In vivo contact kinematics and contact forces of the knee after total knee arthroplasty during dynamic weight-bearing activities

Analysis of polyethylene component wear and implant loosening in total knee arthroplasty (TKA) requires precise knowledge of in vivo articular motion and loading conditions. This study presents a simultaneous in vivo measurement of tibiofemoral articular contact forces and contact kinematics in three TKA patients. These measurements were accomplished via a dual fluoroscopic imaging system and instrumented tibial implants, during dynamic single leg lunge and chair rising-sitting. The measured forces and contact locations were also used to determine mediolateral distribution of axial contact forces. Contact kinematics data showed a medial pivot during flexion of the knee, for all patients in the study. Average axial forces were higher for lunge compared to chair rising-sitting (224% vs. 187% body weight). In this study, we measured peak anteroposterior and mediolateral forces averaging 13.3% BW during lunge and 18.5% BW during chair rising-sitting. Mediolateral distributions of axial contact force were both patient and activity specific. All patients showed equitable medial-lateral loading during lunge but greater loads at the lateral compartment during chair rising-sitting. The results of this study may enable more accurate reproduction of in vivo loads and articular motion patterns in wear simulators and finite element models. This in turn may help advance our understanding of factors limiting longevity of TKA implants, such as aseptic loosening and polyethylene component wear, and enable improved TKA designs.     

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.     

Dynamic joint and muscle forces during knee isokinetic exercise

Isokinetic exercise has been commonly used in knee rehabilitation, conditioning and research in the past two decades. Although many investigators have used various experimental and theoretical approaches to study the muscle and joint force involved in isokinetic knee extension and flexion exercises, only a few of these studies have actually distinguished between the tibiofemoral joint forces and muscle forces. Therefore, the objective of this study was to specify, via an eletromyography(EMG)-driven muscle force model of the knee, the magnitude of the tibiofemoral joint and muscle forces acting during isokinetic knee extension and flexion exercises. Fifteen subjects ranging from 21 to 36 years of age volunteered to participate in this study. A Kin Com exercise machine (Chattecx Corporation, Chattanooga, TN, U.S.A.) was used as the loading device. An EMG-driven muscle force model was used to predict muscle forces, and a biomechanical model was used to analyze two knee joint constraint forces; compression and shear force. The methods used in this study were shown to be valid and reliable (r > 0.84 andp < 0.05). The effects on the tibiofemoral joint force during knee isokinetic exercises were compared with several functional activities that were investigated by earlier researchers. The muscle forces generated during knee isokinetic exercise were also obtained. Based on the findings obtained in this study, several therapeutic justifications for knee rehabilitation are proposed.     

Subject-specific hip geometry affects predicted hip joint contact forces during gait

Hip loading affects bone remodeling and implant fixation. In this study, we have analyzed the effect of subject-specific modeling of hip geometry on muscle activation patterns and hip contact forces during gait, using musculoskeletal modeling, inverse dynamic analysis and static optimization. We first used sensitivity analysis to analyze the effect of isolated changes in femoral neck-length (NL) and neck-shaft angle (NSA) on calculated muscle activations and hip contact force during the stance phase of gait. A deformable generic musculoskeletal model was adjusted incrementally to adopt a physiological range of NL and NSA. In a second similar analysis, we adjusted hip geometry to the measurements from digitized radiographs of 20 subjects with primary hip osteoarthrosis. Finally, we studied the effect of hip abductor weakness on muscle activation patterns and hip contact force. This analysis showed that differences in NL (41-74 mm) and NSA (113-140 degrees ) affect the muscle activation of the hip abductors during stance phase and hence hip contact force by up to three times body weight. In conclusion, the results from both the sensitivity and subject-specific analysis showed that at the moment of peak contact force, altered NSA has only a minor effect on the loading configuration of the hip. Increased NL, however, results in an increase of the three hip contact-force components and a reduced vertical loading. The results of these analyses are essential to understand modified hip joint loading, and for planning hip surgery for patients with osteoarthrosis.     

Three-dimensional knee joint contact forces during walking in unilateral transtibial amputees

Individuals with unilateral transtibial amputations have greater prevalence of osteoarthritis in the intact knee joint relative to the residual leg and non-amputees, but the cause of this greater prevalence is unclear. The purpose of this study was to compare knee joint contact forces and the muscles contributing to these forces between amputees and non-amputees during walking using forward dynamics simulations. We predicted that the intact knee contact forces would be higher than those of the residual leg and non-amputees. In the axial and mediolateral directions, the intact and non-amputee legs had greater peak tibio-femoral contact forces and impulses relative to the residual leg. The peak axial contact force was greater in the intact leg relative to the non-amputee leg, but the stance phase impulse was greater in the non-amputee leg. The vasti and hamstrings muscles in early stance and gastrocnemius in late stance were the largest contributors to the joint contact forces in the non-amputee and intact legs. Through dynamic coupling, the soleus and gluteus medius also had large contributions, even though they do not span the knee joint. In the residual leg, the prosthesis had large contributions to the joint forces, similar to the soleus in the intact and non-amputee legs. These results identify the muscles that contribute to knee joint contact forces during transtibial amputee walking and suggest that the peak knee contact forces may be more important than the knee contact impulses in explaining the high prevalence of intact leg osteoarthritis.     

Computational biodynamics of human knee joint in gait: from muscle forces to cartilage stresses

Using a validated finite element model of the intact knee joint we aim to compute muscle forces and joint response in the stance phase of gait. The model is driven by reported in vivo kinematics-kinetics data and ground reaction forces in asymptomatic subjects. Cartilage layers and menisci are simulated as depth-dependent tissues with collagen fibril networks. A simplified model with less refined mesh and isotropic depth-independent cartilage is also considered to investigate the effect of model accuracy on results. Muscle forces and joint detailed response are computed following an iterative procedure yielding results that satisfy kinematics/kinetics constraints while accounting at deformed configurations for muscle forces and passive properties. Predictions confirm that muscle forces and joint response alter substantially during the stance phase and that a simplified joint model may accurately be used to estimate muscle forces but not necessarily contact forces/areas, tissue stresses/strains, and ligament forces. Predictions are in general agreement with results of earlier studies. Performing the analyses at 6 periods from beginning to the end (0%, 5%, 25%, 50%, 75% and 100%), hamstrings forces peaked at 5%, quadriceps forces at 25% whereas gastrocnemius forces at 75%. ACL Force reached its maximum of 343 N at 25% and decreased thereafter. Contact forces reached maximum at 5%, 25% and 75% periods with the medial compartment carrying a major portion of load and experiencing larger relative movements and cartilage strains. Much smaller contact stresses were computed at the patellofemoral joint. This novel iterative kinematics-driven model is promising for the joint analysis in altered conditions.     

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.     

Contributions of muscle forces and toe-off kinematics to peak knee flexion during the swing phase of normal gait: an induced position analysis

A three-dimensional dynamic simulation of walking was used together with induced position analysis to determine how kinematic conditions at toe-off and muscle forces following toe-off affect peak knee flexion during the swing phase of normal gait. The flexion velocity of the swing-limb knee at toe-off contributed 30 degrees to the peak knee flexion angle; this was larger than any contribution from an individual muscle or joint moment. Swing-limb muscles individually made large contributions to knee angle (i.e., as large as 22 degrees), but their actions tended to balance one another, so that the combined contribution from all swing-limb muscles was small (i.e., less than 3 degrees of flexion). The uniarticular muscles of the swing limb made contributions to knee flexion that were an order of magnitude larger than the biarticular muscles of the swing limb. The results of the induced position analysis make clear the importance of knee flexion velocity at toe-off relative to the effects of muscle forces exerted after toe-off in generating peak knee flexion angle. In addition to improving our understanding of normal gait, this study provides a basis for analyzing stiff-knee gait, a movement abnormality in which knee flexion in swing is diminished.     

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.     

Influence of altered gait patterns on the hip joint contact forces

Children who exhibit gait deviations often present a range of bone deformities, particularly at the proximal femur. Altered gait may affect bone growth and lead to deformities by exerting abnormal stresses on the developing bones. The objective of this study was to calculate variations in the hip joint contact forces with different gait patterns. Muscle and hip joint contact forces of four children with different walking characteristics were calculated using an inverse dynamic analysis and a static optimisation algorithm. Kinematic and kinetic analyses were based on a generic musculoskeletal model scaled down to accommodate the dimensions of each child. Results showed that for all the children with altered gaits both the orientation and magnitude of the hip joint contact force deviated from normal. The child with the most severe gait deviations had hip joint contact forces 30% greater than normal, most likely due to the increase in muscle forces required to sustain his crouched stance. Determining how altered gait affects joint loading may help in planning treatment strategies to preserve correct loading on the bone from a young age.     

Subject-specific hip geometry and hip joint centre location affects calculated contact forces at the hip during gait

Hip loading affects the development of hip osteoarthritis, bone remodelling and osseointegration of implants. In this study, we analyzed the effect of subject-specific modelling of hip geometry and hip joint centre (HJC) location on the quantification of hip joint moments, muscle moments and hip contact forces during gait, using musculoskeletal modelling, inverse dynamic analysis and static optimization. For 10 subjects, hip joint moments, muscle moments and hip loading in terms of magnitude and orientation were quantified using three different model types, each including a different amount of subject-specific detail: (1) a generic scaled musculoskeletal model, (2) a generic scaled musculoskeletal model with subject-specific hip geometry (femoral anteversion, neck-length and neck-shaft angle) and (3) a generic scaled musculoskeletal model with subject-specific hip geometry including HJC location. Subject-specific geometry and HJC location were derived from CT. Significant differences were found between the three model types in HJC location, hip flexion–extension moment and inclination angle of the total contact force in the frontal plane. No model agreement was found between the three model types for the calculation of contact forces in terms of magnitude and orientations, and muscle moments. Therefore, we suggest that personalized models with individualized hip joint geometry and HJC location should be used for the quantification of hip loading. For biomechanical analyses aiming to understand modified hip joint loading, and planning hip surgery in patients with osteoarthritis, the amount of subject-specific detail, related to bone geometry and joint centre location in the musculoskeletal models used, needs to be considered.     

The effect of hamstring muscle compensation for anterior laxity in the ACL-deficient knee during gait

The hamstring muscles have been recognized as an important element in compensating for the loss of stability in the ACL-deficient knee, but it is still not clear whether the hamstring muscle force can completely compensate for the loss of ACL, and the consequences of increased hamstring muscle force. A two-dimensional anatomical knee model in the sagittal plane was developed to examine the effect of various levels of hamstring muscle activation on restraining anterior tibial translation in the ACL-deficient knee during level walking. The model included the tibiofemoral and patellofemoral joints, four major ligaments, the medial capsule, and five muscle units surrounding the knee. Simulations were conducted to determine anterior tibial translation and internal joint loading at a single selected position when the knee was under a peak external flexion moment during early stance phase of gait. Incremental hamstring muscle forces were applied to the modeled normal and the ACL-deficient knees. Results of simulations showed that the ACL injury increased the anterior tibial translation by 11.8mm, while 56% of the maximal hamstring muscle force could reduce the anterior translation of the tibia to a normal level during the stance phase of gait. The consequences of increased hamstring muscle force included increased quadriceps muscle force and joint contact force.     

Predicting muscle forces in gait from EMG signals and musculotendon kinematics

An EMG-driven muscle model for determining muscle force-time histories during gait is presented. The model, based on Hill's equation (1938), incorporates morphological data and accounts for changes in musculotendon length, velocity, and the level of muscle excitation for both concentric and eccentric contractions. Musculotendon kinematics were calculated using three-dimensional cinematography with a model of the musculoskeletal system. Muscle force-length-EMG relations were established from slow isokinetic calibrations. Walking muscle force-time histories were determined for two subjects. Joint moments calculated from the predicted muscle forces were compared with moments calculated using a linked segment, inverse dynamics approach. Moment curve correlations ranged from r = 0.72 to R = 0.97 and the root mean square (RMS) differences were from 10 to 20 Nm. Expressed as a relative RMS, the moment differences ranged from a low of 23% at the ankle to a high of 72% at the hip. No single reason for the differences between the two moment curves could be identified. Possible explanations discussed include the linear EMG-to-force assumption and how well the EMG-to-force calibration represented excitation for the whole muscle during gait, assumptions incorporated in the muscle modeling procedure, and errors inherent in validating joint moments predicted from the model to moments calculated using linked segment, inverse dynamics. The closeness with which the joint moment curves matched in the present study supports using the modeling approach proposed to determine muscle forces in gait.     

Internal forces and moments in the femur of the rat during gait

The rat is of increasing importance for experimental studies on fracture healing. The healing outcome of long bone fractures is strongly influenced by mechanical factors, such as the interfragmentary movement. This movement depends on the stability of the fracture fixation and the musculoskeletal loads. However, little is known about these loads in rats.The musculoskeletal loads during gait were estimated using an inverse-dynamic musculoskeletal model of the right hindlimb of the rat. This model was based on a micro-CT scan of the lower extremities and an anatomical study using 15 rat cadavers. Kinematics were reconstructed from X-ray movies, taken simultaneously from two perpendicular directions during a gait cycle. The ground reaction forces were taken from the literature. The muscle forces were calculated using an optimization procedure.The internal forces and moments varied over the gait cycle and along the femoral axis. The greatest internal force (up to 7 times bodyweight) acted in the longitudinal direction. The greatest internal moment (up to 13.8 bodyweight times millimeter) acted in the sagittal plane of the femur. The validity of the model was corroborated by comparing the estimated strains caused by the calculated loads on the surface of the femoral mid-shaft with those from the literature.Knowledge of the internal loads in the femur of the rat allows adjustment of the biomechanical properties of fixation devices in fracture healing studies to the desired interfragmentary movement.     

Partitioning of knee joint internal forces in gait is dictated by the knee adduction angle and not by the knee adduction moment

Medial knee osteoarthritis is a debilitating disease. Surgical and conservative interventions are performed to manage its progression via reduction of load on the medial compartment or equivalently its surrogate measure, the external adduction moment. However, some studies have questioned a correlation between the medial load and adduction moment. Using a musculoskeletal model of the lower extremity driven by kinematics–kinetics of asymptomatic subjects at gait midstance, we aim here to quantify the relative effects of changes in the knee adduction angle versus changes in the adduction moment on the joint response and medial/lateral load partitioning. The reference adduction rotation of 1.6° is altered by ±1.5° to 3.1° and 0.1° or the knee reference adduction moment of 17 N m is varied by ±50% to 25.5 N m and 8.5 N m. Quadriceps, hamstrings and tibiofemoral contact forces substantially increased as adduction angle dropped and diminished as it increased. The medial/lateral ratio of contact forces slightly altered by changes in the adduction moment but a larger adduction rotation hugely increased this ratio from 8.8 to a 90 while in contrast a smaller adduction rotation yielded a more uniform distribution. If the aim in an intervention is to diminish the medial contact force and medial/lateral load ratio, a drop of 1.5° in adduction angle is much more effective (causing respectively 12% and 80% decreases) than a reduction of 50% in the adduction moment (causing respectively 4% and 13% decreases). Substantial role of changes in adduction angle is due to the associated alterations in joint nonlinear passive resistance. These findings explain the poor correlation between knee adduction moment and tibiofemoral compartment loading during gait suggesting that the internal load partitioning is dictated by the joint adduction angle.     

Non-rigid deformation to include subject-specific detail in musculoskeletal models of CP children with proximal femoral deformity and its effect on muscle and contact forces during gait

To account for proximal femoral deformities in children with cerebral palsy (CP), subject-specific musculoskeletal models are needed. Non-rigid deformation (NRD) deforms generic onto personalized bone geometry and thereby transforms the muscle points. The goal of this study was to determine to what extent the models and simulation outcomes in CP patients differ when including subject-specific detail using NRD or Magnetic Resonance Imaging (MRI)-based models. The NRD models slightly overestimated hip contact forces compared to MRI models and differences in muscle point positions and moment arm lengths (MALs) remained, although differences were smaller than for the generic model.     

Image based weighted center of proximity versus directly measured knee contact location during simulated gait

To understand the mechanical consequences of knee injury requires a detailed analysis of the effect of that injury on joint contact mechanics during activities of daily living. Three-dimensional (3D) knee joint geometric models have been combined with knee joint kinematics to dynamically estimate the location of joint contact during physiological activities—using a weighted center of proximity (WCoP) method. However, the relationship between the estimated WCoP and the actual location of contact has not been defined. The objective of this study was to assess the relationship between knee joint contact location as estimated using the image-based WCoP method, and a directly measured weighted center of contact (WCoC) method during simulated walking. To achieve this goal, we created knee specific models of six human cadaveric knees from magnetic resonance imaging. All knees were then subjected to physiological loads on a knee simulator intended to mimic gait. Knee joint motion was captured using a motion capture system. Knee joint contact stresses were synchronously recorded using a thin electronic sensor throughout gait, and used to compute WCoC for the medial and lateral plateaus of each knee. WCoP was calculated by combining knee kinematics with the MRI-based knee specific model. Both metrics were compared throughout gait using linear regression. The anteroposterior (AP) location of WCoP was significantly correlated with that of WCoC on both tibial plateaus in all specimens (p<0.01, 95% confidence interval of Pearson?s coefficient r>0), but the correlation was not significant in the mediolateral (ML) direction for 4/6 knees (p>0.05). Our study demonstrates that while the location of joint contact obtained from 3D knee joint contact model, using the WCoP method, is significantly correlated with the location of actual contact stresses in the AP direction, that relationship is less certain in the ML direction.     

The effect of perturbing body segment parameters on calculated joint moments and muscle forces during gait

This study examined the effect of body segment parameter (BSP) perturbations on joint moments calculated using an inverse dynamics procedure and muscle forces calculated using computed muscle control (CMC) during gait. BSP (i.e. segment mass, center of mass location (com) and inertia tensor) of the left thigh, shank and foot of a scaled musculoskeletal model were perturbed. These perturbations started from their nominal value and were adjusted to ±40% in steps of 10%, for both individual as well as combined perturbations in BSP. For all perturbations, an inverse dynamics procedure calculated the ankle, knee and hip moments based on an identical inverse kinematics solution. Furthermore, the effect of applying a residual reduction algorithm (RRA) was investigated. Muscle excitations and resulting muscle forces were calculated using CMC. The results show only a limited effect of an individual parameter perturbation on the calculated moments, where the largest effect is found when perturbing the shank com (MS_com,shank, the ratio of absolute difference in torque and relative parameter perturbation, is maximally −7.81 N m for hip flexion moment). The additional influence of perturbing two parameters simultaneously is small (MS_{mass+com,thigh} is maximally 15.2 N m for hip flexion moment). RRA made small changes to the model to increase the dynamic consistency of the simulation (after RRA MS_com,shank is maximally 5.01 N m). CMC results show large differences in muscle forces when BSP are perturbed. These result from the underlying forward integration of the dynamic equations.     

Responses in knee joint muscle activation patterns to different perturbations during gait in healthy subjects

PurposeTo compare the responses in knee joint muscle activation patterns to different perturbations during gait in healthy subjects.ScopeNine healthy participants were subjected to perturbed walking on a split-belt treadmill. Four perturbation types were applied, each at five intensities. The activations of seven muscles surrounding the knee were measured using surface EMG. The responses in muscle activation were expressed by calculating mean, peak, co-contraction (CCI) and perturbation responses (PR) values. PR captures the responses relative to unperturbed gait. Statistical parametric mapping analysis was used to compare the muscle activation patterns between conditions.ResultsPerturbations evoked only small responses in muscle activation, though higher perturbation intensities yielded a higher mean activation in five muscles, as well as higher PR. Different types of perturbation led to different responses in the rectus femoris, medial gastrocnemius and lateral gastrocnemius. The participants had lower CCI just before perturbation compared to the same phase of unperturbed gait.ConclusionsHealthy participants respond to different perturbations during gait with small adaptations in their knee joint muscle activation patterns. This study provides insights in how the muscles are activated to stabilize the knee when challenged. Furthermore it could guide future studies in determining aberrant muscle activation in patients with knee disorders.