In vivo knee moments and shear after total knee arthroplasty

Tibiofemoral loading is very important in cartilage degeneration as well as in component survivorship after total knee arthroplasty. We have previously reported the axial knee forces in vivo. In this study, a second-generation force-sensing device that measured all six components of tibial forces was implanted in a 74-kg, 83-year-old male. Video motion analysis, ground reaction forces, and knee forces were measured during walking, stair climbing, chair-rise, and squat activities. Peak total force was 2.3 times body weight (BW) during walking, 2.5 x BW during chair rise, 3.0 x BW during stair climbing, and 2.1 x BW during squatting. Peak anterior shear force at the tibial tray was 0.30 x BW during walking, 0.17 x BW during chair rise, 0.26 x BW during stair climbing, and 0.15 x BW during squatting. Peak flexion moment at the tray was 1.9% BW x Ht (percentage of body weight multiplied by height) for chair-rise activity and 1.7% BW x Ht for squat activity. Peak adduction moment at the tray was -1.1% BW x Ht during chair-rise, -1.3% BW x Ht during squatting. External knee flexion and adduction moments were substantially greater than flexion and adduction moments at the tray. The axial component of forces predominated especially during the stance phase of walking. Shear forces and moments at the tray were very modest compared to total knee forces. These findings indicate that the soft tissues around the knee absorbed most of the external shear forces. Our results highlight the importance of direct measurements of knee forces.     

Loading of the knee joint during activities of daily living measured in vivo in five subjects

Detailed knowledge about loading of the knee joint is essential for preclinical testing of implants, validation of musculoskeletal models and biomechanical understanding of the knee joint. The contact forces and moments acting on the tibial component were therefore measured in 5 subjects in vivo by an instrumented knee implant during various activities of daily living.Average peak resultant forces, in percent of body weight, were highest during stair descending (346% BW), followed by stair ascending (316% BW), level walking (261% BW), one legged stance (259% BW), knee bending (253% BW), standing up (246% BW), sitting down (225% BW) and two legged stance (107% BW). Peak shear forces were about 10–20 times smaller than the axial force. Resultant forces acted almost vertically on the tibial plateau even during high flexion. Highest moments acted in the frontal plane with a typical peak to peak range ?2.91% BWm (adduction moment) to 1.61% BWm (abduction moment) throughout all activities. Peak flexion/extension moments ranged between ?0.44% BWm (extension moment) and 3.16% BWm (flexion moment). Peak external/internal torques lay between ?1.1% BWm (internal torque) and 0.53% BWm (external torque).The knee joint is highly loaded during daily life. In general, resultant contact forces during dynamic activities were lower than the ones predicted by many mathematical models, but lay in a similar range as measured in vivo by others. Some of the observed load components were much higher than those currently applied when testing knee implants.     

Standardized Loads Acting in Knee Implants

The loads acting in knee joints must be known for improving joint replacement, surgical procedures, physiotherapy, biomechanical computer simulations, and to advise patients with osteoarthritis or fractures about what activities to avoid. Such data would also allow verification of test standards for knee implants. This work analyzes data from 8 subjects with instrumented knee implants, which allowed measuring the contact forces and moments acting in the joint. The implants were powered inductively and the loads transmitted at radio frequency. The time courses of forces and moments during walking, stair climbing, and 6 more activities were averaged for subjects with I) average body weight and average load levels and II) high body weight and high load levels. During all investigated activities except jogging, the high force levels reached 3,372–4,218N. During slow jogging, they were up to 5,165N. The peak torque around the implant stem during walking was 10.5 Nm, which was higher than during all other activities including jogging. The transverse forces and the moments varied greatly between the subjects, especially during non-cyclic activities. The high load levels measured were mostly above those defined in the wear test ISO 14243. The loads defined in the ISO test standard should be adapted to the levels reported here. The new data will allow realistic investigations and improvements of joint replacement, surgical procedures for tendon repair, treatment of fractures, and others. Computer models of the load conditions in the lower extremities will become more realistic if the new data is used as a gold standard. However, due to the extreme individual variations of some load components, even the reported average load profiles can most likely not explain every failure of an implant or a surgical procedure.     

The effect of valgus braces on medial compartment load of the knee joint - in vivo load measurements in three subjects

Knee osteoarthritis occurs predominately at the medial compartment. To unload the affected compartment, valgus braces are used which induce an additional valgus moment in order to shift the load more laterally. Until now the biomechanical effect of braces was mainly evaluated by measuring changes in external knee adduction moments. The aim of this study was to investigate if and to which extent the medial compartment load is reduced in vivo when wearing valgus braces. Six components of joint contact load were measured in vivo in three subjects, using instrumented, telemeterized knee implants. From the forces and moments the medio-lateral force distribution was calculated. Two braces, MOS Genu (Bauerfeind AG) and Genu Arthro (Otto Bock) were investigated in neutral, 4° and 8° valgus adjustment during walking, stair ascending and descending. During walking with the MOS brace in 4°/8° valgus adjustment, medial forces were reduced by 24%/30% on average at terminal stance. During walking with the GA in the 8° valgus position, medial forces were reduced by only 7%. During stair ascending/descending significant reductions of 26%/24% were only observed with the MOS (8°). The load reducing ability of the two investigated valgus braces was confirmed in three subjects. However, the load reduction depends on the brace stiffness and its valgus adjustment and varies strongly inter-individually. Valgus adjustments of 8° might, especially with the MOS brace, not be tolerated by patients for a long time. Medial load reductions of more than 25% can therefore probably not be expected in clinical practise.     

Biomechanics of overground vs. treadmill walking in healthy individuals.

The goal of this study was to compare treadmill walking with overground walking in healthy subjects with no known gait disorders. Nineteen subjects were tested, where each subject walked on a split-belt instrumented treadmill as well as over a smooth, flat surface. Comparisons between walking conditions were made for temporal gait parameters such as step length and cadence, leg kinematics, joint moments and powers, and muscle activity. Overall, very few differences were found in temporal gait parameters or leg kinematics between treadmill and overground walking. Conversely, sagittal plane joint moments were found to be quite different, where during treadmill walking trials, subjects demonstrated less dorsiflexor moments, less knee extensor moments, and greater hip extensor moments. Joint powers in the sagittal plane were found to be similar at the ankle but quite different at the knee and hip joints. Differences in muscle activity were observed between the two walking modalities, particularly in the tibialis anterior throughout stance, and in the hamstrings, vastus medialis and adductor longus during swing. While differences were observed in muscle activation patterns, joint moments and joint powers between the two walking modalities, the overall patterns in these behaviors were quite similar. From a therapeutic perspective, this suggests that training individuals with neurological injuries on a treadmill appears to be justified.     

Load along the tibial shaft during activities of daily living

External load at the tibia during activities of daily living provides baseline measures for the improvement of the design of the bone–implant interface for relevant internal and external prostheses. A motion analysis system was used together with an established protocol with skin markers to estimate three-dimensional forces and moments acting on ten equidistant points along the tibial shaft. Twenty young and able-bodied volunteers were analysed while performing three repetitions of the following tasks: level walking at three different speeds, in a straight-line and with sudden changes of direction to the right and to the left, stair ascending and descending, squatting, rising from a chair and sitting down. Moment and force patterns were normalised to the percentage of body weight per height and body weight, respectively, and then averaged over all subjects for each point, about the three tibial anatomical axes, and for each task. Load patterns were found to be consistent over subjects, but different among the anatomical axes, tasks and points. Generally, moments were higher in the medio/lateral axis and influenced by walking speed. In all five walking tasks and in ascending stairs with alternating feet, the more proximal the point was the smaller the mean moment was. For the remaining tasks the opposite trend was observed. The overall largest value was observed in the medio/lateral direction at the ankle centre in level walking at high speed (9.1% body weight * height on average), nearly three times larger than that of the anterior/posterior axis (2.9) during level walking with a sidestep turn. The present results should be of value also for in-vitro mechanical tests and finite element models.     

Hip contact forces and gait patterns from routine activities.

In vivo loads acting at the hip joint have so far only been measured in few patients and without detailed documentation of gait data. Such information is required to test and improve wear, strength and fixation stability of hip implants. Measurements of hip contact forces with instrumented implants and synchronous analyses of gait patterns and ground reaction forces were performed in four patients during the most frequent activities of daily living. From the individual data sets an average was calculated. The paper focuses on the loading of the femoral implant component but complete data are additionally stored on an associated compact disc. It contains complete gait and hip contact force data as well as calculated muscle activities during walking and stair climbing and the frequencies of daily activities observed in hip patients. The mechanical loading and function of the hip joint and proximal femur is thereby completely documented. The average patient loaded his hip joint with 238% BW (percent of body weight) when walking at about 4 km/h and with slightly less when standing on one leg. This is below the levels previously reported for two other patients (Bergmann et al., Clinical Biomechanics 26 (1993) 969-990). When climbing upstairs the joint contact force is 251% BW which is less than 260% BW when going downstairs. Inwards torsion of the implant is probably critical for the stem fixation. On average it is 23% larger when going upstairs than during normal level walking. The inter- and intra-individual variations during stair climbing are large and the highest torque values are 83% larger than during normal walking. Because the hip joint loading during all other common activities of most hip patients are comparably small (except during stumbling), implants should mainly be tested with loading conditions that mimic walking and stair climbing.     

Knee moment outcomes using inverse dynamics and the cross product function in moderate knee osteoarthritis gait: A comparison study

Inverse dynamics are the cornerstone of biomechanical assessments to calculate knee moments during walking. In knee osteoarthritis, these outcomes have been used to understand knee pathomechanics, but the complexity of an inverse dynamic model may limit the uptake of joint moments in some clinical and research structures. The objective was to determine whether discrete features of the sagittal and frontal plane knee moments calculated using inverse dynamics compare to knee moments calculated using a cross product function. Knee moments from 74 people with moderate knee osteoarthritis were assessed after ambulating at a self-selected speed on an instrumented dual belt treadmill. Standardized procedures were used for surface marker placement, gait speed determination and data processing. Net external frontal and sagittal plane knee moments were calculated using inverse dynamics and the three-dimensional position of the knee joint center with respect to the center of pressure was crossed with the three-dimensional ground reaction forces in the cross product function. Correlations were high between outcomes of the moment calculations (r > 0.9) and for peak knee adduction moment, knee adduction moment impulse and difference between peak flexion and extension moments, the cross product function resulted in absolute values less than 10% of those calculated using inverse dynamics in this treadmill walking environment. This computational solution may allow the integration of knee moment calculations to understand knee osteoarthritis gait without data collection or computational complexity.     

Patellofemoral interactions in walking,stair ascent,and stair descent using a virtual patella model

Restoration of normal patella kinematics is an important clinical outcome of total knee arthroplasty. Failure of the patella within total knee systems has been documented and, upon occurrence, often necessitates revision surgery. It is thus important to understand patella mechanics following implantation, subject to load states that are typically realized during walking and other gaits. Here, a computational model of the patella is developed and used to examine the effects of walking, stair ascent, and stair descent on the development of stress and contact pressure in the patella throughout the gait cycle. Motion of the patella was governed by a combination of kinematic and force control, based on knee flexion and patellofemoral joint reaction force data from the literature. Unlike most previous analyses of full gait, quasi-static equilibrium was enforced throughout the cycle. Results indicate that, though peak forces vary greatly between the three gaits, maximum contact pressure and von Mises stress are roughly equivalent. However, contact area is larger in stair ascent and descent than walking, as patellofemoral loading, implant geometry, and polyethylene yield increase conformity between the femoral component and patella. Additionally, maximum contact pressure does not coincide with maximum load except for the case of walking. Though specific to the implant design considered here, this result has important ramifications for patella testing and emphasizes the need to characterize patella mechanics throughout gait.     

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

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

Biomechanical evaluation of walking and cycling in children

Physical activity in children is important as it leads to healthy growth due to physiological benefits. However, a physiological benefit can be partially negated by excessive or unphysiological loads within the joints. To gain an initial understanding into this, the present study sought to compare joint loading between walking and cycling in children. With institutional ethical approval, 14 pre-pubertal children aged 8–12 walked on an instrumented treadmill and cycled on a stationary ergometer. Two methods were used to match physiological load. Cardiovascular loads between walking and cycling were matched using heart rate. Metabolic load was normalised by matching estimates of oxygen consumption. Joint reaction forces during cycling and walking as well as joint moments were derived using inverse dynamics. Peak compressive forces were greater on the knees and ankles during walking than during cycling. Peak shear peak forces at the knee and ankle were also significantly larger during walking than during cycling, independent of how physiological load was normalised. For both cycling conditions, ankle moments were significantly smaller during cycling than walking. No differences were found for knee moments. At equivalent physiological intensities, cycling results in less joint loading than walking. It can be speculated that for certain populations and under certain conditions cycling might be a more suitable mode of exercise than weight bearing activities to achieve a given metabolic load.     

Effects of training and weight support on muscle activation in Parkinson’s disease

The aim of this study was to investigate the effect of high-intensity locomotor training on knee extensor and flexor muscle activation and adaptability to increased body-weight (BW) support during walking in patients with Parkinson’s disease (PD). Thirteen male patients with idiopathic PD and eight healthy participants were included. The PD patients completed an 8-week training program on a lower-body, positive-pressure treadmill. Knee extensor and flexor muscles activation during steady treadmill walking (3 km/h) were measured before, at the mid-point, and after training. Increasing BW support decreased knee extensor muscle activation (normalization) and increased knee flexor muscle activation (abnormal) in PD patients when compared to healthy participants. Training improved flexor peak muscle activation adaptability to increased (BW) support during walking in PD patients. During walking without BW support shorter knee extensor muscle off-activation time and increased relative peak muscle activation was observed in PD patients and did not improve with 8 weeks of training. In conclusion, patients with PD walked with excessive activation of the knee extensor and flexor muscles when compared to healthy participants. Specialized locomotor training may facilitate adaptive processes related to motor control of walking in PD patients.     

Musculo-skeletal loading conditions at the hip during walking and stair climbing.

Musculo-skeletal loading plays an important role in the primary stability of joint replacements and in the biological processes involved in fracture healing. However, current knowledge of musculo-skeletal loading is still limited. In the past, a number of musculo-skeletal models have been developed to estimate loading conditions at the hip. So far, a cycle-to-cycle validation of predicted musculo-skeletal loading by in vivo measurements has not been possible. The aim of this study was to determine the musculo-skeletal loading conditions during walking and climbing stairs for a number of patients and compare these findings to in vivo data.Following total hip arthroplasty, four patients underwent gait analysis during walking and stair climbing. An instrumented femoral prosthesis enabled simultaneous measurement of in vivo hip contact forces. On the basis of CT and X-ray data, individual musculo-skeletal models of the lower extremity were developed for each patient. Muscle and joint contact forces were calculated using an optimization algorithm. The calculated peak hip contact forces both over- and under-estimated the measured forces. They differed by a mean of 12% during walking and 14% during stair climbing.For the first time, a cycle-to-cycle validation of predicted musculo-skeletal loading was possible for walking and climbing stairs in several patients. In all cases, the comparison of in vivo measured and calculated hip contact forces showed good agreement.Thus, the authors consider the presented approach as a useful means to determine valid conditions for the analysis of prosthesis loading, bone modeling or remodeling processes around implants and fracture stability following internal fixation.     

Ground reaction force estimation using an insole-type pressure mat and joint kinematics during walking

Kinetic analysis of walking requires joint kinematics and ground reaction force (GRF) measurement, which are typically obtained from a force plate. GRF is difficult to measure in certain cases such as slope walking, stair climbing, and track running. Nevertheless, estimating GRF continues to be of great interest for simulating human walking. The purpose of the study was to develop reaction force models placed on the sole of the foot to estimate full GRF when only joint kinematics are provided (Type-I), and to estimate ground contact shear forces when both joint kinematics and foot pressure are provided (Type-II and Type-II-val). The GRF estimation models were attached to a commercial full body skeletal model using the AnyBody Modeling System, which has an inverse dynamics-based optimization solver. The anterior–posterior shear force and medial–lateral shear force could be estimated with approximate accuracies of 6% BW and 2% BW in all three methods, respectively. Vertical force could be estimated in the Type-I model with an accuracy of 13.75% BW. The accuracy of the force estimation was the highest during the mid-single-stance period with an average RMS for errors of 3.10% BW, 1.48% BW, and 7.48% BW for anterior–posterior force, medial–lateral force, and vertical force, respectively. The proposed GRF estimation models could predict full and partial GRF with high accuracy. The design of the contact elements of the proposed model should make it applicable to various activities where installation of a force measurement system is difficult, including track running and treadmill walking.     

In vitro measurement of the restraining role of the anterior cruciate ligament during walking and stair ascent

The study aimed to test the hypothesis that the restraining role of the anterior cruciate ligament (ACL) of the knee is significant during the activities of normal walking and stair ascent. The role of the ACL was determined from the effect of ACL excision on tibiofemoral displacement patterns measured in vitro for fresh-frozen knee specimens subjected to simulated knee kinetics of walking (n = 12) and stair ascent (n = 7). The knee kinetics were simulated using a newly developed dynamic simulator able to replicate the sagittal-plane knee kinetics with reasonable accuracy while ensuring unconstrained tibiofemoral kinematics. The displacements were measured using a calibrated six degree-of-freedom electromechanical goniometer. For the simulation of the walking cycle, two types of knee flexion/extension moment patterns were used: the more common "biphasic" pattern, and an extensor muscle force intensive pattern. For both of these patterns, the restraining role of the ACL to tibial anterior translation was found to be significant throughout the stance phase and in the terminal swing phase, when the knee angle was in the range of 4 degrees to 30 degrees. The effect of ACL excision was an increase in tibial anterior translation by 4 mm to 5 mm. For the stair ascent cycle, however, the restraining role of the ACL was significant only during the terminal stance phase, and not during the initial and middle segments of the phase. Although, in these segments, the knee moments were comparable to that in walking, the knee angle was in the range of 60 degrees to 70 degrees. These results have been shown to be consistent with available data on knee mechanics and ACL function measured under static loading conditions.     

Stair climbing results in more challenging patellofemoral contact mechanics and kinematics than walking at early knee flexion under physiological-like quadriceps loading

The mechanical environment during stair climbing has been associated with patellofemoral pain, but the contribution of loading to this condition is not clearly understood. It was hypothesized that the loading conditions during stair climbing induce higher patellofemoral pressures, a more lateral force distribution on the trochlea and a more lateral shift and tilt of the patella compared to walking at early knee flexion. Optical markers for kinematic measurements were attached to eight cadaveric knees, which were loaded with muscle forces at instances of walking and stair climbing cycles at 12° and 30° knee flexion. Contact mechanics were determined using a pressure sensitive film. At 12° knee flexion, stair climbing loads resulted in higher peak pressure (p=0.012) than walking, more lateral force distribution (p=0.012) and more lateral tilt (p=0.012), whilst mean pressure (p=0.069) and contact area (p=0.123) were not significantly different. At 30° knee flexion, although stair climbing compared to walking loads resulted in significantly higher patellofemoral mean (p=0.012) and peak pressures (p=0.012), contact area (p=0.025), as well as tilt (p=0.017), the medial–lateral force distribution (p=0.674) was not significantly different. No significant differences were observed in patellar shift between walking and stair climbing at either 12° (p=0.093) or 30° (p=0.575) knee flexion. Stair climbing thus leads to more challenging patellofemoral contact mechanics and kinematics than level walking at early knee flexion. The increase in patellofemoral pressure, lateral force distribution and lateral tilt during stair climbing provides a possible biomechanical explanation for the patellofemoral pain frequently experienced during this activity.     

Jogging gait kinetics following fatiguing lumbar paraspinal exercise

A relationship exists between lumbar paraspinal muscle fatigue and quadriceps muscle activation. The objective of this study was to determine whether hip and knee joint moments during jogging changed following paraspinal fatiguing exercise. Fifty total subjects (25 with self-reported history of low back pain) performed fatiguing, isometric lumbar extension exercise until a shift in EMG median frequency corresponding to a mild level of muscle fatigue was observed. We compared 3-dimensional external joint moments of the hip and knee during jogging before and after lumbar paraspinal fatigue using a 10-camera motion analysis system. Reduced external knee flexion, knee adduction, knee internal rotation and hip external rotation moments and increased external knee extension moments resulted from repetitive lumbar paraspinal fatiguing exercise. Persons with a self-reported history of LBP had larger knee flexion moments than controls during jogging. Neuromuscular changes in the lower extremity occur while resisting knee and hip joint moments following isolated lumbar paraspinal exercise. Persons with a history of LBP seem to rely more heavily on quadriceps activity while jogging.     

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

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

Three-dimensional knee joint loading during seated cycling.

The hypothesis which motivated the work reported in this article was that neglecting pure moments developed between the foot and pedal during cycling leads to a substantial error in computing axial and varus/valgus moments at the knee. To test this hypothesis, a mathematical procedure was developed for computing the three-dimensional knee loads using three-dimensional pedal forces and moments. In addition to data from a six-load-component pedal dynamometer, the model used pedal position and orientation and knee position in the frontal plane to determine the knee joint loads. Experimental data were collected from the right leg of 11 male subjects during steady-state cycling at 90 rpm and 225 W. The mean peak varus knee moment calculated was 15.3 N m and the mean peak valgus knee moment was 11.2 N m. Neglecting the pedal moment about the anterior/posterior axis resulted in an average absolute error of 2.6 N m and a maximum absolute error of 4.0 N m in the varus/valgus knee moment. The mean peak internal and external axial knee moments were 2.8 N m and 2.3 N m, respectively. The average and maximum absolute errors in the axial knee moment for not including the moment about an axis normal to the pedal were found to be 2.6 N m and 5.0 N m, respectively. The results strongly support the use of three-dimensional pedal loads in the computation of knee joint moments out of the sagittal plane.