Fibre recruitment and shape changes of knee ligaments during motion: as revealed by a computer graphics-based model

Biomechanical Study of a Tricompartmental Unloader Brace for Patellofemoral or Multicompartment Knee Osteoarthritis

Objective: Off-loader knee braces have traditionally focused on redistributing loads away from either the medial or lateral tibiofemoral (TF) compartments. In this article, we study the potential of a novel "tricompartment unloader" (TCU) knee brace intended to simultaneously unload both the patellofemoral (PF) and TF joints during knee flexion. Three different models of the TCU brace are evaluated for their potential to unload the knee joint. Methods: A sagittal plane model of the knee was used to compute PF and TF contact forces, patellar and quadriceps tendon forces, and forces in the anterior and posterior cruciate ligaments during a deep knee bend (DKB) test using motion analysis data from eight participants. Forces were computed for the observed (no brace) and simulated braced conditions. A sensitivity and validity analysis was conducted to determine the valid output range for the model, and Statistical Parameter Mapping was used to quantify the effectual region of the different TCU brace models. Results: PF and TF joint force calculations were valid between ~0 and 100 degrees of flexion. All three simulated brace models significantly (p < 0.001) reduced predicted knee joint loads (by 30-50%) across all structures, at knee flexion angles >~30 degrees during DKB. Conclusions: The TCU brace is predicted to reduce PF and TF knee joint contact loads during weight-bearing activity requiring knee flexion angles between 30 and 100 degrees; this effect may be clinically beneficial for pain reduction or rehabilitation from common knee injuries or joint disorders. Future work is needed to assess the range of possible clinical and prophylactic benefits of the TCU brace.

Three-dimensional patellar tendon fibre kinematics in navigated TKA with and without patellar resurfacing

PURPOSE

Physiological elongation and orientation of patellar tendon fibres are among the scopes of total knee arthroplasty, but little is known in the three dimensions. The study aims to assess in vitro these variations at the intact and replaced knee, with and without patellar resurfacing. It was hypothesised that fibre patterns differ before and after prosthesis implantation, and between specific prosthesis designs. It was also expected that patellar resurfacing would affect relevant results.

METHODS

Measurements from 16 intact cadaver knees free from anatomical defects are here reported using a surgical navigation system. Data were collected at the intact joint and after implantation with cruciate-retaining or posterior-stabilised prosthesis designs, with and without patellar resurfacing. Relevant anatomical landmarks and patellar tendon attachments were digitised. Anatomical reference frames in the femur, tibia and patella were defined to measure component implantation parameters. Representative tendon fibres were defined as the straight line segments joining the two extremities. Changes in length and orientation of these fibres were calculated and reported versus flexion at the intact knee and after prosthesis implantation, both with and without patellar resurfacing.

RESULTS

A good intra- and inter-specimen repeatability was found at the intact and replaced knees. In both prosthesis designs, the patterns of fibre lengthening were similar to those in the intact knee, though significant differences were observed before and after patellar resurfacing. Corresponding fibre orientations in the frontal and sagittal planes showed significantly smaller ranges than those in the corresponding intact joints. More natural patterns were observed in the knees implanted with the posterior-stabilised design. Significant correlations were identified between patellar component implantation parameters and both patellar tendon fibre elongation and orientation.

CONCLUSIONS

Differences, however small, in patellar tendon fibre elongation and orientation were observed after total knee arthroplasty. The posterior-stabilised design provided better results, whereas patellar resurfacing affected significantly normal patellar function. In the clinical practice, the present findings can contribute to the understanding of current prosthesis designs and patellar resurfacing, recommending also enhanced care during this surgery.

Development and clinical application of meniscal unicompartmental arthroplasty

About one-third of osteoarthritic patients requiring knee replacement have focal lesions limited mainly to the medial compartment and can achieve excellent postoperative function after medial unicompartmental replacement. However, late failures of many unicompartmental prostheses require revision at a rate about twice that of total knee replacement. The use of a fully conforming mobile-bearing meniscal unicompartmental prosthesis in the hands of experienced surgeons can reduce revision rates to levels equivalent to the best results achieved with total knee replacement. The paper argues the case for such a prosthesis and demonstrates that the usual modes of failure of unicompartmental arthroplasty, most of them biomechanical, can thereby be avoided.

SAGITTAL PLANE KNEE LAXITY AFTER LIGAMENT RETAINING UNCONSTRAINED ARTHROPLASTY: A MATHEMATICAL ANALYSIS

Passive knee laxity is an important clinical measure to assess function after joint replacement. Clinical observations suggest that the use of minimally invasive surgical techniques in knee arthroplasty may affect the surgeon's ability to orient and position the prosthetic components accurately. Further, recent studies suggest that malplaced prosthetic components in ligament retaining unconstrained unicompartmental knee arthroplasty (UKA) can affect the ligament forces and, hence, the knee laxity. In the present study, a sagittal plane mathematical model of the knee with intact ligaments and unconstrained prosthetic components is used to analyze antero-posterior (A–P) knee laxity during passive flexion at different force levels. Also, the effects of errors in component placement are evaluated. The model calculations show a reasonable agreement with the experimental observations reported in literature. The results show that the A–P laxity during 0°–120° flexion first increases from 0° to about 30°, remains nearly constant for another 10° and then decreases somewhat linearly for higher flexion angles. Some errors in the placement of femoral component of the order of 1 mm can affect the knee laxity by nearly 3 mm in some flexion positions. The analysis has clinical relevance and suggests that the UKA requires close attention to component placement.

A multiple-bundle model to characterize the mechanical behavior of the cruciate ligaments

Measurements of elongations of the cruciate ligaments have been used to study the behaviors of these ligaments in-vitro and in-vivo, mostly based on simplified two-bundle models of the cruciates. The complex fiber anatomy of the cruciates may suggest a complex deformation behavior across the continuum of their substance that cannot be captured by only two measurement points. In this study, a new methodology was introduced to include more detailed fiber anatomy and to take into consideration the wrapping of the PCL around the intercondylar notch of the femur in deep flexion. The method was used in comparison to the conventional two-bundle models on three sample cadaver knees that underwent a passive flexion up to 150°. The elongation ratios of the bundles were measured as the ratio of change in the length of the bundles over their lengths at 0° flexion. The multiple-bundle models showed ranges of variations across the attachment sites of the cruciates which at all flexion angles were significantly larger than those observed from the conventional two-bundle models. When expressed in percentages, at 150° flexion the ranges of variations in the elongation ratio of the bundles were 32.7%±31.9% and 34%±8.6% for the ACL and PCL, respectively. Results of this study showed that important variations of elongation across the body of the cruciates can be obscured to the conventional two-bundle model of the cruciates, and therefore a more detailed bundle configuration is suggested for the purpose of studying elongation behaviors of these ligaments.

Assessment of isometricity before and after total knee arthroplasty: a cadaver study

Total knee arthroplasty (TKA) relies on soft tissue to regulate joint stability after surgery. In practice, the exact balance of the gaps can be difficult to measure, and various methods including intra-operative spreaders or distraction devices have been proposed. While individual ligament strain patterns have been measured, no data exist on the isometricity of the soft tissue envelope as a whole. In this study, a novel device was developed and validated to compare isometricity in the entire soft tissue envelope for both the intact and TKA knee. A spring-loaded rod was inserted in six cadaver knee joints between the tibial shaft and the tibial plateau or tibial tray after removing a 7 mm slice of bone. The displacement of the rod during passive flexion represented variation in tissue tension around the joint. The rod position in the intact knee remained within 1 mm of its initial position between 15 degrees and 135 degrees of flexion, and within 2 mm (+/-1.2 mm) throughout the entire range of motion (0-150 degrees). After insertion of a mobile-bearing TKA, the rod was displaced a mean of 6 mm at 150 degrees (p<0.001). The results were validated using a force transducer implanted in the tibial baseplate of the TKA, which showed increased tibiofemoral force in the parts of the flexion range where the rod was most displaced. The force measurements were highly correlated with the displacement pattern of the spring-loaded rod (r=-0.338; p=0.006). A simple device has been validated to measure isometricity in the soft tissue envelope around the knee joint. Isometricity measurements may be used in the future to improve implantation techniques during TKA surgery.

ACL/MCL transection affects knee ligament insertion distance of healing and intact ligaments during gait in the Ovine model

The objective of this study was to assess the impact of combined transection of the anterior cruciate and medial collateral ligaments on the intact and healing ligaments in the ovine stifle joint. In vivo 3D stifle joint kinematics were measured in eight sheep during treadmill walking (accuracy: 0.4+/-0.4mm, 0.4+/-0.4 degrees ). Kinematics were measured with the joint intact and at 2, 4, 8, 12, 16 and 20 weeks after either surgical ligament transection (n=5) or sham surgery without transection (n=3). After sacrifice at 20 weeks, the 3D subject-specific bone and ligament geometry were digitized, and the 3D distances between insertions (DBI) of ligaments during the dynamic in vivo motion were calculated. Anterior cruciate ligament/medial collateral ligament (ACL/MCL) transection resulted in changes in the DBI of not only the transected ACL, but also the intact lateral collateral ligament (LCL) and posterior cruciate ligament (PCL), while the DBI of the transected MCL was not significantly changed. Increases in the maximal ACL DBI (2 week: +4.2mm, 20 week: +5.7mm) caused increases in the range of ACL DBI (2 week: 3.6mm, 20 week: +3.8mm) and the ACL apparent strain (2 week: +18.9%, 20 week: +24.0%). Decreases in the minimal PCL DBI (2 week: -3.2mm, 20 week: -4.3mm) resulted in increases in the range of PCL DBI (2 week: +2.7mm, 20 week: +3.2mm). Decreases in the maximal LCL DBI (2 week: -1.0mm, 20 week: -2.0mm) caused decreased LCL apparent strain (2 week: -3.4%, 20 week: -6.9%). Changes in the mechanical environment of these ligaments may play a significant role in the biological changes observed in these ligaments.

A new model to predict in vivo human knee kinematics under physiological-like muscle activation

Although a number of approaches have attempted to model knee kinematics, rarely have they been validated against in vivo data in a larger subject cohort. Here, we assess the feasibility of four-bar linkage mechanisms in addressing knee kinematics and propose a new approach that is capable of accounting for lengthening characteristics of the ligaments, including possible laxity, as well as the internal/external rotation of the joint. MR scans of the knee joints of 12 healthy volunteers were taken at flexion angles of 0 degrees , 30 degrees and 90 degrees under both passive and active muscle conditions. By reconstructing the surfaces at each position, the accuracy of the four-bar linkage mechanism was assessed for every possible combination of points within each cruciate ligament attachment area. The specific set of parameters that minimized the deviation between the predictions and the in vivo pose was derived, producing a mean error of 1.8 and 2.5 on the medial and 1.7 and 2.4mm on the lateral side at 30 degrees and 90 degrees flexion, respectively, for passive motion, significantly improving on the models that did not consider internal/external rotation. For active flexion, mean medial errors were 3.3 and 4.7 mm and lateral errors 3.4 and 4.8 mm. Using this best parameter set, a generic predictive model was created and assessed against the known in vivo positions, producing a maximum average error of 4.9 mm at 90 degrees flexion. The accuracy achieved shows that kinematics may be accurately reconstructed for subject specific musculoskeletal models to allow a better understanding of the load distribution within the knee.

Ligament fibre recruitment at the human ankle joint complex in passive flexion

Knowledge of ligament fibre recruitment at the human ankle joint complex is a fundamental prerequisite for analysing mobility and stability. Previous experimental and modelling studies have shown that ankle motion must be guided by fibres within the calcaneofibular and tibiocalcaneal ligaments, which remain approximately isometric during passive flexion. The purpose of this study was to identify these fibres. Three below-knee amputated specimens were analysed during passive flexion with combined radiostereometry for bone pose estimation and 3D digitisation for ligament attachment area identification. A procedure based on singular value decomposition enabled matching bone pose with digitised data and therefore reconstructing position in space of ligament attachment areas in each joint position. Eleven ordered fibres, connecting corresponding points on origin and insertion curves, were modelled for each of the following ligaments: posterior talofibular, calcaneofibular, anterior talofibular, posterior tibiotalar, tibiocalcaneal, and anterior tibiotalar. The measured changes in length for the ligament fibres revealed patterns of tightening and slackening. The most anterior fibre of the calcaneofibular and the medio-anterior fibre of the tibiocalcaneal ligament exhibited the most isometric behaviour, as well as the most posterior fibre of the anterior talofibular ligament. Fibres within the calcaneofibular ligament remain parallel in the transverse plane, while those within the tibiocalcaneal ligament become almost parallel in joint neutral position. For both these ligaments, fibres maintain their relative inclination in the sagittal plane throughout the passive flexion range. The observed significant change in both shape and orientation of the ankle ligaments suggest that this knowledge is fundamental for future mechanical analysis of their response to external forces.

Ligament fibre recruitment and forces for the anterior drawer test at the human ankle joint

Although the anterior drawer test at the ankle joint is commonly used in routine clinical practice, very little is known about the sharing of load between the individual passive structures and the joint response at different flexion angles.A mathematical model of the ankle joint was devised to calculate ligament fibre recruitment and load/displacement curves at different flexion angles. Ligaments were modelled as three-dimensional arrays of fibres, and their orientations at different flexion angles were taken from a previously validated four-bar-linkage model in the sagittal plane. A non-linear stress/strain relationship was assumed for ligament fibres and relevant mechanical parameters were taken from two reports in the literature. Talus and calcaneus were assumed to move as a single rigid body. Antero/distal motion of the talus relative to the tibia was analysed. The ankle joint was found to be stiffer at the two extremes of the flexion range, and the highest laxity was found around the neutral position, confirming previous experimental works. With a first dataset, a 20N anterior force produced 4.3, 5.5, and 4.4mm displacement respectively at 20 degrees plantarflexion, at neutral, and at 20 degrees dorsiflexion. At 10 degrees plantarflexion, for a 6mm displacement, 65% of the external force was supported by the anterior talofibular, 11% by the deep anterior tibiotalar and 5.5% by the tibionavicular ligament. Corresponding results from a second dataset were 1.4, 2.4 and 1.8mm at 40N force, and 80%, 0% and 2% for a 3mm displacement. A component of the contact force supported the remainder.

Injury initiation and progression in the anterior cruciate ligament

OBJECTIVE

To develop a theoretical model to identify mechanisms by which total and partial tears of the anterior cruciate ligament could occur.

DESIGN

A sagittal-plane knee model was used to investigate anterior cruciate ligament injury due to excessive anterior tibial translation. The ligament was modelled as an ordered array of fibres linking femur and tibia.

BACKGROUND

Despite years of research, the detailed biomechanics of anterior cruciate ligament injury is not well understood.

METHODS

A "critical strain criterion" was used to identify the onset and progression of model ligament fibre disruption. The associated forces were also calculated.

RESULTS

At low flexion angles (<20 degrees ), the posterior fibre of the model ligament failed first, and the tear progressed anteriorly through the ligament. At higher flexion angles, the anterior fibre failed first, and the tear progressed posteriorly. Near the flexion angle at which the progression of injury changed direction, all fibres failed at approximately the same anterior tibial translation. At all but very high flexion angles, the force supported by the injured ligament was maximum when initial fibre failure occurred; the force then decreased with increasing anterior tibial translation.

CONCLUSIONS

Near (20 degrees ) flexion, all model anterior cruciate ligament fibres fail at approximately the same anterior tibial translation, implying that a partial ligament tear may be impossible in this flexion region. Relevance. This study provides insight into possible mechanisms of initiation and progression of anterior cruciate ligament injury. It suggests that a partial tear of the posterior half of the ligament may be difficult to detect clinically.

Biomechanical study of a computer simulated reconstruction of the anterior cruciate ligament (ACL)

The purpose of the study was to use a computer simulation of various surgical techniques for reconstruction of the anterior cruciate ligament (ACL) to study graft biomechanics. To ensure the normal function of the cruciate ligament and, consequently, normal kinematics of the knee joint, the complex structure of the normal ACL must be built into the graft.

METHODS

First the ACL was modeled and then a reconstruction of the ACL was simulated on a computer model of the cadaveric knee. Biomechanical patterns of the ACL and the modeled grafts in different spatial orientations and positions of the femoral attachments were studied. Isometricity of the peripheral and central fibers of the ACL and grafts was measured and the average fiber length change and isometric pattern of fibers in the graft were compared.

RESULTS

None of the ACL fibers is isometric and fiber length change varies with individual fibers of the original ligament or graft. The average length change of graft fibers depends on the position of the femoral attachment in the sagittal plane. It is smaller in anterior positions in relation to the geometric center of the femoral origin of the ACL, and larger in posterior positions. The isometric pattern of fibers in the graft in isometric orientations resembles most closely the pattern of the original ACL.

CONCLUSIONS

A computer simulation of various surgical techniques of reconstruction of the ACL can be successfully used for the study of biomechanics. The most significant kinematic characteristics of the ACL is gradual recruitment of graft fibers during knee extension, which can be defined as the pattern of isometricity. The isometric pattern of the graft is primarily influenced by spatial orientation.

The variation in the orientations and moment arms of the knee extensor and flexor muscle tendons with increasing muscle force: a mathematical analysis

The orientations and moment arms of the knee extensor and flexor muscle tendons are evaluated with increasing values of muscle force during simulated isometric exercises. A four-bar linkage model of the knee in the sagittal plane was used to define the motion of the joint in the unloaded state during 0-120 degrees flexion. The cruciate and collateral ligaments were represented by arrays of elastic fibres, which were recruited sequentially under load or remained buckled when slack. A bi-articular model of the patello-femoral joint was used. Simple straight-line representation was used for the lines of action of the forces transmitted by the model muscle tendons. The effects of tissue deformation with increasing muscle force were considered. During quadriceps contraction resisted by an external flexing load, the maximum change in moment arm of the patellar tendon was found to be 2 per cent at 0 degree flexion when the quadriceps force was increased tenfold, from 250 to 2500 N. The corresponding maximum change in orientation of the tendon was 3 degrees at 120 degrees flexion. During hamstrings contraction resisted by an external extending load, the maximum change in moment arm of the hamstrings tendon was 8 per cent at 60 degrees flexion when the hamstrings force was increased tenfold, from 100 to 1000 N. During gastrocnemious contraction, the corresponding maximum change for the gastrocnemious tendon was 3 per cent at 0 degree. The orientations of the flexor muscle tendons in this range of force either remained constant or changed by 1 degree or less at any flexion angle. The general trend at any flexion angle was that, as the muscle force was increased, the moment arms and the orientations approached nearly constant values, showing asymptotic behaviour. It is concluded that experimental simulations of knee muscle action with low values of the externally applied load, of the order of 50 N, can provide reliable estimates of the relationships between muscle forces and external loads during activity.

A geometric model of the human ankle joint

A two-dimensional four-bar linkage model of the ankle joint is formulated to describe dorsi/plantarflexion in unloaded conditions as observed in passive tests on ankle complex specimens. The experiments demonstrated that the human ankle joint complex behaves as a single-degree-of-freedom system during passive motion, with a moving axis of rotation. The bulk of the movement occurred at the level of the ankle. Fibres within the calcaneofibular and tibiocalcaneal ligaments remained approximately isometric. The experiments showed that passive kinematics of the ankle complex is governed only by the articular surfaces and the ligaments. It was deduced that the ankle is a single-degree-of-freedom mechanism where mobility is allowed by the sliding of the articular surfaces upon each other and the isometric rotation of two ligaments about their origins and insertions, without tissue deformation. The linkage model is formed by the tibia/fibula and talus/calcaneus bone segments and by the calcaneofibular and tibiocalcaneal ligament segments. The model predicts the path of calcaneus motion, ligament orientations, instantaneous axis of rotation, and conjugate talus surface profile as observed in the experiments. Many features of ankle kinematics such as rolling and multiaxial rotation are elucidated. The geometrical model is a necessary preliminary step to the study of ankle joint stability in response to applied loads and can be used to predict the effects of changes to the original geometry of the intact joint. Careful reconstruction of the original geometry of the ligaments is necessary after injury or during total ankle replacement.

The effect of cartilage deformation on the laxity of the knee joint

In this paper, deformation of the articular cartilage layers is incorporated into an existing two-dimensional quasi-static model of the knee joint. The new model relates the applied force and the joint displacement, as measured in the Lachmann drawer test, and allows the effect of cartilage deformation on the knee joint laxity to be determined. The new model augments the previous knee model by calculating the tibio-femoral contact force subject to an approximate 'thin-layer' constitutive equation, and a method is described for finding the configuration of the knee under a specified load, in terms of a displacement from a zero-load reference configuration. The results show that inclusion of deformable cartilage layers can cause a reduction of between 10 and 35 per cent in the force required to produce a given tibial displacement, over the range of flexion angles considered. The presence of cartilage deformation was found to be an important modifier of the loading response but is secondary to the effect of ligamentous extension. The flexion angle dependence of passive joint laxity is much more strongly influenced by fibre recruitment in the ligaments than by cartilage deformation.