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Introduction: Knee OA progression is related to medial knee contact forces, which can be altered by anatomical parameters of tibiofemoral alignment and contact point locations. There is limited and controversial literature on medial-lateral force distribution and the effect of anatomical parameters, especially in motor activities different from walking. We analyzed the effect of tibiofemoral alignment and contact point locations on knee contact forces, and the medial-lateral force distribution in knee OA subjects with varus malalignment during walking, stair ascending and stair descending.Methods: Fifty-one knee OA subjects with varus malalignment underwent weight-bearing radiographs and motion capture during walking, stair ascending and stair descending. We created a set of four musculoskeletal models per subject with increasing level of personalization, and calculated medial and lateral knee contact forces. To analyze the effect of the anatomical parameters, statistically-significant differences in knee contact forces among models were evaluated. Then, to analyze the force distribution, the medial-to-total contact force ratios were calculated from the fully-informed models. In addition, a multiple regression analysis was performed to evaluate correlations between forces and anatomical parameters.Results: The anatomical parameters significantly affected the knee contact forces. However, the contact points decreased medial forces and increased lateral forces and led to more marked variations compared to tibiofemoral alignment, which produced an opposite effect. The forces were less medially-distributed during stair negotiation, with medial-to-total ratios below 50% at force peaks. The anatomical parameters explained 30%–67% of the variability in the knee forces, where the medial contact points were the best predictors of medial contact forces.Discussion: Including personalized locations of contact points is crucial when analyzing knee contact forces in subjects with varus malalignment, and especially the medial contact points have a major effect on the forces rather than tibiofemoral alignment. Remarkably, the medial-lateral force distribution depends on the motor activity, where stair ascending and descending show increased lateral forces that lead to less medially-distributed loads compared to walking.

Altered tibiofemoral contact forces represent a risk factor for osteoarthritis onset and progression, making optimization of the knee force distribution a target of treatment strategies. Musculoskeletal model-based simulations are a state-of-the-art method to estimate joint contact forces, but they typically require laboratory-based input and skilled operators. To overcome these limitations, ambulatory methods, relying on inertial measurement units, have been proposed to estimated ground reaction forces and, consequently, knee contact forces out-of-the-lab. This study proposes the use of a full inertial-capture-based musculoskeletal modelling workflow with an underlying probabilistic principal component analysis model trained on 1787 gait cycles in patients with knee osteoarthritis. As validation, five patients with knee osteoarthritis were instrumented with 17 inertial measurement units and 76 opto-reflective markers. Participants performed multiple overground walking trials while motion and inertial capture methods were synchronously recorded. Moderate to strong correlations were found for the inertial capture-based knee contact forces compared to motion capture with root mean square error between 0.15 and 0.40 of body weight. The results show that our workflow can inform and potentially assist clinical practitioners to monitor knee joint loading in physical therapy sessions and eventually assess long-term therapeutic effects in a clinical context. [ABSTRACT FROM AUTHOR]

Altered tibiofemoral contact forces represent a risk factor for osteoarthritis onset and progression, making optimization of the knee force distribution a target of treatment strategies. Musculoskeletal model-based simulations are a state-of-the-art method to estimate joint contact forces, but they typically require laboratory-based input and skilled operators. To overcome these limitations, ambulatory methods, relying on inertial measurement units, have been proposed to estimated ground reaction forces and, consequently, knee contact forces out-of-the-lab. This study proposes the use of a full inertial-capture-based musculoskeletal modelling workflow with an underlying probabilistic principal component analysis model trained on 1787 gait cycles in patients with knee osteoarthritis. As validation, five patients with knee osteoarthritis were instrumented with 17 inertial measurement units and 76 opto-reflective markers. Participants performed multiple overground walking trials while motion and inertial capture methods were synchronously recorded. Moderate to strong correlations were found for the inertial capture-based knee contact forces compared to motion capture with root mean square error between 0.15 and 0.40 of body weight. The results show that our workflow can inform and potentially assist clinical practitioners to monitor knee joint loading in physical therapy sessions and eventually assess long-term therapeutic effects in a clinical context.

Musculoskeletal modeling is an important tool to estimate knee loads. In these models, anatomical muscles are frequently sub-divided to account for wide origin/insertion areas. The specific sub-division has been shown to affect some muscle recruitment criteria and it has been suggested that normalization factors should be incorporated into models. The primary aim of this study was to investigate the effect of different muscle normalization factors in the muscle recruitment criterion and polynomial order on the estimated muscle and total, medial and lateral knee contact forces during gait. These were evaluated on three different musculoskeletal models with increasing levels of patient-specificity and knee joint model complexity for one subject from the Grand Challenge data set and evaluated against measured forces. The results showed that the introduction of the muscle normalization factors affected the estimated forces and that this effect was most pronounced when a polynomial of order two was applied. Additionally, mainly the second contact force peak was affected. Secondary investigations revealed that the predicted forces can vary substantially as a function of the knee flexor and extensor muscle strength with over one body weight difference in predicted total compressive force between 100% and 40% of the strength. Additionally, the predicted second peak during gait was found to be sensitive to the position of the pelvic skin marker positions in the model. These results imply that caution should be taken when a normalization factor is introduced to account for sub-divided muscles especially for second-order recruitment criteria.

Most of musculoskeletal models (MSKM) estimate the tibiofemoral joint reaction load at a single point or do not support large lower-limb ranges. This study aimed to adapt a generic MSKM that allows large knee and hip flexions to compute medial and lateral tibiofemoral contact forces (TFCF) during gait and squat tasks. The updated model includes medial and lateral knee compartment geometries that allow computing the vertical TFCF. The updated MSKM does not affect kinematics and kinetics outputs in both of the tasks, and the sum of the medial and lateral TFCF was equivalent to the net TFCF of the original MSKM. [ABSTRACT FROM AUTHOR]

Musculoskeletal modeling is an important tool to estimate knee loads. In these models, anatomical muscles are frequently sub-divided to account for wide origin/insertion areas. The specific sub-division has been shown to affect some muscle recruitment criteria and it has been suggested that normalization factors should be incorporated into models. The primary aim of this study was to investigate the effect of different muscle normalization factors in the muscle recruitment criterion and polynomial order on the estimated muscle and total, medial and lateral knee contact forces during gait. These were evaluated on three different musculoskeletal models with increasing levels of patient-specificity and knee joint model complexity for one subject from the Grand Challenge data set and evaluated against measured forces. The results showed that the introduction of the muscle normalization factors affected the estimated forces and that this effect was most pronounced when a polynomial of order two was applied. Additionally, mainly the second contact force peak was affected. Secondary investigations revealed that the predicted forces can vary substantially as a function of the knee flexor and extensor muscle strength with over one body weight difference in predicted total compressive force between 100% and 40% of the strength. Additionally, the predicted second peak during gait was found to be sensitive to the position of the pelvic skin marker positions in the model. These results imply that caution should be taken when a normalization factor is introduced to account for sub-divided muscles especially for second-order recruitment criteria. [ABSTRACT FROM AUTHOR]

Introduction: Knee OA progression is related to medial knee contact forces, which can be altered by anatomical parameters of tibiofemoral alignment and contact point locations. There is limited and controversial literature on medial-lateral force distribution and the effect of anatomical parameters, especially in motor activities different from walking. We analyzed the effect of tibiofemoral alignment and contact point locations on knee contact forces, and the medial-lateral force distribution in knee OA subjects with varus malalignment during walking, stair ascending and stair descending. Methods: Fifty-one knee OA subjects with varus malalignment underwent weight-bearing radiographs and motion capture during walking, stair ascending and stair descending. We created a set of four musculoskeletal models per subject with increasing level of personalization, and calculated medial and lateral knee contact forces. To analyze the effect of the anatomical parameters, statistically-significant differences in knee contact forces among models were evaluated. Then, to analyze the force distribution, the medial-to-total contact force ratios were calculated from the fully-informed models. In addition, a multiple regression analysis was performed to evaluate correlations between forces and anatomical parameters. Results: The anatomical parameters significantly affected the knee contact forces. However, the contact points decreased medial forces and increased lateral forces and led to more marked variations compared to tibiofemoral alignment, which produced an opposite effect. The forces were less medially-distributed during stair negotiation, with medial-to-total ratios below 50% at force peaks. The anatomical parameters explained 30%-67% of the variability in the knee forces, where the medial contact points were the best predictors of medial contact forces. Discussion: Including personalized locations of contact points is crucial when analyzing knee contact forces in subjects with varus malalignment, and especially the medial contact points have a major effect on the forces rather than tibiofemoral alignment. Remarkably, the medial-lateral force distribution depends on the motor activity, where stair ascending and descending show increased lateral forces that lead to less medially-distributed loads compared to walking., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Valente, Grenno, Dal Fabbro, Zaffagnini and Taddei.)

Though walking impairments are prevalent in society, clinical treatments are often ineffective at restoring lost function. For this reason, researchers have begun to explore the use of patient-specific computational walking models to develop more effective treatments. However, the accuracy with which models can predict interna! body forces in muscles and across joints depends on how well relevant model parameter values can be calibrated for the patient. This study investigated how knowledge of internal knee contact forces affects calibration of neuromusculoskeletal model parameter values and subsequent prediction of internal knee contact and leg muscle forces during walking. Model calibration was performed using a novel two-level optimization procedure applied to six normal walking trials from the Fourth Grand Challenge Competition to Predict In Vivo Knee Loads. The outer-level optimization adjusted time-invariant modeI parameter values to minimize passive muscle forces, reserve actuator moments, and model parameter value changes with (Approach A) and without (Approach B) tracking of experimental knee contact forces. Using the current guess for model parameter values but no knee contact force information, the inner-level optimization predicted time-varying muscle activations that were close to experimental muscle synergy patterns and consistent with the experimental inverse dynamic loads (both approaches). For all the six gait trials, Approach A predicted knee contact forces with high accuracy for both compartments (average correlation coefficient r = 0.99 and root mean square error (RMSE) = 52.6N medial; average r = 0.95 and RMSE = 56.6N lateral). In contrast, Approach B overpredicted contact force magnitude for both compartments (average RMSE=323 N medial and 348N lateral) and poorly matched contact force shape for the lateral compartment (average r = 0.90 medial and -0.10 lateral). Approach B had statistically higher lateral muscle forces and lateral optimal muscle fiber lengths but lower medial, central, and lateral normalized muscle fiber lengths compared to Approach A. These findings suggest that poorly calibrated model parameter values may be a major factor limiting the ability of neuromusculoskeletal models to predict knee contact and leg muscle forces accurately for walking. [ABSTRACT FROM AUTHOR]

Purpose: Total knee arthroplasty (TKA) is a very successful surgical procedure. However, implant failures and patient dissatisfaction still persist. Sometimes surgeons are not able to understand and explain these negative performances because the patient's medical images "look good", but the patient "feels bad". Apart from radiograph imaging and clinical outcome scores, conventionally used follow-up methods are mainly based on the analysis of knee kinematics. However, even if kinematics remains close to the "normal" range of motion, the patient may still complain about pain and functional limitations. To provide more insight into this paradox, a better quantitative understanding of TKA mechanics must be developed. For this purpose, improved techniques for clinical follow-up, combining kinetics and kinematics analysis, should be introduced to help surgeons to assess and understand TKA performance.Methods: An analysis on four TKA designs was performed, and the changes in kinematics and in kinetics induced by several implant configurations (simulating implant malalignment and different knee anatomy) were compared. More specifically, analysed tibio-femoral and patello-femoral contact forces and tibio-femoral kinematics were analysed during a squat task up to 120°.Results: The results from this study show that contact forces (with changes up to 67 %) are more heavily affected by malconfigurations than kinematics, for which maximum deviations are of the order of 5 mm or 5°, similar to the simulated surgical errors. The results present a similar trend for the different designs.Conclusions: The results confirm the hypothesis that kinematics is not the only and also not the most relevant parameter to predict or explain knee function after TKA. In the future, techniques to analyse knee kinetics should be integrated in the clinical follow-up. [ABSTRACT FROM AUTHOR]

Objective: This study calculated knee contact forces (KCF) and its relations with knee external knee adduction moments (KAM) and/or flexion moments (KFM) during the stance phase of gait in patients with early osteoarthritis (OA), classified based on early joint degeneration on Magnetic Resonance Imaging (MRI). We aimed at assessing if altered KCF are already present in early structural degeneration.Design: Three-dimensional motion and ground reaction force data in 59 subjects with medial compartment knee OA (N=23 established OA, N=16 early OA, N=20 controls) were used as input for a musculoskeletal model. KAM and KFM, and KCF were estimated using OpenSim software.Results: No significant differences were found between controls and subjects with early OA. In early OA patients, KAM significantly explained 69% of the variance associated with the first peaks KCF but only KFM contributed to the second peaks KCF. The multiple correlation, combining KAM and KFM, showed to be higher. However, only 20% of the variance of second peak KCF was explained by both moments in established OA.Conclusion: KCF are not increased in patients with early OA, suggesting that knee joint overload is more a consequence of further joint degeneration in more advanced stages of OA. Additionally, our results clearly show that KAM is not sufficient to predict joint loading at the end of the stance, where KFM contributes substantially to the loading, especially in early OA. [ABSTRACT FROM AUTHOR]

ABSTRACT We determined if slow, uphill walking (0.75 m/s, 6°) reduced tibiofemoral (TF) loading compared to faster, level walking (1.50 m/s) in obese and nonobese adults. We collected kinematic, kinetic, and electromyographic data as 9 moderately obese and 10 nonobese participants walked on a dual-belt instrumented treadmill. We used OpenSim to scale a musculoskeletal model and calculate joint kinematics, kinetics, muscle forces, and TF forces. Compressive TF forces were greater in the obese adults during both speed/grade combinations. During level walking, obese participants walked with a straighter leg than nonobese participants, resulting in early stance vasti muscle forces that were similar in the obese and nonobese participants. Early stance peak compressive TF forces were reduced by 23% in obese (2,352 to 1,811 N) and 35% in nonobese (1,994 to 1,303 N) individuals during slow, uphill walking compared to brisk level walking. Late stance peak TF forces were similar across speeds/grades, but were greater in obese (∼2,900 N) compared to nonobese (∼1,700 N) individuals. Smaller early stance TF loads and loading rates suggest that slow, uphill walking may be appropriate exercise for obese individuals at risk for musculoskeletal pathology or pain. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:324-330, 2014. [ABSTRACT FROM AUTHOR]

This study introduces a framework for co-simulating neuromuscular dynamics and knee joint mechanics during gait. A knee model was developed that included 17 ligament bundles and a representation of the distributed contact between a femoral component and tibial insert surface. The knee was incorporated into a forward dynamics musculoskeletal model of the lower extremity. A computed muscle control algorithm was then used to modulate the muscle excitations to drive the model to closely track measured hip, knee, and ankle angle trajectories of a subject walking overground with an instrumented knee replacement. The resulting simulations predicted the muscle forces, ligament forces, secondary knee kinematics, and tibiofemoral contact loads. Model-predicted tibiofemoral contact forces were of comparable magnitudes to experimental measurements, with peak medial (1.95 body weight (BW)) and total (2.76 BW) contact forces within 4-17% of measured values. Average root-mean-square errors over a gait cycle were 0.26, 0.42, and 0.51 BW for the medial, lateral, and total contact forces, respectively. The model was subsequently used to predict variations in joint contact pressure that could arise by altering the frontal plane joint alignment. Small variations (±2 deg) in the alignment of the femoral component and tibial insert did not substantially affect the location of contact pressure, but did alter the medio-lateral distribution of load and internal tibia rotation in swing. Thus, the computational framework can be used to virtually assess the coupled influence of both physiological and design factors on in vivo joint mechanics and performance. [ABSTRACT FROM AUTHOR]

Medial knee loading during stair negotiation in individuals with medial knee osteoarthritis, has only been reported in terms of joint moments, which may underestimate the knee loading. This study assessed knee contact forces (KCF) and contact pressures during different stair negotiation strategies. Motion analysis was performed in five individuals with medial knee osteoarthritis (52.8±11.0 years) and eight healthy subjects (51.0±13.4 years) while ascending and descending a staircase. KCF and contact pressures were calculated using a multi-body knee model while performing step-over-step at controlled and self-selected speed, and step-by-step strategies. At controlled speed, individuals with osteoarthritis showed decreased peak KCF during stair ascent but not during stair descent. Osteoarthritis patients showed higher trunk rotations in frontal and sagittal planes than controls. At lower self-selected speed, patients also presented reduced medial KCF during stair descent. While performing step-by-step, medial contact pressures decreased in osteoarthritis patients during stair descent. Osteoarthritis patients reduced their speed and increased trunk flexion and lean angles to reduce KCF during stair ascent. These trunk changes were less safe during stair descent where a reduced speed was more effective. Individuals should be recommended to use step-over-step during stair ascent and step-by-step during stair descent to reduce medial KCF.

Background: Prevention of knee osteoarthritis (OA) following anterior cruciate ligament (ACL) rupture and reconstruction is vital. Risk of postreconstruction knee OA is markedly increased by concurrent meniscal injury. It is unclear whether reconstruction results in normal relationships between tibiofemoral contact forces and cartilage morphology and whether meniscal injury modulates these relationships., Hypotheses: Since patients with isolated reconstructions (ie, without meniscal injury) are at lower risk for knee OA, we predicted that relationships between tibiofemoral contact forces and cartilage morphology would be similar to those of normal, healthy knees 2 to 3 years postreconstruction. In knees with meniscal injuries, these relationships would be similar to those reported in patients with knee OA, reflecting early degenerative changes., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Three groups were examined: (1) 62 patients who received single-bundle hamstring reconstruction with an intact, uninjured meniscus (mean age, 29.8 ± 6.4 years; mean weight, 74.9 ± 13.3 kg); (2) 38 patients with similar reconstruction with additional meniscal injury (ie, tear, repair) or partial resection (mean age, 30.6 ± 6.6 years; mean weight, 83.3 ± 14.3 kg); and (3) 30 ligament-normal, healthy individuals (mean age, 28.3 ± 5.2 years; mean weight, 74.9 ± 14.9 kg) serving as controls. All patients underwent magnetic resonance imaging to measure the medial and lateral tibial articular cartilage morphology (volumes and thicknesses). An electromyography-driven neuromusculoskeletal model determined medial and lateral tibiofemoral contact forces during walking. General linear models were used to assess relationships between tibiofemoral contact forces and cartilage morphology., Results: In control knees, cartilage was thicker compared with that of isolated and meniscal-injured ACL-reconstructed knees, while greater contact forces were related to both greater tibial cartilage volumes (medial: R 2 = 0.43, β = 0.62, P = .000; lateral: R 2 = 0.19, β = 0.46, P = .03) and medial thicknesses ( R 2 = 0.24, β = 0.48, P = .01). In the overall group of ACL-reconstructed knees, greater contact forces were related to greater lateral cartilage volumes ( R 2 = 0.08, β = 0.28, P = .01). In ACL-reconstructed knees with lateral meniscal injury, greater lateral contact forces were related to greater lateral cartilage volumes ( R 2 = 0.41, β = 0.64, P = .001) and thicknesses ( R 2 = 0.20, β = 0.46, P = .04)., Conclusion: At 2 to 3 years postsurgery, ACL-reconstructed knees had thinner cartilage compared with healthy knees, and there were no positive relationships between medial contact forces and cartilage morphology. In lateral meniscal-injured reconstructed knees, greater contact forces were related to greater lateral cartilage volumes and thicknesses, although it was unclear whether this was an adaptive response or associated with degeneration. Future clinical studies may seek to establish whether cartilage morphology can be modified through rehabilitation programs targeting contact forces directly in addition to the current rehabilitation foci of restoring passive and dynamic knee range of motion, knee strength, and functional performance., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Funding support for this research was received from the Australian National Health and Medical Research Council to A.L.B., D.G.L., K.L.B., and F.M.C. (grant No. 628850), as well as the National Health and Medical Research Council R.D. Wright Biomedical Fellowship and Principal Research Fellowship to authors A.L.B. and K.L.B., respectively. The work of author L.M. was supported by the UK Engineering and Physical Sciences Research Council through grant EP/K03877X/1. D.J.S. received a PhD scholarship and stipend awards from Griffith University, as well as a PhD matching dissertation grant from the International Society of Biomechanics. T.W. is a lecturer for Smith & Nephew and Arthrex, receives research support from Smith & Nephew, and is a consultant for Medacta. C.J.V. receives funding from Smith & Nephew.