Acromioclavicular joint reconstruction implants have differing ability to restore horizontal and vertical plane stability

Purpose Persistent acromioclavicular joint (ACJ) instability following high grade injuries causes significant symptoms. The importance of horizontal plane stability is increasingly recognised. There is little evidence of the ability of current implant methods to restore native ACJ stability in the vertical and horizontal planes. The purpose of this work was to measure the ability of three implant reconstructions to restore native ACJ stability. Methods Three groups of nine fresh-frozen shoulders each were mounted into a robotic testing system. The scapula was stationary and the robot displaced the clavicle to measure native anterior, posterior, superior and inferior (A, P, S, I) stability at 50 N force. The ACJ capsule, conoid and trapezoid ligaments were transected and the ACJ was reconstructed using one of three commercially available systems. Two systems (tape loop + screw and tape loop + button) wrapped a tape around the clavicle and coracoid, the third system (sutures + buttons) passed directly through tunnels in the clavicle and coracoid. The stabilities were remeasured. The data for A, P, S, I stability and ranges of A–P and S–I stability were analyzed by ANOVA and repeated-measures Student t tests with Bonferroni correction, to contrast each reconstruction stability versus the native ACJ data for that set of nine specimens, and examined contrasts among the reconstructions. Results All three reconstructions restored the range of A–P stability to that of the native ACJ. However, the coracoid loop devices shifted the clavicle anteriorly. For S–I stability, only the sutures + buttons reconstruction did not differ significantly from native ligament restraint. Conclusions Only the sutures + buttons reconstruction, that passed directly through tunnels in the clavicle and coracoid, restored all stability measures (A, P, S, I) to the native values, while the tape implants wrapped around the bones anteriorised the clavicle. These findings show differing abilities among reconstructions to restore native stability in horizontal and vertical planes. (300 words)

Rapid and Efficient Inactivation of SARS-CoV-2 from Surfaces using UVC Light Emitting Diode Device

Efforts are underway to develop countermeasures to prevent the environmental spread of COVID-19 pandemic caused by SARS-CoV-2. Physical decontamination methods like Ultraviolet radiation has shown to be promising. Here, we describe a novel device emitting ultraviolet C radiation (UVC), called NuvaWave, to rapidly and efficiently inactivate SARS-CoV-2. SARS-CoV-2 was dried on a chambered glass slides and introduced in a NuvaWave robotic testing unit. The robot simulated waving NuvaWave over the virus at a pre-determined UVC radiation dose of 1, 2, 4 and 8 seconds. Post-UVC exposure, virus was recovered and titered by plaque assay in Vero E6 cells. We observed that relative control (no UVC exposure), exposure of the virus to UVC for one or two seconds resulted in a >2.9 and 3.8 log10 reduction in viral titers, respectively. Exposure of the virus to UVC for four or eight seconds resulted in a reduction of greater than 4.7-log10 reduction in viral titers. The NuvaWave device inactivates SARS-CoV-2 on surfaces to below the limit of detection within one to four seconds of UVC irradiation. This device can be deployed to rapidly disinfect surfaces from SARS-CoV-2, and to assist in mitigating its spread in a variety of settings.

An Approach to Robotic Testing of the Wrist Using Three-Dimensional Imaging and a Hybrid Testing Methodology

Robotic technology is increasingly used for sophisticated in vitro testing designed to understand the subtleties of joint biomechanics. Typically, the joint coordinate systems in these studies are established via palpation and digitization of anatomic landmarks. We are interested in wrist mechanics in which overlying soft tissues and indistinct bony features can introduce considerable variation in landmark localization, leading to descriptions of kinematics and kinetics that may not appropriately align with the bony anatomy. In the wrist, testing is often performed using either load or displacement control with standard material testers. However, these control modes either do not consider all six degrees-of-freedom (DOF) or reflect the nonlinear mechanical properties of the wrist joint. The development of an appropriate protocol to investigate complexities of wrist mechanics would potentially advance our understanding of normal, pathological, and artificial wrist function. In this study, we report a novel methodology for using CT imaging to generate anatomically aligned coordinate systems and a new methodology for robotic testing of wrist. The methodology is demonstrated with the testing of 9 intact cadaver specimens in 24 unique directions of wrist motion to a resultant torque of 2.0 N·m. The mean orientation of the major principal axis of range of motion (ROM) envelope was oriented 12.1 ± 2.7 deg toward ulnar flexion, which was significantly different (p < 0.001) from the anatomical flexion/extension axis. The largest wrist ROM was 98 ± 9.3 deg in the direction of ulnar flexion, 15 deg ulnar from pure flexion, consistent with previous studies [1,2]. Interestingly, the radial and ulnar components of the resultant torque were the most dominant across all directions of wrist motion. The results of this study showed that we can efficiently register anatomical coordinate systems from CT imaging space to robotic test space adaptable to any cadaveric joint experiments and demonstrated a combined load-position strategy for robotic testing of wrist.

Enabling Performance Qualification of Additively Manufactured Parts Under Multiaxial Loading Emulating In-Service Conditions

The material imperfections generated by Additive Manufacturing (AM) processes across multiple scales can differ significantly from those arising by conventional manufacturing (CM) methods. To qualify these parts in a manner that accounts for all these imperfections without accounting explicitly for each of them, an outline of a rapid functional qualification methodology based on the concept of Performance Signature (PerSig) is presented first. The PerSigs are defined for both the prequalified CM parts and the AM-produced ones. Comparison measures are defined and enable the construction of differential PerSigs (dPerSig) in a manner that captures the differential performance of the AM part vs. the prequalified CM one. This approach is extended in this paper for the case of multiaxial loading conditions reflecting actual in-service loading. Application of the methodology is presented for a fitting bracket in the P-3C Orion aircraft platform and is based on synthetic data. The application of multiaxial loading emulating in-service loading conditions is proposed by the utilization of a custom-designed 6-DoF robotic testing system that will generate physical data.

Prediction of Anterior Cruciate Ligament Force Produced by Tibiofemoral Compression During Controlled Knee Flexion: A New Robotic Testing Methodology

Application of tibiofemoral compression force (TCF) has been shown to produce anterior cruciate ligament (ACL) injuries in a laboratory setting. A new robotic testing methodology was utilized to predict ACL forces generated by TCF without directly loading the ligament. We hypothesized that ACL force, directly recorded by a miniature load cell during an unconstrained test, could be predicted by measurements of anterior tibial restraining force (ARF) recorded during a constrained test. The knee was first flexed under load control with 25 N TCF (tibial displacements and rotations unconstrained) to record a baseline kinematic pathway. Tests were repeated with increasing levels of TCF, while recording ACL force and knee kinematics. Then tests with increasing TCF were performed under displacement control to reproduce the baseline kinematic pathway (tibia constrained), while recording ARF. This allowed testing to 1500 N TCF since the ACL was not loaded. TCF generated ACL force for all knees (n = 10) at 50 deg flexion, and for eight knees at 30 deg flexion (unconstrained test). ACL force (unconstrained test) and ARF (constrained test) had strong linear correlations with TCF at both flexion angles (R2 from 0.85 to 0.99), and ACL force was strongly correlated with ARF at both flexion angles (R2 from 0.76 to 0.99). Under 500 N TCF, the mean error between ACL force prediction from ARF regression and measured ACL force was 4.8±7.3 N at 30 deg and 8.8±27.5 N at 50 deg flexion. Our hypothesis was confirmed for TCF levels up to 500 N, and ARF had a strong linear correlation with TCF up to 1500 N TCF.

Talar Motion is Constrained by Tricortical Screw Fixation of the Syndesmosis: A Cadaveric Robotic Study

Objectives: High ankle sprains are a common injury that occur in up to 11% of ankle sprains. Injury to the structures of the syndesmosis, the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and interosseous membrane (IOM), has been shown to be predictive of residual symptoms after ankle injury. When the syndesmosis is unstable, it is typically treated surgically with cortical screw fixation or suture button fixation. Studies have shown that a 1 mm lateral shift of the talus relative to the tibia significantly decreases the tibiotalar contact area by 42%. Thus, restoring the tibiotalar kinematics to those of the intact ankle with appropriate fixation is important to avoid accelerated tibiotalar arthritis. The objective of this study was to quantify tibiotalar joint motion after syndesmotic screw and suture button fixation compared to the intact ankle. Methods: Nine fresh-frozen human cadaveric specimens (mean age 60 yrs.; range 38-73 yrs.) were tested using a six degree-of-freedom robotic testing system. The subtalar joint was fused and the tibia and calcaneus were rigidly fixed to a robotic manipulator, while fibular length was maintained and fibular motion was unconstrained. Talar motion with respect to the tibia was measured using the robotic testing system. A 5 Nm external rotation moment and 5 Nm inversion moment were applied independently to the ankle at 0°, 15°, and 30° plantarflexion and 10° dorsiflexion. Outcome variables included talar medial-lateral (ML) translation, anterior-posterior (AP) translation, and internal/external rotation relative to the tibia in the following syndesmosis states: 1) intact, 2) AITFL transected, 3) AITFL, PITFL, and IOM transected, 4) 3.5 mm cannulated tricortical screw fixation, and 5) suture button fixation. An ANOVA with a post-hoc Tukey analysis was performed for statistical analysis. Statistical significance was set at p < 0.05. Results: There were significant differences in ML translation of the talus relative to the tibia between the tricortical screw fixation and the intact ankle. These significant changes were only present during states with no loads applied. Tricotical screw fixation resulted in a significant decrease in medial translation of the talus compared to the intact ankle at 30° plantarflexion and increased lateral translation at 0° flexion (p < 0.05) (Figure 1). The talus moved 1.1 mm less medially at 30° plantarflexion and 0.4 mm more laterally at 0° flexion in the tricortical screw fixation state compared to the intact ankle. The total medial translation of the talus relative to the tibia during plantarflexion decreased from 1.1 mm to only 0.4 mm. No significant difference in AP translation or external rotation of the talus existed between the tricortical screw fixation and the intact ankle. No significant differences existed in translation or rotation of the talus between the suture button fixation and intact ankle at any ankle positions. Conclusion: Suture button fixation restored tibiotalar motion in all planes, with no significant differences compared to the intact ankle. Tricortical screw fixation significantly increased lateral shift of the talus in a neutral ankle position and constrained motion during plantarflexion compared to the intact ankle, which can lead to accelerated tibiotalar arthritis. Thus, physicians should consider hardware removal after tricortical screw fixation for syndesmotic repair to avoid post-traumatic arthritis. [Figure: see text]

Effect of Meniscal Ramp Repair on Knee Kinematics, ACL In Situ Force and Bony Contact Forces - A Biomechanical Study

Objectives: While recent studies showed that all inside meniscal ramp repair is able to restore knee kinematics, the effects of ramp repairs on ACL in-situ forces (ISF) and bony contact forces is still unclear. Therefore, the purpose of this study is to determine the effect of ramp lesion repair on knee kinematics, the ACL-ISF and bony contact forces using a 6-degree-of-freedom (DOF) robotic testing system. It was hypothesized that ramp repair will restore kinematics, ACL-ISF and bony contact forces comparably to the forces of the intact knee. Methods: 5 fresh-frozen human cadaveric knee specimens were tested using a 6-DOF robotic testing system (FRS2010) to continuously flex the knee from 0° to 90° and apply continuous loading conditions: 134 N anterior load + 200 N compressive load (CL), 4 Nm internal torque + 200 N CL, 4 Nm external torque + 200 N CL. Loading conditions were applied to the: 1) Intact knee 2) Arthroscopically induced 25 mm ramp lesion via posteromedial portal 3) All inside ramp repair 4) ACL deficient knee + ramp repair 5) soft tissue removal 6) Transection of the lateral condyle. To mimic an ideal ACL reconstruction the native ACL was kept intact. By replaying kinematics, ACL-ISF and bony contact forces were determined. Repeated measure ANOVAs were performed to compare knee states at each flexion angle (p<0.05). Results: Ramp repair significantly reduced anterior translation compared to the ramp deficient knee in high flexion under anterior load and CL (mean diff. -0.8 mm, range 0.6-0.9 mm) and at all flexions angles while applying internal torque and CL (mean diff. -2.3 mm, range 1.8-3.3 mm). Increased medial translation and valgus position were observed in all loading conditions at all flexion angles. Both ACL-ISF and medial bony contact forces were not significantly altered by the ramp lesion and repair under any applied loading and flexion angle. In contrast, ramp repair significantly increased lateral bony contact forces by under external torque and CL at 60° and 70° flexion compared to the ramp deficient knee, 32 N and 37 N respectively. No significant differences between intact and ramp deficient knee were detected with respect to kinematics, ACL-ISF and bony contact forces. Conclusion: In this study ramp repair decreased anterior translation, increased valgus rotation, and increased bony contact forces in the lateral compartment, disproving the hypothesis under study. The data from this study puts into question potential overconstraint when repairing ramp lesions utilizing all inside devices in 10 degrees of knee flexion. Contrasting previous literature that showed the restoration of the intact state, the results might be attributable to added CL forces and missing influence of the ACL reconstructions. The findings of this study also imply that untreated ramp lesion might not affect ACL-ISF. Future research is needed to better understand the influence of different techniques for repair of ramp lesions and the effect of chronicity on ramp lesions in patients.

Anterolateral Knee Extra-articular Stabilizers: A Robotic Sectioning Study of the Anterolateral Ligament and Distal Iliotibial Band Kaplan Fibers

Background: The individual kinematic roles of the anterolateral ligament (ALL) and the distal iliotibial band Kaplan fibers in the setting of anterior cruciate ligament (ACL) deficiency require further clarification. This will improve understanding of their potential contribution to residual anterolateral rotational laxity after ACL reconstruction and may influence selection of an anterolateral extra-articular reconstruction technique, which is currently a matter of debate. Hypothesis/Purpose: To compare the role of the ALL and the Kaplan fibers in stabilizing the knee against tibial internal rotation, anterior tibial translation, and the pivot shift in ACL-deficient knees. We hypothesized that the Kaplan fibers would provide greater tibial internal rotation restraint than the ALL in ACL-deficient knees and that both structures would provide restraint against internal rotation during a simulated pivot-shift test. Study Design: Controlled laboratory study. Methods: Ten paired fresh-frozen cadaveric knees (n = 20) were used to investigate the effect of sectioning the ALL and the Kaplan fibers in ACL-deficient knees with a 6 degrees of freedom robotic testing system. After ACL sectioning, sectioning was randomly performed for the ALL and the Kaplan fibers. An established robotic testing protocol was utilized to assess knee kinematics when the specimens were subjected to a 5-N·m internal rotation torque (0°-90° at 15° increments), a simulated pivot shift with 10-N·m valgus and 5-N·m internal rotation torque (15° and 30°), and an 88-N anterior tibial load (30° and 90°). Results: Sectioning of the ACL led to significantly increased tibial internal rotation (from 0° to 90°) and anterior tibial translation (30° and 90°) as compared with the intact state. Significantly increased internal rotation occurred with further sectioning of the ALL (15°-90°) and Kaplan fibers (15°, 60°-90°). At higher flexion angles (60°-90°), sectioning the Kaplan fibers led to significantly greater internal rotation when compared with ALL sectioning. On simulated pivot-shift testing, ALL sectioning led to significantly increased internal rotation and anterior translation at 15° and 30°; sectioning of the Kaplan fibers led to significantly increased tibial internal rotation at 15° and 30° and anterior translation at 15°. No significant difference was found when anterior tibial translation was compared between the ACL/ALL- and ACL/Kaplan fiber–deficient states on simulated pivot-shift testing or isolated anterior tibial load. Conclusion: The ALL and Kaplan fibers restrain internal rotation in the ACL-deficient knee. Sectioning the Kaplan fibers led to greater tibial internal rotation at higher flexion angles (60°-90°) as compared with ALL sectioning. Additionally, the ALL and Kaplan fibers contribute to restraint of the pivot shift and anterior tibial translation in the ACL-deficient knee. Clinical Relevance: This study reports that the ALL and distal iliotibial band Kaplan fibers restrain anterior tibial translation, internal rotation, and pivot shift in the ACL-deficient knee. Furthermore, sectioning the Kaplan fibers led to significantly greater tibial internal rotation when compared with ALL sectioning at high flexion angles. These results demonstrate increased rotational knee laxity with combined ACL and anterolateral extra-articular knee injuries and may allow surgeons to optimize the care of patients with this injury pattern.