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Kriener K, Whiting H, Storr N, Homes R, Lala R, Gabrielyan R, Kuang J, Rubin B, Frails E, Sandstrom H, Futter C, Midwinter M. Applied use of biomechanical measurements from human tissues for the development of medical skills trainers: a scoping review. JBI Evid Synth 2023; 21:2309-2405. [PMID: 37732940 DOI: 10.11124/jbies-22-00363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVE The objective of this review was to identify quantitative biomechanical measurements of human tissues, the methods for obtaining these measurements, and the primary motivations for conducting biomechanical research. INTRODUCTION Medical skills trainers are a safe and useful tool for clinicians to use when learning or practicing medical procedures. The haptic fidelity of these devices is often poor, which may be because the synthetic materials chosen for these devices do not have the same mechanical properties as human tissues. This review investigates a heterogeneous body of literature to identify which biomechanical properties are available for human tissues, the methods for obtaining these values, and the primary motivations behind conducting biomechanical tests. INCLUSION CRITERIA Studies containing quantitative measurements of the biomechanical properties of human tissues were included. Studies that primarily focused on dynamic and fluid mechanical properties were excluded. Additionally, studies only containing animal, in silico , or synthetic materials were excluded from this review. METHODS This scoping review followed the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sources of evidence were extracted from CINAHL (EBSCO), IEEE Xplore, MEDLINE (PubMed), Scopus, and engineering conference proceedings. The search was limited to the English language. Two independent reviewers screened titles and abstracts as well as full-text reviews. Any conflicts that arose during screening and full-text review were mediated by a third reviewer. Data extraction was conducted by 2 independent reviewers and discrepancies were mediated through discussion. The results are presented in tabular, figure, and narrative formats. RESULTS Data were extracted from a total of 186 full-text publications. All of the studies, except for 1, were experimental. Included studies came from 33 countries, with the majority coming from the United States. Ex vivo methods were the predominant approach for extracting human tissue samples, and the most commonly studied tissue type was musculoskeletal. In this study, nearly 200 unique biomechanical values were reported, and the most commonly reported value was Young's (elastic) modulus. The most common type of mechanical test performed was tensile testing, and the most common reason for testing human tissues was to characterize biomechanical properties. Although the number of published studies on biomechanical properties of human tissues has increased over the past 20 years, there are many gaps in the literature. Of the 186 included studies, only 7 used human tissues for the design or validation of medical skills training devices. Furthermore, in studies where biomechanical values for human tissues have been obtained, a lack of standardization in engineering assumptions, methodologies, and tissue preparation may implicate the usefulness of these values. CONCLUSIONS This review is the first of its kind to give a broad overview of the biomechanics of human tissues in the published literature. With respect to high-fidelity haptics, there is a large gap in the published literature. Even in instances where biomechanical values are available, comparing or using these values is difficult. This is likely due to the lack of standardization in engineering assumptions, testing methodology, and reporting of the results. It is recommended that journals and experts in engineering fields conduct further research to investigate the feasibility of implementing reporting standards. REVIEW REGISTRATION Open Science Framework https://osf.io/fgb34.
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Affiliation(s)
- Kyleigh Kriener
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Harrison Whiting
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Clinical Medicine, Royal Brisbane Clinical Unit, The University of Queensland, Brisbane, QLD, Australia
| | - Nicholas Storr
- Gold Coast University Hospital, Southport, QLD Australia
| | - Ryan Homes
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Raushan Lala
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Robert Gabrielyan
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
- Ochsner Clinical School, Jefferson, LA, United States
| | - Jasmine Kuang
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
- Ochsner Clinical School, Jefferson, LA, United States
| | - Bryn Rubin
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
- Ochsner Clinical School, Jefferson, LA, United States
| | - Edward Frails
- Department of Chemical Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - Hannah Sandstrom
- Department of Exercise Science and Sport Management, Kennesaw State University, Kennesaw, GA, United States
| | - Christopher Futter
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Anaesthesia and Intensive Care Program, Herston Biofabrication institute, Brisbane, QLD, Australia
| | - Mark Midwinter
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
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Kriener K, Ding-Farrington C, Rodgers S, Midwinter M. Tools measuring high haptic fidelity of procedural skills trainers in physician training and education: a scoping review protocol. JBI Evid Synth 2023; 21:2127-2133. [PMID: 37435682 DOI: 10.11124/jbies-22-00348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
OBJECTIVE The objective of this scoping review is to identify instruments that measure the physical haptic fidelity of procedural skills trainers. INTRODUCTION Procedural skills trainers have demonstrated beneficial outcomes for clinicians when used to practice and rehearse procedures. Despite this, several design flaws currently limit the widespread implementation of such trainers. One notable deficit in current trainer designs is haptic fidelity. Identifying measurements of haptic fidelity may maximize the benefit of using certain training devices as well as guiding future design. INCLUSION CRITERIA This review will consider studies that assess the high fidelity haptics of procedural skills training devices in adult physicians above the level of an intern physician. Studies that do not include physicians will be excluded. METHODS The review will follow the JBI methodology for scoping reviews and will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Both published and unpublished studies will be searched for in MEDLINE (PubMed), Scopus, Web of Science Core Collection, Cochrane Central Register of Controlled Trials (CENTRAL), Embase (Ovid), CINAHL (EBSCOhost), ProQuest Dissertations and Theses (ProQuest), and Google Scholar. There will be no date, setting, or geographical limits, but only studies in English will be included. REVIEW REGISTRATION Open Science Framework osf.io/pvazu/.
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Affiliation(s)
- Kyleigh Kriener
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Finni T, de Brito Fontana H, Maas H. Force transmission and interactions between synergistic muscles. J Biomech 2023; 152:111575. [PMID: 37120913 DOI: 10.1016/j.jbiomech.2023.111575] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 05/02/2023]
Abstract
The classical view of muscles as independent motors has been challenged over the past decades. An alternative view has emerged in which muscles are not isolated but embedded in a three-dimensional connective tissue network that links them to adjacent muscles and other non-muscular structures in the body. Animal studies showing that the forces measured at the distal and proximal ends of a muscle are not equal have provided undisputable evidence that these connective tissue linkages are strong enough to serve as an extra pathway for muscular force transmission. In this historical review, we first introduce the terminology and anatomy related to these pathways of muscle force transmission and provide a definition for the term epimuscular force transmission. We then focus on important experimental evidence indicating mechanical interactions between synergistic muscles that may affect force transmission and/or influence the muscles' force generating capacity. We illustrate that there may exist different expressions of the highly relevant force-length properties depending on whether the force is measured at the proximal or distal tendon and depending on the dynamics of surrounding structures. Changes in length, activation level or disruption of the connective tissue of neighboring muscles, can affect how muscles interact and produce force on the skeleton. While most direct evidence is from animal experiments, studies on humans also suggest functional implications of the connective tissues surrounding muscles. These implications may explain how distant segments, which are not part of the same joint system, affect force generation at a given joint, and, in clinical conditions, explain observations from tendon transfer surgeries, where a muscle transferred to act as an antagonist continues to produce agonistic moments.
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Affiliation(s)
- Taija Finni
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Finland
| | - Heiliane de Brito Fontana
- Department of Morphological Sciences, School of Biological Sciences, Federal University of Santa Catarina, Brazil
| | - Huub Maas
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Movement Sciences, Vrije Universiteit Amsterdam, The Netherlands.
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Ling H, Roberts KL, Kao D, Balasubramanian R. Force-amplifying implant to improve key pinch strength in tendon transfer surgery: Cadaver model proof-of-concept. J Orthop Res 2023. [PMID: 36606426 DOI: 10.1002/jor.25511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/23/2022] [Accepted: 01/04/2023] [Indexed: 01/07/2023]
Abstract
The brachioradialis (BR) to flexor pollicis longus (FPL) tendon transfer surgery is a common procedure used to restore key pinch grip for incomplete spinal cord injury patients. However, the procedure only restores 22% of the physiological grip strength, which is important for successfully grasping objects and minimizing fatigue. The purpose of this study was to evaluate the efficacy of using a novel force-amplifying pulley implant to modify the standard BR to FPL tendon transfer surgery to improve key pinch grip strength in a human cadaver forearm model. A total of eight cadaveric specimens were mounted onto a custom testbed where a torque-controlled motor actuated the BR tendon to produce key pinch grip. In each cadaver, two experimental groups were examined: a standard and an implant-modified BR to FPL tendon transfer surgery. A force sensor mounted to the thumb recorded isometric key pinch grip forces over a range of input BR forces (2 N-25 N) applied in a ramp-and-hold protocol. Across the range of input BR forces, the average improvement in key pinch grip strength in the implant-modified surgery compared to the standard surgery was 58 ± 7.1% (ranging from 41% to 64% improvement). Throughout the experiments, we observed that the implant did not hinder the movement of the BR or FPL tendons. These results suggest that a BR to FPL tendon transfer surgery utilizing a force-amplifying pulley implant to augment force transmission can provide additional functional strength restoration over the standard procedure that directly sutures two tendons together.
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Affiliation(s)
- Hantao Ling
- School of Mechanical, Industrial and Manufacturing Engineering, Oregon State University, Corvallis, Oregon, USA
| | - Kai L Roberts
- School of Mechanical, Industrial and Manufacturing Engineering, Oregon State University, Corvallis, Oregon, USA
| | - Dennis Kao
- Institute of Dermatology and Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ravi Balasubramanian
- School of Mechanical, Industrial and Manufacturing Engineering, Oregon State University, Corvallis, Oregon, USA
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Lieber RL, Fridén J. Teamwork Pays! Ten Tips for a Great Surgeon-Scientist Collaboration. J Hand Surg Am 2022; 47:673-676. [PMID: 35221173 PMCID: PMC9271536 DOI: 10.1016/j.jhsa.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 07/25/2021] [Accepted: 01/03/2022] [Indexed: 02/02/2023]
Abstract
This review represents our summary of what makes a great collaboration between a surgeon and a scientist. At first, with no perspective, such a collaboration seems easy and natural. But as time goes on, with more perspective, you realize how special it is. Now, in our 60s, with approximately 35 years of collaboration and 75 coauthored papers (most of them in The Journal of Hand Surgery), we are thankful and humbled for this tremendously fruitful and, importantly, enjoyable collaboration. We are not so foolish to think that we made this great collaboration-it was a gift. However, we now recognize many characteristics that make it great and have developed the following 10 tips.
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Affiliation(s)
- Richard L. Lieber
- Shirley Ryan AbilityLab,Departments of Physical Medicine and Rehabilitation and Biomedical Engineering, Northwestern University, Chicago, IL, USA
| | - Jan Fridén
- Swiss Paraplegic Center, Nottwil, Switzerland
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De Francesco F, Pugliese P, De Francesco M, Pangrazi PP, Riccio M. Brachioradialis Muscle Tendon Transposition in Extensor Pollicis Longus Reconstruction: Anatomical Study and a New Surgical Approach. Hand (N Y) 2022; 17:780-788. [PMID: 32935585 PMCID: PMC9274876 DOI: 10.1177/1558944720930295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Complete extension of the thumb and activation of the extensor pollicis longus (EPL) tendon are fundamental to ensure maximum function. Many EPL repair techniques are described in the literature. METHODS The authors present an alternative technique using the brachioradialis (BR) tendon. Thirty patients with injuries of the EPL tendon in zone 8 were studied. In all cases, neither direct suture repair nor traditional tendon transfer was possible. RESULTS Thumb extension was restored in all patients with satisfactory extension recovery. All patients achieved excellent extension; good functional results were observed in 2 cases, and in 1 case satisfactory results were achieved using the Geldmacher assessment and the Kapandji assessment. The overall results were rated as excellent, good, fair, or poor according to the Quick Disabilities of the Arm, Shoulder, and Hand Scale. DISCUSSION The BR tendon was suitable to treat all cases, in particular injuries occurring near Lister's tubercle, due to its appropriate length for tenorrhaphy albeit with a short distal head.
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Affiliation(s)
- Francesco De Francesco
- Azienda Ospedaliero Universitaria “Ospedali Riuniti,” Ancona, Italy,Francesco De Francesco, Department of General and Specialties Surgery, Azienda Ospedaliero Universitaria “Ospedali Riuniti,” 60126, Ancona, Italy.
| | | | | | | | - Michele Riccio
- Azienda Ospedaliero Universitaria “Ospedali Riuniti,” Ancona, Italy
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Adkins AN, Fong RM, Dewald JPA, Murray WM. Variability of in vivo Sarcomere Length Measures in the Upper Limb Obtained With Second Harmonic Generation Microendoscopy. Front Physiol 2022; 12:817334. [PMID: 35211028 PMCID: PMC8861439 DOI: 10.3389/fphys.2021.817334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/27/2021] [Indexed: 11/13/2022] Open
Abstract
The lengths of a muscle’s sarcomeres are a primary determinant of its ability to contract and produce force. In addition, sarcomere length is a critical parameter that is required to make meaningful comparisons of both the force-generating and excursion capacities of different muscles. Until recently, in vivo sarcomere length data have been limited to invasive or intraoperative measurement techniques. With the advent of second harmonic generation microendoscopy, minimally invasive measures of sarcomere length can be made for the first time. This imaging technique expands our ability to study muscle adaptation due to changes in stimulus, use, or disease. However, due to past inability to measure sarcomeres outside of surgery or biopsy, little is known about the natural, anatomical variability in sarcomere length in living human subjects. To develop robust experimental protocols that ensure data provide accurate representations of a muscle’s sarcomere lengths, we sought to quantify experimental uncertainty associated with in vivo measures of sarcomere lengths. Specifically, we assessed the variability in sarcomere length measured (1) within a single image, along a muscle fiber, (2) across images captured within a single trial, across trials, and across days, as well as (3) across locations in the muscle using second harmonic generation in two upper limb muscles with different muscle architectures, functions, and sizes. Across all of our measures of variability we estimate that the magnitude of the uncertainty for in vivo sarcomere length is on the order of ∼0.25 μm. In the two upper limb muscles studied we found larger variability in sarcomere lengths within a single insertion than across locations. We also developed custom code to make measures of sarcomere length variability across a single fiber and determined that this codes’ accuracy is an order of magnitude smaller than our measurement uncertainty due to sarcomere variability. Together, our findings provide guidance for the development of robust experimental design and analysis of in vivo sarcomere lengths in the upper limb.
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Affiliation(s)
- Amy N Adkins
- Department of Biomedical Engineering, Northwestern University, Evanston, IL, United States.,Shirley Ryan AbilityLab, Chicago, IL, United States.,Edward Hines, Jr. VA Hospital, Hines, IL, United States
| | - Ryan M Fong
- Department of Biomedical Engineering, Northwestern University, Evanston, IL, United States.,Shirley Ryan AbilityLab, Chicago, IL, United States
| | - Julius P A Dewald
- Department of Biomedical Engineering, Northwestern University, Evanston, IL, United States.,Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Wendy M Murray
- Department of Biomedical Engineering, Northwestern University, Evanston, IL, United States.,Shirley Ryan AbilityLab, Chicago, IL, United States.,Edward Hines, Jr. VA Hospital, Hines, IL, United States.,Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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8
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Persad LS, Binder-Markey BI, Shin AY, Kaufman KR, Lieber RL. In vivo human gracilis whole-muscle passive stress-sarcomere strain relationship. J Exp Biol 2021; 224:272026. [PMID: 34355750 DOI: 10.1242/jeb.242722] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/03/2021] [Indexed: 02/02/2023]
Abstract
We measured the passive mechanical properties of intact, living human gracilis muscles (n=11 individuals, 10 male and 1 female, age: 33±12 years, mass: 89±23 kg, height: 177±8 cm). Measurements were performed in patients undergoing surgery for free-functioning myocutaneous tissue transfer of the gracilis muscle to restore elbow flexion after brachial plexus injury. Whole-muscle force of the gracilis tendon was measured in four joint configurations (JC1-JC4) with a buckle force transducer placed at the distal tendon. Sarcomere length was also measured by biopsy from the proximal gracilis muscle. After the muscle was removed, a three-dimensional volumetric reconstruction of the muscle was created via photogrammetry. Muscle length from JC1 to JC4 increased by 3.3±1.0, 7.7±1.2, 10.5±1.3 and 13.4±1.2 cm, respectively, corresponding to 15%, 34%, 46% and 59% muscle fiber strain, respectively. Muscle volume and an average optimal fiber length of 23.1±0.7 cm yielded an average muscle physiological cross-sectional area of 6.8±0.7 cm2 which is approximately 3 times that measured previously from cadaveric specimens. Absolute passive tension increased from 0.90±0.21 N in JC1 to 16.50±2.64 N in JC4. As expected, sarcomere length also increased from 3.24±0.08 µm at JC1 to 3.63±0.07 µm at JC4, which are on the descending limb of the human sarcomere length-tension curve. Peak passive muscle stress was 27.8±5.5 kPa in JC4 and muscle modulus ranged from 44.8 MPa in JC1 to 125.7 MPa in JC4. Comparison with other mammalian species indicates that human muscle passive mechanical properties are more similar to rodent muscle than to rabbit muscle. These data provide direct measurements of whole-human muscle passive mechanical properties that can be used in modeling studies and for understanding comparative passive mechanical properties among mammalian muscles.
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Affiliation(s)
- Lomas S Persad
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Benjamin I Binder-Markey
- Department of Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA 19104, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Kenton R Kaufman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Richard L Lieber
- Shirley Ryan AbilityLab, Chicago, IL 60611, USA.,Hines V.A. Hospital, Maywood, IL 60141, USA.,Departments of Physiology and Biomedical Engineering, Northwestern University, Chicago, IL60208, USA
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Lieber RL, Theologis T. Muscle-tendon unit in children with cerebral palsy. Dev Med Child Neurol 2021; 63:908-913. [PMID: 33426691 DOI: 10.1111/dmcn.14807] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 12/27/2022]
Abstract
Muscle-tendon unit surgery for correction of deformities and movement dysfunction in children with cerebral palsy (CP) is fairly complicated. An understanding of basic muscle-tendon unit properties and their adaptation to both CP and surgery are important to develop advances in this field. In this review, we provide information to therapists, surgeons, and scientists regarding the short- and long-term adaptations of the muscle-tendon unit. Surgical releases, lengthening, and transpositions are discussed, as are some of the tissue, cellular, and molecular adaptations. What this paper adds Muscle strength, tone, and control must be considered in surgical interventions for cerebral palsy (CP). Muscle-tendon unit lengthening causes significant and lasting weakness requiring prolonged rehabilitation. Sarcomere length increases in CP muscle may be one of the underlying causes of muscle weakness. Muscle satellite cells are decreased and epigenetically modified in a way that may limit muscle growth in CP.
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Affiliation(s)
- Richard L Lieber
- Shirley Ryan AbilityLab, Chicago, IL, USA.,Northwestern University, Chicago, IL, USA.,Hines VA Medical Center, Maywood, IL, USA
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Lieber RL, Binder-Markey B. Biochemical and structural basis of the passive mechanical properties of whole skeletal muscle. J Physiol 2021; 599:3809-3823. [PMID: 34101193 PMCID: PMC8364503 DOI: 10.1113/jp280867] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/06/2021] [Indexed: 01/18/2023] Open
Abstract
Passive mechanical properties of whole skeletal muscle are not as well understood as active mechanical properties. Both the structural basis for passive mechanical properties and the properties themselves are challenging to determine because it is not clear which structures within skeletal muscle actually bear passive loads and there are not established standards by which to make mechanical measurements. Evidence suggests that titin bears the majority of the passive load within the single muscle cell. However, at larger scales, such as fascicles and muscles, there is emerging evidence that the extracellular matrix bears the major part of the load. Complicating the ability to quantify and compare across size scales, muscles and species, definitions of muscle passive properties such as stress, strain, modulus and stiffness can be made relative to many reference parameters. These uncertainties make a full understanding of whole muscle passive mechanical properties and modelling these properties very difficult. Future studies defining the specific load bearing structures and their composition and organization are required to fully understand passive mechanics of the whole muscle and develop therapies to treat disorders in which passive muscle properties are altered such as muscular dystrophy, traumatic laceration, and contracture due to upper motor neuron lesion as seen in spinal cord injury, stroke and cerebral palsy.
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Affiliation(s)
- Richard L. Lieber
- Shirley Ryan AbilityLab
- Departments of Physical Medicine and Rehabilitation and
Biomedical Engineering, Northwestern University, Chicago, IL, USA
- Edward Hines V.A. Medical Center, Hines, IL USA
| | - Ben Binder-Markey
- Department of Physical Therapy and Rehabilitation Sciences
and School of Biomedical Engineering, Sciences and Health Systems, Drexel
University, Philadelphia, PA USA
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Serial sarcomere number is substantially decreased within the paretic biceps brachii in individuals with chronic hemiparetic stroke. Proc Natl Acad Sci U S A 2021; 118:2008597118. [PMID: 34172565 DOI: 10.1073/pnas.2008597118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A muscle's structure, or architecture, is indicative of its function and is plastic; changes in input to or use of the muscle alter its architecture. Stroke-induced neural deficits substantially alter both input to and usage of individual muscles. We combined in vivo imaging methods (second-harmonic generation microendoscopy, extended field-of-view ultrasound, and fat-suppression MRI) to quantify functionally meaningful architecture parameters in the biceps brachii of both limbs of individuals with chronic hemiparetic stroke and in age-matched, unimpaired controls. Specifically, serial sarcomere number (SSN) and physiological cross-sectional area (PCSA) were calculated from data collected at three anatomical scales: sarcomere length, fascicle length, and muscle volume. The interlimb differences in SSN and PCSA were significantly larger for stroke participants than for participants without stroke (P = 0.0126 and P = 0.0042, respectively), suggesting we observed muscle adaptations associated with stroke rather than natural interlimb variability. The paretic biceps brachii had ∼8,200 fewer serial sarcomeres and ∼2 cm2 smaller PCSA on average than the contralateral limb (both P < 0.0001). This was manifested by substantially smaller muscle volumes (112 versus 163 cm3), significantly shorter fascicles (11.0 versus 14.0 cm; P < 0.0001), and comparable sarcomere lengths (3.55 versus 3.59 μm; P = 0.6151) between limbs. Most notably, this study provides direct evidence of the loss of serial sarcomeres in human muscle observed in a population with neural impairments that lead to disuse and chronically place the affected muscle at a shortened position. This adaptation is consistent with functional consequences (increased passive resistance to elbow extension) that would amplify already problematic, neurally driven motor impairments.
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Surgical Mobilization of Skeletal Muscles Changes Functional Properties-Implications for Tendon Transfers. J Hand Surg Am 2021; 46:341.e1-341.e10. [PMID: 33243591 DOI: 10.1016/j.jhsa.2020.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 07/06/2020] [Accepted: 09/10/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Tendon transfer surgery restores function by rerouting working muscle-tendon units to replace the function of injured or paralyzed muscles. This procedure requires mobilizing a donor muscle relative to its surrounding myofascial connections, which improves the muscle's new line of action and increases excursion. However, the biomechanical effect of mobilization on a donor muscle's force-generating function has not been previously studied under in vivo conditions. The purpose of this study was to quantify the effect of surgical mobilization on active and passive biomechanical properties of 3 large rabbit hind limb muscles. METHODS Myofascial connections were mobilized stepwise from the distal end to the proximal end of muscles (0%, 25%, 50%, and 75% of muscle length) and their active and passive length-tension curves were measured after each degree of mobilization. RESULTS Second toe extensor, a short-fibered muscle, exhibited a 30% decline in peak stress and 70% decline in passive stress, whereas extensor digitorum longus, a short-fibered muscle, and tibialis anterior, a long-fibered muscle, both exhibited similar smaller declines in active (about 18%) and passive stress (about 65%). CONCLUSIONS The results highlight 3 important points: (1) a trade-off exists between increasing muscle mobility and decreasing force-generating capacity; (2) intermuscular force transmission is important, especially in second toe extensor, because it was able to generate 70% of its premobilization active force although most fibers were freed from their native origin; and (3) muscle architecture is not the major influence on mobilization-induced force impairment. CLINICAL RELEVANCE These data demonstrate that surgical mobilization itself alters the passive and active force-generating capacity of skeletal muscles. Thus, surgical mobilization should not be viewed simply as a method to redirect the line of action of a donor muscle because this procedure has an impact on the functional properties of the donor muscle itself.
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40 years of experience in functional surgery of the tetraplegic upper limb. HAND SURGERY & REHABILITATION 2020; 39:474-486. [DOI: 10.1016/j.hansur.2020.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 11/18/2022]
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Nelson CM, Marchese V, Rock K, Henshaw RM, Addison O. Alterations in Muscle Architecture: A Review of the Relevance to Individuals After Limb Salvage Surgery for Bone Sarcoma. Front Pediatr 2020; 8:292. [PMID: 32612962 PMCID: PMC7308581 DOI: 10.3389/fped.2020.00292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 05/07/2020] [Indexed: 11/13/2022] Open
Abstract
Osteosarcoma and Ewing's sarcoma are the most common primary bone malignancies affecting children and adolescents. Optimal treatment requires a combination of chemotherapy and/or radiation along with surgical removal when feasible. Advances in multiple aspects of surgical management have allowed limb salvage surgery (LSS) to supplant amputation as the most common procedure for these tumors. However, individuals may experience significant impairment after LSS, including deficits in range of motion and strength that limit function and impact participation in work, school, and the community, ultimately affecting quality of life. Muscle force and speed of contraction are important contributors to normal function during activities such as gait, stairs, and other functional tasks. Muscle architecture is the primary contributor to muscle function and adapts to various stimuli, including periods of immobilization-protected weightbearing after surgery. The impacts of LSS on muscle architecture and how adaptations may impact deficits within the rehabilitation period and into long-term survivorship is not well-studied. The purpose of this paper is to [1] provide relevant background on bone sarcomas and LSS, [2] highlight the importance of muscle architecture, its measurement, and alterations as seen in other relevant populations and [3] discuss the clinical relevance of muscle architectural changes and the impact on muscle dysfunction in this population. Understanding the changes that occur in muscle architecture and its impact on long-term impairments in bone sarcoma survivors is important in developing new rehabilitation treatments that optimize functional outcomes.
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Affiliation(s)
- Christa M Nelson
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Victoria Marchese
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Kelly Rock
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Robert M Henshaw
- Department of Orthopedic Oncology, MedStar Georgetown Orthopedic Institute, Washington, DC, United States.,Department of Orthopedic Oncology, Children's National Medical Center, Washington, DC, United States
| | - Odessa Addison
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, United States.,Baltimore VA GRECC, Baltimore, MD, United States
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15
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Abstract
Reconstructive upper extremity surgeries in tetraplegia are technically challenging because of the many complicated real-time decisions that need to be made, e.g. extent of release of donor muscle-tendon complex, routing of donor muscles, tissue preparation and optimization, tensioning of muscle-tendon units, balancing joints and suturing tendon-to-tendon attachments. Nerve transfer surgeries can add functionality but also make the reconstruction planning more complex. In this overview, we present some of the fundamental muscle-tendon-joint mechanics studies that allow for single-stage surgical reconstruction of hand function as well as early postoperative activity-based training in patients with cervical spinal cord injuries. We foresee an increased need for studies addressing combined nerve and tendon transfer reconstructions in parallel with patient-perceived outcome investigations. These should be combined with implementation of assistive technology such as functional electrical stimulation for diagnostic, prognostic and training purposes.
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Affiliation(s)
- Jan Fridén
- Swiss Paraplegic Centre, Nottwil, Switzerland,Center for Advanced Reconstruction of Extremities and Department of Hand Surgery, Sahlgrenska University Hospital and University of Gothenburg, Gothenburg, Sweden
| | - Richard L. Lieber
- Shirley Ryan Ability Lab, Northwestern University and Hines VA Medical Center Chicago, IL, USA
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16
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Abstract
Skeletal muscle contractures represent the permanent shortening of a muscle-tendon unit, resulting in loss of elasticity and, in extreme cases, joint deformation. They may result from cerebral palsy, spinal cord injury, stroke, muscular dystrophy, and other neuromuscular disorders. Contractures are the prototypic and most severe clinical presentation of increased passive mechanical muscle force in humans, often requiring surgical correction. Intraoperative experiments demonstrate that high muscle passive force is associated with sarcomeres that are abnormally stretched, although otherwise normal, with fewer sarcomeres in series. Furthermore, changes in the amount and arrangement of collagen in the extracellular matrix also increase muscle stiffness. Structural light and electron microscopy studies demonstrate that large bundles of collagen, referred to as perimysial cables, may be responsible for this increased stiffness and are regulated by interaction of a number of cell types within the extracellular matrix. Loss of muscle satellite cells may be related to changes in both sarcomeres and extracellular matrix. Future studies are required to determine the underlying mechanism for changes in muscle satellite cells and their relationship (if any) to contracture. A more complete understanding of this mechanism may lead to effective nonsurgical treatments to relieve and even prevent muscle contractures.
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Affiliation(s)
- Richard L Lieber
- Shirley Ryan AbilityLab, Chicago, Illinois.,Departments of Physical Medicine and Rehabilitation and Biomedical Engineering, Northwestern University , Chicago, Illinois
| | - Jan Fridén
- Swiss Paraplegic Center, Nottwil, Switzerland
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17
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Forearm-Based Turnover Muscle Flaps for Elbow Soft-Tissue Reconstruction: A Comparison of Regional Coverage Based on Distal Flap Perfusion. Plast Reconstr Surg 2018; 142:152-157. [PMID: 29652763 DOI: 10.1097/prs.0000000000004472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Elbow wounds pose a reconstructive challenge. Prior studies have described the vascular anatomy of both the brachioradialis and flexor carpi ulnaris muscle flaps. The goal of this study was to describe the distal flap perfusion of the flexor carpi radialis, with a direct comparison of the brachioradialis, flexor carpi ulnaris, and flexor carpi radialis muscle flaps for coverage around the elbow. METHODS Six fresh-frozen upper extremity specimens were dissected for brachioradialis, flexor carpi radialis, and flexor carpi ulnaris flaps. Vascular data from prior studies were combined with our anatomical measurements to determine the area of perfused coverage around the elbow for the brachioradialis and flexor carpi ulnaris. The flexor carpi radialis flap distal vascular perfusion was examined separately with transverse sections at 1-cm intervals after India ink injections to determine distal flap perfusion and elbow coverage. Perfusion data were plotted on x and y axes over the posterior elbow. RESULTS The brachioradialis muscle covered an average of 56 percent of the x axis and 7.4 percent of the y axis. The flexor carpi ulnaris muscle covered an average of 90 percent of the elbow along the x axis and 23.3 percent of elbow along the y axis. The flexor carpi radialis covered an average of 34 percent of the x axis and 4.8 percent of the y axis. CONCLUSION The flexor carpi ulnaris muscle provides the most versatile and robust coverage over the posterior elbow, followed by the brachioradialis muscle, which consistently provides coverage over the lateral epicondyle.
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18
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Johanson ME, Jaramillo JP, Dairaghi CA, Murray WM, Hentz VR. Multicenter Survey of the Effects of Rehabilitation Practices on Pinch Force Strength After Tendon Transfer to Restore Pinch in Tetraplegia. Arch Phys Med Rehabil 2017; 97:S105-16. [PMID: 27233585 DOI: 10.1016/j.apmr.2016.01.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 01/13/2016] [Accepted: 01/14/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To identify key components of conventional therapy after brachioradialis (BR) to flexor pollicis longus (FPL) transfer, a common procedure to restore pinch strength, and evaluate whether any of the key components of therapy were associated with pinch strength outcomes. DESIGN Rehabilitation protocols were surveyed in 7 spinal cord injury (SCI) centers after BR to FPL tendon transfer. Key components of therapy, including duration of immobilization, participation, and date of initiating therapy activities (mobilization, strengthening, muscle reeducation, functional activities, and home exercise), were recorded by the patient's therapist. Pinch outcomes were recorded with identical equipment at 1-year follow-up. SETTING Seven SCI rehabilitation centers where the BR to FPL surgery is performed on a routine basis. PARTICIPANTS Thirty-eight arms from individuals with C5-7 level SCI injury who underwent BR to FPL transfer surgery (N=34). INTERVENTION Conventional therapy according to established protocol in each center. MAIN OUTCOME MEASURES The frequency of specific activities and their time of initiation (relative to surgery) were expressed as means and 95% confidence intervals. Outcome measures included pinch strength and the Canadian Occupational Performance Measure (COPM). Spearman rank-order correlations determined significant relations between pinch strength and components of therapy. RESULTS There was similarity in the key components of therapy and in the progression of activities. Early cast removal was associated with pinch force (Spearman ρ=-.40, P=.0269). Pinch force was associated with improved COPM performance (Spearman ρ=.48, P=.0048) and satisfaction (Spearman ρ=.45, P=.0083) scores. CONCLUSIONS Initiating therapy early after surgery is beneficial after BR to FPL surgery. Postoperative therapy protocols have the potential to significantly influence the outcome of tendon transfers after tetraplegia.
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Affiliation(s)
| | | | | | | | - Vincent R Hentz
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Department of Surgery, Stanford University, Palo Alto, CA
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19
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Abstract
Tendon transfers provide a substitute, either temporary or permanent, when function is lost due to neurologic injury in stroke, cerebral palsy or central nervous system lesions, peripheral nerve injuries, or injuries to the musculotendinous unit itself. This article reviews the basic principles of tendon transfer, which are important when planning surgery and essential for an optimal outcome. In addition, concepts for coapting the tendons during surgery and general principles to be followed during the rehabilitation process are discussed.
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20
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Surgical Simulations Based on Limited Quantitative Data: Understanding How Musculoskeletal Models Can Be Used to Predict Moment Arms and Guide Experimental Design. PLoS One 2016; 11:e0157346. [PMID: 27310013 PMCID: PMC4911128 DOI: 10.1371/journal.pone.0157346] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 05/29/2016] [Indexed: 12/21/2022] Open
Abstract
The utility of biomechanical models and simulations to examine clinical problems is currently limited by the need for extensive amounts of experimental data describing how a given procedure or disease affects the musculoskeletal system. Methods capable of predicting how individual biomechanical parameters are altered by surgery are necessary for the efficient development of surgical simulations. In this study, we evaluate to what extent models based on limited amounts of quantitative data can be used to predict how surgery influences muscle moment arms, a critical parameter that defines how muscle force is transformed into joint torque. We specifically examine proximal row carpectomy and scaphoid-excision four-corner fusion, two common surgeries to treat wrist osteoarthritis. Using models of these surgeries, which are based on limited data and many assumptions, we perform simulations to formulate a hypothesis regarding how these wrist surgeries influence muscle moment arms. Importantly, the hypothesis is based on analysis of only the primary wrist muscles. We then test the simulation-based hypothesis using a cadaveric experiment that measures moment arms of both the primary wrist and extrinsic thumb muscles. The measured moment arms of the primary wrist muscles are used to verify the hypothesis, while those of the extrinsic thumb muscles are used as cross-validation to test whether the hypothesis is generalizable. The moment arms estimated by the models and measured in the cadaveric experiment both indicate that a critical difference between the surgeries is how they alter radial-ulnar deviation versus flexion-extension moment arms at the wrist. Thus, our results demonstrate that models based on limited quantitative data can provide novel insights. This work also highlights that synergistically utilizing simulation and experimental methods can aid the design of experiments and make it possible to test the predictive limits of current computer simulation techniques.
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21
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Bensamoun SF, Dao TT, Charleux F, Ho Ba Tho MC. ESTIMATION OF MUSCLE FORCE DERIVED FROM IN VIVO MR ELASTOGRAPHY TESTS: A PRELIMINARY STUDY. ACTA ACUST UNITED AC 2013. [DOI: 10.1142/s0218957713500152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The objective is to estimate the vastus medialis (VM) muscle force from multifrequency magnetic resonance elastography (MMRE) tests and two different rheological models (Voigt and springpot). Healthy participants (N = 13) underwent multifrequency (70, 90 and 110 Hz) magnetic resonance elastography MMRE tests. Thus, in vivo experimental elastic (μ) properties of the VM in passive and active (20% MVC) conditions were characterized. Moreover, the muscle viscosity (η) was determined with Voigt and springpot rheological models, in both muscle states. Subsequently, the VM muscle forces were calculated with a generic musculoskeletal model (OpenSIM) where the active and passive shear moduli (μ) were implemented. The viscosity measured with the two rheological models increased when the muscle is contracted. During the stance and the swing phases, the VM tensile forces decrease and the VM force was lower with the springpot model. It can be noted that during the swing phase, the muscle forces estimated from springpot model showed a higher standard deviation compared to the Voigt model. This last result may indicate a strong sensitivity of the muscle force to the change of active and passive contractile components in the swing phase of gait. This study provides for the first time an estimation of the muscle tensile forces for lower limb, during human motion, from in vivo experimental muscle mechanical properties. The assessment of individualized muscle forces during motion is valuable for finite element models, increasing the patient specific parameters. This novel muscle database will be of use for the clinician to better elucidate the muscle pathophysiology and to better monitor the effects of the muscle disease.
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Affiliation(s)
- Sabine F. Bensamoun
- Biomechanics and Bioengineery Laboratory, UMR CNRS 7338, Université de Technologie de Compiègne, Compiègne, France
| | - Tien Tuan Dao
- Biomechanics and Bioengineery Laboratory, UMR CNRS 7338, Université de Technologie de Compiègne, Compiègne, France
| | | | - Marie-Christine Ho Ba Tho
- Biomechanics and Bioengineery Laboratory, UMR CNRS 7338, Université de Technologie de Compiègne, Compiègne, France
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22
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Bland DC, Prosser LA, Bellini LA, Alter KE, Damiano DL. Tibialis anterior architecture, strength, and gait in individuals with cerebral palsy. Muscle Nerve 2011; 44:509-17. [PMID: 21755515 PMCID: PMC3175274 DOI: 10.1002/mus.22098] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2011] [Indexed: 11/11/2022]
Abstract
INTRODUCTION The relationship of tibialis anterior (TA) muscle architecture, including muscle thickness (MT), cross-sectional area (CSA), pennation angle (PA), and fascicle length (FL), to strength and ankle function was examined in ambulatory individuals with CP and unilateral foot drop. METHODS Twenty individuals with CP participated in muscle ultrasound imaging, unilateral strength testing, and three-dimensional gait analysis. RESULTS Muscle size (MT and CSA) was positively related to strength, fast gait velocity, and ankle kinematics during walking. Higher PA was related to a more dorsiflexed ankle position at initial contact and inversely with fast gait velocity. FL was related to strength, fast velocity, and step length at a self-selected speed. CONCLUSIONS Muscle architecture partially explains the degree of impairment in strength and ankle function in CP. Treatments to increase TA size and strength may produce some gait improvement, but other factors that may contribute to ankle performance deficits must be considered.
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Affiliation(s)
| | - Laura A Prosser
- Functional & Applied Biomechanics Section, Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Lindsey A Bellini
- Functional & Applied Biomechanics Section, Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Katharine E Alter
- Functional & Applied Biomechanics Section, Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Diane L Damiano
- Functional & Applied Biomechanics Section, Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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23
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Mogk JPM, Johanson ME, Hentz VR, Saul KR, Murray WM. A simulation analysis of the combined effects of muscle strength and surgical tensioning on lateral pinch force following brachioradialis to flexor pollicis longus transfer. J Biomech 2011; 44:669-75. [PMID: 21092963 PMCID: PMC3042533 DOI: 10.1016/j.jbiomech.2010.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Revised: 11/01/2010] [Accepted: 11/02/2010] [Indexed: 10/18/2022]
Abstract
Biomechanical simulations of tendon transfers performed following tetraplegia suggest that surgical tensioning influences clinical outcomes. However, previous studies have focused on the biomechanical properties of only the transferred muscle. We developed simulations of the tetraplegic upper limb following transfer of the brachioradialis (BR) to the flexor pollicis longus (FPL) to examine the influence of residual upper limb strength on predictions of post-operative transferred muscle function. Our simulations included the transfer, ECRB, ECRL, the three heads of the triceps, brachialis, and both heads of the biceps. Simulations were integrated with experimental data, including EMG and joint posture data collected from five individuals with tetraplegia and BR-FPL tendon transfers during maximal lateral pinch force exertions. Given a measured co-activation pattern for the non-paralyzed muscles in the tetraplegic upper limb, we computed the highest activation for the transferred BR for which neither the elbow nor the wrist flexor moment was larger than the respective joint extensor moment. In this context, the effects of surgical tensioning were evaluated by comparing the resulting pinch force produced at different muscle strength levels, including patient-specific scaling. Our simulations suggest that extensor muscle weakness in the tetraplegic limb limits the potential to augment total pinch force through surgical tensioning. Incorporating patient-specific muscle volume, EMG activity, joint posture, and strength measurements generated simulation results that were comparable to experimental results. Our study suggests that scaling models to the population of interest facilitates accurate simulation of post-operative outcomes, and carries utility for guiding and developing rehabilitation training protocols.
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Affiliation(s)
- Jeremy P M Mogk
- Sensory Motor Performance Program, Rehabilitation Institute of Chicago, 345 E. Superior St., Chicago, IL 60611, USA.
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24
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Yucesoy CA, Ateş F, Akgün U, Karahan M. Measurement of human Gracilis muscle isometric forces as a function of knee angle, intraoperatively. J Biomech 2010; 43:2665-71. [DOI: 10.1016/j.jbiomech.2010.06.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 06/24/2010] [Accepted: 06/25/2010] [Indexed: 01/13/2023]
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25
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Mechanical feasibility of immediate mobilization of the brachioradialis muscle after tendon transfer. J Hand Surg Am 2010; 35:1473-8. [PMID: 20709465 PMCID: PMC2947370 DOI: 10.1016/j.jhsa.2010.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Revised: 05/26/2010] [Accepted: 06/01/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE Tendon transfer is often used to restore key pinch after cervical spinal cord injury. Current postoperative recommendations include elbow immobilization in a flexed position to protect the brachioradialis-flexor pollicis longus (BR-FPL) repair. The purpose of this study was to measure the BR-FPL tendon tension across a range of wrist and elbow joint angles to determine whether joint motion could cause repair rupture. METHODS We performed BR-to-FPL tendon transfers on fresh-frozen cadaveric arms (n = 8) and instrumented the BR-FPL tendon with a buckle transducer. Arms were ranged at 4 wrist angles from 45 degrees of flexion to 45 degrees of extension and 8 elbow angles from 90 degrees of flexion to full extension, measuring tension across the BR-FPL repair at each angle. Subsequently, the BR-FPL tendon constructs were removed and elongated to failure. RESULTS Over a wide wrist and elbow range of motion, BR-FPL tendon tension was under 20 N. Two-way analysis of variance with repeated measures revealed a significant effect of wrist joint angle (p<.001) and elbow joint angle (p<.001) with significant interaction between elbow and joint angles (p<.001). Because the failure load of the repair site was 203 +/- 19 N, over 10 times the loads that would be expected to occur at the repair site, our results demonstrate that the repair has a safety factor of at least 10. CONCLUSIONS Our tendon force measurements support the assertion that the elbow joint need not be immobilized when the BR is used as a donor muscle in tendon transfer to the FPL. This is based on the fact that maximum passive tendon tension was only about 20 N in our cadaveric model and the failure strength of this specific repair was over 200 N. We suggest that it is possible to consider performing multiple tendon transfers in a single stage, avoiding immobilization, which may adversely affect functional recovery. These results must be qualified by the fact that issues unique to living tissues such as postoperative edema and tendon gliding cannot be accounted for by this cadaveric model.
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26
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Lieber RL. Biology and mechanics of skeletal muscle: what hand surgeons need to know when tensioning a tendon transfer. J Hand Surg Am 2008; 33:1655-6. [PMID: 18984353 DOI: 10.1016/j.jhsa.2008.08.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Accepted: 08/07/2008] [Indexed: 02/02/2023]
Affiliation(s)
- Richard L Lieber
- Department of Orthopaedics and Bioengineering, Biomedical Sciences Graduate Group, University of California, San Diego, CA, USA.
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27
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Reconstruction of the Human Gastrocnemius Force–Length Curve in Vivo: Part 2—Experimental Results. J Appl Biomech 2008; 24:207-14. [DOI: 10.1123/jab.24.3.207] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
For a physiologically realistic range of joint motion and therefore range of muscle fiber lengths, only part of the force-length curve can be used in vivo; i.e., the section of the force–length curve that is expressed can vary. The purpose of this study was to determine the expressed section of the force–length relationship of the gastrocnemius for humans. Fourteen male and fourteen female subjects aged 18–27 performed maximal isometric plantar flexions in a Biodex dynamometer. Plantar flexion moments were recorded at five ankle angles: −15°, 0°, 15°, 30°, and 40°, with negative angles defined as dorsiflexion. These measurements were repeated for four randomly ordered knee angles over two testing sessions 4 to 10 days apart. The algorithm of Herzog and ter Keurs (1988a) was used to reconstruct the force–length curves of the biarticular gastrocnemius. Twenty-four subjects operated over the ascending limb, three operated over the descending limb, and one operated over the plateau region. The variation found suggests that large subject groups should be used to determine the extent of normal in vivo variability in this muscle property. The possible source of the variability is discussed in terms of parameters typically used in muscle models.
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28
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Minimally invasive high-speed imaging of sarcomere contractile dynamics in mice and humans. Nature 2008; 454:784-8. [PMID: 18600262 DOI: 10.1038/nature07104] [Citation(s) in RCA: 226] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2007] [Accepted: 05/19/2008] [Indexed: 11/08/2022]
Abstract
Sarcomeres are the basic contractile units of striated muscle. Our knowledge about sarcomere dynamics has primarily come from in vitro studies of muscle fibres and analysis of optical diffraction patterns obtained from living muscles. Both approaches involve highly invasive procedures and neither allows examination of individual sarcomeres in live subjects. Here we report direct visualization of individual sarcomeres and their dynamical length variations using minimally invasive optical microendoscopy to observe second-harmonic frequencies of light generated in the muscle fibres of live mice and humans. Using microendoscopes as small as 350 microm in diameter, we imaged individual sarcomeres in both passive and activated muscle. Our measurements permit in vivo characterization of sarcomere length changes that occur with alterations in body posture and visualization of local variations in sarcomere length not apparent in aggregate length determinations. High-speed data acquisition enabled observation of sarcomere contractile dynamics with millisecond-scale resolution. These experiments point the way to in vivo imaging studies demonstrating how sarcomere performance varies with physical conditioning and physiological state, as well as imaging diagnostics revealing how neuromuscular diseases affect contractile dynamics.
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Kreulen M, Smeulders MJ. Assessment of Flexor carpi ulnaris function for tendon transfer surgery. J Biomech 2008; 41:2130-5. [DOI: 10.1016/j.jbiomech.2008.04.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2007] [Revised: 02/24/2008] [Accepted: 04/27/2008] [Indexed: 11/28/2022]
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30
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Gohritz A, Fridén J, Herold C, Aust M, Spies M, Vogt PM. Ersatzoperationen bei Ausfall motorischer Funktionen an der Hand. Unfallchirurg 2007; 110:759-76. [PMID: 17786397 DOI: 10.1007/s00113-007-1322-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Nerve injuries in the upper extremity can result in severe disability. In the last three decades, progress in microsurgical techniques has improved the outcome for nerve injuries and if the prognosis is reasonably good, nerve repair should usually be performed prior to tendon transfer procedures. However, above all proximal lesions of peripheral nerves such as high radial nerve palsy still often yield unsatisfactory results, despite a technically well-executed nerve repair. Prognosis further depends on the time interval since the injury and also on the age of the patient, as the regenerative process is delayed in older patients. The indication for tendon transfers strongly depends on the personal and professional profiles of the individual patient. Tendon transfer procedures alleviate the suffering from functional hand impairment providing a superior alternative to permanent external splints. Tendon transfers are usually secondary procedures for replacing function after evaluation of the functional motor loss. Numerous transfer procedures have been described for every nerve trunk of the upper extremity, their prognosis depending mainly on the extent and pattern of nerve loss, local effects of the trauma (e.g. involvement of soft tissues, joints), and the physiological characteristics of the transferred muscle. Even if the results of the tendon transfers may finally be less satisfactory in cases of complex nerve damage than in isolated motor nerve lesions, they offer a valuable functional benefit, often being the only possibility to restore hand function. Although regrettably underused, tendon transfer improve upper extremity function in more than 70% of patients with cervical spinal cord injury. Reconstruction of key elements such as wrist extension, key grip between the thumb and the index finger, or digital flexion and extension leads to highly improved use of the tetraplegic hand and thus provides new mobility and independence from the help of others. This article presents an overview of the most common procedures to restore hand function in peripheral nerve injuries and tetraplegia in order to provide a systematic approach for decision making.
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Affiliation(s)
- A Gohritz
- Klinik für Plastische, Hand- und Wiederherstellungschirurgie, Zentrum für Schwerbrandverletzte, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Deutschland.
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31
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Abstract
Long term paralysis of the ulnar nerve is associated with an array of specific deficits and deformities. The numerous options for reconstruction are reviewed, as well as the specific patient considerations in selecting a strategy. An approach to late reconstruction for late ulnar nerve palsy is presented based upon the authors' experience and the available literature.
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Affiliation(s)
- Raymond Tse
- Vancouver Island Health Authority, University of British Columbia, 301 - 1625 Oak Bay Avenue, Victoria, BC, V8R 1B1, Canada
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32
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Takahashi M, Ward SR, Lieber RL. Intraoperative single-site sarcomere length measurement accurately reflects whole-muscle sarcomere length in the rabbit. J Hand Surg Am 2007; 32:612-7. [PMID: 17481997 DOI: 10.1016/j.jhsa.2007.03.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Revised: 02/28/2007] [Accepted: 03/02/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare single-site intraoperative sarcomere length values with sarcomere lengths measured from systematic sampling of the entire transferred muscle. METHODS The tendon of the rabbit second toe extensor muscle was transposed to the ankle extensor retinaculum under levels of stretch over the sarcomere length range of about 2.5 microm to about 4.0 microm. Intraoperative sarcomere length was measured at a single site with a laser diffraction device. Whole-muscle sarcomere length measurement was then determined by sampling across the muscle in the proximal, middle, and distal regions. Linear regression analysis and intraclass correlation coefficients were used to validate single intraoperative sarcomere lengths relative to whole-muscle sarcomere lengths. RESULTS Single intraoperative sarcomere lengths correlated strongly with average whole-muscle sarcomere length, although there was a systematic tendency to overestimate intraoperative sarcomere length. Intraoperative sarcomere length also matched well with all regions sampled, indicating that there was no tendency for intraoperative sarcomere length to better represent one region of the muscle compared with another. CONCLUSIONS These results show that intraoperative sarcomere lengths accurately represent the entire muscle. The relatively small sarcomere length variations validate the use of intraoperative sarcomere length measurement during tendon transfer in which the entire muscle is not available for measurement because of limited surgical exposure.
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Affiliation(s)
- Mitsuhiko Takahashi
- Department of Orthopaedic Surgery, University of California and Veterans Affairs Medical Centers, San Diego, CA 92161, USA
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Smeulders MJC, Kreulen M. Myofascial force transmission and tendon transfer for patients suffering from spastic paresis: a review and some new observations. J Electromyogr Kinesiol 2007; 17:644-56. [PMID: 17369052 DOI: 10.1016/j.jelekin.2007.02.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The current rationale of clinical practice in spastic tendon transfer surgery is based on four assumptions: (1) changes in muscle fiber length (serial number of sarcomeres) determine the available length range and joint excursion, (2) muscle cross-sectional area determines the maximal force output, (3) fiber length and muscle force are invariable functions of muscle length, (4) there is an invariable relation between the elastic force and the active force exerted by the sarcomeres. The validity of these assumptions is discussed. Additionally, some new perspectives in muscle research are discussed and myofascial force transmission is introduced as a co-determinant for the outcome of tendon transfer by presenting some exploratory observations.
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Affiliation(s)
- Mark J C Smeulders
- Department of Plastic, Reconstructive and Hand Surgery, Academic Medical Center, Amsterdam, Suite G4-226, PO Box 22700, 1100 DE Amsterdam, The Netherlands.
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Fridén J, Ward SR, Smallwood L, Lieber RL. Passive muscle-tendon amplitude may not reflect skeletal muscle functional excursion. J Hand Surg Am 2006; 31:1105-10. [PMID: 16945711 DOI: 10.1016/j.jhsa.2006.05.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2006] [Revised: 04/29/2006] [Accepted: 05/25/2006] [Indexed: 02/02/2023]
Abstract
PURPOSE To quantify the gain in muscle mobility with progressive release of surrounding connective-tissue structures and to compare this property with the known architecture of each muscle. METHODS Each of 5 different muscle tendon units (extensor carpi radialis brevis, extensor carpi radialis longus, flexor carpi ulnaris, flexor digitorum superficialis, pronator teres) was released from its insertion and secured into the jaws of a clamp attached to a servomotor that could be operated under length or force control to simulate the load placed on the tendon by a surgical assistant. A constant load of 5 N was applied to the tendon while the muscle-tendon unit was released surgically from the surrounding tissue in 1-cm increments. Mobility was plotted against release distance and analyzed by linear regression to yield mobility gain, the slope of the regression equation. One-way analysis of variance was used to compare mobility gain among muscles. RESULTS In contrast to previous results from the brachioradialis muscle in which the mobility gain was large and highly nonlinear, mobility gain was small, consistent, and linear for all muscles studied. The smallest mobility gain was for the flexor digitorum superficialis and was highly linear. The largest gain was for the pronator teres and again was highly linear. In general, the mobility gain for the extensor carpi radialis brevis was similar to that of the extensor carpi radial longus. The flexor carpi ulnaris muscle was difficult to mobilize, and its gain was modest. There was no significant correlation between mobility gain of the forearm muscles during progressive release and the length of their fibers. CONCLUSIONS The small mobility and complete lack of correlation with fiber length provide strong evidence that mobility gain does not accurately reflect muscle excursion as it is typically described. This calls into question the general practice of tensioning muscles by first passively extending the muscle and then choosing the attachment length as a particular portion of that passive relationship.
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Affiliation(s)
- Jan Fridén
- Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
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Ward SR, Hentzen ER, Smallwood LH, Eastlack RK, Burns KA, Fithian DC, Friden J, Lieber RL. Rotator cuff muscle architecture: implications for glenohumeral stability. Clin Orthop Relat Res 2006; 448:157-63. [PMID: 16826111 DOI: 10.1097/01.blo.0000194680.94882.d3] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We examined the architectural properties of the rotator cuff muscles in 10 cadaveric specimens to understand their functional design. Based on our data and previously published joint angle-muscle excursion data, sarcomere length operating ranges were modeled through all permutations in 75 masculine medial and lateral rotation and 75 masculine abduction at the glenohumeral joint. Based on physiologic cross-sectional area, the subscapularis would have the greatest force-producing capacity, followed by the infraspinatus, supraspinatus, and teres minor. Based on fiber length, the supraspinatus would operate over the widest range of sarcomere lengths. The supraspinatus and infraspinatus had relatively long sarcomere lengths in the anatomic position, and were under relatively high passive tensions at rest, indicating they are responsible for glenohumeral resting stability. However, the subscapularis contributed passive tension at maximum abduction and lateral rotation, indicating it plays a critical role in glenohumeral stability in the position of apprehension. These data illustrate the exquisite coupling of muscle architecture and joint mechanics, which allows the rotator cuff to produce near maximal active tensions in the midrange and produce passive tensions in the various end-range positions. During surgery relatively small changes to rotator cuff muscle length may result in relatively large changes in shoulder function.
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Affiliation(s)
- Samuel R Ward
- Department of Orthopaedics and Bioengineering, University of California and Veterans Administration Medical Centers, San Diego, 92161, USA
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Ward SR, Peace WJ, Fridén J, Lieber RL. Dorsal transfer of the brachioradialis to the flexor pollicis longus enables simultaneous powering of key pinch and forearm pronation. J Hand Surg Am 2006; 31:993-7. [PMID: 16843162 DOI: 10.1016/j.jhsa.2006.02.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Revised: 02/21/2006] [Accepted: 02/22/2006] [Indexed: 02/02/2023]
Abstract
PURPOSE To show biomechanically that the brachioradialis (BR) muscle can be transferred to restore key pinch and forearm pronation simultaneously. METHODS Nine fresh-frozen forearms were thawed and instrumented with a custom muscle-tendon excursion jig. Maximum BR muscle-tendon excursion was measured with the wrist and thumb mobile. Muscle-tendon excursion then was measured from 60 degrees of supination to 60 degrees of pronation in 15 degrees increments with the wrist and thumb fixed. Measurements were performed in 3 configurations: the native BR, the BR transferred volarly to the flexor pollicis longus (FPL) tendon, and the BR transferred dorsally (posterior to the radius) through the interosseous membrane to the FPL tendon. Muscle excursion-joint angle data were differentiated to compute pronation/supination moment arms. Two-way analyses of variance and post hoc Tukey tests were used to compare transfer conditions. RESULTS Maximum muscle excursion was nearly identical when volar and dorsal transfer conditions were compared. When pronation/supination motions were isolated, however, the volar transfer was associated with muscle shortening and small pronation moment arms through 30 degrees +/- 9 degrees of supination. Importantly, the dorsal transfer was associated with muscle shortening and larger pronation moment arms through 28 degrees +/- 10 degrees of pronation, a significant difference of 58.0 degrees +/- 16.0 degrees compared to the traditional volar transfer. CONCLUSIONS These data suggest that dorsal BR-to-FPL transfers can power key pinch and forearm pronation simultaneously even in the absence of other functional pronators. This transfer can be accomplished without changes to total muscle excursion compared with the traditional volar BR-to-FPL transfer. This result may enable the use of the BR-to-FPL transfer in patients who need key pinch but who lack functional pronation muscle groups (eg, ocular cutaneous 3). As result a larger patient population may benefit from the BR-to-FPL reconstructive procedure.
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Affiliation(s)
- Samuel R Ward
- Department of Radiology, University of California and Veterans Administration San Diego, San Diego, CA 92161, USA
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