Ligaments and articular contact guide passive knee flexion

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

Excessive compression of the human tibio-femoral joint causes ACL rupture

The knee is one of the most frequently injured joints in the human body. A recent study suggests that axial compressive loads on the knee may play a role in injury to the anterior cruciate ligament (ACL) for the flexed knee, because of an approximate 10 degrees posterior tilt in the tibial plateau (J. Orthop. Res. 16 (1998) 122-127). The hypothesis of the current study was that excessive axial compressive loads in the human tibio-femoral (TF) joint would cause relative displacement and rotation of the tibia with respect to the femur, and result in isolated injury to the ACL when the knee is flexed to 60 degrees , 90 degrees or 120 degrees . Sixteen isolated knees from eleven fresh cadaver donors (74.3+/-10.5 yr) were exposed to repetitive TF compressive loads increasing in intensity until catastrophic injury. ACL rupture was documented in 14/16 cases. The maximum TF joint compressive force for ACL failure was 5.1+/-2.1 kN for all flexion angles combined. For the 90 degrees flexed knee, the injury occurred with a relative anterior displacement of 5.4+/-3.8mm, a lateral displacement of 4.1+/-1.4mm, and a 7.8+/-7.0 degrees internal rotation of the tibia with respect to the femur.     

The importance of quadriceps and hamstring muscle loading on knee kinematics and in-situ forces in the ACL

This study investigated the effect of hamstring co-contraction with quadriceps on the kinematics of the human knee joint and the in-situ forces in the anterior cruciate ligament (ACL) during a simulated isometric extension motion of the knee. Cadaveric human knee specimens (n = 10) were tested using the robotic universal force moment sensor (UFS) system and measurements of knee kinematics and in-situ forces in the ACL were based on reference positions on the path of passive flexion/extension motion of the knee. With an isolated 200 N quadriceps load, the knee underwent anterior and lateral tibial translation as well as internal tibial rotation with respect to the femur. Both translation and rotation increased when the knee was flexed from full extension to 30 of flexion; with further flexion, these motion decreased. The addition of 80 N antagonistic hamstrings load significantly reduced both anterior and lateral tibial translation as well as internal tibial rotation at knee flexion angles tested except at full extension. At 30 of flexion, the anterior tibial translation, lateral tibial translation, and internal tibial rotation were significantly reduced by 18, 46, and 30%, respectively (p<0.05). The in-situ forces in the ACL under the quadriceps load were found to increase from 27.8+/-9.3 N at full extension to a maximum of 44.9+/-13.8 N at 15 of flexion and then decrease to 10 N beyond 60 of flexion. The in-situ force at 15 was significantly higher than that at other flexion angles (p<0.05). The addition of the hamstring load of 80 N significantly reduced the in-situ forces in the ACL at 15, 30 and 60 of flexion by 30, 43, and 44%, respectively (p<0.05). These data demonstrate that maximum knee motion may not necessarily correspond to the highest in-situ forces in the ACL. The data also suggest that hamstring co-contraction with quadriceps is effective in reducing excessive forces in the ACL particularly between 15 and 60 of knee flexion.     

Does medio-lateral motion occur in the normal knee? An in-vitro study in passive motion

Medio-lateral translation during knee flexion continues to raise controversy. Small population sizes, small joint flexion ranges, less-reliable measurement techniques and disparate experimental conditions led to inconsistent reports in the past. To study this subject with more accurate and reliable measurements, we carried out femur and tibia tracking in 22 intact cadaver knees during passive joint motion using a state-of-the-art surgical navigation system. Trackers with active light-emitting diodes were fixed onto the femur and tibia, and an instrumented pointer was used to digitize a number of anatomical landmarks. International recommendations were adopted for anatomical-based reference frame definitions and joint kinematic analysis. For the first time, knee joint translations were reported in both the femoral and tibial reference frames, and over a flexion/extension arc as large as 140°. During flexion, in the femoral reference frame, the center of the tibial plateau moved 4.8 ± 2.8mm medially when averaged over the specimens. In the tibial frame, the knee center moved 13.3 ± 5.7 mm laterally. The relative femoral-to-tibial medio-lateral translation was, on average over the specimens, nearly 20% of the width of the tibial plateau, and can be as large as 35%. Medio-lateral translation occurs in the natural normal knee joint.     

Tibio-femoral movement in the living knee. A study of weight bearing and non-weight bearing knee kinematics using 'interventional' MRI

The aim of this study was to image tibio-femoral movement during flexion in the living knee. Ten loaded male Caucasian knees were initially studied using MRI, and the relative tibio-femoral motions, through the full flexion arc in neutral tibial rotation, were measured. On knee flexion from hyperextension to 120 degrees , the lateral femoral condyle moved posteriorly 22 mm. From 120 degrees to full squatting there was another 10 mm of posterior translation, with the lateral femoral condyle appearing almost to sublux posteriorly. The medial femoral condyle demonstrated minimal posterior translation until 120 degrees . Thereafter, it moved 9 mm posteriorly to lie on the superior surface of the medial meniscal posterior horn. Thus, during flexion of the knee to 120 degrees , the femur rotated externally through an angle of 20 degrees . However, on flexion beyond 120 degrees , both femoral condyles moved posteriorly to a similar degree. The second part of this study investigated the effect of gender, side, load and longitudinal rotation. The pattern of relative tibio-femoral movement during knee flexion appears to be independent of gender and side. Femoral external rotation (or tibial internal rotation) occurs with knee flexion under loaded and unloaded conditions, but the magnitude of rotation is greater and occurs earlier on weight bearing. With flexion plus tibial internal rotation, the pattern of movement follows that in neutral. With flexion in tibial external rotation, the lateral femoral condyle adopts a more anterior position relative to the tibia and, particularly in the non-weight bearing knee, much of the femoral external rotation that occurs with flexion is reversed.     

The coupled motion of the femur and patella during in vivo weightbearing knee flexion

The movement of the knee joint consists of a coupled motion between the tibiofemoral and patellofemoral articulations. This study measured the six degrees-of-freedom kinematics of the tibia, femur, and patella using dual-orthogonal fluoroscopy and magnetic resonance imaging. Ten normal knees from ten living subjects were investigated during weightbearing flexion from full extension to maximum flexion. The femoral and the patellar motions were measured relative to the tibia. The femur externally rotated by 12.9 deg and the patella tilted laterally by 16.3 deg during the full range of knee flexion. Knee flexion was strongly correlated with patellar flexion (R(2)=0.91), posterior femoral translation was strongly correlated to the posterior patellar translation (R(2)=0.87), and internal-external rotation of the femur was correlated to patellar tilt (R(2)=0.73) and medial-lateral patellar translation (R(2)=0.63). These data quantitatively indicate a kinematic coupling between the tibia, femur, and patella, and provide base line information on normal knee joint kinematics throughout the full range of weightbearing flexion. The data also suggest that the kinematic coupling of tibia, femur, and patella should be considered when investigating patellar pathologies and when developing surgical techniques to treat knee joint diseases.     

On the estimation of joint kinematics during gait.

In gait analysis, the concepts of Euler and helical (screw) angles are used to define the three-dimensional relative joint angular motion of lower extremities. Reliable estimation of joint angular motion depends on the accurate definition and construction of embedded axes within each body segment. In this paper, using sensitivity analysis, we quantify the effects of uncertainties in the definition and construction of embedded axes on the estimation of joint angular motion during gait. Using representative hip and knee motion data from normal subjects and cerebral palsy patients, the flexion-extension axis is analytically perturbed +/- 15 degrees in 5 degrees steps from a reference position, and the joint angles are recomputed for both Euler and helical angle definitions. For the Euler model, hip and knee flexion angles are relatively unaffected while the ab/adduction and rotation angles are significantly affected throughout the gait cycle. An error of 15 degrees in the definition of flexion-extension axis gives rise to maximum errors of 8 and 12 degrees for the ab/adduction angle, and 10-15 degrees for the rotation angles at the hip and knee, respectively. Furthermore, the magnitude of errors in ab/adduction and rotation angles are a function of the flexion angle. The errors for the ab/adduction angles increase with increasing flexion angle and for the rotation angle, decrease with increasing flexion angle. In cerebral palsy patients with flexed knee pattern of gait, this will result in distorted estimation of ab/adduction and rotation. For the helical model, similar results are obtained for the helical angle and associated direction cosines.(ABSTRACT TRUNCATED AT 250 WORDS)     

A method to quantify alteration of knee kinematics caused by changes of TKR positioning

Few in-vitro studies have investigated changes in kinematics caused by total knee replacement (TKR) implantation. The advent of surgical navigation systems allows implant position to be measured accurately and the effects of alteration of TKR position and alignment investigated. A test rig and protocol were developed to compare the kinematics of TKR-implanted knees for different femoral component positions. The TKR was implanted and the component positions documented using a navigation system. The quadriceps was tensed and the knees were flexed and extended manually. Torques and drawer forces were applied to the tibia during knee flexion–extension, while recording the kinematics with the navigation system. The implant was removed and replaced on an intramedullary fixation that allowed proximal–distal, and internal–external rotation of the femoral component without conducting a repeated arthrotomy on the knee. The implant was repositioned using the navigation system to reproduce the previously achieved normally navigated position and the kinematics were recorded again. The recorded kinematics of the knee were not significantly different between both normal implantation and intramedullary remounting for tibial internal–external rotation, varus–valgus angulation, or posterior drawer, at any angle of knee flexion examined. Anterior drawer was increased approximately 2.5 mm across the range 20–35° knee flexion (p<0.05), but was otherwise not significantly different. This method of navigating implant components and of moving them within the closed knee (thus avoiding artefactual effects of repeated soft tissue manipulations) can now be used to quantify the effect on kinematics of alteration of the position of the femoral component.     

A reproducible method for studying three-dimensional knee kinematics

The methods used in movement analysis often rely on the definition of joint coordinate systems permitting three-dimensional (3D) kinematics. The first aim of this research project was to present a functional and postural method (FP method) to define a bone-embedded anatomical frame (BAF) on the femur and tibia, and, subsequently, a knee joint coordinate system. The repeatability of the proposed method was also assessed. Using FP method to define the BAFs, 4 kinematic parameters (flexion/extension, abduction/adduction, tibial internal/external rotation, and antero-posterior translation) were computed for 15 subjects walking on a treadmill. The repeatability for all four kinematic parameters was then assessed, using intra- and inter-observer settings. After pooling the results for all observers, the mean repeatability value ranged between 0.4 degrees and 0.8 degrees for rotation angles and between 0.8 and 2.2 mm for translation.     

Motion of the knee after condylar resurfacing--an in vivo study.

The purpose of this study was determine the amounts of rotation and displacement occurring in a relatively unconstrained condylar replacement knee, and to compare the motion with a matched group of normal knees. The motion was measured using an electromagnetic device, the 3-Space Tracker, for various common activities, for 25 normal volunteers and 25 total knee patients. The main variables studied were internal-external rotation of the tibia about its long axis and anterior-posterior displacement of the femoral origin with respect to the tibia, as a function of flexion angle or per cent of gait cycle. The motion of the total knees was very similar to that of the normals. For sitting, standing and free-swing, the knee rotated internally by 5-10 degrees and the femur displaced posteriorly by 9-14 mm, as the knee was flexed from 0 to 90 degrees. For walking and going upstairs and downstairs the absolute values of the rotations and displacements were similar to the above. However, the mean values of rotation were less due to greater variation in the rotation patterns, due probably to the increased laxity of the knee during the swing phases. From these data, taking the mean motions and one standard deviation (S.D.), it is suggested that a knee prosthesis should allow a rotation from minus to plus 12 degrees (a total range of 24 degrees) and an anterior-posterior displacement of 13 mm. It is suggested that these motions be subject to progressive restraint from the neutral position in the manner of the natural knee.     

Motion of the knee after condylar resurfacing—An in vivo study

The purpose of this study was determine the amounts of rotation and displacement occurring in a relatively unconstrained condylar replacement knee, and to compare the motion with a matched group of normal knees. The motion was measured using an electromagnetic device, the 3-Space Tracker, for various common activities, for 25 normal volunteers and 25 total knee patients. The main variables studied were internal-external rotation of the tibia about its long axis and anterior-posterior displacement of the femoral origin with respect to the tibia, as a function of flexion angle or per cent of gait cycle. The motion of the total knees was very similar to that of the normals. For sitting, standing and free-swing, the knee rotated internally by 5–10° and the femur displaced posteriorly by 9–14 mm, as the knee was flexed from 0 to 90°. For walking and going upstairs and downstairs the absolute values of the rotations and displacements were similar to the above. However, the mean values of rotation were less due to greater variation in the rotation patterns, due probably to the increased laxity of the knee during the swing phases. From these data, taking the mean motions and one standard deviation (S.D.), it is suggested that a knee prosthesis should allow a rotation from minus to plus 12° (a total range of 24°) and an anterior-posterior displacement of 13 mm. It is suggested that these motions be subject to progressive restraint from the neutral position in the manner of the natural knee.     

Cruciate coupling and screw-home mechanism in passive knee joint during extension--flexion

The screw-home mechanism and coupling between forces in cruciate ligaments during passive knee joint flexion were investigated for various boundary conditions, flexion axis alignments and posterior cruciate ligaments (PCL)/anterior cruciate ligament (ACL) conditions. A developed non-linear 3D finite element model was used to perform detailed elasto-static response analyses of the human tibiofemoral joint as a function of flexion angle varying from 10 degrees hyper-extension to 90 degrees flexion. The tibia rotated internally as the femur flexed and externally as the femur extended. The re-alignment of the flexion axis by +/-5 degrees rotation about the axial (distal-proximal) axis, transection of the ACL and changes in cruciate ligament initial strains substantially influenced the 'screw-home' motion. On the other hand, restraint on this coupled rotation diminished ACL forces in flexion. A remarkable coupling was predicted between ACL and PCL forces in flexion; forces in both cruciate ligaments increased as the initial strain or pretension in one of them increased whereas they both diminished as one of them was cut or became slack. This has important consequences in joint functional biomechanics following a ligament injury or replacement surgery and, hence, in the proper management of joint disorders.     

Coupled motions under compressive load in intact and ACL-deficient knees: a cadaveric study

Knowledge of the coupled motions, which develop under compressive loading of the knee, is useful to determine which degrees of freedom should be included in the study of tibiofemoral contact and also to understand the role of the anterior cruciate ligament (ACL) in coupled motions. The objectives of this study were to measure the coupled motions of the intact knee and ACL-deficient knee under compression and to compare the coupled motions of the ACL-deficient knee with those of the intact knee. Ten intact cadaveric knees were tested by applying a 1600 N compressive load and measuring coupled internal-external and varus-valgus rotations and anterior-posterior and medial-lateral translations at 0 deg, 15 deg, and 30 deg of flexion. Compressive loads were applied along the functional axis of axial rotation, which coincides approximately with the mechanical axis of the tibia. The ACL was excised and the knees were tested again. In the intact knee, the peak coupled motions were 3.8 deg internal rotation at 0 deg flexion changing to -4.9 deg external rotation at 30 deg of flexion, 1.4 deg of varus rotation at 0 deg flexion changing to -1.9 deg valgus rotation at 30 deg of flexion, 1.4 mm of medial translation at 0 deg flexion increasing to 2.3 mm at 30 deg of flexion, and 5.3 mm of anterior translation at 0 deg flexion increasing to 10.2 mm at 30 deg of flexion. All changes in the peak coupled motions from 0 deg to 30 deg flexion were statistically significant (p<0.05). In ACL-deficient knees, there was a strong trend (marginally not significant, p=0.07) toward greater anterior translation (12.7 mm) than that in intact knees (8.0 mm), whereas coupled motions in the other degrees of freedom were comparable. Because the coupled motions in all four degrees of freedom in the intact knee and ACL-deficient knee are sufficiently large to substantially affect the tibiofemoral contact area, all degrees of freedom should be included when either developing mathematical models or designing mechanical testing equipment for study of tibiofemoral contact. The increase in coupled anterior translation in ACL-deficient knees indicates the important role played by the ACL in constraining anterior translation during compressive loading.     

In vivo tracking of the human patella.

The purpose of this study was to describe the dynamic, in vivo, three-dimensional tracking pattern of the patella for one normal male subject. Intracortical pins were inserted into the patella, tibia, and femur. The subject performed seated and squatting knee flexion/extension, and maximum voluntary quadriceps contractions. In addition, the vastus medialis oblique was subjected to maximal electrical stimulation. Motions of the markers attached to the intracortical pins were analyzed using an automated video system. Patellar and tibial motions were determined relative to a femoral reference system. While the tibia flexed 50 degrees from full extension (seated condition), the patella flexed 30.3 degrees, tilted laterally 10.3 degrees, and shifted laterally 8.6 mm. In general, these results show qualitative agreement with the data collected from cadaveric specimens [van Kampen and Huiskes, J. orthop. Res. 8, 372-382 (1990)]. The differences present may reflect different passive constraints to patellar motions, and different relative loading of the individual quadriceps components, in our study compared to the cadaveric study. Only small differences were found between patellar motions in the seated and squatting conditions. Differences in patellar displacements produced by (1) maximal electrical stimulation of the vastus medialis oblique, and (2) maximum voluntary quadriceps contraction, at 30 degrees knee flexion and full extension, may reflect the dominant influence of passive constraints, and the vastus lateralis, on normal patellar motions. Further in vivo study of patellar tracking seems warranted to evaluate surgical and conservative interventions for patellofemoral disorders.     

The effects of knee motion and external loading on the length of the anterior cruciate ligament (ACL): a kinematic study

A six-degrees-of-freedom mechanical linkage device was designed and used to study the unconstrained motion of ten intact human cadaver knees. The knees were subjected to externally applied varus and valgus (V-V) moments up to 14 N-m as well as anterior and posterior (A-P) loads up to 100 N. Tests were done at four knee flexion angles; 0, 30, 45, and 90 deg. Significant coupled axial tibial rotation was found, up to 21.0 deg for V-V loading (at 90 deg of flexion) and 14.2 deg for A-P loading (at 45 deg of flexion). Subsequently, the knees were dissected and the locations of the insertion sites to the femur and tibia for the anteromedial (AM), posterolateral (PL), and intermediate (IM) portions of the ACL were identified. The distances between the insertion sites for all external loading conditions were calculated. In the case when the external load was zero, the AM portion of the ACL lengthened with knee flexion, while the PL portion shortened and the intermediate (IM) portion did not change in length. With the application of 14 N-m valgus moment, the PL and IM portions of the ACL lengthened significantly more than the AM portion (p less than 0.001). With the application of 100 N anterior load, the AM portion lengthened slightly less than the PL portion, which lengthened slightly less than the IM portion (p less than 0.005). In general, the amount of lengthening of the three portions of the ACL during valgus and anterior loading was observed to increase with knee flexion angle (p less than 0.001).     

The orientation of the distal part of the quadriceps femoris muscle as a function of the knee flexion-extension angle

Lateral view radiographs of ten autopsy knees were used to determine the orientation of the patellar ligament, patella and quadriceps tendon relative to tibia and femur at different flexion-extension angles (0-120 degrees) of the knee. The results show a linear relationship between the angle of flexion and the movement of the patellar ligament relative to the tibia and of the movement of the patella relative to tibia and femur. There is a non-linear relationship between angle of flexion and the movement of the quadriceps tendon relative to the patellar ligament, patella and femur. The angular changes between patella and patellar ligament are negligible. The complicated movements of the distal part of the quadriceps femoris muscle may significantly influence biomechanical parameters such as the forces acting at the patella and tibial tuberosity.     

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

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

The effect of the point of application of anterior tibial loads on human knee kinematics

Coupled axial tibial rotation in response to an anterior tibial load has been used as a common diagnostic measurement and as a means to load the ligamentous structures during laboratory tests. However, the exact location of the point of application of these loads as well as the corresponding sensitivity of the coupled tibial rotation to this point can have an effect on the function of the soft tissues at the joint. Therefore, the purpose of this study was to determine the effects of four different points of application of the anterior tibial load on the anterior tibial translation and coupled axial tibial rotation. The four points include: (1) geometric point - midway between the collateral ligament insertion sites on the tibia, (2) clinical point - a position that attempts to simulate clinical diagnostic tests, (3) medial point - a position medial to the geometric point and (4) lateral point - a position lateral to the clinical point. A robotic/universal force-moment sensor testing system was used to apply the anterior tibial load at the four points of application and to record the resulting joint motion. Anterior tibial translation in response to an anterior tibial load of 100N was found not to vary between the four points of application of the anterior tibial load at all flexion angles examined. However, internal tibial rotation was found for the lateral point (13+/-10 degrees at 30 degrees of knee flexion) in all specimens and clinical point (8+/-10 degrees at 30 degrees of knee flexion) while external rotation resulted when the load was applied at the medial point (-8+/-7 degrees at 30 degrees of knee flexion). Both internal and external tibial rotations occurred throughout the range of flexion when the tibial load was applied at the geometric point. The results suggest that the clinical point should be used as the point of application of the anterior tibial load whenever clinical examinations are simulated and multi-degree-of-freedom joint and soft tissue function are examined.     

The effect of femoral component malrotation on patellar biomechanics

Patellofemoral complications are among the important reasons for revision knee arthroplasty. Femoral component malposition has been implicated in patellofemoral maltracking, which is associated with anterior knee pain, subluxation, fracture, wear, and aseptic loosening. Rotating-platform mobile bearings compensate for malrotation between the tibial and femoral components and may, therefore, reduce any associated patellofemoral maltracking. To test this hypothesis, we developed a dynamic model of quadriceps-driven open-kinetic-chain extension in a knee implanted with arthroplasty components. The model was validated using tibiofemoral and patellofemoral kinematics and forces measured in cadaver knees. Knee kinematics and patellofemoral forces were measured after simulating malrotation (±3°) of the femoral component. Rotational alignment of the femoral component affected tibial rotation near full extension and tibial adduction at higher flexion angles. External rotation of the femoral component increased patellofemoral lateral tilt, lateral shift, and lateral shear forces. Up to 21° of bearing rotation relative to the tibia was noted in the rotating-bearing condition. However, the rotating bearing had minimal effect in reducing the patellofemoral maltracking or shear induced by femoral component rotation. The rotating platform does not appear to be forgiving of malalignment of the extensor mechanism resulting from femoral component malrotation. These results support the value of improving existing methodologies for accurate femoral component alignment in total knee arthroplasty.