the corresponding gold standard values but were underestimated by both examiners, in contrast to most of the talar parameters that were overestimated and had only poor to fair correlations. CONCLUSIONS: Most of the morphological parameters of the ankle can be estimated from radiographs with good to very good intra-rater, inter-session and inter-rater reliability, for both clinically experienced and less experienced examiners. Clinical experience helped increase the reliability of repeated evaluations after a longer interval, such as in a follow-up assessment. It is suggested that critical clinical decisions based on repeated morphology measurements should be made by more experienced surgeons or after appropriate training.

Evaluation of three force-position hybrid control methods for a robot-based biological joint-testing system.

BACKGROUND: Robot-based joint-testing systems (RJTS) can be used to perform unconstrained laxity tests, measuring the stiffness of a degree of freedom (DOF) of the joint at a fixed flexion angle while allowing the other DOFs unconstrained movement. Previous studies using the force-position hybrid (FPH) control method proposed by Fujie et al. (J Biomech Eng 115(3):211-7, 1993) focused on anterior/posterior tests. Its convergence and applicability on other clinically relevant DOFs such as valgus/varus have not been demonstrated. The current s1tudy aimed to develop a 6-DOF RJTS using an industrial robot, to propose two new force-position hybrid control methods, and to evaluate the performance of the methods and FPH in controlling the RJTS for anterior/posterior and valgus/varus laxity tests of the knee joint. METHODS: An RJTS was developed using an industrial 6-DOF robot with a 6-component load-cell attached at the effector. The performances of FPH and two new control methods, namely force-position alternate control (FPA) and force-position hybrid control with force-moment control (FPHFM), for unconstrained anterior/posterior and valgus/varus laxity tests were evaluated and compared with traditional constrained tests (CT) in terms of the number of control iterations, total time and the constraining forces and moments. RESULTS: As opposed to CT, the other three control methods successfully reduced the constraining forces and moments for both anterior/posterior and valgus/varus tests, FPHFM being the best followed in order by FPA and FPH. FPHFM had root-mean-squared constraining forces and moments of less than 2.2 N and 0.09 Nm, respectively at 0° flexion, and 2.3 N and 0.14 Nm at 30° flexion. The corresponding values for FPH were 8.5 N and 0.33 Nm, and 11.5 N and 0.45 Nm, respectively. Given the same control parameters including the compliance matrix, FPHFM and FPA reduced the constraining loads of FPH at the expense of additional control iterations, and thus increased total time, FPA taking about 10 % longer than FPHFM. CONCLUSIONS: The FPHFM would be the best choice among the methods considered when longer total time is acceptable in the intended clinical applications. The current results will be useful for selecting a force-position hybrid control method for unconstrained laxity tests using an RJTS.

Effects of soft tissue artifacts on differentiating kinematic differences between natural and replaced knee joints during functional activity.

Functional performance of total knee replacement (TKR) is often assessed using skin marker-based stereophotogrammetry, which can be affected by soft tissue artifacts (STA). The current study aimed to compare the STA and their effects on the kinematics of the knee between twelve patients with TKR and twelve healthy controls during sit-to-stand, and to assess the effects of STA on the statistical between-group comparisons. Each subject performed the sit-to-stand task while motions of the skin markers and the knees were measured by a motion capture system integrated with a three-dimensional fluoroscopy technique. The bone motions measured by the three-dimensional fluoroscopy were taken as the gold standard, with respect to which the STA of the markers were obtained. The STA were found to affect the calculated segmental poses and knee kinematics between the groups differently. The STA resulted in artefactual posterior displacements of the knee joint center, with magnitudes significantly greater in TKR than controls (p<0.01). The STA-induced knee external rotations in TKR were smaller than those in controls with mean differences of 2.3-3.0°. These between-group differences in the STA effects on knee kinematics in turn concealed the true between-group differences in the anterior-posterior translation and internal/external rotation of knee while leading to false significant between-group differences in the abduction/adduction and proximal-distal translation.

Three-dimensional computer graphics-based ankle morphometry with computerized tomography for total ankle replacement design and positioning.

Morphometry of the bones of the ankle joint is important for the design of joint replacements and their surgical implantations. However, very little three-dimensional (3D) data are available and not a single study has addressed the Chinese population. Fifty-eight fresh frozen Chinese cadaveric ankle specimens, 26 females, and 32 males, were CT-scanned in the neutral position and their 3D computer graphics-based models were reconstructed. The 3D morphology of the distal tibia/fibula segment and the full talus was analyzed by measuring 31 parameters, defining the relevant dimensions, areas, and volumes from the models. The measurements were compared statistically between sexes and with previously reported data from Caucasian subjects. The results showed that, within a general similarity of ankle morphology between the current Chinese and previous Caucasian subjects groups, there were significant differences in 9 out of the 31 parameters analyzed. From a quantitative comparison with available prostheses designed for the Caucasian population, few of these designs have both tibial and talar components suitable in dimension for the Chinese population. The current data will be helpful for the sizing, design, and surgical positioning of ankle replacements and for surgical instruments, especially for the Chinese population.

Effects of positioning on radiographic measurements of ankle morphology: a computerized tomography-based simulation study.

BACKGROUND: Measurements of the morphology of the ankle joint, performed mostly for surgical planning of total ankle arthroplasty and for collecting data for total ankle prosthesis design, are often made on planar radiographs, and therefore can be very sensitive to the positioning of the joint during imaging. The current study aimed to compare ankle morphological measurements using CT-generated 2D images with gold standard values obtained from 3D CT data; to determine the sensitivity of the 2D measurements to mal-positioning of the ankle during imaging; and to quantify the repeatability of the 2D measurements under simulated positioning conditions involving random errors. METHOD: Fifty-eight cadaveric ankles fixed in the neutral joint position (standard pose) were CT scanned, and the data were used to simulate lateral and frontal radiographs under various positioning conditions using digitally reconstructed radiographs (DRR). RESULTS AND DISCUSSION: In the standard pose for imaging, most ankle morphometric parameters measured using 2D images were highly correlated (R > 0.8) to the gold standard values defined by the 3D CT data. For measurements made on the lateral views, the only parameters sensitive to rotational pose errors were longitudinal distances between the most anterior and the most posterior points of the tibial mortise and the tibial profile, which have important implications for determining the optimal cutting level of the bone during arthroplasty. Measurements of the trochlea tali width on the frontal views underestimated the standard values by up to 31.2%, with only a moderate reliability, suggesting that pre-surgical evaluations based on the trochlea tali width should be made with caution in order to avoid inappropriate selection of prosthesis sizes. CONCLUSIONS: While highly correlated with 3D morphological measurements, some 2D measurements were affected by the bone poses in space during imaging, which may affect surgical decision-making in total ankle arthroplasty, including the amount of bone resection and the selection of the implant sizes. The linear regression equations for the relationship between 2D and 3D measurements will be helpful for correcting the errors in 2D morphometric measurements for clinical applications.

Ellagic acid inhibits oxidized low-density lipoprotein (OxLDL)-induced metalloproteinase (MMP) expression by modulating the protein kinase C-α/extracellular signal-regulated kinase/peroxisome proliferator-activated receptor γ/nuclear factor-κB (PKC-α/ERK/PPAR-γ/NF-κB) signaling pathway in endothelial cells.

Previous studies have shown that vascular endothelium-derived matrix metalloproteinases (MMPs) contribute to the destabilization of atherosclerotic plaques, a key event triggering acute myocardial infarction. In addition, studies have reported that the PKC-MEK-PPARγ signaling pathway is involved in oxidized low-density lipoprotein (oxLDL)-induced expression of MMPs. Ellagic acid, a phenolic compound found in fruits and nuts, has potent antioxidant, anti-inflammatory, and anticancerous properties. However, the molecular mechanisms underlying its antiatherogenic effects remain to be clarified. This study aimed to assess whether the effects of ellagic acid on the fibrotic markers MMP-1 and MMP-3 are modulated by the PKC-ERK-PPAR-γ signaling pathway in human umbilical vein endothelial cells (HUVECs) that have been exposed to oxLDL. It was found that ellagic acid significantly inhibited oxLDL-induced expressions of MMP-1 and MMP-3. Pretreatment with ellagic acid and DPI, a well-known ROS inhibitor, attenuated the oxLDL-induced expression and activity of PKC-α. In addition, ellagic acid as well as pharmacological inhibitors of ROS, calcium, and PKC strongly suppressed the oxLDL-induced phosphorylation of extracellular signal-regulated kinase (ERK) and NF-κB activation. Moreover, ellagic acid ameliorated the oxLDL-induced suppression of PPAR-γ expression. In conclusion, the data suggest that ellagic acid elicits its protective effects by modulating the PKC-α/ERK/PPAR-γ/NF-κB pathway, resulting in the suppression of ROS generation and, ultimately, inhibition of MMP-1 and MMP-3 expression in HUVECs exposed to oxLDL.

Effects of soft tissue artifacts on the calculated kinematics and kinetics of the knee during stair-ascent.

Biomechanics of the knee during stair-ascent has mostly been studied using skin-marker-based motion analysis techniques, but no study has reported a complete assessment of the soft tissue artifacts (STA) and their effects on the calculated joint center translation, angles and moments at the knee in normal subjects during this activity. This study aimed to bridge the gap. Twelve young adults walked up a three-step stair while data were acquired simultaneously from a three-dimensional motion capture system, a force plate and a dynamic fluoroscopy system. The "gold standards" of poses of the knee were obtained using a 3D fluoroscopy method. The STA of the markers on the thigh and shank were then calculated, together with their effects on the calculated joint center translations, angles and moments at the knee. The STA of the thigh markers were greater than those on the shank, leading to significantly underestimated flexion and extensor moments, but overestimated joint center translations during the first half of the stance phase. The results will be useful for a better understanding of the normal biomechanics of the knee during stair-ascent, as a baseline for future clinical applications and for developing a compensation method to correct for the effects of STA.

Influence of soft tissue artifacts on the calculated kinematics and kinetics of total knee replacements during sit-to-stand.

The current study aimed to quantify the soft tissue artifacts of selected markers on the thigh and shank, and their effects on the calculated joint center translations, angles and moments of the knee during sit-to-stand. Ten patients with total knee replacements rose from a chair under simultaneous surveillance of a motion capture system, a force-plate and a fluoroscopy system. The "true" poses of the thigh and shank were defined by those of the femoral and tibial components obtained using a three-dimensional fluoroscopy method. The soft tissue artifacts of the skin markers were calculated as their movement relative to the underlying prosthesis components. The joint center translations, angles and moments at the knee were also calculated separately using skin markers and the registered prosthesis poses. Considerable soft tissue artifacts were found, leading to significantly underestimated flexion and internal rotation angles, and extensor moments, but overestimated joint center translations and adduction. The current study provides accurate data of the kinematics and kinetics of total knee replacements during sit-to-stand. The effects of soft tissue artifacts on the calculated joint center translations, angles and moments were also quantified for the first time in the literature. The results may help in developing guidelines for using skin markers and in establishing databases in the biomechanical assessment of sit-to-stand in patients with total knee replacements.

Anatomy of the ulnar tunnel and the influence of wrist motion on its morphology.

PURPOSE: To examine the anatomy of the ulnar tunnel, with emphasis on the pisohamate arcade and pisohamate hiatus, and study the influence of wrist kinematics on the morphology of these structures. METHODS: Ten fresh-frozen cadaveric hands were dissected. The dimensions and relationships of the ulnar tunnel, pisohamate arcade, and pisohamate hiatus were recorded. The effect of 4 wrist positions on these dimensions and relationships was investigated. RESULTS: The ulnar tunnel has 3 compartments--proximal, middle, and distal relative to the pisiform-with variable morphologies, dimensions, and boundaries. In wrist neutral position, the length of the ulnar tunnel was 45 mm (range, 42 to 51 mm). The middle compartment was found to be the narrowest; the proximal, the widest, averaging 5.0 mm; and the pisohamate hiatus that separates the middle and distal compartments, highly dynamic. The length of the pisohamate arcade was 21.5 mm (range, 18.0 to 26.0 mm), and the length and width of the pisohamate hiatus were 11.0 mm (range, 9.8-11.5 mm) and 6.0 mm (range, 5.3 to 7.2 mm), respectively. During wrist extension, the ulnar nerve was under tension. Wrist flexion was the position that caused the most change in ulnar tunnel and pisohamate arcade and hiatus anatomy, causing the width of the proximal compartment to increase from 5.0 to 10.0 mm. During this motion, the shape of the pisohamate arcade changed from a C shape to linear, and the length increased to 24.5 mm (range, 19.3 to 28.5 mm). The pisohamate hiatus narrowed, its width decreased to 1.5 mm, and the deep branch of the ulnar nerve was somewhat compressed. CONCLUSIONS: The ulnar tunnel is a dynamic space with dimensions and relationships that are influenced by wrist motion. During ulnar tunnel surgery, all 3 compartments of the ulnar tunnel should be explored and decompressed, including the pisohamate hiatus, by releasing the pisohamate arcade.

A volumetric model-based 2D to 3D registration method for measuring kinematics of natural knees with single-plane fluoroscopy.

PURPOSE: Accurate measurement of the three-dimensional (3D) rigid body and surface kinematics of the natural human knee is essential for many clinical applications. Existing techniques are limited either in their accuracy or lack more realistic experimental evaluation of the measurement errors. The purposes of the study were to develop a volumetric model-based 2D to 3D registration method, called the weighted edge-matching score (WEMS) method, for measuring natural knee kinematics with single-plane fluoroscopy to determine experimentally the measurement errors and to compare its performance with that of pattern intensity (PI) and gradient difference (GD) methods. METHODS: The WEMS method gives higher priority to matching of longer edges of the digitally reconstructed radiograph and fluoroscopic images. The measurement errors of the methods were evaluated based on a human cadaveric knee at 11 flexion positions. RESULTS: The accuracy of the WEMS method was determined experimentally to be less than 0.77 mm for the in-plane translations, 3.06 mm for out-of-plane translation, and 1.13 degrees for all rotations, which is better than that of the PI and GD methods. CONCLUSIONS: A new volumetric model-based 2D to 3D registration method has been developed for measuring 3D in vivo kinematics of natural knee joints with single-plane fluoroscopy. With the equipment used in the current study, the accuracy of the WEMS method is considered acceptable for the measurement of the 3D kinematics of the natural knee in clinical applications.

Complete annular and partial oblique pulley release for pediatric locked trigger thumb.

PURPOSE: To report the surgical treatment outcome of pediatric locked trigger thumb by sequential release of the annular pulley and partial release of the oblique pulley. MATERIALS AND METHODS: A retrospective review was undertaken on 28 operative thumbs in 24 patients with an average follow-up of 79 months. Intraoperative observations focused on the pathology of the pulley system. Surgical technique involved complete release of the annular pulley, which alone was insufficient in relieving the deformity, along with release of the proximal 50% of the oblique pulley in all patients. Postoperative parameters of bowstringing, resolution of Notta's node, thumb interphalangeal motion, and patient/parent satisfaction were assessed. RESULTS: The oblique pulley appeared stenotic, whereas the annular pulley was observed to be membranous and nearly indistinguishable from the tendon sheath. No patients had recurrence of thumb locking or triggering. No bowstringing was detected, and Notta's node resolved fully in 19 of 20 thumbs. Five thumbs had an average of 12(o) less active IP joint motion without flexion contracture (i.e., less flexion). All patients or families expressed overall satisfaction with the procedure. CONCLUSION: The annular pulley was attenuated in the majority of cases and the proximal half of the oblique pulley was stenotic in all patients. Releasing 50% of the oblique pulley after complete annular pulley release was necessary in all thumbs to achieve full FPL excursion. Mistaking the constricted proximal oblique pulley for an annular pulley may encourage releasing the entire oblique pulley, leading to an adverse result. Satisfactory outcome was achieved after surgical treatment of pediatric locked trigger thumbs. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Kinematic analysis of a functional and sequential bimanual task in patients with left hemiparesis: intra-limb and interlimb coordination.

PURPOSE: To characterise upper limb performance of each hand (intra-limb coordination) and interlimb coordination on a functional, sequential bimanual task in patients with left hemiparesis and age-matched controls. METHOD: Fourteen patients with left hemiparesis (age: 60.01 +/- 9.09 years) and 13 adults without neurological impairments (age: 59.14 +/- 10.59 years) were instructed to reach-to-grasp a jar with the affected/left limb and to unscrew the jar cap with the unaffected/right limb. Reaching and grasping kinematics were analysed for intra-limb coordination and bimanual synchronisation and temporal correlation for interlimb coordination. RESULTS: The patients showed significantly less efficient, less smooth, and less forceful movement and spent significantly more time for on-line error correction with the affected hand than the healthy controls. Interlimb coordination was disrupted at movement onset but was preserved at movement end in the hemiparetic patients. CONCLUSIONS: The major deficits of the left hemiparetic patients involved heavy reliance on feedback control with the affected hand, and poor bimanual coordination at movement onset, which might be specifically retrained during stroke rehabilitation. Preservation ofinterlimb coordination at movement end in stroke patients suggested that they retained flexibility in response to the impaired temporal performance of the affected hand to achieve the end goal.

Effects of object size on intralimb and interlimb coordination during a bimanual prehension task in patients with left cerebral vascular accidents.

Stroke patients are often left with hemiplegia or hemiparesis of the upper extremities, severely limiting the ability to perform bimanual and functional activities. No studies have investigated how stroke patients adapt their movements to changes in object size in functionally asymmetric bimanual tasks. The influence of object size on intralimb and interlimb coordination during an asymmetrical, functional bimanual task was examined in patients with left cerebral vascular accidents (LCVA) and healthy controls. Fourteen LCVA patients and 13 age-matched controls were instructed to reach to grasp a large and a small jar with the right/affected hand and to open the cap with the other hand. Movement kinematics was analyzed for intralimb coordination (spatial and temporal planning of reaching and grasping) and interlimb coordination (bimanual synchronization and temporal association of the hands). The results demonstrate a spatial adaptation of reaching in the affected hand to the object size and deficits in temporal planning of grasping with the affected hand to object size in the stroke patients. Movement adaptations of the unaffected hand in the stroke patients were similar to those in the healthy adults. Bimanual coordination was independent of object size for both groups.