Length-Change Patterns of the Collateral Ligaments During Functional Activities After Total Knee Arthroplasty

Posterior tibial slope influences joint mechanics and soft tissue loading after total knee arthroplasty

As a solution to restore knee function and reduce pain, the demand for Total Knee Arthroplasty (TKA) has dramatically increased in recent decades. The high rates of dissatisfaction and revision makes it crucially important to understand the relationships between surgical factors and post-surgery knee performance. Tibial implant alignment in the sagittal plane (i.e., posterior tibia slope, PTS) is thought to play a key role in quadriceps muscle forces and contact conditions of the joint, but the underlying mechanisms and potential consequences are poorly understood. To address this biomechanical challenge, we developed a subject-specific musculoskeletal model based on the bone anatomy and precise implantation data provided within the CAMS-Knee datasets. Using the novel COMAK algorithm that concurrently optimizes joint kinematics, together with contact mechanics, and muscle and ligament forces, enabled highly accurate estimations of the knee joint biomechanics (RMSE <0.16 BW of joint contact force) throughout level walking and squatting. Once confirmed for accuracy, this baseline modelling framework was then used to systematically explore the influence of PTS on knee joint biomechanics. Our results indicate that PTS can greatly influence tibio-femoral translations (mainly in the anterior-posterior direction), while also suggesting an elevated risk of patellar mal-tracking and instability. Importantly, however, an increased PTS was found to reduce the maximum tibio-femoral contact force and improve efficiency of the quadriceps muscles, while also reducing the patellofemoral contact force (by approximately 1.5% for each additional degree of PTS during walking). This study presents valuable findings regarding the impact of PTS variations on the biomechanics of the TKA joint and thereby provides potential guidance for surgically optimizing implant alignment in the sagittal plane, tailored to the implant design and the individual deficits of each patient.

Investigation of Characteristic Motion Patterns of the Knee Joint During a Weightbearing Flexion

This study aimed to develop and validate a novel flexion axis concept by calculating the points on femoral condyles that could maintain constant heights during knee flexion. Twenty-two knees of 22 healthy subjects were investigated when performing a weightbearing single leg lunge. The knee positions were captured using a validated dual fluoroscopic image system. The points on sagittal planes of the femoral condyles that had minimal changes in heights from the tibial plane along the flexion path were calculated. It was found that the points do formulate a medial-lateral flexion axis that was defined as the iso-height axis (IHA). The six degrees of freedom (6DOF) kinematics data calculated using the IHA were compared with those calculated using the conventional transepicondylar axis and geometrical center axis. The IHA measured minimal changes in proximal-distal translations and varus-valgus rotations along the flexion path, indicating that the IHA may have interesting clinical implications. Therefore, identifying the IHA could provide an alternative physiological reference for improvement of contemporary knee surgeries, such as ligament reconstruction and knee replacement surgeries that are aimed to reproduce normal knee kinematics and medial/lateral soft tissue tensions during knee flexion.

Medial stability and lateral flexibility of the collateral ligaments during mid-range flexion in medial-pivot total knee arthroplasty patients demonstrates favorable postoperative outcomes

PURPOSE

The objectives of the present study were to investigate the length change in different bundles of the superficial medial collateral ligament (sMCL) and lateral collateral ligament (LCL) during lunge, and to evaluate their association with Knee Society Score (KSS) following medial-pivot total knee arthroplasty (MP-TKA).

METHODS

Patients with unilateral MP-TKA knees performed a bilateral single-leg lunge under dual fluoroscopy surveillance to determine the in-vivo six degrees-of-freedom knee kinematics. The contralateral non-operated knees were used as the control group. The attachment sites of the sMCL and LCL were marked to calculate the 3D wrapping length. The sMCL and LCL were divided into anterior, intermediate, and posterior portions (aMCL, iMCL, pMCL, aLCL, iLCL, pLCL). Correlations between lengths/elongation rate of ligament bundles from full extension to 100° flexion and the KSS were examined.

RESULTS

The sMCL and LCL demonstrated relative stability in length at low flexion, but sMCL length decreased whereas LCL increased with further flexion on operated knees. The sMCL length increased at low flexion and remained stable with further flexion, while the LCL length decreased with flexion on the contralateral non-operated knees. The lengths of aMCL, iMCL, and pMCL showed moderate (0.5 < r < 0.7, p < 0.05) negative correlations with the KSS, and the lengths of aLCL, iLCL, and pLCL were positively correlated with the KSS at mid flexion on operated knees (p < 0.05). The elongation rates of aLCL, iLCL, and pLCL were negatively correlated with the KSS at high flexion on operated knees (p < 0.05). However, no significant correlations between the length of different bundles of sMCL or LCL with KSS were found on contralateral non-operated knees.

CONCLUSIONS

The elongation pattern of sMCL/LCL on MP-TKA knees showed differences with contralateral non-operated knees. The sMCL is tense at low to middle flexion and relaxed at high flexion, while LCL is relaxed at low to middle flexion and tense at high flexion following MP-TKA. Medial stability and proper lateral flexibility during mid flexion were associated with favorable postoperative outcomes in MP-TKA patients. In contrast, lateral relaxation at deep flexion should be avoided when applying soft-tissue balancing in MP-TKA.

LEVEL OF EVIDENCE

Level III.

From fibre to function: are we accurately representing muscle architecture and performance?

The size and arrangement of fibres play a determinate role in the kinetic and energetic performance of muscles. Extrapolations between fibre architecture and performance underpin our understanding of how muscles function and how they are adapted to power specific motions within and across species. Here we provide a synopsis of how this 'fibre to function' paradigm has been applied to understand muscle design, performance and adaptation in animals. Our review highlights the widespread application of the fibre to function paradigm across a diverse breadth of biological disciplines but also reveals a potential and highly prevalent limitation running through past studies. Specifically, we find that quantification of muscle architectural properties is almost universally based on an extremely small number of fibre measurements. Despite the volume of research into muscle properties, across a diverse breadth of research disciplines, the fundamental assumption that a small proportion of fibre measurements can accurately represent the architectural properties of a muscle has never been quantitatively tested. Subsequently, we use a combination of medical imaging, statistical analysis, and physics-based computer simulation to address this issue for the first time. By combining diffusion tensor imaging (DTI) and deterministic fibre tractography we generated a large number of fibre measurements (>3000) rapidly for individual human lower limb muscles. Through statistical subsampling simulations of these measurements, we demonstrate that analysing a small number of fibres (n < 25) typically used in previous studies may lead to extremely large errors in the characterisation of overall muscle architectural properties such as mean fibre length and physiological cross-sectional area. Through dynamic musculoskeletal simulations of human walking and jumping, we demonstrate that recovered errors in fibre architecture characterisation have significant implications for quantitative predictions of in-vivo dynamics and muscle fibre function within a species. Furthermore, by applying data-subsampling simulations to comparisons of muscle function in humans and chimpanzees, we demonstrate that error magnitudes significantly impact both qualitative and quantitative assessment of muscle specialisation, potentially generating highly erroneous conclusions about the absolute and relative adaption of muscles across species and evolutionary transitions. Our findings have profound implications for how a broad diversity of research fields quantify muscle architecture and interpret muscle function.

Can tibio-femoral kinematic and kinetic parameters reveal poor functionality and underlying deficits after total knee replacement? A systematic review

BACKGROUND

Extensive efforts have been made to understand joint kinematics and kinetics in total knee arthroplasty (TKA) in subjects with satisfactory outcomes during daily functional activities and clinical tests, but it remains unclear whether such movement characteristics hold the potential to indicate the underlying aetiology of unsatisfactory or bad TKA outcomes.

PURPOSE

To investigate which kinematic and kinetic parameters assessed during passive clinical tests and functional activities of daily living are associated with poor functionality and underlying deficits after total knee replacement.

METHODS

We focused on studies characterizing the kinematic or kinetic parameters of the knee joint that are associated with poor clinical outcome after TKA. Seventeen articles were included for the review, and kinematic and kinetic data from 719 patients with minimal follow up of 6 months were extracted and analyzed.

RESULTS

Passive posterior translation at 90°flexionexhibited good potential for differentiating stable and unstable TKAs. Anterior-posterior (A-P) translation of the medial condyle at 0-30° and 30-60° flexion, A-P translation of the lateral condyle at 60-90°during closed chain exercises, as well asknee extension moment during stair ascent and descent, knee abduction moment during stair descent, knee internal rotation moment and plantar flexion moment during walking, 2ndpeak ground reaction force during stair ascent and walkingshowed the greatest promise as functional biomarkers for a dissatisfied/poor outcome knee after TKA.

CONCLUSION

In this study, we systematically reviewed the state-of-the-art knowledge of kinematics and kinetics associated with functional deficits, and found 11 biomechanical parameters that showed promise for supportingdecision making in TKA.

Dynamic Knee Joint Line Orientation Is Not Predictive of Tibio-Femoral Load Distribution During Walking

Some approaches in total knee arthroplasty aim for an oblique joint line to achieve an even medio-lateral load distribution across the condyles during the stance phase of gait. While there is much focus on the angulation of the joint line in static frontal radiographs, precise knowledge of the associated dynamic joint line orientation and the internal joint loading is limited. The aim of this study was to analyze how static alignment in frontal radiographs relates to dynamic alignment and load distribution, based on direct measurements of the internal joint loading and kinematics. A unique and novel combination of telemetrically measured in vivo knee joint loading and simultaneous internal joint kinematics derived from mobile fluoroscopy ("CAMS-Knee dataset") was employed to access the dynamic alignment and internal joint loading in 6 TKA patients during level walking. Static alignment was measured in standard frontal postoperative radiographs while external adduction moments were computed based on ground reaction forces. Both static and dynamic parameters were analyzed to identify correlations using linear and non-linear regression. At peak loading during gait, the joint line was tilted laterally by 4°-7° compared to the static joint line in most patients. This dynamic joint line tilt did not show a strong correlation with the medial force (R 2: 0.17) or with the mediolateral force distribution (pseudo R 2: 0.19). However, the external adduction moment showed a strong correlation with the medial force (R 2: 0.85) and with the mediolateral force distribution (pseudo R 2: 0.78). Alignment measured in static radiographs has only limited predictive power for dynamic kinematics and loading, and even the dynamic orientation of the joint line is not an important factor for the medio-lateral knee load distribution. Preventive and rehabilitative measures should focus on the external knee adduction moment based on the vertical and horizontal components of the ground reaction forces.

In Vivo Elongation Patterns of the Collateral Ligaments in Healthy Knees During Functional Activities

BACKGROUND

Improved knowledge of in vivo function of the collateral ligaments is essential for enhancing rehabilitation and guiding surgical reconstruction as well as soft-tissue balancing in total knee arthroplasty. The aim of this study was to quantify in vivo elongation patterns of the collateral ligaments throughout complete cycles of functional activities.

METHODS

Knee kinematics were measured using radiographic images captured with a mobile fluoroscope while healthy subjects performed level walking, downhill walking, and stair descent. The registered in vivo tibiofemoral kinematics were then used to drive subject-specific multibody knee models to track collateral ligament elongation.

RESULTS

The elongation patterns of the medial collateral ligament varied distinctly among its bundles, ranging from lengthening of the anterior fibers to shortening of the posterior bundle with increases in the knee flexion angle. The elongation patterns of the lateral collateral ligament varied considerably among subjects. It showed an average 4% shortening with increasing flexion until 60% to 70% of the gait cycle, and then recovered during the terminal-swing phase until reaching its reference length (defined at heel strike).

CONCLUSIONS

The observed nonuniform elongation of the medial collateral ligament bundles suggests that single-bundle reconstruction techniques may not fully restore healthy ligament function. Moreover, the observed ligament elongation patterns indicate greater varus than valgus laxity in the loaded knee.

CLINICAL RELEVANCE

Through providing key knowledge about the in vivo elongation patterns of the collateral ligaments throughout complete cycles of functional activities, this study offers in vivo evidence for benchmarking ligament reconstruction and soft-tissue balancing in total knee arthroplasty.

Techniques for In Vivo Measurement of Ligament and Tendon Strain: A Review

The critical clinical and scientific insights achieved through knowledge of in vivo musculoskeletal soft tissue strains has motivated the development of relevant measurement techniques. This review provides a comprehensive summary of the key findings, limitations, and clinical impacts of these techniques to quantify musculoskeletal soft tissue strains during dynamic movements. Current technologies generally leverage three techniques to quantify in vivo strain patterns, including implantable strain sensors, virtual fibre elongation, and ultrasound. (1) Implantable strain sensors enable direct measurements of tissue strains with high accuracy and minimal artefact, but are highly invasive and current designs are not clinically viable. (2) The virtual fibre elongation method tracks the relative displacement of tissue attachments to measure strains in both deep and superficial tissues. However, the associated imaging techniques often require exposure to radiation, limit the activities that can be performed, and only quantify bone-to-bone tissue strains. (3) Ultrasound methods enable safe and non-invasive imaging of soft tissue deformation. However, ultrasound can only image superficial tissues, and measurements are confounded by out-of-plane tissue motion. Finally, all in vivo strain measurement methods are limited in their ability to establish the slack length of musculoskeletal soft tissue structures. Despite the many challenges and limitations of these measurement techniques, knowledge of in vivo soft tissue strain has led to improved clinical treatments for many musculoskeletal pathologies including anterior cruciate ligament reconstruction, Achilles tendon repair, and total knee replacement. This review provides a comprehensive understanding of these measurement techniques and identifies the key features of in vivo strain measurement that can facilitate innovative personalized sports medicine treatment.

Development and validation of an in-silico virtual testing rig for analyzing total knee arthroplasty performance during passive deep flexion: A feasibility study

The use of in-silico finite element (FE) models has become more common in orthopedic applications and in the design of biomedical devices, since they can provide results comparable to in vitro experiments while maintaining lower cost. The main downside of this kind of analysis is the high computing time, as it can reach hours or even days to complete; this limitation makes it then not suitable for time-sensitive applications, such as probabilistic analyses or helping clinicians in surgical pre-planning or intra-operative setting. In-silico multibody (MB) simulations, on the other hand, are significantly faster than FE simulations (considering each component of the model as a rigid body); although deformability of each model component is a necessary feature in some applications (e.g. simulation of implant-bone micromotions), several outputs of interest in orthopedic applications, such as implant kinematics and contact forces, do not require a fully deformable model. Therefore, this feasibility study aimed to develop a MB model of a human knee joint implanted with a Total Knee Arthroplasty; a 10 second flexion movement up to 105° was then simulated and the results compared with validated FE models results (under similar boundary conditions) from literature, to perform a preliminary validation in terms of kinematic and kinetic results between the two methods. The agreement and relatively low computing time obtaining with this approach represent a promising starting point for subsequent studies and applications of such techniques in the clinical field.

The effect of increasing heel height on lower limb symmetry during the back squat in trained and novice lifters

Background

Symmetry during lifting is considered critical for allowing balanced power production and avoidance of injury. This investigation assessed the influence of elevating the heels on bilateral lower limb symmetry during loaded (50% of body weight) high-bar back squats.

Methods

Ten novice (mass 67.6 ± 12.4 kg, height 1.73 ± 0.10 m) and ten regular weight trainers (mass 66.0 ± 10.7 kg, height 1.71 ± 0.09 m) were assessed while standing on both the flat level floor and on an inclined board. Data collection used infra-red motion capture procedures and two force platforms to record bilateral vertical ground reaction force (GRF_vert) and ankle, knee and hip joint kinematic and kinetic data. Paired t-tests and statistical parametric mapping (SPM1D) procedures were used to assess differences in discrete and continuous bilateral symmetry data across conditions.

Results

Although discrete joint kinematic and joint moment symmetry data were largely unaffected by raising the heels, the regular weight trainers presented greater bilateral asymmetry in these data than the novices. The one significant finding in these discrete data showed that raising the heels significantly reduced maximum knee extension moment asymmetry (P = 0.02), but in the novice group only. Time-series analyses indicated significant bilateral asymmetries in both GRF_vert and knee extension moments mid-way though the eccentric phase for the novice group, with the latter unaffected by heel lift condition. There were no significant bilateral asymmetries in time series data within the regular weight training group.

Conclusions

This investigation highlights that although a degree of bilateral lower limb asymmetry is common in individuals performing back squats, the degree of this symmetry is largely unaffected by raising the heels. Differences in results for discrete and time-series symmetry analyses also highlight a key issue associated with relying solely on discrete data techniques to assess bilateral symmetry during tasks such as the back squat.

Tibio-femoral kinematics of the healthy knee joint throughout complete cycles of gait activities

Accurate assessment of 3D tibio-femoral kinematics is essential for understanding knee joint functionality, but also provides a basis for assessing joint pathologies and the efficacy of musculoskeletal interventions. Until now, however, the assessment of functional kinematics in healthy knees has been mostly restricted to the loaded stance phase of gait, and level walking only, but the most critical conditions for the surrounding soft tissues are known to occur during high-flexion activities. This study aimed to determine the ranges of tibio-femoral rotation and condylar translation as well as provide evidence on the location of the centre of rotation during multiple complete cycles of different gait activities. Based on radiographic images captured using moving fluoroscopy in ten healthy subjects during multiple cycles of level walking, downhill walking and stair descent, 3D femoral and tibial poses were reconstructed to provide a comprehensive description of tibio-femoral kinematics. Despite a significant increase in joint flexion, the condylar antero-posterior range of motion remained comparable across all activities, with mean translations of 6.3-8.3 mm and 7.3-9.3 mm for the medial and lateral condyles respectively. Only the swing phase of level walking and stair descent exhibited a significantly greater range of motion for the lateral over the medial compartment. Although intra-subject variability was low, considerable differences in joint kinematics were observed between subjects. The observed subject-specific movement patterns indicate that accurate assessment of individual pre-operative kinematics together with individual implant selection and/or surgical implantation decisions might be necessary before further improvement to joint replacement outcome can be achieved.

Elongation Patterns of the Posterior Cruciate Ligament after Total Knee Arthroplasty

This study aimed to understand the ability of fixed-bearing posterior cruciate ligament (PCL)-retaining implants to maintain functionality of the PCL in vivo. To achieve this, elongation of the PCL was examined in six subjects with good clinical and functional outcomes using 3D kinematics reconstructed from video-fluoroscopy, together with multibody modelling of the knee. Here, length-change patterns of the ligament bundles were tracked throughout complete cycles of level walking and stair descent. Throughout both activities, elongation of the anterolateral bundle exhibited a flexion-dependent pattern with more stretching during swing than stance phase (e.g., at 40° flexion, anterolateral bundle experienced 3.9% strain during stance and 9.1% during swing phase of stair descent). The posteromedial bundle remained shorter than its reference length (defined at heel strike of the level gait cycle) during both activities. Compared with loading patterns of the healthy ligament, postoperative elongation patterns indicate a slackening of the ligament at early flexion followed by peak ligament lengths at considerably smaller flexion angles. The reported data provide a novel insight into in vivo PCL function during activities of daily living that has not been captured previously. The findings support previous investigations reporting difficulties in achieving a balanced tension in the retained PCL.

A geometric ratio to predict the flexion gap in total knee arthroplasty

Measured resection is a common technique for obtaining symmetric flexion and extension gaps in posterior-stabilized (PS) total knee arthroplasty (TKA). A known limitation of measured resection, however, is its reliance on osseous landmarks to guide bone resection and component alignment while ignoring the geometry of the surrounding soft tissues such as the medial collateral ligament (MCL), a possible reason for knee instability. To address this clinical concern, we introduce a new geometric proportion, the MCL ratio, which incorporates features of condylar geometry and MCL anterior fibers. The goal of this study was to determine whether the MCL ratio can predict the flexion gaps and to determine whether a range of MCL ratio corresponds to balanced gaps. Six computational knee models each implanted with PS TKA were utilized. Medial and lateral gaps were measured in response to varus and valgus loads at extension and flexion. The MCL ratio was related to the measured gaps for each knee. We found that the MCL ratio was associated with the flexion gaps and had a stronger association with the medial gap (β = -7.2 ± 3.05, P < .001) than with the lateral gap (β = 3.9 ± 7.26, P = .04). In addition, an MCL ratio ranging between 1.1 and 1.25 corresponded to balanced flexion gaps in the six knee models. Future studies will focus on defining MCL ratio targets after accounting for variations in ligament properties in TKA patients. Our results suggest that the MCL ratio could help guide femoral bone resections in measured resection TKA, but further clinical validation is required.