Subject-specific knee joint geometry improves predictions of medial tibiofemoral contact forces

Estimating tibiofemoral joint contact forces is important for understanding the initiation and progression of knee osteoarthritis. However, tibiofemoral contact force predictions are influenced by many factors including muscle forces and anatomical representations of the knee joint. This study aimed to investigate the influence of subject-specific geometry and knee joint kinematics on the prediction of tibiofemoral contact forces using a calibrated EMG-driven neuromusculoskeletal model of the knee. One participant fitted with an instrumented total knee replacement walked at a self-selected speed while medial and lateral tibiofemoral contact forces, ground reaction forces, whole-body kinematics, and lower-limb muscle activity were simultaneously measured. The combination of generic and subject-specific knee joint geometry and kinematics resulted in four different OpenSim models used to estimate muscle–tendon lengths and moment arms. The subject-specific geometric model was created from CT scans and the subject-specific knee joint kinematics representing the translation of the tibia relative to the femur was obtained from fluoroscopy. The EMG-driven model was calibrated using one walking trial, but with three different cost functions that tracked the knee flexion/extension moments with and without constraint over the estimated joint contact forces. The calibrated models then predicted the medial and lateral tibiofemoral contact forces for five other different walking trials. The use of subject-specific models with minimization of the peak tibiofemoral contact forces improved the accuracy of medial contact forces by 47% and lateral contact forces by 7%, respectively compared with the use of generic musculoskeletal model.     

A multibody knee model with discrete cartilage prediction of tibio-femoral contact mechanics

Combining musculoskeletal simulations with anatomical joint models capable of predicting cartilage contact mechanics would provide a valuable tool for studying the relationships between muscle force and cartilage loading. As a step towards producing multibody musculoskeletal models that include representation of cartilage tissue mechanics, this research developed a subject-specific multibody knee model that represented the tibia plateau cartilage as discrete rigid bodies that interacted with the femur through deformable contacts. Parameters for the compliant contact law were derived using three methods: (1) simplified Hertzian contact theory, (2) simplified elastic foundation contact theory and (3) parameter optimisation from a finite element (FE) solution. The contact parameters and contact friction were evaluated during a simulated walk in a virtual dynamic knee simulator, and the resulting kinematics were compared with measured in vitro kinematics. The effects on predicted contact pressures and cartilage–bone interface shear forces during the simulated walk were also evaluated. The compliant contact stiffness parameters had a statistically significant effect on predicted contact pressures as well as all tibio-femoral motions except flexion–extension. The contact friction was not statistically significant to contact pressures, but was statistically significant to medial–lateral translation and all rotations except flexion–extension. The magnitude of kinematic differences between model formulations was relatively small, but contact pressure predictions were sensitive to model formulation. The developed multibody knee model was computationally efficient and had a computation time 283 times faster than a FE simulation using the same geometries and boundary conditions.     

Tibio-femoral joint contact in healthy and osteoarthritic knees during quasi-static squat: A bi-planar X-ray analysis

The aim of this study was to quantify the tibio-femoral contact point (CP) locations in healthy and osteoarthritic (OA) subjects during a weight-bearing squat using stand-alone biplanar X-ray images.Ten healthy and 9 severe OA subjects performed quasi-static squats. Bi-planar X-ray images were recorded at 0°, 15°, 30°, 45°, and 70° of knee flexion. A reconstruction/registration process was used to create 3D models of tibia, fibula, and femur from bi-planar X-rays and to measure their positions at each posture. A weighted centroid of proximity algorithm was used to calculate the tibio-femoral CP locations. The accuracy of the reconstruction/registration process in measuring the quasi-static kinematics and the contact parameters was evaluated in a validation study.The quasi-static kinematics data revealed that in OA knees, adduction angles were greater (p<0.01), and the femur was located more medially relative to the tibia (p<0.01). Similarly, the average CP locations on the medial and lateral tibial plateaus of the OA patients were shifted (6.5±0.7 mm; p<0.01) and (9.6±3.1 mm; p<0.01) medially compared to the healthy group. From 0° to 70° flexion, CPs moved 8.1±5.3 mm and 8.9±5.3 mm posteriorly on the medial and lateral plateaus of healthy knees; while in OA joints CPs moved 10.1±8.4 mm and 3.6±2.8 mm posteriorly. The average minimum tibio-femoral bone-to-bone distances of the OA joints were lower in both compartments (p<0.01).The CPs in the OA joints were located more medially and displayed a higher ratio of medial to lateral posterior translations compared to healthy joints.     

Simultaneous prediction of muscle and contact forces in the knee during gait

Musculoskeletal models are currently the primary means for estimating in vivo muscle and contact forces in the knee during gait. These models typically couple a dynamic skeletal model with individual muscle models but rarely include articular contact models due to their high computational cost. This study evaluates a novel method for predicting muscle and contact forces simultaneously in the knee during gait. The method utilizes a 12 degree-of-freedom knee model (femur, tibia, and patella) combining muscle, articular contact, and dynamic skeletal models. Eight static optimization problems were formulated using two cost functions (one based on muscle activations and one based on contact forces) and four constraints sets (each composed of different combinations of inverse dynamic loads). The estimated muscle and contact forces were evaluated using in vivo tibial contact force data collected from a patient with a force-measuring knee implant. When the eight optimization problems were solved with added constraints to match the in vivo contact force measurements, root-mean-square errors in predicted contact forces were less than 10 N. Furthermore, muscle and patellar contact forces predicted by the two cost functions became more similar as more inverse dynamic loads were used as constraints. When the contact force constraints were removed, estimated medial contact forces were similar and lateral contact forces lower in magnitude compared to measured contact forces, with estimated muscle forces being sensitive and estimated patellar contact forces relatively insensitive to the choice of cost function and constraint set. These results suggest that optimization problem formulation coupled with knee model complexity can significantly affect predicted muscle and contact forces in the knee during gait. Further research using a complete lower limb model is needed to assess the importance of this finding to the muscle and contact force estimation process.     

A comprehensive assessment of the musculoskeletal system: The CAMS-Knee data set

Combined knowledge of the functional kinematics and kinetics of the human body is critical for understanding a wide range of biomechanical processes including musculoskeletal adaptation, injury mechanics, and orthopaedic treatment outcome, but also for validation of musculoskeletal models. Until now, however, no datasets that include internal loading conditions (kinetics), synchronized with advanced kinematic analyses in multiple subjects have been available. Our goal was to provide such datasets and thereby foster a new understanding of how in vivo knee joint movement and contact forces are interlinked – and thereby impact biomechanical interpretation of any new knee replacement design. In this collaborative study, we have created unique kinematic and kinetic datasets of the lower limb musculoskeletal system for worldwide dissemination by assessing a unique cohort of 6 subjects with instrumented knee implants (Charité – Universitätsmedizin Berlin) synchronized with a moving fluoroscope (ETH Zürich) and other measurement techniques (including whole body kinematics, ground reaction forces, video data, and electromyography data) for multiple complete cycles of 5 activities of daily living. Maximal tibio-femoral joint contact forces during walking (mean peak 2.74 BW), sit-to-stand (2.73 BW), stand-to-sit (2.57 BW), squats (2.64 BW), stair descent (3.38 BW), and ramp descent (3.39 BW) were observed. Internal rotation of the tibia ranged from 3° external to 9.3° internal. The greatest range of anterio-posterior translation was measured during stair descent (medial 9.3 ± 1.0 mm, lateral 7.5 ± 1.6 mm), and the lowest during stand-to-sit (medial 4.5 ± 1.1 mm, lateral 3.7 ± 1.4 mm). The complete and comprehensive datasets will soon be made available online for public use in biomechanical and orthopaedic research and development.     

A comparison of the influence of global functional loads vs. local contact anatomy on articular cartilage thickness at the knee

Cartilage contact geometry, along with joint loading, can play an important role in determining local articular cartilage tissue stress. Thus individual variations in cartilage thickness can be associated with both individual variations in joint loading associated with activities of daily living as well as individual differences in the anatomy of the contacting surfaces of the joint. The purpose of this study was to isolate the relationship between cartilage thickness predicted by individual variations in contact surface geometry based on the radii of the femur and tibia vs. cartilage thickness predicted by individual variations in joint loading. Knee magnetic resonance (MR) images and the peak knee adduction moments during walking were obtained from 11 young healthy male subjects (age 30.5+/-5.1 years). The cartilage thicknesses and surface radii of the femoral and tibial cartilage were measured in the weight-bearing regions of the medial and lateral compartments of three-dimensional models from the MR images. The ratio of contact pressure between the medial and lateral compartments was calculated from the radii of tibiofemoral contact surface geometries. The results showed that the medial to lateral pressure ratios were not correlated with the medial to lateral cartilage thickness ratios. However, in general, pressure was higher in the lateral than medial compartments and cartilage was thicker in the lateral than medial compartments. The peak knee adduction moment showed a significant positive linear correlation with medial to lateral thickness ratio in both femur (R(2)=0.43,P<0.01) and tibia (R(2)=0.32,P<0.01). The results of this study suggest that the dynamics of walking is an important factor to describe individual differences in cartilage thickness for normal subjects.     

Sensitivity of medial and lateral knee contact force predictions to frontal plane alignment and contact locations

Musculoskeletal models are increasingly used to estimate medial and lateral knee contact forces, which are difficult to measure in vivo. The sensitivity of contact force predictions to modeling parameters is important to the interpretation and implication of results generated by the model. The purpose of this study was to quantify the sensitivity of knee contact force predictions to simultaneous errors in frontal plane knee alignment and contact locations under different dynamic conditions. We scaled a generic musculoskeletal model for N = 23 subjects’ stature and radiographic knee alignment, then perturbed frontal plane alignment and mediolateral contact locations within experimentally-possible ranges of 10° to −10° and 10 to −10 mm, respectively. The sensitivity of first peak, second peak, and mean medial and lateral knee contact forces to knee adduction angle and contact locations was modeled using linear regression. Medial loads increased, and lateral loads decreased, by between 3% and 6% bodyweight for each degree of varus perturbation. Shifting the medial contact point medially increased medial loads and decreased lateral loads by between 1% and 4% bodyweight per millimeter. This study demonstrates that realistic measurement errors of 5 mm (contact distance) or 5° (frontal plane alignment) could result in a combined 50% BW error in subject specific contact force estimates. We also show that model sensitivity varies between subjects as a result of differences in gait dynamics. These results demonstrate that predicted knee joint contact forces should be considered as a range of possible values determined by model uncertainty.     

A three-dimensional anatomical model of the human patello-femoral joint,for the determination of patello-femoral motions and contact characteristics

The object of this study is to develop a three-dimensional mathematical model of the patello-femoral joint, which is modelled as two rigid bodies representing a moving patella and a fixed femur. Two-point contact was assumed between the femur and patella at the medial and lateral sides and in the analysis, the femoral and patellar articular surfaces were mathematically represented using Coons' bicubic surface patches. Model equations include six equilibrium equations and eleven constraints: six contact conditions, four geometric compatibility conditions, and the condition of a rigid patellar ligament; the model required the solution of a system of 17 nonlinear equations in 17 unknowns, its response describing the six-degress-of-freedom patellar motions and the forces acting on the patella. Patellar motions are described by six motion parameters representing the translations and rotations of the patella with respect to the femur. The forces acting on the patella include the medial and lateral component of patello-femoral contact and the patellar ligament force, all of which were represented as ratios to the quadriceps tendon force. The model response also includes the locations of the medial and lateral contact points on the femur and the patella. A graphical display of its response was produced in order to visualize better the motion of the components of the extensor mechanism.Model calculations show good agreement with experimental results available from the literature. The patella was found to move distally and posteriorly on the femoral condyles as the knee was flexed from full extension. Results indicate that the relative orientation of the patellar ligament with respect to the patella remains unchanged during this motion. The model also predicts a patellar flexion which always lagged knee flexion.Our calculations show that as the angle of knee flexion increased, the lateral contact point moved distally on the femur without moving significantly either medially or laterally. The medial contact point also moved distally on the femur but moved medially from full extension to about 40° of knee flexion, then laterally as the knee flexion angle increased. The lateral contact point on the patella did not change significantly in the medial and lateral direction as the knee was flexed; however, this point moved proximally toward the basis of the patella with knee flexion. The medial contact point also moved proximally on the patella with knee flexion, and in a similar manner the medial contact point on the patella moved distally with flexion from full extension to about 40° of flexion. However, as the angle of flexion increased, the medial contact point did not move significantly in the medial-lateral direction.Model calculations also show that during the simulated knee extension exercise, the ratio of the force in the patellar ligament to the force in the quadriceps tendon remains almost unchanged for the first 30° of knee flexion, then decreases as the angle of knee flexion increases. Furthermore, model results show that the lateral component of the patello-femoral contact force is always greater than the medial component, both components increasing with knee flexion.     

A parametric approach to numerical modeling of TKR contact forces

In vivo knee contact forces are difficult to determine using numerical methods because there are more unknown forces than equilibrium equations available. We developed parametric methods for computing contact forces across the knee joint during the stance phase of level walking. Three-dimensional contact forces were calculated at two points of contact between the tibia and the femur, one on the lateral aspect of the tibial plateau, and one on the medial side. Muscle activations were parametrically varied over their physiologic range resulting in a solution space of contact forces. The obtained solution space was reasonably small and the resulting force pattern compared well to a previous model from the literature for kinematics and external kinetics from the same patient. Peak forces of the parametric model and the previous model were similar for the first half of the stance phase, but differed for the second half. The previous model did not take into account the transverse external moment about the knee and could not calculate muscle activation levels. Ultimately, the parametric model will result in more accurate contact force inputs for total knee simulators, as current inputs are not generally based on kinematics and kinetics inputs from TKR patients.     

A finite element model of the human knee joint for the study of tibio-femoral contact

As a step towards developing a finite element model of the knee that can be used to study how the variables associated with a meniscal replacement affect tibio-femoral contact, the goals of this study were 1) to develop a geometrically accurate three-dimensional solid model of the knee joint with special attention given to the menisci and articular cartilage, 2) to determine to what extent bony deformations affect contact behavior, and 3) to determine whether constraining rotations other than flexion/extension affects the contact behavior of the joint during compressive loading. The model included both the cortical and trabecular bone of the femur and tibia, articular cartilage of the femoral condyles and tibial plateau, both the medial and lateral menisci with their horn attachments, the transverse ligament, the anterior cruciate ligament, and the medial collateral ligament. The solid models for the menisci and articular cartilage were created from surface scans provided by a noncontacting, laser-based, three-dimensional coordinate digitizing system with an root mean squared error (RMSE) of less than 8 microns. Solid models of both the tibia and femur were created from CT images, except for the most proximal surface of the tibia and most distal surface of the femur which were created with the three-dimensional coordinate digitizing system. The constitutive relation of the menisci treated the tissue as transversely isotropic and linearly elastic. Under the application of an 800 N compressive load at 0 degrees of flexion, six contact variables in each compartment (ie., medial and lateral) were computed including maximum pressure, mean pressure, contact area, total contact force, and coordinates of the center of pressure. Convergence of the finite element solution was studied using three mesh sizes ranging from an average element size of 5 mm by 5 mm to 1 mm by 1 mm. The solution was considered converged for an average element size of 2 mm by 2 mm. Using this mesh size, finite element solutions for rigid versus deformable bones indicated that none of the contact variables changed by more than 2% when the femur and tibia were treated as rigid. However, differences in contact variables as large as 19% occurred when rotations other than flexion/extension were constrained. The largest difference was in the maximum pressure. Among the principal conclusions of the study are that accurate finite element solutions of tibio-femoral contact behavior can be obtained by treating the bones as rigid. However, unrealistic constraints on rotations other than flexion/extension can result in relatively large errors in contact variables.     

In vivo determination of normal and anterior cruciate ligament-deficient knee kinematics

The objective of the current study was to use fluoroscopy to accurately determine the three-dimensional (3D), in vivo, weight-bearing kinematics of 10 normal and five anterior cruciate ligament deficient (ACLD) knees. Patient-specific bone models were derived from computed tomography (CT) data. 3D computer bone models of each subject's femur, tibia, and fibula were recreated from the CT 3D bone density data. Using a model-based 3D-to-2D imaging technique registered CT images were precisely fit onto fluoroscopic images, the full six degrees of freedom motion of the bones was measured from the images. The computer-generated 3D models of each subject's femur and tibia were precisely registered to the 2D digital fluoroscopic images using an optimization algorithm that automatically adjusts the pose of the model at various flexion/extension angles. Each subject performed a weight-bearing deep knee bend while under dynamic fluoroscopic surveillance. All 10 normal knees experienced posterior femoral translation of the lateral condyle and minimal change in position of the medial condyle with progressive knee flexion. The average amount of posterior femoral translation of the lateral condyle was 21.07 mm, whereas the average medial condyle translation was 1.94 mm, in the posterior direction. In contrast, all five ACLD knees experienced considerable change in the position of the medial condyle. The average amount of posterior femoral translation of the lateral condyle was 17.00 mm, while the medial condyle translation was 4.65 mm, in the posterior direction. In addition, the helical axis of motion was determined between maximum flexion and extension. A considerable difference was found between the center of rotation locations of the normal and ACLD subjects, with ACLD subjects exhibiting substantially higher variance in kinematic patterns.     

In vivo contact kinematics and contact forces of the knee after total knee arthroplasty during dynamic weight-bearing activities

Analysis of polyethylene component wear and implant loosening in total knee arthroplasty (TKA) requires precise knowledge of in vivo articular motion and loading conditions. This study presents a simultaneous in vivo measurement of tibiofemoral articular contact forces and contact kinematics in three TKA patients. These measurements were accomplished via a dual fluoroscopic imaging system and instrumented tibial implants, during dynamic single leg lunge and chair rising-sitting. The measured forces and contact locations were also used to determine mediolateral distribution of axial contact forces. Contact kinematics data showed a medial pivot during flexion of the knee, for all patients in the study. Average axial forces were higher for lunge compared to chair rising-sitting (224% vs. 187% body weight). In this study, we measured peak anteroposterior and mediolateral forces averaging 13.3% BW during lunge and 18.5% BW during chair rising-sitting. Mediolateral distributions of axial contact force were both patient and activity specific. All patients showed equitable medial-lateral loading during lunge but greater loads at the lateral compartment during chair rising-sitting. The results of this study may enable more accurate reproduction of in vivo loads and articular motion patterns in wear simulators and finite element models. This in turn may help advance our understanding of factors limiting longevity of TKA implants, such as aseptic loosening and polyethylene component wear, and enable improved TKA designs.     

Ligaments and articular contact guide passive knee flexion

The aim of this study was to test the hypothesis that the coupled features of passive knee flexion are guided by articular contact and by the isometric fascicles of the ACL, PCL and MCL. A three-dimensional mathematical model of the knee was developed, in which the articular surfaces in the lateral and medial compartments and the isometric fascicles in the ACL, PCL and MCL were represented as five constraints in a one degree-of-freedom parallel spatial mechanism. Mechanism analysis techniques were used to predict the path of motion of the tibia relative to the femur. Using a set of anatomical parameters obtained from a cadaver specimen, the model predicts coupled internal rotation and ab/adduction with flexion. These predictions correspond well to measurements of the cadaver specimen’s motion. The model also predicts posterior translation of contact on the tibia with flexion. Although this is a well-known feature of passive knee flexion, the model predicts more translation than has been reported from experiments in the literature. Modelling of uncertainty in the anatomical parameters demonstrated that the discrepancy between theoretical predictions and experimental measurement can be attributed to parameter sensitivity of the model. This study shows that the ligaments and articular surfaces work together to guide passive knee motion. A principal implication of the work is that both articular surface geometry and ligament geometry must be preserved or replicated by surgical reconstruction and replacement procedures to ensure normal knee kinematics and by extension, mechanics.     

Multi-body optimization with subject-specific knee models: performance at high knee flexion angles

When estimating knee kinematics from skin markers and stereophotogrammetry, multi-body optimization (MBO) has provided promising results for reducing soft tissue artefacts (STA), but can still be improved. The goal of this study was to assess the performance of MBO with subject-specific knee models at high knee flexion angles (up to 110°) against knee joint kinematics measured by magnetic resonance imaging. Eight subjects were recruited. MBO with subject-specific knee models was more effective in compensating STA compared to no kinematic and spherical constraints, in particular for joint displacements. Moreover, it seems to be more reliable over large ranges of knee flexion angle. The ranges of root mean square errors for knee rotations/displacements were 3.0°–9.2°/1.3–3.5 mm for subject-specific knee models, 6.8°–8.7°/6.0–12.4 mm without kinematic constraint and 7.1°–9.8°/4.9–12.5 mm for spherical constraints.     

Effects of femoral component placement on the balancing of a total knee at surgery

Misalignment and soft-tissue imbalance in total knee arthroplasty (TKA) can cause discomfort, pain, inadequate motion and instability that may require revision surgery. Balancing can be defined as equal collateral ligament tensions or equal medial and lateral compartmental forces during the flexion range. Our goal was to study the effects on balancing of linear femoral component misplacements (proximal, distal, anterior, posterior); and different component rotations in mechanical alignment compared to kinematic alignment throughout the flexion path. A test rig was constructed such that the position of a standard femoral component could be adjusted to simulate the linear and rotational positions. With the knee in neutral reference values of the collateral tensions were adjusted to give anatomic contact force patterns, measured with an instrumented tibial trial. The deviations in the forces for each femoral component position were then determined. Compartmental forces were significantly influenced by 2 mm linear errors in the femoral component placement. However, the errors were least for a distal error, equivalent to undercutting the distal femur. The largest errors mainly increase the lateral condyle force, occurred for proximal and posterior component errors. There were only small contact force differences between kinematic and mechanical alignment. Based on these results, surgeons should avoid overcutting the distal femur and undercutting the posterior femur. However, the 2–3 degrees varus slope of the joint line as in kinematic alignment did not have much effect on balancing, so mechanical or kinematic alignment were equivalent.     

Knee contact force in subjects with symmetrical OA grades: Differences between OA severities

In using musculoskeletal models, researchers can calculate muscle forces, and subsequently joint contact forces, providing insight into joint loading and the progression of such diseases as osteoarthritis (OA). The purpose of this study was to estimate the knee contact force (KCF) in patients with varying degrees of OA severity using muscle forces and joint reaction forces derived from OpenSim. Walking data was obtained from healthy individuals (n=14) and those with moderate (n=10) and severe knee OA (n=2). For each subject, we generated 3D, muscle-actuated, forward dynamic simulations of the walking trials. Muscle forces that reproduced each subject’s gait were calculated. KCFs were then calculated using the vector sum of the muscle forces and joint reaction forces along the longitudinal axis of the femur. Moderate OA subjects exhibited a similar KCF pattern to healthy subjects, with lower second peaks (p=0.021). Although subjects with severe OA had similar initial peak KCF to healthy and moderate OA subjects (more than 4 times BW), the pattern of the KCF was very different between groups. After an initial peak, subjects with severe OA continually unloaded the joint, whereas healthy and moderate OA subjects reloaded the knee during late stance. In subjects with symmetric OA grades, there appears to be differences in loading between OA severities. Similar initial peaks of KCF imply that reduction of peak KCF may not be a compensatory strategy for OA patients; however, reducing duration of high magnitude loads may be employed.     

Alterations of musculoskeletal models for a more accurate estimation of lower limb joint contact forces during normal gait: A systematic review

Musculoskeletal modelling is a methodology used to investigate joint contact forces during a movement. High accuracy in the estimation of the hip or knee joint contact forces can be obtained with subject-specific models. However, construction of subject-specific models remains time consuming and expensive. The purpose of this systematic review of the literature was to identify what alterations can be made on generic (i.e. literature-based, without any subject-specific measurement other than body size and weight) musculoskeletal models to obtain a better estimation of the joint contact forces. The impact of these alterations on the accuracy of the estimated joint contact forces were appraised.The systematic search yielded to 141 articles and 24 papers were included in the review. Different strategies of alterations were found: skeletal and joint model (e.g. number of degrees of freedom, knee alignment), muscle model (e.g. Hill-type muscle parameters, level of muscular redundancy), and optimisation problem (e.g. objective function, design variables, constraints). All these alterations had an impact on joint contact force accuracy, so demonstrating the potential for improving the model predictions without necessarily involving costly and time consuming medical images. However, due to discrepancies in the reported evidence about this impact and despite a high quality of the reviewed studies, it was not possible to highlight any trend defining which alteration had the largest impact.     

Interactions between kinematics and loading during walking for the normal and ACL deficient knee

The relationships between extrinsic forces acting at the knee and knee kinematics were examined with the purpose of identifying specific phases of the walking cycle that could cause abnormal kinematics in the anterior cruciate ligament (ACL) deficient knee. Intersegmental forces and moments in directions that would produce anterior-posterior (AP) translation, internal-external (IE) rotation and flexion-extension (FE) at the knee were compared with the respective translation and rotations of the tibia relative to the femur during four selected phases (heel strike, weight acceptance, terminal extension and swing) of the walking cycle. The kinematic changes associated with loss of the ACL occurred primarily during the terminal portion of swing phase of the walking cycle where, for the ACL deficient knee, the tibia had reduced external rotation and anterior translation as the knee extended prior to heel strike. The kinematic changes during swing phase were associated with a rotational offset relative to the contralateral knee in the average position of the tibia towards internal rotation. The offset was maintained through the entire gait cycle. The abnormal offsets in the rotational position were correlated with the magnitude of the flexion moment (balanced by a net quadriceps moment) during weight acceptance. These results suggest that adaptations to the patterns of muscle firing during walking can compensate for kinematic changes associated with the loss of the ACL. The altered rotational position would cause changes in tibiofemoral contact during walking that could cause the type of degenerative changes reported in the meniscus and the articular cartilage following ACL injury.     

Development and validation of a computational model of the knee joint for the evaluation of surgical treatments for osteoarthritis

A three-dimensional (3D) knee joint computational model was developed and validated to predict knee joint contact forces and pressures for different degrees of malalignment. A 3D computational knee model was created from high-resolution radiological images to emulate passive sagittal rotation (full-extension to 65°-flexion) and weight acceptance. A cadaveric knee mounted on a six-degree-of-freedom robot was subjected to matching boundary and loading conditions. A ligament-tuning process minimised kinematic differences between the robotically loaded cadaver specimen and the finite element (FE) model. The model was validated by measured intra-articular force and pressure measurements. Percent full scale error between FE-predicted and in vitro-measured values in the medial and lateral compartments were 6.67% and 5.94%, respectively, for normalised peak pressure values, and 7.56% and 4.48%, respectively, for normalised force values. The knee model can accurately predict normalised intra-articular pressure and forces for different loading conditions and could be further developed for subject-specific surgical planning.     

Training multi-parameter gaits to reduce the knee adduction moment with data-driven models and haptic feedback

The purpose of this study was to evaluate gait retraining for reducing the knee adduction moment. Our primary objective was to determine whether subject-specific altered gaits aimed at reducing the knee adduction moment by 30% or more could be identified and adopted in a single session through haptic (touch) feedback training on multiple kinematic gait parameters. Nine healthy subjects performed gait retraining, in which data-driven models specific to each subject were determined through experimental trials and were used to train novel gaits involving a combination of kinematic changes to the tibia angle, foot progression and trunk sway angles. Wearable haptic devices were used on the back, knee and foot for real-time feedback. All subjects were able to adopt altered gaits requiring simultaneous changes to multiple kinematic parameters and reduced their knee adduction moments by 29-48%. Analysis of single parameter gait training showed that moving the knee medially by increasing tibia angle, increasing trunk sway and toeing in all reduced the first peak of the knee adduction moment with tibia angle changes having the most dramatic effect. These results suggest that individualized data-driven gait retraining may be a viable option for reducing the knee adduction moment as a treatment method for early-stage knee osteoarthritis patients with sufficient sensation, endurance and motor learning capabilities.