Osteoarthritis is one of the major causes of immobility. Most commonly, osteoarthritis manifests at the knee joint. Prevalence of knee osteoarthritis (KNOA) increases with age. Another important risk factor for KNOA is obesity. Research has shown that obese subjects have almost four times the risk of developing KNOA, which may be explained by both an increased knee loading. In medial compartment KNOA, the knee adduction moment (KAM) during gait is considered a marker for disease severity. KAM is dependent of the magnitude of the ground reaction force and its moment arm relative to the knee joint centre. In addition, obesity has been reported to augment KAM during gait. However, after removal of the direct contributions of body weight, KAM parameters may be different due to obesity-related gait adaptations to limit knee loading. While KAM has been thoroughly investigated during gait, little is known about KAM during stair negotiation, during which knee loads are higher compared to gait. The aim of the current study is therefore to compare normalized KAM during the stance phase of stair negotiation between lean KNOA patients, obese KNOA patients, and healthy controls. This case control study included 20 lean controls, 14 lean KNOA patients, and 16 obese KNOA patients. All subjects ascended and descended a two-step staircase at a self-selected, comfortable speed. Radiographic imaging and MRI were used to evaluate knee cartilage and KNOA status. Motion analysis was performed with a three-dimensional motion capture system. Kinetic data were obtained by one force platform. The parameters of study included: stance phase duration, toe-out angle, KAM peaks and KAM impulse. During stair ascent obese KNOA patients showed a longer stance phase than healthy controls (P 0.050). Despite high between-subject variability, KAM impulse was found 45% higher in the obese KNOA group during stair descent, when compared to healthy controls (P =0.012). The absence of a significant effect of groups on the normalized KAM during stair negotiation may be explained by a lower ambulatory speed in the obese KNOA group, that effectively lowers GRFz. Decreasing ambulatory speed may be an effective strategy to lower KAM during stair negotiation.
Explore whether high tibial osteotomy (HTO) changes knee contact forces and to explore the relationship between the external knee adduction moment (EKAM) pre and 12 months post HTO. Three-dimensional gait analysis was performed on 17 patients pre and 12-months post HTO using a modified Cleveland marker-set. Tibiofemoral contact forces were calculated in SIMM. The scaled musculoskeletal model integrated an extended knee model allowing for 6 degrees of freedom in the tibiofemoral and patellofemoral joint. Joint angles were calculated using inverse kinematics then muscle and contact forces and secondary knee kinematics were estimated using the COMAC algorithm. Paired samples t-test were performed using SPSS version 25 (SPSS Inc., USA). Testing for normality was undertaken with Shapiro-Wilk. Pearson correlations established the relationships between EKAM1 to medial KCF1, and EKAM2 to medial KCF2, pre and post HTO.Abstract
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Aims. This study aimed to analyze kinematics and kinetics of the tibiofemoral joint in healthy subjects with valgus, neutral, and varus limb alignment throughout multiple gait activities using dynamic videofluoroscopy. Methods. Five subjects with valgus, 12 with neutral, and ten with varus limb alignment were assessed during multiple complete cycles of level walking, downhill walking, and stair descent using a combination of dynamic videofluoroscopy, ground reaction force plates, and optical motion capture. Following 2D/3D registration, tibiofemoral kinematics and kinetics were compared between the three limb alignment groups. Results. No significant differences for the rotational or translational patterns between the different limb alignment groups were found for level walking, downhill walking, or stair descent. Neutral and varus aligned subjects showed a mean centre of rotation located on the medial condyle for the loaded stance phase of all three gait activities. Valgus alignment, however, resulted in a centrally located centre of rotation for level and downhill walking, but a more medial centre of rotation during stair descent. Knee
Purpose: Medial compartment osteoarthritis (OA) is the most common primary osteoarthritis of the knee, but the treatment of this disease in young patients remains controversial. High tibial osteotomy (HTO), medial unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) are all viable options. Gait analysis is one tool available to clinically assess knee kinematics, and may prove to be a good way of predicting functional outcomes of these different surgical procedures. The purpose of this study was to compare the knee kinematics, function, and quality of life of patients that underwent either a medial opening wedge HTO, UKA, or TKA for primary medial compartment OA. Method: A matched prospective cohort study of patients between the ages of 45 and 65 who had undergone an HTO, UKA, or TKA for primary medial compartment knee OA was undertaken over a 3-year period. Primary outcome measures were gait variables, namely knee
Abstract. Introduction. Autologous chondrocyte implantation (ACI) is a common procedure, primarily performed in active, young patients to treat knee pain and functional limitations resulting from cartilage injury. Nevertheless, the functional outcomes of ACI remain poorly understood. Thus, the aim of this systematic review was to evaluate the biomechanical outcomes of ACI. Methodology. Ovid MEDLINE, Embase, and Web of Science were systematically searched using the terms ‘Knee OR Knee joint AND Autologous chondrocyte implantation OR ACI’. Strict inclusion and exclusion criteria were used to screen publications by title, abstract, and full text. Study quality and bias were assessed by two reviewers. PROSPERO ID: CRD42021238768. Results. 28 articles including 35 ACI cohorts were included in this review. The average range of motion (ROM) was found to improve with clinical significance (>5˚) and statistical significance (p < 0.05) postoperatively: 133.9 ± 5.5˚ to 139.2 ± 4.9˚ (n=12). Knee strength significantly improved within the first two postoperative years, but remained poorer than control groups at final follow-up (n=17). No statistical differences were found between ACI and control groups in their ability to perform functional activities like the 6-minute walk test. However, peak external knee extension and
Previous research suggests knee joint moments and muscle activity during walking are altered in patients with anterior cruciate ligament (ACL) deficiency and in patients with medial compartment knee osteoarthritis (OA). The objective of this study was to compare knee joint flexion and
Valgus knee unloader braces are often prescribed as treatment for knee osteoarthritis (OA). These braces are designed to redistribute the loading in the knee, thereby reducing medial contact forces. Patient response to bracing is variable; some patients experience improvements in joint loading, pain, and function, others see little to no effect. We hypothesised that patients who experienced beneficial response to the brace, measured by reductions in medial contact force, could be predicted based on static and dynamic measures. Participants completed a WOMAC questionnaire and walked overground with and without an OA Assist knee brace in a motion capture lab. Eighteen patients with medial compartment OA (8 female, 53.8±7.0 years, BMI 30.3±4.1, median Kellgren-Lawrence grade 4 (range 1–4)) were evaluated. The abduction moment applied by the brace was estimated by multiplying brace deflection by the pre-determined brace stiffness. A generic musculoskeletal model was scaled for each participant based on standing full length radiographs and anatomical markers. Inverse kinematics, inverse dynamics, residual reduction, and muscle analysis were completed in OpenSim 3.2. A static optimisation was then performed to estimate muscle forces and then tibiofemoral contact forces were calculated. Brace effectiveness was defined by the difference in the first peak of the medial contact force between braced and unbraced conditions. Principal component analysis was performed on the hip, knee, and ankle angles and moments from the unbraced walking condition to extract the principal component (PC) scores for these variables. A linear regression procedure was used to determine which variables related to brace effectiveness. Potential regressors included: hip-knee-ankle angle and medial joint space measured radiographically; KL grade; mass; WOMAC scores; unbraced walking speed; and the first two principal component scores for each of the unbraced hip, knee, and ankle joint angles and moments. KL grade, walking speed, and hip adduction moment PC1, which represented the magnitude of the first peak were all found to be correlated with change in medial contact force. The brace was more successful in reducing medial contact force in subjects with higher KL grades, faster self-selected walking speeds, and larger peak external hip
Purpose: Hip muscle weakness may result in impaired frontal plane pelvic control during gait, leading to greater medial compartment loading, as measured by the knee adduction moment, in persons with knee osteoarthritis (OA). The purpose of this study was to evaluate the influence of an 8-week home-based strengthening program for the hip abductor muscles on hip muscle strength and the external knee adduction moment during gait in individuals with medial knee OA compared to an asymptomatic control group. Secondary objectives were to determine if hip abductor strengthening exercises would improve physical function and knee symptoms in this sample of people with knee OA. Method: Forty participants with knee OA were age and gender-matched with an asymptomatic control group. Three-dimensional gait analysis was performed to obtain peak knee
Purpose: The purpose of this study was to determine what differences exist in the knee flexion, rotation and
Introduction. Patients with knee osteoarthritis (OA) often tell us that they put extra load on the joints of the opposite leg as they walk. Multiple joint OA is common and has previously been related to gait changes due to hip OA (Shakoor et al 2002). The aim of this study was to determine whether patients with medial compartment knee OA have abnormal biomechanics of the unaffected knee and both hips during normal level gait. Methods. Twenty patients (11 male, 9 female), with severe medial compartment knee OA and no other joint pain were recruited. The control group comprised 20 adults without musculoskeletal pain. Patients were reviewed, x-rays were examined and WOMAC and Oxford knee scores were completed. A 12 camera Vicon (Vicon, Oxford) system was used to collect kinematic data (100Hz) on level walking and the ground reaction force was recorded using three AMTI force plates (1000Hz). Surface electrodes were placed over medial and lateral quadriceps and hamstrings bilaterally to record EMG data (1000Hz). Kinematics and kinetics were calculated using the Vicon ‘plug-in-gait’ model. A co-contraction index was calculated for the EMG signals on each side of the knee, representing the magnitude of the combined readings relative to their maximum contraction during the gait cycle. Statistical comparisons were performed using t-tests with Bonferroni's correction for two variables and ANOVA for more than two variables (SPSS v16). Results. The mean age of the patients was 69 (SD 8.8). Mean gait speed was 0.95m/s (study group) and 1.44m/s (control group). Peak
Focal cartilage defects (FCDs) found in medial and lateral compartments of the knee are accompanied with patient-reported pain and loss of joint function. There is a deficit of evidence to explain why they occur. We hypothesise that aberrant knee joint loading may be partially responsible for FCD pathology, therefore this study aims to use 3-dimensional motion capture (MoCap) analysis methods to investigate differences in gait biomechanics of subjects with symptomatic FCDs. 11 subjects with Outerbridge grade II FCDs of the tibiofemoral joint (5 medial compartment, 6 lateral compartment) and 10 non-pathological controls underwent level-gait MoCap analysis using an infra-red camera (Qualisys) and force-plate (Bertec) passive marker system. 6-degree of freedom models were generated and used to calculate spatio-temporal measures, and frontal and sagittal plane knee, hip and ankle rotation and moment waveforms (Visual 3D). Principle component analysis (PCA) was used to score subjects based on common waveform features, and PC scores were tested for differences using Mann-Whitney tests (SPSS). No group differences were found in BMI, age or spatio-temporal measures. Medial-knee FCD subjects experienced higher (p=0.05) overall knee
Previous studies (. Chen et al., 2003. ; . Kaufmann et al., 2001. ) have shown that persons with osteoarthritis (OA) walk more slowly with lower cadence, have lower peak ground reaction forces and load their injured limb at a lower rate than healthy age matched subjects. However, another study (. Mündermann et al., 2005. ) found that patients with severe bilateral OA loaded their knee joint at a higher rate. They also found these patients had higher knee
A principle of Total Knee Arthroplasty (TKA) is to achieve a neutral standing coronal alignment of the limb (Hip Knee Ankle (HKA) angle) to reduce risks of implant loosening, reduce polyethylene wear, and optimise patella tracking. Several long-term studies have questioned this because the relationship between alignment and implant survivorship is weaker than previously reported. We hypothesize standing HKA poorly predicts implant failure because it does not predict dynamic HKA, dynamic adduction moment, and loading of the knee during gait. Therefore, the aim of our study is to assess the relationship between the standing (or static) and the dynamic (gait activity) HKAs. We performed a prospective study on a cohort of 35 patients (35 knees) who were treated with a posterior-stabilized TKA for primary osteoarthritis between November 2012 and January 2013. Three months after surgery each patient had a standardized digital full-leg coronal radiographs and was classified as neutrally aligned TKA (17 patients), varus aligned (9 patients), and valgus aligned (4 patients). Patients then performed a gait analysis for level walking and dynamic HKA and adduction moment during the stance phase of gait were measured. We found standing HKA having a moderate correlation with the peak dynamic varus (r=0.318, p=0.001) and the mean and peak
Background. A principle of Total Knee Arthroplasty (TKA) is to achieve a neutral standing coronal alignment of the limb (Hip Knee Ankle (HKA) angle) to reduce risks of implant loosening, reduce polyethylene wear, and optimise patella tracking. Several long-term studies have questioned this because the relationship between alignment and implant survivorship is weaker than previously reported. We hypothesize standing HKA poorly predicts implant failure because it does not predict dynamic HKA, dynamic adduction moment, and loading of the knee during gait. Therefore, the aim of our study is to assess the relationship between the standing (or static) and the dynamic (gait activity) HKAs. Methods. We performed a prospective study on a cohort of 35 patients (35 knees) who were treated with a posterior-stabilized TKA for primary osteoarthritis between November 2012 and January 2013. Three months after surgery each patient had standardized digital full-leg coronal radiographs and was classified as neutrally aligned TKA (17 patients), varus aligned (9 patients), and valgus aligned (4 patients) (figure 1). Patients then performed a gait analysis for level walking and dynamic HKA and adduction moment during the stance phase of gait were measured. Results. We found standing HKA having a moderate correlation with the peak dynamic varus (r=0.318, p=0.001) and the mean and peak
To study the association between hip and ankle biomechanics during gait and moderate knee osteoarthritis (OA). Gait analysis was performed on a group of forty-four patients clinically diagnosed with moderate knee OA, and on a group of sixty asymptomatic subjects. Three-dimensional net joint angles and net joint reaction moments at the hip, knee and ankle joints were calculated. Peak values were extracted from the gait waveform patterns and compared between the two subject groups with Student’s t-tests. The peak hip extension moment, the peak hip adduction moment, the peak hip internal and external rotation moments, and the peak ankle dorsiflexion and plantarflexion moments were all reduced in the knee osteoarthritis population compared to the asymptomatic population. Differences in knee joint loading patterns with moderate knee osteoarthritis have been previously reported, but these data suggest that changes in the mechanical environment of all lower extremity joints are associated with early stages of knee osteoarthritis. Other studies have associated reduced peak hip
Valgus unloader knee braces are a conservative treatment option for medial compartment knee osteoarthritis (OA). These braces are designed to reduce painful, and potentially injurious compressive loading on the damaged medial side of the joint through application of a frontal-plane abduction moment. While some patients experience improvements in pain, function, and joint loading, others see little to no benefit from bracing [1]. Previous biomechanical studies investigating the mechanical effectiveness of bracing have been limited in either their musculoskeletal detail [2] or incorporation of altered external joint moments and forces [3]. The first objective was to model the relative contributions of gait dynamics, muscle forces, and the external brace abduction moment to reducing medial compartment knee loads. The second objective was to determine what factors predict the effectiveness of the valgus unloading brace. Seventeen people with knee OA (8 Female age 54.4 +/− 4.2, BMI 30.00 +/− 4.0 kg/m. 2. , Kellgren-Lawrence range of 1–4 with med. = 3) and 20 healthy age-matched controls participated in this study which was approved by the institutional ethics review board. Subjects walked across a 20m walkway with and without a Donjoy OA Assist knee brace while marker trajectories, ground reaction forces, and lower limb electromyography were recorded. The external moment applied by the brace was estimated by multiplying the brace deformation by is pre-determined brace-stiffness. For each subject, a representative stride was selected for each brace condition. A generic musculokeletal model with two legs, a torso, and 96 muscles was modified to include subject-specific frontal plane alignment and medial and lateral contact locations [4]. Muscle forces, and tibiofemoral contact forces were estimated using static optimization [4]. We defined brace effectiveness as the difference in the peak medial contact force between the braced and the unbraced conditions. A stepwise regression analysis was performed to predict brace effectiveness based on: X-ray frontal plane alignment, medial joint space, KL grade, mass, WOMAC scores, unbraced walking speed, trunk, hip and knee joint angles and moments. The OA Assist brace reduced medial joint loading by approximately 0.1 to 0.2 BW or roughly 10%, during stance. This decrease was primarily due to the external brace abduction moment, and not changes in gait dynamics, or muscle forces. The brace effectiveness could be predicted (R. 2. =0.77) by the KL grade, and the magnitude of the hip adduction moment in early stance (unbraced). The brace was more effective for those that had larger hip
INTRODUCTION. Cementless tibial trays commonly fail through failure of fixation due to excessive interface motion. However, the specific combination of axial and shear forces precipitating implant failure is unknown. This has led to generic loading profiles approximating walking to perform pre-clinical assessment of new designs, even though telemetric data demonstrates that much larger forces and moments are generated during other functional activities. This study was undertaken to test the hypotheses: (i) interface motion of cementless tibial trays varies as a function of specific activities, and (ii) the response of the cementless tibial interface to walking loading is not representative of other functional activities. MATERIALS and METHODS. Six fresh-frozen cadaveric tibias were tested using a custom designed functional activity simulator after implantation of a posterior stabilized total knee replacement (NexGen LPS, Zimmer, Warsaw IN). Activity scenarios were selected using force (Fx, Fy, Fz) and moment (Mx, My, Mz) data from patients with instrumented tibial trays (E-tibia) published by Bergmann et al. A pattern of black and white spray paint was applied to the surface of the specimen including the tibial tray and bone. Each specimen was preconditioned through application of a vertical load of 1050N for 500 cycles of flexion-extension from 5–100°. Following preconditioning, each tibia was loaded using e-tibia values of forces and moments for walking, stair-descent, and sit-to-stand activities. The differential motion of the tibial tray and the adjacent bony surface was monitored using digital image correlation (DIC) (resolution: 1–2 microns in plane; 3–4 microns out-of-plane). Four pairs of stereo-images of the tray and tibial bone were prepared at sites around the circumference of the construct in both the loaded and unloaded conditions: (i) before and after pre-conditioning and (ii) before and after the 6 functional loading profiles. The images were processed to provide circumferential measurements of interface motion during loading. Differences in micromotion and migration were evaluated statistically using step-wise multivariate regression. RESULTS. The average 3D motion of the tibial tray varied extensively with the loading conditions corresponding to the different activities (Figs 1,2). The largest 3D motion was seen during the first peak of stair descent (86.6±8.0µm) and the first peak of walking (83.1±10.2µm; p=0.5516), both of which were characterized by large
Introduction. Preservation of the anterior cruciate ligament (ACL), along with the posterior cruciate ligament, is believed to improve functional outcomes in total knee replacement (TKR). The purpose of this study was to examine gait differences and muscle activation levels between ACL sacrificing (ACL-S) and bicruciate retaining (BCR) TKR subjects during level walking, downhill walking, and stair climbing. Methods. Ten ACL-S (Vanguard CR) (69±8 yrs, 28.7±4.7 kg/m2) and eleven BCR (Vanguard XP, Zimmer-Biomet) (63±11 yrs, 31.0±7.6 kg/m2) subjects participated in this IRB approved study. Except for the condition of the ACL, both TKR designs were similar. Subjects were tested 8–14 months post-op in a motion analysis lab using a point cluster marker set and surface electrodes applied to the Vastus Medialis Oblique (VMO), Rectus Femoris (RF), Biceps Femoris (BF) and Semitendinosus (ST). 3D motion and force data and electromyography (EMG) data were collected simultaneously. Subjects were instructed to walk at a comfortable walking speed across a walkway, down a 12.5% downhill slope, and up a staircase. Five trials per activity were collected. Knee kinematics and kinetics were analyzed using BioMove (Stanford, Stanford, CA). The EMG dataset underwent full-wave rectification and was smoothed using a 300ms RMS window. Gait cycle was time normalized to 100%; relative voluntary contraction (RVC) was calculated by dividing the average activation during downhill walking by the maximum EMG value during level walking and multiplying by 100%. Results. There were no significant kinematic or kinetic differences between implant groups for level walking (p≥0.19). Both groups walked at 1.1 m/s on average during level and approximately 0.1 m/s slower during downhill walking, with no differences in speed (p= 0.91 and 0.77, respectively). For both ACL-S and BCR groups, gait changes from level to downhill walking were similar. For downhill walking, ACL-S subjects were significantly more variable (p<0.001) over the gait cycle for all measured kinematics and kinetics. During both downhill walking and stair climbing, the ACL-S group showed an external peak abduction moment (Fig. 1) significantly greater than that of the BCR group (p=0.05, 0.01). Also during stair climbing, ACL-S subjects showed trending higher peak knee
BACKGROUND. High tibial Osteotomy (HTO) realigns the forces in the knee to slow the progression of osteoarthritis. This study relates the changes in knee joint biomechanics during level gait to glutamate signalling in the subchondral bone of patients pre and post HTO. Glutamate transmits mechanical signals in bone and activates glutamate receptors to influence inflammation, degeneration and nociception in arthritic joints. Thus glutamate signalling is a mechanism whereby mechanical load can directly modulate joint pathology and pain. METHODS. 3D motion analysis was used to assess level gait prior to HTO (n=5) and postoperatively (n=2). A biomechanical model of each subject was created in Visual3D (C-motion. Inc) and used for biomechanical analysis. Gene expression was analysed by RT-PCR from bone cores from anterior and posterior drill holes, subdivided according to medial or lateral proximal tibia from HTO patients (n=5). RESULTS. Knee adduction moment is a clinical marker of medial compartment loading. Pre-operatively the mean peak adduction moment was 3.8 ± 1.8 % body weight times height (BW.h). One subject maintained a consistent peak adduction moment pre (1.8 %BW.h) and post-operatively (1.9 %BW.h) with a reduction in the second moment peak. Another subjects peak adduction moment was significantly reduced from 6.7 %BW.h pre-operatively to 1.4 %BW.h postoperatively. GAPDH, osteocalcin, EAAT-1, EAAT1ex9skip, NR2A, KA1, OPG and RANKL mRNA expression was detected in HTO bone cores. In one patient, where HTO reduced medial compartment loading, differential expression of EAAT1ex9skip and KA1 was observed in pre and post HTO bone cores. CONCLUSION. Changes in knee
High tibial osteotomy (HTO) is an established treatment for medial compartment osteoarthritis of the knee; the aim being to achieve a somewhat valgus coronal alignment, thereby unloading the affected medial compartment. This study investigated knee kinematics and kinetics before and after HTO and compared them with matched control data. A three dimensional motion analysis system and two force platforms were used to collect kinematic and kinetic data from eight patients with medial compartment knee osteoarthritis during walking preoperatively and 12 months following HTO (opening wedge). Nine control participants of similar age and the same sex were tested using the same protocol. Sagittal and coronal knee angles and moments were measured on both the operated and non-operated knees and compared between the two time points and between HTO participants and controls. In addition, preoperative and postoperative radiographic coronal plane alignments were compared in the HTO participants. The point at which the mechanical axis passed through the knee joint was corrected from a preoperative mean of 10% tibial width from the medial tibial margin to 56% postoperatively. Stride length and walking speed both improved to essentially normal levels (1.57 m and 1.5 m/s) ostoperatively. In the coronal plane the mean peak adduction angle during stance reduced from 14.3° to 5.2° (control: 6.8°). Mean maximum