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Concept: Knee

558

Birds still share many traits with their dinosaur ancestors, making them the best living group to reconstruct certain aspects of non-avian theropod biology. Bipedal, digitigrade locomotion and parasagittal hindlimb movement are some of those inherited traits. Living birds, however, maintain an unusually crouched hindlimb posture and locomotion powered by knee flexion, in contrast to the inferred primitive condition of non-avian theropods: more upright posture and limb movement powered by femur retraction. Such functional differences, which are associated with a gradual, anterior shift of the centre of mass in theropods along the bird line, make the use of extant birds to study non-avian theropod locomotion problematic. Here we show that, by experimentally manipulating the location of the centre of mass in living birds, it is possible to recreate limb posture and kinematics inferred for extinct bipedal dinosaurs. Chickens raised wearing artificial tails, and consequently with more posteriorly located centre of mass, showed a more vertical orientation of the femur during standing and increased femoral displacement during locomotion. Our results support the hypothesis that gradual changes in the location of the centre of mass resulted in more crouched hindlimb postures and a shift from hip-driven to knee-driven limb movements through theropod evolution. This study suggests that, through careful experimental manipulations during the growth phase of ontogeny, extant birds can potentially be used to gain important insights into previously unexplored aspects of bipedal non-avian theropod locomotion.

Concepts: Bird, Knee, Extinction, Locomotion, Dinosaur, Theropoda, Bipedalism, Archosaur

184

Recent findings suggest that not only the lack of physical activity, but also prolonged times of sedentary behaviour where major locomotor muscles are inactive, significantly increase the risk of chronic diseases. The purpose of this study was to provide details of quadriceps and hamstring muscle inactivity and activity during normal daily life of ordinary people. Eighty-four volunteers (44 females, 40 males, 44.1±17.3 years, 172.3±6.1 cm, 70.1±10.2 kg) were measured during normal daily life using shorts measuring muscle electromyographic (EMG) activity (recording time 11.3±2.0 hours). EMG was normalized to isometric MVC (EMG(MVC)) during knee flexion and extension, and inactivity threshold of each muscle group was defined as 90% of EMG activity during standing (2.5±1.7% of EMG(MVC)). During normal daily life the average EMG amplitude was 4.0±2.6% and average activity burst amplitude was 5.8±3.4% of EMG(MVC) (mean duration of 1.4±1.4 s) which is below the EMG level required for walking (5 km/h corresponding to EMG level of about 10% of EMG(MVC)). Using the proposed individual inactivity threshold, thigh muscles were inactive 67.5±11.9% of the total recording time and the longest inactivity periods lasted for 13.9±7.3 min (2.5-38.3 min). Women had more activity bursts and spent more time at intensities above 40% EMG(MVC) than men (p<0.05). In conclusion, during normal daily life the locomotor muscles are inactive about 7.5 hours, and only a small fraction of muscle's maximal voluntary activation capacity is used averaging only 4% of the maximal recruitment of the thigh muscles. Some daily non-exercise activities such as stair climbing produce much higher muscle activity levels than brisk walking, and replacing sitting by standing can considerably increase cumulative daily muscle activity.

Concepts: Mode, Muscle, Physical exercise, Knee, Electromyography, Arithmetic mean, Thigh, Extension

175

BACKGROUND: Strontium ranelate is currently used for osteoporosis. The international, double-blind, randomised, placebo-controlled Strontium ranelate Efficacy in Knee OsteoarthrItis triAl evaluated its effect on radiological progression of knee osteoarthritis. METHODS: Patients with knee osteoarthritis (Kellgren and Lawrence grade 2 or 3, and joint space width (JSW) 2.5-5 mm) were randomly allocated to strontium ranelate 1 g/day (n=558), 2 g/day (n=566) or placebo (n=559). The primary endpoint was radiographical change in JSW (medial tibiofemoral compartment) over 3 years versus placebo. Secondary endpoints included radiological progression, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and knee pain. The trial is registered (ISRCTN41323372). RESULTS: The intention-to-treat population included 1371 patients. Treatment with strontium ranelate was associated with smaller degradations in JSW than placebo (1 g/day: -0.23 (SD 0.56) mm; 2 g/day: -0.27 (SD 0.63) mm; placebo: -0.37 (SD 0.59) mm); treatment-placebo differences were 0.14 (SE 0.04), 95% CI 0.05 to 0.23, p<0.001 for 1 g/day and 0.10 (SE 0.04), 95% CI 0.02 to 0.19, p=0.018 for 2 g/day. Fewer radiological progressors were observed with strontium ranelate (p<0.001 and p=0.012 for 1 and 2 g/day). There were greater reductions in total WOMAC score (p=0.045), pain subscore (p=0.028), physical function subscore (p=0.099) and knee pain (p=0.065) with strontium ranelate 2 g/day. Strontium ranelate was well tolerated. CONCLUSIONS: Treatment with strontium ranelate 1 and 2 g/day is associated with a significant effect on structure in patients with knee osteoarthritis, and a beneficial effect on symptoms for strontium ranelate 2 g/day.

Concepts: Knee, Joint, Acupuncture, Strontium ranelate

169

The effects of hip muscle strength and activation on anterior cruciate ligament injury biomechanics, particularly knee valgus loading, have been reported in isolation and with equivocal results. However, the combination of these factors influences joint biomechanics. This investigation evaluated the influence of hip strength on gluteal activation and knee valgus motion. Maximal isometric hip abduction (ABD) and external rotation (ER) contractions were used to define High and Low strength groups. Knee kinematics and gluteus maximus (GMax) and medius (GMed) EMG amplitudes obtained during landing were compared between High and Low strength groups after controlling for the potential confounding influence of sex. Knee valgus motion did not differ between the High and Low hip ABD and ER strength groups. However, the Low ABD and ER strength groups displayed greater GMed and GMax EMG amplitudes, respectively, compared to the High strength groups. These findings suggest that weaker individuals compensate for a lack of force production via heightened neural drive. As such, hip muscle strength influences knee valgus motion indirectly by determining neural drive requirements.

Concepts: Knee, Anterior cruciate ligament, Electromyography, Muscular system, Ligament, Anterior cruciate ligament injury, Cruciate ligament, Gluteal muscles

169

Articular cartilage maturation is the postnatal development process that adapts joint surfaces to their site-specific biomechanical demands. Maturation involves gross morphological changes that occur through a process of synchronised growth and resorption of cartilage and generally ends at sexual maturity. The inability to induce maturation in biomaterial constructs designed for cartilage repair has been cited as a major cause for their failure in producing persistent cell-based repair of joint lesions. The combination of growth factors FGF2 and TGFβ1 induces accelerated articular cartilage maturation in vitro such that many molecular and morphological characteristics of tissue maturation are observable. We hypothesised that experimental growth factor-induced maturation of immature cartilage would result in a biophysical and biochemical composition consistent with a mature phenotype. Using native immature and mature cartilage as reference, we observed that growth factor-treated immature cartilages displayed increased nano-compressive stiffness, decreased surface adhesion, decreased water content, increased collagen content and smoother surfaces, correlating with a convergence to the mature cartilage phenotype. Furthermore, increased gene expression of surface structural protein collagen type I in growth factor-treated explants compared to reference cartilages demonstrates that they are still in the dynamic phase of the postnatal developmental transition. These data provide a basis for understanding the regulation of postnatal maturation of articular cartilage and the application of growth factor-induced maturation in vitro and in vivo in order to repair and regenerate cartilage defects.

Concepts: Bone, Gene, Molecular biology, Collagen, Cartilage, Knee, Biochemistry, Articular cartilage repair

169

BACKGROUND: Platelet Rich Plasma (PRP), a blood-derived product rich in growth factors, is a promising treatment for cartilage defects but there is still a lack of clinical evidence. The aim of this study is to show, through a randomized double blind prospective trial, the efficacy of this procedure, by comparing PRP to Hyaluronic Acid (HA) injections for the treatment of knee chondropathy or osteoarthritis (OA). METHODS: 109 patients (55 treated with HA and 54 with PRP) were treated and evaluated at 12 months of follow-up. The patients were enrolled according to the following inclusion criteria: age> 18 years, history of chronic (at least 4 months) pain or swelling of the knee and imaging findings of degenerative changes of the joint (Kellgren-Lawrence Score up to 3). A cycle of 3 weekly injections was administered blindly. All patients were prospectively evaluated before and at 2, 6, and 12 months after the treatment by: IKDC, EQ-VAS, TEGNER, and KOOS scores. Range of motion and knee circumference changes were measured over time. Adverse events and patient satisfaction were also recorded. RESULTS: Only minor adverse events were detected in some patients, such as mild pain and effusion after the injections, in particular in the PRP group, where a significantly higher post-injective pain reaction was observed (p=0.039). At the follow-up evaluations, both groups presented a clinical improvement but the comparison between the two groups showed a not statistically significant difference in all scores evaluated. A trend favorable for the PRP group was only found in patients with low grade articular degeneration (Kellgren-Lawrence score up to 2). CONCLUSIONS: Results suggest that PRP injections offer a significant clinical improvement up to one year of follow-up. However, conversely to what was shown by the current literature, for middle-aged patients with moderate signs of OA, PRP results were not better than those obtained with HA injections, and thus it should not be considered as first line treatment. More promising results are shown for its use in low grade degeneration, but they still have to be confirmed.

Concepts: Clinical trial, Randomized controlled trial, Statistical significance, Cartilage, Knee, Pharmaceutical industry, Clinical research, Adverse event

167

Objective. To study the role of different imaging modalities, ultrasonography, conventional radiography (CR) and CT, in visualization of chondrocalcinosis of the knees in patients with CPDD.Methods. Twenty-five patients (14 males and 11 females) with CPDD were enrolled in the study. Diagnosis was made according to D.J. McCarty classification criteria. All patients had arthritis of the knee and underwent aspiration of SF from the knee and microscopic investigation of SF samples. Diagnosis of CPDD was crystal proven. Three imaging methods were performed in patients: CR, CT and US of the knees.Results. CR of the knee confirmed cartilage calcification (CC) in 13 patients, CT in 18 patients and US in 25 patients. No difference in age or disease duration between patients with CC detected by different imaging methods was found.Conclusion. US appeared to be a helpful tool, possibly better than CR or CT, in revealing CC in patients with CPDD. Informativity of CT and CR in the detection of CC is almost equal.

Concepts: Medical imaging, Cartilage, Osteoarthritis, Knee, Difference

167

BACKGROUND: A common goal of persons post-stroke is to regain community ambulation. The plantar flexor muscles play an important role in propulsion generation and swing initiation as previous musculoskeletal simulations have shown. The purpose of this study was to demonstrate that simulation results quantifying changes in plantar flexor activation and function in individuals post-stroke were consistent with (1) the purpose of an intervention designed to enhance plantar flexor function and (2) expected muscle function during gait based on previous literature. METHODS: Three-dimensional, forward dynamic simulations were created to determine the changes in model activation and function of the paretic ankle plantar flexor muscles for eight patients post-stroke after a 12-weeks FastFES gait retraining program. RESULTS: An median increase of 0.07 (Range [-0.01,0.22]) was seen in simulated activation averaged across all plantar flexors during the double support phase of gait from pre- to post-intervention. A concurrent increase in walking speed and plantar flexor induced forward center of mass acceleration by the plantar flexors was seen post-intervention for seven of the eight subject simulations. Additionally, post-training, the plantar flexors had an simulated increase in contribution to knee flexion acceleration during double support. CONCLUSIONS: For the first time, muscle-actuated musculoskeletal models were used to simulate the effect of a gait retraining intervention on post-stroke muscle model predicted activation and function. The simulations showed a new pattern of simulated activation for the plantar flexor muscles after training, suggesting that the subjects activated these muscles with more appropriate timing following the intervention. Functionally, simulations calculated that the plantar flexors provided greater contribution to knee flexion acceleration after training, which is important for increasing swing phase knee flexion and foot clearance.

Concepts: Knee, Sartorius muscle, Flexion, Extension, Semitendinosus muscle, Semimembranosus muscle, Popliteus muscle, Musculoskeletal system

166

PURPOSE: To compare the biomechanical and technical properties of flexor tendon repairs using a 4-strand cruciate FiberWire (FW) repair and a 2-strand multifilament stainless steel (MFSS) single cross-lock cable-crimp system. METHODS: Eight tests were conducted for each type of repair using cadaver hand flexor digitorum profundus tendons. We measured the required surgical exposure, repair time, and force of flexion (friction) with a custom motor system with an inline load cell and measured ultimate tensile strength (UTS) and 2-mm gap force on a servo-hydraulic testing machine. RESULTS: Repair time averaged less than 7 minutes for the 2-strand MFSS cable crimp repairs and 12 minutes for the FW repairs. The FW repair was performed with 2 cm of exposure and removal of the C-1 and A-3 pulleys. The C-1 and A-3 pulleys were retained in each of the MFSS cable crimp repairs with less than 1 cm of exposure. Following the FW repair, the average increase in friction was 89% compared with an average of 53% for the MFSS repairs. Six of the 8 MFSS specimens achieved the UTS before any gap had occurred, whereas all of the FW repairs had more than 2 mm of gap before the UTS, indicating that the MFSS was a stiffer repair. The average UTS appeared similar for both groups. CONCLUSIONS: We describe a 2-strand multifilament stainless steel single cross-lock cable crimp flexor repair system. In our studies of this cable crimp system, we found that surgical exposure, average repair times, and friction were reduced compared to the traditional 4-strand cruciate FW repair. While demonstrating these benefits, the crimp repair also produced a stiff construct and high UTS and 2-mm gap force. CLINICAL RELEVANCE: A cable crimp flexor tendon repair may offer an attractive alternative to current repair methods. The benefits may be important especially for flexor tendon repair in zone 2 or for the repair of multiple tendons.

Concepts: Knee, Force, Tensile strength, Steel, Titanium, Strength of materials, Flexor digitorum profundus muscle, Stainless steel

161

Clinical features of anterior cruciate ligament (ACL) injury are important for its prevention, diagnosis and treatment. However, few studies have reported such data, especially in China. The purpose of this study was to describe the clinical characteristics of ACL injury on a large cohort.

Concepts: Knee, Anterior cruciate ligament, Cultural studies, Ligament, Anterior cruciate ligament injury, Anterior cruciate ligament reconstruction, Cruciate ligament, Ligaments