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.     

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.     

Biomechanics of the rabbit knee and ankle: muscle, ligament, and joint contact force predictions

Mathematical models of small animals that predict in vivo forces acting on the lower extremities are critical for studies of musculoskeletal biomechanics and diseases. Rabbits are advantageous in this regard because they remodel their cortical bone similar to humans. Here, we enhance a recent mathematical model of the rabbit knee joint to include the loading behavior of individual muscles, ligaments, and joint contact at the knee and ankle during the stance phase of hopping. Geometric data from the hindlimbs of three adult New Zealand white rabbits, combined with previously reported intersegmental forces and moments, were used as inputs to the model. Muscle, ligament, and joint contact forces were computed using optimization techniques assuming that muscle endurance is maximized and ligament strain energy resists tibial shear force along an inclined plateau. Peak forces developed by the quadriceps and gastrocnemius muscle groups and by compressive knee contact were within the range of theoretical and in vivo predictions. Although a minimal force was carried by the anterior cruciate and medial collateral ligaments, force patterns in the posterior cruciate ligament were consistent with in vivo tibial displacement patterns during hopping in rabbits. Overall, our predictions compare favorably with theoretical estimates and in vivo measurements in rabbits, and enhance previous models by providing individual muscle, ligament, and joint contact information to predict in vivo forces acting on the lower extremities in rabbits.     

Does the condylar lift-off method or the separation method better detect loss of contact between tibial and femoral implants based on analysis of single-plane radiographs following total knee arthroplasty?

BackgroundLoss of contact between the femoral and tibial implants following total knee arthroplasty (TKA) has been related to accelerated polyethylene wear and other complications. Two methods have been used to detect loss of contact in single-plane fluoroscopy, the condylar lift-off method and the separation method. The objectives were to assess the ability of each method to detect loss of contact.MethodsTKA was performed on ten cadaveric knee specimens. Tibial force was measured in each compartment as specimens were flexed from 0° to 90° while internal-external and varus-valgus moments were applied. Single-plane radiographs taken simultaneously with tibial force were analyzed for loss of contact using the two methods. Receiver operating characteristic (ROC) and optimum threshold distances were determined.ResultsFor the lift-off method and the separation method, the areas under the ROC curves were 0.89 vs 0.60 for the lateral compartment only and 0.81 vs 0.70 for the medial compartment only, respectively. For the lift-off method, the optimum threshold distances were 0.7 mm in the lateral compartment only and 0.1 mm in the medial compartment only but the false positive rate for the medial compartment only almost doubled. For both compartments jointly, the areas under the ROC curves decreased to 0.70 and 0.59 for the lift-off and separation methods, respectively.ConclusionWhen detecting loss of contact using single-plane fluoroscopy, the lift-off method is useful for the lateral compartment only but not for the medial compartment only and not for both compartments jointly. The separation method is not useful.     

Selective lateral muscle activation in moderate medial knee osteoarthritis subjects does not unload medial knee condyle

There is some debate in the literature regarding the role of quadriceps-hamstrings co-contraction in the onset and progression of knee osteoarthritis. Does co-contraction during walking increase knee contact loads, thereby causing knee osteoarthritis, or might it be a compensatory mechanism to unload the medial tibial condyle? We used a detailed musculoskeletal model of the lower limb to test the hypothesis that selective activation of lateral hamstrings and quadriceps, in conjunction with inhibited medial gastrocnemius, can actually reduce the joint contact force on the medial compartment of the knee, independent of changes in kinematics or external forces. “Baseline” joint loads were computed for eight subjects with moderate medial knee osteoarthritis (OA) during level walking, using static optimization to resolve the system of muscle forces for each subject?s scaled model. Holding all external loads and kinematics constant, each subject?s model was then perturbed to represent non-optimal “OA-type” activation based on mean differences detected between electromyograms (EMG) of control and osteoarthritis subjects. Knee joint contact forces were greater for the “OA-type” than the “Baseline” distribution of muscle forces, particularly during early stance. The early-stance increase in medial contact load due to the “OA-type” perturbation could implicate this selective activation strategy as a cause of knee osteoarthritis. However, the largest increase in the contact load was found at the lateral condyle, and the “OA-type” lateral activation strategy did not increase the overall (greater of the first or second) medial peak contact load. While “OA-type” selective activation of lateral muscles does not appear to reduce the medial knee contact load, it could allow subjects to increase knee joint stiffness without any further increase to the peak medial contact load.     

Comparison of shear forces and ligament loading in the healthy and ACL-deficient knee during gait

The purpose of this study was to predict and explain the pattern of shear force and ligament loading in the ACL-deficient knee during walking, and to compare these results to similar calculations for the healthy knee. Musculoskeletal modeling and computer simulation were combined to calculate ligament forces in the ACL-deficient knee during walking. Joint angles, ground-reaction forces, and the corresponding lower-extremity muscle forces obtained from a whole-body dynamic optimization simulation of walking were input into a second three-dimensional model of the lower extremity that represented the knee as a six degree-of-freedom spatial joint. Anterior tibial translation (ATT) increased throughout the stance phase of gait when the model ACL was removed. The medial collateral ligament (MCL) was the primary restraint to ATT in the ACL-deficient knee. Peak force in the MCL was three times greater in the ACL-deficient knee than in the ACL-intact knee; however, peak force sustained by the MCL in the ACL-deficient knee was limited by the magnitude of the total anterior shear force applied to the tibia. A decrease in anterior tibial shear force was brought about by a decrease in the patellar tendon angle resulting from the increase in ATT. These results suggest that while the MCL acts as the primary restraint to ATT in the ACL-deficient knee, changes in patellar tendon angle reduce total anterior shear force at the knee.     

A method of calculating physiologically relevant joint reaction forces during forward dynamic simulations of movement from an existing knee model

In the commonly used SIMM software, which includes a complete musculoskeletal model of the lower limbs, the reaction forces at the knee are computed. These reaction forces represent the bone-on-bone contact forces and the soft tissue forces (e.g. ligaments) other than muscles acting at the joint. In the knee model integrated into this software, a patellotibial joint rather than a patellofemoral joint is defined, and a force acting along the direction of the patellar ligament is not included. Although this knee model results in valid kinematics and muscle moment arms, the reaction forces at the knee calculated do not represent physiologic knee joint reaction forces. Hence our objectives were to develop a method of calculating physiologic knee joint reaction forces using the knee model incorporated into the SIMM software and to demonstrate the differences in the forces returned by SIMM and the physiologic forces in an example. Our method converts the anatomically fictional patellotibial joint into a patellofemoral joint and computes the force in an inextensible patellar ligament. In our example, the rectus femoris was fully excited isometrically, with the knee and hip flexed to 90 degrees . The resulting SIMM tibiofemoral joint reaction force was primarily shear, because the quadriceps force was applied to the tibia via the fictional patellotibial joint. In contrast the physiologic tibiofemoral joint reaction force was primarily compression, because the quadriceps force was applied through the patellar ligament. This result illustrates that the physiologic knee joint reaction forces are profoundly different than the forces returned by SIMM. However physiologic knee joint reaction forces can be computed with postprocessing of SIMM results.     

Knee joint motion and ligament forces before and after ACL reconstruction

The goal of this in vitro study was to investigate the initial postoperative mechanical state of the knee with various types of anterior cruciate ligament (ACL) reconstructions. An experimental knee testing system was developed for the in vitro measurement of ligament forces and three-dimensional joint motion as external loads were applied to fresh knee specimens. Two groups of knee specimens were tested. In test series #1, two intraarticular reconstructions were performed in each of five specimens using semifree and free patellar tendon grafts with bone blocks. In test series #2, a more carefully controlled intraarticular reconstruction was performed in five specimens using a semifree composite graft consisting of the semitendinosus and gracilis tendons augmented with the Ligament Augmentation Device. Ligament force and joint motion data were collected as anteriorly directed tibial loads were applied to the normal joint, the joint with a cut ACL and the reconstructed joint. These knee joint states were compared on the basis of ACL or graft forces, joint motion and load sharing by the collateral ligaments. The dominate result of the study was that the forces and motions defining the mechanical state of the knee after the ACL reconstructions in both test series were highly variable and abnormal when compared to the normal knee state. The higher level of surgical control series #2 did not decrease this variability. There was a poor correlation between motion of the reconstructed knee relative to normal, and the ACL graft force. There was little consistent difference in force and motion results between the surgical procedures tested.     

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.     

The effect of weightbearing and external loading on anterior cruciate ligament strain

A force balance between the ligaments, articular contact, muscles and body weight maintains knee joint stability. Thus, it is important to study anterior cruciate ligament (ACL) biomechanics, in vivo, under weightbearing conditions. Our objective was to compare the ACL strain response under weightbearing and non-weightbearing conditions and in combination with three externally applied loadings: (1) anterior-posterior shear forces, (2) internal-external torques, and (3) varus-valgus moments. A strain transducer was implanted on the ACL of 11 subjects. All joint loadings were performed with the knee at 20 degrees of flexion. A significant increase in ACL strain was observed as the knee made the transition from non-weightbearing to weightbearing. During anterior shear loading, the strain values produced during weightbearing were greater than those of the non-weightbearing knee (shear loads <40N). At higher shear loads, the strain values became equal. During axial torsion, an internal torque of 10Nm strained the ACL when the knee was non-weightbearing while an equivalent external torque did not. Weightbearing significantly increased ACL strain values in comparison to non-weightbearing with the application of external torques and low internal torques (<3Nm). The strains became equal for higher internal torques. For V-V loading, the ACL was not strained in the non-weightbearing knee. However, weightbearing increased the ACL strain values over the range of moments tested. These data have important clinical ramifications in the development of rehabilitation protocols following ACL reconstruction since weightbearing has been previously thought to provide a protective mechanism to the healing graft.     

Load sharing between solid and fluid phases in articular cartilage: I--Experimental determination of in situ mechanical conditions in a porcine knee.

The in situ mechanical conditions of cartilage in the articulated knee were quantified during joint loading. Six porcine knees were subjected to a 445 N compressive load while cartilage deformations and contact pressures were measured. From roentgenograms, cartilage thickness before and during loading allowed the calculation of tissue deformation on the lateral femoral condyle at different times during the loading process. Contact pressures on the articular surface were measured with miniature fiber-optic pressure transducers. Results showed that the medial side of the lateral femoral condyle had higher contact pressures, as well as deformations. To begin to correlate the pressures and resulting deformations, the intrinsic material properties of the cartilage on the lateral condyle were obtained from indentation tests. Data from four normal control specimens indicated that the aggregate modulus of the medial side was significantly higher than in other areas of the condyle. These experimental measures of the in situ mechanical conditions of articular cartilage can be combined with theoretical modeling to obtain valuable information about the relative contributions of the solid and fluid phases to supporting the applied load on the cartilage surface (see Part II).     

Effects of medial collateral ligament release,limb correction,and soft tissue laxity on knee joint contact force distribution after medial opening wedge high tibial osteotomy: a computational study

In this study, the effects of medial collateral ligament (MCL) release and the limb correction strategies with pre-existing MCL laxity on tibiofemoral contact force distribution after high tibial osteotomy (HTO) were investigated. The medial and lateral contact forces of the knee were quantified during simulated standing using computational modeling techniques. MCL slackness had a primary influence on contact force distribution of the knee, while there was little effect of simulated limb correction. Anterior and middle bundle release, which involved the partial release of two-thirds of the superficial MCL, was shown to be an optimal surgical method in HTO, achieving balanced contact distribution in simulated weight-bearing standing.     

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.     

Quantification of soft tissue balance in total knee arthroplasty using finite element analysis

Unbalanced contact force on the tibial component has been considered a factor leading to loosening of the implant and increased wear of the bearing surface in total knee arthroplasty. Because it has been reported that good alignment cannot guarantee successful clinical outcomes, the soft tissue balance should be checked together with the alignment. Finite element models of patients' lower extremities were developed to analyse the medial and lateral contact force distribution on the tibial insert. The distributions for four out of five patients were not balanced equally, even though the alignment angles were within a clinically acceptable range. Moreover, the distribution was improved by changing soft tissue release and ligament tightening for the specific case. Integration of the biomechanical modelling, image matching and finite element analysis techniques with the patient-specific properties and various dynamic loading would suggest a clinically relevant pre-operative planning for soft tissue balancing.     

The role of patient, surgical, and implant design variation in total knee replacement performance

Clinical studies demonstrate substantial variation in kinematic and functional performance within the total knee replacement (TKR) patient population. Some of this variation is due to differences in implant design, surgical technique and component alignment, while some is due to subject-specific differences in joint loading and anatomy that are inherently present within the population. Combined finite element and probabilistic methods were employed to assess the relative contributions of implant design, surgical, and subject-specific factors to overall tibiofemoral (TF) and patellofemoral (PF) joint mechanics, including kinematics, contact mechanics, joint loads, and ligament and quadriceps force during simulated squat, stance-phase gait and stepdown activities. The most influential design, surgical and subject-specific factors were femoral condyle sagittal plane radii, tibial insert superior-inferior (joint line) position and coronal plane alignment, and vertical hip load, respectively. Design factors were the primary contributors to condylar contact mechanics and TF anterior-posterior kinematics; TF ligament forces were dependent on surgical factors; and joint loads and quadriceps force were dependent on subject-specific factors. Understanding which design and surgical factors are most influential to TKR mechanics during activities of daily living, and how robust implant designs and surgical techniques must be in order to adequately accommodate subject-specific variation, will aid in directing design and surgical decisions towards optimal TKR mechanics for the population as a whole.     

Contact forces in several TKA designs during squatting: A numerical sensitivity analysis

Total knee arthroplasty (TKA) is a very successful procedure, but pain or difficulties during activities still persist in patients. Patient outcomes in TKA surgery can be affected by implant design, alignment or patient-related anatomical factors. This paper presents a numerical sensitivity analysis of several TKA types: a fixed bearing, posterior stabilized prosthesis, a high flexion fixed bearing guided motion prosthesis, a mobile bearing prosthesis and a hinge prosthesis. Each prosthesis was virtually implanted on the same cadaver leg model and it underwent a loaded squat, in 10s, between 0° and 120°, similar to several previous experimental tests performed on knee kinematics simulators. The aim of this examination was to investigate the sensitivity of the patello-femoral (PF) and tibio-femoral (TF) contact forces to patient-related anatomical factors, and component position in the different implant types. The following parameters were used for the sensitivity study: the proximo-distal patellar position, the patellar component tilting, the tibial component position and orientation, the locations of the medial and lateral collateral ligaments with respect to femur and tibia and the patellar tendon length. The sensitivity analysis showed that PF contact forces are mostly affected by patella height (increases up to 67% for one TKA type in patella-alta configuration), by an anterior tibial component translation (increases up to 30%), and by patellar component tilting (increases up to 29%); TF contact forces are mostly affected by the anterior displacement of the insertion points of the medial collateral ligament with respect to the reference position (increases up to 48%).     

Muscle and external load contribution to knee joint contact loads during normal gait

Large knee adduction moments during gait have been implicated as a mechanical factor related to the progression and severity of tibiofemoral osteoarthritis and it has been proposed that these moments increase the load on the medial compartment of the knee joint. However, this mechanism cannot be validated without taking into account the internal forces and moments generated by the muscles and ligaments, which cannot be easily measured. Previous musculoskeletal models suggest that the medial compartment of the tibiofemoral joint bears the majority of the tibiofemoral load, with the lateral compartment unloaded at times during stance. Yet these models did not utilise explicitly measured muscle activation patterns and measurements from an instrumented prosthesis which do not portray lateral compartment unloading. This paper utilised an EMG-driven model to estimate muscle forces and knee joint contact forces during healthy gait. Results indicate that while the medial compartment does bear the majority of the load during stance, muscles provide sufficient stability to counter the tendency of the external adduction moment to unload the lateral compartment. This stability was predominantly provided by the quadriceps, hamstrings, and gastrocnemii muscles, although the contribution from the tensor fascia latae was also significant. Lateral compartment unloading was not predicted by the EMG-driven model, suggesting that muscle activity patterns provide useful input to estimate muscle and joint contact forces.     

Forces acting on the patella during maximal voluntary contraction of the quadriceps femoris muscle at different knee flexion/extension angles

From knee extension moments measured with a dynamometer, the quadriceps muscle force, the patellar ligament force and the reaction force in the patellofemoral joint at various knee angles (0-90 degrees) were estimated. The information needed to calculate the combined effect of both patellofemoral and tibiofemoral joint on the mechanical advantage of the muscle was obtained from lateral-view radiographs of autopsy knees. The results show that the smallest quadriceps force (2,000 N) is exerted at maximal extension, and the largest force (8,000 N) at about 75 degrees of flexion. The patellar ligament force reaches a maximum (5,000 N) at 60 degrees. The reaction force in the patellofemoral joint is the smallest (1,000 N) at extension and is of the same values as the muscle force in a range from 75 to 90 degrees. Especially at large flexion angles, the value of the estimated forces is considerably larger (by 100%) than reported in the literature. This difference is attributed to the influence of the patellofemoral joint on the mechanical advantage of the muscle, which has not been taken into account in other studies.     

The influence of patellofemoral joint contact geometry on the modeling of three dimensional patellofemoral joint forces

The purpose of this study was to determine the influence of patellofemoral joint contact geometry on the modeling of three-dimensional patellofemoral joint forces. To achieve this goal, patellofemoral joint reaction forces (PFJRFs) that were measured from an in-vitro cadaveric set-up were compared to PFJRFs estimated from a computer model that did not consider patellofemoral joint contact geometry. Ten cadaver knees were used in this study. Each was mounted on a custom jig that was fixed to an Instron frame. Quadriceps muscle loads were accomplished using a pulley system and weights. The force in the patellar ligament was obtained using a buckle transducer. To quantify the magnitude and direction of the PFJRF, a six-axis load cell was incorporated into the femoral fixation system so that a rigid body assumption could be made. PFJRF data were obtained at 0 degrees , 20 degrees , 40 degrees and 60 degrees of knee flexion. Following in vitro testing, SIMM modeling software was used to develop computational models based on the three-dimensional coordinates (Microscribe digitizer) of individual muscle and patellar ligament force vectors obtained from the cadaver knees. The overall magnitude of the PFJRF estimated from the computer generated models closely matched the direct measurements from the in vitro set-up (Pearson's correlation coefficient, R(2)=0.91, p<0.001). Although the computational model accurately estimated the posteriorly directed forces acting on the joint, some discrepancies were noted in the forces acting in the superior and lateral directions. These differences however, were relatively small when expressed as a total of the overall PFJRF magnitude.     

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

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