Publications by authors named "Daniel R Sturnick"

22 Publications

  • Page 1 of 1

Articular cartilage thickness changes differ between males and females 4 years following anterior cruciate ligament reconstruction.

J Orthop Res 2021 Jul 20. Epub 2021 Jul 20.

Department of Rehabilitation and Movement Science, College of Nursing and Health Sciences, University of Vermont, Burlington, Vermont, USA.

Anterior cruciate ligament injury and reconstruction (ACLR) affects articular cartilage thickness profiles about the tibial, femoral, and patellar surfaces; however, it's unclear whether the magnitudes of change in cartilage thickness, as well as the locations and areas over which these changes occur, differ between males and females. This is important to consider as differences exist between the sexes with regard to knee biomechanics, patellofemoral pain, and anatomic alignment, which influence risk of an index and repeated injury. Subjects underwent ACLR with a bone-patella tendon-bone autograft. At 4-year follow-up, they had asymptomatic knees; however, significant ACL injured-to-contralateral normal knee differences in articular cartilage thickness values were observed. Both thickening and thinning of cartilage occurred about the tibiofemoral and patellofemoral joints, relative to matched control subjects with normal knees. Further, the location of the areas and magnitudes of thickening and thinning were different between females and males. Thickening (swelling) of articular cartilage is an early finding associated with the onset of posttraumatic osteoarthritis (PTOA). Therefore, the increases in cartilage thickness that were observed in this cohort may represent early signs of the onset of PTOA that occur prior to the patient developing symptoms and radiographic evidence of this disease. The different locations of areas that underwent a change in cartilage thicknesses between males and females suggest that each sex responds differently to knee ligament trauma, reconstruction, rehabilitation, and return to activity, and indicates that sex-specific analysis should be utilized in studies of PTOA.
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http://dx.doi.org/10.1002/jor.25142DOI Listing
July 2021

Clinical-Grade MRI-Based Methods to Identify Combined Anatomic Factors That Predict ACL Injury Risk in Male and Female Athletes.

Am J Sports Med 2021 08 8;49(10):2615-2623. Epub 2021 Jul 8.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA.

Background: Recently developed multivariate sex-specific statistical models can predict anterior cruciate ligament (ACL) injury risk using various knee anatomic factors. However, screening tools able to identify individuals at an increased injury risk are unlikely to be developed based on these models, given that sophisticated and time-consuming methods were used to measure those factors on research-grade resolution magnetic resonance images (MRIs).

Purpose: To determine whether simpler methods, amenable to using clinical-grade resolution MRIs, can identify the same knee anatomic factors previously found to contribute to ACL injury risk using sophisticated methods and research-grade resolution images.

Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: High-resolution 3-dimensional MRIs previously acquired from 87 patients with primary, noncontact, grade III ACL injury and 87 uninjured matched control participants for a series of published studies were downgraded to clinical-grade resolution images. The 4 knee anatomic factors found to contribute to ACL injury risk in women and in men in these published studies-femoral intercondylar notch width at the anterior outlet of the ACL (NW_O), posterior-inferior directed slope of the middle region articular cartilage surface of the tibial plateau's lateral compartment (LTMCS), ACL volume, and tibial plateau's lateral compartment posterior meniscus to subchondral bone wedge angle (LTMBA)-were measured using clinical-grade resolution MRI-based methods. Stepwise multivariate conditional logistic regressions were used to identify the combinations of factors most highly associated with an ACL injury risk in women and men separately.

Results: The multivariate model that best predicted ACL injury risk in the female participants included the LTMCS and the NW_O. For the male participants, this model included the ACL volume and the LTMBA. These results corroborate the previously published results that reported models with the same knee anatomic factors to best predict injury risk in this group of young women and men.

Conclusion: Simpler methods using MRIs downgraded to a clinical-grade resolution can identify the same knee anatomic factors previously found to significantly contribute to ACL injury risk using sophisticated methods and research-grade resolution MRIs.
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http://dx.doi.org/10.1177/03635465211024249DOI Listing
August 2021

Biomechanical evaluation of total ankle arthroplasty. Part I: Joint loads during simulated level walking.

J Orthop Res 2021 01 11;39(1):94-102. Epub 2020 Nov 11.

Department of Biomechanics, Hospital for Special Surgery, New York, USA.

In total ankle arthroplasty, the interaction at the joint between implant and bone is driven by a complex loading environment. Unfortunately, little is known about the loads at the ankle during daily activities since earlier attempts use two- or three-dimensional models to explore simplified joint mechanics. Our goal was to develop a framework to calculate multi-axial loads at the joint during simulated level walking following total ankle arthroplasty. To accomplish this, we combined robotic simulations of level walking at one-quarter bodyweight in three cadaveric foot and ankle specimens with musculoskeletal modeling to calculate the multi-axial forces and moments at the ankle during the stance phase. The peak compressive forces calculated were between 720 and 873 N occurring around 77%-80% of stance. The peak moment, which was the internal moment for all specimens, was between 6.1 and 11.6 N m and occurred between 72% and 88% of the stance phase. The peak moment did not necessarily occur with the peak force. The ankle joint loads calculated in this study correspond well to previous attempts in the literature; however, our robotic simulator and framework provide an opportunity to resolve the resultant three-dimensional forces and moments as others have not in previous studies. The framework may be useful to calculate ankle joint loads in cadaveric specimens as the first step in evaluating bone-implant interactions in total ankle replacement using specimen specific inputs. This approach also provides a unique opportunity to evaluate changes in joint loads and kinematics following surgical interventions of the foot and ankle.
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http://dx.doi.org/10.1002/jor.24902DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749051PMC
January 2021

Biomechanical evaluation of total ankle arthroplasty. Part II: Influence of loading and fixation design on tibial bone-implant interaction.

J Orthop Res 2021 01 20;39(1):103-111. Epub 2020 Oct 20.

Department of Biomechanics, Hospital for Special Surgery, New York, New York, USA.

Finite element (FE) models to evaluate the burden placed on the interaction between total ankle arthroplasty (TAA) implants and the bone often rely on peak axial forces. However, the loading environment of the ankle is complex, and it is unclear whether peak axial forces represent a challenging scenario for the interaction between the implant and the bone. Our goal was to determine how the loads and the design of the fixation of the tibial component of TAA impact the interaction between the implant and the bone. To this end, we developed a framework that integrated robotic cadaveric simulations to determine the ankle kinematics, musculoskeletal models to determine the ankle joint loads, and FE models to evaluate the interaction between TAA and the bone. We compared the bone-implant micromotion and the risk of bone failure of three common fixation designs for the tibial component of TAA: spikes, a stem, and a keel. We found that the most critical conditions for the interaction between the implant and the bone were dependent on the specimen and the fixation design, but always involved submaximal forces and large moments. We also found that while the fixation design influenced the distribution and the peak value of bone-implant micromotion, the amount of bone at risk of failure was specimen dependent. To account for the most critical conditions for the interaction between the implant and the bone, our results support simulating multiple specimens under complex loading profiles that include multiaxial moments and span entire activity cycles.
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http://dx.doi.org/10.1002/jor.24876DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7748995PMC
January 2021

Combined Injury to the ACL and Lateral Meniscus Alters the Geometry of Articular Cartilage and Meniscus Soon After Initial Trauma.

J Orthop Res 2020 04 19;38(4):759-767. Epub 2019 Nov 19.

Department of Biomechanics, Hospital for Special Surgery, New York, New York.

Combined injury to the anterior cruciate ligament (ACL) and meniscus is associated with earlier onset and increased rates of post-traumatic osteoarthritis compared with isolated ACL injury. However, little is known about the initial changes in joint structure associated with these different types of trauma. We hypothesized that trauma to the ACL and lateral meniscus has an immediate effect on morphometry of the articular cartilage and meniscus about the entire tibial plateau that is more pronounced than an ACL tear without meniscus injury. Subjects underwent magnetic resonance imaging scanning soon after injury and prior to surgery. Those that suffered injury to the ACL and lateral meniscus underwent changes in the lateral compartment (increases in the posterior-inferior directed slopes of the articular cartilage surface, and the wedge angle of the posterior horn of the meniscus) and medial compartment (the cartilage-to-bone height decreased in the region located under the posterior horn of the meniscus, and the thickness of cartilage increased and decreased in the mid and posterior regions of the plateau, respectively). Subjects that suffered an isolated ACL tear did not undergo the same magnitude of change to these articular structures. A majority of the changes in morphometry occurred in the lateral compartment of the knee; however, change in the medial compartment of the knee with a normal appearing meniscus also occurred. Statement of clinical significance: Knee injuries that involve combined trauma to the ACL and meniscus directly affect both compartments of the knee, even if the meniscus and articular cartilage appears normal upon arthroscopic examination. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:759-767, 2020.
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http://dx.doi.org/10.1002/jor.24519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071961PMC
April 2020

Influence of Tibial Component Position on Altered Kinematics Following Total Ankle Arthroplasty During Simulated Gait.

Foot Ankle Int 2019 Aug 27;40(8):873-879. Epub 2019 Jun 27.

1 Foot and Ankle Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Background: Ankle and hindfoot kinematics following total ankle arthroplasty (TAA) are poorly understood and it is unclear whether patients can replicate physiologic motion after TAA. Furthermore, the effect of implant position on TAA kinematics is unknown. The objective of this study was to compare ankle and hindfoot kinematics pre- and post-TAA during simulated gait and determine to what degree tibial component position correlated with variations in ankle kinematics.

Methods: Eight midtibia cadaveric specimens were utilized in this institutional review board-approved study. The stance phase of gait was simulated both pre- and post-TAA in each specimen using a 6 degrees of freedom robotic platform. Ankle and hindfoot kinematics were measured from reflective markers attached to bones via surgical pins. The effect of tibial component position on absolute differences in ankle kinematics was assessed using linear regression.

Results: No differences were observed in ankle sagittal and coronal plane motion between the intact and TAA conditions. Differences in ankle joint kinematics were identified in the transverse plane, where internal talar rotation was significantly increased following TAA compared with the native condition. The medial-lateral position of the tibial component was found to correlate with the altered transverse plane motion observed after TAA (β = 1.861 degrees/mm, = 0.72, = .008). No significant differences in subtalar and talonavicular joint kinematics in any plane were observed comparing the pre- and post-TAA condition.

Conclusion: This study demonstrated an increased internal rotation of the ankle in the transverse plane following TAA. This increase was correlated with the medial-lateral position of the tibial implant.

Clinical Relevance: This finding could have clinical implications for how tibial components are positioned during the operative procedure, and how implant design and position may affect ankle kinematics following TAA.
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http://dx.doi.org/10.1177/1071100719858620DOI Listing
August 2019

Biomechanical Comparison of Suture-External Button Fixation vs Internal Suspension Fixation for Tendon Transfers of the Feet.

Foot Ankle Int 2019 Jul 27;40(7):845-852. Epub 2019 Mar 27.

2 Hospital for Special Surgery, New York, NY, USA.

Background: Fixation of tendon transfers in pediatric feet typically involves passing a suture that is secured to a tendon, through an intraosseous tunnel, and tying it over an external button on the plantar foot, with appropriate tension. After adequate time is allowed for bone-tendon healing, the suture and button are removed. This construct can be complicated by suture breakage with loss of fixation, and/or skin ulceration under the button. Internal suspension systems of tendons and ligaments in adults have demonstrated excellent fixation strength and minimal intraosseous tunnel displacement, with no risk of skin ulceration and no need for suture and button removal. This study compared the biomechanical properties of the suture-external button and internal suspension fixation techniques in cadavers. The primary outcome and secondary outcomes were displacement of suture-fixation construct during dynamic loading, and static loading, respectively.

Methods: Nine adult cadaver feet were obtained. Both the external button and internal suspension techniques were tested once in each cadaver, in random order. Relative displacement of the fixation construct within the bone tunnel was recorded with video capture during dynamic and static loading. A custom Matlab script processed video and materials testing data. Static and cyclic displacements were analyzed between fixation groups using a paired test (alpha value =0.05).

Results: Internal suspension fixation had significantly less mean displacement of the tendon within the bone tunnel than the external button technique during dynamic (0.3 mm internal suspension system, 0.7 mm external button, = .0115) and static loading (0.4 mm internal suspension system, 2.2 mm external button, = .0019).

Conclusions: Internal suspension systems may provide superior fixation compared to the traditional external button for tendon transfers, with the added benefit of avoiding the risk of skin ulceration and the need for suture and button removal.

Clinical Relevance: It appears internal suspension method of tendon transfer fixation would be an acceptable alternative to traditional methods of fixation with an external button.
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http://dx.doi.org/10.1177/1071100719839691DOI Listing
July 2019

Quantitative Ultrasound Assessment of the Achilles Tendon Under Varied Loads.

J Ultrasound Med 2018 Oct 8;37(10):2413-2418. Epub 2018 Mar 8.

Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York, USA.

This Institutional Review Board-approved pilot study attempted to detect the correlation between ultrasound shear wave elastographic measures and tendon loads. Five male fresh-frozen cadaveric Achilles tendons were loaded in 10-N increments from 0 to 60 N. Shear wave velocity measurements within each Achilles tendon were obtained at each load in longitudinal and transverse orientations. Shear wave velocity measurements were correlated with tendon tension on both longitudinal and transverse plane imaging and showed moderate and strong positive correlation coefficients, respectively. Of note, limitations of the clinically available shear wave elastographic technology for measuring high velocities exist.
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http://dx.doi.org/10.1002/jum.14589DOI Listing
October 2018

Geometric Characteristics of the Knee Are Associated With a Noncontact ACL Injury to the Contralateral Knee After Unilateral ACL Injury in Young Female Athletes.

Am J Sports Med 2017 Dec 13;45(14):3223-3232. Epub 2017 Oct 13.

Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, Vermont, USA.

Background: Contralateral anterior cruciate ligament (CACL) injury after recovery from a first-time ACL rupture occurs at a high rate in young females; however, little is known about the risk factors associated with bilateral ACL trauma.

Hypothesis: The geometric characteristics of the contralateral knee at the time of the initial ACL injury are associated with risk of suffering a CACL injury in these female athletes.

Study Design: Case-control study; Level of evidence, 3.

Methods: Sixty-two female athletes who suffered their first noncontact ACL injury while participating in sports at the high school or college level were identified, and geometry of the femoral notch, ACL, tibial spines, tibial subchondral bone, articular cartilage surfaces, and menisci of the contralateral, uninjured, knee was characterized in 3 dimensions. We were unable to contact 7 subjects and followed the remaining 55 until either a CACL injury or an ACL graft injury occurred or, if they were not injured, until the date of last contact (mean, 34 months after their first ACL injury). Cox regression was used to identify risk factors for CACL injury.

Results: Ten (18.2%) females suffered a CACL injury. Decreases of 1 SD in femoral intercondylar notch width (measured at its outlet and anterior attachment of the ACL) were associated with increases in the risk of suffering a CACL injury (hazard ratio = 1.88 and 2.05, respectively). Likewise, 1 SD decreases in medial-lateral width of the lateral tibial spine, height of the medial tibial spine, and thickness of the articular cartilage located at the posterior region of the medial tibial compartment were associated with 3.59-, 1.75-, and 2.15-fold increases in the risk of CACL injury, respectively.

Conclusion: After ACL injury, subsequent injury to the CACL is influenced by geometry of the structures that surround the ACL (the femoral notch and tibial spines). This information can be used to identify individuals at increased risk for CACL trauma, who might benefit from targeted risk-reduction interventions.
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http://dx.doi.org/10.1177/0363546517735091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6533631PMC
December 2017

Adjacent Joint Kinematics After Ankle Arthrodesis During Cadaveric Gait Simulation.

Foot Ankle Int 2017 Nov 24;38(11):1249-1259. Epub 2017 Aug 24.

5 Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.

Background: Arthrodesis is an effective and reliable treatment for end-stage ankle arthritis; however, many patients develop ipsilateral adjacent joint arthritis following surgery. The mechanism that drives adjacent joint arthritis remains uncertain. Cadaveric simulation permits direct investigation of the effects of both arthrodesis and movement strategy on adjacent joints during simulated walking. The objective of this study was to identify the isolated effect of ankle arthrodesis on adjacent joint kinematics during simulated walking.

Methods: Effects of ankle arthrodesis on adjacent joint kinematics were assessed in 8 cadaveric foot and ankle specimens using a robotic gait simulator. Gait parameters acquired from healthy adults and patients with ankle arthrodesis were used as inputs for simulations. Three-dimensional subtalar and talonavicular joint kinematics were directly measured before and after ankle arthrodesis, and healthy- and arthrodesis-gait parameters were applied to identify the isolated effect of the ankle arthrodesis on adjacent joint kinematics.

Results: Ankle arthrodesis increased subtalar and talonavicular joint motion during early and midstance independent of which gait parameters were used as inputs to the gait simulator. However, adjacent joint motions did not differ between the control and arthrodesis condition during late stance, when the healthy gait parameters were used as inputs. Conversely, adjacent joint motion decreased during late stance following arthrodesis when simulating gait using parameters typical in arthrodesis patients.

Conclusions: Regardless of the gait parameter inputs, subtalar and talonavicular joint motions increased from normal kinematics, which likely increase the biomechanical burden placed on these adjacent joints and may lead to joint degeneration.

Clinical Relevance: Increased motion of the adjacent joints caused by ankle arthrodesis may explain the articular degeneration observed clinically.
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http://dx.doi.org/10.1177/1071100717726806DOI Listing
November 2017

Relationship between geometry of the extensor mechanism of the knee and risk of anterior cruciate ligament injury.

J Orthop Res 2017 05 12;35(5):965-973. Epub 2016 Dec 12.

McClure Musculoskeletal Research Center, Department of Orthopedics and Rehabilitation, College of Medicine, University of Vermont, Burlington, Vermont.

The complex inter-segmental forces that are developed across an extended knee by body weight and contraction of the quadriceps muscle group transmits an anteriorly directed force on the tibia that strain the anterior cruciate ligament (ACL). We hypothesized that a relationship exists between geometry of the knees extensor mechanism and the risk of sustaining a non-contact ACL injury. Geometry of the extensor mechanism was characterized using MRI scans of the knees of 88 subjects that suffered their first non-contact ACL injury and 88 matched control subjects with normal knees that were on the same team. The orientation of the patellar tendon axis was measured relative to the femoral flexion-extension axis to determine the extensor moment arm (EMA), and relative to tibial long axis to measure coronal patellar tendon angle (CPTA) and sagittal patellar tendon angle (SPTA). Associations between these parameters and ACL injury risk were tested with and without adjustment for flexion and internal rotation position of the tibia relative to the femur during MRI data acquisition. After adjustment for internal rotation position of the tibia relative to the femur there were no associations between EMA, CPTA, and SPTA and risk of suffering an ACL injury. However, increased internal rotation position of the tibia relative to the femur was significantly associated with increased risk of ACL injury in female athletes both in univariate analysis (Odds Ratio = 1.16 per degree of internal rotation of the tibia, p = 0.002), as well as after adjustment for EMA, CPTA, and SPTA.: © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:965-973, 2017.
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http://dx.doi.org/10.1002/jor.23366DOI Listing
May 2017

Geometric Risk Factors Associated With Noncontact Anterior Cruciate Ligament Graft Rupture.

Am J Sports Med 2016 Oct 11;44(10):2537-2545. Epub 2016 Aug 11.

Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, Vermont, USA

Background: Anterior cruciate ligament (ACL) graft rupture occurs at a high rate, especially in young athletes. The geometries of the tibial plateau and femoral intercondylar notch are risk factors for first-time ACL injury; however, little is known about the relationship between these geometries and risk of ACL graft rupture.

Hypothesis: The geometric risk factors for noncontact graft rupture are similar to those previously identified for first-time noncontact ACL injury, and sex-specific differences exist.

Study Design: Case-control study; Level of evidence, 3.

Methods: Eleven subjects who suffered a noncontact ACL graft rupture and 44 subjects who underwent ACL reconstruction but did not experience graft rupture were included in the study. Using magnetic resonance imaging, the geometries of the tibial plateau subchondral bone, articular cartilage, meniscus, tibial spines, and femoral notch were measured. Risk factors associated with ACL graft rupture were identified using Cox regression.

Results: The following were associated with increased risk of ACL graft injury in males: increased posterior-inferior-directed slope of the articular cartilage in the lateral tibial plateau measured at 2 locations (hazard ratio [HR] = 1.50, P = .029; HR = 1.39, P = .006), increased volume (HR = 1.45, P = .01) and anteroposterior length (HR = 1.34, P = .0023) of the medial tibial spine, and increased length (HR = 1.18, P = .0005) and mediolateral width (HR = 2.19, P = .0004) of the lateral tibial spine. In females, the following were associated with increased risk of injury: decreased volume (HR = 0.45, P = .02) and height (HR = 0.46, P = .02) of the medial tibial spine, decreased slope of the lateral tibial subchondral bone (HR = 0.72, P = .01), decreased height of the posterior horn of the medial meniscus (HR = 0.09, P = .001), and decreased intercondylar notch width at the anterior attachment of the ACL (HR = 0.72, P = .02).

Conclusion: The geometric risk factors for ACL graft rupture are different for males and females. For females, a decreased femoral intercondylar notch width and a decreased height of the posterior medial meniscus were risk factors for ACL graft rupture that have also been found to be risk factors for first-time injury. There were no risk factors in common between ACL graft injury and first-time ACL injury for males.
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http://dx.doi.org/10.1177/0363546516657525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604045PMC
October 2016

Multivariate Analysis of the Risk Factors for First-Time Noncontact ACL Injury in High School and College Athletes: A Prospective Cohort Study With a Nested, Matched Case-Control Analysis.

Am J Sports Med 2016 Jun 29;44(6):1492-501. Epub 2016 Mar 29.

McClure Musculoskeletal Research Center, Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, Vermont, USA

Background: Multivariate analysis that identifies the combination of risk factors associated with anterior cruciate ligament (ACL) trauma is important because it provides insight into whether a variable has a direct causal effect on risk or an indirect effect that is mediated by other variables. It can also reveal risk factors that might not be evident in univariate analyses; if a variable's effect is moderated by other variables, its association with risk may be apparent only after adjustment for the other variables. Most important, multivariate analyses can identify combinations of risk factors that are more predictive of risk than individual risk factors.

Hypothesis: A diverse combination of risk factors predispose athletes to first-time noncontact ACL injury, and these relationships are different for male and female athletes.

Study Design: Case-control study; Level of evidence, 3.

Methods: Athletes competing in organized sports at the high school and college levels participated in this study. Data from injured subjects (109 suffering an ACL injury) and matched controls (227 subjects) from the same athletic team were analyzed with multivariate conditional logistic regression to examine the effects of combinations of variables (demographic characteristics, joint laxity, lower extremity alignment, strength, and personality traits) on the risk of suffering their first ACL injury and to construct risk models.

Results: For male athletes, increases in anterior-posterior displacement of the tibia relative to the femur (knee laxity), posterior knee stiffness, navicular drop, and a decrease in standing quadriceps angle were jointly predictive of suffering an ACL injury. For female athletes the combined effects of having a parent who had suffered an ACL injury and increases in anterior-posterior knee laxity and body mass index were predictive of ACL injury.

Conclusion: Multivariate models provided more information about ACL injury risk than individual risk factors. Both male and female risk models included increased anterior-posterior knee laxity as a predictor of ACL injury but were otherwise dissimilar.
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http://dx.doi.org/10.1177/0363546516634682DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6533630PMC
June 2016

Cadaveric gait simulation reproduces foot and ankle kinematics from population-specific inputs.

J Orthop Res 2016 09 6;34(9):1663-8. Epub 2016 Jun 6.

Department of Foot and Ankle Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, New York, 10021.

Cadaveric gait simulation allows researchers to directly investigate biomechanical consequences of surgeries using invasive measurement techniques. However, it is unclear if foot and ankle kinematics that are population-specific are reproduced using these devices. Therefore, we assessed foot and ankle kinematics produced in a cadaveric gait simulator during the stance phase of gait in a set of five cadaveric feet. Tibial motions and ground reaction forces previously collected in vivo in a group of healthy adults were applied as inputs parameters. In vitro foot and ankle kinematics were acquired and directly compared to population-specific in vivo kinematics of the same healthy adults from which input parameters were acquired. Analyses were completed using cross correlation to determine the similarities in kinematic profiles and joint ranges of motion were calculated to determine absolute differences in kinematics. Ankle, subtalar, and talonavicular in vitro joint kinematics were positively correlated to in vivo joint kinematics (rxy  = 0.57-0.87). Further, in vivo and in vitro foot and ankle kinematics demonstrated similar amounts of within-group variability (rxy  = 0.50-0.85 and rxy  = 0.72-0.76, respectively). Our findings demonstrate that cadaveric gait simulation techniques reproduce population-specific foot and ankle kinematics, providing a valuable research tool for testing surgical treatments of foot and ankle maladies. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1663-1668, 2016.
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http://dx.doi.org/10.1002/jor.23169DOI Listing
September 2016

Combined anatomic factors predicting risk of anterior cruciate ligament injury for males and females.

Am J Sports Med 2015 Apr 12;43(4):839-47. Epub 2015 Jan 12.

Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, Vermont, USA

Background: Knee joint geometry has been associated with risk of suffering an anterior cruciate ligament (ACL) injury; however, few studies have utilized multivariate analysis to investigate how different aspects of knee joint geometry combine to influence ACL injury risk.

Hypotheses: Combinations of knee geometry measurements are more highly associated with the risk of suffering a noncontact ACL injury than individual measurements, and the most predictive combinations of measurements are different for males and females.

Study Design: Case-control study; Level of evidence, 3.

Methods: A total of 88 first-time, noncontact, grade III ACL-injured subjects and 88 uninjured matched-control subjects were recruited, and magnetic resonance imaging data were acquired. The geometry of the tibial plateau subchondral bone, articular cartilage, and meniscus; geometry of the tibial spines; and size of the femoral intercondylar notch and ACL were measured. Multivariate conditional logistic regression was used to develop risk models for ACL injury in females and males separately.

Results: For females, the best fitting model included width of the femoral notch at its anterior outlet and the posterior-inferior-directed slope of the lateral compartment articular cartilage surface, where a millimeter decrease in notch width and a degree increase in slope were independently associated with a 50% and 32% increase in risk of ACL injury, respectively. For males, a model that included ACL volume and the lateral compartment posterior meniscus to subchondral bone wedge angle was most highly associated with risk of ACL injury, where a 0.1 cm3 decrease in ACL volume (approximately 8% of the mean value) and a degree decrease in meniscus wedge angle were independently associated with a 43% and 23% increase in risk, correspondingly.

Conclusion: Combinations of knee joint geometry measurements provided more information about the risk of noncontact ACL injury than individual measures, and the aspects of geometry that best explained the relationship between knee geometry and the risk of injury were different between males and females. Consequently, a female with both a decreased femoral notch width and an increased posterior-inferior-directed lateral compartment tibial articular cartilage slope combined or a male with a decreased ACL volume and decreased lateral compartment posterior meniscus angle were most at risk for sustaining an ACL injury.
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http://dx.doi.org/10.1177/0363546514563277DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6607022PMC
April 2015

Tibial articular cartilage and meniscus geometries combine to influence female risk of anterior cruciate ligament injury.

J Orthop Res 2014 Nov 6;32(11):1487-94. Epub 2014 Aug 6.

Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, Vermont.

Tibial plateau subchondral bone geometry has been associated with the risk of sustaining a non-contact ACL injury; however, little is known regarding the influence of the meniscus and articular cartilage interface geometry on risk. We hypothesized that geometries of the tibial plateau articular cartilage surface and meniscus were individually associated with the risk of non-contact ACL injury. In addition, we hypothesized that the associations were independent of the underlying subchondral bone geometry. MRI scans were acquired on 88 subjects that suffered non-contact ACL injuries (27 males, 61 females) and 88 matched control subjects that were selected from the injured subject's teammates and were thus matched on sex, sport, level of play, and exposure to risk of injury. Multivariate analysis of the female data revealed that increased posterior-inferior directed slope of the middle articular cartilage region and decreased height of the posterior horn of the meniscus in the lateral compartment were associated with increased risk of sustaining a first time, non-contact ACL injury, independent of each other and of the slope of the tibial plateau subchondral bone. No measures were independently related to risk of non-contact ACL injury among males.
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http://dx.doi.org/10.1002/jor.22702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6886124PMC
November 2014

A decreased volume of the medial tibial spine is associated with an increased risk of suffering an anterior cruciate ligament injury for males but not females.

J Orthop Res 2014 Nov 24;32(11):1451-7. Epub 2014 Jun 24.

Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, Vermont.

Measurements of tibial plateau subchondral bone and articular cartilage slope have been associated with the risk of suffering anterior cruciate ligament (ACL) injury. Such single-plane measures of the tibial plateau may not sufficiently characterize its complex, three-dimensional geometry and how it relates to knee injury. Further, the tibial spines have not been studied in association with the risk of suffering a non-contact ACL injury. We questioned whether the geometries of the tibial spines are associated with non-contact ACL injury risk, and if this relationship is different for males and females. Bilateral MRI scans were acquired on 88 ACL-injured subjects and 88 control subjects matched for sex, age and sports team. Medial and lateral tibial spine geometries were characterized with measurements of length, width, height, volume and anteroposterior location. Analyses of females revealed no associations between tibial spine geometry and risk of ACL injury. Analyses of males revealed that an increased medial tibial spine volume was associated with a decreased risk of ACL injury (OR = 0.667 per 100 mm(3) increase). Smaller medial spines could provide less resistance to internal rotation and medial translation of the tibia relative to the femur, subsequently increasing ACL strains and risk of ACL injury.
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http://dx.doi.org/10.1002/jor.22670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604057PMC
November 2014

Relationship Between the Risk of Suffering a First-Time Noncontact ACL Injury and Geometry of the Femoral Notch and ACL: A Prospective Cohort Study With a Nested Case-Control Analysis.

Am J Sports Med 2014 Aug 27;42(8):1796-805. Epub 2014 May 27.

McClure Musculoskeletal Research Center, Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, Burlington, Vermont, USA

Background: The morphometric characteristics of the anterior cruciate ligament (ACL) and the femoral intercondylar notch within which it resides have been implicated as risk factors for injuries to this important stabilizer of the knee. Prior research has produced equivocal results with differing methodologies, and consequently, it is unclear how these characteristics affect the injury risk in male and female patients.

Hypothesis: The morphometric characteristics of the ACL and femoral intercondylar notch are individually and independently associated with the risk of suffering a noncontact ACL injury, and these relationships are different in male and female patients.

Study Design: Case-control study; Level of evidence, 3.

Methods: Magnetic resonance imaging scans of the bilateral knees were obtained on 88 case-control pairs (27 male, 61 female) matched for age, sex, and participation on the same sports team. Patients had suffered a grade III, first-time, noncontact ACL tear. The femoral notch width at 4 locations, the thickness of the bony ridge at the anteromedial outlet of the femoral notch, the femoral notch volume, ACL volume, and ACL cross-sectional area were measured.

Results: Multivariate analysis of combined data from male and female patients revealed that decreased ACL volume (odds ratio [OR], 0.829), decreased femoral notch width (OR, 0.700), and increased bony ridge thickness at the anteromedial outlet of the femoral notch (OR, 1.614) were significant independent predictors of an ACL injury. Separate analyses of male and female patients indicated that the femoral notch ridge may be more strongly associated with a risk in female patients, while ACL volume is more strongly associated with a risk in male patients. However, statistical analysis performed with an adjustment for body weight strengthened the association between ACL volume and the risk of injuries in female patients.

Conclusion: Morphometric features of both the ACL and femoral notch combine to influence the risk of suffering a noncontact ACL injury. When included together in a multivariate model that adjusts for body weight, the effects of the morphometric measurements are similar in male and female patients. If body weight is not taken into consideration, ACL volume is not associated with a risk in female patients.
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http://dx.doi.org/10.1177/0363546514534182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604056PMC
August 2014

What is the best material for molding casts in children?

J Pediatr Orthop 2014 Oct-Nov;34(7):743-8

Departments of *Orthopaedics & Rehabilitation †Medical Biostatistics, University of Vermont College of Medicine, Burlington, VT.

Background: Casts are used to treat clubfeet, developmental dysplasia of the hip (DDH), forearm fractures, and femur fractures. The ability of a cast to maintain a desired shape is termed moldability. Clinicians use plaster, fiberglass, and soft casts. To our knowledge the biomechanical molding characteristics of these 3 materials have never been reported. We hypothesized that moldability of plaster would be better than fiberglass and fiberglass would be better than soft cast.

Methods: We compared 12.7 cm wide casts of plaster, fiberglass, and soft cast. Casts were 5 layers thick, prepared in 40°C water, and placed over 2 layers of cotton padding on 5.1 cm and 15.2 cm diameter foam cylinders. A loading device simulated loads applied by clinicians when molding casts for 4 conditions: clubfoot (thumb-shaped 50 N load on 5.1 cm model), DDH (thumb-shaped 100 N load on 15.2 cm model), forearm fracture (palm-shaped 50 N load on 5.1 cm model), and femur fracture (palm-shaped 100 N load on 15.2 cm model). The loading device applied molding for 7 minutes. Five casts of each material were made for each model. Casts were removed, photographed, and the area of maximal deformation was compared with an unmolded cast. A large area of maximal deformation meant that the deformation was spread out over a large area, less precise molding.

Results: In the clubfoot model, plaster was more precise than fiberglass (P=0.002) and soft cast (P<0.0001). In the DDH model, plaster was more precise than fiberglass (P<0.0001) and soft cast (P<0.0001) and fiberglass was more precise than soft cast (P<0.0001).In the femur fracture model, plaster was more precise than fiberglass (P=0.001) and soft cast (P=0.001).

Conclusions: The moldability of plaster is better than fiberglass and soft cast and fiberglass is better than soft cast.

Clinical Relevance: If precise molding is required, plaster has the best moldability. In cases not requiring precise molding, fiberglass and soft cast are lightweight, waterproof, and available in child-friendly colors.
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http://dx.doi.org/10.1097/BPO.0000000000000178DOI Listing
June 2015

Increased slope of the lateral tibial plateau subchondral bone is associated with greater risk of noncontact ACL injury in females but not in males: a prospective cohort study with a nested, matched case-control analysis.

Am J Sports Med 2014 May 3;42(5):1039-48. Epub 2014 Mar 3.

Bruce D. Beynnon, McClure Professor of Musculoskeletal Research, McClure Musculoskeletal Research Center, Department of Orthopedics and Rehabilitation, University of Vermont College of Medicine, Burlington, VT 05405-0084.

Background: There is an emerging consensus that increased posterior-inferior directed slope of the subchondral bone portion of the tibial plateau is associated with increased risk of suffering an anterior cruciate ligament (ACL) injury; however, most of what is known about this relationship has come from unmatched case-control studies. These observations need to be confirmed in more rigorously designed investigations.

Hypothesis: Increased posterior-inferior directed slope of the medial and lateral tibial plateaus are associated with increased risk of suffering a noncontact ACL injury.

Study Design: Case-control study; Level of evidence, 3.

Methods: In sum, 176 athletes competing in organized sports at the college and high school levels participated in the study: 88 suffering their first noncontact ACL injury and 88 matched controls. Magnetic resonance images were acquired, and geometry of the subchondral bone portion of the tibial plateau was characterized on each athlete bilaterally by measuring the medial and lateral tibial plateau slopes, coronal tibial slope, and the depth of the medial tibial plateau. Comparisons between knees of the same person were made with paired t tests, and associations with injury risk were assessed by conditional logistic regression analysis of ACL-injured and control participants.

Results: Controls exhibited side-to-side symmetry of subchondral bone geometry, while the ACL-injured athletes did not, suggesting that the ACL injury may have changed the subchondral bone geometry. Therefore, the uninjured knees of the ACL-injured athletes and the corresponding limbs of their matched controls were used to assess associations with injury risk. Analyses of males and females as a combined group and females as a separate group showed a significant association between ACL injury risk and increased posterior-inferior directed slope of the lateral tibial plateau slope. This relationship was not apparent when males were analyzed as a group. Multivariate analyses indicated that these results were independent of the medial tibial plateau slope, coronal tibial slope, and depth of the medial tibial plateau, which were not associated with ACL injury.

Conclusion: There is a 21.7% increased risk of noncontact ACL injury with each degree increase of the lateral tibial plateau slope among females but not among males. The medial tibial plateau slope, coronal tibial slope, and depth of the medial tibial plateau were not associated with risk of injury for females or males.
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http://dx.doi.org/10.1177/0363546514523721DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604044PMC
May 2014

Geometric profile of the tibial plateau cartilage surface is associated with the risk of non-contact anterior cruciate ligament injury.

J Orthop Res 2014 Jan 30;32(1):61-8. Epub 2013 Sep 30.

McClure Musculoskeletal Research Center, Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, Vermont.

The purpose of this study was to determine if geometry of the articular surfaces of the tibial plateau is associated with non-contact anterior cruciate ligament (ACL) injury. This was a longitudinal cohort study with a nested case-control analysis. Seventy-eight subjects who suffered a non-contact ACL tear and a corresponding number of controls matched by age, sex, and sport underwent 3 T MRI of both knees. Surface geometry of the tibial articular cartilage was characterized with polynomial equations and comparisons were made between knees on the same person and between ACL-injured and control subjects. There was no difference in surface geometry between the knees of the control subjects. In contrast, there were significant differences in the surface geometry between the injured and normal knees of the ACL-injured subjects, suggesting that the ACL injury changed the cartilage surface profile. Therefore, comparisons were made between the uninjured knees of the ACL-injured subjects and the corresponding knees of their matched controls and this revealed significant differences in the surface geometry for the medial (p < 0.006) and lateral (p < 0.001) compartments. ACL-injured subjects tended to demonstrate a posterior-inferior directed orientation of the articular surface relative to the long axis of the tibia, while the control subjects were more likely to show a posterior-superior directed orientation.
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http://dx.doi.org/10.1002/jor.22434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604060PMC
January 2014
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