Vasti Control of Patellofemoral Kinematics in Asymptomatic Volunteers

Vasti 对无症状志愿者髌股运动学的控制

基本信息

批准号：
10928545
负责人：
frances t sheehan
金额：
--
依托单位：
CLINICAL CENTER
依托单位国家：
美国
项目类别：
财政年份：
资助国家：
美国
起止时间：
至
项目状态：
未结题

来源：
https://reporter.nih.gov/project-details/10928545
关键词：
3-Dimensional American Analysis of Variance Anterior Area Award Biomechanics Cartilage Clinical Coin Complex Data Enrollment Equilibrium Etiology Event Exclusion Criteria Femur Fostering Freedom Future Goals Image Individual Injections International Intervention Joints Knee Knee bone Knee joint Knowledge Kolmogorov-Smirnov Test Lateral Lead Leg Length Lidocaine Ligaments Linear Regressions Link Location Magnetic Resonance Imaging Measurement Measures Medial Methodology Modeling Motion Motor Movement Muscle Musculoskeletal Nerve Block Normalcy Operative Surgical Procedures Pain Patellofemoral Pain Syndrome Pathologic Patients Pattern Periodicity Phase Population Property Recording of previous events Reporting Rotation Running Series Shapes Societies Source Stress Structure Subgroup Techniques Testing Therapeutic Time Torque Translations Trauma Validation Variant Visit Visual Work analog anatomic imaging arm bone clinical diagnostics cohort diagnostic tool in vivo kinematics knee pain loss of function next generation patellar ligament quadriceps muscle skeletal statistics theories tibia tool treatment optimization trend two-dimensional volunteer

项目摘要

A major limiting factor in previous studies of both the asymptomatic and pathological knee is the inability to non-invasively measure three-dimensional skeletal and muscular motion simultaneously. Cine phase contrast (PC) MRI (dynamic MRI) is the only technique currently available that can do just this. Cine-PC MRI, which is a combination of cine and phase contrast MRI, provides a temporal series of anatomic images of all cyclically moving and static structures in the imaging plane. Therefore, the overall goal of this work is to determine the specific sources of maltracking patterns in patellofemoral (PF) pain. As part of this overall goal, the purpose of this study is to determine how the loss of function in the vasti medialis muscle alters the dynamic control of patellar kinematics in healthy individuals, using cine-PC as the primary measurement tool. Twenty-three asymptomatic volunteers with no prior history of knee pain, trauma, leg surgery, or contraindications to having an MRI have been enrolled. During the first visit, the PF and tibiofemoral (TF) kinematics were derived from dynamic cine phase contrast velocity data. If the first visit data revealed the presence of a valid exclusion criteria, the subject was removed from the study (n=5, based on the presence of abnormal PF kinemtics); if not, the subject was asked to return within a week for the second segment of the study. For the second visit, the same kinematics were acquired immediately after administering a motor branch block to the VM using 3-5cc of 1% lidocaine. A repeated measures analysis of variance (ANOVA) was used to test the null hypothesis that the post- and pre-injection kinematics were no different across the knee angles of extension. A Kolmogorov-Smirnov test for normality was run. If the data were normally distributed, a repeated measures ANOVA was run using Hotellings T2 test statistic; if not, the non-parametric Friedman's test statistic was used. Upon rejection of the null hypothesis a post-hoc analysis (Wilcoxon signed rank test) was completed to determine at which knee angles the null hypothesis could be rejected. Pearsons correlations between the change in kinematics post-injection and the pre-injection kinematics were quantified at these same knee angles. This was followed by a step-wise linear regression. Significance was set at p0.05. Post-injection, the maximum lateral shift of the patellar and tibial origins (1.8mm, SD=1.7mm, p=0.003 KA=20 and 2.1mm, SD=2.9mm, p=0.02, KA = 15) and the maximum external tibial rotation (3.7, SD=4.4, p=0.006, KA=20) occurred at similar points in the extension arc. These changes were 3.2 to 4.8 times greater than the subject repeatability. The value of PF tilt trended laterally post-I (max=1.6, KA =15), but significant differences pre- to post-I were not found. No individual reported pain, based on a Visual Analog Scale, following the kinematic trials during visit 1 and visit 2. The lateral shift of the PF origin post-I was significantly correlated with the initial value of PF origins superior displacement in terminal extension (Pearson correlation coefficients (r-values) ranged from 0.47 to 0.48 for knee angles ranging from 10-20, p<0.05). To relate the kinematic changes seen following a VM block to those seen in PFPS, it is important to understand that there are likely subgroups within the PFPS population, each with unique kinematic alterations of varying etiologies. In a previous study the PFPS cohort was divided into two groups, lateral and non-lateral maltrackers. The lateral maltrackers demonstrated increased PF lateral and superior shift, lateral tilt, flexion, and valgus rotation. The change in kinematics following the nerve block could account for a portion of the lateral shift and tilt seen in the lateral maltrackers. Increased ligament laxity likely would have increased this shift and tilt, as well as increased the patellar ligament length, resulting in the observed PF superior shift (patella alta) in the lateral maltrackers. Patella alta reduces the influence of the femoral groove on PF kinematics in terminal extension, resulting in increased PF lateral shift (as supported by the correlations within this study), lateral tilt, and valgus rotation. Therefore, a combination of VM weakness and generalized ligament laxity could account for the kinematic variations in the lateral maltracking group. These changes would result in higher contact stresses when the patella is forced to re-engage with the femoral sulcus in early flexion and would reduce the overall contact area, both of which would likely leading to PF pain. The non-lateral maltrackers demonstrated increases in PF flexion and TF internal rotation only, with a trend towards PF medial translation and medial tilt. A larger LTI combined with a normative PF superior location in the non-lateral maltrackers limited lateral PF shift and influenced patellar tilt in this subgroup. Thus, in this sub-group a loss of VM strength likely would have resulted in increased contact force between the lateral femoral sulcus and the patella, resulting in PF pain, without excessive lateral shift and tilt being present. The high LTI and the trend towards medial tilt in the non-lateral maltracking group may help explain the variability in the post-I change in PF lateral tilt. In the presence of a high LTI, a loss of strength in the VMO strength could result in the lateral patellar edge riding up the lateral femoral sulcus, resulting in the observed trend towards medial tilt in the non-lateral maltrackers and the post-I medial tilt observed in some subjects. The current study provides crucial data for validation of musculoskeletal modeling. Specifically, the estimation of the quadriceps ability to produce a torque on the tibia is complicated by the fact that the patella serves as an intermediary (a dynamic fulcrum) between the quadriceps and tibia. Therefore, the term effective quadriceps moment arm was coined to define the ability of the quadriceps to generate a torque on the tibia. Yet, this property has only been calculated two-dimensionally in the sagittal plane. The post-I external tibial rotation clearly demonstrates that acting through the patella, the VM effective moment arm has a component that results in internal tibial rotation. This study has advanced the clinical understanding of PFPS by providing a direct in vivo link between VMO weakness in isolation and knee joint kinematic alterations. In doing so it has demonstrated that VMO weakness is most likely a major factor in, but not the sole source of, PF maltracking. Thus, isolated VM strengthening will likely not fully correct PF maltracking in most individuals. In addition, it demonstrated that even with kinematic alterations in the PF and TF joint, pain was not experienced during the post-I trial, indicating that pain may be a factor that develops over time. Combining these findings with past results pertaining to the kinematics and bone shape alterations in individuals with PFPS supports two paths to PFPS in two kinematically unique subgroups. Such knowledge will likely help foster the next generation of treatments for PFPS that focus on first elucidating subject-specific factors leading to PF pain and then devising an intervention plan that specifically targets these factors in order to optimize treatment. Future work is required to provide further evidence on the validity of these paths and extend the current methodology to create a clinical diagnostic tool that will help guide therapeutic or surgical treatments for patients with PF pain. This work won the prestigious 2011 International Society of Biomechanics Clinical Award and the 2011 American Society of Biomechanics Clinical Award. Currently, the data from this study is being used as part of a cartilage contact analysis.

先前研究无症状和病理膝关节研究的主要限制因素是无法同时非侵入性测量三维骨骼和肌肉运动。 Cine相对比（PC）MRI（动态MRI）是目前唯一可以做到这一点的技术。 Cine-PC MRI是Cine和相比MRI的组合，它为成像平面中所有周期性移动和静态结构提供了一系列时间系列的解剖图像。因此，这项工作的总体目标是确定patelo股（PF）疼痛中的麦芽撞alt虫模式的特定来源。作为这一总体目标的一部分，这项研究的目的是确定大中肌的功能丧失如何使用Cine-PC作为主要的测量工具来改变健康个体中pat骨运动学的动态控制。没有膝盖疼痛，创伤，腿部手术或进行MRI的禁忌症的二十三名无症状志愿者已被录取。在第一次访问期间，PF和胫骨（TF）运动学源自动态的Cine相对比度数据。如果第一次访问数据揭示了存在有效的排除标准，则将受试者从研究中删除（n = 5，基于异常的PF运动学的存在）；如果不是，则要求受试者在一周内返回研究的第二部分。在第二次访问中，使用1％利多卡因的3-5cc对VM进行电动机分支块后立即获得相同的运动学。重复的方差分析（ANOVA）用于检验零假设，即在延伸的膝关节角度上，后注射和注射前运动学没有什么不同。运行了Kolmogorov-Smirnov测试的正常性测试。如果数据是正态分布的，则使用Hotellings T2测试统计量进行重复测量方差分析；如果没有，则使用非参数弗里德曼的测试统计量。拒绝零假设后，完成了事后分析（Wilcoxon签名的等级检验），以确定可以拒绝膝关节角度的膝关节角度。在这些相同的膝盖角度量化了运动后运动后的变化与注射前运动学之间的相关性。接下来是逐步的线性回归。显着性设置为P0.05。注射后，p骨和胫骨起源的最大侧向移动（1.8mm，SD = 1.7mm，p = 0.003 ka = 20和2.1mm，SD = 2.9mm，p = 0.02，ka = 15）和最大外部斜式旋转（3.7，SD = 4.4，p = 4.4，p = 0.006，ka = 20）。这些变化是主题可重复性的3.2至4.8倍。 pf倾斜的值横向I（最大值= 1.6，ka = 15），但未发现在I前到I的显着差异。在访问1和访问2的运动学试验之后，根据视觉模拟量表，没有人报告疼痛。PF来源后的横向移位与终端扩展中PF起源的初始值显着相关（Pearson相关系数（r-values）从0.47到0.48 <0.48 for kneee Angles for kneee angles p p p p p p pers p p p p p。为了将VM块之后看到的运动学变化与PFP中看到的运动变化相关，重要的是要了解，PFPS群体中可能存在亚组，每个人群都具有不同病因的独特运动变化。在先前的研究中，PFPS队列分为两组，侧面和非外侧麦芽导体。横向麦芽导线显示PF侧向和上移，外侧倾斜，屈曲和外翻旋转增加。神经阻滞后运动学的变化可以解释横向麦芽导体中侧向移位和倾斜的一部分。韧带的增加可能会增加这种转移和倾斜，并增加了tellar韧带的长度，从而导致侧向麦导板中观察到的PF上移（patella alta）。 patella alta降低了股骨凹槽对末端扩展中PF运动学的影响，从而导致PF侧向移位增加（根据这项研究中的相关性的支持），侧向倾斜和外向旋转。因此，VM弱点和普遍韧带松弛的结合可以解释侧向损坏组的运动学变化。当patella被迫在早期屈曲中与股骨沟重新接触时，这些变化将导致更高的接触应力，并减少整个接触面积，这两者都可能导致PF疼痛。非外侧麦芽导体仅显示PF屈曲和TF内部旋转的增加，其趋势是PF内侧翻译和内侧倾斜的趋势。较大的LTI与非外侧Maltrackers中的规范性PF较高位置相结合，限制了侧向PF偏移，并影响了该亚组中的patelar倾斜。因此，在这个子组中，VM强度的损失可能会导致股骨沟和the骨之间的接触力增加，从而导致PF疼痛，而不会过度侧向移位和倾斜。非外侧撞车组中的高LTI和内侧倾斜的趋势可能有助于解释PF侧向倾斜后I后变化的变化。在存在高LTI的情况下，VMO强度的强度损失可能会导致肩部边缘沿股骨外侧沟的侧向边缘，从而导致观察到的非上外侧恶台倾斜的趋势趋向于内侧倾斜，并在某些受试者中观察到的后I内侧倾斜。当前的研究提供了验证肌肉骨骼建模的关键数据。具体而言，由于the骨充当股四头肌和胫骨之间的中介（动态支点），对胫骨上产生扭矩的股四头肌的估计使得产生扭矩的能力变得复杂。因此，创造了有效的股四头肌臂臂来定义股四头肌在胫骨上产生扭矩的能力。但是，该特性仅在矢状平面上进行了二维计算。 I后外胫骨旋转清楚地表明，通过the骨起作用，VM有效矩臂具有导致内胫骨旋转的成分。这项研究通过在隔离和膝关节运动学改变之间提供直接的体内联系，使PFP的临床理解提高了对PFP的临床理解。通过这样做，它表明VMO弱点很可能是PF Maltracking的主要因素，但不是唯一的来源。因此，孤立的VM加强可能不会完全纠正大多数个体的PF撞车。此外，它表明，即使在PF和TF关节中进行运动学改变，在I后试验期间也没有疼痛，这表明疼痛可能是随着时间的流逝而发展的因素。将这些发现与PFPS个体的运动学和骨形改变有关的过去结果结合起来，支持了两个运动学上独特的亚组中PFP的两条途径。这些知识可能会帮助促进PFP的下一代治疗方法，该治疗重点是首先阐明特定于受试者的因素，导致PF疼痛，然后制定一项干预计划，该计划专门针对这些因素以优化治疗。需要未来的工作以提供有关这些路径有效性的进一步证据，并扩展了当前的方法，以创建临床诊断工具，以帮助PF疼痛患者指导治疗或手术治疗。这项工作赢得了著名的2011年国际生物力学学会临床奖和2011年美国生物力学临床奖。当前，这项研究的数据被用作软骨接触分析的一部分。