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The biomechanics of the knee joint provide an important basis for the rationale in the design and selection of appropriate total knee arthroplasty. This article examines knee biomechanics in terms of patient function, prosthesis design, cruciate ligament retention, alignment, and fixation of the tibial component. While design and surgical technique for total knee replacement progress, a better understanding of the characteristics of joint loading, stress distribution, and the biologic response of bone to stress will provide the potential to improve both function and implant longevity.

We observed the gait patterns, including time and distance measurements and ground reaction forces, of fifty-one normal children. Thirty-three children were retested once at one, three, six, nine, or twelve months, over a two-year period, for a total of eighty-four gait observations. Time and distance measurements and foot-ground reaction force measurements were found to be dependent on walking speed and the age of the child. An increase in height with age was found to be the major factor in determining the changes in time and distance measurements with age. For example, we found that average stride length was 76 per cent of the child's height at a walking speed of 1.04 meters per second regardless of the child's age. In contrast, the three components of foot-ground reaction force (vertical, lateral, and forward directions) were observed to vary with age up to five years even when normalized. After the age of five years an adult pattern of ground reaction force emerged. In addition, we found that walking patterns of children who were more than found years old did not vary when retested within a three-month period. However, for children less than four years old, measurements were found to change due to growth during the three-month period to retesting. Similar changes due to growth were found in children more than four years old who were tested at intervals more than three months apart. This important finding may be clinically useful in the study of the effects of treatment.

Loading tests showed wide stem-thin cement envelope systems in valgus orientation placed with distal plug to be significantly more stable at higher loads. Narrow stem-thick cement envelope systems in varus without plug were unstable within a marginal factor of safety for cyclic loading. Four cement failures occurred within the thin stem-thick cement system on the upper lateral aspect of the prosthesis cement envelope.

Retention of the posterior cruciate ligament in total knee arthroplasty is discussed in biomechanical and clinical terms and the implications for design, kinematics, function, and prosthesis longevity considered. The specific roles of passive range of motion, femoral rollback, stresses on the implant-bone-prosthesis cement system, and wear are examined. The authors argue that the posterior cruciate ligament improves passive range of motion, the mechanical efficiency of the knee musculature and thus improved stairclimbing efficiency, reduces stress at the cement-bone-implant interfaces, and has little or no impact on the polyethylene wear problems.

The mechanics of the lower limb were analyzed in young, adult normal subjects when rising from a seated position. Limb mechanics were described in terms of flexion-extension motion and moments at the hip, knee and ankle while rising from four seat heights corresponding to 65, 80, 100, and 115% of the subject's knee joint height. The results indicate that the maximum moment tending to flex the hip joint was higher than that occurring at the knee or ankle. The magnitude of the maximum flexion moment at the hip was not substantially influenced by chair height, changing by less than 12% between the highest and lowest chair heights. Conversely, the maximum knee flexion moments were found to be highly dependent on chair height and nearly doubled from the highest to the lowest position. The magnitude of the moments at the ankle did not change with chair height and were significantly lower than the magnitude of the moments found during normal walking. The magnitude of motion and moments at the hip were greater during chair-rising than during stair-climbing or walking. The range of motion required at the knee for the lower chair heights was also greater than was reported during stair-climbing studies. Thus, the combination of moments in joint angles during chair-rising are unique among common activities of daily living and should be considered in chair selection as well as in the guidelines for prosthetic devices.

A three-dimensional stochastic mathematical muscle model of the knee joint has been developed and applied to a study in which the influence of both mechanical and physiological factors were examined in relation to the prediction of muscular forces about the joint. The model includes a representation of the proximal portion of the tibia and distal portion of the femur along with a mathematical expression of the patellar mechanism and 13 muscles crossing the knee joint. The model accounts for the rolling and gliding movement of the tibial-femoral articulation. The computational technique involves equilibrating three components of external moments at the knee joint to the internal moments generated by muscular forces and soft tissue. The variables contained in the moment equilibrium equation are randomly chosen based on the choice of the tibial-femoral contact point. The randomness of the variables, reflected in the final solution, defines a stochastic process in the context of the present model. Studies with the model indicated that a very important mechanical aspect of the model was the capability to simulate the moving contact point between the tibia and femur. The moving contact point increased the mechanical advantage of the quadriceps muscles by 50%, which corresponded to in vivo EMG measurements. Muscle force predictions during normal gait have shown the capability of the model to determine the presence of synergistic and antagonistic muscle action.

The authors quantitatively evaluated the relationship between component placement, limb alignment, and function following unicompartmental knee replacement surgery. It was found that anatomic alignment, prosthetic positioning, and prosthetic design influence the patients' ability to walk and climb stairs. There was wide variation in the placement of the tibial and femoral component among patients. The placement of the femoral component corresponded directly to function during stairclimbing and level walking. Anterior malpositioning of the femoral component resulted in reduced ability to climb stairs. The tibial component position varied primarily in varus-valgus position. Varus-valgus alignment in the frontal plane correlated directly with the magnitude of the adduction moment during level walking. A varus alignment produced a twofold increase in the magnitude of the adduction moment at the knee during walking. Given the potential advantages of the unicompartmental knee, improved precision in component placement should improve the long-term results of hemiarthroplasty knee surgery.

In this study digital images of bone cross-sections obtained by computed tomography were analyzed with an automated outlining method. It was shown that unbiased cross-sectional geometric measurements of cortical bone could be obtained if the periosteal and endosteal surfaces were defined at separate thresholds. Use of different threshold levels for these two surfaces resulted in errors of 2.6% for periosteal diameters, 7.4% for endosteal diameters and 7.3% for cortical area. If incorrect thresholds were used, cortical thickness measurements can have errors as high as 30%. In addition, simulated variation in medullary fat content did not affect measurement of medullary dimensions.

A three-dimensional mathematical model of the ligamentous knee joint has been developed and applied to studies of the mechanical response of the knee joint. The model includes a representation of the bony portion of the knee including the proximal tibia, distal femur, soft tissue structure and the contacting surfaces of the medial and lateral condyles. The bony portions of the model are represented by rigid bodies while the soft tissue structures are represented by spring and beam type elements. The model employs the direct stiffness approach from structural mechanics and uses an incremental linearization procedure for the geometric and material non-linearities. Studies with the model indicate that the geometric type non-linearities contribute to the overall non-linear response of the knee joint. It was also found that the load-displacement response of the knee is highly dependent on constraints to coupled degrees of freedom. This finding may be an important consideration when interpreting the results of standard laxity tests at the knee, which by their nature may impose constraints to motion.

Twenty-six knee arthroplastics in 22 subjects were studied clinically and in a gait laboratory before and on one or more occasions after surgery. The purpose was to identify changes in gait characteristics and relate them to changes in the clinical situation of the patients. The gait patterns of the patients changed following surgery mainly with respect to their time-distance characteristics; stride length, cadence, time of swing, and time of support. Positive correlations were noted between these gait changes and the patient's pain, his limp, and his walking distance. It is concluded that the information obtained in sophisticated gait laboratory is of limited value to the surgeon in his clinical assessment.

Several factors influencing the myoelectric activity of muscles surrounding the knee joint were studied using fine-wire monopolar electrodes. The muscles studied included the vastus lateralis, vastus intermedius, rectus femoris, vastus medialis, gracilis, sartorius, biceps femoris, semimembranosus, semitendinosus, tensor fasciae latae, medial head of the gastrocnemius, and lateral head of the gastrocnemius. Muscle activity was measured in response to unidirectional loads tending to flex and extend the knee, and to combined loads of flexion-adduction, flexion-abduction, extension-adduction, and extension-abduction. Results indicate that the individual muscle responses are dependent upon the direction, magnitude, and combination of external moments, as well as on the flexion angle of the knee joint. Muscle response appeared to be influenced by certain intrinsic mechanical characteristics of the knee joint that tend to change the moment arms of the muscles as the knee moves. For example, the substantial changes in quadriceps myoelectric activity with knee flexion, with constant load applied, can be related to the movement of the tibial-femoral contact changing the lever arm of the quadriceps mechanism. This study indicates that the mechanics of the knee joint must be taken into consideration while attempting to interpret or predict the load response of muscles crossing the knee joint.

One hundred twenty-two total knee arthroplasties were performed with porous ingrowth fixation of the patellar component between February 1984 and February 1987. Twelve subsequently have experienced fatigue fracture of the patellar component at the peg-plate junction. All fractured patellar components demonstrated excellent ingrowth and fixation of the porous titanium fiber mesh-peg surfaces with no ingrowth into the porous plate underlying the polyethylene patellar surface. While the initial group of 122 arthroplasties was only slightly greater than one-third male, the preponderance of patellar fractures was in males (ten of 12). Patients with patellar component failure were on average younger and heavier and had a greater range of knee motion than the index group. The average time from implantation to recognition of fracture was 24 months. Biomechanical analysis of the force system about a domed patella demonstrated that loading of the patellofemoral joint results in eccentric loading of the dome surface. Peg fixation not accompanied by fixation of the overlying plate allows these high eccentric forces to load the peg-plate junction in shear with consequent fatigue at the peg-plate junction. These results indicate that the shear forces are sufficiently high to warrant caution in the use of peg-plate systems in which peg ingrowth without plate ingrowth occurs.(ABSTRACT TRUNCATED AT 250 WORDS)

A relationship between dynamic flexion-extension motion ranges during walking and the magnitude of flexion and extension moments was analyzed for 38 ambulatory children with spastic cerebral palsy. Moments tending to flex the hip and the knee were more than a factor of two times greater than those occurring during normal gait. At the knee, the magnitude of the moments was related to the amount of flexion deformity, whereas at the hip there was no correlation between moment magnitude and extension motion range. The maximum dorsiflexion and plantarflexion ankle moments were of less than normal value in all deformity groupings. An understanding of the longterm influence of these abnormal moments on the terms of the progression or stabilization of the dynamic deformities during walking is an important step toward improving our understanding of and, potentially, our ability to treat patients with cerebral palsy.

The ability of the quadriceps muscles to extend the knee was studied relative to the intrinsic mechanical features of the knee joint. The quadriceps mechanical efficiency changed by nearly 50% between 0 and 90 degrees of knee flexion. The peak efficiency occurred at approximately 20 degrees of knee flexion. The mechanical efficiency of the quadriceps was dependent on the movement of the net anteroposterior (AP) tibiofemoral contact center of pressure, the change in patellar ligament angle, and the change in the quadriceps-to-ligament force transfer ratio. The average net AP tibiofemoral contact center of pressure moved posteriorly on the tibial plateau as the knee flexed from 0 to 90 degrees. The excision of both cruciate ligaments reversed the posteriorly directed movement of the net AP tibiofemoral contact center of pressure at flexion angles from 60 to 90 degrees, resulting in a reduction in extension moment.

Flexion-extension moments occurring at the L5-S1 level of the spine were calculated when subjects lifted a box weighing from 50 to 250 N. Lifting was performed at normal and fast speed, and the lifts were performed using a freestyle and a leglifting technique. The peak moment increased linearly with increasing load. The moment/load relationship was significantly influenced by lifting speed, and a higher moment occurred at each load level when lifting fast. Lifting speed was reduced when the external load was increased, particularly when the load was 150 N and higher. Moments when lifting using the leglifting technique were lower than when lifting freestyle.

The bone-cement interface is an area of concern in the long-term fixation of endoprostheses. The effect of early weight-bearing on the interface has been discussed as an important parameter influencing the characteristics of the interface. In this study, a total hip arthroplasty was performed in two groups of six dogs each. One group was allowed immediate weight-bearing, while in the other, a knee disarticulation amputation was done to prevent weight-bearing. Three animals of each group were killed at three months and three of each group at six months, and a histological study of the interface was done. No morphologic difference was observed between weight-bearing and nonweight-bearing animals in the interface area. Endosteal bone remodeling occurred regardless of weight-bearing stresses. A fibrous membrane was found between the cement and the endosteal surface of the femur, and membrane thickness was similar in all animals. The membrane between the cement and acetabular bone, however, was consistently thicker. Quantitative studies revealed increased femoral cortical bone resorption in the nonweight-bearing animals.

The motions, forces, and moments at the major joints of the lower limbs of ten men ascending and descending stairs were analyzed using an optoelectronic system, a force-plate, and electromyography. The mean values for the maximum sagittalplane motions of the hip, knee, and ankle were 42, 88, and 27 degrees, respectively. The mean maximum net flexion-extension moments were: at the hip, 123.9 newton-meters going up and 112.5 newton-meters going down stairs; at the knee, 57.1 newton-meters going up and 146.6 newton-meters going down stairs; and at the ankle, 137.2 newton-meters going up and 107.5 newton-meters going down stairs. When going up and down stairs large moments are present about weight-bearing joints, but descending movements produce the largest moments. The magnitudes of these moments are considerably higher than those produced during level walking.