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Biomechanical Characerization and Evaluation of Conservative Clubfoot Correction Tamara Loren Cohen Marquette University

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Biomechanical Characerization and Evaluation of Conservative Clubfoot Correction Tamara Loren Cohen Marquette University Marquette University e-Publications@Marquette Dissertations (2009 -) Dissertations, Theses, and Professional Projects Biomechanical Characerization and Evaluation of Conservative Clubfoot Correction Tamara Loren Cohen Marquette University Recommended Citation Cohen, Tamara Loren, "Biomechanical Characerization and Evaluation of Conservative Clubfoot Correction" (2015). Dissertations (2009 -). 603. https://epublications.marquette.edu/dissertations_mu/603 BIOMECHANICAL CHARACTERIZATION AND EVALUATION OF CONSERVATIVE CLUBFOOT CORRECTION by Tamara L. Cohen, B.S. A Dissertation submitted to the Faculty of the Graduate School, Marquette University, in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Milwaukee, Wisconsin December 2015 ABSTRACT BIOMECHANICAL CHARACTERIZATION AND EVALUATION OF CONSERVATIVE CLUBFOOT CORRECTION Tamara L. Cohen, B.S. Marquette University, 2015 Congential talipes equinovarus, or clubfoot, affects approximately 200,000 newborns worldwide each year and presents with equinovarus of the hindfoot, as well as cavus and adduction of the midfoot. In addition to bone malformation and displacement, soft tissue contractures encapsulate the medial and posterior aspects of the affected foot. The Ponseti method is a conservative treatment that progressively repositions the clubfoot through weekly casting, followed by bracing. Concerns exist regarding the variability in outcomes, resistance to treatment, and risk of relapse, which occur in approximately 10% of the population. Potential factors contributing to variability and resistant clubfoot include cast material performance, as well as biomechanics of medial soft tissue of the clubfoot. There are no clinical guidelines for clubfoot correction based upon mechanical response of commonly used casting materials, nor the mechanics of the medial fibrotic clubfoot tissue. Untreated or under-corrected clubfoot can result in abnormal gait, pain, and further foot deformity. The purpose of this research was to investigate the biomechanics of conservative clubfoot correction through: i) a kinematic assessment of the creep behavior of three common cast materials used during conservative correction, ii) development and validation of a benchtop system for the mechanical evaluation of miniature soft tissue specimens, and iii) performing a mechanical analysis to model the behavior of medial fibrotic mass tissue (MFMT) from children with clubfoot. Utilizing a model to simulate clubfoot correction, creep rotation was found to be dependent on cast material with maximum values for plaster-of-Paris (θ ≈ 2.1 deg). Reducing cast creep may result in a more efficient correction. Utilizing nylon monofilament, the benchtop system was validated against a commercial system (MTS). Versatility was demonstrated with quasistatic and viscoelastic protocols performed on PTFE tape and rabbit ligament, respectively. Clubfoot MFMT underwent a quasistatic and viscoelastic protocol, including requisite preconditioning as well as stress relaxation. Major findings include high specimen variability, less relaxation than reported for normal deltoid ligaments, and estimated QLV model parameters with R2 > 0.8 for 16 specimens. Results from this research provide mechanical insight into the correction process that may lead to individualized, evidence-based clubfoot care. Future directions include in vivo analysis of tissue properties and mechanical-genetic correlation. i ACKNOWLEDGEMENTS Tamara L. Cohen, B.S. The journey toward my PhD is Biomedical Engineering began my sophomore year of college. After watching a documentary about pediatric victims of war in need of prosthetics, I was inspired to direct my engineering education to understand and help the body. That said, I’d like to first and foremost, thank the patients whose donated tissue made this research possible. Further, I’d like to thank the children and adults who, in spite of injury or disability, strive for more and inspire me to do the same. The completion of my dissertation would not have been made possible without the support and guidance of many people. I’d like to thank my dissertation advisor, Dr. Gerald Harris, who provided me with unfailing guidance, advice, and opportunities for growth. His expertise, enthusiasm for knowledge, and confidence in my abilities enabled me to be a better researcher and problem solver. I would like to thank my committee members, Dr. Lars Olson, Dr. Mei Wang, Dr. Stephen Heinrich, Dr. Peter Smith, Dr. Haluk Aliok for their guidance over the years. Special thanks are due to Dr. Smith, Dr. Altiok, and Dr. Luiz Caicedo for their collaborative and surgical efforts in the recruitment of patients, as well as harvest and transport of tissue for this research. Many thanks are due to Dr. Jeffrey Toth for his histological expertise and tissue preparation assistance, Dr. Scott Beardsley for his expertise and guidance in bioelectronics and controls, and Dr. Sergey Tarima for his expertise in statistics and R programming. In addition, I am grateful to Dr. Carolyne Albert for her impact on my research and life, providing both expertise in material and tissue mechanics as well as mentorship. My tissue mechanics education would not have been complete without the efforts and generosity of Dr. Stephen Abramowitch (University of Pittsburgh). I am indebted to the many who remained during the long hours of experimentation and to those whose assistance made this research possible. First, I’d like to thank Jacob Rammer, my labmate, business partner, and friend, for being generous with his time, patient, a good listener, a great problem solver, and a supplier of caffeine. I’d also like to thank Ms. Emily Schaefer and Ms. Linda McGrady, both of whom made the experimentation phases of my research possible. Finally, I’d like to thank Dr. Joseph Krzak and Mr. Adam Graf for their continued support. I’d also like to thank Marquette University, the Graduate School, and specifically those involved in the execution of Dissertation Boot Camp. My time spent at DBC propelled my writing (thanks to Dr. George Corliss), opened my eyes to other areas of research, and helped me look at my research in a different way (see Appendix G). I could not have gotten through graduate school without the support from my friends, both in Milwaukee and on the east coast. In Milwaukee, I have people like Matt Friedel, whose laughter, kindness, honesty, and friendship gives my life balance and Kate Dechambre, whose kindness and generosity has no limit, not even at midnight. I’d like to ii especially thank Brian Schlatter for being in my life, for his continued support and confidence in me, and for helping me finish my marathons. Special thanks go out to Ian Ziegler for always keeping my brain stimulated. My running and workout families in Milwaukee have kept me strong and healthy, both mentally and physically. Most importantly, I would not be here at the finish line without my family. Though hundreds of miles away, their love and support were always felt. They are my role models, my pillars of strength, and my confidants. I owe the most to my parents, who instilled in me perseverance, a love a math and science, and the importance of education. My admiration of my brother stems from his thirst for knowledge and his strength in overcoming obstacles. Last but not least, I thank my twin sister for challenging me to do more, inspiring me to find my own path, and for always being my best friend. Finally, I’d like to acknowledge my funding sources. The contents of this dissertation were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR 90RE5006-01-00). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this dissertation do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. iii TABLE OF CONTENTS ACKNOWLEDGMENTS………………………………………………………………....i LIST OF TABLES……………………………………………………………………………...iv LIST OF FIGURES…………………………………………………………………………….vi CHAPTER 1: INTRODUCTION ....................................................................................... 1 1.1 Statement of Problem ................................................................................................ 1 1.2 Clubfoot Pathology and Morphology ........................................................................ 2 1.3 Clubfoot Treatment and Relapse ............................................................................... 3 1.4 Current Conservative Clubfoot Treatment ................................................................ 5 1.5 Cast Materials in Orthopaedics ................................................................................. 7 1.6 Characterization of Clubfoot Soft Tissue .................................................................. 8 1.7 Time-Dependent Mechanical Testing and Analysis ............................................... 10 1.8 Hypotheses and Specific Aims ................................................................................ 15 CHAPTER 2: CAST MATERIAL ASSESSMENT ......................................................... 19 2.1 Introduction ............................................................................................................. 19 2.2 Materials and Methods ............................................................................................ 21 2.2.1 Device Design..................................................................................................
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