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Journal of Biomechanics 40 (2007) S11S17 www.elsevier.com/locate/jbiomech www.JBiomech.com

In vivo knee moments and shear after total knee arthroplasty

Darryl D. DLimaa,b,, Shantanu Patila, Nikolai Steklova, Shu Chienb, Clifford W. Colwell Jr.a
a

Shiley Center for Orthopaedic Research and Education at Scripps Clinic, 11025 N. Torrey Pines Road, Suite 140, La Jolla, CA 92037, USA b Department of Bioengineering, University of California, San Diego, CA, USA

Abstract Tibiofemoral loading is very important in cartilage degeneration as well as in component survivorship after total knee arthroplasty. We have previously reported the axial knee forces in vivo. In this study, a second-generation force-sensing device that measured all six components of tibial forces was implanted in a 74-kg, 83-year-old male. Video motion analysis, ground reaction forces, and knee forces were measured during walking, stair climbing, chair-rise, and squat activities. Peak total force was 2.3 times body weight (BW) during walking, 2.5 BW during chair rise, 3.0 BW during stair climbing, and 2.1 BW during squatting. Peak anterior shear force at the tibial tray was 0.30 BW during walking, 0.17 BW during chair rise, 0.26 BW during stair climbing, and 0.15 BW during squatting. Peak exion moment at the tray was 1.9% BW Ht (percentage of body weight multiplied by height) for chair-rise activity and 1.7% BW Ht for squat activity. Peak adduction moment at the tray was 1.1% BW Ht during chair-rise, 1.3% BW Ht during squatting. External knee exion and adduction moments were substantially greater than exion and adduction moments at the tray. The axial component of forces predominated especially during the stance phase of walking. Shear forces and moments at the tray were very modest compared to total knee forces. These ndings indicate that the soft tissues around the knee absorbed most of the external shear forces. Our results highlight the importance of direct measurements of knee forces. r 2007 Elsevier Ltd. All rights reserved.
Keywords: Total knee arthroplasty; Knee forces; In vivo; Knee sheer; Knee moments

1. Introduction The biomechanics of the knee joint are important in analyzing activities of daily living that primarily involve the lower limbs. The loading of the knee joint correlates with the health of the cartilage, and abnormal loading is associated with the development of cartilage degeneration and osteoarthritis (OA). Patient body weight commonly correlates with OA (Felson et al., 1997). It has been hypothesized that repeated impulse loading leads to the stiffening of bone with concomitant increased stresses at the cartilage (Messier, 1994). Subjects with knee OA walk with a greater than normal peak external knee adduction moment (Baliunas et al., 2002). Another hypothesis is that
Corresponding author. Shiley Center for Orthopaedic Research and Education at Scripps Clinic, 11025 N. Torrey Pines Road, Suite 140, La Jolla, CA 92037, USA. Tel.: +1 858 332 0166; fax: +1 858 332 0140. E-mail address: ddlima@scripps.edu (D.D. DLima).

quadriceps fatigue results in reduced shock absorption of knee forces and is the reason for the higher risk of OA in obese women (Syed and Davis, 2000). Regardless of the precise mechanism, it is commonly believed that knee biomechanics play a major role in the etiology of OA. Total knee arthroplasty (TKA) is a widely accepted treatment for end-stage arthritis. Knee forces have been shown to affect arthroplasty component survivorship, wear of articular-bearing surfaces, and integrity of the bone implant interface. Excessive knee forces have been implicated in the breakdown of the cement interface or in the collapse of underlying bone. Knee forces along with component design also determine the contact stresses on the bearing surfaces. Contact stresses have been correlated with the magnitude and distribution of wear. Additionally, high-exion knee designs are being introduced to permit greater knee exion. These components will allow patients to engage in common activities that involve deep knee exion such as kneeling, squatting, and sitting cross-legged.

0021-9290/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbiomech.2007.03.004

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Studies analyzing these activities have estimated high knee forces (Nagura et al., 2002; Thambyah et al., 2005; Escamilla, 2001). Therefore, existing knee prosthetic designs may have to be modied to withstand increased loading. Almost all studies relating to knee forces have involved either in vitro measurements (Ellis et al., 1984; Singerman et al., 1999; Kaufman et al., 1996) or estimates using mathematical models (Seireg and Arvikar, 1975; Morrison, 1970; Taylor et al., 2004; Lu et al., 1998). We previously reported the rst direct measurement of knee forces in vivo after TKA (DLima et al., 2005, 2006). The tibial component used in that study was instrumented with four load cells that measured the axial components of load on the four quadrants of the tibial tray. This instrumented implant measured the total axial force and the location of the center of pressure. However, shear and moments, which are also important components of knee forces, could not be measured in that design. In collaboration with Zimmer, Inc. (Warsaw, IN), we developed a second-generation, force-sensing device that

measured all components of tibial forces (Kirking et al., 2005). The stem of this design was instrumented with strain gauges that measured all six components of forces. In this study, we report on the rst in vivo measurements of shear and moments in the knee after TKA.
2. Methods
A custom tibial component was manufactured by Zimmer, Inc., based on the Natural Knee II (NK-II) tibial tray design. The tray and locking mechanism were identical to the standard design for implantation with a standard insert. The stem was instrumented with strain gauges to measure three orthogonal forces and three moments. The stem also housed a microtransmitter, which performed analog-to-digital conversion, ltering, and multiplexing before transmitting data via a hermetic glass-feedthrough tantalum antenna. External coil induction was used to power the implant. Details of the implant design, strain gauges, microtransmitter, telemetry system, and accuracy have been previously reported (Kirking et al., 2005). Appropriate Institutional Review Board approval and patients consent were obtained before implantation in a 74-kg, 83-year-old male (Fig. 1a). A standard polyethylene insert (NK-II CR Congruent, Zimmer) and a posterior cruciate-retaining femoral component (NK-II CR, Zimmer)

Direction of Anterior Shear. Adduction Moment is positive about this axis

Direction of Lateral Shear. Flexion Moment is negative about this axis Direction of Vertical Compressive Force.

S M C

Fig. 1. (a) Postoperative radiograph showing the instrumented tibial prosthesis: S, hollow strain-gaged portion of the stem; M, location of microprocessor; C, internal coil; A, transmitting antenna. (b) The center of the right hand orthogonal coordinate system was located at the level of the top surface of the tray in line with the center of the cylindrical stem of the prosthesis. The forces and moments acting on the tray were recorded in the directions shown here.

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D.D. DLima et al. / Journal of Biomechanics 40 (2007) S11S17 were implanted using a standard anteromedial approach. The tibial bone cut was made at 901 to the long axis in the coronal plane (01 varus) and at 901 in the sagital plane (01 posterior slope). The distal femoral cut was made at 61 valgus to the anatomic axis of the femur. The posterior femoral cut was made at 31 external rotation with reference to the posterior surface of the posterior condyles. Intramedullary alignment was used for femoral and tibial bone preparation. The patella was resurfaced with a standard dome-shaped, all-polyethylene component. All components were cemented. The patient underwent routine postoperative rehabilitation as per a standard primary TKA. Three months after the surgery, knee kinematics, ground reaction forces, and tibial forces and moments were measured in a motion analysis laboratory (Center for Human Performance, Childrens Hospital, San Diego, CA). Knee kinematics were monitored using 6 Vicon cameras and infrared reective skin markers (Helen Hayes lower limb marker set) (Kadaba et al., 1989, 1990). Ground reaction forces were measured using three force plates (AMTI, Watertown, MA) mounted in the oor of the walkway. Knee kinematics and moments were computed using commercially available software (OrthoTrak, Motion Analysis Corp, Santa Rosa, CA). Data were collected synchronously for the following activities. S13 Walking was studied at a comfortable self-selected pace. Rising from a chair (sit-to-stand) and sitting down in a chair (stand-to-sit) activities were performed with the arms folded across the chest using a chair with a seat height of 44 cm (equal to the joint-to-oor distance of the patients knee). Stair climbing was conducted on stairs with a 17.8 cm (7 in) riser and with hand-rail support. Squatting was performed with both feet parallel to each other, up to knee exion angle that was within the patients tolerance ($801).

3. Results Forces are reported as multiples of body weight ( BW) and moments as a percentage of body weight multiplied by height (% BW Ht). The direction of forces and moments were computed in the coordinate system of the tibial tray (Fig. 1b), which was implanted at 901 to the intramedullary axis of the tibia in the coronal and the sagittal planes. For example, the shear generated at the tibial tray by the femoral component moving in the anterior direction was denoted as anterior shear. Similarly, the moment generated at the tibial tray by adduction of the knee was termed as adduction moment. The peak total tibial forces were between 2 and 3 BW for the activities studied (Fig. 2). The vertical component of force predominated in all activities (Figs. 36). For example, during walking, the magnitude of the axial component was on average 86% of the magnitude of the total force. During the stance phase of walking, the vertical component averaged 98% of the magnitude of the total force. Peak anteroposterior (AP) and mediolateral (ML) shear forces were substantially lower than the axial component for all the activities studied. Peak anterior shear force was 0.30 BW during walking, 0.17 BW during chair rise, 0.26 BW during stair climbing, and 0.15 BW during squatting. Overall AP shear was mainly directed anteriorly for all activities.

3 xBW

0 Walking Stair Climbing Chair Rise Squat

Fig. 2. Peak total tibial forces (mean of six cycles for each activity) measured during activities of daily living (error bars represent standard deviations).

Ground Reaction Force Total Force

Vertical Force Anterior Shear Lateral Shear Knee Flexion

60

30

-1

Stance

Swing

Fig. 3. Knee kinematics and forces during one representative walking cycle are shown. The ground reaction force was used to divide the walking cycle into stance and swing phases. The total force was almost entirely composed of the vertical component of force, especially during the stance phase. Peak anterior shear forces were small (0.3 BW). Mediolateral shear forces were also in the same range and were laterally directed during most of the stance phase and medially directed during most of the swing phase.

Knee Flexion (degrees)

xBW

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S14 D.D. DLima et al. / Journal of Biomechanics 40 (2007) S11S17
Total Force Vertical Force Anterior Shear

Lateral Shear Knee Flexion

90

2 60 xBW 1 30 0

-1

Swing

Stance

Fig. 4. Knee kinematics and forces measured during one representative stair-climbing cycle are shown. As for walking, the total force was almost entirely composed of the vertical component (the respective plots could not be visually differentiated). Peak anteroposterior shear forces were small (0.26 BW) and were mainly directed anteriorly. Mediolateral shear forces were laterally directed during most of the stance phase and medially directed during most of the swing phase.

Ground Reaction Force Total Force Vertical Force

Anterior Shear Lateral Shear

xBW

0 0 20 40 60 80 100

-1 Knee Flexion (degrees)

Fig. 5. Knee kinematics and forces were measured during one representative chair-rise cycle. Forces are plotted against knee exion angle. Total force and vertical force components could not be visually differentiated. Peak shear forces were even smaller than for walking and stair climbing (0.17 BW). Ground reaction forces under the instrumented limb averaged 4476% of total ground reaction forces.

During walking and stair climbing, ML shear was medially directed during the swing phase and during heel strike, changing to a lateral direction early in the stance phase (Figs. 3 and 4). External knee moments were measured using ground reaction forces and inverse dynamics. Moments generated at the tibial tray were measured directly by the instrumented tibial prosthesis (Fig. 7). External knee exion moments increased with knee exion angle and peaked at 5.7% BW Ht (exion 901) during chair rise and 4.3% BW Ht (exion 821) during squatting. The ground reaction forces under the instrumented side averaged 4476% of total ground reaction forces for the chair-rise

activity and 2473% for the squat activity. The moment generated by the joint reaction force on the tibial tray peaked at much lower levels: 1.9% BW Ht for chair-rise activity and 1.7% BW Ht for squat activity. However, a strong linear correlation was noted between the external knee exion moment and the exion moment measured at the tibial tray (r2 0.81 for chair rise and r2 0.87 for squat activity). Peak external knee adduction moments were 3.4% BW Ht for chair-rise activity and 1.8% BW Ht for squat activity. External adduction moments were higher at low exion angles and decreased with increased knee exion (Fig. 7). Adduction moments measured at the tibial

Knee Flexion (degrees)

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3
Ground Reaction Force Total Force Vertical Force Anterior Shear

S15

Lateral Shear

xBW

0 0 20 40 60 80 100

-1

Knee Flexion (degrees)

Fig. 6. Knee kinematics and forces were measured during one representative squatting cycle. Forces are plotted against knee exion angle. Peak shear forces were even smaller than those measuring for walking and stair climbing (0.17 BW). Ground reaction forces under the instrumented side were lower than for chair activity (2473% of total ground reaction forces for squat-up and 21711% for squat-down activities), indicating that the patient was favoring the instrumented knee.

6%

External Flexion Moment External Adduction Moment Net Joint Reaction Flexion Moment

4%

Net Joint Reaction Adduction Moment

%BWxHt

2%

0%

-2% 0 20 40 60 Knee Flexion (degrees) 80 100

6%

External Flexion Moment External Adduction Moment Net Joint Reaction Flexion Moment

4%

Net Joint Reaction Adduction Moment

%BWxHt

2%

0%

-2% 0 20 40 60 Knee Flexion (degrees) 80 100

Fig. 7. External knee moments (computed from ground reaction forces and knee kinematic data) were typically high. Moments generated by the joint reaction force at the tibial tray were substantially lower. a: Chair-rise activity; b: squat activity.

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tray were negative and peaked at 1.1% BW Ht during chair rise and 1.3% BW Ht during squatting. The external knee adduction moments were poorly correlated with the net moment generated by the joint reaction force at the tibial tray (r2 0.05 for chair-rise activity and r2 0.11 for squat activity). 4. Discussion Previously, we measured axial knee forces in vivo after TKA (DLima et al., 2005, 2006). However, shear forces and moments are also signicant components that affect knee wear and prosthesis survivorship. We therefore developed a second-generation telemetry-enabled tibial prosthesis capable of measuring all six components of force. This is a report of shear and moments measured at the knee joint 3 months after total knee arthroplasty during common activities. The axial component of forces measured at 3 months peaked between 2 and 3 BW, which were similar to those measured with the rst-generation instrumented tibial prosthesis (DLima et al., 2005). The axial component of forces predominated, especially during the stance phase of the activities studied. Shear forces during walking were modest (0.3 BW) compared to total knee forces. The soft tissues around the knee provide most of the resistance to shear and the intact posterior cruciate ligament may explain the low anterior shear recorded at the tibia tray. Low anteroposterior shear forces during walking (0.400.54 BW) have also been reported at the tibia in a patient with an instrumented distal femoral replacement and a hinged knee design (Taylor et al., 1998). Another study on the lower limb model in patients with instrumented hip arthroplasties reported peak contact shear forces that averaged 0.5 BW across four patients (Taylor et al., 2004). The knees in those patients were not implanted. These shear forces are in the same range as those reported for younger subjects with normal knees, i.e., peak external shear forces (computed with inverse dynamics) averaged 0.39 BW (Nagura et al., 2002) and 0.33 BW (Costigan et al., 2002), while peak joint contact shear forces averaged 0.5 BW (Costigan et al., 2002). However, knee joint contact shear forces as high as 2 BW have also been predicted by mathematical models (Seireg and Arvikar, 1975). Shear forces measured in the mediolateral direction were also low, which were similar to earlier estimates (Morrison, 1970). Peak tibial forces were substantially higher while climbing stairs (averaging 3 BW) than for the chair-rise and squat activities. This was possibly because the latter two activities involved a double-legged stance throughout the cycle. For the squat activity, the patient appeared to be loading the instrumented limb less than the contralateral side (as evidenced by the distribution of the ground reaction forces under each foot). Shear forces were also low for the chair-rise and squat activities despite the higher exion angles achieved (greater

than 801 while squatting and greater than 901 during chair rise). Higher peak external anteroposterior shear forces have been computed in young, normal subjects averaging 0.47 BW for stair climbing and 0.580.63 BW for squatting (Nagura et al., 2002). Even higher peak joint contact shear forces (1.2 BW) have also been reported during stair climbing (Costigan et al., 2002). Our measurement of low shear forces during these activities again emphasizes the contribution of muscles and ligaments in resisting tibial shear. We measured moments at the tibial tray for two activities that typically generate high external moments at the knee: rising from a chair and squatting. In young, normal subjects, knee moments were signicantly affected by the height of the chair (Rodosky et al., 1989). When compared to normal subjects, osteoarthritic and TKA patients reduced exion moments by displacing the center of mass anteriorly (Su et al., 1998). This compensation was more pronounced at lower chair heights. At chair seat heights equal to or greater than 100% of the knee joint-tooor height, the differences in kinetics of the sit-to-stand activity between normal and post-TKA patients cease to exist. We therefore chose a seat height equal to the knee joint-to-oor height. The patient was able to rise from the chair without arm support and demonstrated no signicant difculty. Elderly subjects with chair-rise difculties typically require a seat height of 120% of the knee jointto-oor height (Weiner et al., 1993). Patients with unilateral TKA also tend to shift the center of mass to the normal limb as an additional compensatory maneuver (Su et al., 1998). In the present study, the ground reaction forces under the instrumented side averaged 4476% of total ground reaction forces, indicating that the center of mass was not substantially shifted to the contralateral side. Peak external knee exion moment while rising from a chair was moderately high (5.7% BW Ht). This value was higher than the moments generated by normal, osteoarthritic, or post-TKA subjects of similar age range [34% BW Ht (Su et al., 1998)]. The peak external knee moment calculated during the squat activity (4.3% BW Ht) was similar to that reported for healthy subjects in the same age range [4.5% BW Ht (Flanagan et al., 2003)]. However, substantially larger peak exion moments (13.5% BW Ht) have been reported for younger, normal subjects (Nagura et al., 2002). This is likely due to the difference in peak exion angle achieved during the squat activity: 1501 for young subjects vs. 1001 for older subjects. Peak exion moment measured at the tibial tray was substantially lower (o2% BW Ht for both activities). The peak external adduction moment during chair-rise activity (3.4% BW Ht) was higher than that for squat activity (1.8% BW Ht). Low peak external adduction moments have been reported during chair rise for older normal subjects (1.15% BW Ht) and for subjects with chronic knee pain [1.31% BW Ht (Amin et al., 2004)]. Adduction moments at the tibial tray were also low (around 1% BW Ht) and, unlike exion moments,

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correlated poorly with external adduction moments (r2p0.11 for both activities). This is a report of knee forces and moments measured in only one patient. Due to patient-to-patient variation and implant design differences, these absolute values cannot be extrapolated to all knee arthroplasty patients. In addition, forces were measured at the 3-month postoperative time point. We have shown that tibial forces can increase up to 2 years postoperative (DLima et al., 2005). Finally, only activities of daily living are reported under carefully controlled laboratory conditions. Forces during other activities and during unanticipated events such as stumbling may be substantially higher than those reported here. We are in the process of implanting more patients with this second-generation implant. We are actively following all patients to increase the duration of follow-up, as well as the range of activities analyzed. Overall, shear forces, as well as moments at the tibial tray, were fairly low. These results indicate that accurate computation of knee contact forces requires appropriate modeling of the passive and active soft tissues. Direct measurements of knee joint reaction forces and moments coupled with robust mathematical models are extremely valuable in increasing our understanding of the loading of the soft tissues, cartilage, and bone of the natural knee, as well as the prosthetic components of the implanted knee. References
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