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.     

Elbow and wrist joint contact forces during occupational pick and place activities

A three-dimensional, mathematical model of the elbow and wrist joints, including 15 muscle units, 3 ligaments and 4 joint forces, has been developed. A new strain gauge transducer has been developed to measure functional grip forces. The device measures radial forces divided into six components and forces of up to 250N per segment can be measured with an accuracy of +/-1%. Ten normal volunteers were asked to complete four tasks representing occupational activities, during which time their grip force was monitored. Together with kinematic information from the six-camera Vicon data, the moment effect of these loads at the joints was calculated. These external moments are assumed to be balanced by the internal moments, generated by the muscles, passive soft tissue and bone contact. The effectiveness of the body's internal structures in generating joint moments was assessed by studying the geometry of a simplified model of the structures, where information about the lines of action and moment arms of muscles, tendons and ligaments is contained. The assumption of equilibrium between these external and internal joint moments allows formulation of a set of equations from which muscle and joint forces can be calculated. A two stage, linear optimisation routine minimising the overall muscle stress and the sum of the joint forces has been used to overcome the force-sharing problem. Humero-ulnar forces of up to 1600N, humero-radial forces of up to 800N and wrist joint forces of up to 2800N were found for moderate level activity. The model was validated by comparison with other studies.     

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.     

A multiaxial force-sensing implantable tibial prosthesis

Accurate in vivo measurement of tibiofemoral forces is important in total knee arthroplasty. These forces determine polyethylene stresses and cold-flow, stress distribution in the implant, and stress transfer to the underlying implant bone interface. Theoretic estimates of tibiofemoral forces have varied widely depending on the mathematical models used. The six degrees of freedom of motion, complex articular surface topography, changing joint-contact position, intra- and extra-articular ligaments, number of muscles crossing the knee joint, and the presence of the patellofemoral joint contribute to the difficulty in developing reliable models of the knee. A prototype instrumented total knee replacement tibial prosthesis was designed, manufactured, and tested. This prosthesis accurately measured all six components of tibial forces (R2>0.997). The prosthesis was also instrumented with an internal microtransmitter for wireless data transmission. Remote powering of the sealed implanted electronics was achieved using magnetic coil induction. This device can be used to validate existing models of the knee that estimate these forces or to develop more accurate models. In conjunction with kinematic data, accurate tibiofemoral force data may be used to design more effective knee-testing rigs and wear simulators. Additional uses are intraoperative measurement of forces to determine soft-tissue balancing and to evaluate the effects of rehabilitation, external bracing, and athletic activities, and activities of daily living.     

A force transducer to measure individual finger loads during activities of daily living.

A new six-degree-of-freedom force transducer has been manufactured, with the sensitivity to measure forces in the range +/-100 N and moments of up to +/-5 Nm. The transducer incorporates two mechanical components: shear forces and bending moments are measured via a strain-gauged tubular section whilst axial forces are transmitted to a cantilevered load cell. Both components are instrumented with 350 ohms strain gauge full bridge circuits and are temperature compensated. After calibration, measurement errors are less than +/-0.3 N for direct forces and +/-0.03 Nm for applied moments. In order to measure sub-maximal finger loads during activities of daily living, the transducer has been incorporated into several housings representing objects in domestic use: a jar, a tap, a key in a lock and a jug kettle.     

Can a reduction approach predict reliable joint contact and musculo-tendon forces?

Musculoskeletal models generally solve the muscular redundancy by numerical optimisation. They have been extensively validated using instrumented implants. Conversely, a reduction approach considers only one flexor or extensor muscle group at the time to equilibrate the inter-segmental joint moment. It is not clear if such models can still predict reliable joint contact and musculo-tendon forces during gait.Tibiofemoral contact force and gastrocnemii, quadriceps, and hamstrings musculo-tendon forces were estimated using a reduction approach for five subjects walking with an instrumented prosthesis. The errors in the proximal-distal tibiofemoral contact force fell in the range (0.3–0.9 body weight) reported in the literature for musculoskeletal models using numerical optimisation. The musculo-tendon forces were in agreement with the EMG envelops and appeared comparable to the ones reported in the literature with generic musculoskeletal models.Although evident simplifications and limitations, it seems that the reduction approach can provided quite reliable results. It can be a useful pedagogical tool in biomechanics, e.g. to illustrate the theoretical differences between inter-segmental and contact forces, and can provide a first estimate of the joint loadings in subjects with limited musculoskeletal deformities and neurological disorders.     

6R instrumented spatial linkages for anatomical joint motion measurement--Part 2: Calibration.

The six-revolute-joint instrumented spatial linkage (6R ISL) is often the measurement system of choice for monitoring motion of anatomical joints. However, due to tolerances of the linkage parameters, the system may not be as accurate as desired. A calibration algorithm and associated calibration device have been developed to refine the initial measurements of the ISL's mechanical and electrical parameters so that the measurement of six-degree-of-freedom motion will be most accurate within the workspace of the anatomical joint. The algorithm adjusts the magnitudes of selected linkage parameters to reduce the squared differences between the six known and calculated anatomical position parameters at all the calibration positions. Weighting is permitted so as to obtain a linkage parameter set that is specialized for measuring certain anatomical position parameters. Output of the algorithm includes estimates of the measuring system accuracy. For a particular knee-motion-measuring ISL and calibration device, several interdependent design parameter relationships have been identified. These interdependent relationships are due to the configuration of the ISL and calibration device, the number of calibration positions, and the limited resolution of the devices that monitor the position of the linkage joints. It is shown that if interdependence is not eliminated, then the resulting ISL parameter set will not be accurate in measuring motion outside of the calibration positions, even though these positions are within the ISL workspace.     

Predictions of knee and ankle moments of force in walking from EMG and kinematic data

A deterministic model was developed and validated to calculate instantaneous ankle and knee moments during walking using processed EMG from representative muscles, instantaneous joint angle as a correlate of muscle length and angular velocity as a correlate of muscle velocity, and having available total instantaneous joint moments for derivation of certain model parameters. A linear regression of the moment on specifically processed EMG, recorded while each subject performed cycled isometric calibration contractions, yielded the constants for a basic moment-EMG relationship. Using the resultant moment for optimization, the predicted moment was proportionally augmented for longer muscle lengths and reduced for shorter lengths. Similarly, the predicted moment was reduced for shortening velocities and increased if the muscle was lengthening. The plots of moments predicted using the full model and those calculated from link segment mechanics followed each other quite closely. The range of root mean square errors were: 3.2-9.5 Nm for the ankle and 4.7-13.0 Nm for the knee.     

Age-related changes in finger coordination in static prehension tasks.

We studied age-related changes in the performance of maximal and accurate submaximal force and moment production tasks. Elderly and young subjects pressed on six dimensional force sensors affixed to a handle with a T-shaped attachment. The weight of the whole system was counterbalanced with another load. During tasks that required the production of maximal force or maximal moment by all of the digits, young subjects were stronger than elderly. A greater age-related deficit was seen in the maximal moment production tests. During maximal force production tests, elderly subjects showed larger relative involvement of the index and middle fingers; they moved the point of thumb force application upward (toward the index and middle fingers), whereas the young subjects rolled the thumb downward. During accurate force/moment production trials, elderly persons were less accurate in the production of both total moment and total force. They produced higher antagonistic moments, i.e., moment by fingers that acted against the required direction of the total moment. Both young and elderly subjects showed negative covariation of finger forces across repetitions of a ramp force production task. In accurate moment production tasks, both groups showed negative covariation of two components of the total moment: those produced by the normal forces and those produced by the tangential forces. However, elderly persons showed lower values of the indexes of both finger force covariation and moment covariation. We conclude that age is associated with an impaired ability to produce both high moments and accurate time profiles of moments. This impairment goes beyond the well-documented deficits in finger and hand force production by elderly persons. It involves worse coordination of individual digit forces and of components of the total moment. Some atypical characteristics of finger forces may be viewed as adaptive to the increased variability in the force production with age.     

Direct comparison of measured and calculated total knee replacement force envelopes during walking in the presence of normal and abnormal gait patterns

Knee joint forces measured from instrumented implants provide important information for testing the validity of computational models that predict knee joint forces. The purpose of this study was to validate a parametric numerical model for predicting knee joint contact forces against measurements from four subjects with instrumented TKRs during the stance phase of gait. Model sensitivity to abnormal gait patterns was also investigated. The results demonstrated good agreement for three subjects with relatively normal gait patterns, where the difference between the mean measured and calculated forces ranged from 0.05 to 0.45 body weights, and the envelopes of measured and calculated forces (from three walking trials) overlapped. The fourth subject, who had a "quadriceps avoidance" external moment pattern, initially had little overlap between the measured and calculated force envelopes. When additional constraints were added, tailored to the subject's gait pattern, the model predictions improved to complete force envelope overlap. Coefficient of multiple determination analysis indicated that the shape of the measured and calculated force waveforms were similar for all subjects (adjusted coefficient of multiple correlation values between 0.88 and 0.92). The parametric model was accurate in predicting both the magnitude and waveform of the contact force, and the accuracy of model predictions was affected by deviations from normal gait patterns. Equally important, the envelope of forces generated by the range of solutions substantially overlapped with the corresponding measured envelope from multiple gait trials for a given subject, suggesting that the variable strategic processes of in vivo force generation are covered by the solution range of this parametric model.     

An EMG-driven musculoskeletal model to estimate muscle forces and knee joint moments in vivo

This paper examined if an electromyography (EMG) driven musculoskeletal model of the human knee could be used to predict knee moments, calculated using inverse dynamics, across a varied range of dynamic contractile conditions. Muscle-tendon lengths and moment arms of 13 muscles crossing the knee joint were determined from joint kinematics using a three-dimensional anatomical model of the lower limb. Muscle activation was determined using a second-order discrete non-linear model using rectified and low-pass filtered EMG as input. A modified Hill-type muscle model was used to calculate individual muscle forces using activation and muscle tendon lengths as inputs. The model was calibrated to six individuals by altering a set of physiologically based parameters using mathematical optimisation to match the net flexion/extension (FE) muscle moment with those measured by inverse dynamics. The model was calibrated for each subject using 5 different tasks, including passive and active FE in an isokinetic dynamometer, running, and cutting manoeuvres recorded using three-dimensional motion analysis. Once calibrated, the model was used to predict the FE moments, estimated via inverse dynamics, from over 200 isokinetic dynamometer, running and sidestepping tasks. The inverse dynamics joint moments were predicted with an average R(2) of 0.91 and mean residual error of approximately 12 Nm. A re-calibration of only the EMG-to-activation parameters revealed FE moments prediction across weeks of similar accuracy. Changing the muscle model to one that is more physiologically correct produced better predictions. The modelling method presented represents a good way to estimate in vivo muscle forces during movement tasks.     

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.     

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.     

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.     

Computed tomography-based joint locations affect calculation of joint moments during gait when compared to scaling approaches

Hip joint moments are an important parameter in the biomechanical evaluation of orthopaedic surgery. Joint moments are generally calculated using scaled generic musculoskeletal models. However, due to anatomical variability or pathology, such models may differ from the patient's anatomy, calling into question the accuracy of the resulting joint moments. This study aimed to quantify the potential joint moment errors caused by geometrical inaccuracies in scaled models, during gait, for eight test subjects. For comparison, a semi-automatic computed tomography (CT)-based workflow was introduced to create models with subject-specific joint locations and inertial parameters. 3D surface models of the femora and hemipelves were created by segmentation and the hip joint centres and knee axes were located in these models. The scaled models systematically located the hip joint centre (HJC) up to 33.6 mm too inferiorly. As a consequence, significant and substantial peak hip extension and abduction moment differences were recorded, with, respectively, up to 23.1% and 15.8% higher values in the image-based models. These findings reaffirm the importance of accurate HJC estimation, which may be achieved using CT- or radiography-based subject-specific modelling. However, obesity-related gait analysis marker placement errors may have influenced these results and more research is needed to overcome these artefacts.     

Muscle forces predicted using optimization methods are coordinate system dependent

Optimization methods are widely used to predict in vivo muscle forces in musculoskeletal joints. Moment equilibrium at the joint center (usually chosen as the origin of the joint coordinate system) has been used as a constraint condition for optimization procedures and the joint reaction moments were assumed zero. This study, through the use of a three-dimensional elbow model, investigated the effect of coordinate system origin (joint center) location on muscle forces predicted using a nonlinear static optimization method. The results demonstrated that moving the origin of the coordinate system medially and laterally along the flexion-extension axis caused dramatic variations in the predicted muscle forces. For example, moving the origin of the coordinate system from a position 5mm medial to 5mm lateral of the geometric elbow center caused the predicted biceps force to vary from 12% to 46% and the brachialis force to vary from 80% to 34% of the total muscle loading. The joint reaction force reduced by 24% with this medial to lateral variation of the coordinate system origin location. This data revealed that the muscle forces predicted using the optimization method are sensitive to the coordinate system origin location due to the zero joint reaction moment assumption in the moment constraint condition. For accurate prediction of muscle load distributions using optimization methods, it is necessary to determine the accurate coordinate system origin location where the condition of a zero joint reaction moment is satisfied.     

Hybrid neuromusculoskeletal modeling to best track joint moments using a balance between muscle excitations derived from electromyograms and optimization

Current electromyography (EMG)-driven musculoskeletal models are used to estimate joint moments measured from an individual?s extremities during dynamic movement with varying levels of accuracy. The main benefit is the underlying musculoskeletal dynamics is simulated as a function of realistic, subject-specific, neural-excitation patterns provided by the EMG data. The main disadvantage is surface EMG cannot provide information on deeply located muscles. Furthermore, EMG data may be affected by cross-talk, recording and post-processing artifacts that could adversely influence the EMG?s information content. This limits the EMG-driven model?s ability to calculate the multi-muscle dynamics and the resulting joint moments about multiple degrees of freedom. We present a hybrid neuromusculoskeletal model that combines calibration, subject-specificity, EMG-driven and static optimization methods together. In this, the joint moment tracking errors are minimized by balancing the information content extracted from the experimental EMG data and from that generated by a static optimization method. Using movement data from five healthy male subjects during walking and running we explored the hybrid model?s best configuration to minimally adjust recorded EMGs and predict missing EMGs while attaining the best tracking of joint moments. Minimally adjusted and predicted excitations substantially improved the experimental joint moment tracking accuracy than current EMG-driven models. The ability of the hybrid model to predict missing muscle EMGs was also examined. The proposed hybrid model enables muscle-driven simulations of human movement while enforcing physiological constraints on muscle excitation patterns. This might have important implications for studying pathological movement for which EMG recordings are limited.     

An instrumented shoe—A portable force measuring device

Effective protection from fracture for diseased or partially healed bones can be quantitatively developed only with a knowledge of the external forces applied to the bone. While force studies using force plates have documented the forces for certain activities, a more portable force measuring device is required to determine forces during most daily activities. The authors have developed an instrumented shoe with load cells attached directly to the shoe which measured orthogonal components of foot-to-ground forces and moments. Goniometers simultaneously monitor the position of the lower leg. The signals are transported to a system of loads acting at the lower leg. Typical load curves are presented.