Background: Pronation deformity in patients with cerebral palsy can have a major impact on upper limb functionality. There is lack of consensus in the literature about the preferred surgical technique to address this deformity. Study aim: To evaluate and synthesize the outcome of different surgical techniques for pronation deformity in patients with cerebral palsy. Methodology: The databases MEDLINE and Embase were searched for publications up to December 2021. Articles were considered eligible for inclusion when the included patients had a pronation deformity caused by cerebral palsy and results of surgical intervention for pronation deformity were examined. Evaluation of the quality of the retrieved study was conducted using the MINORS tool. Meta-analysis was not possible due to the heterogeneity of interventions and reported outcomes. Results: Nineteen studies, involving 475 patients and eight different techniques were included. All studies reported gain of active supination in most patients. The effect of surgery on functional gain was less clear and there was a large heterogeneity of reported functional outcome measures. There were 46 reported complications. Overall quality of study design was poor, illustrated by the average MINOR score of 6.9/16. Overall, there is a high risk of bias due to poor internal and external validity of the studies. Conclusion: Despite positive reports on gain in supination and functionality after most procedures addressing pronation deformity in CP patients, no conclusions can be drawn concerning the preferred technique due to the low quality of the evidence.

Background Optical tracking systems (OTSs) are essential components of many modern computer assisted orthopaedic surgery (CAOS) systems but patient movement is often neglected in the evaluation of the accuracy. The aim of this study was to develop a representative test to assess the accuracy of OTSs including patient movement and demonstrate the effect of pointer design and OTS choice. Method A mobile phantom with dynamic reference base (DRB) attached was designed and constructed. The point registration trueness and precision were evaluated for measurements with both a static and moving phantom. Results The trueness of the total target registration error (TTRE) was 1.4 to 2.7 times worse with a moving phantom compared to a static phantom. Conclusion The accuracy of OTSs for CAOS applications should be evaluated by measurements with a moving phantom as the evaluation of the TTRE with a static frame significantly underestimates the measurement error.

ABSTRACT Introduction The success of orthotic interventions depends on how well an individual patient's needs are identified and addressed. In this prospective study, we addressed the following question: Is it possible to additively manufacture an ankle-foot orthosis (AFO) with predefined ankle stiffness that would decrease excessive plantarflexion in the dropfoot gait? Materials and Methods A child with unilateral drop foot was recruited for this study and took part in three gait assessments. In the first gait assessment, the “optimal” AFO stiffness was determined using a hinged AFO with adjustable ankle stiffness. A leaf-spring-type AFO with predefined optimal ankle stiffness was then virtually designed and additively manufactured. The impact of this orthosis on the patient's gait before and after 6 weeks of acclimatization period was evaluated in the second and the third gait assessments, respectively. Results A hinged orthosis with an ankle stiffness of 0.009 N·m·deg−1·kg−1 was deemed to be the optimal for the study patient. The ankle stiffness of the additively manufactured AFO was 0.008 N·m·deg−1·kg−1. This orthosis decreased patient's excessive plantarflexion, but its impact was moderately inferior compared with that of the optimal hinged orthosis. Conclusions Despite having the same ankle stiffness, hinged AFO and leaf-spring AFO did not produce the same gait pattern. Therefore, to prescribe an optimal AFO, a better understanding of subject-AFO interaction in walking is needed.

The purpose of this survey in Belgium and the Netherlands was to assess treatment variation in glenohumeral osteoarthritis between experienced and less experienced orthopedic surgeons, and to investigate perioperative treatment after shoulder arthroplasty in a large group of orthopedic surgeons. Orthopedic surgeons specialized in shoulder surgery were invited to complete a survey between November 2013 and February 2015. Seventy-one percent of the approached surgeons com-pleted the survey. Less experienced surgeons (< 6 years) and surgeons from the Netherlands find patient characteristics (e.g. smoking p=0.01) more relevant than more experienced surgeons (≥ 6 years) and surgeons from Belgium. Less experienced surgeons will less likely (p=0.001) perform resurfacing arthroplasty compare to experienced surgeons. The less and the experienced surgeons use similar indications for a reverse shoulder arthroplasty regarding age limit and cuff arthropathy without osteoarthritis. Less experienced surgeon will more likely (p=0.003) prescribe a low molecular weight heparin during the hospital stay after a shoulder arthroplasty. In this survey, we found a decrease in the use of resurfacing arthroplasty and a strong increase in the use of reverse shoulder arthroplasty. Besides, there is little consensus concerning pre-operative planning, patient characteristics, surgical technique, and patient reported outcome measures. Level of evidence: IV.

PURPOSE:Ankle foot orthosis (AFO) stiffness is a key characteristic that determines how much support or restraint an AFO can provide. Thus, the goal of the current study is twofold: (1) to quantify AFO prescriptions for a group of patients; (2) to evaluate what impact these AFO have on the push-off phase.METHOD:Six patients were included in the study. Three patients were prescribed an AFO for ankle support and three patients were prescribed an AFO for ankle and knee support. Two types of AFO - a traditional polypropylene AFO (AFOPP) and a novel carbon-selective laser sintered polyamide AFO (AFOPA), were produced for each patient. AFO ankle stiffness was measured in a dedicated test rig. Gait analysis was performed under shod and orthotic conditions.RESULTS:Patient mass normalized AFOPP stiffness for ankle support ranged from 0.042 to 0.069 N·m·deg-1·kg-1, while for ankle and knee support it ranged from 0.081 to 0.127 N·m·deg-1·kg-1. On the group level, the ankle range of motion and mean ankle velocity in the push-off phase significantly decreased in both orthotic conditions, while peak ankle push-off power decreased non-significantly. Accordingly, on the group level, no significant improvements in walking speed were observed. However, after patient differentiation into good and bad responders it was found that in good responders peak ankle push-off power tended to be preserved and walking speed tended to increase.CONCLUSIONS:Quantification of AFO stiffness may help to understand why certain orthotic interventions are successful (unsuccessful) and ultimately lead to better AFO prescriptions. Implications for rehabilitation AFO ankle stiffness is key characteristic that determines how much support or restraint an AFO can provide. In a typical clinical setting, AFO ankle stiffness is not quantified. AFO has to meet individual patient's biomechanical needs. More objective AFO prescription and more controlled AFO production methods are needed to increase AFO success rate.

The purpose of this study was to create and validate a standardized framework for the evaluation of the ankle stiffness of two designs of 3D printed ankle foot orthoses (AFOs). The creation of four finite element (FE) models allowed patient-specific quantification of the stiffness and stress distribution over their specific range of motion during the second rocker of the gait. Validation was performed by comparing the model outputs with the results obtained from a dedicated experimental setup, which showed an overall good agreement with a maximum relative error of 10.38% in plantarflexion and 10.66% in dorsiflexion. The combination of advanced computer modelling algorithms and 3D printing techniques clearly shows potential to further improve the manufacturing process of AFOs.

BACKGROUND:Ankle foot orthoses are external medical devices applied around the ankle joint area to provide stability to patients with neurological, muscular, and/or anatomical disabilities, with the aim of restoring a more natural gait pattern.STUDY DESIGN:This is a literature review.OBJECTIVES:To provide a description of the experimental and computational methods present in the current literature for evaluating the mechanical properties of the ankle foot orthoses.METHODS:Different electronic databases were used for searching English-language articles realized from 1990 onward in order to select the newest and most relevant information available.RESULTS:A total of 46 articles were selected, which describe the different experimental and computational approaches used by research groups worldwide.CONCLUSION:This review provides information regarding processes adopted for the evaluation of mechanical properties of ankle foot orthoses, in order to both improve their design and gain a deeper understanding of their clinical use. The consensus drawn is that the best approach would be represented by a combination of advanced computational models and experimental techniques, capable of being used to optimally mimic real-life conditions.CLINICAL RELEVANCE:In literature, several methods are described for the mechanical evaluation of ankle foot orthoses (AFOs); therefore, the goal of this review is to guide the reader to use the best approach in the quantification of the mechanical properties of the AFOs and to help gaining insight in the prescription process.

Ankle foot orthoses (AFOs) are traditionally manufactured using vacuum thermoforming as shaping technology. Additive manufacturing has the potential to disruptively change the way these orthopaedic devices are produced. In this study, AFOs are developed which are virtually designed and produced with laser sintering as shaping technology. The mechanical and clinical performances of these laser-sintered AFOs are compared with traditionally manufactured AFO by asking seven patients (both children and adults) to walk with each type of AFO.

The purpose of this study was the construction of a new semi-automated experimental setup for the evaluation of the stiffness of ankle foot orthoses (AFOs) around an axis aligned to the anatomical ankle joint during the second rocker of the gait. The setup, developed in close collaboration with the orthopedic device company V!GO NV (Wetteren, Belgium), allows measurement of plantarflexion and dorsiflexion in the sagittal plane for a maximal range of motion of 50° (− 25° plantarflexion up to 25° dorsiflexion) in a non-destructive way.

Background/Aim: Estimating the measurement error (reliability) of three dimensional gait analysis (3DGA) is crucial to interpretation of gait data. The purpose of this study was to investigate the intrarater reliability of 3DGA and apply a novel method of visualising reliability of gait cycle waveforms.Methods: A test re-test design was employed. A convenience sample of 30 healthy adults (18F; 12M: mean age 30 +/- 6.8 years) participated. Subjects walked along a 10 m walkway at their preferred gait speed and 3DGA data were collected using a VICON (R) 3DGA system. Testing was performed by the same investigator on two separate days within two weeks. Data from 10 trials were averaged and analysed.Analysis: The intraclass correlation coefficient (ICC), the standard error of measurement (SEM), minimal detectable change (MDC) and limits of agreement were calculated for kinetic and kinematic data. Bland and Altman plots were applied to gait cycle waveforms.Results: Spatio-temporal parameters such as cadence, step length, velocity, step time and step width were highly repeatable generating ICC's of 0.90 and above and low SEM/MDC. Range of joint movement across the gait cycle was generally more reliable than either minimum or maximum values and higher ICCs were obtained for movement in the sagittal plane. For kinematic data the standard error of measurement was low (<=(5) over circle) for the majority of parameters. Transverse plane measurements showed poor reliablility with lowest ICC's. ICCs for kinetic data ranged from 0.51 to 0.81.Conclusions: Reliability of 3DGA has been estimated for our gait laboratory. Bland and Altman plots of gait cycle waveforms provide a useful addition to reliability analysis. (C) 2013 Elsevier B. V. All rights reserved.

Force plate targeting has been referenced as a confounding factor in gait research, but the literature is sparse. Asking participants to target force plates is a convenient strategy to increase the number of acceptable trials, but may inadvertently alter the motor control of gait and limit external validity. This study aimed to investigate the effect of visual targeting on spatiotemporal, kinematic, and kinetic measures of gait and their variability. Young healthy participants were asked to traverse a walkway with three embedded hidden force plates. Starting from a participant-specific initial position and leading with the same foot each time, participants performed series of natural walking trials (no targeting and unaware of the hidden force plates), followed by targeting walking trials. For the targeting trials, participants were asked to step completely within the bounds of a tape outline (∼50 cm × 45 cm), which coincided with the position of the last hidden force plate. The results demonstrated evidence of targeting during targeting trials; compared to natural walking trials, mean heel–target distance variability for targeting trials decreased progressively for the steps approaching the targeting step, reaching significance (p < 0.05) for the target (41%), and post-target steps (39%). Despite visual targeting, no significant differences between targeting and natural trials were detected in spatiotemporal, kinematic, and kinetic gait measures, or the variability of the measures. When the experimental set-up was tailored to the individual participant's gait variables (step/stride length), visual targeting of the force plates appeared to have no effect on the magnitude or variability of any gait measures.

AIM:Energy cost of walking (ECOW) is defined as 'walking oxygen consumption minus resting oxygen consumption divided by speed', where 'resting' data can be obtained either at the start or cessation of a test. This study aimed to ascertain when resting data should be taken during an ECOW test in children with cerebral palsy (CP).METHOD:Resting oxygen consumption per unit mass (VO(2) ) and heart rate were recorded in children without physical impairment (18 males, 13 females; mean age 11 y [SD 2 y 1 mo]) and children with diplegic CP (18 males, 13 females; mean age 11 y [SD 2 y 6 mo, Gross Motor Function Classification System levels I and II]) at three stages, namely pre- and posttest sitting and pretest standing before and after an 8-minute ECOW test using the Cosmed K4b.RESULTS:Heart rate and VO(2) differed significantly between groups and stages (p ≤ 0.05) except for heart rate in standing and posttest sitting in the unimpaired children and for VO(2) during pretest sitting between groups. These differences impacted on the calculation of non-dimensional net oxygen cost (NDNOC) and physiological cost index (PCI) in CP but not in the unimpaired group. PCI was correlated with NDNOC in CP but not in the unimpaired cohort.INTERPRETATION:Pretest sitting resting data appear to be the most appropriate for use in the calculation of NDNOC and PCI. PCI may still have relevance in pathology where walking efficiency is compromised.

Measurement of VO2 based ‘energy cost of walking’ indices provide quantitative information that can be used clinically to ascertain progress and relative functional impairment in pathology. The accuracy and validity of these indices relies on being able to identify periods of steady state conditions, since it is only in steady state that there is a direct and predictable relationship between VO2 consumption and energy expenditure. This paper presents a comparison of two new mathematically based approaches that have recently gained recognition as methods for identifying steady state during an energy cost assessment. The first applies a mathematically defined threshold for steady state within a (non-treadmill) walking trial. This method is compared with a statistically based approach that relies on the calculation of the correlation coefficient, Kendall's Tau to define steady state data. To examine the impact of both methods on the calculation of the energy cost of walking, each was applied to the calculation of two oxygen based energy cost of walking parameters, the non-dimensional net oxygen cost and the net oxygen cost with speed normalised to height in a cohort of unimpaired subjects and children with cerebral palsy. The results revealed that overall there were no clinically significant differences between the two methods. It is suggested that the methods can be used interchangeably to calculate the energy cost of walking.

Lower limb joint loadings are increased during sloped walking compared to level walking and muscle forces are major contributors to lower limb joint forces. Therefore, the aim of this study was to analyze lower limb muscle forces during sloped walking at different inclinations. Eighteen healthy male participants (27.0 ± 4.7 y, 1.80 ± 0.05 m, 74.5 ± 8.2 kg) walked at a pre-set speed of 1.1 m/s on a ramp at the inclinations of 0°, ±6°, ±12° and ±18°. Kinematic data were captured with a motion capture system and kinetic data were recorded with two force plates imbedded into the ramp. A musculoskeletal model was used to compute lower limb muscle forces (normalized to body weight and gait cycle duration). During downhill walking gluteus maximus, quadriceps, soleus, peroneus and tibialis anterior muscle forces increased (p ≤ 0.002) compared to level walking, while gluteus minimus, piriformis, adductor, iliopsoas, hamstrings and gastrocnemii muscle forces decreased (p ≤ 0.002). Uphill walking decreased gluteus minimus, iliopsoas and tibialis anterior muscle forces (p ≤ 0.002), while all other muscle forces increased (p ≤ 0.002, except gluteus medius). Joint-muscle-force waveforms provided information on possible muscle contributions to joint compression forces. The most important muscles were: gluteus medius for hip forces, quadriceps and gastrocnemii for tibiofemoral forces, quadriceps for patellofemoral forces and triceps surae for ankle forces. The contribution of each muscle changed with the inclination during sloped walking compared to level walking. The current study provided important information on muscle forces during sloped walking that can be useful for rehabilitation and training procedures.

The aim of this study was to investigate whether it is possible to distinguish between computer workers with (cases) and without (controls) work-related neck–shoulder complaints by combining multiple surface electromyography (EMG) parameters in a logistic regression model. Fourteen controls and 13 cases performed five tasks: a unilateral dynamic hand task, a typing task, an editing task, a mouse task and a stress task. EMG of the trapezius muscle was measured using multi-channel electrode arrays. Root-mean-square value and median power frequency, the number of motor unit action potentials (MUAPs) per second and MUAP shape properties were assessed. Logistic regression models were developed for each task with data from ten controls and nine cases. The mouse task resulted in the most discriminative model with correct classification of 89% (jackknife evaluation). MUAP-related parameters were selected as most discriminative. Explorative evaluation with the remaining subjects resulted in a sensitivity and specificity of 3 out of 4 in both groups. In conclusion, a combination of multiple surface EMG parameters was capable of distinguishing computer workers with and without neck–shoulder complaints in a small pilot sample.The results are promising for development of an objective assessment method that can identify workers who are at risk to develop chronic neck–shoulder complaints.

Differences in the function of the anterolateral abdominal muscles have been the subject of much investigation, but primarily using electromyography. Recently changes in thickness of transversus abdominis and internal oblique measured from real-time ultrasound images have been shown to represent activity within these muscles. However it is still unclear if such a change in thickness in external oblique similarly represents activity within that muscle. The purpose of this study was to investigate the relationship between change in thickness and muscle activity in the external oblique using real-time ultrasound and surface electromyography.Simultaneous measurements of electromyography and real-time ultrasound images of external oblique were studied in up to 24 subjects during two tasks compared to the muscle at rest (1) isometric trunk rotation and (2) drawing in the lower abdomen.Changes in muscle thickness correlated significantly with electromyography during isometric trunk rotation in the majority of subjects but with a significant difference between subjects. In contrast, the relationship between change in thickness and electrical activity in the muscle when drawing in the lower abdomen was significant in less than 50% of subjects and the muscle often got thinner.Thickness changes of external oblique can be used as a valid indicator of electromyography activity during isometric trunk rotation, though the relationship is not as good as previously published data for transversus abdominis. Thickness changes of external oblique measured during lower abdominal drawing in cannot be used to detect activity within this muscle.

Transient ischemic attacks (TIA) after carotid endarterectomy (CEA) are not well-studied. We aimed to investigate the characteristics and the predictive role of intraoperative neurophysiological monitoring (IONM) in TIA post-CEA.Patients who underwent CEA utilizing IONM from 2009-2020 were included. Analyses included TIA incidence, sensitivity, specificity, and predictive values of IONM, risk factor regression analyses, and mortality Kaplan Meier plots.Out of 2232 patients, 46 experienced TIA, 14 of which were within 24 hours of CEA (p < 0.01). Nine of these patients displayed significant IONM changes during CEA. The odds of TIA increased with somatosensory evoked potential (SSEP) changes (Odds Ratio (OR): 2.48 95% Confidence Interval (CI): 1.14–5.4), electroencephalogram (EEG) changes (OR: 2.65 95% CI: 1.22–5.77), and combined SSEP/EEG changes (OR: 2.98 95% CI: 1.17–7.55). Patients with TIA were less likely to be alive after an average of 4.3 years (OR: 0.5 95% CI: 0.26–0.96).The odds a patient will have TIA post-CEA are greater in patients with IONM changes. This risk is inversely related to the time post-CEA.Changes in IONM during CEA predict postoperative TIA. Post-CEA TIA may increase long-term mortality, thus further research is needed to better elucidate clinical implications of postoperative TIA.

La prueba neurodinámica del nervio mediano (PNES1, prueba neurodinámica 1 de la extremidad superior, o ULNT1 en inglés) se utiliza con frecuencia para evaluar la mecánica y la fisiología del plexo braquial y del nervio mediano. El presente estudio investiga las PNES1 positivas en una población sana con arco axilar de Langer (AAL) y analiza si el AAL afecta al arco de movimiento durante la extensión de codo (AM-EC) durante la PNES1. De los 640 voluntarios examinados, finalmente se incluyeron 26 lados con AAL. La realización de un cuestionario clínico adicional reveló “síntomas menores” en algunos sujetos. Estos síntomas menores no se consideraron un trastorno porque no suponían un obstáculo para la realización de las actividades diarias y los sujetos no solicitaron atención médica. Este estudio investiga si la PNES1 puede producir o reproducir síntomas menores o respuestas anormales en sujetos con AAL. Se comparó el AM-EC del lado izquierdo y derecho de los sujetos. Por otra parte, se comparó el ángulo de sustracción, que es el efecto de colocar la columna cervical en flexión lateral contralateral, entre los lados con AAL y los controles. Los lados con arco axilar de Langer mostraron un aumento significativo en la aparición de síntomas menores y PNES1 positivas, pero no se observó efecto alguno en el AM-EC. Estos hallazgos indican que el AAL puede afectar de forma transitoria al haz neurovascular axilar. La falta de efectos sobre los AM-EC puede ser consecuencia del origen vascular de los síntomas menores o de una respuesta del nervio cubital/cordón medial a la PNES1. The neurodynamic test of the median nerve (ULNT1) is frequently used to assess the mechanics and physiology of the brachial plexus and median nerve. The present study looks for a positive ULNT1 in a healthy population with Langer's axillary arch (LAA) and analyzes whether LAA affects the elbow extension range of motion (EE-ROM) of the ULNT1. Of 640 volunteers screened, 26 LAA sides were finally included. Additional history taking revealed “minor symptoms” in some subjects. Minor symptoms do not qualify as a disorder because there is no interference with daily activities and no medical advice is sought. This study investigates whether the ULNT1 can (re)produce minor symptoms or abnormal responses in subjects with LAA. The EE-ROM was compared between the subjects’ left and right side, and the subtraction angle–which is the effect of placing the cervical spine in contralateral lateral flexion–was compared between LAA sides and controls. Langer's axillary arch sides showed a significant increase in the occurrence of minor symptoms and positive ULNT1, but no influence was observed on the EE-ROM. These findings suggest that LAA may be capable of transiently provoking the axillary neurovascular bundle. The unaffected EE-ROM may be the consequence of a vascular origin of the minor symptoms or the consequence of an ulnar nerve/medial cord response to the ULNT1.

OBJECTIVE:The neurodynamic test of the median nerve (ULNT1) is frequently used to assess the mechanics and physiology of the brachial plexus and median nerve. The present study looks for a positive ULNT1 in a healthy population with Langer's axillary arch (LAA) and analyzes whether LAA affects the elbow extension range of motion (EE-ROM) of the ULNT1.METHOD:Of 640 volunteers screened, 26 LAA sides were finally included. Additional history taking revealed "minor symptoms" in some subjects. Minor symptoms do not qualify as a disorder because there is no interference with daily activities and no medical advice is sought. This study investigates whether the ULNT1 can (re)produce minor symptoms or abnormal responses in subjects with LAA. The EE-ROM was compared between the subjects' left and right side, and the subtraction angle-which is the effect of placing the cervical spine in contralateral lateral flexion-was compared between LAA sides and controls.RESULTS:Langer's axillary arch sides showed a significant increase in the occurrence of minor symptoms and positive ULNT1, but no influence was observed on the EE-ROM.CONCLUSIONS:These findings suggest that LAA may be capable of transiently provoking the axillary neurovascular bundle. The unaffected EE-ROM may be the consequence of a vascular origin of the minor symptoms or the consequence of an ulnar nerve/medial cord response to the ULNT1.