New evaluation indices for rotational knee angles in standing anteroposterior knee radiographs

BACKGROUND: Identifying the time course of rotational knee alignment is crucial for elucidating the etiology in knee osteoarthritis. OBJECTIVE: The aim of this study was to propose new rotational indices for calculating the change in relative rotational angles between the femur and tibia in standing anteroposterior (AP) radiographs. METHODS: Forty healthy elderly volunteers (20 women and 20 men; mean age, 70 ± 6 years) were assessed. The evaluation parameters were as follows: (1) femoral rotational index: the distance between the sphere center of the medial posterior femoral condyle and the lateral edge of the patella, and (2) tibial rotational index: the distance between the medial eminence of the tibia and the lateral edge of the fibula head. The indices were standardized by the diameter of the sphere of the medial posterior femoral condyle. This study (1) identified the relationship between changes in rotational indices and the simulated rotational knee angles in the standing position, (2) proposed a regression equation for the change in relative rotational angles between the femur and tibia in standing AP radiographs, and (3) verified the accuracy of the regression equation. RESULTS: The rotational indices increased in direct proportion to simulated rotational knee angles (femoral index: r > 0.9,p < 0.0001; tibial index: r > 0.9, p < 0.0001). Based on the results, the regression equation with the accuracy of 0.45 ± 0.26° was determined. CONCLUSIONS: The proposed regression equations can potentially predict the change in relative rotational angles between the femur and tibia in a pair of standing AP radiographs taken at different dates in longitudinal studies.

The effect of surgical decompression on symptoms in peroneal nerve entrapment neuropathy

Objective CPN entrapment neuropathy is a form of lower extremity entrapment, most commonly seen at the level of the fibula head, often presenting with foot drop findings. We aimed to investigate whether decompressive surgical intervention contributes to neuropathy clinic. Materials and methods Patients who were admitted to our clinic with a preliminary diagnosis of peroneal entrapment neuropathy and underwent surgical intervention were included in the study. Preoperative and postoperative motor functions and pain were evaluated. Results Postoperative significant changes in pain and muscle strength scores were observed. A significant decrease was observed in the postoperative VAS score. Conclusion Surgical decompression is the right option for the recovery of motor function in the treatment of peroneal nerve entrapment neuropathy.

Bilateral Avulsion Fracture of the Fibula Head of the Knee Associated with Avulsion Fracture of the Iliotibial Band: A Rare Case of Fracture Segond Associated with Arcuate Fracture

Fibular head avulsion fractures are rare and are so-called the arcuate signal. Avulsion fracture of the iliotibial band and anterolateral ligament is known as a Segond fracture, and it is another rare entity. We describe the case of a 27-year-old woman who was hit by a car and suffered polytrauma, mainly suffering injuries to both knees. Radiographs of the knees showed a Segond fracture associated with the arched signal bilaterally. The aim of this study is to present a rare case report and literature review of a bilateral fibular head avulsion fracture associated with an anterolateral tibial avulsion fracture.

Level options for the formation and branching of the common peroneal nerve

The study of topographic and anatomical features of the common peroneal nerve and its main branches was performed on 72 lower extremities of adult corpses. Morphoscopic and morphometric established that the higher the level of development of the common peroneal nerve, the greater the diameter, it has held more distance to the branch of the lateral cutaneous nerve of the calf. The average value of the diameter of the common peroneal nerve at the place of formation is10,1±2,8 mm. Differences in the level of development of the common peroneal nerve play an important role in the evaluation of the clinical picture of his injuries. In the «high» version of the formation, the probability of isolated damage to the common peroneal nerve is higher with trauma to the upper and middle third of the thigh. In this embodiment, the formation between the tibial and the common peroneal nerve revealed «anastomoses». Their presence helps to explain the possible dissonance between the clinical picture and the anatomical substrate of the lesion. It is shown that the lower the level of nerve formation, the greater the angle at which the nerve departs. The loose type of branching of the common peroneal nerve at the level of the head of the fibula does not allow adequate mobilization of the nerve in this area. This, in turn, does not allow intraoperatively overcome diastasis with nerve injury at the level of the fibula head. The surface location of the nerve, as well as its immobility in this place cause a high risk of compression-ischemic neuropathy. These features of the formation and variant anatomy of the common peroneal nerve explain a small percentage of favorable outcomes of surgical treatment of lesions of the common peroneal nerve and its main branches. The obtained morphometric data should be used as an indicator of the range of anatomical norms in the conduct of neuroimaging examination techniques (ultrasound, magnetic resonance) in the diagnosis of damage to the common peroneal nerve.

Safety and tolerability of cryocompression as a method of enhanced limb hypothermia to reduce taxane-induced peripheral neuropathy

Purpose Severe peripheral neuropathy is a common dose-limiting toxicity of taxane chemotherapy, with no effective treatment. Frozen gloves have shown to reduce the severity of neuropathy in several studies but comes with the incidence of undesired side effects such as cold intolerance and frostbite in extreme cases. A device with thermoregulatory features which can safely deliver tolerable amounts of cooling while ensuring efficacy is required to overcome the deficiencies of frozen gloves. The role of continuous-flow cooling in prevention of neurotoxicity caused by paclitaxel has been previously described. This study hypothesized that cryocompression (addition of dynamic pressure to cooling) may allow for delivery of lower temperatures with similar tolerance and potentially improve efficacy. Method A proof-of-concept study was conducted in cancer patients receiving taxane chemotherapy. Each subject underwent four-limb cryocompression with each chemotherapy infusion (three hours) for a maximum of 12 cycles. Cryocompression was administered at 16 °C and cyclic pressure (5–15 mmHg). Skin surface temperature and tolerance scores were recorded. Neuropathy was assessed using clinician-graded peripheral sensory neuropathy scores, total neuropathy score (TNS) and nerve conduction studies (NCS) conducted before (NCSpre), after completion (NCSpost) and 3 months post-chemotherapy (NCS3m). Results were retrospectively compared with patients who underwent paclitaxel chemotherapy along with continuous-flow cooling and controls with no hypothermia. Results In total, 13 patients underwent 142 cycles of cryocompression concomitant with chemotherapy. Limb hypothermia was well tolerated, and only 1 out of 13 patients required an intra-cycle temperature increase, with no early termination of cryocompression in any subject. Mean skin temperature reduction of 3.8 ± 1.7 °C was achieved. Cryocompression demonstrated significantly greater skin temperature reductions compared to continuous-flow cooling and control (p < 0.0001). None of the patients experienced severe neuropathy (clinician-assessed neuropathy scores of grade 2 or higher). NCS analysis showed preservation of motor amplitudes at NCS3m in subjects who underwent cryocompression, compared to the controls who showed significant deterioration (NCS3m cryocompression vs. NCS3m control: ankle stimulation: 8.1 ± 21.4%, p = 0.004; below fibula head stimulation: 12.7 ± 25.6%, p = 0.0008; above fibula head stimulation: 9.4 ± 24.3%, p = 0.002). Cryocompression did not significantly affect taxane-induced changes in sensory nerve amplitudes. Conclusion When compared to continuous-flow cooling, cryocompression permitted delivery of lower temperatures with similar tolerability. The lower skin surface temperatures achieved potentially lead to improved efficacy in neurotoxicity amelioration. Larger studies investigating cryocompression are required to validate these findings.

Predictive prosthetic socket design: part 2—generating person-specific candidate designs using multi-objective genetic algorithms

In post-amputation rehabilitation, a common goal is to return to ambulation using a prosthetic limb, suspended by a customised socket. Prosthetic socket design aims to optimise load transfer between the residual limb and mechanical limb, by customisation to the user. This is a time-consuming process, and with the increase in people requiring these prosthetics, it is vital that these personalised devices can be produced rapidly while maintaining excellent fit, to maximise function and comfort. Prosthetic sockets are designed by capturing the residual limb’s shape and applying a series of geometrical modifications, called rectifications. Expert knowledge is required to achieve a comfortable fit in this iterative process. A variety of rectifications can be made, grouped into established strategies [e.g. in transtibial sockets: patellar tendon bearing (PTB) and total surface bearing (TSB)], creating a complex design space. To date, adoption of advanced engineering solutions to support fitting has been limited. One method is numerical optimisation, which allows the designer a number of likely candidate solutions to start the design process. Numerical optimisation is commonly used in many industries but not prevalent in the design of prosthetic sockets. This paper therefore presents candidate shape optimisation methods which might benefit the prosthetist and the limb user, by blending the state of the art from prosthetic mechanical design, surrogate modelling and evolutionary computation. The result of the analysis is a series of prosthetic socket designs that preferentially load and unload the pressure tolerant and intolerant regions of the residual limb. This spectrum is bounded by the general forms of the PTB and TSB designs, with a series of variations in between that represent a compromise between these accepted approaches. This results in a difference in pressure of up to 31 kPa over the fibula head and 14 kPa over the residuum tip. The presented methods would allow a trained prosthetist to rapidly assess these likely candidates and then to make final detailed modifications and fine-tuning. Importantly, insights gained about the design should be seen as a compliment, not a replacement, for the prosthetist’s skill and experience. We propose instead that this method might reduce the time spent on the early stages of socket design and allow prosthetists to focus on the most skilled and creative tasks of fine-tuning the design, in face-to-face consultation with their client.

Avaliação postural em membros inferiores de escolares por meio da biofotogrametria

Introdução: Este estudo preocupou-se com o tema postura corporal em escolares com 10 a 15 anos de idade da rede pública de ensino do município de Águia Branca (ES). Objetivo: avaliar membros inferiores de escolares de 10 a 15 anos de idade de ambos os sexos. Métodos: foram demarcados pontos anatômicos localizados em membros inferiores (espinha ilíaca ântero-superior, trocânter maior do fêmur, cabeça da fíbula, ponto médio da patela, tuberosidade da tíbia, maléolos medial e lateral, e ponto entre o segundo e terceiro osso metatarsal) seguidos de fotografias (biofotogrametria). Em seguida foi utilizado o Software para a Avaliação Postural (SAPO) para realizar a análise das fotografias. Resultados: verificou-se que os desvios mais frequentes foram o desnível do quadril, joelho valgo e joelho flexo. Houve maior frequência de desvios no joelho no sexo feminino e de desvios no quadril no sexo masculino (apesar de ambos os sexos apresentarem porcentagem altas nas duas localidades de desvios). Conclusão: é sugestivo que as escolas e os professores, não apenas do município estudado, trabalhem com propostas de prevenção de tais desvios, pois a partir destes, outras alterações (articulares, musculares ou em forma de desvios) poderão surgir ao longo de suas vidas.ABSTRACT. Postural evaluation in lower limbs of schoolchildren by biophotogrammetry. Introduction: this study was concerned with the theme of corporal posture in students aged 10 to 15 years of age in the public school system of the city Águia Branca-ES. Objective: to evaluate the lower members of schoolchildrens between 10 and 15 years of age of both genders. Methods: anatomical points were demarcated in lower members (antero-superior iliac spine, bigger trochanter of the femur, fibula head, mid-point of the patella, tuberosity of the tibia, medial and lateral malleoli, and point between the second and third metatarsal bones), and then photographed (biophotogrammetry). After, using the Posture Assessment Software (PAS/SAPO) to perform the analysis of the photographs. Results: it was verified that the most frequent deviations were the hip drop, valgus knee and flex knee. There was a higher frequency of female knee deviations and hip deviations in males (although both genders presented high percentage in the two deviation locations). Conclusion: It is suggestive that schools and teachers, not only in the city studied, work with proposals to prevent such deviations, since from these, other changes (joint, muscle or in the form of deviations) may arise throughout their lives.

Minimizing Pain in Below Knee Amputees’ Patients Wearing Prosthetic Socket by Increasing Flexibility in Specific Relief Areas

Background: Pressure distribution for transtibial amputees (TTA) patients varies at the limb socket interface according to several factors. Although socket technology is getting more advanced, the majority of researchers are still facing problems with relief areas. Objectives: This study focused on the theoretical and experimental aspects of the design to figure out patients’ sensitivity to pain when wearing sockets. Relief areas were analyzed using data collected from patients’ centers and optimized under different static and dynamic conditions. Methods: Finite element trials and DOE optimization using Design Expert 8 software and analysis of variance (ANOVA) revealed that holes with relief areas are appropriates for lower extremities patients where scanning electron images (SEM) of the worn areas show direct relations between relieved sockets with holes at fibula head (FH) and patient lifestyle and activity. Clinical Relevance: A patient that moves rather slowly, as a result of old age or sedentary level of activity would greatly benefit from the FH socket hole implementation, and thus reduces the wear of socket materials after longer period of time and increases the level of comfort of patient skins. the interviews conducted were evident that patients endured pain at the PT and FH. Moreover, further studies were performed on the FH, and results revealed that lateral forces play a major role and is influenced by the lifestyle of the patient.

Fibular epiphyseal transfer: the peroneal vessels revisited

The case of a seven-year-old boy with a Ewing’s sarcoma of the humerus diaphysis extending into the epiphysis proximally. He underwent chemotherapy followed by 12 cm resection of the proximal humerus with preservation of rotator cuff. Reconstruction was performed using a 15 cm vascularized fibula epiphyseal transfer raised using a postero-lateral approach based on the peroneal artery and its venae commitans. The common peroneal nerve was protected proximally and all motor branches were preserved. The pedicle length was 7cm. When isolated on the peroneal artery, bleeding was seen at the level of the epiphysis and periosteum of the fibula head.