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Effect of Anconeus Muscle Blocking on Elbow Kinematics: Electromyographic, Inertial Sensors and Finite Element Study

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Effect of Anconeus Muscle Blocking on Elbow Kinematics: Electromyographic, Inertial Sensors and Finite Element Study Annals of Biomedical Engineering (Ó 2016) DOI: 10.1007/s10439-016-1715-2 Effect of Anconeus Muscle Blocking on Elbow Kinematics: Electromyographic, Inertial Sensors and Finite Element Study 1 1 1 1,2 ISRAEL MIGUEL-ANDRES, TERESA ALONSO-RASGADO, ALAN WALMSLEY, and ADAM C. WATTS 1Bioengineering Research Group, School of Materials, The University of Manchester, Manchester M13 9PL, UK; and 2Wrightington Hospital, Wigan and Leigh NHS Foundation Trust, Lancashire, UK (Received 22 April 2016; accepted 15 August 2016) Associate Editor Peter E. McHugh oversaw the review of this article. Abstract—The specific contribution of the anconeus muscle is the most common instability of the elbow. The an- to elbow function is still uncertain. This study aimed to coneus muscle is currently used in clinical practice in investigate the effect on elbow kinematics and kinetics of the rehabilitation of patients with this condition as it is blocking anconeus using lidocaine. Ten healthy volunteers thought to be an important secondary stabiliser of the performed experimental trials involving flexion–extension 15,22 and supination–pronation movements in horizontal and elbow. sagittal planes. Inertial sensors and surface electromyogra- Patients are trained in anconeus activation and phy were used to record elbow kinematics and kinetics and strengthening programmes are initiated. This function electrical activity from the anconeus, biceps and triceps may be compromised if iatrogenic denervation occurs. brachii before and after blocking anconeus. Moreover, a finite element model of the elbow was created to further The anconeus may be denervated during surgical investigate the contribution of anconeus to elbow kinematics. approaches to the elbow such as when performing elbow The electrical activity results from the trials before blocking arthroscopy, or an olecranon osteotomy.18,31,36,37,50,51 clearly indicated that activity of anconeus was increased While surgical approaches have been described that will during extension, suggesting that it behaves as an extensor. preserve anconeus function they increase surgical time However, blocking anconeus had no effect on the elbow and are often avoided because the anconeus may be kinematics and kinetics, including the angular velocity, net 38 torque and power of the joint. The electrical activity of the perceived to be unimportant. Whilst some studies biceps and triceps brachii did not alter significantly following have reported that patients have experienced no defi- anconeus blocking. These results suggest that anconeus is a ciencies in elbow function after anconeus sacrificing weak extensor, and the relative small contribution of surgery,31,50 these claims have been questioned and a anconeus to extension before blocking was compensated by triceps brachii. The finite element results indicated that more recent study has suggested that there may be anconeus does not contribute significantly to elbow kine- consequences for elbow function and stability of matics. removing anconeus.5 If it is shown that anconeus is important to normal Keywords—Lidocaine, Weak extensor, Flexion–extension, elbow kinematics then surgeons would be encouraged Pronation–supination, Net torque, Power. to employ techniques that preserve the muscle and the nerve supply to it. The specific function and contribution of the anco- INTRODUCTION neus muscle to elbow kinematics is yet to be clearly established. Electromyographic studies have found The anconeus muscle has been implicated in com- that the electrical activity of the anconeus is greater in mon elbow conditions such as lateral epicondylosis extension,28–30,41,44,53 suggesting that it is an elbow 10 and posterolateral rotatory instability (PLRI). PLRI extensor muscle. Furthermore, it has been proposed that the anconeus could abduct the ulna during pronation.13 This idea was later supported by Ray Address correspondence to Teresa Alonso-Rasgado, Bioengineering 46 20 Research Group, School of Materials, The University of Manchester, et al. and Gleason et al. Other studies have Manchester M13 9PL, UK. Electronic mail: israel.miguelandres@ observed that the anconeus is active during resisted manchester.ac.uk, [email protected], alan.walmsley@ pronation–supination movement, implying that it manchester.ac.uk, [email protected] Ó 2016 The Author(s). This article is published with open access at Springerlink.com MIGUEL-ANDRES et al. could contribute to elbow stability.24,41,53 In addition, before and after the anconeus muscle was blocked with several studies have suggested that the strong adher- lidocaine. Measurements were taken using elec- ence between the lateral joint capsule and the anconeus tromyography (EMG) and motion tracking devices (3D makes the latter an active stabiliser of the elbow.3,35,39 inertial sensors) during the performance of three flex- Recent anatomical studies have been undertaken to ion–extension movements and supination–pronation. clarify the function of anconeus. For example, Cori- olano et al.12 found that the muscle fibres of anconeus Subjects were penniform, a formation proficient for force pro- duction. In another anatomical and biomechanical Ten right-handed volunteers, five males and five fe- study, it was observed that anconeus behaves as an males, mean age 29.3 ± 2.21 years and mean body mass extensor muscle and provides posterolateral stability of 66.80 ± 9.56 kg, with no history of neuromuscular or the elbow.42 musculoskeletal disease took part in this investigation. Although it has been argued that anconeus is an All trials were carried out using the dominant hand of accessory muscle at the elbow, some researchers have the participant. The participants were informed about suggested that the muscle could contribute up to 15% the procedures before the tests and the protocol was of the extension moment during isometric contrac- approved by the ethics committee of the University of tions.56 In addition, it has been suggested that anco- Manchester (approval number 11335). neus plays an important role when torque values are low.29,30 However, a re-examination of these results Subject Preparation indicates that anconeus was active tonically at torques First, the skin on the belly of anconeus, biceps and below 39 Nm and exhibited approximately constant triceps brachii of each participant was cleaned with activity at all elbow angles at a constant torque of 70% isopropyl alcohol and then shaved before being 6 Nm. In addition, anconeus activity was observed to cleaned for a second time. increase markedly with increasing angular velocity For the trials where the anconeus was blocked, the with maximum activation occurring concurrently with skin was prepared with an alcoholic chlorhexidine maximum angular velocity. The close correspondence solution, then a trained orthopaedic surgeon injected with maximum angular velocity appears to indicate 10 ml of plain lidocaine through a 25 gauge hypoder- that anconeus contributes to the centripetal force mic needle into the soft tissue at a point midway required to maintain joint integrity. between the tip of the olecranon and the lateral epi- A potential reason as to why research to date has condyle of humerus. The injection was performed with failed to elucidate anconeus function was put forward by the elbow flexed approximately 90°. At least 10 min Capdarest-Arest et al.8 who suggested there is evidence were allowed for the local anaesthetic to work before to argue that the anconeus muscle has a primary func- the experimental protocol was initiated. tion as a stabilizer in human infants during the period when infants crawl but that as they grow and develop, the anconeus then takes on a more accessory-type role. Equipment The current study aims to elucidate the role of an- coneus in order to determine its importance to normal Myoelectric Activity: Electromyography (EMG) elbow kinematics and in doing so to help inform the A BTS pocket EMG Electromyography system debate as to whether surgeons should be encouraged to (BTS Bioengineering, Milan, Italy) was used to record employ techniques that preserve the muscle and the the electrical activity of the anconeus, biceps and tri- nerve supply to it during surgery or could potentially ceps brachii muscles. Bipolar paediatric electrodes (Ag/ consider its sacrifice without a risk to elbow function. AgCl) were used at a sampling frequency of 2000 Hz to In this study the role of anconeus was investigated by obtain the required data from these muscles. Elec- determining the effect of blocking the action of anco- trodes were positioned on the belly of the anconeus, neus muscle on elbow kinematics and kinetics, and the biceps and triceps brachii muscles and on the styloid activation of biceps and triceps brachii, using experi- process of the ulna at the wrist. The electrode placed mental trials and computational modelling. on the ulna was used for ground/reference purposes. Kinematics and Kinetics: Inertial Measurement Units MATERIALS AND METHODS (IMUs) In order to clarify the contribution of the anconeus To obtain the kinematic data for the elbow of each muscle to the motion of the elbow, the electrical activity participant, 3D wireless inertial measurement units of anconeus, biceps and triceps were recorded both (Xsens Technologies, Enschede Netherlands) were Effect of Anconeus Muscle Blocking on Elbow Kinematics used. Before the trial began, the sensors were cali- Flexion–extension in a sagittal plane with the spine brated by placing them on a flat surface and then bent forward 90° and the upper arm aligned hori- executing a heading reset. This was to ensure that the zontally and parallel to the ground gravitational acceleration vector and the global Z axis Supination–pronation with the elbow flexed 90° remained vertical. The active range of motion for flexion–extension Data were acquired at a sampling rate of 75 Hz. was constrained to 90° by a custom-made frame con- Three inertial measurement units (IMUs) were em- structed out of wood. The frame was attached to the ployed; the first sensor (IMU1) was attached below the lateral side of the arm. Supination–pronation motions external notch of the thorax.
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