In-vitro measurement of static pressure distribution in synovial joints--Part II: Retropatellar surface

Covariance in human limb joint articular morphology

OBJECTIVES

Limb synovial joints exhibit complex shapes that must accommodate often-antagonistic demands of function, mobility, and stability. These demands presumably dictate coordination among joint articular shapes, but the structure of morphological covariance within and among joints is unknown. This study analyzes the human shoulder, elbow, hip, and knee to determine how articular covariance is structured in relation to joint structure, accessory cartilage, and function.

MATERIALS AND METHODS

Surface models were created from the CT scans of 200 modern skeletons from the University of Tennessee Donated Skeletal Collection. Three-dimensional landmarks were collected on the shoulder, elbow, hip, and knee joints. Two-block partial least squares were conducted to determine associations between surfaces of conarticular shapes, functionally analogous articulations, and articulations belonging to the same bone.

RESULTS

Except for the components of the shoulder, all conarticular pairs exhibit covariance, though the strength of these relationships appears unrelated to the amount of accessory cartilage in the joint. Only the analogous articulations of the humerus and femur exhibit significant covariance, but it is unlikely that this pattern is due to function alone. Stronger covariance within the lower limb than the upper limb is consistent broader primate patterns of within-limb integration.

DISCUSSION

With the exception of the elbow, complementary joint function does not appear to promote strong covariance between articulations. Analogous humeral and femoral surfaces are also serially homologous, which may result in the articular associations observed between these bones. Broadly, these patterns highlight the indirect relationship between joint congruence and covariance.

Experimental Methods for Studying the Contact Mechanics of Joints

Biomechanics researchers often experimentally measure static or fluctuating dynamic contact forces, areas, and stresses at the interface of natural and artificial joints, including the shoulders, elbows, hips, and knees. This information helps explain joint contact mechanics, as well as mechanisms that may contribute to disease, damage, and degradation. Currently, the most common in vitro experimental technique involves a thin pressure-sensitive film inserted into the joint space; but, the film's finite thickness disturbs the joint's ordinary articulation. Similarly, the most common in vivo experimental technique uses video recording of 3D limb motion combined with dynamic analysis of a 3D link-segment model to calculate joint contact force, but this does not provide joint contact area or stress distribution. Moreover, many researchers may be unaware of older or newer alternative techniques that may be more suitable for their particular research application. Thus, this article surveys over 50 years of English-language scientific literature in order to (a) describe the basic working principles, advantages, and disadvantages of each technique, (b) examine the trends among the studies and methods, and (c) make recommendations for future directions. This article will hopefully inform biomechanics investigators about various in vitro and in vivo experimental methods for studying the contact mechanics of joints.

Meniscal extrusion: risk factors and diagnostic tools to predict early osteoarthritis

Meniscal extrusion (ME) is strongly correlated with cartilage wear and osteoarthritis (OA), be-cause of the altered kinematic and the decreased contact area between the tibia and femur. The aim of this narrative review is to analyze the process of ME, focusing on the possible causes, and to evaluate the correlation between ME and knee OA, in order to provide early diagnosis and treatments. Studies written in English that analyzed the causes of ME, provided indications re-garding diagnosis and treatment, and evaluated the relation between ME and early OA were in-cluded. Injuries, degeneration of the meniscal substance and meniscus root tears are associated with significantly increased ME. An extruded meniscus could be a manifestation of other pa-thologies such as disruption of coronary ligaments, cartilage loss, knee malalignment, ligament injuries, or OA. ME is strongly associated with osteoarthritis features, particularly with bone marrow lesion and cartilage damage. Magnetic resonance imaging represents the gold standard for the detection of ME. The severity of the medial meniscus extrusion may also affect healing af-ter repair, and meniscus extrusion is not completely reduced by meniscus posterior root tear re-pair. In this study, we proved that ME represents an important risk factor for early knee OA. We provided alternative theories of ME, such as meniscal fibers injury first and "dynamic extrusion of the menisci". The phenomenon of aging has been described as a new concept in the etiology of ME. Finally, we stated all the main techniques and characteristics of the diagnostic process, as well as the current knowledge in the therapeutic field.

Toward defining the role of the synovium in mitigating normal articular cartilage wear and tear

Cartilage repair has been studied extensively in the context of injury and disease, but the joint's management of regular sub-injurious damage to cartilage, or 'wear and tear,' which occurs due to normal activity, is poorly understood. We hypothesize that this cartilage maintenance is mediated in part by cells derived from the synovium that migrate to the worn articular surface. Here, we demonstrate in vitro that the early steps required for such a process can occur. First, we show that under physiologic mechanical loads, chondrocyte death occurs in the cartilage superficial zone along with changes to the cartilage surface topography. Second, we show that synoviocytes are released from the synovial lining under physiologic loads and attach to worn cartilage. Third, we show that synoviocytes parachuted onto a simulated or native cartilage surface will modify their behavior. Specifically, we show that synoviocyte interactions with chondrocytes lead to changes in synoviocyte mechanosensitivity, and we demonstrate that cartilage-attached synoviocytes can express COL2A1, a hallmark of the chondrogenic phenotype. Our findings suggest that synoviocyte-mediated repair of cartilage 'wear and tear' as a component of joint homeostasis is feasible and is deserving of future study.

Numerical investigation of patellar instability during knee flexion due to an unbalanced medial retinaculum loading effect

Background and aim

Healthy patellofemoral (PF) joint mechanics are critical to optimal knee joint function. Patella plays a vital role in distributing quadriceps load during the knee extension. Patellar tracking, not physiological tracking, causes an increase of strains in PF ligaments, peaks of localized stress of soft tissues and articular cartilage and bony parts, and knee pain; these problems lead to complications such as bone abnormalities and osteoarthritis. This research aimed to develop a Finite Element (FE) model to evaluate patellar instability due to the medial retinaculum asymmetric loading effect.

Methods

A numerical model of the knee was obtained by matching nuclear magnetic resonance (MRI) for soft tissues and computerized tomography (CT) for bones, carried on a normal adult. Loading setup was chosen by using literature data. The intensity of the muscle forces was calculated by a static optimization taking into account ground reaction and knee flexion/extension during walking. The effect of patellar instability was obtained by gradually unbalancing this symmetry, one side was unloaded till 90 N, and the other loaded till 110 N.

Results

Unbalanced forces of 10 N acting on the retinaculum alone can produce a real difference in displacements of about 7 mm, and an increment of about 44% on patellar contact forces.

Conclusion

This research demonstrated how an unbalanced forces acting on the retinaculum can produce significant patellar instability. Patellar instability starts at 25-30° of the knee flexion angle but tends to appear at 15° when the unbalanced muscular loading conditions are acting.

Computational biomechanics of human knee joint in stair ascent: Muscle-ligament-contact forces and comparison with level walking

About a third of knee joint disorders originate from the patellofemoral (PF) site that makes stair ascent a difficult activity for patients. A detailed finite element model of the knee joint is coupled to a lower extremity musculoskeletal model to simulate the stance phase of stair ascent. It is driven by the mean of measurements on the hip-knee-ankle moments-angles as well as ground reaction forces reported in healthy individuals. Predicted muscle activities compare well to the recorded electromyography data. Peak forces in quadriceps (3.87 BW, body weight, at 20% instance in our 607 N subject), medial hamstrings (0.77 BW at 20%), and gastrocnemii (1.21 BW at 80%) are estimated. Due to much greater flexion angles-moments in the first half of stance, large PF contact forces (peak of 3.1 BW at 20% stance) and stresses (peak of 4.83 MPa at 20% stance) are estimated that exceed their peaks in level walking by fourfold and twofold, respectively. Compared with level walking, ACL forces diminish in the first half of stance but substantially increase later in the second half (peak of 0.76 BW at 75% stance). Under nearly similar contact forces at 20% of stance, the contact stress on the tibiofemoral (TF) medial plateau reaches a peak (9.68 MPa) twice that on the PF joint suggesting the vulnerability of both joints. Compared with walking, stair ascent increases peak ACL force and both peak TF and PF contact stresses. Reductions in the knee flexion moment and/or angle appear as a viable strategy to mitigate internal loads and pain.

Dynamic versus static medial patellofemoral ligament reconstruction technique in the treatment of recurrent patellar dislocation: a randomized clinical trial protocol

BACKGROUND

The redislocation rate of conservatively treated patella instability is high. One of the leading surgical strategies is medial patellofemoral ligament reconstruction. Over-tensioning is one of the most challenging complications in static medial patellofemoral ligament reconstruction as the graft used for reconstruction is isometric and the anatomical MPFL is a mostly dynamic structure. As an alternative to established static reconstruction techniques, dynamic graft techniques have been introduced for stabilizing the patella with the aim of providing a more physiological reconstruction of the medial patellofemoral ligament. To date, data on clinical outcomes are scarce and on biomechanical outcomes of the dynamic MPFL reconstruction are lacking. Here, we present the protocol of a randomized clinical trial for comparing clinical and biomechanical outcomes of dynamic versus static medial patellofemoral ligament reconstruction.

METHODS

This study is a prospective, single blinded, randomized, multicenter, multimodal (clinical and biomechanical) clinical trial. Patients with recurrent patella dislocation requiring isolated MPFL reconstruction will be recruited and randomized to the dynamic or static reconstruction technique. Participants will be followed up for 2 years with a total of five follow-ups. Preoperative magnetic resonance imaging, upright radiographs, surgical reports and patient records will be evaluated, and clinical and functional outcomes will be measured. Patient-reported knee function and anterior knee pain as assessed with the Kujala score will serve as primary outcome. For biomechanical outcome, pre- and postoperative evaluations will be performed to assess isokinetic muscle strength, gait asymmetry, joint kinematics and kinetics, and timing of muscle activity.

DISCUSSION

The results of the study will clarify whether the reported surgery success for patella stabilization via dynamic MPFL reconstruction is due to muscle contraction or to the passive tenodesis effect combined with clinical outcome measures. With this study, we will provide much needed information on knee biomechanics after dynamic versus static MPFL reconstruction to provide evidence to support orthopedic surgeons in evidence-based decision-making in their quest for surgical techniques most favorable for their patients. Trial registration The study protocol was registered at clinicaltrials.gov (NCT04849130). Registered 19 April 2021, https://clinicaltrials.gov/ct2/show/NCT04849130 .

The Nonintuitive Contributions of Individual Quadriceps Muscles to Patellar Tracking

The purpose of this study was to quantify the contribution of the individual quadriceps muscles to patellar tracking. The individual and/or combined quadriceps muscles were activated in rabbits (n = 6) during computer-controlled flexion/extension of the knee. Three-dimensional patellar tracking was measured for the vastus lateralis, vastus medialis, and rectus femoris when activated alone and when activated simultaneously at different frequencies, producing a range of knee extensor torques. Patellar tracking changed substantially as a function of knee extensor torque and differed between muscles. Specifically, when all quadriceps muscles were activated simultaneously, the patella shifted more medially and proximally and rotated and tilted more medially compared with when vastus lateralis and rectus femoris were activated alone (P < .05), whereas vastus medialis activation alone produced a similar tracking pattern to that observed when all quadriceps muscles were activated simultaneously. Furthermore, patellar tracking for a given muscle condition shifted more medially and proximally and rotated and tilted more medially with increasing knee extensor torques across the entire range of knee joint angles. The authors conclude that patellar tracking depends crucially on knee extensor force/torque and that vastus medialis affects patellar tracking in a distinctly different way than vastus lateralis and rectus femoris, which produce similar tracking patterns.

Evolution of Meniscal Biomechanical Properties with Growth: An Experimental and Numerical Study

The menisci of the knee are complex fibro-cartilaginous tissues that play important roles in load bearing, shock absorption, joint lubrication, and stabilization. The objective of this study was to evaluate the interaction between the different meniscal tissue components (i.e., the solid matrix constituents and the fluid phase) and the mechanical response according to the developmental stage of the tissue. Menisci derived from partially and fully developed pigs were analyzed. We carried out biochemical analyses to quantify glycosaminoglycan (GAG) and DNA content according to the developmental stage. These values were related to tissue mechanical properties that were measured in vitro by performing compression and tension tests on meniscal specimens. Both compression and tension protocols consisted of multi-ramp stress-relaxation tests comprised of increasing strains followed by stress-relaxation to equilibrium. To better understand the mechanical response to different directions of mechanical stimulus and to relate it to the tissue structural composition and development, we performed numerical simulations that implemented different constitutive models (poro-elasticity, viscoelasticity, transversal isotropy, or combinations of the above) using the commercial software COMSOL Multiphysics. The numerical models also allowed us to determine several mechanical parameters that cannot be directly measured by experimental tests. The results of our investigation showed that the meniscus is a non-linear, anisotropic, non-homogeneous material: mechanical parameters increase with strain, depend on the direction of load, and vary among regions (anterior, central, and posterior). Preliminary numerical results showed the predominant role of the different tissue components depending on the mechanical stimulus. The outcomes of biochemical analyses related to mechanical properties confirmed the findings of the numerical models, suggesting a specific response of meniscal cells to the regional mechanical stimuli in the knee joint. During maturation, the increase in compressive moduli could be explained by cell differentiation from fibroblasts to metabolically active chondrocytes, as indicated by the found increase in GAG/DNA ratio. The changes of tensile mechanical response during development could be related to collagen II accumulation during growth. This study provides new information on the changes of tissue structural components during maturation and the relationship between tissue composition and mechanical response.

Histological Evaluation of Harvested Specimen of a Patient Who Underwent Unicompartmental Knee Arthroplasty Two Years and Six Months After Medial Meniscus Posterior Root Tear Transtibial Pull-Out Repair

Transtibial pull-out repair is routinely performed to treat medial meniscal posterior root tear (MMPRT). However, data on the postoperative histological evaluation of the repaired medial meniscus posterior attachment after the procedure is scarce. In this report, we present a histological evaluation of the harvested specimen of a patient who underwent unicompartmental knee arthroplasty (UKA) approximately two years and six months after MMPRT transtibial pull-out repair. The patient was a 75-year-old female. Her X-ray showed Kellgren-Lawrence classification grade II and her MRI revealed MMPRT. Arthroscopic transtibial pull-out repair was performed two months after the onset, and her condition was fine two years after the operation. However, her knee pain gradually worsened, and UKA was performed two years and six months after the initial surgery. The medial meniscus posterior root was continuous from the resected tibia. Tissue specimens were prepared and evaluated. There were Sharpey's fiber-like tissues in the tibial bone tunnel. The medial meniscus posterior attachment showed a four-layer structure of ligaments, uncalcified fibrocartilage, calcified fibrocartilage, and subchondral bone zone. The structures were observed 2,000 ㎛ medially from the bone tunnel. The results revealed that the reconstructed graft after a transtibial pull-out repair for the medial meniscus posterior root showed different histological findings compared with the native posterior root and similar to the anterior root of the medial meniscus.

Effect of Vastus Medialis Loss on Rabbit Patellofemoral Joint Contact Pressure Distribution

Vastus medialis (VM) weakness is thought to alter patellar tracking, thereby changing the loading of the patellofemoral joint (PFJ), resulting in patellofemoral pain. However, it is challenging to measure VM force and weakness in human studies, nor is it possible to measure the associated mechanical changes in the PFJ. To obtain fundamental insight into VM weakness and its effects on PFJ mechanics, the authors determined PFJ loading in the presence of experimentally simulated VM weakness. Skeletally mature New Zealand White rabbits were used (n = 6), and the vastus lateralis, VM, and rectus femoris were stimulated individually through 3 custom-built nerve cuff electrodes. Muscle torque and PFJ pressure distribution were measured while activating all muscles simultaneously, or when the vastus lateralis and rectus femoris were activated, while VM was not, to simulate a quadriceps muscle strength imbalance. For a given muscular joint torque, peak pressures were greater and joint contact areas were smaller when simulating VM weakness compared with the condition where all muscles were activated simultaneously. The results in the rabbit model support that VM weakness results in altered PFJ loading, which may cause patellofemoral pain, often associated with a strength imbalance of the knee extensor muscle group.

Influence of the posterior cruciate ligament on kinematics of the knee during experimentally simulated clinical tests and activities of daily living

Clinical outcomes following posterior cruciate ligament (PCL) reconstruction are often suboptimal. A better understanding of the biomechanical contributions of the PCL to knee stability under physiologic, clinically-relevant loading conditions could improve reconstruction techniques and outcomes. We employed a servohydraulic joint motion simulator to investigate the kinematics of intact and PCL-deficient knees during simulated clinical tests and activities of daily living(ADL), including gait, stair ascent and descent. PCL transection caused the tibia to be displaced posterior, relative to the intact joint, throughout flexion. PCL transection also increased the amount of posterior tibial displacement measured during posterior laxity testing by up to 9.6 ± 1.7 mm at 75° (p = 0.001). During internal-external rotational laxity testing, PCL transection increased the allowable internal and external rotation of the tibia, by up to 2.9 ± 0.5°at90° (p = 0.001) and 1.0 ± 0.2° at45°(p = 0.001), respectively. PCL transection did not have a significant effect on abduction-adduction kinematics or laxity, regardless of flexion angle. PCL transection resulted in a relative posterior displacement of the tibia during the stance phase of gait when the knee was extended (2.2 ± 2.2 mm, p = 0.045), and when the knee was flexed during stair ascent (2.4 ± 2.2 mm, p = 0.035) and descent (1.6 ± 1.4 mm, p = 0.037). Our results support previous studies of the role of the PCL on neutral joint kinematics and laxity, and provide new data quantifying the effect of PCL transection on AP kinematics during simulated ADL.

Effects of Ultra-Purified Alginate Gel Implantation on Meniscal Defects in Rabbits

BACKGROUND

Many tissue-engineered methods for meniscal repair have been studied, but their utility remains unclear.

HYPOTHESIS

Implantation of low-endotoxin, ultra-purified alginate (UPAL) gel without cells could induce fibrocartilage regeneration on meniscal defects in rabbits.

STUDY DESIGN

Controlled laboratory study.

METHODS

Forty-two mature Japanese White rabbits were divided into 2 groups of 21 animals each. In each animal, a cylindrical defect measuring 2 mm in diameter was created with a biopsy punch on the anterior horn of the medial meniscus. In the control group, no treatment was applied on the left medial meniscal defect. In the UPAL gel group, the right medial meniscal defect was injected with the UPAL gel and gelated by a CaCl₂ solution. Samples were evaluated at 3, 6, and 12 weeks postoperatively. For biomechanical evaluation, 6 additional samples from intact animals were used for comparison.

RESULTS

The macroscopic score was significantly greater in the UPAL gel group than in the control group at 3 weeks (mean ± SE: 5.6 ± 0.82 vs 3.4 ± 0.83, P = .010), 6 weeks (5.9 ± 0.72 vs 2.5 ± 0.75, P = .026), and 12 weeks (5.2 ± 1.21 vs 1.0 ± 0.63, P = .020). The histological score was significantly greater in the UPAL group than in the control group at 3 weeks (2.1 ± 0.31 vs 1.2 ± 0.25, P = .029) and 12 weeks (2.2 ± 0.55 vs 0.3 ± 0.21, P = .016). The mean stiffness of the reparative tissue in the UPAL gel group was significantly greater than that in the control group at 6 weeks (24.325 ± 3.920 N/mm vs 8.723 ± 1.190 N/mm, P = .006) and at 12 weeks (27.804 ± 6.169 N/mm vs not applicable [because of rupture]).

CONCLUSION

The UPAL gel enhanced the spontaneous repair of fibrocartilage tissues in a cylindrical meniscal defect in rabbits.

CLINICAL RELEVANCE

These results imply that the acellular UPAL gel may improve the repair of traumatic meniscal injuries.

Vastus lateralis and vastus medialis produce distinct mediolateral forces on the patella but similar forces on the tibia in the rat

Improper activation of the quadriceps muscles vastus medialis (VM) and vastus lateralis (VL) has been implicated in the development of patellofemoral pain (PFP). This explanation of PFP assumes that VM and VL produce opposing mediolateral forces on the patella. Although studies have provided evidence for opposing actions of VM and VL on the patella, other studies have suggested that their actions might be similar. In this study, we took advantage of the experimental accessibility of the rat to directly measure the forces on the patella produced by VM and VL. We found that VM and VL produce opposing mediolateral forces on the patella when the patella was lifted away from the femur. These distinct mediolateral forces were not transmitted to the tibia, however: forces measured at the distal tibia were very similar for VM and VL. Further, when the patella was placed within the trochlear groove, the forces on the patella produced by VM and VL were very similar to one another. These results suggest that mediolateral forces produced by VM and VL are balanced by reaction forces from the trochlear groove and so are not transmitted to the tibia. These results provide a rich characterization of the mechanical actions of VM and VL and have implications about the potential role of these muscles in PFP and their neural control during behavior.

Coronal Knee Alignment 40 Years after Total Meniscectomy in Adolescents: A Prospective Cohort Study

Introduction:

Meniscectomies result in altered knee biomechanics and increase contact forces on the operated knee joint.

Methods:

We assessed coronal knee alignment in relation to radiological osteoarthritis grading, clinical range of movement and patient reported outcome measures 40 years after total open meniscectomies in adolescence. Thirty eight knees (30 patients) that underwent total open meniscectomy were assessed on standardised weight-bearing anteroposterior radiographs for deviation from ‘physiological valgus angle’ in either direction (magnitude of malalignment). These values were analysed as per site of meniscectomy for correlations with radiographic scoring systems, range of motion and patient reported outcome measures.

Results:

Tibiofemoral angle was significantly more varus, and the magnitude of malalignment was significantly higher for the medial meniscectomy patients. The range of flexion was lower for those patients who underwent medial and lateral meniscectomies of the same knee. The patients who underwent meniscectomies of both knees had worse scores for IKDC and KOOS quality of life. Tibiofemoral angle, magnitude of malalignment and range of flexion strongly correlated with Ahlback, and Kellgren and Laurence scores, but patient reported that outcome measures did not correlate.

Conclusion:

Meniscectomy induced malalignment corresponds to the site of meniscectomy and the radiographic degree of osteoarthritis. While malalignment and reduced range of movement correlate well with worsening radiographic signs of arthritis, patient reported outcome measures do not correlate.

Role of Patellofemoral Offset in Total Knee Arthroplasty: A Randomized Trial

Total knee arthroplasty occasionally does not meet expectations. This randomized clinical trial assessed the effect of restoration of the native patellofemoral height on clinical outcomes. Group I underwent standard patellar bone resection; group II underwent modified patellar bone resection that adjusted the amount of anterior condylar bone removed and the anterior flange thickness. There were no differences in anterior knee pain, Western Ontario and McMaster Universities Arthritis Index scores, or Knee Injury and Osteoarthritis Outcome Score scores. Patellofemoral compartment height restoration versus patellar height alone does not appear to significantly reduce pain or improve function.

Does Anteromedial Portal Drilling Improve Footprint Placement in Anterior Cruciate Ligament Reconstruction?

BACKGROUND

Considerable debate remains over which anterior cruciate ligament (ACL) reconstruction technique can best restore knee stability. Traditionally, femoral tunnel drilling has been done through a previously drilled tibial tunnel; however, potential nonanatomic tunnel placement can produce a vertical graft, which although it would restore sagittal stability, it would not control rotational stability. To address this, some suggest that the femoral tunnel be created independently of the tibial tunnel through the use of an anteromedial (AM) portal, but whether this results in a more anatomic footprint or in stability comparable to that of the intact contralateral knee still remains controversial.

QUESTIONS/PURPOSES

(1) Does the AM technique achieve footprints closer to anatomic than the transtibial (TT) technique? (2) Does the AM technique result in stability equivalent to that of the intact contralateral knee? (3) Are there differences in patient-reported outcomes between the two techniques?

METHODS

Twenty male patients who underwent a bone-patellar tendon-bone autograft were recruited for this study, 10 in the TT group and 10 in the AM group. Patients in each group were randomly selected from four surgeons at our institution with both groups demonstrating similar demographics. The type of procedure chosen for each patient was based on the preferred technique of the surgeon. Some surgeons exclusively used the TT technique, whereas other surgeons specifically used the AM technique. Surgeons had no input on which patients were chosen to participate in this study. Mean postoperative time was 13 ± 2.8 and 15 ± 3.2 months for the TT and AM groups, respectively. Patients were identified retrospectively as having either the TT or AM Technique from our institutional database. At followup, clinical outcome scores were gathered as well as the footprint placement and knee stability assessed. To assess the footprint placement and knee stability, three-dimensional surface models of the femur, tibia, and ACL were created from MRI scans. The femoral and tibial footprints of the ACL reconstruction as compared with the intact contralateral ACL were determined. In addition, the AP displacement and rotational displacement of the femur were determined. Lastly, as a secondary measurement of stability, KT-1000 measurements were obtained at the followup visit. An a priori sample size calculation indicated that with 2n = 20 patients, we could detect a difference of 1 mm with 80% power at p < 0.05. A Welch two-sample t-test (p < 0.05) was performed to determine differences in the footprint measurements, AP displacement, rotational displacement, and KT-1000 measurements between the TT and AM groups. We further used the confidence interval approach with 90% confidence intervals on the pairwise mean group differences using a Games-Howell post hoc test to assess equivalence between the TT and AM groups for the previously mentioned measures.

RESULTS

The AM and TT techniques were the same in terms of footprint except in the distal-proximal location of the femur. The TT for the femoral footprint (DP%D) was 9% ± 6%, whereas the AM was -1% ± 13% (p = 0.04). The TT technique resulted in a more proximal footprint and therefore a more vertical graft compared with intact ACL. The AP displacement and rotation between groups were the same and clinical outcomes did not demonstrate a difference.

CONCLUSIONS

Although the AM portal drilling may place the femoral footprint in a more anatomic position, clinical stability and outcomes may be similar as long as attempts are made at creating an anatomic position of the graft.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The effects of the sagittal plane malpositioning of the patella and concomitant quadriceps hypotrophy on the patellofemoral joint: a finite element analysis

PURPOSE

Anterior knee pain is a common symptom after intramedullary nailing in tibia shaft fracture. Moreover, patellofemoral malalignment is also known to be a major reason for anterior knee pain. Patellofemoral malalignment predisposes to increased loading in patellar cartilage. In the previous study, we have demonstrated the quadriceps atrophy and patellofemoral malalignment after intramedullary nailing due to tibia shaft fracture. In this study, our aim was to clarify the effects of quadriceps atrophy and patellofemoral malalignment with the pathologic loading on the joint cartilage.

METHODS

Mesh models of patellofemoral joint were constructed with CT images and integrated with soft tissue components such as menisci and ligaments. Physiological and sagittal tilt models during extension and flexion at 15°, 30° and 60° were created generating eight models. All the models were applied with 137 N force to present the effects of normal loading and 115.7 N force for the simulation of quadriceps atrophy. Different degrees of loading were applied to evaluate the joint contact area and pressure value with the finite element analysis.

RESULTS

There was increased patellofemoral contact area in patellar tilt models with respect to normal models. The similar loading patterns were diagnosed in all models at 0° and 15° knee flexion when 137 N force was applied. Higher loading values were obtained at 30° and 60° knee flexions in sagittal tilt models. Furthermore, in the sagittal tilt models, in which the quadriceps atrophy was simulated, the loadings at 30° and 60° knee flexion were higher than in the physiological ones.

CONCLUSIONS

Sagittal malalignment of the patellofemoral joint is a new concept that results in different loading patterns in the patellofemoral joint biomechanics. This malalignment in sagittal plane leads to increased loading values on the patellofemoral joint at 30° and 60° of the knee flexions. This new concept should be kept in mind during the course of diagnosis and treatment in patients with anterior knee pain. Definition of the exact biomechanical effects of the sagittal tilting will lead to the development of new treatment modalities.

Ultrasonographic evaluation of the femoral cartilage thickness in patients with chronic renal failure

OBJECTIVE

To investigate the effects of chronic renal failure (CRF) on the distal femoral cartilage thickness by using ultrasonography and to determine the relationship between cartilage thickness and certain disease-related parameters.

DESIGN

Fifty-seven CRF patients (41 male and 16 female) (mean [SD] age, 44.7 [12.1] years) and 60 healthy controls (41 male and 19 female) (mean [SD] age, 43.5 [13.3] years) were enrolled in this study. Demographic and clinical characteristics were recorded. Cartilage thickness measurements were taken from the medial and lateral condyles, and intercondylar areas of both knees.

RESULTS

Groups were similar in terms of age, weight, height, body mass index and gender (all p>0.05). The mean cartilage thickness was found to be less in CRF patients than in controls (statistically significant for medial condyles and intercondylar areas both in right and the left knees [all p<0.05]). Cartilage thickness showed no correlation with eGFR, and with the levels of serum urea, creatinine, calcium, magnesium, phosphor, hemoglobin, uric acid and as well as steroid use (all p>0.05) in CRF patients.

CONCLUSION

In the light of our findings, we imply that patients with CRF have thinner femoral cartilage than healthy controls. This result may support the view that patients with CRF are at increased risk for developing early knee osteoarthritis. Last but not least, clinicians should be aware of the importance of rehabilitation strategies aimed at decreasing onset and progression of knee osteoarthritis in patients with CRF.

Biphasic Analysis of Cartilage Stresses in the Patellofemoral Joint

The objective of this study was to examine the state of stress within the solid matrix of articular cartilage in the patellofemoral joint, using anatomically faithful biphasic models of the articular layers, with the joint subjected to physiologic muscle force magnitudes. Finite element models of five joints were created from human cadaver knees. Biphasic sliding contact analyses were performed using FEBio software to analyze the response of the joint from 30 to 60 degrees of knee flexion. Results demonstrated that the collagen matrix always sustains tensile stresses, despite the fact that the articular layers are loaded in compression. The principal direction of maximum solid stresses was consistent with the known orientation of collagen fibrils in cartilage. The magnitudes of these tensile stresses under muscle forces representative of activities of daily living were well below tensile failure stresses reported in the prior literature. Results also hinted that solid matrix stresses were higher in the patellar versus femoral superficial zone. These anatomically correct finite element models predicted outcomes consistent with our understanding of structure-function relationships in articular cartilage, while also producing solid matrix stress estimates not observable from experiments alone, yet highly relevant to our understanding of tissue degeneration.

Comparison of the biomechanical tensile and compressive properties of decellularised and natural porcine meniscus

Meniscal repair is widely used as a treatment for meniscus injury. However, where meniscal damage has progressed such that repair is not possible, approaches for partial meniscus replacement are now being developed which have the potential to restore the functional role of the meniscus, in stabilising the knee joint, absorbing and distributing stress during loading, and prevent early degenerative joint disease. One attractive potential solution to the current lack of meniscal replacements is the use of decellularised natural biological scaffolds, derived from xenogeneic tissues, which are produced by treating the native tissue to remove the immunogenic cells. The current study investigated the effect of decellularisation on the biomechanical tensile and compressive (indentation and unconfined) properties of the porcine medial meniscus through an experimental-computational approach. The results showed that decellularised medial porcine meniscus maintained the tensile biomechanical properties of the native meniscus, but had lower tensile initial elastic modulus. In compression, decellularised medial porcine meniscus generally showed lower elastic modulus and higher permeability compared to that of the native meniscus. These changes in the biomechanical properties, which ranged from less than 1% to 40%, may be due to the reduction of glycosaminoglycans (GAG) content during the decellularisation process. The predicted biomechanical properties for the decellularised medial porcine meniscus were within the reported range for the human meniscus, making it an appropriate biological scaffold for consideration as a partial meniscus replacement.

The use of blood vessel-derived stem cells for meniscal regeneration and repair

PURPOSE

Surgical repairs of tears in the vascular region of the meniscus usually heal better than repairs performed in the avascular region; thus, we hypothesized that this region might possess a richer supply of vascular-derived stem cells than the avascular region.

METHODS

In this study, we analyzed 6 menisci extracted from aborted human fetuses and 12 human lateral menisci extracted from adult human subjects undergoing total knee arthroplasty. Menisci were immunostained for CD34 (a stem cell marker) and CD146 (a pericyte marker) in situ, whereas other menisci were dissected into two regions (peripheral and inner) and used to isolate meniscus-derived cells by flow cytometry. Cell populations expressing CD34 and CD146 were tested for their multilineage differentiation potentials, including chondrogenic, osteogenic, and adipogenic lineages. Fetal peripheral meniscus cells were transplanted by intracapsular injection into the knee joints of an athymic rat meniscal tear model. Rat menisci were extracted and histologically evaluated after 4 wk posttransplantation.

RESULTS

Immunohistochemistry and flow cytometric analyses demonstrated that a higher number of CD34- and CD146-positive cells were found in the peripheral region compared with the inner region. The CD34- and CD146-positive cells isolated from the vascular region of both fetal and adult menisci demonstrated multilineage differentiation capacities and were more potent than cells isolated from the inner (avascular) region. Fetal CD34- and CD146-positive cells transplanted into the athymic rat knee joint were recruited into the meniscal tear sites and contributed to meniscus repair.

CONCLUSIONS

The vascularized region of the meniscus contains more stem cells than the avascular region. These meniscal-derived stem cells were multipotent and contributed to meniscal regeneration.

Using Design of Experiments Methods for Assessing Peak Contact Pressure to Material Properties of Soft Tissue in Human Knee

Contact pressure in the knee joint is a key element in the mechanisms of knee pain and osteoarthritis. Assessing the contact pressure in tibiofemoral joint is a challenging mechanical problem due to uncertainty in material properties. In this study, a sensitivity analysis of tibiofemoral peak contact pressure to the material properties of the soft tissue was carried out through fractional factorial and Box-Behnken designs. The cartilage was modeled as linear elastic material, and in addition to its elastic modulus, interaction effects of soft tissue material properties were added compared to previous research. The results indicated that elastic modulus of the cartilage is the most effective factor. Interaction effects of axial/radial modulus with elastic modulus of cartilage, circumferential and axial/radial moduli of meniscus were other influential factors. Furthermore this study showed how design of experiment methods can help designers to reduce the number of finite element analyses and to better interpret the results.

Validation of an MRI-based method to assess patellofemoral joint contact areas in loaded knee flexion in vivo

PURPOSE

To develop and validate short axial and sagittal MRI scans (<1min) to assess in vivo patellofemoral contact areas in loaded knee flexion.

MATERIALS AND METHODS

Contact area was assessed in four cadaver knee specimens from axial and sagittal scans using two contact area extraction techniques (delineation and intersection) and three calculation techniques (slice thickness multiplication, linear interpolation, and spline interpolation). Error was expressed as the mean absolute and percentage difference from a dye staining-based reference standard. Intrareader and intrasubject repeatability, expressed as the mean standard deviation, was determined.

RESULTS

Contact area assessments from the sagittal MRI scans using the delineation and slice thickness multiplication technique had the smallest error (47.7 ± 38.1 mm(2) or 10.7%). The intrareader repeatability from assessments using the sagittal scans was smaller than those using the axial scans when the delineation method was used (<9.4 ± 4.3 mm(2) and <15.4 ± 14.1 mm(2) , respectively). The intrasubject repeatability of the assessment from the sagittal scan was less than 39.9 ± 23.0 mm(2) .

CONCLUSION

This protocol yields assessments of contact area in less than 1 minute that have errors similar to those made using scans many times longer and can be used in series with kinematic scans to carry out simultaneous assessments in vivo to study patellofemoral joint disease.

A geometric approach to study the contact mechanisms in the patellofemoral joint of normal versus patellofemoral pain syndrome subjects

The biomechanics of the patellofemoral (PF) joint is complex in nature, and the aetiology of such manifestations of PF instability as patellofemoral pain syndrome (PFPS) is still unclear. At this point, the particular factors affecting PFPS have not yet been determined. This study has two objectives: (1) The first is to develop an alternative geometric method using a three-dimensional (3D) registration technique and linear mapping to investigate the PF joint contact stress using an indirect measure: the depth of virtual penetration (PD) of the patellar cartilage surface into the femoral cartilage surface. (2) The second is to develop 3D PF joint models using the finite element analysis (FEA) to quantify in vivo cartilage contact stress and to compare the peak contact stress location obtained from the FE models with the location of the maximum PD. Magnetic resonance images of healthy and PFPS subjects at knee flexion angles of 15°, 30° and 45° during isometric loading have been used to develop the geometric models. The results obtained from both approaches demonstrated that the subjects with PFPS show higher PD and contact stresses than the normal subjects. Maximum stress and PD increase with flexion angle, and occur on the lateral side in healthy and on the medial side in PFPS subjects. It has been concluded that the alternative geometric method is reliable in addition to being computationally efficient compared with FEA, and has the potential to assess the mechanics of PFPS with an accuracy similar to the FEA.

The measurement of joint mechanics and their role in osteoarthritis genesis and progression

Mechanics play a role in the initiation and progression of osteoarthritis. However, our understanding of which mechanical parameters are most important, and what their impact is on the disease, is limited by the challenge of measuring the most important mechanical quantities in living subjects. Consequently, comprehensive statements cannot be made about how mechanics should be modified to prevent, slow or arrest osteoarthritis. Our current understanding is based largely on studies of deviations from normal mechanics caused by malalignment, injury, and deformity. Some treatments for osteoarthritis focus on correcting mechanics, but there appears to be scope for more mechanically based interventions.

Computational aspects in mechanical modeling of the articular cartilage tissue

This review focuses on the modeling of articular cartilage (at the tissue level), chondrocyte mechanobiology (at the cell level) and a combination of both in a multiscale computation scheme. The primary objective is to evaluate the advantages and disadvantages of conventional models implemented to study the mechanics of the articular cartilage tissue and chondrocytes. From monophasic material models as the simplest form to more complicated multiscale theories, these approaches have been frequently used to model articular cartilage and have contributed significantly to modeling joint mechanics, addressing and resolving numerous issues regarding cartilage mechanics and function. It should be noted that attentiveness is important when using different modeling approaches, as the choice of the model limits the applications available. In this review, we discuss the conventional models applicable to some of the mechanical aspects of articular cartilage such as lubrication, swelling pressure and chondrocyte mechanics and address some of the issues associated with the current modeling approaches. We then suggest future pathways for a more realistic modeling strategy as applied for the simulation of the mechanics of the cartilage tissue using multiscale and parallelized finite element method.

A detailed and validated three dimensional dynamic model of the patellofemoral joint

A detailed 3D anatomical model of the patellofemoral joint was developed to study the tracking, force, contact and stability characteristics of the joint. The quadriceps was considered to include six components represented by 15 force vectors. The patellar tendon was modeled using four bundles of viscoelastic tensile elements. Each of the lateral and medial retinaculum was modeled by a three-bundle nonlinear spring. The femur and patella were considered as rigid bodies with their articular cartilage layers represented by an isotropic viscoelastic material. The geometrical and tracking data needed for model simulation, as well as validation of its results, were obtained from an in vivo experiment, involving MR imaging of a normal knee while performing isometric leg press against a constant 140 N force. The model was formulated within the framework of a rigid body spring model and solved using forth-order Runge-Kutta, for knee flexion angles between zero and 50 degrees. Results indicated a good agreement between the model predictions for patellar tracking and the experimental results with RMS deviations of about 2 mm for translations (less than 0.7 mm for patellar mediolateral shift), and 4 degrees for rotations (less than 3 degrees for patellar tilt). The contact pattern predicted by the model was also consistent with the results of the experiment and the literature. The joint contact force increased linearly with progressive knee flexion from 80 N to 210 N. The medial retinaculum experienced a peak force of 18 N at full extension that decreased with knee flexion and disappeared entirely at 20 degrees flexion. Analysis of the patellar time response to the quadriceps contraction suggested that the muscle activation most affected the patellar shift and tilt. These results are consistent with the recent observations in the literature concerning the significance of retinaculum and quadriceps in the patellar stability.

Effects of aging on articular cartilage homeostasis

This review is focused on aging-related changes in cells and extracellular matrix of the articular cartilage. Major extracellular matrix changes are a reduced thickness of cartilage, proteolysis, advanced glycation and calcification. The cellular changes include reduced cell density, cellular senescence with abnormal secretory profiles, and impaired cellular defense mechanisms and anabolic responses. The extracellular and cellular changes compound each other, leading to biomechanical dysfunction and tissue destruction. The consequences of aging-related changes for joint homeostasis and risk for osteoarthritis are discussed. This article is part of a Special Issue entitled "Osteoarthritis".

Changes in patellofemoral joint contact pressures caused by vastus medialis muscle weakness

BACKGROUND

Patellofemoral joint pain is a common knee disorder, but its underlying causes remain unknown. One proposed mechanism is an imbalance in force in the knee extensor muscles. Specifically, the vastus medialis and vastus lateralis are thought to play a crucial role in proper patellar tracking, and weakness in vastus medialis is thought to lead to a lateral shift in the patella causing increased contact pressures and pain. The purpose of this study was to create an animal model of vastus medialis weakness and to test the effect of this weakness on patellofemoral contact pressures.

METHODS

Experiments were performed using New Zealand white rabbits (mass 4.9-7.7 kg, n=12). Loading of the patellofemoral joint was produced by femoral nerve stimulation of the knee extensor muscles. Knee extensor imbalance was produced by vastus medialis ablation. Fuji pressure sensitive film was used to record contact area, shape and pressures for maximal and sub-maximal, matched-force contractions at knee angles of 30°, 60°, and 90°.

FINDINGS

Patellofemoral peak pressures, average pressures, contact areas and contact shapes were the same across all loading conditions for matched-force contractions before and after elimination of vastus medialis.

INTERPRETATION

We conclude that vastus medialis weakness does not cause changes in patellofemoral contact pressures. Since the muscular and knee joint geometry in rabbits and humans is similar, we question the idea of vastus medialis weakness as a cause of patellar mal-tracking and patellofemoral joint pain.

Density and strength distribution in the human subchondral bone plate of the patella

PURPOSE

The aim of this study was to map the strength distribution of the human patella and correlate it to the subchondral bone plate density obtained by means of computed tomographyosteoabsorptiometry (CT-OAM).

METHODS

Measurements were performed at 34 standardized points on each patella. The mineralization patterns of the subchondral bone plate of 20 patellae were displayed with the help of CT-OAM. False-coloured distribution patterns for our measurements were generated. The mechanical strength was determined at the same points by indentation testing.

RESULTS

We showed that neither the density nor the mechanical strength is distributed homogeneously but exhibited regular, reproducible distribution patterns which mirror long-term stress distribution in articular surfaces. A direct correlation was found between both parameters in the subchondral bone plate.

CONCLUSION

The correlation of density and mechanical strength makes CT-OAM a valuable tool to assess and monitor changes in the strength of the subchondral bone plate in vivo.

Magnetic resonance imaging study of alteration of tibiofemoral joint articulation after posterior cruciate ligament injury

Cadaveric studies have shown that the posterior cruciate ligament (PCL) is an important constraint to posterior translation of the tibia. Arthroscopic studies have shown that chronic PCL injuries predispose to articular cartilage lesions in the medial compartment and the patellofemoral joint. The aim of the present study was to investigate sagittal plane articulation of the tibiofemoral joint of subjects with an isolated PCL injury. Magnetic resonance was used to generate sagittal images of 10 healthy knees and 10 knees with isolated PCL injuries. The subjects performed a supine leg press against a 150N load. Images were generated at 15° intervals as the knee flexed from 0 to 90°. The tibiofemoral contact and the flexion facet centre (FFC) were measured from the posterior tibial cortex. The contact pattern and FFC was significantly more anterior in the injured knee from 45 to 90° of knee flexion in the medial compartment compared to the healthy knee. The greatest difference between the mean TFC points of both groups occurred at 75 and 90°, the difference being 4mm and 5mm respectively. The greatest difference between the mean FFC of both groups occurred at 75° of flexion, which was 3mm. There was no significant difference in the contact pattern and FFC between the injured and healthy knees in the lateral compartment. Our findings show that there is a significant difference in the medial compartment sagittal plane articulation of the tibiofemoral joint in subjects with an isolated PCL injury.

Repair of meniscal defect using an induced myoblast-loaded polyglycolic acid mesh in a canine model

Defects of the meniscus greatly alter knee function and predispose the joint to degenerative changes. The purpose of this study was to test a recently developed cell-scaffold combination for the repair of a critical-size defect in the canine medial meniscus. A bilateral, complete resection of the anterior horn of the medial meniscus was performed in 18 Beagle canines. A PLGA scaffold was implanted into the defect of one knee of 6 canines and the contralateral defect was left untreated. Scaffolds loaded with autologous myoblasts and cultured in a chondrogenic medium for 14 days were implanted in a second series of 12 canines. Empty scaffolds were implanted in the contralateral knees. Menisci were harvested at 12 weeks. Untreated defects had a muted fibrous healing response. Defects treated with cell-free implants also showed predominantly fibrous tissue, whereas fibrocartilage was present in several scaffolds. The thickness of the repair tissue after treatment with cell-free scaffolds was significantly greater compared to the controls (p<0.05). Pre-cultured implants integrated with the host tissue, and 9 of 12 contained meniscus-like fibrocartilage when compared to 2 of the 12 controls (p<0.05). The thickness of the pre-cultured implant repair tissue was greater compared to the controls (p<0.05). This study demonstrates the repair of a critical size meniscal defect using a stem cell and scaffold-based tissue engineering approach.

Individuals with patellofemoral pain exhibit greater patellofemoral joint stress: a finite element analysis study

OBJECTIVE

To test the hypothesis that individuals with patellofemoral pain (PFP) exhibit greater patellofemoral joint stress profiles compared to persons who are pain-free.

METHODS

Ten females with PFP and ten gender, age, and activity-matched pain-free controls participated. Patella and femur stress profiles were quantified utilizing subject-specific finite element (FE) models of the patellofemoral joint at 15° and 45° of knee flexion. Input parameters for the FE model included: (1) joint geometry, (2) quadriceps muscle forces, and (3) weight-bearing patellofemoral joint kinematics. Using a nonlinear FE solver, quasi-static loading simulations were performed to quantify each subject's patellofemoral joint stress profile during a static squatting maneuver. The patella and femur peak and mean hydrostatic pressure as well as the peak and mean octahedral shear stress for the elements representing the chondro-osseous interface were quantified.

RESULTS

Compared to the pain-free controls, individuals with PFP consistently exhibited greater peak and mean hydrostatic pressure as well as peak and mean octahedral shear stress for the elements representing the patella and femur chondro-osseous interface across the two knee flexion angles tested (15° and 45°).

CONCLUSIONS

The combined finding of elevated hydrostatic pressure and octahedral shear stress across the two knee flexion angles supports the premise that PFP may be associated with elevated joint stress. Therefore, treatments aimed at decreasing patellofemoral joint stress may be indicated in this patient population.

Differences in patellar cartilage thickness, transverse relaxation time, and deformational behavior: a comparison of young women with and without patellofemoral pain

BACKGROUND

The origin of patellofemoral pain (PFP) may be associated with the inability of the patellofemoral joint cartilage to absorb and distribute patellofemoral joint forces.

HYPOTHESIS

When compared with a pain-free control group, young active women with PFP will demonstrate differences in their baseline patellar cartilage thickness and transverse (T2) relaxation time, as well as a less adaptive response to an acute bout of joint loading.

STUDY DESIGN

Controlled laboratory study; Level of evidence, 3.

METHODS

Ten women between the ages of 23 to 37 years with PFP and 10 sex-, age-, and activity-matched pain-free controls participated. Quantitative magnetic resonance imaging of the patellofemoral joint was performed at baseline and after participants performed 50 deep knee bends. Differences in baseline cartilage thickness and T2 relaxation time, as well as the postexercise change in patellar cartilage thickness and T2 relaxation time, were compared between groups.

RESULTS

Individuals with PFP demonstrated reductions in baseline cartilage thickness of 14.0% and 14.1% for the lateral patellar facet and total patellar cartilage, respectively. Similarly, individuals with PFP exhibited significantly lower postexercise cartilage thickness change for the lateral patellar facet (2.1% vs 8.9%) and the total patellar cartilage (4.4% vs 10.0%) when compared with the control group. No group differences in baseline or postexercise change in T2 relaxation time were found.

CONCLUSION

The findings suggest that a baseline reduction in patellar cartilage thickness and a reduced deformational behavior of patellar cartilage following an acute bout of loading are associated with presence of PFP symptoms.

Posterior root tear of the medial meniscus in multiple knee ligament injuries

The purposes of the present study were to examine the frequency and characteristics of root tears of the medial meniscus associated with ligament injuries of the knee and to evaluate the effectiveness of pull-out repair for restoring meniscus function. We retrospectively analyzed the 9 patients (10 knees) with posterior root tears of the medial meniscus and ligament injuries of the knee treated between August 2004 and February 2007. All the patients were male, with average age of 29.8 years, and the mean follow-up period was 29.7 months. The pull-out suture technique was used to repair the root tears. Clinical outcomes were evaluated using the Lysholm, IKDC, and Tegner scores, as well as the McMurray and Apley tests. The mean follow-up period was 41.1 months (range, 30 to 63 months). The incidence of root tears of the medial meniscus with ligament injuries was 2.74% (10 cases in 365 ligament surgeries). All clinical results showed significant improvement. At the final follow-up, McMurray test showed one positive and nine negative cases, and the Apley test revealed two positive and eight negative cases. There were no positive findings in anterior drawer test, posterior drawer test, valgus and varus stress test, and posterolateral instability test. Healing of the root tear was confirmed by arthroscopy in five patients and by MR in four patients. Root tears of the medial meniscus may occur in multiple knee ligament injuries. It is important not to miss them. Our results indicate that pull-out repair provides satisfactory results and evidence of healing.

The evaluation of a biphasic osteochondral implant coupled with an electrospun membrane in a large animal model

Conventional clinical therapies are unable to resolve osteochondral defects adequately; hence, tissue engineering solutions are sought to address the challenge. A biphasic implant that was seeded with mesenchymal stem cells (MSCs) and coupled with an electrospun membrane was evaluated as an alternative. This dual phase construct comprised of a polycaprolactone (PCL) cartilage scaffold and a PCL-tricalcium phosphate osseous matrix. Autologous MSCs were seeded into the entire implant via fibrin and the construct was inserted into critically sized osteochondral defects located at the medial condyle and patellar groove of pigs. The defect was resurfaced with a PCL-collagen electrospun mesh, which served as a substitute for periosteal flap in preventing cell leakage. Controls without either implanted MSCs or resurfacing membrane were included. After 6 months, cartilaginous repair was observed with a low occurrence of fibrocartilage at the medial condyle. Osteochondral repair was promoted and host cartilage degeneration was arrested as shown by superior glycosaminoglycan maintenance. This positive morphological outcome was supported by a higher relative Young's modulus, which indicated functional cartilage restoration. Bone ingrowth and remodeling occurred in all groups, with a higher degree of mineralization in the experimental group. Tissue repair was compromised in the absence of the implanted cells or the resurfacing membrane. Moreover, healing was inferior at the patellar groove when compared with the medial condyle and this was attributed to the native biomechanical features.

Anterior Cruciate Ligament Injury: Compensation during Gait using Hamstring Muscle Activity

Previous research has shown that an increase in hamstring activation may compensate for anterior tibial transalation (ATT) in patients with anterior cruciate ligament deficient knee (ACLd); however, the effects of this compensation still remain unclear. The goals of this study were to quantify the activation of the hamstring muscles needed to compensate the ATT in ACLd knee during the complete gait cycle and to evaluate the effect of this compensation on quadriceps activation and joint contact forces. A two dimensional model of the knee was used, which included the tibiofemoral and patellofemoral joints, knee ligaments, the medial capsule and two muscles units. Simulations were conducted to determine the ATT in healthy and ACLd knee and the hamstring activation needed to correct the abnormal ATT to normal levels (100% compensation) and to 50% compensation. Then, the quadriceps activation and the joint contact forces were calculated. Results showed that 100% compensation would require hamstring and quadriceps activations larger than their maximum isometric force, and would generate an increment in the peak contact force at the tibiofemoral (115%) and patellofemoral (48%) joint with respect to the healthy knee. On the other hand, 50% compensation would require less force generated by the muscles (less than 0.85 of maximum isometric force) and smaller contact forces (peak tibiofemoral contact force increased 23% and peak patellofemoral contact force decreased 7.5% with respect to the healthy knee). Total compensation of ATT by means of increased hamstring activity is possible; however, partial compensation represents a less deleterious strategy.

Meniscal tears

The menisci are two semilunar-shaped fibrocartilagenous structures, which are interposed between the femoral condyles and tibial plateaux. They have an important role in knee function. Long-term follow-up studies showed that virtually all meniscectomized knees develop arthritic changes with time. The meniscus has functions in load bearing, load transmission, shock absorption, joint stability, joint lubrication, and joint congruity. Because of these functions, meniscal tissue should be preserved whenever possible. A well-trained surgeon can safely rely on clinical examination for diagnosing meniscal injuries. History and clinical examination are at least as accurate as magnetic resonance imaging in the skilled orthopedic surgeon’s hand. When meniscal repair is not possible, partial resection of the meniscus is indicated. Meniscal repair has evolved from open to arthroscopic techniques, which include the inside-out and outside-in suture repairs and the all-inside techniques. Meniscal transplantation is generally accepted as a management alternative option for selected symptomatic patients with previous complete or near-complete meniscectomy.

The effect of load magnitude on three-dimensional patellar kinematics in vivo

Studies of three-dimensional patellar kinematics done with little or no applied load may not accurately reflect kinematics at physiological load levels, and may provide different results to those acquired with greater applied loads or in physiologic weightbearing. We report the effect of load magnitude on three-dimensional patellar kinematics (flexion, spin and tilt; proximal, lateral and anterior translation) using a validated, sequential static, MRI-based method. Ten healthy subjects loaded their study knee to 0% (no load), 15% and 30% bodyweight (BW) using a custom designed loading rig. Differences between loading levels were determined as a function of knee flexion for each kinematic parameter using linear hierarchical random-effects models. Quadratic and random slope terms were included in the models when significant. We found that the patellae flexed less with knee flexion at 30% BW load compared to 0% BW load (p<0.001) and 15% BW (p=0.004) load. The patellae showed a slight medial tilt with knee flexion at 30% BW load which was significantly less than the medial tilt seen at 0% BW load (p=0.017) and 15% BW load (p=0.043) with knee flexion. Small but statistically significant differences were also observed for proximal and anterior translation; the patellae were in a more proximal and posterior position at 30% BW load than at 0% BW load (p=0.010 and p=0.005, respectively) and 15% BW load (p<0.001 and p=0.029, respectively). Since differences in three-dimensional patellar kinematics were observed between loading levels, magnitudes of prescribed loads must be considered when designing studies and comparing results between studies.

Imaging the role of biomechanics in osteoarthritis

Osteoarthritis is widely believed to result from local mechanical factors acting within the context of systemic susceptibility. This narrative review delineates current understanding of the etiopathogenesis of osteoarthritis and more specifically examines the critical role of biomechanics in disease pathogenesis. There are several ways the mechanical forces across the joint can be measured, including some that rely heavily on imaging methods. These are described and methods to advance the field are proposed.

The role of interstitial fluid pressurization in articular cartilage lubrication

Over the last two decades, considerable progress has been reported in the field of cartilage mechanics that impacts our understanding of the role of interstitial fluid pressurization on cartilage lubrication. Theoretical and experimental studies have demonstrated that the interstitial fluid of cartilage pressurizes considerably under loading, potentially supporting most of the applied load under various transient or steady-state conditions. The fraction of the total load supported by fluid pressurization has been called the fluid load support. Experimental studies have demonstrated that the friction coefficient of cartilage correlates negatively with this variable, achieving remarkably low values when the fluid load support is greatest. A theoretical framework that embodies this relationship has been validated against experiments, predicting and explaining various outcomes, and demonstrating that a low friction coefficient can be maintained for prolonged loading durations under normal physiological function. This paper reviews salient aspects of this topic, as well as its implications for improving our understanding of boundary lubrication by molecular species in synovial fluid and the cartilage superficial zone. Effects of cartilage degeneration on its frictional response are also reviewed.