Abstract. Introduction. Osteoarthritis (OA) affects more than four million people in the UK alone. Bone marrow lesions (BMLs) are a common feature of subchondral bone pathology in OA. Both bone volume fraction and mineral density within the BML are abnormal. The aim of this study was to investigate the effect of a potential treatment (bone augmentation) for BMLs on the knee joint mechanics in cases with healthy and fully degenerated cartilage, using finite element (FE) models of the joint to study the effect of BML size. Methods. FE models of a human tibiofemoral joint were created based on models from the Open Knee project (simtk.org). Following initial mesh convergence studies, each model was manipulated in ScanIP (Synopsys-Simpleware, UK) to incorporate a BML 2mm below the surface of the tibial contact region. Models representing extreme cases (healthy cartilage, no cartilage; BML region as an empty cavity or filled with bone substitution material (200GPa)) were generated, each with different sizes of BML. Models were tested under a representative physiological load of 2kN. Results. In the absence of cartilage, the stress distribution through the bone was more localized with higher peaks in comparison to models with cartilage. In models with cartilage, BML cavity led to changes in the stress distribution through the tibia, with increasing BML size leading to higher stresses. When the BML region was represented by the substitution material very little difference was seen in comparison to models with no defect at all. Conclusions. The results of this study illustrate how the cartilage and bone behaviour in the tibiofemoral joint are linked, and that augmentation of a BML with a bone substitute has the potential to reduce adverse loading of the surrounding bone. Funders. EPSRC, NIHR. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. Osteoarthritis (OA), a painful, debilitating joint disease, often caused by excessive joint stress, is a leading cause of disability (World Health Organisation, 2003) and increases with age and obesity. A 5° varus malalignment increases loading in the medial knee compartment from 70% to 90% (Tetsworth and Paley, 1994). Internal unloading implants, placed subcutaneously upon the medial aspect of the knee joint, are designed to offload the medial compartment of the knee without violating natural joint tissues. The aim of this study is to investigate the effect of an unloading implant, such as the Atlas™ knee system, on stress within the tibiofemoral joint with different grades of cartilage defects. Methods. To simulate surgical treatment of medial knee OA, a three-dimensional computer-aided design of an Atlas™ knee system was virtually fixed to the medial aspect of a validated finite element knee model (Mootanah, 2014), using CATIA v5 software (Dassault Systèmes, Velizy Villacoublay, France). The construct was meshed and assigned material properties and boundary conditions, using Abaqus finite element software (Dassault Systèmes, Velizy Villacoublay, France). A cartilage defect was simulated by removing elements corresponding to 4.7 mm. 2. The international cartilage repair society (ICRS) Grade II and III damage were simulated by normalized defect depth of 33% and 67%, respectively. The femur was mechanically grounded and the tibia was subjected to loading conditions corresponding to the stance phase of walking of a healthy 50-year-old 68-Kg male with anthropometrics that matched those of the cadaver. Finite element analyses were run for peak shear and von Mises stress in the medial and lateral tibiofemoral compartments. Results. Von Mises stress distribution in the tibial cartilage, with ICRS Grade II and III defects, without the unloading implant, at the end of weight acceptance (15% of the gait cycle) were analysed. The internal unloading implant reduces peak von Mises stress by 40% and 43% for Grade II and Grade III cartilage defects, respectively. The corresponding reductions in shear stress are 36% and 40%. Consistent reduction in peak von Mises stress values in the medial cartilage-cartilage and cartilage-meniscus contact areas were predicted throughout the stance phase of the gait cycle for ICRS Grade II defect. Similar results were obtained for Grade III defect and for peak shear stress values. There were no overall increases in peak von Mises stress values in the lateral tibial cartilage. Discussion and Conclusions. The internal unloading implant is capable of reducing von Mises and shear stress values in the medial tibial cartilage with ICRS Grade II and III defects at the cartilage-cartilage and cartilage-meniscus interfaces throughout the stance phase of the gait cycle. This did not result in increased stress values in the lateral tibial cartilage. Our model did not account for the viscoelastic effects of the cartilage and meniscus. Results of this study are based on only one knee specimen. The internal unloading implant may protect the cartilage in individuals with medial knee osteoarthritis, thereby delaying the need for knee replacements

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 adduction/abduction moments were significantly influenced by limb alignment, with an increasing knee adduction moment from valgus through neutral to varus. Conclusion. Limb alignment was not reflected in the condylar kinematics, but did significantly affect the knee adduction moment. Variations in frontal plane limb alignment seem not to be a main modulator of condylar kinematics. The presented data provide insights into the influence of anatomical parameters on tibiofemoral kinematics and kinetics towards enhancing clinical decision-making and surgical restoration of natural knee joint motion and loading. Cite this article: Bone Joint Res 2024;13(9):485–496

Aims. Focal knee arthroplasty is an attractive alternative to knee arthroplasty for young patients because it allows preservation of a large amount of bone for potential revisions. However, the mechanical behaviour of cartilage has not yet been investigated because it is challenging to evaluate in vivo contact areas, pressure, and deformations from metal implants. Therefore, this study aimed to determine the contact pressure in the tibiofemoral joint with a focal knee arthroplasty using a finite element model. Methods. The mechanical behaviour of the cartilage surrounding a metal implant was evaluated using finite element analysis. We modelled focal knee arthroplasty with placement flush, 0.5 mm deep, or protruding 0.5 mm with regard to the level of the surrounding cartilage. We compared contact stress and pressure for bone, implant, and cartilage under static loading conditions. Results. Contact stress on medial and lateral femoral and tibial cartilages increased and decreased, respectively, the most and the least in the protruding model compared to the intact model. The deep model exhibited the closest tibiofemoral contact stress to the intact model. In addition, the deep model demonstrated load sharing between the bone and the implant, while the protruding and flush model showed stress shielding. The data revealed that resurfacing with a focal knee arthroplasty does not cause increased contact pressure with deep implantation. However, protruding implantation leads to increased contact pressure, decreased bone stress, and biomechanical disadvantage in an in vivo application. Conclusion. These results show that it is preferable to leave an edge slightly deep rather than flush and protruding. Cite this article: Bone Joint Res 2023;12(8):497–503

In an attempt to alleviate symptoms of the disease, patients with knee osteoarthrosis (KOA) frequently alter their gait patterns. Understanding the underlying pathomechanics and identifying KOA phenotypes is essential for improving treatments. We aimed to investigate altered kinematics in patients with KOA to identify subgroups.

Sixty-six patients with symptomatic KOA scheduled for total knee arthroplasty and 12 age-matched healthy volunteers with asymptomatic knees were included. We used k-means to separate the patients based on dynamic radiostereometric assessed knee kinematics. Ligament lesions, KOA score, and clinical outcome were assessed by magnetic resonance imaging, radiographs, and patient reported outcome measures, respectively.

We identified four clusters that were supported by clinical characteristics. Compared with the healthy group; The flexion group (n=20): revealed increased flexion, greater adduction, and joint narrowing and consisted primarily of patients with medial KOA. The abduction group (n=17): revealed greater abduction, joint narrowing and included primarily patients with lateral KOA. The anterior draw group (n=10): revealed greater anterior draw, external tibial rotation, lateral tibial shift, adduction, and joint narrowing. This group was composed of patients with medial KOA, some degree of anterior cruciate ligament lesion and the greatest KOA score. The external rotation group (n=19): revealed greater external tibial rotation, lateral tibial shift, adduction, and joint narrowing while no anterior draw was observed. This group included primarily patients with medial collateral and posterior cruciate ligament lesions.

Patients with KOA can, based on their gait patterns, be classified into four subgroups, which relate to their clinical characteristics. The findings add to our understanding of associations between disease pathology characteristics in the knee and the pathomechanics in patients with KOA. A next step is to investigate if patients in the pathomechanic clusters have different outcomes following total knee arthroplasty.

Accurate in vivo knee joint contact forces are required for joint simulator protocols and finite element models during the development and testing of total knee replacements (Varadarajan et al., 2008.) More accurate knowledge of knee joint contact forces during high flexion activities may lead to safer high flexion implant designs, better understanding of wear mechanisms, and prevention of complications such as aseptic loosening (Komistek et al., 2005.) High flexion is essential for lifestyle and cultural activities in the developing world, as well as in Western cultures, including ground-level tasks and chores, prayer, leisure, and toileting (Hemmerich et al., 2006.) In vivo tibial loads have been reported while kneeling; but only while the subject was at rest in the kneeling position (Zhao et al., 2007), meaning that the loads were submaximal due to muscle relaxation and thigh-calf contact support. The objective of this study was to report the in vivo loads experienced during high flexion activities and to determine how closely the measured axial joint contact forces can be estimated using a simple, non-invasive model. It provides unique data to better interpret non-invasively determined joint-contact forces, as well as directly measured tiobiofemoral joint contact force data for two subjects.

Two subjects with instrumented tibial implants performed kneeling and deep knee bend activities. Two sets of trials were carried out for each activity. During the first set, an electromagnetic tracking system and two force plates were used to record lower limb kinematics and ground reaction forces under the foot and under the knee when it was on the ground. In the second set, three-dimensional joint contact forces were directly measured in vivo via instrumented tibial implants (Heinlein et al., 2007.) The measured axial joint contact forces were compared to estimates from a non-invasive joint contact force model (Smith et al., 2008.)

The maximum mean axial forces measured during the deep knee bend were 24.2 N/kg at 78.2° flexion (subject A) and 31.1 N/kg at 63.5° flexion (subject B) during the deep knee bend (Figure 1.) During the kneeling activity, the maximum mean axial force measured was 29.8 N/kg at 86.8° flexion (subject B.) While the general shapes of the model-estimated curves were similar to the directly measured curves, the axial joint contact force model underestimated the measured contact forces by 7.0 N/kg on average (Figure 2.) The most likely contributor to this underestimation is the lack of co-contraction in the model.

The study protocol was limited in that data could not be simultaneously collected due to electromagnetic interference between the motion tracking system and the inductively powered instrumented tibial component. Because skin-mounted markers were used, kinematics may be affected by skin motion artefacts. Despite these limitations, this study presents valuable information that will advance the development of high flexion total knee replacements. The study provides in vivo measurements and non-invasive estimates of joint contact forces during high flexion activities that can be used for joint simulator protocols and finite element modeling.

Autologous osteochondral grafting has demonstrated positive outcomes for treating articular cartilage defects by replacing the damaged region with a cylindrical graft consisting of bone with a layer of cartilage, taken from a non-loadbearing region of the knee. Despite positive clinical use, factors that cause graft subsidence or poor integration are relatively unknown. The aim of this study was to develop finite element (FE) models of osteochondral grafts within a tibiofemoral joint and to investigate parameters affecting osteochondral graft stability. Initial experimental tests on cadaveric femurs were performed to calibrate the bone properties and graft-bone frictional forces for use in corresponding FE models, generated from µCT scan data. The effects of cartilage defects and osteochondral graft repair were measured by examining contact pressure changes using in vitro tests on a single cadaveric human tibiofemoral joint. Six defects were created in the femoral condyles which were subsequently treated with osteochondral autografts or metal pins. Matching µCT scan-based FE models were created, and the contact patches were compared. Sensitivity to graft bone properties was investigated. The bone material properties and graft-bone frictional forces were successfully calibrated from the initial tests with good resulting levels of agreement (CCC=0.87). The tibiofemoral joint experiment provided a range of cases to model. These cases were well captured experimentally and represented accurately in the FE models. Graft properties relative to host bone had large effects on immediate graft stability despite limited changes to resultant cartilage contact pressure. Model confidence was built through extensive validation and sensitivity testing, and demonstrated that specimen-specific properties were required to accurately represent graft behaviour. The results indicate that graft bone properties affect the immediate stability, which is important for the selection of allografts and design of future synthetic grafts. Acknowledgements. Supported by the EPSRC-EP/P001076

Aims. The aim of this retrospective study was to determine if there are differences in short-term clinical outcomes among four different types of matrix-associated autologous chondrocyte transplantation (MACT). Methods. A total of 88 patients (mean age 34 years (SD 10.03), mean BMI 25 kg/m. 2. (SD 3.51)) with full-thickness chondral lesions of the tibiofemoral joint who underwent MACT were included in this study. Clinical examinations were performed preoperatively and 24 months after transplantation. Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC) Subjective Knee Form, the Brittberg score, the Tegner Activity Scale, and the visual analogue scale (VAS) for pain. The Kruskal-Wallis test by ranks was used to compare the clinical scores of the different transplant types. Results. The mean defect size of the tibiofemoral joint compartment was 4.28 cm. 2. (SD 1.70). In total, 11 patients (12.6%) underwent transplantation with Chondro-Gide (matrix-associated autologous chondrocyte implantation (MACI)), 40 patients (46.0%) with Hyalograft C (HYAFF), 21 patients (24.1%) with Cartilage Regeneration System (CaReS), and 15 patients (17.2%) with NOVOCART 3D. The mean IKDC Subjective Knee Form score improved from 35.71 (SD 6.44) preoperatively to 75.26 (SD 18.36) after 24 months postoperatively in the Hyalograft group, from 35.94 (SD 10.29) to 71.57 (SD 16.31) in the Chondro-Gide (MACI) group, from 37.06 (SD 5.42) to 71.49 (SD 6.76) in the NOVOCART 3D group, and from 45.05 (SD 15.83) to 70.33 (SD 19.65) in the CaReS group. Similar improvements were observed in the VAS and Brittberg scores. Conclusion. Two years postoperatively, there were no significant differences in terms of outcomes. Our data demonstrated that MACT, regardless of the implants used, resulted in good clinical improvement two years after transplantation for localized tibiofemoral defects. Cite this article: Bone Joint Res 2021;10(7):370–379

Abstract. Objectives. Investigate Magnetic Resonance Imaging (MRI) as an alternative to Computerised Tomography (CT) when calculating kinematics using Biplane Video X-ray (BVX) by quantifying the accuracy of a combined MRI-BVX methodology by comparing with results from a gold-standard bead-based method. Methods. Written informed consent was given by one participant who had four tantalum beads implanted into their distal femur and proximal tibia from a previous study. Three-dimensional (3D) models of the femur and tibia were segmented (Simpleware Scan IP, Synopsis) from an MRI scan (Magnetom 3T Prisma, Siemens). Anatomical Coordinate Systems (ACS) were applied to the bone models using automated algorithms. 1. The beads were segmented from a previous CT and co-registered with the MRI bone models to calculate their positions. BVX (60 FPS, 1.25 ms pulse width) was recorded whilst the participant performed a lunge. The beads were tracked, and the ACS position of the femur and tibia were calculated at each frame (DSX Suite, C-Motion Inc.). The beads were digitally removed from the X-rays (MATLAB, MathWorks) allowing for blinded image-registration of the MRI models to the radiographs. The mean difference and standard deviation (STD) between bead-generated and image-registered bone poses were calculated for all degrees of freedom (DOF) for both bones. Using the principles defined by Grood and Suntay. 2. , 6 DOF kinematics of the tibiofemoral joint were calculated (MATLAB, MathWorks). The mean difference and STD between these two sets of kinematics were calculated. Results. The absolute mean femur and tibia ACS position differences (Table 1) between the bead and image-registered poses were found to be within 0.75mm for XYZ, with all STD within ±0.5mm. Mean rotation differences for both bones were found to be within 0.2º for XYZ (Table 1). The absolute mean tibiofemoral joint translations (Table 1) were found to be within ±0.7mm for all DOF, with the smallest absolute mean in compression-distraction. The absolute mean tibiofemoral rotations were found to be within 0.25º for all DOF (Table 1), with the smallest mean was found in abduction-adduction. The largest mean and STD were found in internal-external rotation due to the angle of the X-rays relative to the joint movement, increasing the difficulty of manual image registration in that plane. Conclusion. The combined MRI-BVX method produced bone pose and tibiofemoral kinematics accuracy similar to previous CT results. 3. This allows for confidence in future results, especially in clinical applications where high accuracy is needed to understand the effects of disease and the efficacy of surgical interventions. Acknowledgements: This research was supported by the Engineering and Physical Sciences Research Council (EPSRC) doctoral training grant (EP/T517951/1). Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. Instability in ACL deficient knees can lead to medial compartment osteoarthritis. The risk of developing significant OA is 5x higher in knees with ACL deficiency. In associated Varus, there is quicker progression of the medial OA along with a varus thrust exerting strain on the ACL graft. The simultaneous valgus HTO and ACL reconstruction decompresses the medial tibiofemoral joint, corrects the mechanical-axis and reduces strain on the graft. Outcomes for this simultaneous procedure are still unclear in literature and we attempt evaluating its functional outcome. Methods. This Panel study was performed using data from 2019 to 2022 on 21 patients who had ACL insufficiency with Varus or medial OA and underwent a simultaneous Opening-wedge HTO with Arthroscopic ACL reconstruction. The mean follow-up was 2 years. The patients were evaluated with IKDC and Lysholm scores, Lachman test and ROM pre and post-operatively. The HKA was compared pre and post-operatively and the complications were evaluated. The progression of OA was evaluated with serial radiographs post-operatively. Results. There was a significant improvement in lifestyle and knee joint function post-operatively. The mechanical femorotibial angle was corrected from an average of 8.2° Varus to 0.8° Valgus. There was a significant improvement in IKDC and Lysholm scoring (IKDC score improved to 86.20 from 34.48 and the Lysholm score improved to 89 points from 37 points). There was significant improvement in the laxity which was evaluated by Lachman test. One patient had a clinical progression of medial-OA. No patients had non-union, graft or implant failure. Conclusion. Single stage HTO and ACL Reconstruction in patients with medial OA or Varus with ACL insufficiency is an option showing a satisfactory functional and radiological outcome along with activity scores

From October 2005 to March 2014, we performed 46 arthroscopic surgeries for painful knee after knee arthroplasty. We excluded 16 cases for this study such as, unicompartmental knee arthroplasty, infection, patellar clunk syndrome, patellofemoral synovial hyperplasia, aseptic loosening, and follow-up period after arthroscopic surgery less than 6 months. Thirty cases matched the criteria. They had knee pain longer than 6 months after initial total knee arthroplasty (TKA), they had marked tenderness at medial and/or lateral tibiofemoral joint space, and also they complained walking pain with or without resting pain. Twenty one cases had initial TKA at our institute. In consideration of total number of TKA (n=489) in the period at our institute, incident rate of painful knee after initial TKA was 4.3%. Of 30 cases, 3 cases were male, and 27 cases were female. Types of implant were 4 in cruciate retaining type, 1 in cruciate substituting type, and 25 in posterior stabilized type. Age at the arthroscopy was 72 years old (51–87 years old), and period form initial TKA to pain perception was 18 months(1 – 144 months), and period from initial TKA to arthroscopic surgery was 29 months (6 – 125 months), and follow-up period after arthroscopy was 36 months (6 – 93 months). All arthroscopic debridement were performed through 3 portals, anteromedial, anterolateral, and proximal superomedial portal. Scar tissue impingements more than 5 mm wide were found in 87% of the cases both medial and lateral femorotibial joint spaces. Infrapatellar fat pad were covered with whitish scar tissue in all cases, and the scar tissue were connecting with the scar tissue which found at medial or lateral femorotibial joint spaces. We removed all scar tissue with motorized shaver or punches. At final follow-up, complete pain free in 63%, marked improvement in 3%, half improvement in 20%, slight improvement in 3%, and no change in 10% of the cases. Previously in the literatures, two reasons of the pain after total knee arthroplasty had been reported, patellar clunk syndrome, and patellar synovial hyperplasia. All cases reported this study had marked tenderness at tibiofemoral joint space. It was difficult to explain the tenderness by previously reported pathological mechanisms. We had to find another pathological mechanism to explain the pain of our cases. Painful knee due to scar tissue formation known as “infrapatellar contracture syndrome” after anterior cruciate ligament reconstruction surgery was previously reported. We hypothesized similar scar tissue formation should occur after TKA that caused painful knee. Continuity of the solid scar tissue between infrapatellar fat pad with the scar tissue at tibiofemoral joint space should be the cause of impingement at femorotibial joint even small size of scar tissue. From this study, we have to recognize that painful knee after TKA is not infrequent complication. And, if we could deny infection, and aseptic loosening in painful knee after TKA, arthroscopic debridement was good option to solve the pain. We could expect improvement of the pain more than half in 87% of cases

Aims. A functional anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) has been assumed to be required for patients undergoing unicompartmental knee arthroplasty (UKA). However, this assumption has not been thoroughly tested. Therefore, this study aimed to assess the biomechanical effects exerted by cruciate ligament-deficient knees with medial UKAs regarding different posterior tibial slopes. Methods. ACL- or PCL-deficient models with posterior tibial slopes of 1°, 3°, 5°, 7°, and 9° were developed and compared to intact models. The kinematics and contact stresses on the tibiofemoral joint were evaluated under gait cycle loading conditions. Results. Anterior translation increased in ACL-deficient UKA cases compared with intact models. In contrast, posterior translation increased in PCL-deficient UKA cases compared with intact models. As the posterior tibial slope increased, anterior translation of ACL-deficient UKA increased significantly in the stance phase, and posterior translation of PCL-deficient UKA increased significantly in the swing phase. Furthermore, as the posterior tibial slope increased, contact stress on the other compartment increased in cruciate ligament-deficient UKAs compared with intact UKAs. Conclusion. Fixed-bearing medial UKA is a viable treatment option for patients with cruciate ligament deficiency, providing a less invasive procedure and allowing patient-specific kinematics to adjust posterior tibial slope. Patient selection is important, and while AP kinematics can be compensated for by posterior tibial slope adjustment, rotational stability is a prerequisite for this approach. ACL- or PCL-deficient UKA that adjusts the posterior tibial slope might be an alternative treatment option for a skilled surgeon. Cite this article: Bone Joint Res 2022;11(7):494–502

Many recent knee prostheses are designed aiming to the physiological knee kinematics on tibiofemoral joint, which means the femoral rollback and medial pivot motion. However, there have been few studies how to design a patellar component. Since patella and tibia are connected by a patellar tendon, tibiofemoral and patellofemoral motion or contact forces might affect each other. In this study, we aimed to discuss the optimal design of patellar component and simulated the knee flexion using four types of patellar shape during deep knee flexion. Our simulation model calculates the position/orientation, contact points and contact forces by inputting knee flexion angle, muscle forces and external forces. It can be separated into patellofemoral and tibiofemoral joints. On each joint, calculations are performed using the condition of point contact and force/moment equilibrium. First, patellofemoral was calculated and output patellar tendon force, and tibiofemoral was calculated with patellar tendon force as external force. Then patellofemoral was calculated again, and the calculation was repeated until the position/orientation of tibia converged. We tried four types of patellar shape, circular dome, cylinder, plate and anatomical. Femoral and tibial surfaces are created from Scorpio NRG PS (Stryker Co.). Condition of knee flexion was passive, with constant muscle forces and varying external force acting on tibia. Knee flexion angle was from 80 to 150 degrees. As a result, the internal rotation of tibia varied much by using anatomical or plate patella than dome or cylinder shape. Although patellar contact force did not change much, tibial contact balances were better on dome and cylinder patella and the medial contact forces were larger than lateral on anatomical and plate patella. Thus, the results could be divided into two types, dome/cylinder and plate/anatomical. It might be caused by the variations of patellar rotation angle were large on anatomical and plate patella, though patellar tilt angles were similar in all the cases. We have already reported that the anatomical shape of patella would contact in good medial-lateral balance when tibia moved physiologically, therefore we have predicted the anatomical patella might facilitate the physiological tibiofemoral motion. However, the results were not as we predicted. Actually our previous and this study are not in the same condition; we used a posterior-stabilized type of prosthesis, and the post and cam mechanism could not make the femur roll back during deep knee flexion. It might be better to choose dome or cylinder patella to obtain the stability of tibiofemoral joint, and to choose anatomical or plate to the mobility

Summary Statement. An MRI-derived subject-specific finite element model of a knee joint was loaded with subject-specific kinetic data to investigate stress and strain distribution in knee cartilage during the stance phase of gait in-vivo. Introduction. Finite element analysis (FEA) has been widely used to predict the local stress and strain distribution at the tibiofemoral joint to study the effects of ligament injury, meniscus injury and cartilage defects on soft tissue loading under different loading conditions. Previous studies have focused on static FEA of the tibiofemoral joint, with few attempts to conduct subject-specific FEA on the knee during physical activity. In one FEA study utilising subject-specific loading during gait, the knee was simplified by using linear springs to represent ligaments. To address the gap that no studies have performed subject-specific FEA at the tibiofemoral joint with detailed structures, the present study aims to develop a highly detailed subject-specific FE model of knee joint to precisely simulate the stress distribution at knee cartilage during the stance phase of the gait cycle. Method. A detailed three-dimensional model of a healthy human knee was developed from MRI images of a living subject, including the main anatomical structures (bones, all principal ligaments, menisci and articular cartilages). The femur, tibia and fibula were considered as rigid bodies, while the menisci and articular cartilage were modelled as linearly elastic, isotropic and homogeneous while the ligaments were considered to be hyperelastic. Loading and boundary condition assignment was based on the kinematic and kinetic data recorded during gait analysis. Ten time intervals during the stance phase of gait were separately simulated to quantify the time–dependent stress distribution throughout the cycle from heel-strike to toe-off. Loading condition of the tibiofemoral joint varys during the gait cycle since the joint angle changes from extension to flextion, therefore different joint angles at relative time interval were determined to accurately simulate the varing loading condition. Results. The compressive stress and tensile strain distributions in the femoral cartilage, tibia cartilage and menisci of each selected time interval during the stance phase of gait cycle were quantified and corresponded to specific amount of varus/valgus knee moment obtained by inverse dynamics analysis of the kinematic and kinetic data from gait analysis. Therefore a correlation between stress/strain and the frontal movement was established and analysed. For example, at 10% of stance phase, the stress concentration was observed on the lateral compartment due to the valgus moment created at heel strike. At the next interval, the stress concentration shifted to the medial side as the frontal knee moment shifted to a varus orientation. Discussion. The results suggest that the stress distribution of tibiofemoral articular cartilage is qualitatively consistent with the valgus and varus moment observed during the stance phase of gait. The methods described could be applied to investigate the effects of injury and reconstruction on stress distribution within the tibiofemoral joint

Introduction. t is accepted dogma in total knee arthroplasty (TKA) that resecting the posterior cruciate ligament (PCL) increases the flexion space by approximately 4mm, which significantly affects intra-operative decisions and surgical techniques. Unfortunately, this doctrine is based on historical cadaveric studies of limited size. This study purpose was to more accurately determine the effect of PCL resection on the tibiofemoral flexion gap dimension in vivo in a large sample. Methods. Tibiofemoral joint space measurements were made during 127 standardized TKAs by two arthroplasty surgeons. A medial parapatellar approach, computer navigation and provisional tibial and femoral bone cuts were performed in all cases with particular attention to preserving PCL integrity. Cases with an incompetent or damaged PCL were excluded. The tibiofemoral gap dimension was measured with a calibrated tension device at full extension, 45-degrees, and 90-degrees before and after complete PCL resection. Results. 52% of patients were female (66/127), with mean age and BMI of 69.4 years and 34.3 kg/m. 2. , respectively. After PCL resection, the mean joint space dimension increased 0.3mm (range, 0–3mm) at extension, 0.9mm (range, 0–4mm) at 45-degrees, and 1.7mm (range, 0–5mm) at 90-degrees (p<0.001). The 90-degree flexion space opened ≤1mm in 48% of patients and ≥3mm in only 10%. Dividing the flexion gap change by the femoral implant dimension to account and calibrate for patient size, the joint space at 90-degrees increased more in females (0.031 vs. 0.023, p=0.022). Conclusion. The tibiofemoral joint space increases progressively from extension, to mid-flexion through 90-degrees flexion after PCL resection, yet is substantially less than reported in historical studies. However, large variation in the degree of flexion space opening was observed with some patients failing to increase their flexion space whatsoever with PCL resection. This runs counter to conventional TKA understanding and should be considered in modern surgical techniques and education. For figures, tables, or references, please contact authors directly

Non-invasive, in vivo measurement of the three-dimensional (3-D) motion of the tibiofemoral joint is essential for the study of the biomechanics and functional assessment of the knee. Real-time magnetic resonance imaging (MRI) techniques enable the measurement of dynamic motions of the knee with satisfactory image quality and free of radiation exposures but are limited to planar motions in selected slice(s). The aims of the current study were to propose a slice-to-volume registration (SVR) method in conjunction with dual-slice, real-time MRI for measuring 3-D tibiofemoral motion; and to evaluate its repeatability during passive knee flexion. Eight healthy young adults participated in the current study, giving informed written consent as approved by the Institutional Research Board. A 3-T MRI system (Verio, Siemens, Erlangen, Germany) incorporated with a neck matrix coil was used to collect the MRI data. A 3-D scanning using the VIBE sequence was used to collect the volumetric data of the knee at fully extended position (TR = 4.64 ms, TE = 2.3 ms, flip angle = 15°, in-plane resolution = 0.39 × 0.39 mm. 2. and slice thickness = 0.8 mm). A real-time MRI using the refocused radial FLASH sequence (TR = 4.3 ms, TE = 2.3 ms, flip angle = 20°, in-plane resolution = 1.0 × 1.0 mm. 2. , slice thickness = 6 mm) was used to acquire a pair of image slices of the knee at a frame rate of 3 fps during passive flexion. The volumetric MRI data sets were segmented for the femur and tibia/fibula to isolate the sub-volumes containing bone segments. A slice-to-volume registration method was then performed to determine the 3-D poses of the bones based on the spatial matching between sub-volume of the bones and the real-time image slices. The bone poses for all frames were used to calculate the rigid-body kinematics of the tibiofemoral joint in terms of the flexion/extension (FE), internal/external rotation (IR/ER), abduction/adduction (Abd/Add) and joint center translations along three anatomical axis of the tibia. The procedures were carried out five times for repeatability analysis. The standard deviation (SD) of the rigid-body kinematics for each frame from the five trials were calculated and then averaged across all frames to give quantitative measures of the repeatability of the kinematic variables. The repeatability analysis showed that the mean±SD of the averaged SD in FE, Abd/Add and IR/ER components across all subjects were 0.25±0.09, 0.46±0.13 and 0.77±0.16 degrees, respectively. The corresponding values for the joint translations in anterior/posterior, proximal/distal and medial/lateral directions were 0.21±0.04, 0.11±0.03 and 0.43±0.09 mm. An SVR method in conjunction with dual-slice real-time MRI has been successfully developed and its repeatability in measuring 3-D motion of the tibiofemoral joint evaluated. The results show that the proposed method is capable of providing rigid-body kinematics with sub-millimeter and sub-degree precision (repeatability). The proposed SVR method using real-time MRI will be a valuable tool for non-invasive, functional assessment of the knee without involving ionizing radiation, and may be further developed for joint stability assessment

Introduction. Traditional applied loading of the knee joint in experimental testing of RTKR components is usually confined to replicating the tibiofemoral joint alone. The second joint in the knee, the patellofemoral joint, can experience forces of up to 9.7 times body weight during normal daily living activities (Schindler and Scott 2011). It follows that with such high forces being transferred, particularly in high flexion situations such as stair climbing, it may be important to also represent the patellofemoral joint in all knee component testing. This research aimed to assess the inclusion of the patellofemoral joint during in vitro testing of RTKR components by comparing tibial strain distribution in two experimental rigs. The first rig included the traditional tibiofemoral joint loading design. The second rig incorporated a combination of both joints to more accurately replicate physiological loading. Five implanted tibia specimens were tested on both rigs following the application of strain gauge rosettes to provide cortical strain data through the bone as an indication of the load transfer pattern. This investigation aimed to highlight the importance of the applied loading technique for pre-clinical testing and research of knee replacement components to guide future design and improve patient outcomes. Methods. Five composite tibias (4th Generation Sawbones) were prepared with strain gauge rosettes (HBM), correctly aligned and potted using guides for repeatability across specimens. The tibias were then implanted with Stryker Triathlon components according to surgical protocol. The first experimental rig was developed to replicate traditional knee loading conditions through the tibiofemoral joint in isolation. The second experimental rig produced an innovative method of replicating a combination of the tibiofemoral and patellofemoral joint loading scenarios. Both rigs were used to assess the load distribution through the tibia using the same tibia specimens and test parameters for comparison integrity (Figure 1). The cortical strains were recorded under an equivalent 500 N cyclical load applied at 10° of flexion by a hydraulic test machine. Results. The average results comparing both experimental rigs at three strain gauge locations are shown in Figure 2. Paired t-tests were performed on all results and a p value of p<0.05 was considered significant. No significant differences were found between the rigs. There was a trend towards a reduction in proximal principal strain with the inclusion of the patellofemoral joint (p=0.058). Discussion. The results of this study indicate that there is no significant difference in tibial load transfer between the traditional and novel applied loading techniques at small flexion angles. There is a trend towards a reduction in proximal strain when including the patellofemoral joint. This reduction may be linked to the patella tendon force counteracting the effect of tibiofemoral loading at this small flexion angle. At high flexion angles the patellofemoral reaction load increases significantly relative to the tibiofemoral load. This will have a significant effect on tibial strains and so it is recommended that testing at higher flexion angles should be performed in a combined loading rig

Abstract. Objectives. The need for gender specific knee arthroplasty is debated. This research aimed to establish whether gender differences in patellar tendon moment arm (PTMA), a composite measure that characterises function of both the patellofemoral and tibiofemoral joints, are a consequence of knee size or other variation. Methods. PTMA about the instantaneous helical axis was calculated from positional data acquired using optical tracking. First, data post-processing was optimised, comparing four smoothing techniques (raw, Butterworth filtered, generalised cross-validation cubic spline interpolated and combined filtered/interpolated) using a fabricated knee. Then PTMA was measured during open-chain extension for N=24 (11 female) fresh-frozen cadaveric knees, with physiologically based loading and extension rates (420°/s) applied. Gender differences in PTMA were assessed before and after accounting for knee size with epicondylar width. Results. Combined smoothing enabled sub-mm accuracy (root-mean-squared (RMS) error 0.16mm, max error 0.47mm), whereas large errors were measured for raw (RMS 3.61mm, max 23.71mm), filtered-only (RMS 1.19mm, max 7.38mm) and interpolated-only (RMS 0.68mm, max 1.80mm) techniques. Before scaling, average PTMA throughout knee flexion was 46mm and mean, maximum, and minimum absolute values of PTMA were larger in males (mean differences >8mm, p<0.001), as were the PTMAs at terminal extension and flexion, and the change in PTMA from peak to terminal extension (differences >4mm, p<0.05). After scaling, the PTMA in deep flexion and the change in PTMA from peak to terminal extension were still larger in male knees (differences >2mm, p<0.05). The flexion angle of peak PTMA, unaffected by scaling, was closer to terminal extension for female knee (female 15°, male 29°, p<0.05). Conclusion. Gender differences in PTMA were identified both before and after accounting for knee size, with implications for gender-specific arthroplasty and musculoskeletal models. The developed measurement framework could also be applied in vivo for accurate measurement of the PTMA. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Objective. 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. Methods. 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. Results. Total knee contact force peak 1 significantly reduced from 2.6 x body weight pre-HTO to 2.3 x body weight 12-months post-HTO. Medial contact force peak 1 significantly reduced from 1.7 x body weight pre-HTO to 1.5 x body weight 12-months post-HTO. Second peak lateral knee contact force significantly increased from 0.9 body weight pre-HTO to 1.1 x body weight 12-months post-HTO. Furthermore, this study found very strong correlations between EKAM1 and medial KCF1 pre-HTO (r=0.85) as well as post-HTO (r=0.91). There was a significantly moderate relationship between EKAM2 and medial KCF2 pre-HTO (r=0.625). Conclusion. HTO significantly reduced overall and medial KCF during the first half of stance whilst increasing second half of stance peak lateral knee contact force. This study demonstrated a strong relationship between EKAM peaks and respective medial KCF peaks, supporting the usefulness of EKAM as a surrogate measure of medial compartment tibiofemoral contact forces. This demonstrates HTO successfully offloads the tibiofemoral joint overall, as well as offloading the medial compartment

Objective. Kinematically aligned total knee arthroplasty (TKA) is of increasing interest because this method may improve patient satisfaction. However, the biomechanics of kinematically aligned TKA remain largely unknown. Therefore, we analyzed whether the kinematic alignment method cause to increase the contact force on patellofemoral and tibiofemoral joints. Methods. A musculoskeletal computer simulation was used to determine the effects of kinematically or mechanically aligned TKA. Patellofemoral and tibiofemoral contact forces were examined for a mechanically aligned model and a kinematically aligned model using finite element analysis. Results. The peak contact stress on the patellofemoral joint in the kinematically aligned model was greater than that in the mechanically aligned model at 30° and 60°. Maximum peak contact stress was found at 30° flexion in the kinematically aligned model (73 MPa) and this was 221% higher than the stress in the mechanically aligned model (33 MPa). Similarly, peak contact stress of 33.0 MPa at 60° flexion occurred in the kinematically aligned model and this was 114% higher than that in the mechanically aligned model (29 MPa). The peak contact stress on the tibiofemoral joint in the kinematically aligned model was greater than that in the mechanically aligned model at 30°, 60° and 90° flexion. Maximum peak contact stress was found at 30° flexion in the kinematically aligned model (22 MPa) and this was 200% higher than the stress in the mechanically aligned model (11 MPa). Conclusions. Kinematically aligned TKA may have increased risks for implant longevity. Therefore, a strict surgical indication, including age and implant design, is needed to achieve excellent longevity after kinematically aligned TKA