Arthroscopy or ultrasound in undergraduate anatomy education: a randomized cross-over controlled trial

Background: The exponential growth of image-based diagnostic and minimally invasive interventions requires a detailed three-dimensional anatomical knowledge and increases the demand towards the undergraduate anatomical curriculum. This randomized controlled trial investigates whether musculoskeletal ultrasound (MSUS) or arthroscopic methods can increase the anatomical knowledge uptake. Methods: Second-year medical students were randomly allocated to three groups. In addition to the compulsory dissection course, the ultrasound group (MSUS) was taught by eight, didactically and professionally trained, experienced student-teachers and the arthroscopy group (ASK) was taught by eight experienced physicians. The control group (CON) acquired the anatomical knowledge only via the dissection course. Exposure (MSUS and ASK) took place in two separate lessons (75 minutes each, shoulder and knee joint) and introduced standard scan planes using a 10-MHz ultrasound system as well as arthroscopy tutorials at a simulator combined with video tutorials. The theoretical anatomic learning outcomes were tested using a multiple-choice questionnaire (MCQ), and after cross-over an objective structured clinical examination (OSCE). Differences in student's perceptions were evaluated using Likert scale-based items. Results: The ASK-group (n = 70, age 23.4 (20--36) yrs.) performed moderately better in the anatomical MC exam in comparison to the MSUS-group (n = 84, age 24.2 (20--53) yrs.) and the CON-group (n = 88, 22.8 (20--33) yrs.; p = 0.019). After an additional arthroscopy teaching 1 % of students failed the MC exam, in contrast to 10 % in the MSUS- or CON-group, respectively. The benefit of the ASK module was limited to the shoulder area (p < 0.001). The final examination (OSCE) showed no significant differences between any of the groups with good overall performances. In the evaluation, the students certified the arthroscopic tutorial a greater advantage concerning anatomical skills with higher spatial imagination in comparison to the ultrasound tutorial (p = 0.002; p < 0.001). Conclusions: The additional implementation of arthroscopy tutorials to the dissection course during the undergraduate anatomy training is profitable and attractive to students with respect to complex joint anatomy. Simultaneous teaching of basic-skills in musculoskeletal ultrasound should be performed by medical experts, but seems to be inferior to the arthroscopic 2D-3D-transformation, and is regarded by students as more difficult to learn. Although arthroscopy and ultrasound teaching do not have a major effect on learning joint anatomy, they have the potency to raise the interest in surgery

Recent trends, technical concepts and components of computer-assisted orthopedic surgery systems: A comprehensive review

Computer-assisted orthopedic surgery (CAOS) systems have become one of the most important and challenging types of system in clinical orthopedics, as they enable precise treatment of musculoskeletal diseases, employing modern clinical navigation systems and surgical tools. This paper brings a comprehensive review of recent trends and possibilities of CAOS systems. There are three types of the surgical planning systems, including: systems based on the volumetric images (computer tomography (CT), magnetic resonance imaging (MRI) or ultrasound images), further systems utilize either 2D or 3D fluoroscopic images, and the last one utilizes the kinetic information about the joints and morphological information about the target bones. This complex review is focused on three fundamental aspects of CAOS systems: their essential components, types of CAOS systems, and mechanical tools used in CAOS systems. In this review, we also outline the possibilities for using ultrasound computer-assisted orthopedic surgery (UCAOS) systems as an alternative to conventionally used CAOS systems.Web of Science1923art. no. 519

Automating the multimodal analysis of musculoskeletal imaging in the presence of hip implants

In patients treated with hip arthroplasty, the muscular condition and presence of inflammatory reactions are assessed using magnetic resonance imaging (MRI). As MRI lacks contrast for bony structures, computed tomography (CT) is preferred for clinical evaluation of bone tissue and orthopaedic surgical planning. Combining the complementary information of MRI and CT could improve current clinical practice for diagnosis, monitoring and treatment planning. In particular, the different contrast of these modalities could help better quantify the presence of fatty infiltration to characterise muscular condition after hip replacement. In this thesis, I developed automated processing tools for the joint analysis of CT and MR images of patients with hip implants. In order to combine the multimodal information, a novel nonlinear registration algorithm was introduced, which imposes rigidity constraints on bony structures to ensure realistic deformation. I implemented and thoroughly validated a fully automated framework for the multimodal segmentation of healthy and pathological musculoskeletal structures, as well as implants. This framework combines the proposed registration algorithm with tailored image quality enhancement techniques and a multi-atlas-based segmentation approach, providing robustness against the large population anatomical variability and the presence of noise and artefacts in the images. The automation of muscle segmentation enabled the derivation of a measure of fatty infiltration, the Intramuscular Fat Fraction, useful to characterise the presence of muscle atrophy. The proposed imaging biomarker was shown to strongly correlate with the atrophy radiological score currently used in clinical practice. Finally, a preliminary work on multimodal metal artefact reduction, using an unsupervised deep learning strategy, showed promise for improving the postprocessing of CT and MR images heavily corrupted by metal artefact. This work represents a step forward towards the automation of image analysis in hip arthroplasty, supporting and quantitatively informing the decision-making process about patient’s management

Corticospinal excitability, mental rotation task, motor performance and disability in subjects with musculoskeletal disorders of the wrist and hand

L'objectif de cette thèse était de démontrer la présence de modifications des processus sensorimoteurs du système nerveux central (excitabilité corticospinale et schéma corporel tels que mesurés avec la Tâche de Reconnaissance de la Latéralité des Images droite gauche (TRLI)) chez des participants ayant des désordres musculosquelettiques au poignet et à la main. Un deuxième objectif était de déterminer la relation entre les changements de ces processus sensorimoteurs corticaux et des mesures sensorielles, de la fonction motrice, d'incapacité autodéclarée, de la douleur et des facteurs psychosociaux liés à la douleur. Une étude observationnelle transversale a d'abord été menée pour mesurer l'excitabilité corticospinale des muscles de la main en utilisant la stimulation magnétique transcrânienne et la TRLI chez des participants en santé et des participants présentant des douleurs chroniques au poignet et à la main. L’excitabilité corticospinale du muscle court abducteur du pouce de la main affectée était augmentée chez les participants présentant une douleur chronique et ces changements étaient significativement corrélés avec l'intensité de la douleur, l'incapacité autodéclarée, et négativement corrélés avec l'excitabilité motoneuronale. Des différences de performances sur le TRLI, à la fois pour la précision et le temps de réaction, ont également été trouvées entre les participants du groupe contrôle et les participants avec douleur. Dans une deuxième étude transversale, le TRLI, des mesures de motricité, sensibilité et des fonctions cognitives ont été administrées à soixante et un participants présentant des désordres musculosquelettiques du poignet ou de la main droite. Les modèles de régression linéaire multiple ont révélé que la prise de médicaments pour contrer la douleur, la participation à des activités (sociales, professionnelles, domestiques et récréatives), la discrimination tactile de deux points et le niveau de performance motrice expliquent les performances au TRLI. Les participants ayant pris des médicaments pour la douleur la journée de l’évaluation avaient une performance diminuée sur la précision et le temps de réaction sur le TRLI pour la main droite (affectée). Ces participants présentaient aussi une sévérité de douleur et d'incapacité plus élevée et une diminution de fonctions cognitives et motrices plus élevée que le reste des participants avec douleur qui ont été évalués. Dans l’ensemble, ces résultats suggèrent que les participants présentant des désordres musculosquelettiques hétérogènes du poignet ou de la main montrent des changements des processus sensorimoteurs corticaux. Alors que l'excitabilité corticospinale semble être liée à l'intensité de la douleur et à l’incapacité autodéclarée, le TRLI peut être associé à une confluence de facteurs (sensoriels, moteurs, cognitifs-affectifs et comportementaux). Ces résultats suggèrent aussi que les changements sensorimoteurs corticaux ne sont pas simplement le résultat du désordre musculosquelettique, mais impliquent plutôt une interaction complexe entre la douleur, les processus sensorimoteurs et cognitivo-affectifs, et peut-être aussi des réponses comportementales à l’atteinte musculosquelettique. Les résultats fournissent également des informations précieuses à propos des personnes qui pourraient bénéficier d'interventions orientées vers le rétablissement des processus centraux en plus des traitements de réadaptation axés sur les structures périphériques.The objective of the thesis was to investigate for the presence of changes in cortical sensorimotor processes (corticospinal excitability and the body schema measured with the Left Right Judgment Task (LRJT) performance), in participants with Musculoskeletal Disorders (MSD) of the wrist/hand. A second objective was to determine the relationship between these cortical sensorimotor processes and measures of sensory and hand motor function, disability, pain and pain related psychosocial factors. First, an observational cross-sectional study was conducted to explore corticospinal excitability of muscles in the hand and cortical sensorimotor processes, utilizing transcranial magnetic stimulation and the LRJT in healthy, pain-free participants and participants with chronic wrist/hand pain. Increased corticospinal excitability for the abductor pollicis brevis of the affected hand in participants with chronic MSD of the wrist/hand was found and these changes were significantly correlated with pain intensity, disability, and negatively correlated with spinal motoneuronal excitability. Differences in LRJT performance were also found between healthy control participants and participants with pain for both LRJT accuracy and reaction time. In a second cross-sectional study, LRJT performance, motor, sensory and cognitive assessments were performed on sixty-one participants with MSD of the right dominant wrist/hand. The multiple linear regression model revealed that taking pain medication, participating in (social, work, household and leisure) activities, two-point discrimination, and motor performance explained performance on the LRJT of the right (affected) hand. Those participants that took pain medication on the day of the evaluation performed more poorly on both LRJT accuracy and reaction time of the right (affected) hand. These participants had higher pain severity and disability scores and decreased cognitive and motor function. Collectively, these results suggest that participants with heterogeneous MSD of the wrist/hand display altered cortical sensorimotor processes. Whereas corticospinal excitability appears to be related to pain intensity and disability, the LRJT may be associated with a confluence of factors (sensory, motor, cognitive-affective, and behaviours). These findings suggest that cortical sensorimotor changes do not simply appear to be the result of the condition but involve a complex interaction between pain, sensorimotor and cognitive-affective processes, and possibly behavioural responses to the condition. The findings also provide valuable insight as to those persons who may benefit from cognitively directed interventions in addition to peripherally driven rehabilitative treatments

Focal Spot, Spring 1994

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Focal Spot, Fall/Winter 1999

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Imaging Pain And Brain Plasticity: A Longitudinal Structural Imaging Study

Chronic musculoskeletal pain is a leading cause of disability worldwide yet the mechanisms of chronification and neural responses to effective treatment remain elusive. Non-invasive imaging techniques are useful for investigating brain alterations associated with health and disease. Thus the overall goal of this dissertation was to investigate the white (WM) and grey matter (GM) structural differences in patients with musculoskeletal pain before and after psychotherapeutic intervention: cognitive behavioral therapy (CBT). To aid in the interpretation of clinical findings, we used a novel porcine model of low back pain-like pathophysiology and developed a post-mortem, in situ, neuroimaging approach to facilitate translational investigation. The first objective of this dissertation (Chapter 2) was to identify structural brain alterations in chronic pain patients compared to healthy controls. To achieve this, we examined GM volume and diffusivity as well as WM metrics of complexity, density, and connectivity. Consistent with the literature, we observed robust differences in GM volume across a number of brain regions in chronic pain patients, however, findings of increased GM volume in several regions are in contrast to previous reports. We also identified WM changes, with pain patients exhibiting reduced WM density in tracts that project to descending pain modulatory regions as well as increased connectivity to default mode network structures, and bidirectional alterations in complexity. These findings may reflect network level dysfunction in patients with chronic pain. The second aim (Chapter 3) was to investigate reversibility or neuroplasticity of structural alterations in the chronic pain brain following CBT compared to an active control group. Longitudinal evaluation was carried out at baseline, following 11-week intervention, and a four-month follow-up. Similarly, we conducted structural brain assessments including GM morphometry and WM complexity and connectivity. We did not observe GM volumetric or WM connectivity changes, but we did discover differences in WM complexity after therapy and at follow-up visits. To facilitate mechanistic investigation of pain related brain changes, we used a novel porcine model of low back pain-like pathophysiology (Chapter 6). This model replicates hallmarks of chronic pain, such as soft tissue injury and movement alteration. We also developed a novel protocol to perform translational post-mortem, in situ, neuroimaging in our porcine model to reproduce WM and GM findings observed in humans, followed by a unique perfusion and immersion fixation protocol to enable histological assessment (Chapter 4). In conclusion, our clinical data suggest robust structural brain alterations in patients with chronic pain as compared to healthy individuals and in response to therapeutic intervention. However, the mechanism of these brain changes remains unknown. Therefore, we propose to use a porcine model of musculoskeletal pain with a novel neuroimaging protocol to promote mechanistic investigation and expand our interpretation of clinical findings

Focal Spot, Summer 1992

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