Forearm Supination Research Articles

Poster 188: The Effect of Forearm Supination Versus Pronation at the Time of UCL Reconstruction Graft Tensioning on Post-Surgical Medial Elbow Joint Gapping in a Biomechanical Cadaveric Model

Objectives:The anterior bundle of the ulnar collateral ligament (UCL) is the primary static valgus restraint of the elbow joint. In general, the effect of forearm supination and pronation on native and reconstructed UCL strain is poorly characterized. Specifically, the effect of placing the forearm in supination versus pronation during final graft tensioning at the time of UCL reconstruction has not been quantified. Therefore, the objectives of the current study were the following: 1) to determine the effect of forearm pronation and supination on medial elbow joint gapping with an intact native UCL and 2) to determine if placing the forearm in maximum supination or pronation at the time of UCL reconstruction graft tensioning affects subsequent medial elbow joint gapping under simulated valgus stress test at varying degrees of elbow flexion. Our hypotheses were that under valgus load: 1) medial elbow joint gapping will be larger when the forearm is in maximal pronation for both the native and reconstructed ligament and 2) tightening the UCL reconstruction graft in maximum pronation would allow larger gap formation during valgus load testing.Methods:Eighteen full arm specimens were stripped of soft tissue, leaving only the elbow ligamentous and capsular structures intact. All specimens were statically tested at 30°, 60°, and 90° of elbow flexion with the forearm in full pronation, full supination, and neutral in an unloaded and loaded (3Nm valgus) configuration (Figure 1A). Medial joint gapping was measured using retroreflective markers attached to the ulna and humerus with a 3D motion capture system. Following intact testing, the UCL was transected and an ipsilateral flexor carpi radialis (FCR) tendon autograft was used to reconstruct the UCL with a standard docking technique (Figure 1B). For graft tensioning, all specimens were placed in 45 degrees of elbow flexion and randomized to either full supination or full pronation. Valgus testing was then repeated for medial joint gapping measurements. Following UCL reconstruction, the change in medial elbow joint gap under valgus load was calculated by subtracting the intact gap measurement from the reconstructed gap measurement for each specimen. A positive gap measurement was used to indicate an increase in joint gapping after reconstruction while a negative gap value indicated a smaller medial joint gap after UCL reconstruction. Two-way ANOVA were used to determine the effect of forearm position during reconstruction on change in gap and for each of the elbow flexion positions. Significance was set as p<0.05.Results:Valgus load testing of the native UCL demonstrated no significant difference in medial elbow joint gapping between the pronated and supinated position at all elbow flexion angles (Figure 2). Following UCL reconstruction, this finding was maintained as there was no significant difference in medial elbow joint gapping during a valgus load test regardless of forearm testing position. However, forearm position (i.e. maximum supination or maximum pronation) at the time of UCL reconstruction graft tensioning significantly affected the difference of post-operative medial elbow joint gapping at 30-and 60-degrees, but not at 90-degrees of elbow flexion (Figure 3). Placing the arm in maximum supination at the time of UCL graft tensioning resulted in a larger post-operative medial elbow gap compared to specimens with a reconstruction graft tensioned in maximum pronation.Conclusions:Our hypothesis was disproven. In a cadaveric biomechanical model, forearm pronation or supination did not affect medial joint gapping with the native or reconstructed UCL during valgus load testing. However, securing the UCL reconstruction graft in maximal supination resulted in a larger difference in post-operative medial elbow gap at 30° and 60° of elbow flexion. While statistically significant differences were found, the post-operative gap difference was less than 1mm at each level of elbow flexion regardless of the forearm rotation during testing. It is unknown if this small amount of additional joint gapping following UCL reconstruction graft tensioning in maximum supination can result in a clinically notable difference in elbow function, strength or pain. Further research is necessary to determine the clinical significance of the current cadaveric model findings and whether other factors related to the native or reconstructed UCL can affect medial elbow joint gapping.Figure 1.A. Picture of biomechanical testing set-up for native and reconstructed elbow ulnar collateral ligament (UCL) valgus stress testing. B) Picture of a reconstructed elbow UCL using a standard docking technique, resulting in a two-tailed graft (blue arrow).Figure 2.Medial elbow joint gapping with intact native ulnar collateral ligament (UCL) based on forearm position of maximum pronation or supination. Comparison of joint gapping between the pronated and supinated positions revealed no significant differences (p>0.05).Figure 3.Change in medial elbow joint gapping following ulnar collateral ligament (UCL) reconstruction with final graft tensioning in maximum forearm pronation or supination.

Paper 64: The Fate of Distal Biceps Partial Thickness Tears

Objectives:Distal biceps tendon tears, although rare, significantly impair patient’s elbow mobility and function. There is a paucity of literature reporting outcomes of partial thickness tears to inform management strategies. Therefore, the authors sought to identify magnetic resonance imaging (MRI) confirmed partial thickness distal biceps tears and report on (1) demographics and treatment strategies, (2) outcomes and complications, and (3) any identifiable risk factors for progression to surgery or full thickness tear.Methods:Patients who experienced a partial thickness distal biceps tear confirmed on MRI from 1996 to 2016 were identified by a musculoskeletal radiologist through an institutional image database. Patients were included if they had complete medical records and at least one visit of clinical follow-up. Patients with inflammatory arthritis and enthesitis, polytrauma, or incidental findings without clinical assessment were excluded. Medical records were reviewed to confirm the diagnosis and obtain study details. Multivariate logistic regression models were created using baseline characteristics, injury details and physical exam findings in order to predict operative intervention.Results:Overall, 111 patients (22F, 89M, age: 53.6 years ± 13) were identified and included. Baseline injury characteristics and patient demographics including weakness in elbow flexion, forearm supination, and patient reported sensation at time of injury were all found to be statistically different between treatment groups (Table 1). Patients were followed to a mean of 10 years of clinical follow up. Within the cohort, 57 patients were treated non-operatively, while 54 were treated operatively. Patients who received surgical intervention were more likely to report missing time from work and greater loss of productivity due to missed time (Table 2); however, almost 90% of patients returned to work without restrictions, regardless of treatment modality (88% vs 88%, Table 2). For surgical patients, there were 5 re-operations (9%), 3 re-ruptures (6%), and overall, 31% of the operatively treated cohort experienced a complication. Results of the final multivariate logistic regression model are included in Table 3; final model variables included age at initial consult, tenderness to palpation tendon insertion on exam, and supination weakness. Of these, supination weakness at initial consult was found to be a statistically significant predictor for surgical intervention (p=.001, OR=24.8).Conclusions:Operative patients tended to be male with more profound supination weakness; these patients tended to report increased loss of productivity due to time missed after treatment. At 10 year clinical follow up 31% experienced some complication and 9% underwent a re-operation. However, patients demonstrated uniform ability to return to work without modification and no statistical differences in functional outcomes, regardless of treatment modality. Patients who suffer from a partial distal biceps tear should be counseled that operative management represents a balance of returning function with potential complications and increased loss of productivity.Table 1.Cohort Baseline CharacteristicsTable 2.Operative and Nonoperative OutcomesTable 3.Multivariate Logistic Regression Model Identifies Risk Factors for Progression to Surgery

Distal Biceps Tendon Repair Using a Unicortical Button

Background: Distal biceps tendon ruptures occur most commonly in the dominant arm of men in their 4th through 6th decades of life. These injuries lead to a 30% reduction in flexion strength and 40% reduction in supination strength. Numerous methods exist for fixation of the distal biceps tendon, including bicortical endobutton, transosseous tunnels, suture anchors, and interference screws. We review the technique for using a unicortical button fixation method. Indications: Indications for surgical fixation of the distal biceps tendon include complete tendon ruptures, where a loss of elbow flexion and forearm supination strength of 30% and 40%, respectively, is not desired and partial tendon ruptures that have failed nonoperative treatment. Typically, nonoperative treatment of partial tendon ruptures is tried for a minimum of 3 months. Technique Description: We present the technique of repairing a distal biceps tendon rupture using a unicortical button. A 1-incision technique is utilized through a transverse incision approximately 3-4 cm distal to the elbow flexion crease. Onlay fixation of the distal biceps tendon to the radial tuberosity is achieved with a unicortical, or intramedullary, button. The postoperative protocol varies with surgeon but is similar to other fixation techniques. Results: Outcomes for primary repair of the distal biceps tendon are promising in the literature with both patient-reported outcomes and objective data showing good to excellent results. Bicortical button fixation has traditionally shown to be stiffer with a higher load to failure than other fixation techniques, including suture anchors, transosseous tunnels, and interference screws. The unicortical button has been shown to be statistically equivalent to the bicortical button, with similar cyclic loading and load to failure values. Discussion/Conclusion: The unicortical button technique for distal biceps repairs has the benefit of using a small footprint in the radial tuberosity, potentially decreasing the risk of heterotopic ossification, providing a safer avenue of obtaining anatomic placement and trajectory of repair, and decreasing the risk of posterior interosseous nerve injury. The unicortical button has been shown to have a similar strength profile to the bicortical button, which is higher than all other fixation techniques previously described in the literature.

Distal biceps tendon ruptures occur with the almost extended elbow and supinated forearm – an online video analytic study

BackgroundDistal biceps tendon ruptures can lead to significant restrictions in affected patients. The mechanisms of injury described in scientific literature are based exclusively on case reports and theoretical models. This study aimed to determine the position of the upper extremities and forces involved in tendon rupture through analyzing video recordings.MethodsThe public YouTube.com database was queried for videos capturing a clear view of a distal biceps tendon rupture. Two orthopedic surgeons independently assessed the videos for the activity that led to the rupture, the arm position at the time of injury and the forces imposed on the elbow joint.ResultsFifty-six video segments of a distal biceps rupture were included (55 male). In 96.4%, the distal biceps tendon ruptured with the forearm supinated and the elbow isometrically extended (non-dynamic muscle engagement) (71.4%) or slightly flexed (24%). The most common shoulder positions were adduction (85.7%) and neutral position with respect to rotation (92.9%). Most frequently a tensile force was enacted on the elbow (92.9%) and the most common activity observed was deadlifting (71.4%).ConclusionDistal biceps tendon ruptures were most commonly observed in weightlifting with a slightly flexed or isometrically extended elbow and forearm supination. These observations may provide useful information for sports specific evidence-based injury prevention, particularly in high performing athletes and individuals engaged in resistance training.Level of evidenceObservational study.

Functional and biomechanical assessment of the hand following ulnar forearm free flap transfer: Prospective self-controlled study.

There is a shortage of well-designed self-controlled studies evaluating hand biomechanics following ulnar forearm flap (UFF) harvest. This study was conducted to evaluate objective and subjective functional outcomes of the donor's hand following UFF harvest. All patients undergoing UFF were included for analysis. Grip strength, wrist movement, forearm supination and pronation, pinch strengths, sensation to light touch and temperature, and hand dexterity were assessed preoperatively and at 1, 3, and 6months postoperatively. In addition, DASH score (disabilities of the arm, shoulder, and hand score) and Patient and Observer Scar Assessment Scale (POSAS) were analyzed. A total of 18 patients were enrolled. A significant reduction in grip strength for donor's hand was observed between preoperative and postoperative 1 and 3months (mean difference=14 kg, 7.38 kg, respectively, p=0.000 for all). A similar trend was observed for pinch strength and range of motion (p < 0.05). Three months after surgery, there is still a significant reduction in tip pinch, tripod pinch, wrist extension, and supination. All biomechanics outcomes returned to preoperative baseline at 6months after surgery. No patients suffered significant changes in sensation to light touch, temperature, and numbness by 6months. There was a significant increase in DASH score by 3.37 points 6months after operation (p=0.000). The POSAS score indicates satisfaction with the appearance of the donor site. UFF is a safe and reliable option for oral cavity reconstruction with minimum donor site morbidities, mainly when cosmesis is paramount. Furthermore, objective hand biomechanics ultimately returns to its preoperative state within 6months after surgery.

Improvement in long head of biceps function and lower rate of biceps deformities after subpectoral tenodesis with cortical button and interference screw vs. arthroscopic tenotomy: a 4-year follow-up.

BackgroundThis study aimed to evaluate clinical, cosmetic, and strength midterm outcomes in arthroscopic biceps tenotomy and subpectoral biceps tenodesis using bicortical endobutton and interference screw.MethodsIn this retrospective study, inclusion criteria were long head of the biceps (LHB) pathologies treated either with tenotomy or an additional tenodesis. Postoperative assessment included Long Head of Biceps Score (LHBS), age-adjusted Constant-Murley Score, and Subjective Shoulder Value. Elbow flexion and forearm supination strength were measured. The presence of Popeye sign, cramps, and tenderness over the bicipital grove was evaluated. Statistical analysis of continuous variables without normal distribution was performed using Mann-Whitney U test. Grouped analysis was performed using 2-way analysis of variance. Binominal data were analyzed using chi-square test.ResultsA total of 73 patients with a mean age of 63.1 ± 9.6 years and a mean follow-up of 4.2 ± 0.5 years were included. Tenotomy was performed in 34 and tenodesis in 39 patients. Tenodesis group displayed a significantly higher LHB score (P = .0006), but no significant differences were detected for the age-adjusted Constant-Murley Score and Subjective Shoulder Value. Tenodesis group showed a significantly lower rate of Popeye deformities (P = .0007) and tenderness over the bicipital groove (P = .004). Patients from the tenotomy group with biceps deformity showed a significantly higher mean contralateral supination strength (P = .002) but no significant difference in contralateral elbow flexion compared with patients without biceps deformity. There was one (1.4%) complication in the tenotomy group (postoperative shoulder stiffness).ConclusionBoth techniques resulted in comparable outcome scores on preselected patients, with tenodesis leading to better LHB function. Tenodesis did not improve elbow flexion and forearm supination strength beyond the tenotomy; however, it reduced the frequency of biceps deformities and tenderness over the bicipital groove. Patients with a strong contralateral forearm supination strength could be at risk of developing a biceps deformity after tenotomy.

Effects of dry needling on muscle spasticity of the upper limb in a survivor of traumatic brain injury: a case report

BackgroundSurvivors of moderate and severe traumatic brain injury typically present with spasticity, an upper motor neuron lesion associated with hyperexcitability of the stretch reflex due to disinhibition of cortical influences on spinal cord circuits and structural and functional changes in skeletal muscle. There is growing evidence supporting the effectiveness of dry needling in abating spasticity.Case presentationThe present case aims to quantify the effects of dry needling on upper limb spastic muscles in a survivor of severe traumatic brain injury in a 27-year-old Iranian man. The treated muscles were biceps brachii, brachialis, flexor digitorum superficialis and profundus, flexor carpi radialis, flexor carpi ulnaris, opponens pollicis, and adductor pollicis. Outcome measures were evaluated before and 1 hour after the intervention. Our results showed that the patient’s upper limb recovery stage and hand function improved one grade according to Brunnstrom recovery stages. Spasticity assessed using the Modified Modified Ashworth Scale in all movements showed one-grade abatement, except in the forearm pronator. Passive resistance force decreased in all movements except in forearm supination. Active range of motion and passive range of motion increased in all movements except in active and passive forearm supination. Hand dexterity improved in both affected and unaffected hands.ConclusionsResults shown that dry needling could be a favorable option for reducing spasticity.

A Case Series on Morphological Variations of Biceps Brachii in Adult Human Cadavers and its Clinical Implications

Biceps brachii, a powerful forearm supinator, is a muscle in which many anatomical variations have been reported. Biceps brachii anomalies may play an important role in neurovascular compression syndromes in the arm and also affect shoulder joint movements. Three significant morphological variations in Biceps brachii were noted during routine dissection of upper limbs used for undergraduate teaching purposes. An extra articular origin of tendon of long head of Biceps brachii which was passing through the subpectoral tunnel formed by Pectoralis major was observed in one right upper limb. Nonfusion of two bellies of Biceps brachii with an accessory bicipital tendon was observed in one right upper limb. Presence of one supernumerary head of Biceps Brachii with a communicating branch between Median and Musculocutaneous nerves was observed in one right upper limb. Knowledge of these variations is essential for Surgeons and Orthopaedicians during surgery involving shoulder, arm and elbow regions. Key words: Biceps brachii, Supernumerary heads, Extra articular.

Posteriorly Displaced Radial Head Fractures May Represent the Footprint of an Elbow Dislocation or Subluxation as a Variant of Modified Mason Type 4.

The purpose of this case series is to describe surgical decision making and clinical outcomes in posteriorly displaced radial head fractures with a major fragment (more than 50% of the head) located behind the humeral condyle. We also document the outcome of open reduction and internal fixation of completely displaced radial head fractures. A retrospective review of the ICUC® (Integrated Comprehensive Unchanged Complete) database was performed between 2012 and 2020. Patients were included if preoperative radiographs demonstrated a major radial head fracture fragment located posterior to the humeral condyle and a minimum of 2-year follow-up data was available. Ten patients met inclusion criteria. Two patients had an associated elbow dislocation whereas 8 patients did not. All patients were found to have disruption of the lateral collateral ligament complex intraoperatively. Nine radial head fractures were successfully fixed with interfragmentary screws. One multi-fragmented radial head fracture could not be successfully stabilized with interfragmentary screw fixation and was resected. The average time to final follow-up was 4.8 years (range 2.2-8.1). At final follow-up, 6 patients demonstrated radiographic evidence of a healed radial head, 1 patient had avascular necrosis, and 2 had post-traumatic arthritis. None demonstrated radiographic instability. The average functional score was 0.64 (SD 0.81) and pain score was 0.45 (SD 0.93). The average elbow extension was 8 degrees (SD 11), elbow flexion was 139 degrees (SD 6), forearm supination was 60 degrees (SD 27), and forearm pronation was 69 degrees (SD 3). Recognition of a posteriorly displaced radial head fracture is essential, as it may be an indirect sign of elbow instability. This instability should be addressed during surgical intervention.

Treatment of Congenital Radioulnar Synostosis Using a Free Vascularized Fascia Lata Graft.

ObjectiveTo describe the modified mobilization surgery technique that uses a free vascularized fascia lata graft as the interposition graft, and to evaluate the outcome of this procedure in treating congenital radioulnar synostosis (CRUS).MethodsEleven patients (eight boys and three girls with an average age of 6.0 years) were treated using this procedure between 2012 and 2017 in our institution. Five bilateral cases (four left forearms and one right forearm were treated), and six unilateral cases (three left forearms and three right forearms) were included. All 11 cases were treated with mobilization procedure with free vascularized fascia lata as the interposition graft, and were followed‐up for an average of 2.2 years (range, 2–4 years). The parental satisfaction, postoperative ankylosis at proximal radioulnar joint, and active range of forearm rotation motion (measured by physical examination) were evaluated at the last follow‐up.ResultsThe average preoperative fixed pronation angle was 67.3° (range, 20°–90°). Ipsilateral thumb hypoplasia was noted in one case, and cleft palate and bilateral thumb hypoplasia were noted in one case; none of the patients had a family history of congenital radioulnar synostosis. Pronation and supination splints were used 3 days after the operation and were worn every night for 4–6 months postoperatively. Active and passive rehabilitation for elbow flexion and forearm rotation was initiated 4 weeks postoperatively. All patients were followed up for at least 2 years (average, 26 months; range, 24–48 months). The average forearm pronation range was 39° (range, 20°–60°), and the average forearm supination range was 33.2° (range, 10°–60°) at the latest follow‐up. Re‐ankylosis occurred in one case. An osseous bridge developed between the radius and ulna at the osteotomy site in one case. Radial nerve paralysis developed in two cases and spontaneously resolved 2 months later. Plate breakage was noted in one case 9 weeks postoperatively; however, union was achieved 7 months later.ConclusionMobilization of proximal radioulnar synostosis using a free vascularized fascia lata graft as the interposition graft may prevent re‐ankylosis and restore the forearm rotation function, making it a good option for the surgical treatment of CRUS.

Partial tear of the distal biceps tendon: Current concepts

BackgroundPatients with partial rupture of the distal biceps tendon can present with vague elbow pain and weakness. Understanding of the anatomy and aetiology of this disease is essential to management. Patients can present with a single or multiple traumatic events or with a chronic degenerative history. On clinical examination, patients will have an intact tendon making the diagnosis more challenging. Clinicians, therefore, should have a high index of suspicion and should actively look for this pathology. Objectives and RationaleThis review aims to discuss the current evidence in managing partial rupture of the distal biceps tendon with a suggested treatment algorithm. ConclusionSeveral clinical tests have been described in the literature including resisted hook test, biceps provocation test, and TILT sign. However, the diagnosis is usually confirmed by a magnetic resonance scan with the arm positioned in elbow flexion, shoulder abduction, and forearm supination and commonly known as FABS MR. Partial tendon tears that involve less than 50% of the tendon can be successfully managed conservatively. Tears that include more than 50% of the tendon are more likely to fail conservative management and would benefit from surgical intervention. It is crucial, however, to involve the patient in the decision making, which is based on their objectives and needs.

Pediatric Monteggia Fracture Outcome Assessment - Preliminary Report.

The term Monteggia fracture refers to a class of injuries encompassing the fracture ofthe proximal end of the ulna with subluxation or dislocation of the radial head. These injuries account for 0.4-1% of all forearm fractures in children. Despite its low incidence, Monteggia fractures require particular attention, since as much as 30-50% of the cases may be unrecognized, which subsequently leads to complications. The purpose of this paper is to evaluate treatment outcomes of Monteggia fractures in children. Both conservative treatment and surgery were analyzed. 15 children (7 boys and 8 girls) between the ages of 4-16.3 years (mean age 8.3 years) with Monteggia fractures were hospitalized at our center in the years 2015-2020. Closed reduction and immobilization in a cast were performed in 12 patients, while three children underwent surgical treatment with internal fixation of the ulna. The radial head dislocation was reduced successfully in every patient. Every child from the study group who received conservative treatment regained full elbow mobility as well as normal forearm supination and pronation. Only one ofthepatients who underwent the surgery demonstrated a 20° deficit in elbow flexion that did not affect limb function. 1. Our experience shows that closed reduction together with immobilization in a cast is usually a sufficient treatment in Monteggia fractures. 2. However, the dislocated radial head should be properly reduced in all patients. 3. Correct diagnosis and treatment followed by appropriate rehabilitation result in full recovery and no mobility limitations in children and teenagers.

CyberLimb: a novel robotic prosthesis concept with shared and intuitive control

BackgroundExisting assistive technologies attempt to mimic biological functions through advanced mechatronic designs. In some occasions, the information processing demands for such systems require substantial information bandwidth and convoluted control strategies, which make it difficult for the end-user to operate. Instead, a practical and intuitive semi-automated system focused on accomplishing daily tasks may be more suitable for end-user adoption.MethodsWe developed an intelligent prosthesis for the Cybathlon Global Edition 2020. The device was designed in collaboration with the prosthesis user (pilot), addressing her needs for the competition and aiming for functionality. Our design consists of a soft robotic-based two finger gripper controlled by a force-sensing resistor (FSR) headband interface, automatic arm angle dependent wrist flexion and extension, and manual forearm supination and pronation for a shared control system. The gripper is incorporated with FSR sensors to relay haptic information to the pilot based on the output of a neural network model that estimates geometries and objects material.ResultsAs a student team of the Munich Institute of Robotics and Machine Intelligence, we achieved 12th place overall in the Cybathlon competition in which we competed against state-of-the-art prosthetic devices. Our pilot successfully accomplished two challenging tasks in the competition. During training sessions, the pilot was able to accomplish the remaining competition tasks except for one. Based on observation and feedback from training sessions, we adapted our developments to fit the user’s preferences. Usability ratings indicated that the pilot perceived the prosthesis to not be fully ergonomic due to the size and weight of the system, but argued that the prosthesis was intuitive to control to perform the tasks from the Cybathlon competition.ConclusionsThe system provides an intuitive interface to conduct common daily tasks from the arm discipline of the Cybathlon competition. Based on the feedback from our pilot, future improvements include the prosthesis’ reduction in size and weight in order to enhance its mobility. Close collaboration with our pilot has allowed us to continue with the prosthesis development. Ultimately, we developed a simple-to-use solution, exemplifying a new paradigm for prosthesis design, to help assist arm amputees with daily activities.

Revision Open Subpectoral Biceps Tenodesis With Allograft Tendon Reconstruction for Symptomatic Failed Biceps Tenodesis

Biceps tenodesis and tenotomy are both effective surgical procedures for management of shoulder pain and dysfunction secondary to SLAP tears, biceps tendinitis, rotator interval pulley lesions, and failed SLAP repairs. These procedures are generally safe with low complication rates. However, failure of a proximal biceps tenodesis or tenotomy can rarely lead to symptomatic Popeye deformity with pain and cramping with repetitive forearm supination and elbow flexion. Surgical revision is indicated in young active patients to restore the length tension relationship of the biceps brachii to improve supination and flexion strength, as well as to provide symptomatic relief and improved endurance. Failed biceps tenodesis can be a challenging surgical scenario, as oftentimes there is limited available proximal biceps tendon tissue, especially in the setting of prior subpectoral biceps tenodesis. We report a technique of revision open subpectoral biceps tenodesis with allograft tendon augmentation for the management of symptomatic Popeye deformity in young active patients with little to no remaining proximal biceps tendon.

Development of Self-Powered 5-Finger Pneumatically Driven Hand Prosthesis Using Supination of Forearm

Recently, myoelectric hand prostheses produced by the combination of 3D-CAD and printer have gained attention. 3D printing of hand prosthesis has resulted in cost reduction. However, when an electric actuator with reduction gears is used as the driving source of the hand prosthesis, the joint rigidity becomes high; therefore, compliance control is required to grasp soft target objects. In this study, we propose a pneumatically driven hand prosthesis using a flexible bellows actuator. The hand prosthesis is lightweight and inexpensive because it is self-powered and generates compressed air through the supination motion of the user’s forearm instead of an external compressor, which is essential for conventional pneumatic systems. Stable flexible grasping of the target object was achieved by driving a five-finger hand using this system.

Hybridized neural network for upper limb movement detection using EEG signals

PurposeThis paper aims to propose a new upper limb movement classification with two phases like pre-processing and classification. Investigation of human limb movements is a significant topic in biomedical engineering, particularly for treating patients. Usually, the limb movement is examined by analyzing the signals that occurred by the movements. However, only few attempts were made to explore the correlations among the movements that are recognized by the human brain.Design/methodology/approachThe initial process is the pre-processing that is performed for detecting and removing noisy channels. The artifacts are marked by band-pass filtering that discovers the values below and above thresholds of 200 and –200 µV, correspondingly. It also discovers the trials with unusual joint probabilities, and the trials with unusual kurtosis are also determined using this method. After this, the pre-processed signals are subjected to a classification process, where the neural network (NN) model is used. The model finally classifies six movements like “elbow extension, elbow flexion, forearm pronation, forearm supination, hand open, and hand close,” respectively. To make the classification more accurate, this paper intends to optimize the weights of NN by a new hybrid algorithm known as bypass integrated jaya algorithm (BI-JA) that hybrids the concept of rider optimization algorithm (ROA) and JA. Finally, the performance of the proposed model is proved over other conventional models concerning certain measures like accuracy, sensitivity, specificity, and precision, false positive rate, false negative rate, false discovery rate, F1-score and Matthews correlation coefficient.FindingsFrom the analysis, the adopted BI-JA-NN model in terms of accuracy was high at 80th population size was 7.85%, 3.66%, 7.53%, 2.09% and 0.52% better than Levenberg–Marquardt (LM)-NN, firefly (FF)-NN, JA-NN, whale optimization algorithm (WOA)-NN and ROA-NN algorithms. On considering sensitivity, the proposed method was 2%, 0.2%, 5.01%, 0.29% and 0.3% better than LM-NN, FF-NN, JA-NN, WOA-NN and ROA-NN algorithms at 50th population size. Also, the specificity of the implemented BI-JA-NN model at 80th population size was 7.47%, 4%, 7.05%, 2.1% and 0.5% better than LM-NN, FF-NN, JA-NN, WOA-NN and ROA-NN algorithms. Thus, the betterment of the presented scheme was proved.Originality/valueThis paper adopts the latest optimization algorithm called BI-JA to introduce a new upper limb movement classification with two phases like pre-processing and classification. This is the first work that uses BI-JA based optimization for improving the upper limb movement detection using electroencephalography signals.

Hinge positioning method of Ilizarov apparatus in correcting radial head luxation caused by multiple hereditary exostoses.

Objectives In this study, we present a specified hinge positioning method to achieve satisfying and steerable lengthening and angulation to correct forearm multiple hereditary exostoses (MHE) combined with severe radiocapitellar joint dislocation using Ilizarov ring fixators.Patients and methods Between January 2014 and December 2018, a total of 30 forearms of 23 patients (11 males, 12 females; mean age: 18.3±6.8 years; range, 8 to 35 years) who suffered from type IIa (n=2) or IIb (n=28) MHE with severe radiocapitellar joint luxation were retrospectively analyzed. All patients were treated with Ilizarov external fixators with our specified hinge positioning method. Range of motion of the elbow, forearm and wrist and Visual Analog Scale (VAS), as well as Disabilities of Arm, Shoulder, and Hand (DASH) score, and radiological parameters, including radial articular angle (RAA), ulnar variance (UV) and carpi slip (CS), were recorded preoperatively and at final follow-up and were compared.Results Clinical and radiological outcomes were evaluated. Range of motion of the elbow, forearm and wrist, VAS, DASH and radiological features, including RAA, CS, and UV were significantly improved, except for range of motion of the forearm supination. Temporary nail track infection was seen in two of the forearms and was controlled with oral antibiotics. None of the patients developed radial head dislocation again.Conclusion Clinical and radiological outcomes of this novel hinge positioning method are satisfactory in treating MHE with severe radial head dislocation, and this method can be an alternative treatment for MHE by setting a milestone for accurate radiocapitellar joint reduction.

Physical treatment of posttraumatic elbow contractures in children – our experience

The most common complications of elbow trauma are contractures and neurovascular injuries. The complications can be a result of the initial injury, but they can also be a result of a surgical treatment. In addition to orthopedic treatment of elbow fractures, physical therapy and rehabilitation play a significant role in treatment of posttraumatic contractures. To determine the effects of physical therapy and rehabilitation of posttraumatic elbow contractures in children. This was a retrospective cross-sectional study conducted in the University Clinic for Physical Medicine and Rehabilitation, Skopje in the period 01.01.2021 – 01.07.2022. A total of 52 children were included, at the age between 2 and 13 years who had a posttraumatic elbow contracture, limited range of motion, pain and/or limitations in accomplishing daily activities. Depending on the clinical finding, children underwent a relevant physical therapy (kinesitherapy, functional therapy, electrotherapy, thermotherapy, hydrotherapy and magnetotherapy) in duration of three weeks. For assessing the effects of the rehabilitation therapy, the range of motion of the elbow and forearm was examined along with the Flynn’s scale in all children, prior to and after completion of the physical treatment. Applied physical treatment resulted in a significant improvement in all analyzed movements such as: elbow flexion (p=0.00001), elbow extension (p=0.00001), forearm pronation (p=0.00001), forearm supination (p=0.0000) and Flynn’s scale (p=0.0000). After completion of the rehabilitation treatment, excellent results were registered in 41 (85%) children, moderate in 10 (19.23%) and favorable in 1 (1.92%). Timely and adequate application of physical therapy and rehabilitation can significantly improve the final outcome in treatment of posttraumatic elbow contractures in children. A combination of different physical procedures adequately applied and personalized can significantly improve the range of motion of the elbow.&#x0D;

Tenodesis yields better functional results than tenotomy in long head of the biceps tendon operations\u2014a systematic review and meta-analysis

BackgroundPathology of the long head of the biceps tendon (LHBT) is a common disorder affecting muscle function and causing considerable pain for the patient. The literature on the two surgical treatment methods (tenotomy and tenodesis) is controversial; therefore, our aim was to compare the results of these interventions.MethodsWe performed a meta-analysis using the following strategy: (P) patients with LHBT pathology, (I) tenodesis, (C) tenotomy, (O) elbow flexion and forearm supination strength, pain assessed on the ten-point Visual Analog Scale (VAS), bicipital cramping pain, Constant, ASES, and SST score, Popeye deformity, and operative time. We included only randomized clinical trials. We searched five databases. During statistical analysis, odds ratios (OR) and weighted mean differences (WMD) were calculated for dichotomous and continuous outcomes, respectively, using the Bayesian method with random effect model.ResultsWe included 11 studies in the systematic review, nine of these were eligible for the meta-analysis, containing data about 572 patients (279 in the tenodesis, 293 in the tenotomy group). Our analysis concluded that tenodesis is more beneficial considering 12-month elbow flexion strength (WMD: 3.67 kg; p = 0.006), 12-month forearm supination strength (WMD: 0.36 kg; p = 0.012), and 24-month Popeye deformity (OR: 0.19; p < 0.001), whereas tenotomy was associated with decreased 3-month pain scores on VAS (WMD: 0.99; p < 0.001). We did not find significant difference among the other outcomes.ConclusionTenodesis yields better results in terms of biceps function and is non-inferior regarding long-term pain, while tenotomy is associated with earlier pain relief.

Reliability and concurrent validity of mobile health technology for patient self-monitoring in physical rehabilitation

BackgroundForearm pronation and supination are important for everyday functional tasks and some recreational activities. Healthcare providers use reliable and valid tools during the physical rehabilitation process to measure joint range of motion (ROM), assess functional mobility, guide decisions for skilled interventions, and progress a plan of care. Since the onset of the COVID-19 pandemic, both healthcare providers and patients benefited from mobile health technologies that have emerged, which can be used by patients in the home to monitor ROM and assist the healthcare provider in guiding the rehabilitation process when utilizing telehealth.PurposeThe goal of this study was to investigate the reliability and concurrent validity of a smartphone application for obtaining goniometric measurements of forearm pronation and supination.MethodsThis study consisted of 83 participants that were recruited on a voluntary basis from an academic institution. An iPhone with the application Clinometer and a standard goniometer (SG) were utilized to obtain goniometric measurements of forearm pronation and supination. The intraclass correlation coefficient (ICC) was used to analyze intrarater reliability, and the Pearson correlation coefficient was used to analyze concurrent validity. Scatterplots with regression lines were created to visually display the results.ResultsThe smartphone demonstrated strong correlations for both pronation and supination (r = 0.71, P < .001; r = 0.73, P < .001). This study demonstrated overall good-excellent intrarater reliability and good concurrent validity for the smartphone application with a higher test-retest reliability in the measurement of forearm pronation compared to supination.ConclusionsThis study concludes that the reliability and concurrent validity of the smartphone was consistent with the SG for assessing forearm pronation and supination. It may be of value to further investigate interrater reliability between patient and healthcare practitioner, and report on the ease of use to assess ROM with a smartphone.