Aims. To fully quantify the effect of posterior tibial slope (PTS) angles on joint kinematics and contact mechanics of intact and anterior cruciate ligament-deficient (ACLD) knees during the gait cycle. Methods. In this controlled laboratory study, we developed an original multiscale subject-specific finite element musculoskeletal framework model and integrated it with the tibiofemoral and patellofemoral joints with high-fidelity joint motion representations, to investigate the effects of 2.5° increases in PTS angles on joint dynamics and contact mechanics during the gait cycle. Results. The ACL tensile force in the intact knee was significantly affected with increasing PTS angle. Considerable differences were observed in kinematics and initial posterior femoral translation between the intact and ACLD joints as the PTS angles increased by more than 2.5° (beyond 11.4°). Additionally, a higher contact stress was detected in the peripheral posterior horn areas of the menisci with increasing PTS angle during the gait cycle. The maximum tensile force on the horn of the medial meniscus increased from 73.9 N to 172.4 N in the ACLD joint with increasing PTS angles. Conclusion. Knee joint instability and larger loading on the medial meniscus were found on the ACLD knee even at a 2.5° increase in PTS angle (larger than 11.4°). Our biomechanical findings support recent clinical evidence of a high risk of failure of ACL reconstruction with steeper PTS and the necessity of ACL reconstruction, which would prevent meniscus tear and thus the development or progression of osteoarthritis. Cite this article: Bone Joint Res 2022;11(10):739–750

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).

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

Aims. Commonly performed unicompartmental knee arthroplasty (UKA) is not designed for the lateral compartment. Additionally, the anatomical medial and lateral tibial plateaus have asymmetrical geometries, with a slightly dished medial plateau and a convex lateral plateau. Therefore, this study aims to investigate the native knee kinematics with respect to the tibial insert design corresponding to the lateral femoral component. Methods. Subject-specific finite element models were developed with tibiofemoral (TF) and patellofemoral joints for one female and four male subjects. Three different TF conformity designs were applied. Flat, convex, and conforming tibial insert designs were applied to the identical femoral component. A deep knee bend was considered as the loading condition, and the kinematic preservation in the native knee was investigated. Results. The convex design, the femoral rollback, and internal rotation were similar to those of the native knee. However, the conforming design showed a significantly decreased femoral rollback and internal rotation compared with that of the native knee (p < 0.05). The flat design showed a significant difference in the femoral rollback; however, there was no difference in the tibial internal rotation compared with that of the native knee. Conclusion. The geometry of the surface of the lateral tibial plateau determined the ability to restore the rotational kinematics of the native knee. Surgeons and implant designers should consider the geometry of the anatomical lateral tibial plateau as an important factor in the restoration of native knee kinematics after lateral UKA. Cite this article: Bone Joint Res 2019;8:593–600

Introduction. PEEK-OPTIMA™ has been considered as an alternative to cobalt chrome in the femoral component of total knee replacements. Whole joint wear simulation studies of both the tibiofemoral and patellofemoral joints carried out to date have shown an equivalent wear rate of UHMWPE tibial and patella components against PEEK and cobalt chrome (CoCr) femoral components. In this study, the influence of third body wear on UHMWPE-on-PEEK was investigated, tests on UHMWPE-on-CoCr were carried out in parallel to compare PEEK to a conventional femoral component material. Methods. Wear simulation was carried out in simple geometry using a 6-station multi-directional pin-on-plate simulator. 5 scratches were created on each PEEK and CoCr plate perpendicular to the direction of the wear test using a diamond stylus to produce scratches with a geometry similar to that observed in retrieved CoCr femoral components. To investigate the influence of scratch lip height on wear, scratches of approximately 1, 2 and 4µm lip height were created. Wear simulation of GUR 1020 UHMWPE pins (conventional, non-sterile) against the plates was carried out for 1 million cycles (MC) using 17g/l bovine serum as a lubricant using kinematic conditions to replicate the average contact pressure and cross-shear in a total knee replacement. Wear of UHMWPE pins was measured gravimetrically and the surface topography of the plates assessed using a contacting Form Talysurf. Wear factors of the pins against the scratched plates were compared to unscratched controls (0µm lip height). Minimum n=3 for each condition and statistical analysis carried out using ANOVA with significance taken at p<0.05. Results. For the control tests (0µm lip height), the wear factor of UHMWPE pins was similar (p=0.64) against PEEK and CoCr plates. Against CoCr, with an increasing lip height, an exponential increase in wear factor of UHMWPE pins was observed; for PEEK, with increasing lip height, the wear factor did not show an exponential increase. When articulated against the largest scratches, 4µm, the wear factor of UHMWPE was significantly higher against CoCr than PEEK (p=0.01). At the conclusion of the study, on the PEEK plates, a polishing effect of the pin against the plates was observed and in the area of the wear test, the lip height of the scratches was lower than pre-test values; for the CoCr plates, no change in lip height was measured after 1MC wear simulation. Conclusion. The exponential relationship between scratch lip height in CoCr and wear of UHMWPE has previously been described. However, the trend in the wear of UHMWPE was different when articulating against scratched PEEK compared to CoCr, with a significantly higher wear factor of UHMWPE against CoCr than PEEK at a scratch lip height of 4µm. This study suggests that the third body wear behaviour of this all-polymer knee replacement will be different to that of conventional implant materials

Introduction. PEEK-OPTIMA™ has been considered as an alternative to cobalt chrome in the femoral component of total knee replacements. Wear simulation studies of both the tibiofemoral and patellofemoral joints carried out to date have shown an equivalent wear rate of UHMWPE tibial and patella components against PEEK and cobalt chrome (CoCr) femoral components implanted under optimal alignment conditions. In this study, fundamental pin-on-plate studies have been carried out to investigate the wear of UHMWPE-on-PEEK under a wider range of contact pressure and cross-shear conditions. Methods. The study was carried out in a 6 station multi-axial pin-on-plate reciprocating rig. UHMPWE pins (conventional, non- sterile) were articulated against PEEK-OPTIMA™ plates, initial Ra ∼0.02µm. The lubricant used was 25% bovine serum (17g/l) supplemented with 0.03% sodium azide. The contact pressure and cross-shear ratio conditions were selected to replicate those in total knee replacements and to be comparable to previously reported studies of UHMPWE-on-CoCr tested in the same pin-on-plate simulators. Contact pressures from 2.1 to 25.5MPa were created by changing the diameter of the contact face of the pin, the cross-shear ratios ranged from 0 (uniaxial motion) to 0.18. Wear of the UHMWPE pins was measured gravimetrically and the surface topography of the plates assessed using a contacting Form Talysurf. N=6 was carried out for each condition and statistical analysis carried out using ANOVA with significance taken at p<0.05. Results. When compared to conventional materials (UHMWPE-on-CoCr), the wear factor of UHMPWE-on-PEEK was generally lower than that of moderately cross-linked UHMWPE-on-CoCr. With increasing contact pressure, there was a trend of decreasing wear factor and a significant difference (p=0.001) in the wear factor of the UHMPWE pins tested under different contact pressures. The wear of UHMWPE-on-PEEK followed a similar trend as that of UHMWPE-on-CoCr. Under uniaxial motion (cross-shear ratio = 0), the wear of UHMWPE was low, introducing multi-axial motion increased the wear of the UHMWPE. There was a significant difference (p<0.01) in the wear factor at different cross-shear ratios however, post hoc analysis showed only the test carried out under unidirectional motion to be significantly different from the other conditions tested. At the conclusion of the studies, there was a polished region in the centre of the plate, however, there was no significant difference in the post-test surface roughness of the plate under any of the conditions tested. Conclusion. The influence of contact pressure and cross-shear ratio on the wear of UHMWPE pins has shown a similar trend when articulating against either PEEK-OPTIMA™ or cobalt chrome plates. The wear factors determined in this study will provide inputs to future computational models which will allow the wear of this all-polymer knee replacement to be investigated under a wider range of clinically relevant conditions

Objectives

Posterior condylar offset (PCO) and posterior tibial slope (PTS) are critical factors in total knee arthroplasty (TKA). A computational simulation was performed to evaluate the biomechanical effect of PCO and PTS on cruciate retaining TKA.

In some regions in Asia or Arab, there are lifestyles without chair or bed and sitting down on a floor directly, by flexing their knee deeply. However, there are little data about the joint angles, muscle forces or joint loads at such sitting postures or descending to and rising from the posture. In this study, we report the knee joint force and the muscle forces of lower limb at deep squatting and kneeling postures.

The model to estimate the forces were constructed as 2D on sagittal plane. Floor reacting force, gravity forces and thigh-calf contact force were considered as external forces. And as the muscle, rectus and vastus femoris, hamstrings, gluteus maximus, gastrocnemius and soleus were taken into the model. The rectus and vastus were connected to the tibia with patella and patella tendon. First the muscle forces were calculated by the moment equilibrium conditions around hip, knee and ankle joint, and then the knee joint force was calculated by the force equilibrium conditions at tibia and patella.

For measuring the acting point of the floor reacting force, thigh-calf contact force and joint angles during the objective posture, we performed the experiments. The postures to be subjected were heel-contact squatting (HCS), heel-rise squatting (HRS), kneeling and seiza (Japanese sedentary kneeling), as shown in the Fig.1. The test subjects were ten healthy male, and the average height was 1.71[m], weight was 66.1[kgf] and age was 21.5[years]. The thigh-calf contact force and its acting point were measured by settling the pressure distribution sensor sheet between thigh and calf.

Results were normalized by body weight, and shown in Fig.1. The thigh-calf contact force was the largest at the heel-rise squatting posture (1.16BW), and the smallest at heel-contact squatting (0.60BW). The patellofemoral and the tibiofemoral joint forces were shown in the figure. Both forces were the largest at the heel-contact squatting, and were the smallest at the seiza posture. And it might be estimated that the thigh-calf contact force acted anterior when the ankle joint dorsiflexed, and the force was larger when the hip joint extended. The thigh-calf contact force might be decided by not only the knee joint angle but also the hip and ankle joints.

As a limitation of this study, we should mention about the effect of the neglected soft tissues. It could be considerable that the compressive internal force of the soft tissues behind a knee joint substance the tibiofemoral force, and then the real tibiofemoral force might be smaller than the calculated values in this study. Then, the tensile force of quadriceps also might be smaller, and then the patellofemoral joint force is also small.

Objectives

The aim of the current study was to analyse the effects of posterior cruciate ligament (PCL) deficiency on forces of the posterolateral corner structure and on tibiofemoral (TF) and patellofemoral (PF) contact force under dynamic-loading conditions.

Objectives

Malrotation of the femoral component can result in post-operative complications in total knee arthroplasty (TKA), including patellar maltracking. Therefore, we used computational simulation to investigate the influence of femoral malrotation on contact stresses on the polyethylene (PE) insert and on the patellar button as well as on the forces on the collateral ligaments.

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

The patellofemoral joint is an important source of symptoms in osteoarthritis of the knee. We have used a newly designed surgical model of patellar strengthening to induce osteoarthritis in BALB/c mice and to establish markers by investigating the relationship between osteoarthritis and synovial levels of matrix metalloproteinases (MMPs). Osteoarthritis was induced by using this microsurgical technique under direct vision without involving the cavity of the knee. Degeneration of cartilage was assessed by the Mankin score and synovial tissue was used to determine the mRNA expression levels of MMPs. Irrigation fluid from the knee was used to measure the concentrations of MMP-3 and MMP-9. Analysis of cartilage degeneration was correlated with the levels of expression of MMP.

After operation the patellofemoral joint showed evidence of mild osteoarthritis at eight weeks and further degenerative changes by 12 weeks. The level of synovial MMP-9 mRNA correlated with the Mankin score at eight weeks, but not at 12 weeks. The levels of MMP-2, MMP-3 and MMP-14 mRNA correlated with the Mankin score at 12 weeks. An increase in MMP-3 was observed from four weeks up to 16 weeks. MMP-9 was notably increased at eight weeks, but the concentration at 16 weeks had decreased to the level observed at four weeks.

Our observations suggest that MMP-2, MMP-3 and MMP-14 could be used as markers of the progression of osteoarthritic change.

We present a prospective review of the two-year functional outcome of 37 Avon patellofemoral joint replacements carried out in 29 patients with a mean age of 66 years (30 to 82) between October 2002 and March 2007. No patients were lost to follow-up. This is the first independent assessment of this prosthesis using both subjective and objective analysis of outcome. At two years the median Oxford knee score was 39 (interquartile range 32 to 44), the median American Knee Society objective score was 95 (interquartile range 90 to 100), the median American Knee Society functional score was 85 (interquartile range 60 to 100), and the median Melbourne Knee score was 28 (interquartile range 21 to 30). Two patients underwent further surgery. Only one patient reported an unsatisfactory outcome.

We conclude that the promising early results observed by the designing centre are reproducible and provide further support for the role of patellofemoral joint replacement.

Smoking is known to have an adverse effect on wound healing and musculoskeletal conditions. This case-controlled study looked at whether smoking has a deleterious effect in the outcome of autologous chondrocyte implantation for the treatment of full thickness chondral defects of the knee.

The mean Modified Cincinatti Knee score was statistically significantly lower in smokers (n = 48) than in non-smokers (n = 66) both before and after surgery (p < 0.05). Smokers experienced significantly less improvement in the knee score two years after surgery (p < 0.05). Graft failures were only seen in smokers (p = 0.016). There was a strong negative correlation between the number of cigarettes smoked and the outcome following surgery (Pearson’s correlation coefficient −0.65, p = 0.004).

These results suggest that patients who smoke have worse pre-operative function and obtain less benefit from this procedure than non-smokers. The counselling of patients undergoing autologous chondrocyte implantation should include smoking, not only as a general cardiopulmonary risk but also because poorer results can be expected in smokers following this procedure.

We have developed a new tensor for total knee replacements which is designed to assist with soft-tissue balancing throughout the full range of movement with a reduced patellofemoral joint. Using this tensor in 40 patients with osteoarthritis we compared the intra-operative joint gap in cruciate-retaining and posterior-stabilised total knee replacements at 0°, 10°, 45°, 90° and 135° of flexion, with the patella both everted and reduced.

While the measurement of the joint gap with a reduced patella in posterior-stabilised knees increased from extension to flexion, it remained constant for cruciate-retaining joints throughout a full range of movement. The joint gaps at deep knee flexion were significantly smaller for both types of prosthetic knee when the patellofemoral joint was reduced (p < 0.05).

Introduction: There has been an increasing use of orthotic knee braces in the management of knee injuries. To ensure the biomechanics of the knee are not adversely affected, it is important that orthotic knee braces accurately provide the desired angle of immobilisation. The objective of our study was to measure the actual knee flexion angles for a lockable orthotic knee brace, and measure the resulting knee flexion moment. Materials and methods: Eight healthy male volunteers participated in the study looking at six different types of knee immobilisation: locked in 0, 10, 20, 30 degrees of knee flexion, with the brace unlocked, and without a brace. Force and 3-dimensional motion data were collected using a single Kistler force plate and an eight-camera Qualisys ProReflex motion analysis system. Results: The kinematic knee flexion angles were significantly different when compared with the angles set at the orthotic knee brace for 0 degrees (p=0.001) and 10 degrees (p=0.011). The kinematic knee flexion angle when no brace was used was significantly different from the angle for the unlocked orthotic knee brace (p= 0.003). The knee flexion moment was directly proportional to the knee flexion angle. There was a statistically significant difference between the knee flexion moment for the six types of immobilisation (p< 0.001). Discussion: The knee flexion angles measured using the kinematic data did not always correspond with the angle set at the orthotic knee brace. These findings highlight inadequacies in the design of lockable orthotic knee braces, especially at low flexion angles of 0 and 10 degrees. The resulting higher actual knee flexion angles were associated with greater knee flexion moments and joint reaction forces at the tibiofemoral and patellofemoral joints. This can, at best result in increased energy expenditure and decreased agility, and at worse potentially augment injuries to the knee

We investigated the association between the radiological findings and the symptoms arising from the patellofemoral joint in advanced osteoarthritis (OA) of the knee. Four radiological features, joint space narrowing, osteophyte formation, translation of the patella and focal attrition were assessed in 151 consecutive osteoarthritic knees in 107 patients undergoing total knee replacement. The symptoms which were assessed included anterior knee pain which was scored, the ability to rise from a chair and climb stairs, and quadriceps weakness.

Among the radiological features, only patellar translation and obliteration of the joint space had a statistically significant association with anterior knee pain (odds ratio (OR) 4.85; 95% confidence interval (CI) 1.83 to 12.88 and OR 11.23; 95% CI 2.44 to 51.62) respectively. Patellar translation had a statistically significant association with difficulty in rising from a chair (OR 9.06; 95% CI 1.75 to 45.11). Other radiological features, including osteophytes, joint space narrowing, and focal attrition had no significant association.

Our study indicates that the radiological findings of patellar translation and significant loss of cartilage are predictive of patellofemoral symptoms and functional limitation in advanced OA of the knee.

The Oxford medial unicompartmental knee replacement was designed to reproduce normal mobility and forces in the knee, but its detailed effect on the patellofemoral joint has not been studied previously. We have examined the effect on patellofemoral mechanics of the knee by simultaneously measuring patellofemoral kinematics and forces in 11 cadaver knee specimens in a supine leg-extension rig. Comparison was made between the intact normal knee and sequential unicompartmental and total knee replacement. Following medial mobile-bearing unicompartmental replacement in 11 knees, patellofemoral kinematics and forces did not change significantly from those in the intact knee across any measured parameter. In contrast, following posterior cruciate ligament retaining total knee replacement in eight knees, there were significant changes in patellofemoral movement and forces.

The Oxford device appears to produce near-normal patellofemoral mechanics, which may partly explain the low incidence of complications with the extensor mechanism associated with clinical use.

Patellar maltracking after total knee arthroplasy (TKA) introduces complications such as anterior knee pain and patellar subluxation, generally due to prosthetic component malallignment in both tibiofemoral (TF) and patellofemoral joints. It is still debated if it is necessary to resurface the patella, which would better adapt the patellar articular surface to the prosthetic femoral troclea with a prosthesis, but also result in possible bone fractures. In this study, an in-vitro analysis is presented in order to identify differences between intact and TKA patellar tracking with and without patellar resurfacing and to show how much the latter is similar to intact knee patellar tracking. Three fresh-frozen amputated legs with knees free from anatomical defects and with intact joint capsule, collaterals and quadriceps tendon were analyzed using the Stryker knee navigation system (Kalamazoo, MI-USA). Landmark digitations were used to define anatomical frames for femur, tibia and patella. Manually driven TF flexions, from 0 to 140, were performed under conditions of no load and of 10 kg on the quadriceps, with intact knee and TKA with patella resurfaced and not. TF flex/extension, intra/extra rotation, ad/abduction were calculated according to a standard convention. Patellar flex/extension, medial/lateral tilt, rotation and shift were calculated according to a recently proposed articular convention. Since more repeatable, results relative to trials under 10 kg are reported. Intact knee: 4 abduction; considerable intra rotation (from 16 to 4), followed by continuous extra rotation starting at 30 TF flexion; linear increase in patellar flexion (from 20 to 110); initial medial patellar rotation (from 12 to 8), followed by medial rotation starting at 60 TF flexion; initial lateral patellar tilt (from 4 lateral to 4 medial), followed by medial tilt starting at 70 TF flexion; initial 6 mm lateral patellar shifts from 0 to 80 TF flexion, followed by 4 mm medial shift. TKA knee: small differences in ad/abduction between intact and TKA knees, both with and without resurfaced patella; slight initial extra rotation, followed by continuous intra rotation starting at 20 TF flexion; linear increase in the flexion of the patella, both resurfaced and not, close to the that of the intact knee; patellar rotation more lateral than in the intact knee; patellar tilt without resurfaced patella closer to the intact knee one; 6 mm lateral patellar shift, likely accounted for the surgical technique. Slightly more than TKA with resurfaced patella, TKA with non resurfaced patella flexes nearly like the intact knee. The closeness in values of patellar flexion and tilt represents a proof of the closeness in behavior of not resurfaced patella in TKA to the patella in the intact knee