Torsion Tool: An automated tool for personalising femoral and tibial geometries in OpenSim musculoskeletal models

Full-length radiograph based automatic musculoskeletal modeling using convolutional neural network

Full-length radiographs contain information from which many anatomical parameters of the pelvis, femur, and tibia may be derived, but only a few anatomical parameters are used for musculoskeletal modeling. This study aimed to develop a fully automatic algorithm to extract anatomical parameters from full-length radiograph to generate a musculoskeletal model that is more accurate than linear scaled one. A U-Net convolutional neural network was trained to segment the pelvis, femur, and tibia from the full-length radiograph. Eight anatomic parameters (six for length and width, two for angles) were automatically extracted from the bone segmentation masks and used to generate the musculoskeletal model. Sørensen-Dice coefficient was used to quantify the consistency of automatic bone segmentation masks with manually segmented labels. Maximum distance error, root mean square (RMS) distance error and Jaccard index (JI) were used to evaluate the geometric accuracy of the automatically generated pelvis, femur and tibia models versus CT bone models. Mean Sørensen-Dice coefficients for the pelvis, femur and tibia 2D segmentation masks were 0.9898, 0.9822 and 0.9786, respectively. The algorithm-driven bone models were closer to the 3D CT bone models than the scaled generic models in geometry, with significantly lower maximum distance error (28.3 % average decrease from 24.35 mm) and RMS distance error (28.9 % average decrease from 9.55 mm) and higher JI (17.2 % average increase from 0.46) (P < 0.001). The algorithm-driven musculoskeletal modeling (107.15 ± 10.24 s) was faster than the manual process (870.07 ± 44.79 s) for the same full-length radiograph. This algorithm provides a fully automatic way to generate a musculoskeletal model from full-length radiograph that achieves an approximately 30 % reduction in distance errors, which could enable personalized musculoskeletal simulation based on full-length radiograph for large scale OA populations.

A framework based on subject-specific musculoskeletal models and Monte Carlo simulations to personalize muscle coordination retraining

Excessive loads at lower limb joints can lead to pain and degenerative diseases. Altering joint loads with muscle coordination retraining might help to treat or prevent clinical symptoms in a non-invasive way. Knowing how much muscle coordination retraining can reduce joint loads and which muscles have the biggest impact on joint loads is crucial for personalized gait retraining. We introduced a simulation framework to quantify the potential of muscle coordination retraining to reduce joint loads for an individuum. Furthermore, the proposed framework enables to pinpoint muscles, which alterations have the highest likelihood to reduce joint loads. Simulations were performed based on three-dimensional motion capture data of five healthy adolescents (femoral torsion 10°-29°, tibial torsion 19°-38°) and five patients with idiopathic torsional deformities at the femur and/or tibia (femoral torsion 18°-52°, tibial torsion 3°-50°). For each participant, a musculoskeletal model was modified to match the femoral and tibial geometry obtained from magnetic resonance images. Each participant's model and the corresponding motion capture data were used as input for a Monte Carlo analysis to investigate how different muscle coordination strategies influence joint loads. OpenSim was used to run 10,000 simulations for each participant. Root-mean-square of muscle forces and peak joint contact forces were compared between simulations. Depending on the participant, altering muscle coordination led to a maximum reduction in hip, knee, patellofemoral and ankle joint loads between 5 and 18%, 4% and 45%, 16% and 36%, and 2% and 6%, respectively. In some but not all participants reducing joint loads at one joint increased joint loads at other joints. The required alteration in muscle forces to achieve a reduction in joint loads showed a large variability between participants. The potential of muscle coordination retraining to reduce joint loads depends on the person's musculoskeletal geometry and gait pattern and therefore showed a large variability between participants, which highlights the usefulness and importance of the proposed framework to personalize gait retraining.

Influence of femoral anteversion angle and neck-shaft angle on muscle forces and joint loading during walking

Femoral deformities, e.g. increased or decreased femoral anteversion (AVA) and neck-shaft angle (NSA), can lead to pathological gait patterns, altered joint loads, and degenerative joint diseases. The mechanism how femoral geometry influences muscle forces and joint load during walking is still not fully understood. The objective of our study was to investigate the influence of femoral AVA and NSA on muscle forces and joint loads during walking. We conducted a comprehensive musculoskeletal modelling study based on three-dimensional motion capture data of a healthy person with a typical gait pattern. We created 25 musculoskeletal models with a variety of NSA (93°-153°) and AVA (-12°-48°). For each model we calculated moment arms, muscle forces, muscle moments, co-contraction indices and joint loads using OpenSim. Multiple regression analyses were used to predict muscle activations, muscle moments, co-contraction indices, and joint contact forces based on the femoral geometry. We found a significant increase in co-contraction of hip and knee joint spanning muscles in models with increasing AVA and NSA, which led to a substantial increase in hip and knee joint contact forces. Decreased AVA and NSA had a minor impact on muscle and joint contact forces. Large AVA lead to increases in both knee and hip contact forces. Large NSA (153°) combined with large AVA (48°) led to increases in hip joint contact forces by five times body weight. Low NSA (108° and 93°) combined with large AVA (48°) led to two-fold increases in the second peak of the knee contact forces. Increased joint contact forces in models with increased AVA and NSA were linked to changes in hip muscle moment arms and compensatory increases in hip and knee muscle forces. Knowing the influence of femoral geometry on muscle forces and joint loads can help clinicians to improve treatment strategies in patients with femoral deformities.

The gait pattern and not the femoral morphology is the main contributor to asymmetric hip joint loading

Gait asymmetry and skeletal deformities are common in many children with cerebral palsy (CP). Changes of the hip joint loading, i.e. hip joint contact force (HJCF), can lead to pathological femoral growth. A child's gait pattern and femoral morphology affect HJCFs. The twofold aim of this study was to (1) evaluate if the asymmetry in HJCFs is higher in children with CP compared to typically developing (TD) children and (2) identify if the bony morphology or the subject-specific gait pattern is the main contributor to asymmetric HJCFs. Magnetic resonance images (MRI) and three-dimensional gait analysis data of twelve children with CP and fifteen TD children were used to create subject-specific musculoskeletal models and calculate HJCF using OpenSim. Root-mean-square-differences between left and right HJCF magnitude and orientation were computed and compared between participant groups (CP versus TD). Additionally, the influence on HJCF asymmetries solely due to the femoral morphology and solely due to the gait pattern was quantified. Our findings demonstrate that the gait pattern is the main contributor to asymmetric HJCFs in CP and TD children. Children with CP have higher HJCF asymmetries which is probably the result of larger asymmetries in their gait pattern compared to TD children. The gained insights from our study highlight that clinical interventions should focus on normalizing the gait pattern and therefore the hip joint loading to avoid the development of femoral deformities.

The Role of Multifidus in the Biomechanics of Lumbar Spine: A Musculoskeletal Modeling Study

BACKGROUND

The role of multifidus in the biomechanics of lumbar spine remained unclear.

PURPOSE

This study aimed to investigate the role of multifidus in the modeling of lumbar spine and the influence of asymmetric multifidus atrophy on the biomechanics of lumbar spine.

METHODS

This study considered five different multifidus conditions in the trunk musculoskeletal models: group 1 (with entire multifidus), group 2 (without multifidus), group 3 (multifidus with half of maximum isometric force), group 4 (asymmetric multifidus atrophy on L5/S1 level), and group 5 (asymmetric multifidus atrophy on L4/L5 level). In order to test how different multifidus situations would affect the lumbar spine, four trunk flexional angles (0°, 30°, 60°, and 90°) were simulated. The calculation of muscle activation and muscle force was done using static optimization function in OpenSim. Then, joint reaction forces of L5/S1 and L4/L5 levels were calculated and compared among the groups.

RESULTS

The models without multifidus had the highest normalized compressive forces on the L4/L5 level in trunk flexion tasks. In extreme cases produced by group 2 models, the normalized compressive forces on L4/L5 level were 444% (30° flexion), 568% (60° flexion), and 576% (90° flexion) of upper body weight, which were 1.82 times, 1.63 times, and 1.13 times as large as the values computed by the corresponding models in group 1. In 90° flexion, the success rate of simulation in group 2 was 49.6%, followed by group 3 (84.4%), group 4 (89.6%), group 5 (92.8%), and group 1 (92.8%).

CONCLUSIONS

The results demonstrate that incorporating multifidus in the musculoskeletal model is important for increasing the success rate of simulation and decreasing the incidence of overestimation of compressive load on the lumbar spine. Asymmetric multifidus atrophy has negligible effect on the lower lumbar spine in the trunk flexion posture. The results highlighted the fine-tuning ability of multifidus in equilibrating the loads on the lower back and the necessity of incorporating multifidus in trunk musculoskeletal modeling.

Intra- and inter-subject variability of femoral growth plate stresses in typically developing children and children with cerebral palsy

Little is known about the influence of mechanical loading on growth plate stresses and femoral growth. A multi-scale workflow based on musculoskeletal simulations and mechanobiological finite element (FE) analysis can be used to estimate growth plate loading and femoral growth trends. Personalizing the model in this workflow is time-consuming and therefore previous studies included small sample sizes (N < 4) or generic finite element models. The aim of this study was to develop a semi-automated toolbox to perform this workflow and to quantify intra-subject variability in growth plate stresses in 13 typically developing (TD) children and 12 children with cerebral palsy (CP). Additionally, we investigated the influence of the musculoskeletal model and the chosen material properties on the simulation results. Intra-subject variability in growth plate stresses was higher in cerebral palsy than in typically developing children. The highest osteogenic index (OI) was observed in the posterior region in 62% of the TD femurs while in children with CP the lateral region was the most common (50%). A representative reference osteogenic index distribution heatmap generated from data of 26 TD children's femurs showed a ring shape with low values in the center region and high values at the border of the growth plate. Our simulation results can be used as reference values for further investigations. Furthermore, the code of the developed GP-Tool ("Growth Prediction-Tool") is freely available on GitHub (https://github.com/WilliKoller/GP-Tool) to enable peers to conduct mechanobiological growth studies with larger sample sizes to improve our understanding of femoral growth and to support clinical decision making in the near future.

Increased Femoral Anteversion Does Not Lead to Increased Joint Forces During Gait in a Cohort of Adolescent Patients

Orthopedic complications were previously reported for patients with increased femoral anteversion. A more comprehensive analysis of the influence of increased femoral anteversion on joint loading in these patients is required to better understand the pathology and its clinical management. Therefore, the aim was to investigate lower-limb kinematics, joint moments and forces during gait in adolescent patients with increased, isolated femoral anteversion compared to typically developing controls. Secondly, relationships between the joint loads experienced by the patients and different morphological and kinematic features were investigated. Patients with increased femoral anteversion (n = 42, 12.8 ± 1.9 years, femoral anteversion: 39.6 ± 6.9°) were compared to typically developing controls (n = 9, 12.0 ± 3.0 years, femoral anteversion: 18.7 ± 4.1°). Hip and knee joint kinematics and kinetics were calculated using subject-specific musculoskeletal models. Differences between patients and controls in the investigated outcome variables (joint kinematics, moments, and forces) were evaluated through statistical parametric mapping with Hotelling T2 and t-tests (α = 0.05). Canonical correlation analyses (CCAs) and regression analyses were used to evaluate within the patients’ cohort the effect of different morphological and kinematic predictors on the outcome variables. Predicted compressive proximo-distal loads in both hip and knee joints were significantly reduced in patients compared to controls. A gait pattern characterized by increased knee flexion during terminal stance (KneeFlex_tSt) was significantly correlated with hip and knee forces, as well as with the resultant force exerted by the quadriceps on the patella. On the other hand, hip internal rotation and in-toeing, did not affect the loads in the joints. Based on the finding of the CCAs and linear regression analyses, patients were further divided into two subgroups based KneeFlex_tSt. Patients with excessive KneeFlex_tSt presented a significantly higher femoral anteversion than those with normal KneeFlex_tSt. Patients with excessive KneeFlex_tSt presented significantly larger quadriceps forces on the patella and a larger posteriorly-oriented shear force at the knee, compared to patients with normal KneeFlex_tSt, but both patients’ subgroups presented only limited differences in terms of joint loading compared to controls. This study showed that an altered femoral morphology does not necessarily lead to an increased risk of joint overloading, but instead patient-specific kinematics should be considered.

Conclusion or Illusion: Quantifying Uncertainty in Inverse Analyses From Marker-Based Motion Capture due to Errors in Marker Registration and Model Scaling

Estimating kinematics from optical motion capture with skin-mounted markers, referred to as an inverse kinematic (IK) calculation, is the most common experimental technique in human motion analysis. Kinematics are often used to diagnose movement disorders and plan treatment strategies. In many such applications, small differences in joint angles can be clinically significant. Kinematics are also used to estimate joint powers, muscle forces, and other quantities of interest that cannot typically be measured directly. Thus, the accuracy and reproducibility of IK calculations are critical. In this work, we isolate and quantify the uncertainty in joint angles, moments, and powers due to two sources of error during IK analyses: errors in the placement of markers on the model (marker registration) and errors in the dimensions of the model’s body segments (model scaling). We demonstrate that IK solutions are best presented as a distribution of equally probable trajectories when these sources of modeling uncertainty are considered. Notably, a substantial amount of uncertainty exists in the computed kinematics and kinetics even if low marker tracking errors are achieved. For example, considering only 2 cm of marker registration uncertainty, peak ankle plantarflexion angle varied by 15.9°, peak ankle plantarflexion moment varied by 26.6 N⋅m, and peak ankle power at push off varied by 75.9 W during healthy gait. This uncertainty can directly impact the classification of patient movements and the evaluation of training or device effectiveness, such as calculations of push-off power. We provide scripts in OpenSim so that others can reproduce our results and quantify the effect of modeling uncertainty in their own studies.

Altered Muscle Contributions are Required to Support the Stance Limb During Voluntary Toe-Walking

Toe-walking characterizes several neuromuscular conditions and is associated with a reduction in gait stability and efficiency, as well as in life quality. The optimal choice of treatment depends on a correct understanding of the underlying pathology and on the individual biomechanics of walking. The objective of this study was to describe gait deviations occurring in a cohort of healthy adult subjects when mimicking a unilateral toe-walking pattern compared to their normal heel-to-toe gait pattern. The focus was to characterize the functional adaptations of the major lower-limb muscles which are required in order to toe walk. Musculoskeletal modeling was used to estimate the required muscle contributions to the joint sagittal moments. The support moment, defined as the sum of the sagittal extensive moments at the ankle, knee, and hip joints, was used to evaluate the overall muscular effort necessary to maintain stance limb stability and prevent the collapse of the knee. Compared to a normal heel-to-toe gait pattern, toe-walking was characterized by significantly different lower-limb kinematics and kinetics. The altered kinetic demands at each joint translated into different necessary moment contributions from most muscles. In particular, an earlier and prolonged ankle plantarflexion contribution was required from the soleus and gastrocnemius during most of the stance phase. The hip extensors had to provide a higher extensive moment during loading response, while a significantly higher knee extension contribution from the vasti was necessary during mid-stance. Compensatory muscular activations are therefore functionally required at every joint level in order to toe walk. A higher support moment during toe-walking indicates an overall higher muscular effort necessary to maintain stance limb stability and prevent the collapse of the knee. Higher muscular demands during gait may lead to fatigue, pain, and reduced quality of life. Toe-walking is indeed associated with significantly larger muscle forces exerted by the quadriceps to the patella and prolonged force transmission through the Achilles tendon during stance phase. Optimal treatment options should therefore account for muscular demands and potential overloads associated with specific compensatory mechanisms.

Effectiveness of Global Optimisation and Direct Kinematics in Predicting Surgical Outcome in Children with Cerebral Palsy

Multibody optimisation approaches have not seen much use in routine clinical applications despite evidence of improvements in modelling through a reduction in soft tissue artifacts compared to the standard gait analysis technique of direct kinematics. To inform clinical use, this study investigated the consistency with which both approaches predicted post-surgical outcomes, using changes in Gait Profile Score (GPS) when compared to a clinical assessment of outcome that did not include the 3D gait data. Retrospective three-dimensional motion capture data were utilised from 34 typically developing children and 26 children with cerebral palsy who underwent femoral derotation osteotomies as part of Single Event Multi-Level Surgeries. Results indicated that while, as expected, the GPS estimated from the two methods were numerically different, they were strongly correlated (Spearman's ρ = 0.93), and no significant differences were observed between their estimations of change in GPS after surgery. The two scores equivalently classified a worsening or improvement in the gait quality in 93% of the cases. When compared with the clinical classification of responders versus non-responders to the intervention, an equivalent performance was found for the two approaches, with 27/41 and 28/41 cases in agreement with the clinical judgement for multibody optimisation and direct kinematics, respectively. With this equivalent performance to the direct kinematics approach and the benefit of being less sensitive to skin artefact and allowing additional analysis such as estimation of musculotendon lengths and joint contact forces, multibody optimisation has the potential to improve the clinical decision-making process in children with cerebral palsy.