Passive resistance of the human knee: The effect of immobilization

The effects of immobilization on both the circumferential dimensions of the lower limb, and the passive resistance of the knee to sinusoidal motion in the flexion-extension plane, were studied in patients immobilized after tibial fractures or ligamentous injuries of the knee. Immobilization resulted in a decrease of circumferential dimensions of the lower limb, indicating atrophy of thigh and calf musculature. The equilibrium angle of the knee, i.e. the angle at which the net passive moment equals zero, approached the angle of the knee during immobilization. At knee angles of 60° (the maximal angle imposed on the immobilized knee) and 45°, the resistance was increased, and at angles of 30° and 15°, the resistance was decreased. The passive resistances at ± 22.5, 15 and 7.5° relative to the equilibrium angle were all increased. A simple model, taking into account changes in the length of muscles at the anterior and posterior side of the knee, explains changes in passive resistance. The duration of immobilization for patients with ligamentous injuries of the knee was less than 50% of that for patients with tibial fractures, whose ankle joint was not immobilized, both resulted in a smaller muscular atrophy for patients with ligamentous injuries. Differences in passive resistance between unaffected and immobilized legs were the same in both groups of patients. Changes in passive resistance in the immobilized leg for those with ligamentous injury are probably not the effect of immobilization alone but the combined effect of immobilization and ligamentous lesions.     

Effects of joint unloading and reloading on human cartilage morphology and function, muscle cross-sectional areas, and bone density - a quantitative case report

Recent studies have shown that thinning of human cartilage occurs with unloading, but no data are available on the effect of remobilization (after immobilization) on knee joint cartilage status in humans. We examined a 36-year-old patient after 6 weeks of unilateral immobilization. Knee joint cartilage morphology (patella and tibia), patellar cartilage deformation, and thigh muscle cross-sectional areas were assessed with quantitative MR imaging and bone density with peripheral quantitative computed tomography (pQCT) during 24 months of remobilization. The immobilized limb displayed lower muscle cross-sectional areas (MCSA) of the knee extensors (-36%), lower bone density of the femur and tibia (-12/-6%), lower patellar cartilage thickness (-14%), but no side differences of tibial cartilage thickness. During remobilization, side differences decreased to -4% for knee extensor MCSAs, to -6%/-3% for femoral and tibial BMD, and to -8% for patellar cartilage thickness. No change was observed in tibial cartilage. Patellar deformation decreased from 9% to 4% after 15 months. In conclusion, we observed substantial changes of thigh MCSAs, but little (patella) to no (tibia) change in cartilage thickness during remobilization. These preliminary results indicate that human cartilage macro-morphology may be less adaptive to variations of the mechanical loading than muscle and bone.     

A comparison of the effects of immobilization and continuous passive motion on surgical wound healing in mature rabbits

The purpose of this investigation was to compare the effects of continuous passive motion (CPM) and cast immobilization on postoperative wound healing. Medical parapatellar skin incisions and arthrotomies were performed on both knees of 10 mature New Zealand rabbits. After closure of the incisions, one knee was immobilized in a cast while the other was treated by continuous passive motion for 3 weeks. Six standardized skin specimens (2 mm wide) from each wound were tested to failure and one specimen was examined histologically. With respect to the breaking force, tensile strength, strain at failure, stiffness, and toughness, the wounds in the continuous-passive-motion group were significantly stronger, stiffer, and tougher than those in the cast group. Histologically, the structural organization of the collagen fibers was also superior in the scars treated with continuous passive motion. The results of the present investigation indicate that compared to immobilization, continuous passive motion enhances postoperative wound healing in rabbits.     

Effects of long-term immobilization and recovery on human triceps surae and collagen turnover in the Achilles tendon in patients with healing ankle fracture.

The aim of the present study was to analyze how human tendon connective tissue responds to an approximately 7-wk period of immobilization and a remobilization period of a similar length, in patients with unilateral ankle fracture, which is currently unknown. Calf muscle cross-sectional area (CSA) decreased by 15% (5,316 to 4,517 mm2) and strength by 54% (239 to 110 N.m) in the immobilized leg after 7 wk. During the 7-wk remobilization, the CSA increased by 9% (to 4,943 mm2) and strength by 37% (to 176 Nm). Achilles tendon CSA did not change significantly during either immobilization or remobilization. Local collagen turnover was measured as the peritendinous concentrations of NH2-terminal propeptide of type I collagen (PINP) and COOH-terminal telopeptide region of type I collagen (ICTP), markers thought to be indexes of type I collagen synthesis and degradation, respectively. Both markers were increased (PINP: 257 vs. 56 ng/ml; ICTP: 9.8 vs. 2.1 microg/l) in the immobilized leg compared with the control leg after the 7 wk of immobilization, and levels decreased again in the immobilized leg during the recovery period (PINP: 103 vs. 44 ng/ml; ICTP: 4.2 vs. 1.9 microg/l). A significant reduction in calf muscle CSA and strength was found in relation to 7 wk of immobilization. Immobilization increased both collagen synthesis and degradation in tendon near tissue. However, it cannot be excluded that the facture of the ankle in close proximity could have affected these data. Remobilization increased muscle size and strength and tendon synthesis and degradation decreased to baseline levels. These dynamic changes in tendon connective tissue turnover were not associated with macroscopic changes in tendon size.     

Effect of altered physical loading on bone and muscle in the forearm

Cast immobilization of injured forearms is common clinical practice yet little is known about the effect of reduced skeletal loading in the absence of pathology. This study reports the changes in the forearms of nine healthy young adults owing to six weeks in a plaster cast followed by 1 year of either habitual activity or a strengthening program. Both groups exhibited similar patterns of change in wrist mobility, forearm muscle strength, and bone variables. Because of small sample size and poor compliance with the exercise protocol, no conclusions can be drawn about the effect of exercise. In all subjects, reduced loading caused a decrease in wrist mobility (p < 0.02) and grip strength (p = 0.01) with full recovery following 3 months of remobilization. Six months after removing the cast, bone size was reduced in the middle region of the radius (p = 0.02) and recovered after 1 year of remobilization. Given that radial bone mass tended to decrease while bone density was unchanged, we conclude that the effect of casting was modulated by changes in gross bone morphology rather than in material characteristics.     

Influence of patellar position on tibial rotation after total knee arthroplasty]

AIM: Common total knee arthroplasty leads to resection of the anterior cruciate ligament. Lacking the ligamentous guidance, tibial rotation depends on different factors, i.e., muscle vectors. The present study measured the influence of the knee extensor mechanism determined by the mediolateral patella position on tibial rotation after implantation of two different knee prostheses. MATERIALS AND METHODS: Physiologic tibial rotation and mediolateral patella translation were measured in ten fresh-frozen knee specimens. After implantation of the Interax- and Genesis II-prosthesis in each five of the ten specimens, kinematic measurements were made again with a determination of significant alterations. RESULTS: The maximal medial patella position relative to the centre of the tibia was -6.6 mm (representing lateralisation); the maximal external tibial rotation was 4.1 degrees. After implantation of the Genesis II-prosthesis the external tibial rotation was reduced (p=0.03) with a relatively medialised patella (p=0.01), whereas after implantation of the Interax-prosthesis the external tibial rotation was increased (p=0.01) while the patella was measured to be lateralised similar to physiologic conditions. CONCLUSION: The results of the current study revealed a potential influence of mediolateral patella position on tibial rotation following total knee arthroplasty, while both prosthesis systems were not able to reproduce physiologic joint kinematics.     

Anatomical differences in the femur and tibia between Negroids and Caucasoids antheir effects upon locomotion.

Nine variables of length, width and circumference of the femur and tibia were measured on post-cranial remains of 28 Caucasoids and 45 Negroids. The distance from the point of tibial attachment of the patellar ligament to the head of the tibia (PLID) was also determined. It was found that the Negroid has a significantly longer and narrower femur and tibia than the Caucasoid, although PLID did not vary between the two groups. Thus PLID, relative to the length of the tibia, was less in Negroids than Caucasoids. A factor analysis was carried out in order to examine the relation between PLID and the other variables. It appeared that the same three factors governed the ten variables in both races. In Caucasoids, PLID did not load on either the "length" or "width" factors and appeared unique. In Negroids, PLID loaded on Factor III with two width measures, and this factor correlated positively with the "width" factor. It is suggested that in Caucasoids PLID does not relate to length or width dimensions of the leg but in Negroids it is related to width rather than length.     

AdipoRon reduces TGFβ1-mediated collagen deposition in vitro and alleviates knee stiffness in vivo

Arthrofibrosis, which causes joint motion restrictions, is a common complication following total knee arthroplasty (TKA). Key features associated with arthrofibrosis include myofibroblast activation, knee stiffness, and excessive scar tissue formation. We previously demonstrated that adiponectin levels are suppressed within the knee tissues of patients affected by arthrofibrosis and showed that AdipoRon, an adiponectin receptor agonist, exhibited anti-fibrotic properties in human mesenchymal stem cells. In this study, the therapeutic potential of AdipoRon was evaluated on TGFβ1-mediated myofibroblast differentiation of primary human knee fibroblasts and in a mouse model of knee stiffness. Picrosirius red staining revealed that AdipoRon reduced TGFβ1-induced collagen deposition in primary knee fibroblasts derived from patients undergoing primary TKA and revision TKA for arthrofibrosis. AdipoRon also reduced mRNA and protein levels of ACTA2, a key myofibroblast marker. RNA-seq analysis corroborated the anti-myofibrogenic effects of AdipoRon. In our knee stiffness mouse model, 6 weeks of knee immobilization, to induce a knee contracture, in conjunction with daily vehicle (DMSO) or AdipoRon (1, 5, and 25 mg/kg) via intraperitoneal injections were well tolerated based on animal behavior and weight measurements. Biomechanical testing demonstrated that passive extension angles (PEAs) of experimental knees were similar between vehicle and AdipoRon treatment groups in mice evaluated immediately following immobilization. Interestingly, relative to vehicle-treated mice, 5 mg/kg AdipoRon therapy improved the PEA of the experimental knees in mice that underwent 4 weeks of knee remobilization following the immobilization and therapy. Together, these studies revealed that AdipoRon may be an effective therapeutic modality for arthrofibrosis.     

Effect of motor function disorder on the properties of the muscle fiber membrane

Experiments on frogs with the use of the microelectrode techniques were made to study the effect of tenotomy and immobilization of a limb with a metal cast in the extension position on the properties of the membrane of muscle fibers. Two weeks after tenotomy there were no changes in the magnitude of the membrane rest potential, input resistance and time constant of the membrane of muscle fibers or in the pattern of its sensitivity to acetylcholine. Two and three weeks after the limb immobilization no changes in the membrane rest potential and passive electrical properties of the muscle membrane were recorded either. However, if the time elapsed after immobilization was 2 and 3 weeks, the zone of the sensitivity of muscle fibers to acetylcholine was slightly greater than in the control. It is suggested that the motor activity in the frog per se is not the determinant of the muscle fiber differentiation preset by the nervous system.     

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.     

Correlates of knee extensor training load used in rehabilitation after knee surgery

Resistance training is one of the major components of rehabilitation after musculoskeletal injury and surgery. Despite the importance of resistance training and the frequency of its use in rehabilitation, little is known about factors that are related to training load that might be useful in devising and monitoring training in a patient and comparing training intensities between individuals and groups. We hypothesized that the following would show a statistically significant relationship to training load: injury chronicity, self-assessed knee function (Hughston Clinic questionnaire), knee swelling (injured-uninjured midpatellar knee girth), uninjured knee girth, and body mass. The purpose of this study was to evaluate whether factors such as body mass are related to the load used in training the knee extensors in rehabilitation after knee surgery. Thirty-six individuals undergoing early-phase rehabilitation after knee arthroscopic meniscectomy surgery participated in this study. Subjects were tested 5 days after surgery, just prior to commencing a 6-week outpatient rehabilitation program, and again soon after the end of this rehabilitation program. The independent variables evaluated were age, gender, body mass, meniscus injured, injury chronicity, knee function self-assessment, knee swelling (injured-uninjured midpatellar girth), uninjured knee girth, and knee flexion and extension passive range of motion (difference between injured and uninjured side). The dependent variable was the load used for training the knee extensors on the knee extension machine in the final training session prior to the posttest. The only variable exhibiting a statistically significant (p = 0.001) relationship to knee extensor final training was age (r = -0.529). This finding, that age was the only variable to have a significant relationship with training load, suggests that clinicians' expectation of training intensity should decrease with an increase in the patient's age in the range studied (20-58 years) for patients recovering from knee arthroscopic meniscectomy.     

Assessment of body cell mass at bedside in critically ill patients

Critical illness affects body composition profoundly, especially body cell mass (BCM). BCM loss reflects lean tissue wasting and could be a nutritional marker in critically ill patients. However, BCM assessment with usual isotopic or tracer methods is impractical in intensive care units (ICUs). We aimed to modelize the BCM of critically ill patients using variables available at bedside. Fat-free mass (FFM), bone mineral (Mo), and extracellular water (ECW) of 49 critically ill patients were measured prospectively by dual-energy X-ray absorptiometry and multifrequency bioimpedance. BCM was estimated according to the four-compartment cellular level: BCM = FFM - (ECW/0.98) - (0.73 × Mo). Variables that might influence the BCM were assessed, and multivariable analysis using fractional polynomials was conducted to determine the relations between BCM and these data. Bootstrap resampling was then used to estimate the most stable model predicting BCM. BCM was 22.7 ± 5.4 kg. The most frequent model included height (cm), leg circumference (cm), weight shift (Δ) between ICU admission and body composition assessment (kg), and trunk length (cm) as a linear function: BCM (kg) = 0.266 × height + 0.287 × leg circumference + 0.305 × Δweight - 0.406 × trunk length - 13.52. The fraction of variance explained by this model (adjusted r(2)) was 46%. Including bioelectrical impedance analysis variables in the model did not improve BCM prediction. In summary, our results suggest that BCM can be estimated at bedside, with an error lower than ±20% in 90% subjects, on the basis of static (height, trunk length), less stable (leg circumference), and dynamic biometric variables (Δweight) for critically ill patients.     

The line of action in the tibia during axial compression of the leg

Compression of the leg induces bending in the tibia, which can lead to tensile failure of the bone in the midshaft. The purpose of this study was to determine the orientation of the compressive load vector in the human tibia. Five cadaveric lower extremities were instrumented with in situ 6-axis tibial and fibular load cells and subjected to quasistatic axial leg compression tests in two knee positions and nine ankle positions. For each test, the location and angle of the line of action were calculated at the tibial midshaft. The line of action was extended to the bone ends in order to determine the locations of the effective centers of pressure on the tibial plafond and tibial plateau. The effective center of pressure on the tibial plafond consistently migrated anteriorly in dorsiflexion, laterally in eversion, posteriorly in plantarflexion, and medially in inversion. An opposite pattern was observed on the tibial plateau. When the knee was flexed, the effective center of pressure was generally isolated to a small area in the posterior portion of the medial tibial condyle. The percentage of the axial load borne by the fibula varied from -8% to 19%, and was related to the inversion/eversion angle of the ankle (p<0.02), as well as the distance between the fibula and the axial load path at the midshaft (p<0.001). The line of action through the tibia appeared to follow the external load path to the extent allowed by the available joint contact surfaces.     

Noninvasive monitoring of deterioration in skeletal muscle function with forearm cast immobilization and the prevention of deterioration

BACKGROUND: In this research inactivity was simulated by immobilizing the forearm region in a plaster cast. Changes in skeletal muscle oxidative function were measured using near-infrared spectroscopy (NIRS), and the preventative effect of the training protocol on deterioration of skeletal muscle and the clinical utility of NIRS were examined. METHODS: Fourteen healthy adult men underwent immobilization of the forearm of the non-dominant arm by plaster cast for 21 days. Eight healthy adult subjects were designated as the immobilization group (IMM) and six were designated as the immobilization + training group (IMM+TRN). Grip strength, forearm circumference and dynamic handgrip exercise endurance were measured before and after the 21-day immobilization period. Using NIRS, changes in oxidative function of skeletal muscles were also evaluated. Muscle oxygen consumption recovery was recorded after the completion of 60 seconds of 40% maximum voluntary contraction (MVC) dynamic handgrip exercise 1 repetition per 4 seconds and the recovery time constant (TcVO2mus) was calculated. RESULTS: TcVO2mus for the IMM was 59.7 +/- 5.5 seconds (average +/- standard error) before immobilization and lengthened significantly to 70.4 +/- 5.4 seconds after immobilization (p < 0.05). For the IMM+TRN, TcVO2mus was 78.3 +/- 6.2 seconds before immobilization and training and shortened significantly to 63.1 +/- 5.6 seconds after immobilization and training (p < 0.05). CONCLUSIONS: The training program used in this experiment was effective in preventing declines in muscle oxidative function and endurance due to immobilization. The experimental results suggest that non-invasive monitoring of skeletal muscle function by NIRS would be possible in a clinical setting.     

Stability of an underactuated bipedal gait

A self-excited biped walking mechanism consisting of two legs that are connected in series at the hip joint through a servomotor is studied as a cyclic system with collisions. A torque proportional to angle between the shank of the swinging leg and the vertical is seen to sustain a gait. Each leg has a thigh and a shank connected at a passive knee joint that has a knee stopper restricting hyperextension similar to the human knee. A mathematical model for the dynamics of the system including the impact equations is used to analyse the stability of the system through examination of phase plane plots. Attractor lines along which the system approaches stability have been identified. A leg length for optimal stability has been identified. The biological basis for the proposed system has been identified by comparison with human gait.     

Range of motion specificity resulting from closed and open kinetic chain resistance training after anterior cruciate ligament reconstruction

The purpose of this study was to examine whether joint angle specificity occurs in open and closed kinetic chain resistance training of the knee extensors after anterior cruciate ligament reconstruction (ACLR). Isokinetic knee extensor strength was measured at 60 and 210 degrees.s(-1) in 32 patients, 2 and 6 weeks after surgery. Between test sessions, patients participated in a 4-week program of injured leg resistance training of the knee extensors in either open kinetic chain (OKC) knee extension or leg press exercises. Isokinetic testing knee range of motion (ROM) was divided into 5 equal portions from flexion to extension, and the mean torque was calculated over those divisions: 0-20%, 20-40%, 40-60%, 60-80%, and 80-100% ROM. Analysis of variance indicated that there were no significant differences between patients in the knee extension or leg press exercise groups.     

Short-term immobilization and recovery affect skeletal muscle but not collagen tissue turnover in humans

Not much is known about the effects of immobilization and subsequent recovery on tendon connective tissue. In the present study, healthy young men had their nondominant leg immobilized for a 2-wk period, followed by a recovery period of the same length. Immobilization resulted in a mean decrease of 6% (5,413 to 5,077 mm(2)) in cross-sectional area (CSA) of the triceps surae muscles and a mean decrease of 9% (261 to 238 N.m) in strength of the immobilized calf muscles. Two weeks of recovery resulted in a 6% increased in CSA (to 5,367 mm(2)), whereas strength remained suppressed (240 N.m). No difference in Achilles tendon CSA was detected between the two legs at any time point. Local tendon collagen synthesis, measured as the peritendinous concentrations of PINP (NH(2)-terminal propeptide of type I collagen; indirect marker for collagen synthesis), was unchanged after 2 wk of immobilization. However, peritendinous levels of PINP were significantly elevated in the immobilized leg (15 to 139 ng/ml) following 2 wk of remobilization compared with preimmobilization levels. In contradiction hereto, systemic concentrations of PINP remained unchanged throughout the study. Immobilization reduced muscle size and strength, while tendon size and collagen turnover were unchanged. While recovery resulted in an increase in muscle size, strength was unchanged. No significant difference in tendon size could be detected between the two legs after 2 wk of recovery, although collagen synthesis was increased in the previously immobilized leg. Thus 2 wk of immobilization are sufficient to induce significant changes in muscle tissue, whereas tendon tissue seems to be more resistant to short-term immobilization.     

Myofascial force transmission in the lower limb: An in vivo experiment

Anatomical studies have shown structural continuity between the lumbopelvic region and the lower limb. The present study aimed to verify how simultaneous changes on knee/hip positions modify the ankle’s resting position and passive torque. Thirty-seven subjects underwent an isokinetic assessment of ankle passive torque. The relationship between the absolute values of ankle passive resistance torque and the ankle angular position was used to calculate the dependent variables: ankle resting position (position in which the passive resistance torque is zero); and ankle passive torque at 0° (torque at the neutral position of the ankle in the sagittal plane). These measures were carried out under three test conditions: 0° at knee and 0° at hip (0°/0°); 90° at knee and 90° at hip (90°/90°); and, 135° at knee and 120° at hip (135°/120°). The results demonstrated that the ankle resting position shifted towards dorsiflexion when knee/hip position changed from 0°/0° to 90°/90° and shifted towards plantar flexion when knee/hip position changed from 90°/90° to 135°/120°, achieving values close to the ones at the position 0°/0°. Similarly, passive torque reduced when knee/hip position changed from 0°/0° to 90°/90°, but it increased when knee/hip position changed from 90°/90° to 135°/120°. The unexpected changes observed in ankle passive torque and resting position due to changes in knee and hip from 90°/90° to 135°/120°, cannot be explained exclusively by forces related to tissues crossing the knee and ankle. This result supports the existence of myofascial force transmission among lower limb joints.     

Comparison of kinematics in the healthy and ACL injured knee using MRI

Magnetic Resonance Imaging (MRI) was used to examine the characteristics of abnormal motion in the injured knee by mapping tibiofemoral contact. Eleven healthy subjects and 20 subjects with a unilateral ACL injury performed a leg-press against resistance. MRI scans of both knees at 15 degrees intervals from 0 degrees to 90 degrees of flexion were used to record the tibiofemoral contact pattern. The tibiofemoral contact pattern of the injured knees was more posterior on the tibial plateau than the healthy knees, particularly in the lateral compartment. The tibiofemoral contact pattern of the loaded knees did not differ from the unloaded knees. The difference in the tibiofemoral contact pattern in the ACL injured knee was associated with more severe knee symptoms, irrespective of the passive anterior laxity of the knee.