Technological advances in orthopedics: upper and lower limbs analysis

Abstracts

A Biomecânica, atualmente, é caracterizada por novos procedimentos para análise do movimento humano e por novas técnicas de medição, armazenamento e processamento de dados, contribuindo para os avanços na prática ortopédica. A temática proposta no presente trabalho baseia-se na aplicação da biomecânica ortopédica em diferentes quadros clínicos, através de avaliações quantitativas do movimento dos membros superiores e inferiores, além da criação de novas técnicas de medição. Três exemplos são mostrados neste artigo: (I) análise tridimensional do movimento de abdução do ombro; (II) análise da marcha de indivíduos com lesão no ligamento cruzado anterior; e (III) o desenvolvimento de instrumentação eletrônica para dispositivos de auxílio, ou seja, bengalas e muletas instrumentalizadas para o estudo das relações de força entre os membros superiores e inferiores, durante a marcha de pacientes com lesão ortopédica e neurológica.

Biomecânica; Tecnologia médica; Ortopedia; Ombro; Ligamento cruzado anterior

UPDATE ARTICLE

Technological advances in orthopedics: Upper and lower limbs analysis

Alberto Cliquet Júnior^I; Juracy Emanuel Magalhães da Franca^II; Denise Sônego^III; Tatiana Grana^IV; Fernando Idalírio de Lima Leite^V; Alessandra Rossi Paolillo^VI; Fernanda Rossi Paolillo^VII

^IChairman: Electric Engineering Department – USP, São Carlos /Orthopedics and Traumatology Department – FCM, UNICAMP

^IIMaster – Electric Engineering – USP, São Carlos

^IIIPostgraduate student - Surgery /Orthopedics and Traumatology Department – FCM, UNICAMP

^IVMaster - Surgery / Orthopedics and Traumatology Department – FCM, UNICAMP

^VMaster – Electric Engineering – USP, São Carlos

^VIPostgraduate student - Bioengineering – USP, São Carlos

^VIIPostgraduate student - Bioengineering – USP, São Carlos

^{Correspondence}

SUMMARY

Biomechanics is nowadays characterized by new procedures for human movement analysis and by modern measurement techniques, data processing and storage, contributing to the advances in the orthopedic practice. The proposed thematic in this work is based on the application of orthopedic biomechanics to different clinical cases, through quantitative evaluation of the upper and lower limb movement and the development of new assessment techniques. Three examples are shown in this paper: (I) a tridimensional analysis of the abduction movement of the shoulder; (II) a gait analysis in individuals with anterior cruciate ligament injury; and (III) the development of electronic instrumentation for walking aids i.e., instrumented canes and crutches for the study of the relationship between the upper and lower limb loads during gait of orthopedic and neurologic patients.

Key words: Biomechanics, Medical Technology, Orthopedics, Shoulder, and anterior cruciate ligament

INTRODUCTION

Biomechanics as an interdisciplinary science, comprehends the description, analysis and interpretation of human body movements through synergic application of the concepts physics, chemistry, mathematics, anatomy, and physiology, among others. It ,contributes to several fields such as Rehabilitation Engineering, Ergonomics, Orthopedics and Traumatology ⁽¹⁾. In Orthopedics, Biomechanics made has enable an increase in the understanding of the functions of the bone, muscles, ligaments and tendons. It has allowed better perception of the mechanical tension effects over physical properties of bones besides the development of new surgical techniques and the treatment of bone malformations, fracture consolidations and osteoporosis due to disuse and muscular atrophy. It also contributes to the development of ortheses, neuroprostheses and new devices for the upper and lower limb rehabilitation. The evaluations and biomechanical analyses of the shoulder and knee disorders, as well as the development of new electronic instrumentation for clinical use are considered other technological advances in Orthopedics

TRIDIMENSIONAL EVALUATION OF SHOULDER ABDUCTION

Biomechanical evaluation through tridimensional image (3D) allows a dynamic analysis and a visualization of articular movements, and it is widely used for a gait analysis. However, in clinical practice, the evaluation of upper limbs with a disorder hasn't been properly settled yet⁽¹⁶⁾. There is some difficulty to settle the protocol for the upper limbs movements present higher variability and complexity compared to the cyclical patterns of the lower limbs movements. Thus, the movement restriction allows the analysis of a particular problem in the upper limb. The shoulder abduction movement in individuals presenting a shoulder rotator cuff disease and a humerus tuberosity fracture can be used to evaluate the evolution of different stages of physiotherapeutical treatment^(12,14).

In this paper, the patterns of abduction movements of the normal and pathological shoulders were quantified by the Qualysis optelectronical system that captures the movements.

Fifteen healthy individuals and five patients were evaluated (one with shoulder rotator cuff lesion and four with humerus tuberosity). In the pathological cases, the shoulder abduction movement was severely committed.

Five infrared cameras set on a 120º angle were used to obtain the 3D coordinates of four reflexive spherical markers, with a diameter of 13 mm, fixed with a scotch tape on the following anatomical references (Figure 1): lateral epycondyle of right humerus (I) right (II) and left (III) acromion surface and the right superior anterior iliac spine (IV).

The shoulder abduction angle was defined as a result of a two-straight-line intersection and quantified by the 3-D coordinates of the markers. So, the abduction is measured through the angle formed between the segments (I-II) and (II – IV), while the compensation of the movement in the frontal plane was evaluated by the segment (II-III) as shown in Figure 1. The data were obtained while the individuals were standing in front of the camera performing constant abduction movements up to 90º, for 16 seconds using the right arm.

The patients presented a decrease in the abduction width degrees and a larger variability of movements compared to the healthy ones (Figure 2-b). A wide compensatory movement in the frontal plane was also noticed, observed by the segments II-III (Figure 3-b). On the other hand, the healthy individuals performed the movements uniformly, presenting larger width angles and repeatability (Figure 2-a).

This evaluation clearly shows the shoulder disorder, although it can't be used to identify a particular pathology (e.g., to distinguish the humerus tuberosity fracture from the shoulder rotator cuff lesion). The results are important to settle the protocols for the physiotherapeutical and orthopedical evaluation used to analyze the dynamic movement of pathological shoulder, unlikely the statistical evaluations made by goniometers that present a larger margin of error and less accuracy.

Gait analysis in individuals with anterior cruciate ligament injury

The Cruciate Ligament Injury is one of the most frequent diseases induced by locomotion. ⁽⁶⁾. According to the literature, the cruciate ligament injuries influence the knee articulation functional mechanism, reducing its flexibility and increasing the articular instability⁽¹³⁾.

The proposal of this paper is to evaluate the biomechanical changes from the cruciate ligament injuries due to reaction forces, angular variations and knee articulation torque.

During the gait seven patients showing a unilateral deficiency of anterior cruciate ligament and ten healthy individuals were evaluated. The kinematic and kinetic data of hip, knee and ankle articulations were bilaterally obtained in all patients and in the control group during the proposed activity. The gait analysis was performed by using the force platform and the Qualisys system that includes the Q gait 2.0 software, a set of six cameras – 60 Hz and reflexive markers placed in anatomical sites (Figure 4) to data collection of tri-dimensional coordinates. The kinematic data and the reaction force were collected and matched through the inverse dynamic method to calculate the articular torque and the power.

The results confirm that patients showing a Cruciate Ligament Injury modify their extraclinical activities and the standard of the gait during the stance phase, in the sub-phase of second double support, with a reduction of the flexion moment peak when the knee is flexed in 30 degrees. These changes are related to the patients' tendency of avoiding/diminishing the quadriceps contraction, flexing the knee with the anterior cruciate injury at the time of full extension, as well as the load in ACL, for the maximum contraction of quadriceps occurs when the knee is flexed between 5 and 25 degrees approximately. The knee articulation angles of the control group and those of the patients with an anterior cruciate ligament deficiency can be seen in figures 5 and 6, respectively. The differences between the mean values obtained by the groups were identified by the Studant t test (Table 1).

This study was the first step in order to identify the mechanisms related to the gait functional adaptation of patients with a cruciate ligament injury. The development of the lesion adaptation process suggests the selfselection of factors and neuromuscular responses which can be regarded as a strategy to a new movement. One can suppose that such adaptations are performed unconsciously, in order to avoid the proximal dislocation of the tibia that may occur in cases of lack of the anterior cruciate ligament function^(2,5)

INSTRUMENTED WALKING AIDS FOR GAITS

To obtain the biomechanical effectiveness during pathological gaits, it is essential to suit the applied loads on the upper and lower limbs in order to improve the posture and the balance besides improving the rehabilitation of individuals with orthopedic and/or neurological lesions (medulary injury, cerebrovascular accident, cranioencephalic traumas during bone fractures consolidation among others). The favorable prognosis in some of these pathologies depends, for example, on the weight support on lower limbs, generating the piezoelectric effect on the bone structures⁽¹¹⁾, as well as the reduction of the corporal overweight on upper limbs to prevent from articular lesions or complications from posttraumatic syringomyelia ^(3,4).

So, considering the necessity of quantifying the applied loads and the relationship of forces among upper and lower limbs during the gait, electronic instrumentation for walking aids such as, instrumented canes and crutches (Figure 7) and a software for the reception and treatment sign (figure 8) were developed.

In the lower shaft of walking aids, strain-gage sensors were placed in order to measure the force. The captured load signs can be sent to an analogical/digital converter, with a reception rate of 50 Hz⁽¹⁵⁾ kept in a microcontroller memory to further on be analyzed by the developed software. Another option is the use of a cable connection or telemetry, allowing the data visualization in real time.

By using this developed system, it is possible to verify the axial force applied to the cane or crutch versus the time (push) during the gait cycles, enabling the dynamic visualization of the pathological gait (Figure 9).

CONCLUSION

The technological advances showed in this paper can provide biomechanical parameters for the diagnosis, prognosis and therapeutical interventions, helping in the development of treatment protocols in Orthopedics and Rehabilitation, specifically focusing the clinical case of each patient.

Acknowledgments

The authors acknowledge the Fundação de Pesquisa do Estado de São Paulo (FAPESP) – Process nº 96/12198-2.

REFERÊNCIAS BIBLIOGRÁFICAS

Work performed at Orthopedics and Traumatology Department, Medical School, Campinas State University, UNICAMP, Campinas, Brazil

Electric Engineering and Bioengineering Department, Universidade de São Paulo (USP), São Carlos, Brazil

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Publication Dates

• Publication in this collection
  24 June 2004
• Date of issue
  Mar 2004

History

• Accepted
  16 Feb 2004
• Received
  27 May 2003