Muscle, ligament, and joint-contact forces at the knee during walking

Partitioning of knee joint internal forces in gait is dictated by the knee adduction angle and not by the knee adduction moment

Medial knee osteoarthritis is a debilitating disease. Surgical and conservative interventions are performed to manage its progression via reduction of load on the medial compartment or equivalently its surrogate measure, the external adduction moment. However, some studies have questioned a correlation between the medial load and adduction moment. Using a musculoskeletal model of the lower extremity driven by kinematics-kinetics of asymptomatic subjects at gait midstance, we aim here to quantify the relative effects of changes in the knee adduction angle versus changes in the adduction moment on the joint response and medial/lateral load partitioning. The reference adduction rotation of 1.6° is altered by ±1.5° to 3.1° and 0.1° or the knee reference adduction moment of 17Nm is varied by ±50% to 25.5Nm and 8.5Nm. Quadriceps, hamstrings and tibiofemoral contact forces substantially increased as adduction angle dropped and diminished as it increased. The medial/lateral ratio of contact forces slightly altered by changes in the adduction moment but a larger adduction rotation hugely increased this ratio from 8.8 to a 90 while in contrast a smaller adduction rotation yielded a more uniform distribution. If the aim in an intervention is to diminish the medial contact force and medial/lateral load ratio, a drop of 1.5° in adduction angle is much more effective (causing respectively 12% and 80% decreases) than a reduction of 50% in the adduction moment (causing respectively 4% and 13% decreases). Substantial role of changes in adduction angle is due to the associated alterations in joint nonlinear passive resistance. These findings explain the poor correlation between knee adduction moment and tibiofemoral compartment loading during gait suggesting that the internal load partitioning is dictated by the joint adduction angle.

Standardized loads acting in knee implants

The loads acting in knee joints must be known for improving joint replacement, surgical procedures, physiotherapy, biomechanical computer simulations, and to advise patients with osteoarthritis or fractures about what activities to avoid. Such data would also allow verification of test standards for knee implants. This work analyzes data from 8 subjects with instrumented knee implants, which allowed measuring the contact forces and moments acting in the joint. The implants were powered inductively and the loads transmitted at radio frequency. The time courses of forces and moments during walking, stair climbing, and 6 more activities were averaged for subjects with I) average body weight and average load levels and II) high body weight and high load levels. During all investigated activities except jogging, the high force levels reached 3,372–4,218N. During slow jogging, they were up to 5,165N. The peak torque around the implant stem during walking was 10.5 Nm, which was higher than during all other activities including jogging. The transverse forces and the moments varied greatly between the subjects, especially during non-cyclic activities. The high load levels measured were mostly above those defined in the wear test ISO 14243. The loads defined in the ISO test standard should be adapted to the levels reported here. The new data will allow realistic investigations and improvements of joint replacement, surgical procedures for tendon repair, treatment of fractures, and others. Computer models of the load conditions in the lower extremities will become more realistic if the new data is used as a gold standard. However, due to the extreme individual variations of some load components, even the reported average load profiles can most likely not explain every failure of an implant or a surgical procedure.

Biomechanical changes in gait of subjects with medial knee osteoarthritis

Objective

Demonstrate the presence and magnitude of biomechanical variables during gait in patients with medial knee osteoarthritis (OA) and the relationship with the knee loading.

Methods

Gait of 21 subjects diagnosed with medial knee OA was evaluated and compared to the control group.

Results

The group with OA showed: Lower gait speed (0.8 ± 0.1 vs. 1.1 ± 0.1m/s), higher peak early (2.6 ± 1.2 vs. 0.3 ± 1.4 Nm/Kg) and late peak of the adduction moment (1.8 ± 0.7 vs. 0.9 ± 0.2 Nm/Kg), higher peak flexor moment (1.6 ± 0.9 vs. 0.6 ± 0.4 Nm/Kg), high dynamic peak varus (11.5º ± 8.3 vs. 3º ± 3.9), higher peak flexion (15.6º ± 8 vs. 9.3º to ± 4.1), with a flexion tendency (5.5º ± 8.5) in the stance phase, smaller peak of flexion (58.7º ± 13.3 vs. 67.5º ± 4.8) in the balance phase and higher peaks of external rotation (25.5º ± 12.7 vs. 0.5º ± 22.4).

Conclusion

Patients with medial knee OA show changes in gait with increased external rotation, speed reduction, increased flexor moment and flexion in the stance phase, insufficient for reduction of the load. Level of Evidence III, Case Control Study.

Evaluation of a musculoskeletal model with prosthetic knee through six experimental gait trials

Knowledge of the forces acting on musculoskeletal joint tissues during movement benefits tissue engineering, artificial joint replacement, and our understanding of ligament and cartilage injury. Computational models can be used to predict these internal forces, but musculoskeletal models that simultaneously calculate muscle force and the resulting loading on joint structures are rare. This study used publicly available gait, skeletal geometry, and instrumented prosthetic knee loading data [1] to evaluate muscle driven forward dynamics simulations of walking. Inputs to the simulation were measured kinematics and outputs included muscle, ground reaction, ligament, and joint contact forces. A full body musculoskeletal model with subject specific lower extremity geometries was developed in the multibody framework. A compliant contact was defined between the prosthetic femoral component and tibia insert geometries. Ligament structures were modeled with a nonlinear force-strain relationship. The model included 45 muscles on the right lower leg. During forward dynamics simulations a feedback control scheme calculated muscle forces using the error signal between the current muscle lengths and the lengths recorded during inverse kinematics simulations. Predicted tibio-femoral contact force, ground reaction forces, and muscle forces were compared to experimental measurements for six different gait trials using three different gait types (normal, trunk sway, and medial thrust). The mean average deviation (MAD) and root mean square deviation (RMSD) over one gait cycle are reported. The muscle driven forward dynamics simulations were computationally efficient and consistently reproduced the inverse kinematics motion. The forward simulations also predicted total knee contact forces (166N<MAD<404N, 212N<RMSD<448N) and vertical ground reaction forces (66N<MAD<90N, 97N<RMSD<128N) well within 28% and 16% of experimental loads, respectively. However the simplified muscle length feedback control scheme did not realistically represent physiological motor control patterns during gait. Consequently, the simulations did not accurately predict medial/lateral tibio-femoral force distribution and muscle activation timing.

Evaluation of knee joint muscle forces and tissue stresses-strains during gait in severe OA versus normal subjects

Osteoarthritis (OA) is the leading cause of pain and disability in the elderly with the knee being the most affected weight bearing joint. We used a musculoskeletal biomechanical model of the lower extremity including a detailed validated knee joint finite element model to compute lower extremity muscle forces and knee joint stresses-strains during the stance phase of gait. The model was driven by gait data on OA patients, and results were compared with those of the same model driven by data on normal controls. Additional analyses were performed with altered cartilage-menisci properties to evaluate the effects of deterioration during OA. In OA patients compared to normal subjects, muscle forces dropped at nearly all stance periods except mid-stance. Force in the anterior cruciate ligament remained overall the same. Total contact forces-stresses deceased by about 25%. Alterations in properties due to OA had negligible effects on muscle forces, but increased contact areas and cartilage strains and reduced contact pressures. Reductions in contact stresses and increases in tissue strains and transfer of load via menisci are partly due to the altered kinetics-kinematics of gait and partly due to deterioration in cartilage-menisci properties in OA patients.

Simulation on the internal structure of three-dimensional proximal tibia under different mechanical environments

Background

Bone can adjust its morphological structure to adapt to the changes of mechanical environment, i.e. the bone structure change is related to mechanical loading. This implies that osteoarthritis may be closely associated with knee joint deformity. The purposes of this paper were to simulate the internal bone mineral density (BMD) change in three-dimensional (3D) proximal tibia under different mechanical environments, as well as to explore the relationship between mechanical environment and bone morphological abnormity.

Methods

The right proximal tibia was scanned with CT to reconstruct a 3D proximal tibia model in MIMICS, then it was imported to finite element software ANSYS to establish 3D finite element model. The internal structure of 3D proximal tibia of young normal people was simulated using quantitative bone remodeling theory in combination with finite element method, then based on the changing pattern of joint contact force on the tibial plateau in valgus knees, the mechanical loading was changed, and the simulated normal tibia structure was used as initial structure to simulate the internal structure of 3D proximal tibia for old people with 6° valgus deformity. Four regions of interest (ROIs) were selected in the proximal tibia to quantitatively analyze BMD and compare with the clinical measurements.

Results

The simulation results showed that the BMD distribution in 3D proximal tibia was consistent with clinical measurements in normal knees and that in valgus knees was consistent with the measurement of patients with osteoarthritis in clinics.

Conclusions

It is shown that the change of mechanical environment is the main cause for the change of subchondral bone structure, and being under abnormal mechanical environment for a long time may lead to osteoarthritis. Besides, the simulation method adopted in this paper can more accurately simulate the internal structure of 3D proximal tibia under different mechanical environments. It helps to better understand the mechanism of osteoarthritis and provides theoretical basis and computational method for the prevention and treatment of osteoarthritis. It can also serve as basis for further study on periprosthetic BMD changes after total knee arthroplasty, and provide a theoretical basis for optimization design of prosthesis.

Knee proprioception and strength and landing kinematics during a single-leg stop-jump task

CONTEXT

The importance of the sensorimotor system in maintaining a stable knee joint has been recognized. As individual entities, knee-joint proprioception, landing kinematics, and knee muscles play important roles in functional joint stability. Preventing knee injuries during dynamic tasks requires accurate proprioceptive information and adequate muscular strength. Few investigators have evaluated the relationship between knee proprioception and strength and landing kinematics.

OBJECTIVE

To examine the relationship between knee proprioception and strength and landing kinematics.

DESIGN

Cross-sectional study.

SETTING

University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Fifty physically active men (age = 26.4 ± 5.8 years, height = 176.5 ± 8.0 cm, mass = 79.8 ± 16.6 kg).

INTERVENTION(S)

Three tests were performed. Knee conscious proprioception was evaluated via threshold to detect passive motion (TTDPM). Knee strength was evaluated with a dynamometer. A 3-dimensional biomechanical analysis of a single-legged stop-jump task was used to calculate initial contact (IC) knee-flexion angle and knee-flexion excursion.

MAIN OUTCOME MEASURE(S)

The TTDPM toward knee flexion and extension, peak knee flexion and extension torque, and IC knee-flexion angle and knee flexion excursion. Linear correlation and stepwise multiple linear regression analyses were used to evaluate the relationships of both proprioception and strength against landing kinematics. The α level was set a priori at .05.

RESULTS

Enhanced TTDPM and greater knee strength were positively correlated with greater IC knee-flexion angle (r range = 0.281-0.479, P range = .001-.048). The regression analysis revealed that 27.4% of the variance in IC knee-flexion angle could be accounted for by knee-flexion peak torque and TTDPM toward flexion (P = .001).

CONCLUSIONS

The current research highlighted the relationship between knee proprioception and strength and landing kinematics. Individuals with enhanced proprioception and muscular strength had better control of IC knee-flexion angle during a dynamic task.

Kinematic and kinetic interactions during normal and ACL-deficient gait: a longitudinal in vivo study

The interactions between different tissues within the knee joint and between different kinematic DOF and joint flexion during normal gait were investigated. These interactions change following ACL transection, in both short (4 weeks) and long (20 weeks) term. Ten skeletally mature sheep were used in control (N = 5) and experimental (N = 5) groups. The 6-DOF stifle joint motion was first measured during normal gait. The control group were then euthanized and mounted on a unique robotic testing platform for kinetic measurements. The experimental group underwent ACL transection surgery, and kinematics measurements were repeated 4 and 20 weeks post-operatively. The experimental group were then euthanized and underwent kinetic assessment using the robotic system. Results indicated significant couplings between joint flexion vs. abduction and internal tibial rotation, as well as medial, anterior, and superior tibial translations during both normal and ACL-deficient gait. Distinct kinetic interactions were also observed between different tissues within the knee joint. Direct relationships were found between ACL vs. LM/MM, and PCL vs. MCL loads during normal gait; inverse relationships were detected between ACL vs. PCL and PCL vs. LM/MM loads. These kinetic interaction patterns were considerably altered by ACL injury. Significant inter-subject variability in joint kinematics and tissue loading patterns during gait was also observed. This study provides further understanding of the in vivo function of different tissues within the knee joint and their couplings with joint kinematics during normal gait and over time following ACL transection.

Effect of partial medial meniscectomy on anterior tibial translation in stable knees: a prospective controlled study on 32 patients

BACKGROUND

Quantitative measurement of anterior translation of the tibia (ATT) by KT 1000 is used mainly to provide an objective assessment of knee laxity after anterior cruciate ligament (ACL) tears or ACL reconstructions. Only few papers described its use after menisectomies in knees with intact ACL. The objective of this paper is to determine whether partial medial meniscectomies could induce significant immediate post-operative ATT.

METHODS

Thirty-two patients with a diagnosis of partial medial meniscal tear limited to the posterior horn and documented with magnetic resonance imaging (MRI) were assessed under anesthesia before and immediately after arthroscopic meniscectomy. The assessment was performed by the same examiner by means of the MEDmetric(R) KT-1000 instrument using manual maximum (MM) force. The opposite knees were also assessed.

RESULTS

There is a significant difference between pre and post-operative KT MM mean values for the operated knees (CI: -3.933953 to -2.947297, p < 0.0001). No significance was found between the mean values for the contralateral knees before and after the completion of the menisectomy on the operated knees (p = 0.4). For the operated knees, 14 (43.75%) had a side-to-side difference between pre-and post-operative values of more than 3 mm, whereas for the contralateral knees, only 2 (6%) had the same.

CONCLUSION

Less than half of operated knees showed significant side-to-side difference values of ATT (>3 mm), immediately after meniscectomies in unconscious patients. Our values might reflect a temporarily increase of anterior laxity under specific conditions but whether a significant laxity remains in some knees, such changes may lead to higher cartilage loading and early osteoarthritis.

Dual-joint modeling for estimation of total knee replacement contact forces during locomotion

Model-based estimation of in vivo contact forces arising between components of a total knee replacement is challenging because such forces depend upon accurate modeling of muscles, tendons, ligaments, contact, and multibody dynamics. Here we describe an approach to solving this problem with results that are tested by comparison to knee loads measured in vivo for a single subject and made available through the Grand Challenge Competition to Predict in vivo Tibiofemoral Loads. The approach makes use of a "dual-joint" paradigm in which the knee joint is alternately represented by (1) a ball-joint knee for inverse dynamic computation of required muscle controls and (2) a 12 degree-of-freedom (DOF) knee with elastic foundation contact at the tibiofemoral and patellofemoral articulations for forward dynamic integration. Measured external forces and kinematics were applied as a feedback controller and static optimization attempted to track measured knee flexion angles and electromyographic (EMG) activity. The resulting simulations showed excellent tracking of knee flexion (average RMS error of 2.53 deg) and EMG (muscle activations within ±10% envelopes of normalized measured EMG signals). Simulated tibiofemoral contact forces agreed qualitatively with measured contact forces, but their RMS errors were approximately 25% of the peak measured values. These results demonstrate the potential of a dual-joint modeling approach to predict joint contact forces from kinesiological data measured in the motion laboratory. It is anticipated that errors in the estimation of contact force will be reduced as more accurate subject-specific models of muscles and other soft tissues are developed.

Knee joint passive stiffness and moment in sagittal and frontal planes markedly increase with compression

Knee joints are subject to large compression forces in daily activities. Due to artefact moments and instability under large compression loads, biomechanical studies impose additional constraints to circumvent the compression position-dependency in response. To quantify the effect of compression on passive knee moment resistance and stiffness, two validated finite element models of the tibiofemoral (TF) joint, one refined with depth-dependent fibril-reinforced cartilage and the other less refined with homogeneous isotropic cartilage, are used. The unconstrained TF joint response in sagittal and frontal planes is investigated at different flexion angles (0°, 15°, 30° and 45°) up to 1800 N compression preloads. The compression is applied at a novel joint mechanical balance point (MBP) identified as a point at which the compression does not cause any coupled rotations in sagittal and frontal planes. The MBP of the unconstrained joint is located at the lateral plateau in small compressions and shifts medially towards the inter-compartmental area at larger compression forces. The compression force substantially increases the joint moment-bearing capacities and instantaneous angular rigidities in both frontal and sagittal planes. The varus-valgus laxities diminish with compression preloads despite concomitant substantial reductions in collateral ligament forces. While the angular rigidity would enhance the joint stability, the augmented passive moment resistance under compression preloads plays a role in supporting external moments and should as such be considered in the knee joint musculoskeletal models.

Lateral wedges alter mediolateral load distributions at the knee joint in obese individuals

Obesity is the primary risk factor for knee osteoarthritis (OA). Greater external knee adduction moments, surrogate measures for medial compartment loading, are present in Obese individuals and may predispose them to knee OA. Laterally wedged insoles decrease the magnitude of the external adduction moment in Obese individuals but it is unknown how they alter the center of pressure on the tibial plateau. A gait analysis was performed on 14 Obese (avg. 29.3 years; BMI range: 30.3-51.6 kg/m(2) ) and 14 lean women (avg. 26.1 years; BMI range: 20.9-24.6 kg/m(2) ) with and without a full-length, wedged insole. Computed joint angles, joint moments, and knee extensor strength values were input into a musculoskeletal model to estimate center of pressure of the contact force on the tibial plateau. Statistical significance was assessed using a two-way ANOVA to compare the main effects of group and insole condition (α = 0.05). The insole resulted in a significant (p < 0.01) lateral shift in the center of pressure location in both the Obese and Control groups (mean: 2.9 ± 0.7 and 1.5 ± 0.7 mm, respectively). The insole also significantly reduced the peak external knee adduction moment 1.88 ± 1.82 N m in the Control group (p < 0.01) and 3.62 ± 3.90 N m in the Obese group (p < 0.01). The results of this study indicate the effects of a prophylactic wedged insole for reducing the magnitude of the load on the knee's medial compartment in Obese women who are at risk for knee OA development.

Cryopreservation with glycerol improves the in vitro biomechanical characteristics of human patellar tendon allografts

PURPOSE

To evaluate the in vitro biomechanical characteristics of patellar tendon ligaments (BTB) when stored as fresh frozen or as glycerol cryopreserved allografts.

METHODS

Seventy patellar tendons were harvested from 35 cadaveric human donors and randomly assigned into seven groups. Grafts in group FRESH were mechanically tested within 2 h of harvesting. FROZ-3, FROZ-6, and FROZ-9 were deep-frozen to -80 °C for 3, 6, and 9 months, respectively. Grafts in groups CRYO-3, CRYO-6, and CRYO-9 were initially incubated with 10% glycerol in a phosphate-buffered saline for 1 h and then stored in glycerol solution (10% glycerol in PBS) at -80 °C for 3, 6, and 9 months, respectively. Grafts were mechanically tested with two cycling modes (50-250 °N and 150-500 °N) and then loaded to failure.

RESULTS

Cryopreserved grafts demonstrated more consistent results and expressed lower elongation rates after both cycling loading protocols compared to their frozen counterparts at all storage times. During load-to-failure analysis, ultimate stiffness levels were predominantly higher (23.9-61.5%) in cryopreserved grafts compared with frozen grafts, and ultimate stress levels were 26% (13.3-47.7%) higher, regardless of the storage time. Moreover, cryopreserved grafts revealed similar ultimate elongation and uniformly higher ultimate stiffness and ultimate stress levels compared to fresh grafts.

CONCLUSION

The results of this in vitro study demonstrated superior mechanical properties of cryopreserved grafts compared to frozen grafts within a preservation period of 9 months. Cryopreservation with glycerol solution might be used to further improve the quality of preserved soft-tissue allografts.

The biomechanical effects of 1.0 to 1.2 Mrad of γ irradiation on human bone-patellar tendon-bone allografts

BACKGROUND

Recent data suggest that anterior cruciate ligament (ACL) reconstruction with irradiated allograft tissue may lead to increased failure rates.

HYPOTHESIS

Low-dose (1.0-1.2 Mrad) gamma irradiation does not significantly alter the preimplantation biomechanical properties of bone-patellar tendon-bone (BTB) allografts.

STUDY DESIGN

Controlled laboratory study.

METHODS

Cyclic and failure mechanical properties were evaluated for 20 paired central-third human BTB allografts, with and without 1.0 to 1.2 Mrad of gamma irradiation. Testing included cyclic loading at 0.5 Hz for 100 cycles from 50 to 200 N and failure testing at a strain rate of 10% per second.

RESULTS

Cyclic elongation did not change significantly (P = .151) with irradiation, increasing from a mean ± SD of 9.4 ± 2.1 mm to 11.3 ± 3.4 mm. Cyclic creep strain approached a significant increase with irradiation (1.3% ± 0.8% to 2.6% ± 1.5%; P = .076). Failure testing was not affected with irradiation with regard to maximum load (1680 ± 417 mm to 1494 ± 435 mm), maximum stress (40.8 ± 10.6 MPa to 37.5 ± 15.7 MPa), elongation (7.85 ± 1.35 mm to 8.67 ± 2.05 mm), or strain at maximum stress (0.158 ± 0.03 to 0.175 ± 0.03). Graft stiffness significantly decreased by 20% with irradiation (278 ± 67 N/mm to 221 ± 50 N/mm; P = .035).

CONCLUSION

Low-dose (1.0-1.2 Mrad) gamma irradiation decreases BTB graft stiffness by 20%, but it does not affect other failure or cyclic parameters.

CLINICAL RELEVANCE

Aside from graft stiffness during load to failure testing, low-dose (1.0-1.2 Mrad) gamma irradiation of central-third human BTB allografts is not deleterious to preimplantation biomechanical properties.

Knee joint loading during gait in healthy controls and individuals with knee osteoarthritis

OBJECTIVE

People with knee osteoarthritis (OA) are thought to walk with high loads at the knee which are yet to be quantified using modeling techniques that account for subject specific electromyography (EMG) patterns, kinematics and kinetics. The objective was to estimate medial and lateral loading for people with knee OA and controls using an approach that is sensitive to subject specific muscle activation patterns.

METHODS

Sixteen OA and 12 control (C) subjects walked while kinematic, kinetic and EMG data were collected. Muscle forces were calculated using an EMG-Driven model and loading was calculated by balancing the external moments with internal muscle and contact forces.

RESULTS

OA subjects walked slower and had greater laxity, static and dynamic varus alignment, less flexion and greater knee adduction moment (KAM). Loading [normalized to body weight (BW)] was no different between the groups but OA subjects had greater absolute medial load than controls and maintained a greater %total load on the medial compartment. These patterns were associated with body mass, sagittal and frontal plane moments, static alignment and close to significance for dynamic alignment. Lateral compartment unloading during mid-late stance was observed in 50% of OA subjects.

CONCLUSIONS

Loading for control subjects was similar to data from instrumented prostheses. Knee OA subjects had high medial contact loads in early stance and half of the OA cohort demonstrated lateral compartment lift-off. Results suggest that interventions aimed at reducing BW and dynamic malalignment might be effective in reducing medial compartment loading and establishing normal medio-lateral load sharing patterns.

Biomechanics of high tibial osteotomy

PURPOSE

This paper is a review of the biomechanical principles that support limb realignment surgery via osteotomy around the knee, principally high (proximal) tibial osteotomy.

METHODS

The basic biomechanical principles have been described, and the related literature examined for evidence to support the recommendations made.

RESULTS

The forces on the knee when walking are shown to lead to most of the load acting through the medial compartment, the most frequent site of degeneration of the knee, due to the adduction moment that acts during the weight-acceptance phase. Realignment of the limb to move the mechanical axis to a desired point within the knee is described, and the resulting joint contact pressures in the medial and lateral compartments are shown to be higher in the less-congruent lateral articulation when the load passes through the centre of the knee. At the same time, there can be changes of the posterior slope of the tibial plateau, and a slope of ten degrees can induce a shearing force, which stretches the ACL, of 0.5 body weight when the knee force is 3 times body weight. The options regarding tibial or femoral or even double osteotomies are discussed in relation to medial-lateral slope of the joint line. Secondary effects such as alteration of collateral ligament tension or of the height of the patella are described.

CONCLUSION

Critical review of the publications supporting osteotomy surgery suggests that many of the accepted 'rules' have little scientific evidence to show that they represent the best practise for long-term preservation of the joint.

Pre-operative muscle activation patterns during walking are associated with TKA tibial implant migration

BACKGROUND

Gait biomechanical variables have been associated with total knee arthroplasty tibial implant migration measured with Radiostereometric Analysis (RSA), but no studies have examined the role of the periarticular musculature, which is responsible for a high proportion of the forces on the joint. The purpose of this study was to measure the pre-operative electromyography (EMG) patterns of the periarticular knee muscles during gait and determine the association of these patterns with the post-operative tibial implant migration measured with RSA. We hypothesized that pre-operative muscle activation patterns (specifically the activation patterns of the vastus and gastrocnemius muscle groups) measured with EMG are associated with migration at 6months.

METHODS

Electromyographic data were collected from 6 periarticular knee joint muscles on 37 patients pre-operatively during gait. Radiostereometric exams were performed immediately and at 6 months post-operatively. Relationships between the pre-operative patterns of muscle activation and micromotion of the implant were examined using Pearson correlation and regression models.

FINDINGS

Statistically significant correlations were found between the pattern of the quadriceps and gastrocnemius muscle activations during gait and implant translation in the posterior direction. Regression analysis illustrated that a substantial proportion of the variance in the post-operative tibial component posterior translation (R2=0.49) was explained by a prolonged activation of the vastus medialis muscle and higher activation of the lateral gastrocnemius muscle during early stance.

INTERPRETATION

The variability in migration explained by the muscle activation patterns supports the hypothesis that pre-operative functional characteristics can contribute to predicting implant migration following total knee arthroplasty surgery.

Cruciate ligament loading during common knee rehabilitation exercises

Cruciate ligament injuries are common and may lead to dysfunction if not rehabilitated. Understanding how to progress anterior cruciate ligament and posterior cruciate ligament loading, early after injury or reconstruction, helps clinicians prescribe rehabilitation exercises in a safe manner to enhance recovery. Commonly prescribed therapeutic exercises include both weight-bearing exercise and non-weight-bearing exercise. This review was written to summarize and provide an update on the available literature on cruciate ligament loading during commonly used therapeutic exercises. In general, weight-bearing exercise produces smaller loads on the anterior cruciate ligament and posterior cruciate ligament compared with non-weight-bearing exercise. The anterior cruciate ligament is loaded less at higher knee angles (i.e. 50-100 degrees). Squatting and lunging with a more forward trunk tilt and moving the resistance pad proximally on the leg during the seated knee extension unloads the anterior cruciate ligament. The posterior cruciate ligament is less loaded at lower knee angles (i.e. 0-50 degrees), and may be progressed from level ground walking to a one-leg squat, lunges, wall squat, leg press, and the two-leg squat (from smallest to greatest). Exercise type and technique variation affect cruciate ligament loading, such that the clinician may prescribe therapeutic exercises to progress ligament loading safely, while ensuring optimal recovery of the musculoskeletal system.

A musculoskeletal modeling approach for estimating anterior cruciate ligament strains and knee anterior-posterior shear forces in stop-jumps performed by young recreational female athletes

The central goal of this study was to contribute to the advancements being made in determining the underlying causes of anterior cruciate ligament (ACL) injuries. ACL injuries are frequently incurred by recreational and professional young female athletes during non-contact impact activities in sports like volleyball and basketball. This musculoskeletal-neuromuscular study investigated stop-jumps and factors related to ACL injury like knee valgus and internal-external moment loads, knee anterior-posterior (AP) shear forces, ACL strains and internal forces. Motion capture data was obtained from the landing phase of stop-jumps performed by eleven young recreational female athletes and electromyography (EMG) data collected from quadriceps, hamstring and gastrocnimius muscles which were then compared to numerically estimated activations. Numerical simulation tools used were Inverse Kinematics, Computed Muscle Control and Forward Dynamics and the knee modeled as a six degree of freedom joint. Results showed averaged peak strains of 12.2 ± 4.1% in the right and 11.9 ± 3.0% in the left ACL. Averaged peak knee AP shear forces were 482.3 ± 65.7 N for the right and 430.0 ± 52.4 N for the left knees, approximately equal to 0.7-0.8 times body weight across both knees. A lack of symmetry was observed between the knees for valgus angles (p < 0.04), valgus moments (p < 0.001) and muscle activations (p < 0.001), all of which can be detrimental to ACL stability during impact activities. Comparisons between recorded EMG data and estimated muscle activations show the relation between electrical signal and muscle depolarization. In summary, this study outlines a musculoskeletal simulation approach that provides numerical estimations for a number of variables associated with ACL injuries in female athletes performing stop-jumps.

Multiscale mechanics of articular cartilage: potentials and challenges of coupling musculoskeletal, joint, and microscale computational models

Articular cartilage experiences significant mechanical loads during daily activities. Healthy cartilage provides the capacity for load bearing and regulates the mechanobiological processes for tissue development, maintenance, and repair. Experimental studies at multiple scales have provided a fundamental understanding of macroscopic mechanical function, evaluation of the micromechanical environment of chondrocytes, and the foundations for mechanobiological response. In addition, computational models of cartilage have offered a concise description of experimental data at many spatial levels under healthy and diseased conditions, and have served to generate hypotheses for the mechanical and biological function. Further, modeling and simulation provides a platform for predictive risk assessment, management of dysfunction, as well as a means to relate multiple spatial scales. Simulation-based investigation of cartilage comes with many challenges including both the computational burden and often insufficient availability of data for model development and validation. This review outlines recent modeling and simulation approaches to understand cartilage function from a mechanical systems perspective, and illustrates pathways to associate mechanics with biological function. Computational representations at single scales are provided from the body down to the microstructure, along with attempts to explore multiscale mechanisms of load sharing that dictate the mechanical environment of the cartilage and chondrocytes.

Compressive tibiofemoral force during crouch gait

Crouch gait, a common walking pattern in individuals with cerebral palsy, is characterized by excessive flexion of the hip and knee. Many subjects with crouch gait experience knee pain, perhaps because of elevated muscle forces and joint loading. The goal of this study was to examine how muscle forces and compressive tibiofemoral force change with the increasing knee flexion associated with crouch gait. Muscle forces and tibiofemoral force were estimated for three unimpaired children and nine children with cerebral palsy who walked with varying degrees of knee flexion. We scaled a generic musculoskeletal model to each subject and used the model to estimate muscle forces and compressive tibiofemoral forces during walking. Mild crouch gait (minimum knee flexion 20-35°) produced a peak compressive tibiofemoral force similar to unimpaired walking; however, severe crouch gait (minimum knee flexion>50°) increased the peak force to greater than 6 times body-weight, more than double the load experienced during unimpaired gait. This increase in compressive tibiofemoral force was primarily due to increases in quadriceps force during crouch gait, which increased quadratically with average stance phase knee flexion (i.e., crouch severity). Increased quadriceps force contributes to larger tibiofemoral and patellofemoral loading which may contribute to knee pain in individuals with crouch gait.

Grand challenge competition to predict in vivo knee loads

Impairment of the human neuromusculoskeletal system can lead to significant mobility limitations and decreased quality of life. Computational models that accurately represent the musculoskeletal systems of individual patients could be used to explore different treatment options and optimize clinical outcome. The most significant barrier to model-based treatment design is validation of model-based estimates of in vivo contact and muscle forces. This paper introduces an annual "Grand Challenge Competition to Predict In Vivo Knee Loads" based on a series of comprehensive publicly available in vivo data sets for evaluating musculoskeletal model predictions of contact and muscle forces in the knee. The data sets come from patients implanted with force-measuring tibial prostheses. Following a historical review of musculoskeletal modeling methods used for estimating knee muscle and contact forces, we describe the first two data sets used for the first two competitions and summarize four subsequent data sets to be used for future competitions. These data sets include tibial contact force, video motion, ground reaction, muscle EMG, muscle strength, static and dynamic imaging, and implant geometry data. Competition participants create musculoskeletal models to predict tibial contact forces without having access to the corresponding in vivo measurements. These blinded predictions provide an unbiased evaluation of the capabilities and limitations of musculoskeletal modeling methods. The paper concludes with a discussion of how these unique data sets can be used by the musculoskeletal modeling research community to improve the estimation of in vivo muscle and contact forces and ultimately to help make musculoskeletal models clinically useful.

Anterior cruciate ligament strain and tensile forces for weight-bearing and non-weight-bearing exercises: a guide to exercise selection

There is a growing body of evidence documenting loads applied to the anterior cruciate ligament (ACL) for weight-bearing and non-weight-bearing exercises. ACL loading has been quantified by inverse dynamics techniques that measure anterior shear force at the tibiofemoral joint (net force primarily restrained by the ACL), ACL strain (defined as change in ACL length with respect to original length and expressed as a percentage) measured directly in vivo, and ACL tensile force estimated through mathematical modeling and computer optimization techniques. A review of the biomechanical literature indicates the following: ACL loading is generally greater with non-weight-bearing compared to weight-bearing exercises; with both types of exercises, the ACL is loaded to a greater extent between 10° to 50° of knee flexion (generally peaking between 10° and 30°) compared to 50° to 100° of knee flexion; and loads on the ACL change according to exercise technique (such as trunk position). Squatting with excessive forward movement of the knees beyond the toes and with the heels off the ground tends to increase ACL loading. Squatting and lunging with a forward trunk tilt tend to decrease ACL loading, likely due to increased hamstrings activity. During seated knee extension, ACL force decreases when the resistance pad is positioned more proximal on the anterior aspect of the lower leg, away from the ankle. The evidence reviewed as part of this manuscript provides objective data by which to rank exercises based on loading applied to the ACL. The biggest challenge in exercise selection post-ACL reconstruction is the limited knowledge of the optimal amount of stress that should be applied to the ACL graft as it goes through its initial incorporation and eventual maturation process. Clinicians may utilize this review as a guide to exercise selection and rehabilitation progression for patients post-ACL reconstruction.

Partial Meniscectomy Changes Fluid Pressurization in Articular Cartilage in Human Knees

Partial meniscectomy is believed to change the biomechanics of the knee joint through alterations in the contact of articular cartilages and menisci. Although fluid pressure plays an important role in the load support mechanism of the knee, the fluid pressurization in the cartilages and menisci has been ignored in the finite element studies of the mechanics of meniscectomy. In the present study, a 3D fibril-reinforced poromechanical model of the knee joint was used to explore the fluid flow dependent changes in articular cartilage following partial medial and lateral meniscectomies. Six partial longitudinal meniscectomies were considered under relaxation, simple creep, and combined creep loading conditions. In comparison to the intact knee, partial meniscectomy not only caused a substantial increase in the maximum fluid pressure but also shifted the location of this pressure in the femoral cartilage. Furthermore, these changes were positively correlated to the size of meniscal resection. While in the intact joint, the location of the maximum fluid pressure was dependent on the loading conditions, in the meniscectomized joint the location was predominantly determined by the site of meniscal resection. The partial meniscectomy also reduced the rate of the pressure dissipation, resulting in even larger difference between creep and relaxation times as compared to the case of the intact knee. The knee joint became stiffer after meniscectomy because of higher fluid pressure at knee compression followed by slower pressure dissipation. The present study indicated the role of fluid pressurization in the altered mechanics of meniscectomized knees.

Direct comparison of measured and calculated total knee replacement force envelopes during walking in the presence of normal and abnormal gait patterns

Knee joint forces measured from instrumented implants provide important information for testing the validity of computational models that predict knee joint forces. The purpose of this study was to validate a parametric numerical model for predicting knee joint contact forces against measurements from four subjects with instrumented TKRs during the stance phase of gait. Model sensitivity to abnormal gait patterns was also investigated. The results demonstrated good agreement for three subjects with relatively normal gait patterns, where the difference between the mean measured and calculated forces ranged from 0.05 to 0.45 body weights, and the envelopes of measured and calculated forces (from three walking trials) overlapped. The fourth subject, who had a "quadriceps avoidance" external moment pattern, initially had little overlap between the measured and calculated force envelopes. When additional constraints were added, tailored to the subject's gait pattern, the model predictions improved to complete force envelope overlap. Coefficient of multiple determination analysis indicated that the shape of the measured and calculated force waveforms were similar for all subjects (adjusted coefficient of multiple correlation values between 0.88 and 0.92). The parametric model was accurate in predicting both the magnitude and waveform of the contact force, and the accuracy of model predictions was affected by deviations from normal gait patterns. Equally important, the envelope of forces generated by the range of solutions substantially overlapped with the corresponding measured envelope from multiple gait trials for a given subject, suggesting that the variable strategic processes of in vivo force generation are covered by the solution range of this parametric model.

In vivo tibiofemoral kinematics during 4 functional tasks of increasing demand using biplane fluoroscopy

BACKGROUND

The anterior cruciate ligament (ACL) has been well defined as the main passive restraint to anterior tibial translation (ATT) in the knee and plays an important role in rotational stability. However, it is unknown how closely the ACL and other passive and active structures of the knee constrain translations and rotations across a set of functional activities of increasing demand on the quadriceps.

HYPOTHESIS

Anterior tibial translation and internal rotation of the tibia relative to the femur would increase as the demand on the quadriceps increased.

STUDY DESIGN

Controlled laboratory study.

METHODS

The in vivo 3-dimensional knee kinematics of 10 adult female patients (height, 167.8 ± 7.1 cm; body mass, 57 ± 4 kg; body mass index [BMI], 24.8 ± 1.7 kg/m(2); age, 29.7 ± 7.9 years) was measured using biplane fluoroscopy while patients completed 4 functional tasks. The tasks included an unloaded knee extension in which the patient slowly extended the knee from 90° to 0° of flexion in 2 seconds; walking at a constant pace of 90 steps per minute; a maximum effort isometric knee extension with the knee at 70° of flexion; and landing from a height of 40 cm in which the patient stepped off a box, landed, and immediately performed a maximum effort vertical jump.

RESULTS

Landing (5.6 ± 1.9 mm) produced significantly greater peak ATT than walking (3.1 ± 2.2 mm) and unweighted full extension (2.6 ± 2.1 mm) (P < .01), but there was no difference between landing and a maximum isometric contraction (5.0 ± 1.9 mm). While there was no significant difference in peak internal rotation between landing (19.4° ± 5.7°), maximum isometric contraction (15.9° ± 6.7°), and unweighted full knee extension (14.5° ± 7.7°), each produced significantly greater internal rotation than walking (3.9° ± 4.2°) (P < .001). Knee extension torque significantly increased for each task (P < .01): unweighted knee extension (4.7 ± 1.2 N·m), walking (36.5 ± 7.9 N·m), maximum isometric knee extension (105.1 ± 8.2 N·m), and landing (140.2 ± 26.2 N·m).

CONCLUSION

Anterior tibial translations significantly increased as demand on the quadriceps and external loading increased. Internal rotation was not significantly different between landing, isometric contraction, and unweighted knee extension. Additionally, ATT and internal rotation from each motion were within the normal range, and no excessive amounts of translation or rotation were observed.

CLINICAL RELEVANCE

This study demonstrated that while ATT will increase as demand on the quadriceps and external loading increases, the knee is able to effectively constrain ATT and internal rotation. This suggests that the healthy knee has a safe envelope of function that is tightly controlled even though task demand is elevated.

Relationship of knee shear force and extensor moment on knee translations in females performing drop landings: a biplane fluoroscopy study

BACKGROUND

Research has linked knee extensor moment and knee shear force to the non-contact anterior cruciate ligament injury during the landing motion. However, how these biomechanical performance factors relate to knee translations in vivo is not known as knee translations cannot be obtained with traditional motion capture techniques. The purpose of this study was to combine traditional motion capture with high-speed, biplane fluoroscopy imaging to determine relationships between knee extensor moment and knee shear force profiles with anterior and lateral tibial translations occurring during drop landing in female athletes.

METHODS

15 females performed drop landings from a height of 40 cm while being recorded using a high speed, biplane fluoroscopy system and simultaneously being recorded using surface marker motion capture techniques to estimate knee joint angle, reaction force and moment profiles.

FINDINGS

No significant statistical relationships were observed between peak anterior or posterior knee shear force and peak anterior and lateral tibial translations; or, between peak knee extensor moment and peak anterior and lateral tibial translations. Although differences were noted in peak shear force (P=0.02) and peak knee extensor moment (P<0.001) after stratification into low and high shear force and moment cohorts, no differences were noted in anterior and lateral tibial translations (all P ≥ 0.18).

INTERPRETATION

Females exhibiting high knee extensor moment and knee shear force during drop landings do not yield correspondingly high anterior and lateral tibial translations.

Estimation of in vivo ACL force changes in response to increased weightbearing

Accurate knowledge of in vivo anterior cruciate ligament (ACL) forces is instrumental for understanding normal ACL function and improving surgical ACL reconstruction techniques. The objective of this study was to estimate the change in ACL forces under in vivo loading conditions using a noninvasive technique. A combination of magnetic resonance and dual fluoroscopic imaging system was used to determine ACL in vivo elongation during controlled weightbearing at discrete flexion angles, and a robotic testing system was utilized to determine the ACL force-elongation data in vitro. The in vivo ACL elongation data were mapped to the in vitro ACL force-elongation curve to estimate the change in in vivo ACL forces in response to full body weightbearing using a weighted mean statistical method. The data demonstrated that by assuming that there was no tension in the ACL under zero weightbearing, the changes in in vivo ACL force caused by full body weightbearing were 131.4 ± 16.8 N at 15 deg, 106.7 ± 11.2 N at 30 deg, and 34.6 ± 4.5 N at 45 deg of flexion. However, when the assumed tension in the ACL under zero weightbearing was over 20 N, the change in the estimated ACL force in response to the full body weightbearing approached an asymptotic value. With an assumed ACL tension of 40 N under zero weightbearing, the full body weight caused an ACL force increase in 202.7 ± 27.6 N at 15 deg, 184.9 ± 22.5 N at 30 deg, and 98.6 ± 11.7 N at 45 deg of flexion. The in vivo ACL forces were dependent on the flexion angle with higher force changes at low flexion angles. Under full body weightbearing, the ACL may experience less than 250 N. These data may provide a valuable insight into the biomechanical behavior of the ACL under in vivo loading conditions.

Model predictions of increased knee joint loading in regions of thinner articular cartilage after patellar tendon adhesion

Patellar tendon adhesion is a complication from anterior cruciate ligament (ACL) reconstruction that may affect patellofemoral and tibiofemoral biomechanics. A computational model was used to investigate the changes in knee joint mechanics due to patellar tendon adhesion under normal physiological loading during gait. The calculations showed that patellar tendon adhesion up to the level of the anterior tibial plateau led to patellar infera, increased patellar flexion, and increased anterior tibial translation. These kinematic changes were associated with increased patellar contact force, a distal shift in peak patellar contact pressure, a posterior shift in peak tibial contact pressure, and increased peak tangential contact sliding distance over one gait cycle (i.e., contact slip). Postadhesion, patellar and tibial contact locations corresponded to regions of thinner cartilage. The predicted distal shift in patellar contact was in contrast to other patellar infera studies. Average patellar and tibial cartilage pressure did not change significantly following patellar tendon adhesion; however, peak medial tibial pressure increased. These results suggest that changes in peak tibial cartilage pressure, contact slip, and the migration of contact to regions of thinner cartilage are associated with patellar tendon adhesion and may be responsible for initiating patellofemoral pain and knee joint structural damage observed following ACL reconstruction.

Protocol for constructing subject-specific biomechanical models of knee joint

A robust protocol for building subject-specific biomechanical models of the human knee joint is proposed which uses magnetic resonance imaging, motion analysis and force platform data in conjunction with detailed 3D finite element models. The proposed protocol can be used for determining stress and strain distributions and contact kinetics in different knee elements at different body postures during various physical activities. Several examples are provided to highlight the capabilities and potential applications of the proposed protocol. This includes preliminary results on the role of body weight on the stresses and strains induced in the knee articular cartilages and meniscus during single-leg stance and calculations of the induced stresses and ligament forces during the gait cycle.

A one-degree-of-freedom spherical mechanism for human knee joint modelling

In-depth comprehension of human knee kinematics is necessary in prosthesis and orthosis design and in surgical planning but requires complex mathematical models. Models based on one-degree-of-freedom equivalent mechanisms have replicated well the passive relative motion between the femur and tibia, i.e. the knee joint motion in virtually unloaded conditions. In these mechanisms, fibres within the anterior and posterior cruciate and medial collateral ligaments were taken as isometric and anatomical articulating surfaces as rigid. A new one-degree-of-freedom mechanism is analysed in the present study, which includes isometric fibres within the two cruciates and a spherical pair at the pivot point of the nearly spherical motion as measured for this joint. Bounded optimization was applied to the mechanism to refine parameter first estimates from experimental measurements on four lower-limb specimens and to best-fit the experimental motion of these knees. Relevant results from computer simulations were compared with those from one previous equivalent mechanism, which proved to be very accurate in a former investigation. The spherical mechanism represented knee motion with good accuracy, despite its simple structure. With respect to the previous more complex mechanism, the less satisfactory results in terms of replication of natural motion were counterbalanced by a reduction of computational costs, by an improvement in numerical stability of the mathematical model, and by a reduction of the overall mechanical complexity of the mechanism. These advantages can make the new mechanism preferable to the previous ones in certain applications, such as the design of prostheses, orthoses, and exoskeletons, and musculoskeletal modelling of the lower limb.

In vivo length patterns of the medial collateral ligament during the stance phase of gait

PURPOSE

The function of the medial collateral ligament (MCL) during gait has not been investigated. Our objective was to measure the kinematics of the medial collateral ligament during the stance phase of gait on a treadmill using a combined dual fluoroscopic imaging system (DFIS) and MRI technique.

METHODS

Three-dimensional models of the knee were constructed using magnetic resonance images of 7 healthy human knees. The contours of insertion areas of the superficial MCL (sMCL) and deep MCL (dMCL) on the femur and tibia were constructed using the coronal plane MR images of each knee. Both the sMCL and the dMCL were separated into 3 portions: the anterior, mid, and posterior bundles. The relative elongation of the bundles was calculated using the bundle length at heel strike (or 0% of the stance phase) as a reference.

RESULTS

The lengths of the anterior bundles were positively correlated with the knee flexion angle. The mid-bundles of the sMCL and dMCL were found to function similarly in trend with the anterior bundles during the stance phase of the gait and their lengths had weak correlations with the knee flexion angles. The elongations of the posterior bundles of sMCL and dMCL were peaked at mid-stance and terminal extension/pre-swing stance phase. The lengths of the posterior bundles were negatively correlated with the knee flexion during the stance phase.

CONCLUSION

The data of this study demonstrated that the anterior and posterior bundles of the sMCL and dMCL have a reciprocal function during the stance phase of gait. This data provide insight into the function of the MCL and a normal reference for the study of physiology and pathology of the MCL. The data may be useful in designing reconstruction techniques to better reproduce the native biomechanical behavior of the MCL.

LEVEL OF EVIDENCE

IV.

Different knee joint loading patterns in ACL deficient copers and non-copers during walking

PURPOSE

Rupture of the anterior cruciate ligament (ACL) causes changes in the walking pattern. ACL deficient subjects classified as copers and non-copers have been observed to adopt different post-injury walking patterns. How these different patterns affect the knee compression and shear forces is unresolved. Thus, the aim of the present study was to investigate how different walking patterns observed between copers, non-copers, and controls affect the knee compression and shear forces during walking.

METHODS

Three-dimensional gait analyses were performed in copers (n = 9), non-copers (n = 10), and control subjects (n =19). The net knee joint moment, knee joint reaction forces, and the sagittal knee joint angle were input parameters to a biomechanical model that assessed the knee compression and shear forces.

RESULTS

The results showed that the non-copers walked with significantly reduced knee compression and shear forces than the controls. The overall knee compression force pattern was similar between the copers and controls, although this variable was significantly increased at heel strike in the copers compared to both non-copers and controls. The peak shear force was significantly dependent on the peak knee extensor moment. This covariance was significantly different between groups meaning that at a given knee extensor moment the shear force was significantly reduced in the copers compared to controls.

CONCLUSION

The different knee joint loading patterns observed between non-copers and copers reflected the different walking strategies adopted by these groups, which may have implications for the knee joint stability. The strategy adopted by the copers may resemble an effective way to stabilize the knee joint during walking after an ACL rupture and that the knee kinematics may play a key role for this strategy. It is clinically relevant to investigate if gait retraining would enable non-copers to walk as copers and thereby improve their knee joint stability.

The effect of valgus braces on medial compartment load of the knee joint - in vivo load measurements in three subjects

Knee osteoarthritis occurs predominately at the medial compartment. To unload the affected compartment, valgus braces are used which induce an additional valgus moment in order to shift the load more laterally. Until now the biomechanical effect of braces was mainly evaluated by measuring changes in external knee adduction moments. The aim of this study was to investigate if and to which extent the medial compartment load is reduced in vivo when wearing valgus braces. Six components of joint contact load were measured in vivo in three subjects, using instrumented, telemeterized knee implants. From the forces and moments the medio-lateral force distribution was calculated. Two braces, MOS Genu (Bauerfeind AG) and Genu Arthro (Otto Bock) were investigated in neutral, 4° and 8° valgus adjustment during walking, stair ascending and descending. During walking with the MOS brace in 4°/8° valgus adjustment, medial forces were reduced by 24%/30% on average at terminal stance. During walking with the GA in the 8° valgus position, medial forces were reduced by only 7%. During stair ascending/descending significant reductions of 26%/24% were only observed with the MOS (8°). The load reducing ability of the two investigated valgus braces was confirmed in three subjects. However, the load reduction depends on the brace stiffness and its valgus adjustment and varies strongly inter-individually. Valgus adjustments of 8° might, especially with the MOS brace, not be tolerated by patients for a long time. Medial load reductions of more than 25% can therefore probably not be expected in clinical practise.

Effect of posterior tibial slope on knee biomechanics during functional activity

Treatment of medial compartment knee osteoarthritis with high tibial osteotomy can produce an unintended change in the slope of the tibial plateau in the sagittal plane. The effect of changing posterior tibial slope (PTS) on cruciate ligament forces has not been quantified for knee loading in activities of daily living. The purpose of this study was to determine how changes in PTS affect tibial shear force, anterior tibial translation (ATT), and knee-ligament loading during daily physical activity. We hypothesized that tibial shear force, ATT, and ACL force all increase as PTS increases. A previously validated computer model was used to calculate ATT, tibial shear force, and cruciate-ligament forces for the normal knee during three common load-bearing tasks: standing, squatting, and walking. The model calculations were repeated with PTS altered in 1° increments up to a maximum change in tibial slope of 10°. Tibial shear force and ATT increased as PTS was increased. For standing and walking, ACL force increased as tibial slope was increased; for squatting, PCL force decreased as tibial slope was increased. The effect of changing PTS on ACL force was greatest for walking. The true effect of changing tibial slope on knee-joint biomechanics may only be evident under physiologic loading conditions which include muscle forces.

The interaction of trunk-load and trunk-position adaptations on knee anterior shear and hamstrings muscle forces during landing

CONTEXT

Because anterior cruciate ligament (ACL) injuries can occur during deceleration maneuvers, biomechanics research has been focused on the lower extremity kinetic chain. Trunk mass and changes in trunk position affect lower extremity joint torques and work during gait and landing, but how the trunk affects knee joint and muscle forces is not well understood.

OBJECTIVE

To evaluate the effects of added trunk load and adaptations to trunk position on knee anterior shear and knee muscle forces in landing.

DESIGN

Crossover study.

SETTING

Controlled laboratory environment.

PATIENTS OR OTHER PARTICIPANTS

Twenty-one participants (10 men: age = 20.3 +/- 1.15 years, height = 1.82 +/- 0.04 m, mass = 78.2 +/- 7.3 kg; 11 women: age = 20.0 +/- 1.10 years, height = 1.72 +/- 0.06 m, mass = 62.3 +/- 6.4 kg).

INTERVENTION(S)

Participants performed 2 sets of 8 double-leg landings under 2 conditions: no load and trunk load (10% body mass). Participants were categorized into one of 2 groups based on the kinematic trunk adaptation to the load: trunk flexor or trunk extensor.

MAIN OUTCOME MEASURE(S)

We estimated peak and average knee anterior shear, quadriceps, hamstrings, and gastrocnemius forces with a biomechanical model.

RESULTS

We found condition-by-group interactions showing that adding a trunk load increased peak (17%) and average (35%) knee anterior shear forces in the trunk-extensor group but did not increase them in the trunk-flexor group (peak: F(1,19) = 10.56, P = .004; average: F(1,19) = 9.56, P = .006). We also found a main effect for condition for quadriceps and gastrocnemius forces. When trunk load was added, peak (6%; F(1,19) = 5.52, P = .030) and average (8%; F(1,19) = 8.83, P = .008) quadriceps forces increased and average (4%; F(1,19) = 4.94, P = .039) gastrocnemius forces increased, regardless of group. We found a condition-by-group interaction for peak (F(1,19) = 5.16, P = .035) and average (F(1,19) = 12.35, P = .002) hamstrings forces. When trunk load was added, average hamstrings forces decreased by 16% in the trunk-extensor group but increased by 13% in the trunk-flexor group.

CONCLUSIONS

Added trunk loads increased knee anterior shear and knee muscle forces, depending on trunk adaptation strategy. The trunk-extensor adaptation to the load resulted in a quadriceps-dominant strategy that increased knee anterior shear forces. Trunk-flexor adaptations may serve as a protective strategy against the added load. These findings should be interpreted with caution, as only the face validity of the biomechanical model was assessed.

Effect of frontal plane tibiofemoral angle on the stress and strain at the knee cartilage during the stance phase of gait

Subject-specific three-dimensional finite element models of the knee joint were created and used to study the effect of the frontal plane tibiofemoral angle on the stress and strain distribution in the knee cartilage during the stance phase of the gait cycle. Knee models of three subjects with different tibiofemoral angle and body weight were created based on magnetic resonance imaging of the knee. Loading and boundary conditions were determined from motion analysis and force platform data, in conjunction with the muscle-force reduction method. During the stance phase of walking, all subjects exhibited a valgus-varus-valgus knee moment pattern with the maximum compressive load and varus knee moment occurring at approximately 25% of the stance phase of the gait cycle. Our results demonstrated that the subject with varus alignment had the largest stresses at the medial compartment of the knee compared to the subjects with normal alignment and valgus alignment, suggesting that this subject might be most susceptible to developing medial compartment osteoarthritis (OA). In addition, the magnitude of stress and strain on the lateral cartilage of the subject with valgus alignment were found to be larger compared to subjects with normal alignment and varus alignment, suggesting that this subject might be most susceptible to developing lateral compartment knee OA.

Effect of a focal articular defect on cartilage deformation during patello-femoral articulation

The objective of this study was to determine cartilage strains near, and in apposition to, a focal defect during patello-femoral articulation. Bovine osteochondral blocks from the trochlea (TRO) and patella (PAT) were apposed, compressed 12%, and subjected to sliding under video microscopy. Samples, lubricated with synovial fluid, were tested intact and then with a full-thickness defect in PAT cartilage. Shear (E(xz)), axial (E(zz)), and lateral (E(xx)) strains were determined locally for TRO and PAT cartilage. For articulation with a focal defect, the strain amplitudes of PAT cartilage near the surface were ∼2-8× lower in E(xz) and ∼1.4× higher in -E(zz) than intact PAT cartilage. At 20% depth, E(xz) and E(xx) for PAT cartilage with a focal defect were ∼2× and ∼10-25× higher than intact PAT, respectively. For TRO articulating against a focal defect, E(xz) and -E(zz) near the surface and at 20% depth were ∼2-4× lower than that for articulation against intact cartilage. The results elucidate dramatic region-specific changes in strain due to lateral motion. In these regions, such altered cartilage mechanics during knee movement may cause focal defects to extend by induction of damaging levels of strain to bordering regions of cartilage.

The Effect of the Frontal Plane Tibiofemoral Angle and Varus Knee Moment on the Contact Stress and Strain at the Knee Cartilage

Subject-specific models were developed and finite element analysis was performed to observe the effect of the frontal plane tibiofemoral angle on the normal stress, Tresca shear stress and normal strain at the surface of the knee cartilage. Finite element models were created for three subjects with different tibiofemoral angle and physiological loading conditions were defined from motion analysis and muscle force mathematical models to simulate static single-leg stance. The results showed that the greatest magnitude of the normal stress, Tresca shear stress and normal strain at the medial compartment was for the varus aligned individual. Considering the lateral knee compartment, the individual with valgus alignment had the largest stress and strain at the cartilage. The present investigation is the first known attempt to analyze the effects of tibiofemoral alignment during single-leg support on the contact variables of the cartilage at the knee joint. The method could be potentially used to help identify individuals most susceptible to osteoarthritis and to prescribe preventive measures.

Contribution of knee adduction moment impulse to pain and disability in Japanese women with medial knee osteoarthritis

BACKGROUND

An increase in the knee adduction moment is one of the risk factors of medial knee osteoarthritis. This study examined the relationship between knee adduction moment and self-reported pain and disability. We also investigated the influence of pain on the relationships between knee adduction moment and gait performance and disability.

METHODS

Thirty-eight Japanese women with medial knee osteoarthritis participated in this study (66.37 years (41-79 years)). Gait analysis involved the measurement of the external knee adduction moment impulse in the stance duration and during 3 subdivisions of stance. The total, pain and stiffness, and physical function Japanese Knee Osteoarthritis Measure scores were determined.

FINDINGS

The pain and stiffness, physical function, and total scores were positively correlated with the knee adduction moment impulses in the stance duration, and initial and second double support interval, and single limb support interval. The knee adduction moment impulse during the stance duration was related to the pain and stiffness subscale and gait velocity. The pain and stiffness subscale was related to the physical function subscale.

INTERPRETATION

Our results suggest that increasing in the knee adduction moment impulse, a proxy for loading on the medial compartment of the knee, is related to increased pain during weight-bearing activities such as walking, thereby restricting walking performance and causing disability by reducing gait velocity. Thus, the reduction in the knee adduction moment impulse during gait may result in pain relief and may serve as a conservative treatment option with disease-modifying potential.

Application of robotic technology in biomechanics to study joint laxity

PRIMARY OBJECTIVE

To evaluate whether in vitro joint testing using a robot with six degrees of freedom is useful for evaluating changes in joint laxity as a result of chronic osteoarthritis (OA).

RESEARCH DESIGN

Repeated measures.

METHODS

Broyden's method of solving nonlinear systems of equations drove a hybrid method of load and position robotic control. Sheep stifles (knee joints) were loaded between 3 Nm of internal load through to 3 Nm of external load in 1 Nm increments. Kinematic and morphologic data from five healthy ovine stifles were compared to the chronic OA effects in four surgically destabilized stifles.

RESULTS

Stifles with chronic OA showed increases in stiffness while range of motion decreased. Gross morphologic changes included osteophytes and cartilage fibrillation.

DISCUSSION

Robotic testing proved useful for evaluating changes in joint mechanics as a result of chronic OA. We observed morphological changes and associated increases in joint stiffness and decreased laxity.

ACL graft migration under cyclic loading

Elongation and migration of ACL grafts will lead to a deterioration of the initial stability of ACL reconstructions. The graft migration has been sparsely investigated independently from the elongation of the graft-fixation complex. The hypothesis of this investigation was that cyclic tensile loads cause a measurable migration of the grafts. Three graft/fixation combinations were investigated in human femora (n = 7): human bone-patellar tendon grafts fixed with a biointerference screw (BPTG-IS) and free tendon grafts (porcine) fixed with either a Bio-TransFix pin (FTG-TF) or an Endobutton CL (FTG-EB). The grafts were fitted with tantalum markers. Then, the specimens were repetitively loaded (50-250 N, 800 cycles). The marker position was fluoroscopically determined at defined intervals and the migration calculated from the change in position relative to a fiducial marker within the bone. A migration of the grafts occurred in all three groups. The migration in the FTG-EB group was significantly larger than in the two other groups (P < 0.01). After 800 cycles, average migration was 0.3 (+/-0.2) mm in the BPTG-IS group, 0.7 (+/-0.4) mm FTG-TF group, 2.0 (+/-1.3) mm in the FTG-EB group. This migration might contribute to a loss of initial stability. Because the graft migration was dependent on the technique, the presented data might provide additional arguments for making the decision on the most appropriate graft/fixation combination.