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Search Results (47)

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8 pages, 4947 KiB  
Case Report
Subcapital Femoral Neck Fracture in a Professionally Active Patient Undergoing Palliative Treatment for Endothelial Cell-Derived Epithelioid Haemangioendothelioma (EHE)
by Paulina Kluszczyk, Aleksandra Tobiasz, Dawid Szumilas, Mateusz Winder, Jacek Pająk, Robert Kwiatkowski and Jerzy Chudek
Reports 2024, 7(4), 111; https://doi.org/10.3390/reports7040111 - 9 Dec 2024
Viewed by 474
Abstract
Background and Clinical Significance: Femoral neck fracture frequently occurs in the elderly population but may also present in patients diagnosed with primary cancer or bone metastases. A pathological, oligosymptomatic fracture associated with epithelioid haemangioendothelioma (EHE), a rare endothelial cell-derived sarcoma, is uncommon. Case [...] Read more.
Background and Clinical Significance: Femoral neck fracture frequently occurs in the elderly population but may also present in patients diagnosed with primary cancer or bone metastases. A pathological, oligosymptomatic fracture associated with epithelioid haemangioendothelioma (EHE), a rare endothelial cell-derived sarcoma, is uncommon. Case Presentation: A 44-year-old patient underwent biopsy procedures three times (2010, 2012, 2013) for a focal lesion of the left ischium, none confirming its malignant nature. The last biopsy revealed a neoplastic tissue with features of discrete dysplasia. The lesion did not undergo medical follow-up for seven consecutive years. In August 2020, the patient presented with right lower limb pain. A CT scan, PET/CT scan, and biopsy confirmed EHE with spindle/sarcomatous features. In November 2020, chemotherapy (5xADIC) started (PET/CT confirmed a partial response). After its completion in July 2021, bone progression occurred and sirolimus-based therapy was started. After 3 months, a small liver metastasis was visualized on PET/CT, which did not result in the termination of treatment. In December 2021, pamidronate-based antiresorptive therapy was started. Liver metastasis remained stable in follow-up CT scans. Due to pelvic and spinal lesions, the patient was assisted by elbow crutches and underwent radiotherapy, remaining professionally active. The patient did not report any trauma, but in August 2023, a subsequent CT scan revealed a subcapital fracture of the left femoral neck in the fusion phase. Due to pelvic changes and the stable nature of the fracture, surgical treatment was abandoned. Conclusions: An oligosymptomatic femoral neck fracture, not requiring medical intervention is considered a rare complication of bone cancer. Full article
(This article belongs to the Section Oncology)
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Figure 1
<p>CT scan from 2009 (<b>A</b>) showing a well-demarcated osteolytic lesion in the left ischium (red arrow). The mean density of the tumour in the pre-contrast scan was 87 Hounsfield units (HU) and showed moderate enhancement in the subsequent phases reaching 112 HU in the venous phase. PET-CT from 2009 (<b>B</b>) with increased radiotracer uptake at the tumour location (red arrow).</p>
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<p>Haematoxylin and eosin (HE) staining (magnification is shown for each picture). (<b>A</b>) Intertrabecular space (a bone trabeculae visible in the lower left corner) filled with malignant mesenchymal neoplastic cells with myxomatous lining. Epithelioid, polymorphic tumour cells. (<b>B</b>) Epithelioid and spindle-shaped tumour cells. (<b>C</b>) Cluster of epithelioid cells. (<b>D</b>) Spindle-shaped tumour cells with intracytoplasmic inclusions. (<b>E</b>) Tumour cells with intracytoplasmic inclusions. (<b>F</b>) Cluster of tumour cells. Erythrocytes are visible in the cytoplasm of one tumour cell (central part of the photo). (<b>G</b>) Cluster of tumour cells. In a single cell, intranuclear inclusion and an eosinophil are visible. (<b>H</b>) Cluster of tumour cells. A lymphocyte visible in the cytoplasm of a single cell. (<b>I</b>) The interbone space filled with malignant mesenchymal neoplasm with myxomatous lining. Polymorphic epithelioid tumour cells.</p>
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<p>CT scans from September 2022 (<b>A</b>), January 2023 (<b>B</b>), and April 2023 showing decreased bone density in the left femur and pathological lesions in the vertebrae and left pelvic bones. Early signs of a subcapital fracture of the left femoral neck (red arrow) first seen in the CT from April 2023 (<b>C</b>).</p>
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<p>CT scan from August 2023 (<b>A</b>) showing extensive lytic infiltration of the left ischium at the initial tumour site (red arrow). Coronal plane maximum intensity projection (MIP) of the same CT (<b>B</b>). Impacted fracture of the left femoral neck (blue arrowhead) caused by the neoplastic infiltration. Pathological lesions in the left ischium and hip bone as well as in ribs 10 and 11 on the right side.</p>
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9 pages, 2458 KiB  
Article
Assessment of a New Gait Asymmetry Index in Patients After Unilateral Total Hip Arthroplasty
by Jarosław Kabaciński, Lechosław B. Dworak and Michał Murawa
J. Clin. Med. 2024, 13(22), 6677; https://doi.org/10.3390/jcm13226677 - 7 Nov 2024
Viewed by 514
Abstract
Background/Objectives: Comparing a given variable between the lower extremities (LEs) usually involves calculating the value of a selected asymmetry index. The aim of this study was to evaluate the mean-dependent asymmetry index for gait variables. Methods: The three-point crutch gait asymmetry between the [...] Read more.
Background/Objectives: Comparing a given variable between the lower extremities (LEs) usually involves calculating the value of a selected asymmetry index. The aim of this study was to evaluate the mean-dependent asymmetry index for gait variables. Methods: The three-point crutch gait asymmetry between the non-surgical LE (NS) and surgical LE (S) was assessed in 14 patients after unilateral total hip arthroplasty. An eight-camera motion capture system integrated with two force platforms was used. The values of the new gait asymmetry index (MA) were calculated for such variables as stance phase time (ST), knee flexion and extension range of motion (KFE RoM), hip flexion and extension range of motion (HFE RoM), and vertical ground reaction force (VGRF). Results: An analysis related to gait asymmetry showed significantly higher values for all variables for the NS than for the S (the MA ranged from 9.9 to 42.0%; p < 0.001). In the case of comparisons between the MA and other indices, the intraclass correlation coefficient ranged from 0.566 to 0.998 (p < 0.001) with Bland–Altman bias values that ranged from −18.2 to 0.3 %GC (ST), from 0.0 to 0.5° (KFE RoM), from −12.4 to 1.4° (HFE RoM), and from −11.9 to −0.1 %BW (VGRF). Conclusions: The findings revealed a prominent three-point crutch gait asymmetry for all variables, especially a disturbingly large asymmetry for the HFE RoM and VGRF. The comparisons also showed generally excellent or good agreement with the other indices. Furthermore, the mean MA result from n single values was the same as the MA result calculated using the mean values of a given variable. The MA, as an accurate asymmetry index, can be used to objectively assess pathological gait asymmetry. Full article
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<p>The ICCs for the absolute agreement between the MA and the RI, GA, SI, and NSI. ICC—the intraclass correlation coefficient, MA—the new asymmetry index, RI—the ratio index, GA—the gait asymmetry index, SI—the symmetry index, NSI—the normalized symmetry index, ST—stance phase time, KFE RoM—knee flexion and extension range of motion, HFE RoM—hip flexion and extension range of motion, VGRF—vertical ground reaction force.</p>
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<p>Bland–Altman plots for the MA vs. the RI, the MA vs. the GA, the MA vs. the SI, and the MA vs. the NSI for (<b>a</b>) ST, (<b>b</b>) KFE RoM, (<b>c</b>) HFE RoM, and (<b>d</b>) VGRF. MA—the new asymmetry index, RI—the ratio index, GA—the gait asymmetry index, SI—the symmetry index, NSI—the normalized symmetry index, ST—stance phase time, KFE RoM—knee flexion and extension range of motion, HFE RoM—hip flexion and extension range of motion, VGRF—vertical ground reaction force, SD—the standard deviation for the average difference between the two indices, +1.96 * SD—the upper limit of agreement, −1.96 * SD—the lower limit of agreement, bias—the average difference between the two indices.</p>
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16 pages, 22963 KiB  
Case Report
Perioperative Benefits of a 3D Printed Spine Biomodel in the Setting of Congenital Scoliosis Surgery
by Dean C. Perfetti, Stanley Kisinde, Theodore A. Belanger and Isador H. Lieberman
Surg. Tech. Dev. 2024, 13(3), 278-293; https://doi.org/10.3390/std13030021 - 9 Aug 2024
Viewed by 663
Abstract
The spine community is continuously adding to its armamentarium of intraoperative techniques for visualization and instrumentation of the spine. Recently, three-dimensional printed spine models were introduced for use in preoperative planning, surgical simulation, and intraoperative guidance. We present a 14-year old African male [...] Read more.
The spine community is continuously adding to its armamentarium of intraoperative techniques for visualization and instrumentation of the spine. Recently, three-dimensional printed spine models were introduced for use in preoperative planning, surgical simulation, and intraoperative guidance. We present a 14-year old African male with congenital kyphoscoliosis, small stature, an obvious gibbus deformity and coronal imbalance, who underwent a three-staged posterior surgical correction procedure, during which a 3D-printed spine biomodel was utilized for better appreciation of his complex spinal deformity patho-anatomy. During the first stage of the procedure, he developed diminished lower extremity motor strength bilaterally and bowel/bladder control, but, following his third stage procedure and with focused rehabilitation efforts, he has regained full control of his bowel and bladder function, and is able to ambulate and perform activities of daily living independently, albeit still requiring intermittent walking support with a single forearm crutch due to residual left leg weakness. The 3D spine biomodel functioned successfully as a valuable tool and surrogate anatomic blueprint for the surgeons, enabling adequate appreciation of the complex bony anatomy which could not be easily resolved on the conventionally available imaging modalities, intraoperative navigation or robotic platform. Theoretically, up to $2900 USD in savings, translated from the mean estimated time saved per procedure with the use 3D-printed spine models has been proposed in some studies. Therefore, 3D-printed spine models have utility in complex spinal deformity correction surgery. Full article
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<p>Initial physical examination photographs showing an individual with small stature, a congenital Gibbus deformity and coronally imbalanced.</p>
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<p>Full length AP and lateral EOS images taken pre-operatively.</p>
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<p>Standing, pre-operative total spine AP &amp; lateral X-ray images with sagittal and coronal alignment measurements. Curve type 5C + (L)–Lenke classification of AIS [<a href="#B17-std-13-00021" class="html-bibr">17</a>]. (<b>A</b>) (Anterior-posterior)–C7PL 1.54 cm; Major Cobb [MC] 69.9°, T12 Superior-L2 Inferior; Secondary Cobb [SC] 53.8°, L3 Superior-L5 Inferior; Tertiary Cobb [TC] 38.1°, T2 Superior-T11 Inferior. (<b>B</b>) (Lateral)–Sagittal Pelvic Tilt [PT] 25.3°; Pelvic Incidence [PI] 52.3°; Sacral Slope [SS] 27.1°; Lumbar Lordosis [LL] 45.4°; Sagittal Cobb [SC]-thoracolumbar kyphotic deformity of 110°, T9 Superior-L2 Inferior; Thoracic Kyphosis T4-T12 69.1°.</p>
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<p>Representative pre-op CT scan views of the congenital deformity. Cross-reference grid lines mark the intersection of the corresponding image planes: Blue—sagittal; Pink—Coronal; Yellow—Axial views.</p>
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<p>Pre-operative plan for computer-assisted robotic guided screw placement. Solid yellow (<b>Left</b>) and blue (<b>Right</b>) screw-shaped models are computer assisted designs of the planned screw trajectories with rods (continuous rectangular sketches) attached to them. Red rhomboid outlines indicate abutting of the planned trajectories. The area between the dotted yellow lines corresponds to that represented in the axial (AX) and lateral (LT) view windows.</p>
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<p>Full length (<b>A</b>) &amp; partial (thoracolumbar) (<b>B</b>) images of the 3D-printed spine biomodel with resection and osteotomy boundaries marked in red. 1–Anterior, 2–Right lateral, 3–Left lateral, and 4–Posterior views. * Incompletely formed/Congenitally malformed posterior elements. T—Thoracic; L—Lumbar.</p>
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<p>Full length (<b>A</b>) &amp; partial (thoracolumbar) (<b>B</b>) images of the 3D-printed spine biomodel with resection and osteotomy boundaries marked in red. 1–Anterior, 2–Right lateral, 3–Left lateral, and 4–Posterior views. * Incompletely formed/Congenitally malformed posterior elements. T—Thoracic; L—Lumbar.</p>
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<p>AP &amp; Lateral fluoroscopy images of temporary spinal instrumentation stabilization.</p>
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<p>AP &amp; Lateral fluoroscopy images of the final instrumentation &amp; deformity correction.</p>
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<p>Full-length AP and lateral EOS images—4-months Post-operatively.</p>
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<p>Representative post-op CT scan views—4-months Post-operatively. Cross-reference grid lines mark the intersection of the corresponding image planes: Blue—sagittal; Pink—Coronal; Yellow—Axial view.</p>
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<p>Full length (<b>A</b>) &amp; partial (thoracolumbar) (<b>B</b>) images of the post-operative 3D spine biomodel. 1—Anterior, 2—Right lateral, 3—Left lateral, and 4—Posterior views. T—Thoracic; L—Lumbar.</p>
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<p>Pre vs. Post-operative clinical examination photographs showing correction of the severe thoracolumbar junctional kyphotic deformity and coronal balance with the patient’s head positioned neutrally above the rest of the body postoperatively.</p>
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20 pages, 6877 KiB  
Systematic Review
Doctor, When Should I Start Walking? Revisiting Postoperative Rehabilitation and Weight-Bearing Protocols in Operatively Treated Acetabular Fractures: A Systematic Review and Meta-Analysis
by Vincenzo Giordano, Robinson Esteves Pires, Luiz Paulo Giorgetta de Faria, Igor Temtemples, Tomas Macagno, Anderson Freitas, Alexander Joeris and Peter V. Giannoudis
J. Clin. Med. 2024, 13(12), 3570; https://doi.org/10.3390/jcm13123570 - 18 Jun 2024
Viewed by 1758
Abstract
Background and Objectives: Management of acetabular fractures is aimed at anatomically reducing and fixing all displaced or unstable fractures, as the accuracy of fracture reduction has been demonstrated to strongly correlate with clinical outcomes. However, there is a noticeable gap in the [...] Read more.
Background and Objectives: Management of acetabular fractures is aimed at anatomically reducing and fixing all displaced or unstable fractures, as the accuracy of fracture reduction has been demonstrated to strongly correlate with clinical outcomes. However, there is a noticeable gap in the literature concerning the perioperative and postoperative care of patients with acetabular fractures, which ultimately can be potential risk factors for adverse outcomes and permanent disabilities. This study aimed to systematically review the available literature regarding rehabilitation practices, including weight-bearing protocols, across time points in surgically treated acetabular fracture patients and correlate these practices with functional outcomes. Methods: We systematically reviewed the Medline and PubMed databases and the Cochrane Central Register of Controlled Trials in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were studies with adult patients (19+ years), publications from the last 10 years, articles focusing on rehabilitation or mentioning any aspect related to rehabilitation (such as weight-bearing or muscle training), and describing the surgical management of acute, isolated acetabulum fractures. Specific information was collected, including the fracture classification, time to surgery, surgical approach, surgical time, blood loss, fixation strategy, quality of reduction, postoperative rehabilitation protocol, complication rate, type(s) of complication, and outcome measurement(s). The choice(s) of surgical approach, surgical time, blood loss, and fixation strategy were stratified based on the fracture classification. The complication rate and type(s) of complication were calculated for all studies. Fractures were classified based on the Letournel classification. Results: A total of 494 articles were identified from the initial search, of which 22 (1025 patients) were included in the final review. The most common rehabilitation protocol favored isometric quadriceps and abductor strengthening exercises starting on the first postoperative day, with passive hip movement at 1–3 days postoperatively and active hip movement ranging from the first postoperative day to 4 weeks postoperatively. Partial weight-bearing with a walker or a pair of crutches was permitted from 1 to 12 weeks after surgery, and full weight-bearing was allowed depending on the patient’s general condition and fracture healing state (generally at the end of 3 months). In only three studies did the patients start bearing weight in the early postoperative period (≤1 week). Meta-regression analysis was not performed due to the discrepancy between studies that reported a weight-bearing protocol ≤1 week and >1 week postoperatively. Conclusions: Our study suggests that an accelerated postoperative rehabilitation protocol, including early permissive weight-bearing, does not appear to increase the risk of loss of reduction or the rate of complications after surgical treatment of acetabular fractures. However, a proper meta-analysis was not possible, and the heterogeneity of the included studies did not allow us to conclude anything about the potential biomechanical and clinical benefits nor the negative effects related to this rehabilitation regimen in terms of functional results. There is an inconsistent use of PROMs for objectively calculating the effect size of the accelerated protocol compared with restricted weight-bearing regimes. We pose the need for higher-level evidence to proof our hypothesis. Full article
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<p>Systematic review search strategy.</p>
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<p>Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram displaying number of studies retrieved following searches and removal criterion at each screening stage.</p>
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<p>Results of the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool for non-randomized studies, visualized in traffic light plots for each individual domain assessed using Cochrane robvis visualization tool [<a href="#B17-jcm-13-03570" class="html-bibr">17</a>,<a href="#B18-jcm-13-03570" class="html-bibr">18</a>,<a href="#B19-jcm-13-03570" class="html-bibr">19</a>,<a href="#B20-jcm-13-03570" class="html-bibr">20</a>,<a href="#B21-jcm-13-03570" class="html-bibr">21</a>,<a href="#B22-jcm-13-03570" class="html-bibr">22</a>,<a href="#B23-jcm-13-03570" class="html-bibr">23</a>,<a href="#B24-jcm-13-03570" class="html-bibr">24</a>,<a href="#B25-jcm-13-03570" class="html-bibr">25</a>,<a href="#B26-jcm-13-03570" class="html-bibr">26</a>,<a href="#B27-jcm-13-03570" class="html-bibr">27</a>,<a href="#B28-jcm-13-03570" class="html-bibr">28</a>,<a href="#B29-jcm-13-03570" class="html-bibr">29</a>,<a href="#B30-jcm-13-03570" class="html-bibr">30</a>,<a href="#B31-jcm-13-03570" class="html-bibr">31</a>,<a href="#B32-jcm-13-03570" class="html-bibr">32</a>,<a href="#B33-jcm-13-03570" class="html-bibr">33</a>,<a href="#B34-jcm-13-03570" class="html-bibr">34</a>,<a href="#B35-jcm-13-03570" class="html-bibr">35</a>,<a href="#B36-jcm-13-03570" class="html-bibr">36</a>,<a href="#B37-jcm-13-03570" class="html-bibr">37</a>,<a href="#B38-jcm-13-03570" class="html-bibr">38</a>].</p>
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<p>Bubble plot of functional outcomes of the mean MDPS versus early (<math display="inline"><semantics> <mrow> <mo>≤</mo> </mrow> </semantics></math>1 week) and delayed (&gt;1 week) weight-bearing times [<a href="#B17-jcm-13-03570" class="html-bibr">17</a>,<a href="#B18-jcm-13-03570" class="html-bibr">18</a>,<a href="#B19-jcm-13-03570" class="html-bibr">19</a>,<a href="#B20-jcm-13-03570" class="html-bibr">20</a>,<a href="#B21-jcm-13-03570" class="html-bibr">21</a>,<a href="#B22-jcm-13-03570" class="html-bibr">22</a>,<a href="#B25-jcm-13-03570" class="html-bibr">25</a>,<a href="#B26-jcm-13-03570" class="html-bibr">26</a>,<a href="#B28-jcm-13-03570" class="html-bibr">28</a>,<a href="#B29-jcm-13-03570" class="html-bibr">29</a>,<a href="#B30-jcm-13-03570" class="html-bibr">30</a>,<a href="#B31-jcm-13-03570" class="html-bibr">31</a>,<a href="#B34-jcm-13-03570" class="html-bibr">34</a>,<a href="#B36-jcm-13-03570" class="html-bibr">36</a>,<a href="#B38-jcm-13-03570" class="html-bibr">38</a>].</p>
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<p>Bubble plot of functional outcomes of the mean HHS versus early (<math display="inline"><semantics> <mrow> <mo>≤</mo> </mrow> </semantics></math>1 week) and delayed (&gt;1 week) weight-bearing times [<a href="#B18-jcm-13-03570" class="html-bibr">18</a>,<a href="#B19-jcm-13-03570" class="html-bibr">19</a>,<a href="#B29-jcm-13-03570" class="html-bibr">29</a>,<a href="#B33-jcm-13-03570" class="html-bibr">33</a>,<a href="#B34-jcm-13-03570" class="html-bibr">34</a>,<a href="#B35-jcm-13-03570" class="html-bibr">35</a>].</p>
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14 pages, 1794 KiB  
Article
Assessment of Gait Patterns during Crutch Assisted Gait through Spatial and Temporal Analysis
by Marien Narvaez Dorado, Miguel Salazar and Joan Aranda
Sensors 2024, 24(11), 3555; https://doi.org/10.3390/s24113555 - 31 May 2024
Viewed by 1305
Abstract
The use of crutches is a common method of assisting people during recovery from musculoskeletal injuries in the lower limbs. There are several different ways to walk with crutches depending on the patient’s needs. The structure of crutch gaits or crutch gait patterns [...] Read more.
The use of crutches is a common method of assisting people during recovery from musculoskeletal injuries in the lower limbs. There are several different ways to walk with crutches depending on the patient’s needs. The structure of crutch gaits or crutch gait patterns varies based on the delay between the aid and foot placement, the number of concurrent points of contact, and laterality. In a rehabilitation process, the prescribed pattern may differ according to the injury, the treatment and the individual’s condition. Clinicians may improve diagnosis, assessment, training, and treatment by monitoring and analyzing gait patterns. This study aimed to assess and characterize four crutch walking patterns using spatial and temporal parameters obtained from the instrumented crutches. For this purpose, 27 healthy users performed four different gait patterns over multiple trials. Each trial was recorded using a portable system integrated into the crutches, which measured force, position, and acceleration. Based on the data angle, an algorithm was developed to segment the trials into gait cycles and identify gait phases. The next step was to determine the most appropriate metrics to describe each gait pattern. Several metrics were used to analyze the collected data, including force, acceleration, angle, and stride time. Among 27 participants, significant differences were found between crutch gait patterns. Through the use of these spatial and temporal parameters, promising results were obtained for monitoring assisted gait with crutches. Furthermore, the results demonstrated the possibility of using instrumented crutches as a clinical tool. Full article
(This article belongs to the Section Wearables)
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<p>Subject walking with the instrumented crutches along the 10 m corridor performing a three-point gait. Green squares represent markers located every 2 m. Blue squares indicate the circuit boxes for each crutch.</p>
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<p>Crutch gait cycle division according to pitch angle peaks.</p>
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<p>Mean forces, angle, and accelerations for all the participants in each gait pattern. The first column shows the force average, the second column represents the angles and the third column shows the accelerations. The dotted lines show the transition between the swing and stance phases.</p>
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<p>Mean forces, angle, and accelerations for Participant number 20 in each gait pattern. The first column shows the force average, the second column represents the angles and the third column shows the accelerations. Dotted lines show the range of the swing phase.</p>
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12 pages, 2037 KiB  
Review
Clinical Application of Unidirectional Porous Hydroxyapatite to Bone Tumor Surgery and Other Orthopedic Surgery
by Toshiyuki Kunisada, Eiji Nakata, Tomohiro Fujiwara, Toshiaki Hata, Kohei Sato, Haruyoshi Katayama, Ayana Kondo and Toshifumi Ozaki
Biomimetics 2024, 9(5), 294; https://doi.org/10.3390/biomimetics9050294 - 15 May 2024
Cited by 2 | Viewed by 1534
Abstract
Unidirectional porous hydroxyapatite (UDPHAp) was developed as a remarkable scaffold characterized by a distinct structure with unidirectional pores oriented in the horizontal direction and connected through interposes. We evaluated the radiographic changes, clinical outcomes, and complications following UDPHAp implantation for the treatment of [...] Read more.
Unidirectional porous hydroxyapatite (UDPHAp) was developed as a remarkable scaffold characterized by a distinct structure with unidirectional pores oriented in the horizontal direction and connected through interposes. We evaluated the radiographic changes, clinical outcomes, and complications following UDPHAp implantation for the treatment of bone tumors. Excellent bone formation within and around the implant was observed in all patients treated with intralesional resection and UDPHAp implantation for benign bone tumors. The absorption of UDPHAp and remodeling of the bone marrow space was observed in 45% of the patients at a mean of 17 months postoperatively and was significantly more common in younger patients. Preoperative cortical thinning was completely regenerated in 84% of patients at a mean of 10 months postoperatively. No complications related to the implanted UDPHAp were observed. In a pediatric patient with bone sarcoma, when the defect after fibular resection was filled with UDPHAp implants, radiography showed complete resorption of the implant and clear formation of cortex and marrow in the resected part of the fibula. The patient could walk well without crutches and participate in sports activities. UDPHAp is a useful bone graft substitute for the treatment of benign bone tumors, and the use of this material has a low complication rate. We also review and discuss the potential of UDPHAp as a bone graft substitute in the clinical setting of orthopedic surgery. Full article
(This article belongs to the Special Issue Advances in Bioceramics for Bone Regeneration)
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<p>Three-dimensional micro-CT image of UDPHAp (provided by Kuraray Co., Ltd., Tokyo, Japan), showing the unidirectional pores in the vertical direction and some interconnection in the horizontal direction.</p>
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<p>Radiographs of a 23-year-old simple bone cyst of the right proximal femur treated with UDPHAp [<a href="#B6-biomimetics-09-00294" class="html-bibr">6</a>]. (<b>a</b>) The UDPHAp implantation and internal fixation were shown on a radiograph 2 weeks postoperatively. A lytic change with cortical thinning of the medial bone cortex (arrows) was noted. Full weight bearing was allowed one day after surgery, and the patient returned to normal daily activities 2 months postoperatively; (<b>b</b>) moderate bone formation in UDPHAp was confirmed 7 months postoperatively; (<b>c</b>) the generation of medial cortical thinning was seen 13 months postoperatively; (<b>d</b>) UDPHAp resorption and bone marrow remodeling were observed 2 years and 6 months postoperatively. The decrease in medial cortical thickness was completely reversed (arrows).</p>
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<p>Radiographs of UDPHAp implantation in a segmental bone defect of the fibula after harvesting [<a href="#B7-biomimetics-09-00294" class="html-bibr">7</a>]. (<b>a</b>) Column-shaped UDPHAp implants were visible one week after surgery. Full weight bearing on the left leg was not allowed within 6 weeks after surgery to stabilize the pelvic reconstruction. The patient returned to normal daily activities 6 months postoperatively due to postoperative chemotherapy; (<b>b</b>) the resorption of the implanted UDPHAp was detected, and partial remodeling of the marrow space was seen 11 months after surgery; (<b>c</b>) new bone formation and resorption of implanted UDPHAp had progressed 2.5 years after surgery; (<b>d</b>) the complete resorption of implanted UDPHAp and clear formation of cortex and marrow were observed 12 years after surgery.</p>
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16 pages, 6715 KiB  
Review
A Comparative Analysis of Osteochondritis Dissecans and Avascular Necrosis: A Comprehensive Review
by Wojciech Konarski, Tomasz Poboży, Klaudia Konarska, Andrzej Śliwczyński, Ireneusz Kotela and Jan Krakowiak
J. Clin. Med. 2024, 13(1), 287; https://doi.org/10.3390/jcm13010287 - 4 Jan 2024
Cited by 1 | Viewed by 2838
Abstract
Musculoskeletal disorders, standing as the fifth leading cause of disability-adjusted life years globally, present significant challenges in orthopedics. Osteochondritis dissecans (OCD) and avascular necrosis (AVN) are distinct but closely related conditions within this spectrum, impacting patients’ quality of life with pain, limited mobility, [...] Read more.
Musculoskeletal disorders, standing as the fifth leading cause of disability-adjusted life years globally, present significant challenges in orthopedics. Osteochondritis dissecans (OCD) and avascular necrosis (AVN) are distinct but closely related conditions within this spectrum, impacting patients’ quality of life with pain, limited mobility, and dysfunction. OCD, involving cartilage and bone detachment in joints, predominantly affects young athletes, but its exact etiology and optimal management remain subjects of ongoing research. Conversely, AVN, marked by bone tissue death due to compromised blood supply, is linked to systemic factors like corticosteroid use and traumatic injuries. Diagnosis for both conditions relies on radiography and magnetic resonance imaging. Conservative treatment for AVN includes the use of a cane or crutches, pharmacological therapy, or physical therapy. On the other hand, in OCD, the primary approach is activity/sports restriction. Surgical treatment options for AVN patients encompass core decompression, bone grafting, or, in the most advanced cases, total hip arthroplasty. OCD may be surgically treated through subchondral drilling or fixation of unstable lesions. Advanced cases of OCD involve cartilage salvage with resurfacing techniques. The presentation of differences between these conditions enhances our understanding, facilitating improved diagnosis and management strategies. Full article
(This article belongs to the Section Orthopedics)
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<p>MRI image of AVN of the lateral and medial condyle of the femoral bone of the knee joint. (<b>A</b>) T1-weighted image; (<b>B</b>) short T1 inversion recovery (STIR) image.</p>
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<p>T1-weighted image of AVN of the talus bone.</p>
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<p>T1-weighted image of bilateral AVN of the femoral head.</p>
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<p>MRI image of talus OCD. (<b>A</b>) T1-weighted image (sagittal view); (<b>B</b>) T2-weighted image (coronal view); (<b>C</b>) short T1 inversion recovery (STIR) image (coronal view).</p>
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<p>MRI image of medial condyle OCD. (<b>A</b>) T1-weighted image (sagittal view); (<b>B</b>) T1-weighted image (coronal view); (<b>C</b>) short T1 inversion recovery (STIR) image (coronal view).</p>
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32 pages, 5622 KiB  
Review
Review and Analysis of Platform-Related Performance of Rehabilitation Lower Limb Exoskeletons
by Hossein Karami, Stefano Maludrottu, Christian Vassallo, Matteo Laffranchi and Lorenzo De Michieli
Actuators 2023, 12(11), 406; https://doi.org/10.3390/act12110406 - 29 Oct 2023
Cited by 2 | Viewed by 2487
Abstract
Powered Lower Limb Exoskeletons (PLLE) have attracted much interest due to their potential applications. They provide assistance for persons with disabilities to accomplish activities of daily living (ADL), and more importantly, assist them in achieving their rehabilitation goals. However, there is still uncertainty [...] Read more.
Powered Lower Limb Exoskeletons (PLLE) have attracted much interest due to their potential applications. They provide assistance for persons with disabilities to accomplish activities of daily living (ADL), and more importantly, assist them in achieving their rehabilitation goals. However, there is still uncertainty regarding the quality and benefits that PLLEs can offer to patients. This is due to limited usability and performance of current PLLEs, insufficient clinical use of PLLEs for different patients with high diversity in their disability type and impairment, and also the large gap between the technological state of the art and clinical expectations. In this study, we review and analyse various factors that can improve the effectiveness of PLLEs at yielding better assistance and rehabilitation training for patients with motor impairments. First, we define a set of criteria that characterize the majority of expectations for the rehabilitation and assistance domains and we use them for evaluating PLLEs depending on the context. Then, we include the effects of control strategies and combined approaches which include auxiliary devices such as functional electrical stimulation and smart crutches applied to PLLEs with regard to the criteria we defined. Full article
(This article belongs to the Section Actuators for Robotics)
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<p>Flowchart representing inclusion and exclusion criteria we adopted for paper selection.</p>
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<p>Wearable robot (WR) evaluation perspectives to be considered as proposed by [<a href="#B33-actuators-12-00406" class="html-bibr">33</a>].</p>
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<p>Spectrum of human locomotion phases characterised by bio mechanical events. Overall gait is divided into stance and swing phases. Each phase comprises some sub-phase segments representing bio mechanical events [<a href="#B46-actuators-12-00406" class="html-bibr">46</a>].</p>
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<p>(<b>left</b>) Vector of GRF (summation of ground normal reaction and friction forces) passes through CoM and rate of angular momentum is zero and balance is maintained. (<b>right</b>) GRF vector is creating a clock-wise rate of angular momentum and causing an excessive forward lean and enhancing fall danger.</p>
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<p>The reference planes of the human body in the standard anatomical position [<a href="#B68-actuators-12-00406" class="html-bibr">68</a>].</p>
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<p>Some examples of partial PLLEs: (<b>a</b>) Honda Walking Assist, with two active hip joints [<a href="#B94-actuators-12-00406" class="html-bibr">94</a>], (<b>b</b>) C-Brace orthotic device [<a href="#B95-actuators-12-00406" class="html-bibr">95</a>], (<b>c</b>) Hal single-leg exoskeleton with actuated hip and knee joints [<a href="#B79-actuators-12-00406" class="html-bibr">79</a>], (<b>d</b>) AlterG Bionic Leg with actuated knee joint [<a href="#B96-actuators-12-00406" class="html-bibr">96</a>] and (<b>e</b>) MAK, actuated knee [<a href="#B97-actuators-12-00406" class="html-bibr">97</a>]. Some examples of complete PLLEs: (<b>f</b>) Atalante of Wandercraft with 12 DoF [<a href="#B94-actuators-12-00406" class="html-bibr">94</a>], (<b>g</b>) REX PLLE with ten actuated joints [<a href="#B98-actuators-12-00406" class="html-bibr">98</a>], (<b>h</b>) Ekso GT exoskeleton with four actuated joints [<a href="#B99-actuators-12-00406" class="html-bibr">99</a>], (<b>i</b>) TWIN PLLE with four actuated joints [<a href="#B100-actuators-12-00406" class="html-bibr">100</a>] and (<b>j</b>) Indego PLLE with four actuated joints [<a href="#B101-actuators-12-00406" class="html-bibr">101</a>].</p>
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<p>Some examples of partial PLLEs: (<b>a</b>) Honda Walking Assist, with two active hip joints [<a href="#B94-actuators-12-00406" class="html-bibr">94</a>], (<b>b</b>) C-Brace orthotic device [<a href="#B95-actuators-12-00406" class="html-bibr">95</a>], (<b>c</b>) Hal single-leg exoskeleton with actuated hip and knee joints [<a href="#B79-actuators-12-00406" class="html-bibr">79</a>], (<b>d</b>) AlterG Bionic Leg with actuated knee joint [<a href="#B96-actuators-12-00406" class="html-bibr">96</a>] and (<b>e</b>) MAK, actuated knee [<a href="#B97-actuators-12-00406" class="html-bibr">97</a>]. Some examples of complete PLLEs: (<b>f</b>) Atalante of Wandercraft with 12 DoF [<a href="#B94-actuators-12-00406" class="html-bibr">94</a>], (<b>g</b>) REX PLLE with ten actuated joints [<a href="#B98-actuators-12-00406" class="html-bibr">98</a>], (<b>h</b>) Ekso GT exoskeleton with four actuated joints [<a href="#B99-actuators-12-00406" class="html-bibr">99</a>], (<b>i</b>) TWIN PLLE with four actuated joints [<a href="#B100-actuators-12-00406" class="html-bibr">100</a>] and (<b>j</b>) Indego PLLE with four actuated joints [<a href="#B101-actuators-12-00406" class="html-bibr">101</a>].</p>
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<p>(<b>a</b>) RoM of actuators for various PLLEs. A—Active joint, P—Passive joint, N—No joint, NA—information is not available. The x-axis represents the range in degrees. (<b>b</b>) Ratio of PLLE maximum torque of motors to overall weight of the exoskeleton as an indicator for deliverable power, w.r.t DoF of each leg. Passive joints are considered to have 0.5 DoF. Blue circles depict stiff joints and red circles joints with SEA actuation. Human biological lower limb is considered to weigh 40 kg and provide 150 Nm torque. We considered 50 Nm torque for PLLEs with unknown max torque value.</p>
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<p>Assistive controllers: (<b>a</b>) Linear model of the coupled 1-DOF human–exoskeleton system [<a href="#B106-actuators-12-00406" class="html-bibr">106</a>]. (<b>b</b>) Hybrid zero dynamic-based controller supplemented with foot detection-based switching condition [<a href="#B107-actuators-12-00406" class="html-bibr">107</a>]. (<b>c</b>) Performance of the proposed controller acting on paretic leg in forcing the trajectories back into the deadzone throughout gait [<a href="#B108-actuators-12-00406" class="html-bibr">108</a>]. (<b>d</b>) AAN controller with the user torque contribution for different gait pathologies [<a href="#B108-actuators-12-00406" class="html-bibr">108</a>].</p>
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<p>(<b>a</b>) Overview of the lower limb exoskeleton shared control system [<a href="#B138-actuators-12-00406" class="html-bibr">138</a>]. (<b>b</b>) The architecture of the balance control strategy presented in [<a href="#B125-actuators-12-00406" class="html-bibr">125</a>]. (<b>c</b>) Control structure of the human–exoskeleton system [<a href="#B126-actuators-12-00406" class="html-bibr">126</a>], (<b>d</b>) Autonomous gait pattern planning framework presented in [<a href="#B139-actuators-12-00406" class="html-bibr">139</a>].</p>
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10 pages, 688 KiB  
Article
Prevalence of Impaired Physical Mobility in Dialysis Patients: A Single-Centre Cross-Sectional Study
by Špela Bogataj, Jernej Pajek, Blaž Slonjšak and Vanja Peršič
J. Clin. Med. 2023, 12(20), 6634; https://doi.org/10.3390/jcm12206634 - 20 Oct 2023
Cited by 1 | Viewed by 1533
Abstract
Impaired physical mobility in hemodialysis (HD) patients is considered an important modifiable risk factor of increased all-cause morbidity and mortality. To our knowledge, no study to date has determined the overall burden of limited physical mobility in prevalent HD patients. The aim of [...] Read more.
Impaired physical mobility in hemodialysis (HD) patients is considered an important modifiable risk factor of increased all-cause morbidity and mortality. To our knowledge, no study to date has determined the overall burden of limited physical mobility in prevalent HD patients. The aim of this research is to investigate impaired physical mobility and its clinical correlates. We conducted a cross-sectional observational study in all patients of the Centre for Acute and Complicated Dialysis at the University Medical Centre of Ljubljana, where the most complex patients receive HD on average three times per week. The data were collected through interviews based on a prepared questionnaire and medical history review. A total of 205 patients were included in this study (63.9 ± 15.4 years). Sixty percent (122/205) of the patients had little or no physical mobility impairment, and others were categorized with a minor or severe mobility limitation. A minor mobility impairment was found in 21% (43/205) of patients: 10 patients (5%) used a mobility aid in the form of a crutch, 9 patients (4%) were dependent on two crutches or a walker, and 24 patients (12%) were temporarily dependent on the assistance of a third person. Severe mobility limitations were observed in 22% (40/205) of patients, ranging from being confined to bed (19/205, 9%), confined to bed but able to perform some movements (19/205, 9%), and ambulatory but dependent on the assistance of a third person for locomotion (2/205, 1%). The most common causes of the limitation of mobility were neurological (19/40, 47.5%), cardiovascular (9/40, 22.5%), musculoskeletal (8/40, 20%), and other causes (4/40, 10%). A significant, moderate positive correlation was observed between mobility problems and the age of the participants (r = 0.36, p < 0.001), while a significant, small positive correlation was obtained between the mobility problems and C-reactive protein (r = 0.15, p = 0.044). Moreover, mobility problems had a small but significant negative correlation with albumin levels (r = −0.15, p = 0.042). When controlling for age, results yield no significant correlations, and, in regression analysis, only the age (p < 0.001) and male gender (p = 0.007) of the participants were independent predictors of mobility impairment. We conclude that impaired mobility has a high overall prevalence among chronic HD patients. Strategies to prevent and improve mobility limitations are strongly needed. Full article
(This article belongs to the Special Issue Clinical Application of Hemodialysis and Its Adverse Effects)
7 pages, 1782 KiB  
Interesting Images
A Case Showing a New Diagnostic Aspect of the Application of Radiofrequency Echographic Multi-Spectrometry (REMS)
by Nikola Kirilov, Fabian Bischoff, Stoyanka Vladeva and Elena Bischoff
Diagnostics 2023, 13(20), 3224; https://doi.org/10.3390/diagnostics13203224 - 17 Oct 2023
Cited by 3 | Viewed by 1254
Abstract
Radiofrequency echographic multi-spectrometry (REMS) is an ultrasound technique that has been recently introduced in the medical field to detect osteoporosis and fracture risk at axial sites. The use of sonography to visualize the region of interest (ROI) of the hip neck provides the [...] Read more.
Radiofrequency echographic multi-spectrometry (REMS) is an ultrasound technique that has been recently introduced in the medical field to detect osteoporosis and fracture risk at axial sites. The use of sonography to visualize the region of interest (ROI) of the hip neck provides the opportunity to identify occult fractures. A 91-year-old woman with persistent right leg pain was referred to rheumatologist due to a known history of arthritis and osteoporosis. She was able to walk using a crutch, although experiencing an antalgic gait. The patient had recently fallen on her right side from standing height. During the visualization of the ROI of the right femoral neck using REMS, an abrupt break of the femoral cortex suspected to be a fracture was seen; therefore, the measurement of the femoral neck was performed on the left side. The T-score had value of −2.9 SD and the fragility score was 86.7. Due to unclear signs of a fracture after an X-ray of the hip, a computed tomography (CT) exam of the hip was performed, which revealed a femoral neck fracture. Occult fractures of the femoral neck are challenging to diagnose and require numerous radiologic exams. The use of ultrasound as a method to measure bone density allows the simultaneous diagnosis of osteoporosis and detection of fractures. Full article
(This article belongs to the Special Issue Recent Advances in Bone and Joint Imaging—2nd Edition)
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<p>Visualization of ROI of the femoral neck using REMS for bone density measurement. Red arrow showing abrupt break of the bone cortex. In recent years, a new non-ionizing technique called radiofrequency echographic multi-spectrometry (REMS) has been introduced, which captured the interest of many medical specialists in the field of osteoporosis after single- and multi-center studies demonstrated the diagnostic accuracy of REMS compared to dual-energy X-ray absorptiometry (DEXA) [<a href="#B1-diagnostics-13-03224" class="html-bibr">1</a>,<a href="#B2-diagnostics-13-03224" class="html-bibr">2</a>,<a href="#B3-diagnostics-13-03224" class="html-bibr">3</a>,<a href="#B4-diagnostics-13-03224" class="html-bibr">4</a>]. During the evaluation with REMS, raw unfiltered native ultrasound signals, so-called radio frequency (RF) ultrasound signals, are analyzed. The spectra of the analyzed signals are compared with reference spectral models to obtain a DEXA-equivalent bone mineral density (BMD) of the lumbar spine and/or hip [<a href="#B5-diagnostics-13-03224" class="html-bibr">5</a>]. Based on the BMD value, subjects are classified as healthy (T-score &gt; −1.0 SD), osteopenic (T-score between −1 and −2.5 SD) and osteoporotic (T-score of &lt; −2.5 SD) according to the definition of the World Health Organization (WHO) [<a href="#B6-diagnostics-13-03224" class="html-bibr">6</a>]. The T-score represents a standard deviation of the BMD from the average BMD of the young adult reference population [<a href="#B7-diagnostics-13-03224" class="html-bibr">7</a>]. In addition to the T-score, microarchitectural deterioration of the bone tissue was found to be important for the diagnosis of osteoporosis due to its association with an increased risk of fractures [<a href="#B8-diagnostics-13-03224" class="html-bibr">8</a>]. In this context, the novel fragility score (FS) parameter, obtained during the REMS scan of lumbar spine and/or femoral regions, has been developed to estimate the ultrasound-based skeletal fragility. The FS value is acquired through comparison between the patient-specific spectral profiles with models of “fractured” and “non-fractured” subjects, which gives information about the quality of the bone microarchitecture independently of BMD [<a href="#B9-diagnostics-13-03224" class="html-bibr">9</a>]. A 91-year-old woman with persistent right leg pain was referred to her treating rheumatologist for examination. The clinical examination narrowed the pain down to the right hip, radiating down to the knee. The palpation of the greater trochanter was painful and there were no signs of a shortened, externally rotated or abducted leg. Straight leg raise was performed with great difficulty. She was able to walk using crutch for support, although experiencing an antalgic gait. The patient reported to have recently fallen on her right side from standing height. Due to a known history of arthritis and osteoporosis treated with bisphosphonate and denosumab since 2016, a bone density measurement was performed using REMS by a certified orthopedist. The T-score of the lumbar spine was −2.6 SD and BMD was 0.761 g/cm<sup>2</sup>, with a fragility score of 72. During the visualization of the region of interest (ROI) of the right femoral neck, an abrupt break of the cortex (red arrow) of the femur with a suspected fracture was seen; therefore, the measurement of the femoral neck was performed on the left side. The T-score had value of −2.9 SD and BMD was 0.527 g/cm<sup>2</sup> with fragility score of 86.7.</p>
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<p>Plain radiograph of the right hip showing no clear signs of a fracture. The doctor then performed an X-ray imaging of the hip, which did not give clear signs of a fracture. Occult fractures are a type of nondisplaced fracture, which are not visible on plain radiographs or, sometimes, computed tomography (CT). This makes them prone to diagnostic errors, requiring a detailed anamnesis and clinical examination. The prevalence of such fractures is relatively high among children [<a href="#B10-diagnostics-13-03224" class="html-bibr">10</a>], whereas in adults the prevalence is under 10% [<a href="#B11-diagnostics-13-03224" class="html-bibr">11</a>,<a href="#B12-diagnostics-13-03224" class="html-bibr">12</a>]. An occult fracture should always be suspected when clinical symptoms and examination do not match the radiographic finding [<a href="#B12-diagnostics-13-03224" class="html-bibr">12</a>]. After X-ray, the next diagnostic step is the CT, which does not always exclude a false negative result. In addition to plain radiographs and CT, magnetic resonance imaging (MRI) plays an important role. Unfortunately, facilities equipped with MRI scanners are not available nationwide in all countries, and the cost–benefit has not yet been proven [<a href="#B13-diagnostics-13-03224" class="html-bibr">13</a>].</p>
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<p>Computed tomography of the right hip reveals the femoral neck fracture. Considering the ultrasound finding and the clinical symptoms, a CT exam of the hip was performed, which revealed a femoral neck fracture. Due to the unquestionable nature of the image, we did not consider MRI for further diagnosis. The patient was then scheduled for a hemiarthroplasty of the right hip joint in the department of orthopedic surgery due to the old age of the patient. Ultrasound is not the primary diagnostic method for discovering hip fractures. Despite that, numerous studies and case reports have shown its reliability and potential in diagnosing occult femoral neck fractures where CT and X-ray fall short [<a href="#B14-diagnostics-13-03224" class="html-bibr">14</a>]. REMS is an accurate non-ionizing method for measuring the bone density at axial skeleton sites, and its results highly correlate to those measured using DEXA [<a href="#B2-diagnostics-13-03224" class="html-bibr">2</a>]. Moreover, the use of sonography to visualize and identify the ROI of the hip neck provides the opportunity to identify occult fractures. Such fractures are often hard to diagnose and missed by practitioners due to their atypical clinical and radiographic manifestation [<a href="#B15-diagnostics-13-03224" class="html-bibr">15</a>]. Fractures of the proximal femur are a common type of fragility fractures [<a href="#B16-diagnostics-13-03224" class="html-bibr">16</a>]. The ultrasound image of occult fractures may not always appear clearly as a break of the bone cortex, but also as an interference or abnormality of the surrounding tissue. The scan of the other hip is useful as a comparison. In addition, the joint could be examined for effusion. [<a href="#B17-diagnostics-13-03224" class="html-bibr">17</a>] The gold standard for diagnosis when plain radiographs and CT yield negative results is the MRI exam [<a href="#B18-diagnostics-13-03224" class="html-bibr">18</a>]. This method is costly and not highly available. On the other hand, bone density measurements such as REMS are carried out regularly and performed by wide variety of specialists.</p>
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<p>Combining matrix of REMS BMD against fragility score (each diagnosis has 3 classes of fragility score). Fragility score is a dimensionless parameter that allows the estimation of skeletal fragility using the ultrasound scan performed with REMS, and it can vary from 0 to 100. The physician can identify the risk class corresponding to the current patient by combining the measured REMS T-score and FS values using the combining matrix. The fragility score is an accurate estimation of the risk of osteoporotic (fragility) fractures at 5 years [<a href="#B19-diagnostics-13-03224" class="html-bibr">19</a>]. These include fractures of the proximal femur, the vertebrae, the proximal humerus and the distal radius caused by low-energy or minor trauma, such as a fall from standing height [<a href="#B20-diagnostics-13-03224" class="html-bibr">20</a>]. The potential to simultaneously diagnose osteoporosis and fragility fractures proves this approach to be effective. This allows preventive measures to be taken to avoid the secondary displacement of the fracture, immobilization and complications following the future treatment [<a href="#B21-diagnostics-13-03224" class="html-bibr">21</a>]. Furthermore, the adequate treatment of the primary disease osteoporosis can be initiated to prevent further fractures.</p>
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<p>REMS definition of risk classes according to fragility score. Risk class can range from R1 to R7. A higher risk class corresponds to a higher fracture risk. Once the risk class is identified for the patient through the matrix described above, it is possible to quantify the patient-associated fracture risk range expressed in terms of ‰ per 5 years. In our case, the patient was classified into class R7 for hip and class R6 for spine, meaning that the risk of osteoporotic fracture of the hip at 5 years was much higher than that of the spine. BMD and T-score alone are not sufficient measurements when it comes to the diagnosis and treatment of osteoporosis. The microarchitecture of the bone tissue plays an important role too. The REMS technology provides a combining matrix of the REMS BMD against the fragility score in order to obtain a full picture of the condition and enhance decision making. Occult fractures of the femoral neck are hard to diagnose and require numerous radiologic exams. Recent studies show the importance of ultrasound methods. The REMS method for measuring bone density using ultrasound allows the simultaneous diagnosis of osteoporosis and estimation of the fracture risk. It is accessible to large number of specialists, and the ultrasound analysis offers the opportunity to discover occult femoral neck fractures, especially in cases where patients are bedridden and other diagnostic methods are hard to perform. In addition to the sonographic scan, the possibility to diagnose osteoporosis with the REMS method is helpful for initiating osteoporosis treatment.</p>
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8 pages, 2616 KiB  
Case Report
Isolated Avulsion Fracture of the Tibial Tuberosity in an Adult Treated with Suture-Bridge Fixation: A Rare Case and Literature Review
by Dong Hwan Lee, Hwa Sung Lee, Chae-Gwan Kong and Se-Won Lee
Medicina 2023, 59(9), 1565; https://doi.org/10.3390/medicina59091565 - 29 Aug 2023
Cited by 4 | Viewed by 4310
Abstract
Background and objectives: Isolated tibial tuberosity avulsion fractures are exceptionally uncommon among adults, with limited instances documented in published literature. Here, we describe a case of an isolated tibial tuberosity avulsion fracture in an adult that was treated successfully with the suture bridge [...] Read more.
Background and objectives: Isolated tibial tuberosity avulsion fractures are exceptionally uncommon among adults, with limited instances documented in published literature. Here, we describe a case of an isolated tibial tuberosity avulsion fracture in an adult that was treated successfully with the suture bridge repair technique. Patient concerns: A 65-year-old female visited the outpatient department with left knee pain after a slip and fall. Lateral radiographs and sagittal MR images of the left knee revealed the tibial tuberosity avulsion fracture, but the fracture line did not extend into the knee joint space. Surgical intervention was performed on the patient’s knee using an anterior midline approach, involving open reduction and internal fixation. The avulsed tendon was grasped and pulled, and an appropriate suture location was identified. Using a suture hook, the suture was guided through the patellar tendon as near to its uppermost point of the fragment as achievable, and tied over tendon. A single suture limb from each anchor was fastened over the tibial tuberosity to the distally positioned foot print anchor, effectively anchoring the tibial tuberosity using the suture bridge technique. The patient started walking on crutches after one week and was able to walk independently with a brace after two weeks from the operation day. After three months, the patient had regained her mobility to the level prior to the injury and exhibited painless active range of motion from 0 to 130 degrees. Hardware positioning and bony union were maintained at the one-year follow-up. Conclusions: In our case, the open suture bridge fixation method for tibial tuberosity avulsion fractures produced satisfactory results. Open suture bridge fixation may be considered for isolated tibial tuberosity avulsion fractures in adults, especially when the avulsion tip is too small for screw fixation. Full article
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<p>Lateral radiograph (<b>a</b>) and sagittal MR image (<b>b</b>) of the left knee, revealing the tibial tuberosity avulsion fracture, but the fracture line does not extend into the knee joint space. Plain radiography exhibited osteoporotic bone quality in the patella, distal femur, and proximal tibia, which is presumed to be a result of previous trauma and two prior surgeries.</p>
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<p>Intra-operative images. (<b>a</b>) Image depicts a tibial tuberosity avulsion fracture, as indicated by the forceps holding the avulsed fragment. (<b>b</b>) The avulsed tendon was grasped and pulled using No. 2 Ethibond suture, and an appropriate suture anchor location was identified. (<b>c</b>) Image shows the fixation method using the suture bridge technique. A single suture limb from each anchor was secured over the tibial tuberosity and fastened to the distally positioned footprint anchors. (<b>d</b>) A well-reduced state was observed with the suture bridge repair technique.</p>
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<p>Schematic image of surgical techniques. (<b>A</b>) An image viewed from the undersurface of the patellar tendon showing the passage of the suture. Two orange circles indicate the fracture surfaces. Two navy blue triangles indicate the position of the 5.5 mm metal anchors. The red and blue lines indicate the sutures that are attached to the anchors. (<b>B</b>) An image depicting the appearance after suture bridge fixation. Two yellow markers indicate the positions of the 5.5 mm footprint anchors. The image shows the crossing of suture limbs from each anchor to secure the avulsed tibial tuberosity fragment using the distally positioned footprint anchor. To achieve firm fixation, maintaining proper tension during the crossing of suture limbs and fixation is crucial, along with the placement of the anchors.</p>
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<p>Clinical image of the patient’s lower extremity with recovery of range of motion at three months after the operation.</p>
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<p>Post-operative X-rays. (<b>a</b>) Immediate postoperative X-rays show that the avulsed tibial tuberosity fragment has been successfully reduced to its anatomical position. (<b>b</b>) 12-month postoperative X-rays show that the fracture fragment is well-maintained without any displacement and has successfully achieved union.</p>
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13 pages, 699 KiB  
Article
Rehabilitation Prognostic Factors following Hip Fractures Associated with Patient’s Pre-Fracture Mobility and Functional Ability: A Prospective Observation Study
by Smaragda Koudouna, Dimitrios S. Evangelopoulos, Michail Sarantis, Efstathios Chronopoulos, Ismene A. Dontas and Spiridon Pneumaticos
Life 2023, 13(8), 1748; https://doi.org/10.3390/life13081748 - 15 Aug 2023
Cited by 3 | Viewed by 1426
Abstract
Low physical function is associated with poor outcomes in the elderly population suffering from hip fractures. The present study aims to evaluate the prognostic tools for predicting patient recovery after hip fractures and investigate the correlation between the pre-fracture motor and functional statuses. [...] Read more.
Low physical function is associated with poor outcomes in the elderly population suffering from hip fractures. The present study aims to evaluate the prognostic tools for predicting patient recovery after hip fractures and investigate the correlation between the pre-fracture motor and functional statuses. A prospective study was performed, including 80 patients suffering from hip fractures. Patient history, previous falls, the type of fracture and overall survival were evaluated. Patient-reported outcome measures (SF-36, EQ-5D/VAS, Charlson Comorbidity Index (CCI), Short Physical Performance Battery (SPPB), Timed Up and Go (TUG) and Harris Hip Score (HHS)) were monitored before hospital discharge at 6 weeks, and 3, 6 and 12 months postoperatively. Overall, 55% of patients experienced at least one fall, and 46% of them used crutches before the fracture. The average CCI score was 6.9. The SPPB score improved from 1.4 ± 1.3 (1 week) to 4.4 ± 2.1 (48 weeks). A one-year age increase, female sex, and prior history of falls lead to 0.1-, 0.92-, 0.56-fold lower SPPB scores, respectively, at 12 months. The HHS recorded the greatest improvement between 6 and 12 weeks (52.1 ± 14.6), whereas the TUG score continued to improve significantly from 139.1 ± 52.6 s (6 weeks) to 66.4 ± 54 s (48 weeks). The SPPB and performance test can be routinely used as a prognostic tool. Full article
(This article belongs to the Special Issue Orthopaedics and Traumatology: Surgery and Research)
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<p>Univariate analyses of SPPB at 12-month follow-up in statistical significant relation with demographics and clinical characteristics.</p>
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<p>Mean parametrical SPPB change during the 12-month follow-up.</p>
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10 pages, 451 KiB  
Article
Return to Work Following Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Case Series
by Zachary I. Li, Dhruv S. Shankar, Sharif Garra, Andrew J. Hughes, Jairo Triana, Anna M. Blaeser and Thomas Youm
Surgeries 2023, 4(3), 391-400; https://doi.org/10.3390/surgeries4030039 - 1 Aug 2023
Cited by 1 | Viewed by 1778
Abstract
The expected rate and timing of return to work (RTW) following hip arthroscopy is an important consideration for patients. The purpose of this study was to evaluate the rates of RTW following hip arthroscopy, the time required to RTW, and factors correlated with [...] Read more.
The expected rate and timing of return to work (RTW) following hip arthroscopy is an important consideration for patients. The purpose of this study was to evaluate the rates of RTW following hip arthroscopy, the time required to RTW, and factors correlated with successful RTW. A retrospective review was performed of patients who underwent hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) from 2018–2021. Data were collected regarding pre-injury employment, work activity level, workers’ compensation (WC) status, ability to return to work, the pre- and postoperative pain visual analog score (VAS), and the Nonarthritic Hip Score (NAHS). Overall, 76 patients (90.5%) returned to their pre-surgical occupation at an average of 9.3 weeks (range: 0.14–56 weeks) postoperatively. Of those who returned, 62 patients (81.6%) returned to full work duties. The NAHSs improved significantly from the preoperative period to follow-up at 1 year (64.7 vs. 83.7, p < 0.001). A linear regression found elevated BMI to be associated with an increased time to return (β = 0.757, p = 0.012). On average, patients with WC status returned to work 9 weeks later than non-WC patients, though this difference did not reach statistical significance (18.4 vs. 9.9 weeks, p = 0.130). There is a high rate of return to full work duties at an average of 9.3 weeks following hip arthroscopy for FAIS. Full article
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<p>Work physical activity level classification.</p>
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18 pages, 4503 KiB  
Article
Validation of Estimators for Weight-Bearing and Shoulder Joint Loads Using Instrumented Crutches
by Marco Ghidelli, Cristina Nuzzi, Francesco Crenna and Matteo Lancini
Sensors 2023, 23(13), 6213; https://doi.org/10.3390/s23136213 - 7 Jul 2023
Viewed by 1469
Abstract
This research paper aimed to validate two methods for measuring loads during walking with instrumented crutches: one method to estimate partial weight-bearing on the lower limbs and another to estimate shoulder joint reactions. Currently, gait laboratories, instrumented with high-end measurement systems, are used [...] Read more.
This research paper aimed to validate two methods for measuring loads during walking with instrumented crutches: one method to estimate partial weight-bearing on the lower limbs and another to estimate shoulder joint reactions. Currently, gait laboratories, instrumented with high-end measurement systems, are used to extract kinematic and kinetic data, but such facilities are expensive and not accessible to all patients. The proposed method uses instrumented crutches to measure ground reaction forces and does not require any motion capture devices or force platforms. The load on the lower limbs is estimated by subtracting the forces measured by the crutches from the subject’s total weight. Since the model does not consider inertia contribution in dynamic conditions, the estimation improves with low walking cadence when walking with the two-point contralateral and the three-point partial weight-bearing patterns considered for the validation tests. The shoulder joint reactions are estimated using linear regression, providing accurate values for the forces but less accurate torque estimates. The crutches data are acquired and processed in real-time, allowing for immediate feedback, and the system can be used outdoors in real-world walking conditions. The validation of this method could lead to better monitoring of partial weight-bearing and shoulder joint reactions, which could improve patient outcomes and reduce complications. Full article
(This article belongs to the Collection Sensors for Gait, Human Movement Analysis, and Health Monitoring)
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<p>Comparison between the flowcharts of the biomechanical model approach and the shoulder reactions estimator.</p>
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<p>(<b>a</b>) Instrumented crutches and marker placement; (<b>b</b>) subject walking with instrumented crutches during validation. Red dots highlight the visible markers from the frontal point of view.</p>
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<p>(<b>a</b>) The gait event at the start of the interval for the validation of the PWB. The single support phase of the right leg started from this event until the next left foot’s heel contact. (<b>b</b>) The double leg support phase with all external forces measured by instrumented crutches and force plates. (<b>c</b>) The gait event at the end of the interval for the validation of the PWB. The left leg’s single support phase was between the last toe-off and the next heel contact of the right foot. (<b>d</b>) Comparison between the PWB estimated by the instrumented crutches and the reference value from the force plates, shown in the right leg’s gait cycle. The blank background is due to the interval with unknown external forces applied to the foot still resting on the floor.</p>
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<p>Boxplots of the PWB’s RMSE. The line inside each box is the sample median, and the top and bottom edges of each box are the upper and lower quartiles (0.75 and 0.25), respectively. The distance between the top and bottom edges is the interquartile range.</p>
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<p>Boxplots of the PWB’s ME. The line inside of each box is the sample median, and the top and bottom edges of each box are the upper and lower quartiles (0.75 and 0.25), respectively. The distance between the top and bottom edges is the interquartile range.</p>
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<p>Comparison between the estimated PWB and the reference and the status of the leg support. The line represents the mean value, and the standard deviation is shown with the colored band around the mean. The data are from four conditions combining the walking pattern while walking at 50 or 90 steps/min. Data are visualized with respect to time, and the green and red backgrounds indicate the double-leg support interval.</p>
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<p>Comparison between the estimated PWB and the reference during the gait cycle and the status of the leg support. The line represents the mean value, and the standard deviation is shown with the colored band around the mean. The data are from four conditions combining the walking pattern while loading 20 or 40% of the body weight on the crutch. Data are visualized with respect to the percentage of the gait cycle, and the green and red backgrounds indicate the gait cycle interval with double-leg support. The missing data between 0–15% of the gait cycle are due to the interval with unknown external forces applied to the foot still resting on the floor.</p>
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<p>Regression of the shoulder joint force RMS and peaks. The force is shown as a percentage of the subject’s BW.</p>
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<p>Regression of the shoulder joint torque. The torque is shown as a percentage of the BW times the height (H) of the subject.</p>
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<p>PWB’s RMSE boxplots in the single-support phase of the affected limb. The line inside of each box is the sample median, and the top and bottom edges of each box are the upper and lower quartiles (0.75 and 0.25), respectively. The distance between the top and bottom edges is the interquartile range.</p>
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<p>Normal probability plots of regression residuals of the identification subset for RMS and peak shoulder force.</p>
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<p>Shoulder torque RMSE boxplots for (<b>a</b>) walking pattern; (<b>b</b>) the inverse of stance time; (<b>c</b>) crutch angle range of motion; (<b>d</b>) BMI.</p>
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<p>Shoulder torque RMSE boxplots for (<b>a</b>) walking pattern; (<b>b</b>) the inverse of stance time; (<b>c</b>) crutch angle range of motion; (<b>d</b>) BMI.</p>
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11 pages, 3814 KiB  
Communication
Optimum Handle Location for the Hand-Assisted Sit-to-Stand Transition: A Tool
by Arash Bagheri and Keith Alexander
Biomechanics 2023, 3(2), 267-277; https://doi.org/10.3390/biomechanics3020023 - 14 Jun 2023
Viewed by 1755
Abstract
Background: The aging process contributes to the decline in physical capacity that leads to loss of independence in performing life activities. Immobility and instability are the most significant predictors and indicators of physical disability and dependence. As a result, a variety of assistive [...] Read more.
Background: The aging process contributes to the decline in physical capacity that leads to loss of independence in performing life activities. Immobility and instability are the most significant predictors and indicators of physical disability and dependence. As a result, a variety of assistive devices exist to address immobility and instability in older adults, including walkers, canes, crutches, wheelchairs and handrails. Sit-to-stand (STS) transitions are the most common transitions in daily mobility activities. The ability to perform STS transitions successfully is therefore one of the most important activities to focus attention on. As a result of physical deterioration, older adults will sooner or later be faced with their physical limitations, and in particular, will not be able to provide enough torque at critical body joints to make the STS transition. Aim: This paper suggests employing two-arm assistance using two handles located symmetrically in the body’s sagittal plane. During the aging process, people are faced with varying levels of muscle deterioration and body constraints and consequently require different levels of assistance to complete the transition successfully. This paper aims to develop a tool to find the optimum handle location for people based on their body constraints to reduce knee torque (identified as the critical joint in the STS transition). These findings are also used to measure the effects of assistive device handle position on the biomechanics of the two-arm assisted STS transition. Methods: For this purpose, a theoretical tool was developed by integrating human body kinetics with a multi-objective genetic algorithm to find the optimum hand force required at the seat-off point for a set of potential handle locations. The tool was set to achieve the minimum knee torque within the defined body constraints and assumptions. In line with the physics of the STS transition, the “seat-off point”, when subjects lose their seat support, was chosen as the most challenging point of the task. This was coupled with the “nose over toes” posture recommended to older adults by occupational therapists. Results and Discussion: The schematic of the developed tool shows that the best handle locations requiring the minimum torques at the body joints are positioned in handle zone 2, where the handles are placed vertically above the knee and below the hip joints and horizontally located ahead of the hip and behind the knee joints. Within this handle zone, both components of the hand forces (vertical downward and horizontal backward) provide assisting torque to all the body joints and consequently reduce the torques required at body joints. Full article
(This article belongs to the Topic Human Movement Analysis)
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<p>Schematic of the developed tool.</p>
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<p>Free body diagram of the body above the hip (head and arms are not shown); m and T represent mass and torque, respectively.</p>
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<p>Free body diagram of the body above the knee (head and arms are not shown); m and T represent mass and torque, respectively.</p>
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<p>Free body diagram of the body above the ankle (head and arms are not shown); m and T represent mass and torque, respectively.</p>
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<p>Seat-off posture employed in the theoretical tool.</p>
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<p>The minimum hand force required to achieve zero knee torque with no other constraint. (Note that the numbers around the circles are values for hand force (black), knee torque (blue circle) and hip torque (red circle), as shown in the key. The subject is shown in dotted black lines at the seat-off position (head and arms are not shown). Potential handle positions are shown in the sagittal (XZ) plane indicated. The resultant hand force required from each of the two hands to achieve zero knee torque is shown by straight blue and green arrows at each location. Green arrows show that while minimum hand force is achieved, balance is not achieved at this handle location. The size of the circle represents torque magnitude compared with the scale on the bottom right. The torque direction is shown by arrowheads on the circle, blue for anticlockwise and red for clockwise. Three coloured zones are shown: green with zero knee torque, blue with knee torque below 80% of maximum, and red with knee torque above 80% of maximum.</p>
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<p>Handle location zones (arrows show the hand force directions that reduce torque at the knee, hip and ankle joints).</p>
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