Medial collateral ligament insertion site and contact forces in the ACL-deficient knee

Reproducibility in modeling and simulation of the knee: Academic, industry, and regulatory perspectives

Stakeholders in the modeling and simulation (M&S) community organized a workshop at the 2019 Annual Meeting of the Orthopaedic Research Society (ORS) entitled "Reproducibility in Modeling and Simulation of the Knee: Academic, Industry, and Regulatory Perspectives." The goal was to discuss efforts among these stakeholders to address irreproducibility in M&S focusing on the knee joint. An academic representative from a leading orthopedic hospital in the United States described a multi-institutional, open effort funded by the National Institutes of Health to assess model reproducibility in computational knee biomechanics. A regulatory representative from the United States Food and Drug Administration indicated the necessity of standards for reproducibility to increase utility of M&S in the regulatory setting. An industry representative from a major orthopedic implant company emphasized improving reproducibility by addressing indeterminacy in personalized modeling through sensitivity analyses, thereby enhancing preclinical evaluation of joint replacement technology. Thought leaders in the M&S community stressed the importance of data sharing to minimize duplication of efforts. A survey comprised 103 attendees revealed strong support for the workshop and for increasing emphasis on computational modeling at future ORS meetings. Nearly all survey respondents (97%) considered reproducibility to be an important issue. Almost half of respondents (45%) tried and failed to reproduce the work of others. Two-thirds of respondents (67%) declared that individual laboratories are most responsible for ensuring reproducible research whereas 44% thought that journals are most responsible. Thought leaders and survey respondents emphasized that computational models must be reproducible and credible to advance knee M&S.

Finite element modeling of meniscal tears using continuum damage mechanics and digital image correlation

Meniscal tears are a common, painful, and debilitating knee injury with limited treatment options. Computational models that predict meniscal tears may help advance injury prevention and repair, but first these models must be validated using experimental data. Here we simulated meniscal tears with finite element analysis using continuum damage mechanics (CDM) in a transversely isotropic hyperelastic material. Finite element models were built to recreate the coupon geometry and loading conditions of forty uniaxial tensile experiments of human meniscus that were pulled to failure either parallel or perpendicular to the preferred fiber orientation. Two damage criteria were evaluated for all experiments: von Mises stress and maximum normal Lagrange strain. After we successfully fit all models to experimental force-displacement curves (grip-to-grip), we compared model predicted strains in the tear region at ultimate tensile strength to the strains measured experimentally with digital image correlation (DIC). In general, the damage models underpredicted the strains measured in the tear region, but models using von Mises stress damage criterion had better overall predictions and more accurately simulated experimental tear patterns. For the first time, this study has used DIC to expose strengths and weaknesses of using CDM to model failure behavior in soft fibrous tissue.

Predicting the Effect of Localized ACL Damage on Neighbor Ligament Mechanics via Finite Element Modeling

The anterior cruciate ligament (ACL) plays a pivotal role in support of the knee under loading. When damaged, it is known that substantial changes in the mechanics of the neighboring ligaments can be observed. However, a localized damage approach to investigating how ACL deficiency influences the neighboring ligaments has not been carried out. To do this, a finite element model, incorporating a continuum damage material model of the ACL, was implemented. Localized ACL damage was induced using high quadriceps force loading. Once damaged, anterior shear forces or tibial torque loadings were applied to the knee joint. The relative changes in stress contour and average mid-substance stress were examined for each of the neighboring ligaments following localized ACL damage. It was observed that localized ACL damage could produce notable changes in the mechanics of the neighboring knee ligaments, with non-homogenous stress contour shape changes and average stress magnitude being observed to increase in most cases, with a notable exception occurring in the MCL for both loading modes. In addition, the ligament bearing the most loading also changed with ACL deficiency. These changes carry implications as to morphological effects that may be induced following localized ACL damage, indicating that early diagnosis of ACL injury may be helpful in mitigating other complications post injury.

A biphasic response of polymerized Type 1 collagen architectures to dermatan sulfate

Collagen I, the most abundant extracellular matrix (ECM) protein in vertebrate tissues provides mechanical durability to tissue microenvironments and regulates cell function. Its fibrillogenesis in biological milieu is predominantly regulated by dermatan sulfate proteoglycans, proteins conjugated with iduronic acid-containing dermatan sulfate (DS) glycosaminoglycans (GAG). Although DS is known to regulate tissue function through its modulation of Coll I architecture, a precise understanding of the latter remains elusive. We investigated this problem by visualizing the fibrillar pattern of fixed Coll I gels polymerized in the presence of varying concentrations of DS using second harmonic generation microscopy. Measuring mean second harmonic generation signal (which estimates the ordering of the fibrils), and surface occupancy (which estimates the space occupied by fibrils) supported by confocal reflectance microscopy, our observations indicated that the effect on fibril pattern of DS is contextual upon the latter's concentrations: Lower levels of DS resulted in sparse disorganized fibrils; higher levels restore organization, with fibrils occupying greater space. An appropriate change in elasticity as a result of DS levels was also observed through atomic force microscopy. Examination of dye-based GAG staining and scanning electron microscopy suggested distinct constitutions of Coll I gels when polymerized with higher and lower levels of DS. We observed that adhesion of the invasive ovarian cancer cells SKOV3 decreased for lower DS levels but was partially restored at higher DS levels. Our study shows how the Coll I gel pattern-tuning of DS is of relevance for understanding its biomaterial applications and possibly, pathophysiological functions.

Computational frame of ligament in situ strain in a full knee model

The biomechanical function of connective tissues in a knee joint is to stabilize the kinematics-kinetics of the joint by augmenting its stiffness and limiting excessive coupled motion. The connective tissues are characterized by an in vivo reference configuration (in situ strain) that would significantly contribute to the mechanical response of the knee joint. In this work, a novel iterative method for computing the in situ strain at reference configuration was presented. The framework used an in situ strain gradient approach (deformed reference configuration) and a detailed finite element (FE) model of the knee joint. The effect of the predicted initial configuration on the mechanical response of the joint was then investigated under joint axial compression, passive flexion, and coupled rotations (adduction and internal), and during the stance phase of gait. The inclusion of the reference configuration has a minimal effect on the knee joint mechanics under axial compression, passive flexion, and at two instances (0% and 50%) of the stance phase of gait. However, the presence of the ligaments in situ strains significantly increased the joint stiffness under passive adduction and internal rotations, as well as during the other simulated instances (25%, 75% and 100%) of the stance phase of gait. Also, these parameters substantially altered the local loading state of the ligaments and resulted in better agreement with the literature during joint flexion. Therefore, the proposed computational framework of ligament in situ strain will help to overcome the challenges in considering this crucial biological aspect during knee joint modeling. Besides, the current construct is advantageous for a better understanding of the mechanical behavior of knee ligaments under physiological and pathological states and provide relevant information in the design of reconstructive treatments and artificial grafts.

A Validated, Subject-Specific Finite Element Model for Predictions of Rotator Cuff Tear Propagation

Rotator cuff tears are a significant clinical problem previously investigated by unvalidated computational models that either use simplified geometry or isotropic elastic material properties to represent the tendon. The objective of this study was to develop an experimentally validated, finite element model of supraspinatus tendon using specimen-specific geometry and inhomogeneous material properties to predict strains in intact supraspinatus tendon. Three-dimensional tendon surface strains were determined at 60°, 70°, and 90° of glenohumeral abduction for articular and bursal surfaces of supraspinatus tendon during cyclic loading to serve as validation data. A finite element model was developed using the tendon geometry and inhomogeneous material properties to predict surface strains for loading conditions mimicking experimental loading conditions. Experimental strains were directly compared with computational model predictions to validate the model. Overall, the model successfully predicted magnitudes of strains that were within the experimental repeatability of 3% strain of experimental measures on both surfaces of the tendon. Model predictions and experiments showed the largest strains to be located on the articular surface (~8% strain) between the middle and anterior edge of the tendon. Importantly, the reference configuration chosen to calculate strains had a significant effect on strain calculations, and therefore must be defined with an innovative optimization algorithm. This study establishes a rigorously validated, specimen-specific computational model using novel surface strain measurements for use in investigating the function of the supraspinatus tendon and to ultimately predict the propagation of supraspinatus tendon tears based on the tendon's mechanical environment.

Correlation Between Intraoperative Anterior Stability and Flexion Gap in Total Knee Arthroplasty

BACKGROUND

Instability is a common failure mode after total knee arthroplasty. There have been only a few methods to quantify anterior translation with fixed forces applied during surgery. The purpose of the study was to measure the anterior translation with a new device and to analyze the relationships between the amount of anterior translation and the joint gaps.

METHODS

Fifty knees with medial osteoarthritis underwent surgery using a posterior-stabilized implant. During surgery, measurement of anterior translation was performed at 90° of knee flexion with a trial implant, applying a traction force of 70 N. The joint gap was measured using a tensor device, applying a distraction force of 178 N in flexion. The Pearson correlation coefficient was calculated between anterior translation and joint gaps and laxity.

RESULTS

On average, anterior translation during surgery was 8.5 mm (standard deviation [SD] = 3.6 mm). Medial gap (correlation coefficient [r] = 0.30), medial laxity (r = 0.33), and center laxity (r = 0.29) had a positive correlation with anterior translation, and anterior translation increased with larger joint gap or greater laxity.

CONCLUSION

Anterior translation was measured with a new device by applying the anterior force to the tibia, and the correlations between anterior translation and joint gap and laxity were analyzed. A larger medial gap and greater medial laxity were correlated with greater anterior translation, which could cause symptomatic feelings of instability. Surgeons should pay attention to the tension of medial structures in flexion and avoid excessive medial release during surgery.

The evaluation of the role of medial collateral ligament maintaining knee stability by a finite element analysis

Background

A three-dimensional finite element model (FEM) of the knee joint was established to analyze the biomechanical functions of the superficial and deep medial collateral ligaments (MCLs) of knee joints and to investigate the treatment of the knee medial collateral ligament injury.

Methods

The right knee joint of a healthy male volunteer was subjected to CT and MRI scans in the extended position. The scanned data were imported into MIMICS, Geomagic, and ANSYS software to establish a three-dimensional FEM of the human knee joint. The anterior-posterior translation, valgus-varus rotation, and internal-external rotation of knee joints were simulated to observe tibial displacement or valgus angle. In addition, the magnitude and distribution of valgus stress in the superficial and deep layers of the intact MCL as well as the superficial, deep, and overall deficiencies of the MCL were investigated.

Results

In the extended position, the superficial medial collateral ligament (SMCL) would withstand maximum stresses of 48.63, 16.08, 17.23, and 16.08 MPa in resisting the valgus of knee joints, tibial forward displacement, internal rotation, and external rotation, respectively. Meanwhile, the maximum stress tolerated by the SMCL in various ranges of motion mainly focused on the femoral end point, which was located at the anterior and posterior parts of the femur in resisting valgus motion and external rotation, respectively. However, the deep medial collateral ligament could tolerate only minimum stress, which was mainly focused at the femoral start and end points.

Conclusions

This model can effectively analyze the biomechanical functions of the superficial and deep layers of the MCLs of knee joints. The results show that the knee MCL II° injury is the indication of surgical repair.

Clinical assessment of antero-medial rotational knee laxity: a systematic review

PURPOSE

To inventory the examination methods available to assess antero-medial rotational laxity (AMRL) of the knee following medial collateral ligament injury.

METHODS

Searches were conducted in accordance with the PRISMA guidelines and using four online databases: WEB OF SCIENCE, MEDLINE, EMBASE, and AMED. The Critical Appraisal Skills Programme guidelines for Diagnostic Test Studies were used for the quality assessment of the articles.

RESULTS

A total of 2241 articles were identified from the database searches. From this, four articles were included in the final review. All were case-control studies, considered a combined ACL/MCL injury and had small study populations. Specialised equipment was required in all studies, and one needed additional imaging support before measurements could be taken. Two employed commercially available measuring equipment as part of the assessment process.

CONCLUSION

Clinical assessment of AMRL in relation to a MCL injury remains challenging. Although methods have been developed to support clinical examination, they are limited by a number of factors, including the need for additional time in the clinical environment when setting up equipment, the need for specific equipment to produce and measure rotational movement and imaging support. In addition, there are patient safety concerns from the repeated imaging. A reliable and valid clinical examination remains to be found to truly assess antero-medial rotational laxity of the knee.

LEVEL OF EVIDENCE

IV.

Finite element models of the human shoulder complex: a review of their clinical implications and modelling techniques

The human shoulder is a complicated musculoskeletal structure and is a perfect compromise between mobility and stability. The objective of this paper is to provide a thorough review of previous finite element (FE) studies in biomechanics of the human shoulder complex. Those FE studies to investigate shoulder biomechanics have been reviewed according to the physiological and clinical problems addressed: glenohumeral joint stability, rotator cuff tears, joint capsular and labral defects and shoulder arthroplasty. The major findings, limitations, potential clinical applications and modelling techniques of those FE studies are critically discussed. The main challenges faced in order to accurately represent the realistic physiological functions of the shoulder mechanism in FE simulations involve (1) subject-specific representation of the anisotropic nonhomogeneous material properties of the shoulder tissues in both healthy and pathological conditions; (2) definition of boundary and loading conditions based on individualised physiological data; (3) more comprehensive modelling describing the whole shoulder complex including appropriate three-dimensional (3D) representation of all major shoulder hard tissues and soft tissues and their delicate interactions; (4) rigorous in vivo experimental validation of FE simulation results. Fully validated shoulder FE models would greatly enhance our understanding of the aetiology of shoulder disorders, and hence facilitate the development of more efficient clinical diagnoses, non-surgical and surgical treatments, as well as shoulder orthotics and prosthetics. © 2016 The Authors. International Journal for Numerical Methods in Biomedical Engineering published by John Wiley & Sons Ltd.

A general framework for application of prestrain to computational models of biological materials

It is often important to include prestress in computational models of biological tissues. The prestress can represent residual stresses (stresses that exist after the tissue is excised from the body) or in situ stresses (stresses that exist in vivo, in the absence of loading). A prestressed reference configuration may also be needed when modeling the reference geometry of biological tissues in vivo. This research developed a general framework for representing prestress in finite element models of biological materials. It is assumed that the material is elastic, allowing the prestress to be represented via a prestrain. For prestrain fields that are not compatible with the reference geometry, the computational framework provides an iterative algorithm for updating the prestrain until equilibrium is satisfied. The iterative framework allows for enforcement of two different constraints: elimination of distortion in order to address the incompatibility issue, and enforcing a specified in situ fiber strain field while allowing for distortion. The framework was implemented as a plugin in FEBio (www.febio.org), making it easy to maintain the software and to extend the framework if needed. Several examples illustrate the application and effectiveness of the approach, including the application of in situ strains to ligaments in the Open Knee model (simtk.org/home/openknee). A novel method for recovering the stress-free configuration from the prestrain deformation gradient is also presented. This general purpose theoretical and computational framework for applying prestrain will allow analysts to overcome the challenges in modeling this important aspect of biological tissue mechanics.

Development and initial evaluation of a finite element model of the pediatric craniocervical junction

OBJECT There is a significant deficiency in understanding the biomechanics of the pediatric craniocervical junction (CCJ) (occiput-C2), primarily because of a lack of human pediatric cadaveric tissue and the relatively small number of treated patients. To overcome this deficiency, a finite element model (FEM) of the pediatric CCJ was created using pediatric geometry and parameterized adult material properties. The model was evaluated under the physiological range of motion (ROM) for flexion-extension, axial rotation, and lateral bending and under tensile loading. METHODS This research utilizes the FEM method, which is a numerical solution technique for discretizing and analyzing systems. The FEM method has been widely used in the field of biomechanics. A CT scan of a 13-month-old female patient was used to create the 3D geometry and surfaces of the FEM model, and an open-source FEM software suite was used to apply the material properties and boundary and loading conditions and analyze the model. The published adult ligament properties were reduced to 50%, 25%, and 10% of the original stiffness in various iterations of the model, and the resulting ROMs for flexion-extension, axial rotation, and lateral bending were compared. The flexion-extension ROMs and tensile stiffness that were predicted by the model were evaluated using previously published experimental measurements from pediatric cadaveric tissues. RESULTS The model predicted a ROM within 1 standard deviation of the published pediatric ROM data for flexion-extension at 10% of adult ligament stiffness. The model's response in terms of axial tension also coincided well with published experimental tension characterization data. The model behaved relatively stiffer in extension than in flexion. The axial rotation and lateral bending results showed symmetric ROM, but there are currently no published pediatric experimental data available for comparison. The model predicts a relatively stiffer ROM in both axial rotation and lateral bending in comparison with flexion-extension. As expected, the flexion-extension, axial rotation, and lateral bending ROMs increased with the decrease in ligament stiffness. CONCLUSIONS An FEM of the pediatric CCJ was created that accurately predicts flexion-extension ROM and axial force displacement of occiput-C2 when the ligament material properties are reduced to 10% of the published adult ligament properties. This model gives a reasonable prediction of pediatric cervical spine ligament stiffness, the relationship between flexion-extension ROM, and ligament stiffness at the CCJ. The creation of this model using open-source software means that other researchers will be able to use the model as a starting point for research.

Ligament and meniscus loading in the ovine stifle joint during normal gait

BACKGROUND

The ovine stifle joint is an ideal preclinical model to study knee joint biomechanics. Knowledge of the ovine ligamentous and meniscal loading during normal gait is currently limited.

METHODS

The in vivo kinematics of the ovine stifle joint (N=4) were measured during "normal" gait using a highly accurate instrumented spatial linkage (ISL, 0.3±0.2mm). These motions were reproduced in vitro using a unique robotic testing platform and the loads carried by the anterior/posterior cruciate ligaments (ACL/PCL), medial/lateral collateral ligaments (MCL/LCL), and medial/lateral menisci (MM/LM) during gait were determined.

RESULTS

Considerable inter-subject variability in tissue loads was observed. The load in the ACL was near zero at hoof-strike (0% gait) and reached a peak (100 to 300N) during early-stance (~10% gait). The PCL reached a peak load (200 to 500N) just after hoof-strike (~5% gait) and was mostly unloaded throughout the remainder of stance. Load in the MCL was substantially lower than the cruciate ligaments, reaching a maximum of 50 to 100N near the beginning of stance. The LCL carried a negligible amount of load through the entire gait cycle. There was also a major contribution of the MM and LM to load transfer from the femur to the tibia during normal gait. The total meniscal load reached a maximum average between 350 and 550N during gait.

CONCLUSION

Knowledge of joint function during normal motion is essential for understanding normal and pathologic joint states. The considerable variability in the magnitudes and patterns of tissue loads among animals simulates clinical variability in humans.

LEVEL OF EVIDENCE

III.

Vascular structure and function in the medial collateral ligament of anterior cruciate ligament transected rabbit knees

To determine if decreased vascular responsiveness in the medial collateral ligament (MCL) of anterior cruciate ligament transected (ACL-t) rabbit knees is due to pericyte deficiency associated with angiogenesis. Vascular responses to potassium chloride (KCl), phenylephrine, acetylcholine, and sodium nitroprusside (SNP) were evaluated in ACL-t rabbit knees (n = 6) and control knees (n = 5) using laser speckle perfusion imaging. Ligament degeneration was determined by ultrasound imaging. Vascular and pericyte volume were measured using quantitative immunohistochemical volumetric analysis using CD31 and α-smooth muscle actin antibodies with co-localization analysis. Perfusion was increased in the ACL-t rabbits 2.5-fold. Responsiveness to phenylephrine, SNP, and acetylcholine was significantly decreased in the ACL knee while no change in KCl responses was seen. MCL ultrasound imaging revealed decreased collagen organization, increased ligament thickness, and increased water content in the ACL-t MCL. Vascular Volume was increased fourfold in ACL deficient knees, while pericyte volume to endothelial volume was not changed. No difference in CD31 and α-SMA co-localization was found. Blood vessels in the MCL of ACL-t knees do not lack smooth muscle. The MCL vasculature can undergo constrictive response to KCl, but have impaired receptor mediated responses and impaired nitric oxide signaling.

Decreased posterior cruciate and altered collateral ligament loading following ACL transection: a longitudinal study in the ovine model

Although ACL deficiency is shown to lead to joint degeneration, few quantitative data are reported on its effect on soft tissue structures surrounding the knee joint, specifically, the posterior cruciate and collateral ligaments. The kinematics of the stifle joint of sheep (N = 5) were measured during "normal" gait, as well as 4 and 20 weeks after ACL transection. These motions were reproduced using a unique robotic manipulator and the loads borne by PCL, MCL, and LCL during gait were determined. Our results demonstrated a significant decrease in mean PCL loads 20 weeks post-ACL injury, at hoof-strike (0% of gait, p = 0.034), hoof-off (66% of gait, p = 0.006), peak-swing (85% of gait, p = 0.026), and extension-before-hoof-strike (95% of gait, p = 0.028). Mean MCL loads did not significantly increase following ACL transection, maybe due to large between-animal variation. Finally, mean LCL loads indicated a significant decrease (p < 0.047) at 20 weeks across the entire gait cycle. From a clinical perspective, the load redistributions observed in cruciate and collateral ligaments following ACL injury indicate that these tissues can carry/adapt to the altered mechanical environment of the joint. The considerable variability in the magnitudes of change following ACL injury among animals also simulates clinical variability in humans after trauma.

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.

Consideration of growth factors and bio-scaffolds for treatment of combined grade II MCL and ACL injury

The literature suggests that a Grade II medial collateral ligament (MCL) injury in combination with anterior cruciate ligament (ACL) injury will heal naturally and not compromise patient outcome following ACL reconstruction. Evidence based on bone-patella tendon-bone autograft use is stronger than evidence supporting anatomically placed soft tissue graft use. Current ACL reconstruction practices make greater use of soft tissue grafts, differing fixation methods, and anatomically lower placement on the inner wall of the lateral femoral condyle. Anatomical graft placement aligns the femoral bone tunnel more directly with valgus knee loading forces. Differences in the soft tissue graft-bone tunnel integration and ligamentization timetable following ACL reconstruction also increase concerns regarding residual Grade II MCL laxity and functional deficiency during accelerated functional rehabilitation. MCL dysfunction may increase susceptibility to early ACL graft slippage, elongation, outright failure, and medial femoral condyle lift-off with valgus knee loading. This concept paper discusses the potential role of growth factors and bio-scaffolds for improving Grade II MCL injury healing and mechanical integrity when the injury occurs in combination with an ACL injury that is reconstructed with a soft tissue graft and an anatomical surgical approach.

Finite element modelling of the glenohumeral capsule can help assess the tested region during a clinical exam

The objective of this research was to examine the efficacy of evaluating the region of the glenohumeral capsule being tested by clinical exams for shoulder instability using finite element (FE) models of the glenohumeral joint. Specifically, the regions of high capsule strain produced by glenohumeral joint positions commonly used during a clinical exam were identified. Kinematics that simulated a simple translation test with an anterior load at three external rotation angles were applied to a validated, subject-specific FE model of the glenohumeral joint at 60° of abduction. Maximum principal strains on the glenoid side of the inferior glenohumeral ligament (IGHL) were significantly higher than the maximum principal strains on the humeral side, for all three regions of the IGHL at 30° and 60° of external rotation. These regions of localised strain indicate that these joint positions might be used to test the glenoid side of the IGHL during this clinical exam, but are not useful for assessing the humeral side of the IGHL. The use of FE models will facilitate the search for additional joint positions that isolate high strains to other IGHL regions, including the humeral side of the IGHL.

Finding consistent strain distributions in the glenohumeral capsule between two subjects: implications for development of physical examinations

The anterior-inferior glenohumeral capsule is the primary passive stabilizer to the glenohumeral joint during anterior dislocation. Physical examinations following dislocation are crucial for proper diagnosis of capsule pathology; however, they are not standardized for joint position which may lead to misdiagnoses and poor outcomes. To suggest joint positions for physical examinations where the stability provided by the capsule may be consistent among patients, the objective of this study was to evaluate the distribution of maximum principal strain on the anterior-inferior capsule using two validated subject-specific finite element models of the glenohumeral joint at clinically relevant joint positions. The joint positions with 25 N anterior load applied at 60° of glenohumeral abduction and 10°, 20°, 30° and 40° of external rotation resulted in distributions of strain that were similar between shoulders (r² ≥ 0.7). Furthermore, those positions with 20-40° of external rotation resulted in capsule strains on the glenoid side of the anterior band of the inferior glenohumeral ligament that were significantly greater than in all other capsule regions. These findings suggest that anterior stability provided by the anterior-inferior capsule may be consistent among subjects at joint positions with 60° of glenohumeral abduction and a mid-range (20-40°) of external rotation, and that the glenoid side has the greatest contribution to stability at these joint positions. Therefore, it may be possible to establish standard joint positions for physical examinations that clinicians can use to effectively diagnose pathology in the anterior-inferior capsule following dislocation and lead to improved outcomes.

The Impact of Glenoid Labrum Thickness and Modulus on Labrum and Glenohumeral Capsule Function

The glenoid labrum is an integral component of the glenohumeral capsule’s insertion into the glenoid, and changes in labrum geometry and mechanical properties may lead to the development of glenohumeral joint pathology. The objective of this research was to determine the effect that changes in labrum thickness and modulus have on strains in the labrum and glenohumeral capsule during a simulated physical examination for anterior instability. A labrum was incorporated into a validated, subject-specific finite element model of the glenohumeral joint, and experimental kinematics were applied simulating application of an anterior load at 0 deg, 30 deg, and 60 deg of external rotation and 60 deg of glenohumeral abduction. The radial thickness of the labrum was varied to simulate thinning tissue, and the tensile modulus of the labrum was varied to simulate degenerating tissue. At 60 deg of external rotation, a thinning labrum increased the average and peak strains in the labrum, particularly in the labrum regions of the axillary pouch (increased 10.5% average strain) and anterior band (increased 7.5% average strain). These results suggest a cause-and-effect relationship between age-related decreases in labrum thickness and increases in labrum pathology. A degenerating labrum also increased the average and peak strains in the labrum, particularly in the labrum regions of the axillary pouch (increased 15.5% strain) and anterior band (increased 10.4% strain). This supports the concept that age-related labrum pathology may result from tissue degeneration. This work suggests that a shift in capsule reparative techniques may be needed in order to include the labrum, especially as activity levels in the aging population continue to increase. In the future validated, finite element models of the glenohumeral joint can be used to explore the efficacy of new repair techniques for glenoid labrum pathology.

Validation of computational models in biomechanics

The topics of verification and validation have increasingly been discussed in the field of computational biomechanics, and many recent articles have applied these concepts in an attempt to build credibility for models of complex biological systems. Verification and validation are evolving techniques that, if used improperly, can lead to false conclusions about a system under study. In basic science, these erroneous conclusions may lead to failure of a subsequent hypothesis, but they can have more profound effects if the model is designed to predict patient outcomes. While several authors have reviewed verification and validation as they pertain to traditional solid and fluid mechanics, it is the intent of this paper to present them in the context of computational biomechanics. Specifically, the task of model validation will be discussed, with a focus on current techniques. It is hoped that this review will encourage investigators to engage and adopt the verification and validation process in an effort to increase peer acceptance of computational biomechanics models.

Coronal plane knee laxity measurement: Is computer-assisted navigation useful?

INTRODUCTION

The goal of this observational study is to measure the physiological laxity of a knee, supposedly normal in the coronal plane, at 0 and 90° of flexion with a navigation system that can be used during total knee replacement.

HYPOTHESIS

The physiological laxity measured by this navigation system is different from the results already published using other measurement devices.

MATERIALS AND METHODS

Twenty patients consecutively operated on for an isolated anterior cruciate ligament injury were selected. Medial and lateral laxities at 0 and 90° of knee flexion were measured by the navigation system during cruciate replacement.

RESULTS

The mean medial laxity in extension was 3.6±1.2°. The mean lateral laxity in extension was 4.1±1.9°. The mean medial laxity at 90° of flexion was 2.1±1.2°. The mean lateral laxity at 90° of flexion was 3.7±1.2°. The medial and lateral laxities in extension were not asymmetric. The medial and lateral laxities at 90° of flexion were asymmetric. Medial laxities in extension and at 90° of flexion were asymmetric. Lateral laxities in extension and at 90° of flexion were not asymmetric.

DISCUSSION

The data collected in our study suggest, during total knee replacement, the following tolerable ligamentous balance: medial and lateral laxities in extension about 3°, medial laxity at 90° of flexion about 2°, and lateral laxity at 90° of flexion about 4°.

LEVEL OF EVIDENCE

Level IV. Prospective study.

Strain measurement in the left ventricle during systole with deformable image registration

The objective of this study was to validate a deformable image registration technique, termed Hyperelastic Warping, for left ventricular strain measurement during systole using cine-gated, non-tagged MR images with strains measured from tagged MRI. The technique combines deformation from high resolution, non-tagged MR image data with a detailed computational model, including estimated myocardial material properties, fiber direction, and active fiber contraction, to provide a comprehensive description of myocardial contractile function. A normal volunteer (male, age 30) with no history of cardiac pathology was imaged with a 1.5 T Siemens Avanto clinical scanner using a TrueFISP imaging sequence and a 32-channel cardiac coil. Both tagged and non-tagged cine MR images were obtained. The Hyperelastic Warping solution was evolved using a series of non-tagged images in ten intermediate phases from end-diastole to end-systole. The solution may be considered as ten separate warping problems with multiple templates and targets. At each stage, an active contraction was initially applied to a finite element model, and then image-based warping penalty forces were utilized to generate the final registration. Warping results for circumferential strain (R(2)=0.75) and radial strain (R(2)=0.78) were strongly correlated with results obtained from tagged MR images analyzed with a Harmonic Phase (HARP) algorithm. Results for fiber stretch, LV twist, and transmural strain distributions were in good agreement with experimental values in the literature. In conclusion, Hyperelastic Warping provides a unique alternative for quantifying regional LV deformation during systole without the need for tags.

Verification, validation and sensitivity studies in computational biomechanics

Computational techniques and software for the analysis of problems in mechanics have naturally moved from their origins in the traditional engineering disciplines to the study of cell, tissue and organ biomechanics. Increasingly complex models have been developed to describe and predict the mechanical behavior of such biological systems. While the availability of advanced computational tools has led to exciting research advances in the field, the utility of these models is often the subject of criticism due to inadequate model verification and validation (V&V). The objective of this review is to present the concepts of verification, validation and sensitivity studies with regard to the construction, analysis and interpretation of models in computational biomechanics. Specific examples from the field are discussed. It is hoped that this review will serve as a guide to the use of V&V principles in the field of computational biomechanics, thereby improving the peer acceptance of studies that use computational modeling techniques.

Noninvasive determination of ligament strain with deformable image registration

Ligament function and propensity for injury are directly related to regional stresses and strains. However, noninvasive techniques for measurement of strain are currently limited. This study validated the use of Hyperelastic Warping, a deformable image registration technique, for noninvasive strain measurement in the human medial collateral ligament using direct comparisons with optical measurements. Hyperelastic Warping determines the deformation map that aligns consecutive images of a deforming material, allowing calculation of strain. Diffeomorphic deformations are ensured by representing the deformable image as a hyperelastic material. Ten cadaveric knees were subjected to six loading scenarios each. Tissue deformation was documented with magnetic resonance imaging (MRI) and video-based experimental measurements. MRI datasets were analyzed using Hyperelastic Warping, representing the medial collateral ligament (MCL) with a hexahedral finite element (FE) model projected to a manually segmented ligament surface. The material behavior was transversely isotropic hyperelastic. Warping predictions of fiber stretch were strongly correlated with experimentally measured strains (R (2) = 0.81). Both sets of measurements were in agreement with previous ex vivo studies. Warping predictions of fiber stretch were insensitive to bulk:shear modulus ratio, fiber stiffness, and shear modulus in the range of +2.5SD to -1.0SD. Correlations degraded when the shear modulus was decreased to 2.5SD below the mean (R (2) = 0.56), and when an isotropic constitutive model was substituted for the transversely isotropic model (R (2) = 0.65). MCL strains in the transitional region near the joint line, where the material behavior and material symmetry are more complex, showed the most sensitivity to changes in shear modulus. These results demonstrate that Hyperelastic Warping requires the use of a constitutive model that reflects the material symmetry, but not subject-specific material properties for accurate strain predictions for this application. Hyperelastic Warping represents a powerful technique for noninvasive strain measurement of musculoskeletal tissues and has many advantages over other image-based strain measurement techniques.

The effect of anterior cruciate ligament deficiency on the in vivo elongation of the medial and lateral collateral ligaments

BACKGROUND

Although anterior cruciate ligament deficiency has been shown to lead to joint degeneration, few quantitative data have been reported on its effect on soft tissue structures surrounding the knee joint.

HYPOTHESIS

Anterior cruciate ligament deficiency will alter the deformation of both collateral ligaments during in vivo weight-bearing knee function from 0 degrees to 90 degrees.

STUDY DESIGN

Controlled laboratory study.

METHODS

Six patients who had acute anterior cruciate ligament injury in 1 knee with the contralateral side intact participated in this study. Using magnetic resonance and dual orthogonal fluoroscopic imaging techniques, we measured the length of the fiber bundles of the superficial medial collateral ligament, deep medial collateral ligament, and lateral collateral ligament of the 6 patients; the healthy contralateral knee of each patient served as a control.

RESULTS

Anterior cruciate ligament injury caused a significant elongation of the fiber bundles of the superficial and deep medial collateral ligament at every flexion angle. In contrast, the lateral collateral ligament fiber bundles shortened after anterior cruciate ligament injury.

CONCLUSION

The altered deformations of the collateral ligaments associated with the changes in tibiofemoral joint kinematics after anterior cruciate ligament injury demonstrate that deficiency of 1 of the knee joint structures upsets the in vivo knee homeostasis.

CLINICAL RELEVANCE

Restoring normal knee kinematics after anterior cruciate ligament reconstruction is critical to restore the normal function of the collateral ligaments.