Flexion Position Research Articles

Articulation of the femoral condyle during knee flexion

Femoral condyle motion of the knee is generally reported using a morphological trans-epicondyle axis (TEA) or geometric center axis (GCA) in the investigation of the knee kinematics. Axial rotation of the femur is recognized as a characteristic motion of the knee during flexion, but is controversial in the literature. This study investigated the biomechanical factors that could be associated to the axial rotations of the femur using both physiological and morphological measurement methods. Twenty healthy knees were investigated during a weightbearing flexion from 0° to 120° at a 15° increment using an imaging technique. A 3D model was constructed for each knee using MR images. Tibiofemoral cartilage contact points were determined at each flexion position to represent physiological knee motion. The contact distance on each condyle was measured between consecutive contact points. The TEA and GCA were used to measure morphological anteroposterior translations of the femoral condyles. The differences between the medial and lateral condyle motions were used to calculate the physiological and morphological axial rotations of the femur. Both the physiological and morphological methods measured external rotations of the femur at low flexion range (0°-45°) and minimal rotations at higher flexion angles. However, the morphological method measured larger posterior translations of the lateral femoral condyle than the medial condyle (p < 0.05), implying a medial pivoting rotation; in contrast, the physiological method measured larger contact distances on the medial condyle than on the lateral condyle (p < 0.05), implying a lateral pivoting rotation. These data could provide useful references for future investigation of kinematics of the knee before and after surgical repair, such as using total knee arthroplasty.

Role of Pre-operative Intravenous Methylprednisolone for Post-operative Pain Control after IFF Surgery

Background: Intertrochanteric region are common in older ages. 33% females and 15% males in their 90s suffer from hip fracture, most commonly intertrochanteric fractures (50%). The pain associated with the surgery of the intertrochanteric fractures is quite troublesome and reduces patient mobilization thus increasing morbidity. Aim: To compare preoperative intravenous methylprednisolone vs control in terms of mean VAS score in patients presenting with intertrochanteric femur fractures. Study design: Randomized control trial Place and duration of study: Orthopaedic Department &amp; General Surgery Department POF Hospital Wah Cantt and Izzat Ali Shah Hospital Wah Cantt from 1st Jan 2020 till 31st Dec 2020 Methodology: Sixty patients were enrolled and divided in two groups. Thirty patients in methylprednisolone group and 30 patients in control Group were enrolled. Age 40-75 years old people of both genders with intertrochanteric femur fractures were included. Post-operative pain was recorded at resting position and 45° hip flexion position 24 hours post-surgery through VAS. Results: In group A, 18 patients were males and 12 were female. In group B 19 patients were male and 11 were female. Mean age in group A was 56.37±4.56 years and in group B, 55.89±4.13 years. Mean VAS pain score in the control group was 5.03±1.542 while the mean VAS pain score in the treatment group was 3.70±15.79 (P=0.002). Conclusion: Methylprednisolone preoperatively reduces postoperative pain at 24 hours after surgery in patients undergoing intertrochanteric fracture fixation. Keywords: Methylprednisolone, Preoperative, Visual Analogue Scale, Pain, Postoperative’

The Influence of Ankle Position on Radiographic Diagnosis of Acute Achilles Tendon Rupture

No previous study has demonstrated the relationship between the ankle position and radiographic diagnosis of acute Achilles tendon rupture. The purpose of this study was to investigate the influence of ankle position in the presence of diagnostic radiographic signs in acute Achilles tendon rupture. A retrospective review of 154 ankle lateral radiographs of acute Achilles tendon rupture was performed. Ankle position was classified as dorsiflexion, neutral, or plantar flexion by measurement of the tibiotalar angle. Kager's triangle, Toygar's angle, Arner's sign, and thickening of the Achilles tendon were assessed as diagnostic radiographic signs, and their relations to ankle position were analyzed. Interobserver reliabilities of radiographic signs were moderate to substantial (kappa value, range 0.41-0.68). All 4 signs were significantly more visible in ankle plantar flexion than dorsiflexion. The presence of Toygar's angle and positive Arner's sign were significantly increased in ankle plantar flexion compared to neutral, while the presence of Kager's triangle, and thickening of the Achilles tendon did not differ according to ankle position. The diagnostic radiographic signs of acute Achilles tendon rupture were better presented in ankle plantar flexion position than neutral and dorsiflexion positions. Neutral and dorsiflexion ankle positions should be avoided when performing lateral radiographs of patients with suspected acute Achilles tendon rupture.

Effects of cervical rotatory manipulation on the cervical spinal cord: a finite element study

BackgroundLittle information is available concerning the biomechanism involved in the spinal cord injury after cervical rotatory manipulation (CRM). The primary purpose of this study was to explore the biomechanical and kinematic effects of CRM on a healthy spinal cord.MethodsA finite element (FE) model of the basilaris cranii, C1–C7 vertebral bodies, nerve root complex and vertebral canal contents was constructed and validated against in vivo and in vitro published data. The FE model simulated CRM in the flexion, extension and neutral positions. The stress distribution, forma and relative position of the spinal cord were observed.ResultsLower von Mises stress was observed on the spinal cord after CRM in the flexion position. The spinal cord in CRM in the flexion and neutral positions had a lower sagittal diameter and cross-sectional area. In addition, the spinal cord was anteriorly positioned after CRM in the flexion position, while the spinal cord was posteriorly positioned after CRM in the extension and neutral positions.ConclusionCRM in the flexion position is less likely to injure the spinal cord, but caution is warranted when posterior vertebral osteophytes or disc herniations exist.

Effects of passive exoskeleton support on EMG measures of the neck, shoulder and trunk muscles while holding simulated surgical postures and performing a simulated surgical procedure

Exoskeletons have shown significant impact at reducing the biomechanical demand on muscles during repetitive lifting and overhead tasks in non-healthcare industries. However, the benefits of exoskeletons are yet to be realized in the operating room, particularly as work-related musculoskeletal disorders continue to be a concern for surgeons. This study quantified the effect of using neck, arm, and trunk exoskeletons on muscle activity while assuming typical postures held in the operating room. Fourteen participants were recruited to participate in this study. In this two-part experiment participants were asked to 1) hold a series of neck flexion, arm abduction and trunk flexion postures seen in surgical procedures, and 2) perform a simulated surgical task requiring five different trunk flexion posture levels. Participants were required to complete these tasks with and without passive exoskeleton(s). This study showed that even for postures held short time periods, exoskeletons are beneficial at reducing the demand on muscles; however, the reduction in muscle demand depends on body segment and postural angle, as intended with these passive exoskeletons. Furthermore, for the simulated surgical task with awkward trunk flexion postures (10–65°), the trunk exoskeletons showed a significant reduction in the rate of rise in back muscle sEMG (+1.365%MVC/min vs. +0.769%MVC/min for non-dominant lumbar extensor muscles, p = 0.0108; +1.377%MVC/min vs. +0.770%MVC/min for the dominant lumbar extensor muscles, p = 0.0196) over 25 min, consequently resulting in improved trunk subjective discomfort scores (7.34 vs. 4.30, p < 0.05), with no impact on the neck and shoulder biomechanical demand. The results from this study indicate that exoskeletons may be a potential intervention to reduce biomechanical loading during surgery.

Effect of different attributes of the mimic human lumbar spine biomechanics material structure change by finite element analysis

In this study, we compared stress changes and quantity effect relationships from 3D finite element models of normal and degenerative lumbar segments. We further defined the mechanisms causing alterations in mechanical stability the control of normal and degenerative lumbar segments using traditional Chinese medicine. The characteristics of the stress change and the quantity effect relationships of the three-dimensional finite element model of normal and degenerative lumbar segments were compared. The mechanism(s) leading to changes in mechanical stability and the intervention and balance between normal and degenerative lumbar segments of the traditional Chinese medicine was analyzed. The change trend of stress and strain was compared with the three dimensional finite element model under different motion states of normal lumbar vertebrae. A 3D-FEM of degenerative lumbar segments L4 ~ 5 of the human spine was established to simulate the physiological and pathological changes of the lumbar spine in response to flexion, extension, lateral bending and torsion. The stress changes in the normal and degenerative lumbar vertebrae were assessed through external force interventions and the response to TCM. Stress in the degenerative lumbar vertebrae changed according the external load. Stress and strain were compared in the FEM model under a range of motion states. Components of the human lumbar vertebrae including the cortical vertebrae, cancellous bone, endplates, fibrous rings, and facet articular processes were investigated. The elastic modulus of the nerve roots and the posterior marginal structures of the vertebral body increased with lumbar degeneration. Under stress trends in normal lumbar and different degrees of degenerative lumbar structures including cortical bone, loose bone, terminal plate, fiber ring, nucleus, small articular processes, nerve roots and posterior structures. In normal lumbar spine, 20%, 50%, 70% lumbar degeneration, 106 different lumbar anterior flexion 30 and posterior extension with different external forces showed that ANOVA F was between 3.623 and 11.381 and P changed between 0.001 and 0.05.It is clear that in the lumbar movement segments under different pressure intervention, the changes in the degree of degeneration are significantly different from each constituent structure, among which the trend of expected change between the constituent structures of the lumbar anterior flexion 30 is particularly obvious. The stress distribution in the intervertebral discs were influenced by TCM, and the space in the spinal canal enlarged so that nerve root stress decreased, vertebral body stress increased, and facet processes and pedicle stress in the posterior regions exceeded those of the anterior flexion position. The internal stress of the intervertebral disc increased in the flexion compared to the extension position, gradually increasing from top to bottom. The stress concentration point of the degenerative lumbar disc is significantly greater than the stress in the normal lumbar disc stress distribution area, and increases with the degree of degeneration. Compared with the load capacity of normal lumbar and mild (15% reduction), moderate (40% reduction) lumbar disc protrusion model in bending, extension, axial rotation, lateral bending, the results found that the load transmission of lumbar disc degeneration model to different degrees has also changed, so its compression stiffness, strain distribution and size are also different. TCM can improve and treat lumbar disc disease through its ability to regulate the mechanical environment of degenerative lumbar vertebrae. Compared to the FEM models of the lumbar vertebrae, lumbar degenerative changes could be assessed in response to alterations in the biomechanical environment. These findings provide a scientific basis for the popularization and application of TCM to prevent and treat spinal degenerative disease.

Determining the Delay Time of the Muscles Around the Knee Joint in Response to Rotational Perturbation From Support Surface

Introduction: Knee joint injuries usually occur in a short time, so analyzing the mechanism and process of this short time can be helpful to prevent similar injuries. This study aimed to determine and compare the reaction time of knee muscles and investigate the effect of knee position and perturbation direction on the reaction time of knee muscles in response to horizontal rotational perturbation applied to lower leg from support surface area. Materials and Methods: A total of 30 healthy women volunteers were received ±35 degrees of horizontal rotational perturbation and speed of 120 degrees per second from the sole while standing on the right leg in four conditions (external versus internal rotation of surface while the knee was in both extension and flexion position). Electromyography of knee muscles (vastus medialis and lateralis, medial and lateral hamstring and medial and lateral gastrocnemius) was measured to study the reaction time. Results: The reaction time of knee muscles during the perturbation was relatively long in this study (124 to 151 ms). It seems that muscles are recruited simultaneously in most conditions except in external rotation perturbation, with extension knee that the internal gastrocnemius muscle had significantly less delay time than the internal hamstring (P&lt;0.05) and external quadriceps (P&lt;0.05). The results show that most of these muscles do not react selectively and dependently on perturbation direction and knee position in response to horizontal rotational perturbation. Conclusion: In this study, little difference was seen in the reaction time of most knee muscles in all conditions. Thus in response to this type of perturbation, the knee muscles showed co-contraction.

A tensor with a flat surface overestimates midflexion laxity in total knee arthroplasty: Comparison between a tensor with a flat-shaped surface and a tensor with an insert-shaped surface

BackgroundSoft tissue balance is important for the success of total knee arthroplasty (TKA). Various types of tensors have been developed for the precise measurement of a gap. We hypothesized that the surface shape of the tensor that contacted the TKA component affected the gap measurement. This study aimed to compare the gaps obtained with flat and insert-shaped surface tensors. MethodsTwo senior surgeons performed 95 TKAs (Vanguard-PS:55 knees; Persona-PS:40 knees). The joint gap was measured in each static knee flexion status (0°, 30°, 45°, 60°, 90°, 120°, and full flexion). We compared the gaps measured with a flat surface tensor and an insert-shape surface tensor. We defined a significant change as a gap difference of >1 mm with a statistical significance. ResultsIn Vanguard-PS, significant changes were observed at 30° and 45°. In Persona-PS, significant changes were observed at 30°, 45°, and 60°. In both implants, gaps measured with the flat tensor were larger than those measured with the insert tensor at approximately midflexion, and the significant changes disappeared in higher flexion position over midflexion. ConclusionsThe surface shape of the tensor affected the measurement of midflexion laxity in TKA. When measuring the gap with a flat tensor, the midflexion laxity was overestimated. A tensor with an insert-shaped surface should be used to measure the gap in TKA.

Changing the pattern of the back-muscle flexion-relaxation phenomenon through flexibility training in relatively inflexible young men.

Although several studies have investigated the back-muscle flexion–relaxation phenomenon (FRP), the effect of individual flexibility on the FRP has been discussed infrequently, with very limited data on the influence of flexibility training on the FRP. This study thus examined the effect of flexibility training on the change of back-muscle FRP pattern in relatively inflexible young men. We collected and analyzed the valid data from 20 male participants (10 each with high and low flexibility included in the control and trained groups, respectively) when flexing their trunks at seven trunk flexion positions (0°–90°, in increments of 15°); their erector spinae and hamstring activation, pelvic tilt, and lumbosacral angle were then recorded. After 7 weeks of flexibility training for the low-flexibility group, no difference in flexibility was discovered between this group and the control (originally high-flexibility) group. The trunk flexion experiment was then repeated. The results showed that before the training stage, the low-flexibility group had lower erector spinae and higher hamstring activation, a larger pelvic tilt, and a smaller lumbosacral angle. By contrast, after training, the erector spinae and hamstring activation, pelvic tilt, and lumbosacral angle were significantly changed, and no intergroup differences were observed in FRP patterns. The study results suggest that flexibility training changes lumbopelvic movement and thereby reduces the degree of the back-muscle FRP when trunk flexion is performed.

The effect of osteochondral lesion size and ankle joint position on cartilage behavior - numerical and in vitro experimental results

Osteochondral lesion of the talus is defined as damage in the cartilage that covers the talus bone, compromising the integrity of the joint in the long term. Due to the low incidence of this pathology, there are few studies to understand the importance of lesion size and position in cartilage strains. The purpose of this study is then to analyze the influence of the lesion size in joint behavior.A 3D virtual and in vitro model of a patient's injured ankle joint was developed. The models were built using CT scan and MRI images, to obtain the CAD models of intact and with 10 mm lesion size for 3D print models using additive manufacturing. The physical model was tested with 685N applied vertically to determine experimentally the principal strains and contact pressures in the cartilage. Five finite element models were developed with lesion dimensions (5 to 20 mm) and with 3 ankle joint positions.The numerical and experimental results were correlated with an R2 = 0.86 justified by the complexity of the model geometry. The maximum principal strain was 2566µε in the plantar flexion position without lesion. The experimental contact area between cartilages increased by 1.2% in the 10 mm lesion size for 431 mm2. The maximum stress in the cartilage was observed for a 20 mm lesion size with 2.5 MPa.The 5 and 10 mm sizes present similar results; the 15 mm lesion size presents a stress increase of 13% comparatively with 10 mm. Plantar flexion seems to be the most critical configuration; stress increases with an increase of lesion size around the cartilage.

Open MRI assessment of anterior femoroacetabular clearance in active and passive impingement-provoking postures.

AimsCam and pincer morphologies are potential precursors to hip osteoarthritis and important contributors to non-arthritic hip pain. However, only some hips with these pathomorphologies develop symptoms and joint degeneration, and it is not clear why. Anterior impingement between the femoral head-neck contour and acetabular rim in positions of hip flexion combined with rotation is a proposed pathomechanism in these hips, but this has not been studied in active postures. Our aim was to assess the anterior impingement pathomechanism in both active and passive postures with high hip flexion that are thought to provoke impingement.MethodsWe recruited nine participants with cam and/or pincer morphologies and with pain, 13 participants with cam and/or pincer morphologies and without pain, and 11 controls from a population-based cohort. We scanned hips in active squatting and passive sitting flexion, adduction, and internal rotation using open MRI and quantified anterior femoroacetabular clearance using the β angle.ResultsIn squatting, we found significantly decreased anterior femoroacetabular clearance in painful hips with cam and/or pincer morphologies (mean -11.3° (SD 19.2°)) compared to pain-free hips with cam and/or pincer morphologies (mean 8.5° (SD 14.6°); p = 0.022) and controls (mean 18.6° (SD 8.5°); p < 0.001). In sitting flexion, adduction, and internal rotation, we found significantly decreased anterior clearance in both painful (mean -15.2° (SD 15.3°); p = 0.002) and painfree hips (mean -4.7° (SD 13°); p = 0.010) with cam and/pincer morphologies compared to the controls (mean 7.1° (SD 5.9°)).ConclusionOur results support the anterior femoroacetabular impingement pathomechanism in hips with cam and/or pincer morphologies and highlight the effect of posture on this pathomechanism.Cite this article: Bone Jt Open 2021;2(11):988–996.

Abdominal tendon reflexes in lesions of the pyramidal tract

Abdominal tendon reflexes were studied in Th. Dosuzkov and Fr. Bodlakova (Revue v. Neurologii i psychiatrii, 1928, no. 4). They find the reflex of the rectus abdominis muscles described by Astvatsaturov not only in paraplegia (and hemiplegia) with the lower limbs in the extension position (Erb'a type), but also in the flexion position (Babinsky type).

Investigating the role of low level reinforcement reflex loops in insect locomotion

Insects are highly capable walkers, but many questions remain regarding how the insect nervous system controls locomotion. One particular question is how information is communicated between the ‘lower level’ ventral nerve cord (VNC) and the ‘higher level’ head ganglia to facilitate control. In this work, we seek to explore this question by investigating how systems traditionally described as ‘positive feedback’ may initiate and maintain stepping in the VNC with limited information exchanged between lower and higher level centers. We focus on the ‘reflex reversal’ of the stick insect femur-tibia joint between a resistance reflex (RR) and an active reaction in response to joint flexion, as well as the activation of populations of descending dorsal median unpaired (desDUM) neurons from limb strain as our primary reflex loops. We present the development of a neuromechanical model of the stick insect (Carausius morosus) femur-tibia (FTi) and coxa-trochanter joint control networks ‘in-the-loop’ with a physical robotic limb. The control network generates motor commands for the robotic limb, whose motion and forces generate sensory feedback for the network. We based our network architecture on the anatomy of the non-spiking interneuron joint control network that controls the FTi joint, extrapolated network connectivity based on known muscle responses, and previously developed mechanisms to produce ‘sideways stepping’. Previous studies hypothesized that RR is enacted by selective inhibition of sensory afferents from the femoral chordotonal organ, but no study has tested this hypothesis with a model of an intact limb. We found that inhibiting the network’s flexion position and velocity afferents generated a reflex reversal in the robot limb’s FTi joint. We also explored the intact network’s ability to sustain steady locomotion on our test limb. Our results suggested that the reflex reversal and limb strain reinforcement mechanisms are both necessary but individually insufficient to produce and maintain rhythmic stepping in the limb, which can be initiated or halted by brief, transient descending signals. Removing portions of this feedback loop or creating a large enough disruption can halt stepping independent of the higher-level centers. We conclude by discussing why the nervous system might control motor output in this manner, as well as how to apply these findings to generalized nervous system understanding and improved robotic control.

Dystocia due to breech presentation and caesarean under local anaesthesia and sedation in a mare

A nulliparous non-descript mare presented at full term with a history of straining (utero-abdominal contractions) for the last 24 hours. Vaginal examination revealed a dead foal in posterior presentation with bilateral hip flexion and dorso-iliac left position. Pre-operatively, 5 mL Tetanus toxoid as intramuscular injection, 3g Ceftriaxone and 4 mL Dexamethasone in 3L 5% Dextrose normal saline (DNS) as intravenous infusion (i/v) was administered. The per-vaginal delivery of the foal could not be attempted due to breech presentation, therefore, caesarean section was planned. Local anaesthetic infiltration along with sedation was done for carrying out the caesarean by employing an oblique ventro-lateral approach in lateral recumbency. Intravenous fluids, anti-inflammatory drugs and daily antiseptic dressing were included in post-operative management and led to uneventful recovery of mare. The authors would like to perorate the case as a rare breech presentation induced dystocia in equine and emergency caesarean by employing an oblique ventro-lateral approach under local anaesthesia and sedation.

Small Non-Rigid Variations Can Assist Robust IMPT Plan Selection for Head and Neck Patients

Interfraction anatomical variability increases dosimetric discrepancy during delivery of intensity-modulated proton therapy (IMPT). Small non-rigid variations (sNRVs) such as neck extension, spinal flexion, jaw and shoulder position occur during IMPT for head & neck cancer. We assess dosimetric discrepancies caused by sNRVs and suggest a population-based model to incorporate sNRVs into robust evaluation of IMPT plans.A total of 20 nasopharynx and 15 oropharynx radiotherapy patients were retrospectively analyzed, each with weekly CT scans. Anatomical variations during the first week of treatment are predominately due to sNRV, when progressive changes (weight-loss, tumor shrinkage) are less significant. Using deformable image registration, we obtained deformations between week 0/week 1 of treatment for all 35 patients, creating a distribution of possible sNRVs. The deformations from this distribution are then applied to the planning CT of two patients. Patient 1 has a laterally located gross tumor volume (GTV), patient 2 has a central GTV, both with bilateral low-risk clinical target volume (CTV). For both patients, IMPT plans using 3-field, 4-field, and 5-field beam arrangements were generated (nominal dose) and dose was forward calculated on the 35 deformed CT images representing the possible sNRV dose (n = 210) to assess dose degradation. Dose-volume histogram (DVH) bandwidths for sNRV doses were calculated per patient and beam arrangement to evaluate the robustness of the nominal plans with respect to the sNRVs.Among both patients (210 scenarios), we observe a maximum difference to the nominal dose of: 7% degradation of CTV D95, increase in parotid Dmean 10.6 Gy (RBE), increase in brainstem Dmax 14.8 Gy (RBE), increase in chiasm Dmax 18 Gy (RBE), increase in larynx Dmean15 Gy (RBE). For both patients, the 4-field plan shows the narrowest bandwidth and thus best robustness against sNRV in terms of CTV coverage (tab 1). For patient 1, the 4-field plan appears most robust in terms of organ at risk dose. For patient 2, the 3-field plan shows the best parotid sparing while dose metrics for brainstem and chiasm are similar for all beam arrangements.We demonstrate that sNRVs can substantially degrade the dose to the target volume and increase OAR doses. Including the influence of sNRVs during robust evaluation may assist in plan selection, providing information on clinical uncertainties additional to the conventional rigid isocenter shift and CT number uncertainty.

Effect of muscle selection for botulinum neurotoxin treatment on spasticity in patients with post-stroke elbow flexor muscle over-activity: an observational prospective study

Purpose/Aim To investigate the effect of muscle selection for botulinum neurotoxin A (BoNT-A) treatment on spasticity in patients with post-stroke elbow flexor muscle over-activity. Materials and Methods Chronic stroke patients with a deforming spastic paresis in the upper limb (elbow flexion with forearm pronation) who were injected BoNT-A into at least one of elbow flexor muscles (brachialis, brachioradialis, and biceps brachii) were included in this prospective observational study. The main outcome measure was spasticity angle by Tardieu Scale recorded at pre-treatment and week 4 after treatment. Results Three muscle selection groups with sufficient sample size for statistical analysis were able to be created; brachialis (n = 14), biceps brachii (n = 21), and brachialis plus brachioradialis (n = 11). Although there was a significant improvement in spasticity angle within all groups over time (p < 0.05), the change in spasticity angle was not different between the groups (p > 0.05 for each pairwise comparison). However, the magnitude of the change in spasticity angle was larger in the groups in which brachialis was preferred. Conclusions In stroke patients with a spontaneous spastic posture of elbow flexion and forearm pronation, targeting brachialis for BoNT-A injection seems more effective in reducing the severity of spasticity. Clinical trial registration no NCT04036981

189 Anterior Ankle Surface Pressures in Lower Extremity Splints: Minimizing Insult After Injury

Though ubiquitously utilized in lower extremity orthopaedic trauma, lower extremity splints are not without their associated iatrogenic risk of morbidity. In fact, improper splinting not only necessitates replacement, but splint- related soft tissue complications are the second most common iatrogenic cause for referral to plastic surgery. Pressure ulcers result from perpendicular forces that compress the soft tissues between body mass, bony prominences, and the support surfaces below. Within those soft tissues are vessels that run parallel to the surface of the site of skin collapse and may collapse easily from pressure loads. As such, prolonged pressure above the threshold for capillary tolerance results in occluded blood flow, interstitial fluid flow, ischemia, pain, necrosis, and sloughing of dead tissue. While clinicians commonly pad bony prominences to minimize the skin pressure, the effect of joint position on skin pressure and, more specifically, changing joint position, is real but has not been well studied or described. The purpose of this biomechanical study is to identify problems with anterior ankle skin pressure secondary to joint position change during splinting and ultimately to determine the optimal position of the ankle during application of the splint as well as the padding technique required over the anterior ankle to minimize iatrogenic skin pressure ulcers. Following ethics approval by our institutional review board, various constructs of lower extremity, short-leg splints were applied to two healthy subjects (two limbs total in this preliminary data set) with an underlying pressure transducer (Tekscan® I-Scan® system, (Tekscan Inc, South Boston, MA, USA) on the skin surface centered on the anterior ankle on the tibialis anterior tendon. All subjects underwent anterior ankle surface pressure assessment when padding was applied in maximum plantar flexion and neutral position for conventional short leg splints application. Percent change from initial contact pressure centered on the tibialis anterior with either Webril© (Covidien/Medtronic, Dublin, Ireland), or Specialist© Cotton Blend Cast Padding (BSN Medical, Charlotte, NC, USA) were calculated. Neutral position of the foot/ankle will be confirmed with a goniometer. There were two limbs total that were analyzed for presentation of pilot data for this study. The percent change in anterior ankle contact pressure when padding was applied in maximum plantar flexion (PF) and then placed in neutral was increased at least two-fold without the addition of plaster and subsequently with the addition of plaster in lower extremity short leg splints (Figure 1). In this pilot data, we report significant increases in anterior ankle contact pressures when splint padding is applied in plantar-flexion and re-positioned into neutral during splint application which may precipitate iatrogenic pressure ulcers. This data, though preliminary, underscores the importance of proper splinting techniques for all clinicians that manage lower extremity trauma (eg, orthopaedic surgery, emergency medicine, urgent care, etc).

Impact of Therapeutic Ultrasound and Myofascial Release Technique on Quality of Life of Students Having Neck Pain Following Virtual Learning

Background: Neck pain is a ubiquitous complaint leading to work place absenteeism, disabilities and disturbed sleep wake cycle in many young working and studying people. In ongoing covid scenario, since there is increased use of laptops and mobile phones facilitating work from home for employee and virtual learning for students, there has been increased prevalence of non-specific neck pain among the people due to prolonged fixed flexion posture. Neck pain has become the condition of major consideration since 45% of UG students had experienced neck pain in last 12 months.&#x0D; Aims and Objectives: to evaluate combined and individual effects of Therapeutic Ultrasound and Myofascial Release Technique on Quality of Life of students suffering from neck pain owing to virtual learning.&#x0D; Methods: The participant (n=33) will be recruited in study experiencing non-specific neck pain and meeting the inclusion criteria. Three groups will be formed such that the patient in Group A will receive treated with therapeutic ultrasound. Group B will be receiving treatment using Myofascial Release Technique and Group C will be treated using combined use of both Therapeutic Ultrasound and Myofascial release Technique. The protocol will cover 1 week of treatment. Regular assessment at 0,3rd and 7th day of week will be carried out. We will evaluate using Numerical Pain Rating Scale (NPRS), Neck Disability Index (NDI), and Range of motion of neck and Manual Muscle testing of cervical musculature.&#x0D; Results: The result of the study will provide affirmation on using combination therapy of Therapeutic Ultrasound and Myofascial Release Technique in people having nonspecific neck pain.

Using Wearable Technology to Measure the Association Between Neck Posture and Pain During Urologic Open and Robotic Surgery.

Purpose: Chronic neck pain is the most prevalent work-related musculoskeletal injury among surgeons. Urologists may be at higher risk of neck injury due to extended time spent operating in deep anatomical structures during open surgery. Our goal was to use wearable technology to quantify the relationship between neck posture and pain during open and robotic surgery. Materials and Methods: Urologic attendings and residents who spent at least 1 day per week performing surgery for >6 hours took part in this study. Neck posture was measured in real time during surgery using inertial measurement devices attached at the occipital protuberance and seventh cervical vertebrae. Self-reported neck pain scores were obtained throughout their workday. Results: Thirty participants and 202 hours of surgery were included in the study (21 attendings, 9 residents). There was a significant association between neck posture and pain (p = 0.04). Surgeons performing open procedures spent on average 147 minutes with their head in neck flexion postures of 30° or greater compared with 68 minutes for those performing robotic procedures (p = 0.007). Surgeons performing open procedures reported a mean change in neck pain of 2.0 on the numeric analogue scale, compared with 1.3 for those performing robotic procedures (p = 0.04). Conclusions: Real-time measurements of neck flexion during urologic surgery shows that greater duration and higher degree of neck flexion were associated with increased neck pain. Raising awareness about ergonomics in the operating room during residency will enable future generations of surgeons to make conscious decisions regarding their neck posture in surgery.

Possible predictive markers in surgical decision making in patients with degenerative or isthmic lumbar spondylolisthesis

Background: Although age, comorbidity, duration and severity of symptoms, slippage degree, and flexion-extension slipping stability during X-ray imaging are effective in making a surgical decision in patients with spondylolisthesis, these factors are rarely based on definitive evidence. The aim of this study was to determine the efficacy of clinical, radiological and biochemical findings in surgical decision making in these patients. Materials and Methods: Patients’ data including age, gender, degree and type (i.e. degenerative or isthmic) of the spondylolisthesis, urinary incontinence, neurogenic claudication were recorded. Radiological imaging studies (lumbar dynamic X-ray, computed tomography, magnetic resonance imaging), serum glucose, C-reactive protein and erythrocyte sedimentation rate values of the patients obtained during hospital admissions were evaluated. Results: Forty patients were followed conservatively and 12 patients were treated surgically. Degenerative spondylolisthesis was seen in 22 patients. Nine patients had neurogenic urinary incontinence and 19 patients had neurogenic claudication. When the patients were divided into two groups with and without surgical treatment, the presence of the pars defect, slipping distance in a neutral position and slipping distance in flexion position was significantly different between groups. A positive correlation was found between pars defect and surgical treatment. Likelihood ratio test results revealed that the presence of pars defect, neurogenic claudication and neurogenic urinary incontinence could be the best parameters in decision making the surgical treatment. Conclusion: The presence of pars defect, neurogenic claudication and urinary incontinence could be the best parameters that may help the surgeon to make the surgical treatment decision.