A novel non-invasive method for measuring knee joint laxity in four dof: In vitro proof-of-concept and validation

Knee joint laxity or instability is a common problem that may have detrimental consequences for patients. Unfortunately, assessment of knee joint laxity is limited by current methodologies resulting in suboptimal diagnostics and treatment. This paper presents a novel method for accurately measuring non-invasive knee joint laxity in four degrees-of-freedom (DOF). An arthrometer, combining a parallel manipulator and a six-axis force/moment sensor, was developed to be used in combination with a low-dose biplanar x-ray system and 3D image data to reconstruct tibiofemoral position and orientation of laxity measurements.As proof-of-concept, four cadaveric knees were tested in the device. Each cadaveric knee was mounted in the device at approximately 30° of flexion and twelve monoplanar anteroposterior, mediolateral and internal/external load cases were applied. Additionally, four biplanar load cases were applied, consisting of different combinations of anteroposterior and internal/external loads. The arthrometer was limited to four DOF to address the specific measurements. For validation purposes, the pose reconstructions of tibia and femur were compared with pose reconstructions of bone pin marker frames mounted on each bone.The measurements from the arthrometer in terms of translation and rotations displayed comparable values to what have previously been presented in the literature. Furthermore, the measurements revealed coupled motions in multiple planes, demonstrating the importance of multi DOF laxity measurements. The validation displayed an average mean difference for translations of 0.08 mm and an average limit of agreement between −1.64 mm and 1.80 mm. The average mean difference for rotations was 0.10° and the limit of agreement was between −0.85° and 1.05°.The presented method eliminates several limitations present in current methods and may prove a valuable tool for assessing knee joint laxity.     

A comparison of optimisation methods and knee joint degrees of freedom on muscle force predictions during single-leg hop landings

The aim of this paper was to compare the effect of different optimisation methods and different knee joint degrees of freedom (DOF) on muscle force predictions during a single legged hop. Nineteen subjects performed single-legged hopping manoeuvres and subject-specific musculoskeletal models were developed to predict muscle forces during the movement. Muscle forces were predicted using static optimisation (SO) and computed muscle control (CMC) methods using either 1 or 3 DOF knee joint models. All sagittal and transverse plane joint angles calculated using inverse kinematics or CMC in a 1 DOF or 3 DOF knee were well-matched (RMS error<3°). Biarticular muscles (hamstrings, rectus femoris and gastrocnemius) showed more differences in muscle force profiles when comparing between the different muscle prediction approaches where these muscles showed larger time delays for many of the comparisons. The muscle force magnitudes of vasti, gluteus maximus and gluteus medius were not greatly influenced by the choice of muscle force prediction method with low normalised root mean squared errors (<48%) observed in most comparisons. We conclude that SO and CMC can be used to predict lower-limb muscle co-contraction during hopping movements. However, care must be taken in interpreting the magnitude of force predicted in the biarticular muscles and the soleus, especially when using a 1 DOF knee. Despite this limitation, given that SO is a more robust and computationally efficient method for predicting muscle forces than CMC, we suggest that SO can be used in conjunction with musculoskeletal models that have a 1 or 3 DOF knee joint to study the relative differences and the role of muscles during hopping activities in future studies.     

Accuracy and repeatability of Roentgen stereophotogrammetric analysis (RSA) for measuring knee laxity in longitudinal studies

Roentgen stereophotogrammetric analysis (RSA) can be used to assess temporal changes in anterior-posterior (A-P) knee laxity. However, the accuracy and precision of RSA is dependent on many factors and should be independently evaluated for a particular application. The objective of this study was to evaluate the use of RSA for measuring A-P knee laxity. The specific aims were to assess the variation or "noise" inherent to RSA, to determine the reproducibility of RSA for repeated A-P laxity testing, and to assess the accuracy of these measurements. Two experiments were performed. The first experiment utilized three rigid models of the tibiofemoral joint to assess the noise and to compare digitization errors of two independent examiners. No differences were found in the kinematic outputs of the RSA due to examiner, repeated trials, or the model used. In a second experiment, A-P laxity values between the A-P shear load limits of +/-60 N of five cadaver goat knees were measured to assess the error associated with repeated testing. The RSA laxity values were also compared to those obtained from a custom designed linkage system. The mean A-P laxity values with the knee 30 degrees, 60 degrees, and 90 degrees of flexion for the ACL-intact goat knee (+/-95% confidence interval) were 0.8 (+/-0.25), 0.9 (+/-0.29), and 0.4 (+/-0.22) mm, respectively. In the ACL-deficient knee, the A-P laxity values increased by an order of magnitude to 8.8 (+/-1.39), 7.6 (+/-1.32), and 3.1 (+/-1.20)mm, respectively. No significant differences were found between the A-P laxity values measured by RSA and the independent measurement technique. A highly significant linear relationship (r(2)=0.83) was also found between these techniques. This study suggests that the RSA method is an accurate and precise means to measure A-P knee laxity for repeated testing over time.     

The effect of anterior cruciate ligament rupture on the timing and amplitude of gastrocnemius muscle activation: a study of alterations in EMG measures and their relationship to knee joint stability

Changes in hamstring and quadriceps activity are well known in individuals with anterior cruciate ligament deficiency (ACLD) to potentially compensate for knee joint instability. However, few studies have explored gastrocnemius activity or its relationship to knee stability. The purpose of this study was therefore to examine the activation characteristics of medial gastrocnemius (MG) in ACLD subjects and relate any changes to knee joint laxity. Two subject cohorts were assessed: those with unilateral ACLD (n=15) and uninjured control subjects (n=11). Surface EMG of the left and right MG were recorded during a controlled single leg hop on each limb. Onset and offset of MG activation relative to take-off, during flight and landing were calculated as well as muscle activity (RMS). Passive antero-posterior knee laxity was measured with a KT1000 arthrometer during a maximal manual displacement test. Medial gastrocnemius activity on the injured side of ACLD participants demonstrated significantly prolonged activation in preparation to hop, minimal muscle inactivity prior to take-off, and increased duration of overall muscle activity when compared to the uninjured side and control subjects (p<0.05). Significant positive correlations were found between passive knee joint laxity and prolonged activation prior to knee bend. RMS of the muscle signal was not significantly different between limbs. Overall, MG on the ACLD side demonstrated longer activation, with minimal rest during the hop test, which may be an attempt to maintain knee stability. Furthermore, the strong relationship between knee laxity and prolonged muscle activation suggests that individuals with a loss of knee stability are more reliant on active control of the gastrocnemius muscle.     

Dynamic finite element knee simulation for evaluation of knee replacement mechanics

In vitro pre-clinical testing of total knee replacement (TKR) devices is a necessary step in the evaluation of new implant designs. Whole joint knee simulators, like the Kansas knee simulator (KKS), provide a controlled and repeatable loading environment for comparative evaluation of component designs or surgical alignment under dynamic conditions. Experimental testing, however, is time and cost prohibitive for design-phase evaluation of tens or hundreds of design variations. Experimentally-verified computational models provide an efficient platform for analysis of multiple components, sizes, and alignment conditions. The purpose of the current study was to develop and verify a computational model of a dynamic, whole joint knee simulator. Experimental internal-external and valgus-varus laxity tests, followed by dynamic deep knee bend and gait simulations in the KKS were performed on three cadaveric specimens. Specimen-specific finite element (FE) models of posterior-stabilized TKR were created from magnetic resonance images and CAD geometry. The laxity data was used to optimize mechanical properties of tibiofemoral soft-tissue structures on a specimen-specific basis. Each specimen was subsequently analyzed in a computational model of the experimental KKS, simulating both dynamic activities. The computational model represented all joints and actuators in the experimental setup, including a proportional-integral-derivative (PID) controller to drive quadriceps actuation. The computational model was verified against six degree-of-freedom patellofemoral (PF) and tibiofemoral (TF) kinematics and actuator loading during both deep knee bend and gait activities, with good agreement in trends and magnitudes between model predictions and experimental kinematics; differences were less than 1.8 mm and 2.2° for PF and TF translations and rotations. The whole joint FE simulator described in this study can be applied to investigate a wide range of clinical and research questions.     

In vitro analysis of varus-valgus laxity of the knee joint: Comparison of clinical evaluation with measurements using a reference motion analysis system

IntroductionNumerous measurement devices can help clinicians during the knee examination. However, manual evaluation still remains routinely used to assess the knee laxities. The present study evaluated how accurate was a clinician for a varus-valgus stress test. We compared the clinician evaluation to the objective measurement of the knee movements during the same test session.MethodsWe studied six fresh-frozen anatomical lower limbs. The clinician performed a varus-valgus stress test in extension and at 25° flexion. The limbs were equipped with intracortical pins in femur and tibia, and spherical retro-reflecting markers were glued on the pins. Objective knees movements were measured by means of a Motion Analysis^® system (Motion Analysis Corporation, Santa Rosa, CA, USA). Two statistical analyses were performed. A single sample t-test was first used to verify the required 25? flexion. Then, a multivariate anova was performed to analyse the varus-valgus laxity under the fixed factors of measurement method and flexion of the knee.ResultsThe results for varus-valgus and total laxity of the clinician always exhibited a greater variability than objective measurements of the device. Test condition is a factor of grouping differences for Valgus and for global mediolateral laxity. Statistical analysis revealed that the objective measurement was able to show a difference between extension and 25° flexion for global mediolateral laxity, whereas the clinician was not.DiscussionThe clinician was relatively accurate in his manual evaluation. However, we demonstrated that a measurement device could clearly help clinician to exhibit differences in laxity. This can be very useful to compare a knee to itself in two successive conditions, e.g., before and after a surgery.     

A global verification study of a quasi-static knee model with multi-bundle ligaments

The ligaments of the knee consist of fiber bundles with variable orientations, lengths and mechanical properties. In concept, however, these structures were too often seen as homogeneous structures, which are either stretched or slack during knee motions. In previous studies, we proposed a new structural concept of the ligaments of the knee. In this concept, the ligaments were considered as multi-bundle structures, with nonuniform mechanical properties and zero force lengths. The purpose of the present study was to verify this new concept.

For this purpose, laxity characteristics of a human knee joint were compared as measured in an experiment and predicted in a model simulation study. In the experiment, the varus-valgus and anterior-posterior laxities of a knee-joint specimen containing the ligaments and the articular surfaces only, were determined. From this knee-joint, geometric and mechanical parameters were derived to supply the parameters for a three-dimensional quasi-static knee-joint model. These parameters included (i) the three-dimensional insertion points of bundles, defined in the four major knee ligaments, (ii) the mechanical properties of these ligament, as functions of their relative insertion orientations and (iii) three-dimensional representations of the articular surfaces. With this model the experiments were simulated. If knee-model predictions and experimental results agree, then the multi-bundle ligament models are validated, at least with respect to their functional role in anterior-posterior and varus-valgus loading of the joint.

The model described the laxity characteristics in AP-translation and VV-rotation of the cadaveric knee-joint specimen reasonably well. Both display the same patterns of laxity changes during knee flexion. Only if a varus moment of 8 N m was applied and if the tibia was posteriorly loaded, did the model predict a slightly higher laxity than that measured experimentally.

From the model-experiment comparisons it was concluded that the proposed structural representations of the ligaments and their mechanical property distributions seem to be valid for studying the anterior-posterior and varus-valgus laxity characteristics of the human knee-joint.     

OpenSim as a preliminary kinematic testing platform for the development of total knee arthroplasty implants

The design of a total knee replacement implant needs to take account the complex surfaces of the knee which it is replacing. Ensuring design performance of the implant requires in vitro testing of the implant. A considerable amount of time is required to produce components and evaluate them inside an experimental setting. Numerous adjustments in the design of an implant and testing each individual design can be time consuming and expensive.Our solution is to use the OpenSim simulation software to rapidly test multiple design configurations of implants. This study modeled a testing rig which characterized the motion and laxity of knee implants. Three different knee implant designs were used to test and validate the accuracy of the simulation: symmetrical, asymmetric, and anatomic. Kinematics were described as distances measured from the center of each femoral condyle to a plane intersecting the most posterior points of the tibial condyles between 0 and 135° of flexion with 15° increments. Excluding the initial flexion measurement (∼0°) results, the absolute differences between all experimental and simulation results (neutral path, anterior-posterior shear, internal-external torque) for the symmetric, asymmetric, and anatomical designs were 1.98 mm ± 1.15, 1.17 mm ± 0.89, and 1.24 mm ± 0.97, respectively. Considering all designs, the accuracy of the simulation across all tests was 1.46 mm ± 1.07. It was concluded that the results of the simulation were an acceptable representation of the testing rig and hence applicable as a design tool for new total knees.     

Computer-assisted evaluation of kinematics of the two bundles of the anterior cruciate ligament.

The aim of this cadaveric study was to describe the kinematics of the anterior cruciate ligament (ACL)-intact, posterolateral (PL) bundle-deficient and ACL-deficient knee by applying a protocol for computer-assisted evaluation of knee kinematics. The hypothesis that the PL bundle functions mainly at low knee flexion angles was tested. An optical tracking system was used to acquire knee joint motion on 10 knees during clinical evaluations by tracking markers rigidly attached to the bones. The protocol included acquisition of anterior-posterior (AP) translations and internal-external (IE) rotations, and evaluation of three clinical knee laxity tests (anterior drawer, manual and instrumented Lachman). The data demonstrated no significant contribution to AP translation and IE laxity from the PL bundle over the entire range of motion. The clinical knee laxity tests showed no significant differences between the ACL-intact and PL bundle-deficient states. The hypothesis could not be proven. Current clinical knee laxity measurements may not be suited for detecting subtle changes such as PL bundle deficiency in the ACL anatomy. The computation of knee laxity might be a step towards a more precise kinematic test of knee stability not only in the native and torn ACL state of the knee but also in the reconstructed knee.     

Dynamic and static control of the human knee joint in abduction-adduction

It is unclear whether humans can voluntarily control dynamic and static properties in knee abduction-adduction, which may be important in performing functional tasks and preventing injuries, whether the main load is about the abduction axis or not. A joint-driving device was used to perturb the knee in abduction-adduction at full knee extension under both passive (muscle relaxed) and active (muscle contracted in abduction or adduction) conditions. Dynamic control properties in knee abduction-adduction were characterized by joint stiffness, viscosity, and limb inertia, and quasi-static knee torque-angle relationship was characterized by knee abduction-adduction laxity and quasi-static stiffness (at a 20Nm moment). It was found that the subjects were capable of generating net abduction and adduction moment through differential co-contraction of muscles crossing the medial and lateral sides of the knee, which helped to reduce the abduction-adduction joint laxity (p< or =0.01) and increase stiffness (p<0.027) and viscous damping. Knee abduction laxity was significantly lower than adduction laxity (p=0.043) and the quasi-static abduction stiffness was significantly higher than adduction stiffness (p<0.001). The knee joint showed significantly higher stiffness and viscosity in abduction-adduction than their counterparts in knee flexion-extension at comparable levels of joint torque (p<0.05). Similar to dynamic flexion-extension properties, the system damping ratio remained constant over different levels of contraction, indicating simplified control tasks for the central nervous system; while the natural undamped frequency increased considerably with abduction-adduction muscle contraction, presumably making the knee a quicker system during strenuous tasks involving strong muscle contraction.     

A new method to measure post-traumatic joint contractures in the rabbit knee

A new device and method to measure rabbit knee joint angles are described. The method was used to measure rabbit knee joint angles in normal specimens and in knee joints with obvious contractures. The custom-designed and manufactured gripping device has two clamps. The femoral clamp sits on a pinion gear that is driven by a rack attached to a materials testing system. A 100 N load cell in series with the rack gives force feedback. The tibial clamp is attached to a rotatory potentiometer. The system allows the knee joint multiple degrees-of-freedom (DOF). There are two independent DOF (compression-distraction and internal-external rotation) and two coupled motions (medial-lateral translation coupled with varus-valgus rotation; anterior-posterior translation coupled with flexion-extension rotation). Knee joint extension-flexion motion is measured, which is a combination of the materials testing system displacement (converted to degrees of motion) and the potentiometer values (calibrated to degrees). Internal frictional forces were determined to be at maximum 2% of measured loading. Two separate experiments were performed to evaluate rabbit knees. First, normal right and left pairs of knees from four New Zealand White (NZW) rabbits were subjected to cyclic loading. An extension torque of 0.2 Nm was applied to each knee. The average change in knee joint extension from the first to the fifth cycle was 1.9 deg +/- 1.5 deg (mean +/- sd) with a total of 49 tests of these eight knees. The maximum extension of the four left knees (tested 23 times) was 14.6 deg +/- 7.1 deg, and of the four right knees (tested 26 times) was 12.0 deg +/- 10.9 deg. There was no significant difference in the maximum extension between normal left and right knees. In the second experiment, nine skeletally mature NZW rabbits had stable fractures of the femoral condyles of the right knee that were immobilized for five, six or 10 weeks. The left knee served as an unoperated control. Loss of knee joint extension (flexion contracture) was demonstrated for the experimental knees using the new methodology where the maximum extension was 35 deg +/- 9 deg, compared to the unoperated knee maximum extension of 11 deg +/- 7 deg, 10 or 12 weeks after the immobilization was discontinued. The custom gripping device coupled to a materials testing machine will serve as a measurement test for future studies characterizing a rabbit knee model of post-traumatic joint contractures.     

Knee joint laxity affects muscle activation patterns in the healthy knee.

This study investigated the effects of anterior knee joint laxity on muscle activation patterns prior to and following a lower extremity perturbation. Participants were subjected to a forward and either internal (IR) or external (ER) rotation perturbation of the trunk and thigh on the weight-bearing shank. Pre-activity (%MVIC) before the perturbation, and reflex time (ms) and mean reflex amplitude (%MVIC) following the perturbation were recorded via surface electromyography (sEMG) in the medial and lateral gastrocnemius, hamstring and quadriceps muscles. Twenty-one NCAA DI intercollegiate female athletes with below average anterior knee laxity (3-5 mm) were compared to 21 with above average anterior knee laxity (7-14 mm) as measured by a standard knee arthrometer. Groups differed in reflex timing by muscle (P = 0.013), with females with above average knee laxity (KT((>7 mm))) demonstrating a 16 ms greater delay in biceps femoris reflex timing compared to females with below average knee laxity (KT((<5 mm))). Groups also differed in muscle activation amplitude by response, muscle and direction of rotation (i.e. a 4-way interaction; P = 0.027). The magnitude of change from pre to post perturbation was significantly less in KT((>7 mm)) vs. KT((<5 mm)) for the medial (MG) and lateral (LG) gastrocnemius muscles, primarily due to higher levels of muscle preactivity while awaiting the perturbation (MG = 20% vs. 12% MVIC, P = 0.05; LG = 33% vs. 21% MVIC, P = 0.11). Further, KT((>7 mm)) demonstrated higher activation levels in the biceps femoris than KT((<5 mm)) (47% vs. 27% MVIC; P = 0.025) regardless of response (pre vs. post perturbation) or direction of rotation. These findings suggest females with increased knee laxity may be less sensitive to joint displacement or loading (delayed reflex), and are more reliant on active control of the gastrocnemius and biceps femoris muscles to potentially compensate for reduced passive joint stability.     

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.     

Effect of implementing magnetic resonance imaging for patient-specific OpenSim models on lower-body kinematics and knee ligament lengths

BackgroundOpenSim models are typically based on cadaver findings that are generalized to represent a wide range of populations, which curbs their validity. Patient-specific modelling through incorporating magnetic resonance imaging (MRI) improves the model’s biofidelity with respect to joint alignment and articulations, muscle wrapping, and ligament insertions. The purpose of this study was to determine if the inclusion of an MRI-based knee model would elicit differences in lower limb kinematics and resulting knee ligament lengths during a side cut task.MethodsEleven participants were analyzed with the popular Rajagopal OpenSim model, two variations of the same model to include three and six degrees of freedom knee (DOF), and a fourth version featuring a four DOF MRI-based knee model. These four models were used in an inverse kinematics analysis of a side cut task and the resulting lower limb kinematics and knee ligament lengths were analyzed.ResultsThe MRI-based model was more responsive to the movement task than the original Rajagopal model while less susceptible to soft tissue artifact than the unconstrained six DOF model. Ligament isometry was greatest in the original Rajagopal model and smallest in the six DOF model.ConclusionsWhen using musculoskeletal modelling software, one must acutely consider the model choice as the resulting kinematics and ligament lengths are dependent on this decision. The MRI-based knee model is responsive to the kinematics and ligament lengths of highly dynamic tasks and may prove to be the most valid option for continuing with late-stage modelling operations such as static optimization.     

Kinematic performance of a six degree-of-freedom hand model (6DHand) for use in occupational biomechanics

Upper extremity musculoskeletal disorders represent an important health issue across all industry sectors; as such, the need exists to develop models of the hand that provide comprehensive biomechanics during occupational tasks. Previous optical motion capture studies used a single marker on the dorsal aspect of finger joints, allowing calculation of one and two degree-of-freedom (DOF) joint angles; additional algorithms were needed to define joint centers and the palmar surface of fingers. We developed a 6DOF model (6DHand) to obtain unconstrained kinematics of finger segments, modeled as frusta of right circular cones that approximate the palmar surface. To evaluate kinematic performance, twenty subjects gripped a cylindrical handle as a surrogate for a powered hand tool. We hypothesized that accessory motions (metacarpophalangeal pronation/supination; proximal and distal interphalangeal radial/ulnar deviation and pronation/supination; all joint translations) would be small (less than 5° rotations, less than 2mm translations) if segment anatomical reference frames were aligned correctly, and skin movement artifacts were negligible. For the gripping task, 93 of 112 accessory motions were small by our definition, suggesting this 6DOF approach appropriately models joints of the fingers. Metacarpophalangeal supination was larger than expected (approximately 10°), and may be adjusted through local reference frame optimization procedures previously developed for knee kinematics in gait analysis. Proximal translations at the metacarpophalangeal joints (approximately 10mm) were explained by skin movement across the metacarpals, but would not corrupt inverse dynamics calculated for the phalanges. We assessed performance in this study; a more rigorous validation would likely require medical imaging.     

The effect of ankle constraint on the torsional laxity of the knee during internal-external rotation of the foot

The in vivo torsional laxity and stiffness of the knee joint are usually determined by rotating the foot and measuring the torque generated at the knee. However, when rotation is applied to the foot, significant three-dimensional forces and moments are produced at the knee. These forces and moments depend upon the external constraint of the ankle complex, and as a result, the observed laxity of the knee also depends on the ankle constraint. Tests are conducted with the foot of a subject in a shoe, with and without the ankle taped, and in a buckled and unbuckled (ski) boot that can effectively constrain ankle rotation. The average laxity of the primary (linear) region of the axial moment vs internal-external rotation is 30% greater when the ankle is constrained by the buckled boot than it is in three other cases of lesser ankle constraint.     

Quantifying in vivo laxity in the anterior cruciate ligament and individual knee joint structures

A custom knee loading apparatus (KLA), when used in conjunction with magnetic resonance imaging, enables in vivo measurement of the gross anterior laxity of the knee joint. A numerical model was applied to the KLA to understand the contribution of the individual joint structures and to estimate the stiffness of the anterior-cruciate ligament (ACL). The model was evaluated with a cadaveric study using an in situ knee loading apparatus and an ElectroForce test system. A constrained optimization solution technique was able to predict the restraining forces within the soft-tissue structures and joint contact. The numerical model presented here allowed in vivo prediction of the material stiffness parameters of the ACL in response to applied anterior loading. Promising results were obtained for in vivo load sharing within the structures. The numerical model overestimated the ACL forces by 27.61–92.71%. This study presents a novel approach to estimate ligament stiffness and provides the basis to develop a robust and accurate measure of in vivo knee joint laxity.     

Validation of a non-invasive fluoroscopic imaging technique for the measurement of dynamic knee joint motion

The accurate measurement of the in vivo knee joint kinematics in six degrees-of-freedom (6DOF) remains a challenge in biomedical engineering. We have adapted a dual fluoroscopic imaging system (DFIS) to investigate the various in vivo dynamic knee joint motions. This paper presents a thorough validation of the accuracy and repeatability of the DFIS system when used to measure 6DOF dynamic knee kinematics. First, the validation utilized standard geometric spheres made from different materials to demonstrate the capability of the DFIS technique to determine the object positions under changing speeds. The translational pose of the spheres could be recreated to less than 0.15±0.09 mm for velocities below 300 mm/s. Next, tantalum beads were inserted into the femur and tibia of two fresh frozen cadaver knees to compare the dynamic kinematics measured by matching knee models to the kinematics from the tantalum bead matching—a technique similar to Roentgen stereophotogrammetric analysis (RSA). Each cadaveric knee was attached to the crosshead of a tensile testing machine and vertically translated at a rate of 16.66 mm/s while images were captured with the DFIS. Subsequently, the tibia was held fixed and the femur manually flexed from full extension to 90° of flexion, as the DFIS acquired images. In vitro translation of the cadaver knee using the tensile testing machine deviated from predicted values by 0.08±0.14 mm for the matched knee models. The difference between matching the knee and tantalum bead models during the dynamic flexion–extension motion of the knee was 0.1±0.65°/s in flexion speed; 0.24±0.16 mm in posterior femoral translation; and 0.16±0.61° in internal–external tibial rotation. Finally, we applied the method to investigate the knee kinematics of a living subject during a step ascent and treadmill gait. High repeatability was demonstrated for the in vivo application. Thus, the DFIS provides an easy and powerful tool for accurately determining 6DOF positions of the knee when performing daily functional activities.     

Empirical relationship between lengthening an anterior cruciate ligament graft and increases in knee anterior laxity: a human cadaveric study

Lengthening of an anterior cruciate ligament (ACL) graft construct can occur as a result of lengthening at the sites of tibial and/or femoral fixation and manifests as an increase in anterior laxity. Although lengthening at the site of fixation has been measured for a variety of fixation devices, it is difficult to place these results in a clinical context because the mathematical relationship between lengthening of an ACL graft construct and anterior laxity is unknown. The purpose of our study was to determine empirically this relationship. Ten cadaveric knees were reconstructed with a double-looped tendon graft. With the knee in 25 degrees of flexion, the position of the proximal end of the graft inside the femoral tunnel was adjusted by moving the femoral fixation device until the anterior laxity at an applied anterior force of 134 N matched that of the intact knee. In random order, the graft construct was lengthened 1, 2, 3, 4, and 5 mm by moving the femoral fixation device distally along the femoral tunnel and anterior laxity was measured. The increase in the length of the graft construct was related to the increase in anterior laxity by a simple linear regression model. Lengthening the graft construct from 1 to 5 mm caused an equal increase in anterior laxity (slope=1.0 mmmm, r(2)=0.800, p<0.0001). Because an anterior laxity increase of 3 mm or greater in a reconstructed knee is considered unstable clinically and because many fixation devices in widespread use clinically allow 3 mm or greater of lengthening in in vitro tests, our empirical relationship indicates that lengthening at the site of fixation probably is an important cause of knee instability following ACL reconstructive surgery. Our empirical relation also indicates that an important criterion in the design of future fixation devices is that lengthening at the sites of fixation in in vitro tests should be limited to less than 3 mm.     

Prediction of total knee motion using a three-dimensional computer-graphics model

Twenty-three knees were sectioned, digitized, and standardized to determine the 'average' three-dimensional bony geometry and ligamentous attachments. Data on normal knee motion were obtained from a cadaveric study. An algorithm was written to simulate three-dimensional patella motion. Verification of the knee model was achieved by determining femoro-tibial and patello-femoral contact locations, as well as ligament length patterns, and comparing the results with published data. The criterion for maximum predicted knee motion with a prosthesis in place was the length of the posterior cruciate ligament. Three total knee replacement surfaces were mathematically generated: flat, laxity and conforming. A greater flexion angle was obtained with a flat tibial surface than for the laxity or conforming. Posterior tibial component displacement increased the range of motion, but only slightly. For all tibial surfaces, increased range of motion was achieved with a 10 degrees posterior tilt of the tibial tray. Anterior femoral component displacement increased motion due to reduction in posterior cruciate tension during flexion. The results are applicable to the design and surgical technique of total knee replacement.