Baseline knee adduction moment interacts with body mass index to predict loss of medial tibial cartilage volume over 2.5 years in knee Osteoarthritis

Walking While Acting Sad and Happy Emotions Influences Risk Factors of Knee Osteoarthritis

Greater knee adduction moment is associated with increased risk and progression of knee osteoarthritis, and this biomechanical risk factor is modulated through kinematic gait modifications. Emotions are known to influence walking kinematics and speed, but the effect of different emotions on knee mechanics is unclear. To test this, 20 healthy participants walked while instrumented gait data was recorded. Participants initially walked naturally (baseline) and then acting 4 emotional walking conditions: Anger, Happy, Fear, and Sad, in randomized order. Statistical parametric mapping with an analysis of variance model determined the extent to which emotions influenced knee joint mechanics. Results indicated both the happy (P = .009) and sad (P < .001) condition resulted in lower knee adduction moment compared with baseline. Walking both happy and sad also resulted in walking speed changes from baseline (P < .001). A secondary analysis of covariance model with speed as the covariate indicated no significant effect of emotional condition on knee adduction moment (P > .05), which suggests that the changes from baseline can be attributed to the changes in walking speed. Decreased knee adduction is associated with reduced osteoarthritis progression and increased knee function, suggesting that walking while acting different emotions, specifically happy and sad, may moderate knee osteoarthritis risk.

Kinematic Alignment Compared With Mechanical Alignment Techniques Results in Greater Peak Three-Dimensional Knee Joint Moments During Stair Negotiation

BACKGROUND

This study investigated the influence of surgical alignment techniques on knee joint biomechanics during stair negotiation tasks. Our hypothesis was that a more personalized joint alignment would result in reduced medial knee loading biomechanics to negotiate the stairs.

METHODS

There were 28 adults (14 mechanical alignments [MAs] and 14 kinematic alignment [KA]) who underwent total knee arthroplasty at least one year postoperatively and performed five stair ascent and descent trials at their preferred velocities. The three-dimensional knee joint moments were calculated using a six-degree-of-freedom model in Visual 3D. Data were tested for normality using the Shapiro-Wilk test. Cohen's d was used to quantify effect size magnitude.

RESULTS

The KA technique methods were associated with greater knee moments compared with the MA technique. Due to the minimal differences in joint line between the groups, the greater trunk lean observed in the MA technique, and the preservation of soft tissue structures in the KA technique, the KA technique's lower extremity biomechanics enabled patients to move in a more symmetric manner within the frontal plane. This contrasted with the MA technique, which might result in an avoidance strategy during stair negotiation.

CONCLUSIONS

Since our joint line did not significantly change between technique groups, future work is warranted to understand the effects of joint line-driven changes on lower extremity joint biomechanics in total knee arthroplasty populations.

LEVEL OF EVIDENCE

Level 2 prospective cohort study.

Determining Individualized Foot Progression Angle for Reduction of Knee Medial Compartment Loading during Stepping

PURPOSE

Modifying foot progression angle (FPA), the angle between the line from the heel to the second metatarsal head and the line of progression, can reduce peak knee adduction moment (pKAM). However, determining the optimal FPA that minimizes pKAM without inducing unnatural walking patterns can be challenging. This study investigated the FPA-pKAM relationship using a robotic stepping trainer to assess the feasibility of determining the optimal FPA based on this relationship. In addition, it examined knee moments during stepping with three different FPAs, as stepping is a recommended exercise for knee osteoarthritis rehabilitation.

METHODS

Twenty-six asymptomatic individuals stepped on a robotic stepping trainer, which measured six-axis footplate-reaction forces/torques and three-dimensional ankle kinematics to determine external knee moments. The robot rotated the footplates slowly (~0.5 deg·s -1 ) between 10°-toe-out and 10°-toe-in while participants stepped continuously, unaware of the footplate rotations. The slope of pKAM-FPA relationship during continuous stepping was determined. Peak three-dimensional knee moments were compared between the 10°-toe-in, 0°-FPA, and 10°-toe-out FPAs with repeated-measures ANOVA. Multiple linear regression determined the covariates that predicted pKAM during stepping.

RESULTS

Eighteen participants had lower pKAM and KAM impulse with 10°-toe-in than 10°-toe-out ( P < 0.001) and 0°-FPA ( P < 0.001 and P = 0.008, respectively; called toe-in responders). Conversely, eight participants reduced pKAM and KAM impulse with 10°-toe-out compared with 0°-FPA ( P < 0.001, P = 0.017) and 10°-toe-in ( P = 0.026, P = 0.004; called toe-out responders). A linear pKAM-FPA relationship was determined for each individual, and its slope (the pKAM rate with FPA) was positive for toe-in responders ( P < 0.01) and negative for toe-out responders ( P = 0.02). Regression analysis revealed that smaller pKAM with toe-in, in toe-in responders, was explained by increased tibia medial tilt, tibia internal rotation, footplate-reaction lateral force, footplate-reaction anterior force, and decreased footplate-reaction internal rotation torque.

CONCLUSIONS

Individuals may exhibit different responses to FPA modification during stepping. The slope and intercept of the linear pKAM-FPA relationship can be determined for individual subjects. This allows for a targeted pKAM reduction through guided FPA positioning and potentially offers subject-specific precision knee osteoarthritis rehabilitation.

Movement Pattern Biofeedback Training After Total Knee Arthroplasty: A Randomized Controlled Trial

OBJECTIVE

Habitual movement compensations, such as decreased surgical peak knee extension moments (pKEM), persist years after total knee arthroplasty (TKA), are linked to poorer recovery, and may influence contralateral osteoarthritis progression. The purpose of this randomized clinical trial was to determine if a movement training program (MOVE) improves movement quality and recovery after TKA compared to a standardized rehabilitation program without movement training (CONTROL).

METHODS

One hundred thirty-eight individuals were randomized to either MOVE or CONTROL groups after TKA. Participants were assessed preoperatively, 10 weeks after (end of intervention), and six months after (primary endpoint) TKA. Outcomes assessed were pKEM during walking, six-minute walk test, stair climb test, 30-second sit to stand test (30STS), timed up and go test (TUG), physical activity level, strength, range of motion, and self-reported outcomes.

RESULTS

At six months, there were no between-group differences in surgical pKEM during walking (primary outcome). The MOVE group exhibited less contralateral pKEM compared to CONTROL during self-selected gait speed (d = 0.44, P = 0.01). CONTROL performed better on TUG and 30STS at 10 weeks (P < 0.05), but differences attenuated at six months.

CONCLUSION

The MOVE intervention did not lead to improved surgical pKEM during walking after TKA compared to CONTROL. However, the MOVE group did demonstrate less contralateral pKEM during walking. The CONTROL group demonstrated faster recovery on the TUG and 30STS, but it is unknown if this is due to improved recovery in the surgical knee or increased movement compensation relying on contralateral knee function.

Physical activity and joint health: Implications for knee osteoarthritis disease pathophysiology and mechanics

Knee osteoarthritis is experienced by hundreds of millions of people worldwide and is a major cause of disability. Although enhancing physical activity levels and the participation in exercise programmes has been proved to improve the debilitating illness of osteoarthritis, many do not engage in recommended levels of physical activity. One of the reported barriers to exercise engagement is the perception that physical activity can damage joint health and is attributed to the incorrect perception of 'wear and tear'. We posit that these perceptions arise from uncertainty and ambiguity generated from conflicting research findings. In this review, we explore the complex relationship between knee osteoarthritis and physical activity. We demonstrate how factors contribute to the uncertainty around the effects of physical activity on joint tissue metabolism, structure and function. The aim of this review is to demonstrate how a nuanced approach to the relationship between physical activity and knee osteoarthritis can help to dispel misconceptions, leading to better management strategies and improved quality of life for patients.

Mechanical Signal Transduction: A Key Role of Fluid Shear Forces in the Development of Osteoarthritis

Globally, osteoarthritis is a common and highly disabling disease that places a heavy burden on society and medical systems. The role of biomechanical factors in the development of osteoarthritis has gradually received more attention. As a key biomechanical stimulus, fluid shear force is becoming the focus of research for its dual role in maintaining cartilage health and disease progression. This paper conducts an in-depth discussion on the mechanism of fluid shear force in osteoarthritis and its impact on the disease process, aiming to reveal how fluid shear stress affects the development of osteoarthritis by regulating the physiological function and signal transduction pathways of chondrocytes.

Influencing factors analysis of asymmetry in knee adduction moment among patients with unilateral knee osteoarthritis

BACKGROUND

The knee adduction moment(KAM) of both lower limbs in patients with unilateral knee osteoarthritis(KOA) exhibits asymmetry during walking, but the factors influencing this asymmetry remain unclear. This study aimed to explore the influencing factors of KAM asymmetry in patients with unilateral KOA.

METHODS

A total of 148 patients with unilateral medial compartment KOA were selected for this retrospective study, and general data such as gender, age, and duration of disease were collected. The hip-knee-ankle (HKA) angle, degree of pain, and knee-extension muscle strength on the affected side were assessed through radiographic outcomes, the visual analog scale(VAS), and the Biodex isokinetic system. The peak KAM of both lower limbs was analyzed using a BTS motion-capture system and force platform. The asymmetry index(ASI) of KAM was calculated, and the patients were further categorized into the KAM symmetry group(ASI value ≤ 10%) and the KAM asymmetry group(ASI value>10%).Binary logistic regression analysis was employed to analyze the factors influencing the asymmetry of KAM.

RESULTS

90 patients were categorized into the KAM asymmetry group, representing 60.8% of the cohort. A significant difference in the ASI value of KAM was observed between the two groups. Correlation analysis identified nine factors, including sex, age, and BMI, that were positively correlated with the ASI value of KAM. In contrast, knee-extension muscle strength and per-capita monthly household income were negatively correlated with the ASI value of KAM. Regression analysis revealed that being female(OR = 1.752), older age(OR = 2.472), increased BMI(OR = 1.535), larger varus angle(OR = 3.965), higher VAS score(OR = 2.617), Kellgren-Lawrence(K-L) grade IV(OR = 4.474), history of knee joint trauma(OR = 5.684), and living in a rural location(OR = 1.554) increased the risk of KAM asymmetry. Conversely, increased knee-extension muscle strength(OR = 0.758) and a per-capita monthly household income of 3000 ~ 6000 yuan(OR = 0.814) decreased the risk of KAM asymmetry.

CONCLUSION

Female gender, older age, increased BMI, larger varus angle, higher VAS score, K-L grade IV, history of knee joint trauma, and living in a rural location are identified as risk factors for KAM asymmetry. Conversely, increased knee-extension muscle strength and a per-capita monthly household income of 3000 ~ 6000 yuan serve as protective factors against this asymmetry.

Associations between Body Mass Index, Gait Mechanics and Trochlear Cartilage Thickness in Those with ACL Reconstruction

PURPOSE

High body mass index (BMI) is a strong predictor of posttraumatic osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR). Altered gait mechanics are independently affected by BMI and ACLR, and influence OA risk. Yet, evidence directly assessing the impact of high BMI on gait or cartilage characteristics after ACLR are limited. Here, we evaluated if high BMI moderates associations between gait and trochlear cartilage structure in individuals with ACLR.

METHODS

Treadmill walking biomechanics were evaluated in 40 normal BMI and 24 high BMI participants with ACLR at self-selected speeds. Normalized and absolute peak and cumulative loads (i.e., impulse) were extracted for peak knee flexion and adduction moments (KFM, KAM) and vertical ground reaction force (GRF). Medial and lateral femoral cartilage thickness and medial/lateral thickness ratios were assessed via ultrasound.

RESULTS

Those with ACLR and high BMI walked with reduced normalized peak vertical GRFs, and greater absolute peak and cumulative loads compared with normal BMI individuals with ACLR. Those with ACLR and high BMI also exhibited thinner cartilage and greater medial/lateral ratios in ACLR limbs compared with contralateral limbs whereas normal BMI individuals with ACLR exhibited thicker ACLR limb cartilage. Lastly, greater peak KAM and KAM cumulative load were associated with thicker lateral cartilage and lesser medial/lateral thickness ratios, but only in the high BMI group.

CONCLUSIONS

We observed those with high BMI after ACLR exhibited trochlear cartilage structural alterations not observed in normal BMI patients, whereas differential associations between loading outcomes and cartilage thickness in ACLR knees were observed between groups. Those with high BMI after ACLR may require different therapeutic strategies to optimize joint health in this subset of patients.

Interactions of cumulative load with biomarkers of cartilage turnover predict knee cartilage change over 2 years: data from the osteoarthritis initiative

The purpose was to investigate relationships of cumulative load and cartilage turnover biomarkers with 2-year changes in cartilage in knee osteoarthritis. From participants with Kellgren-Lawrence (KL) grades of 1 to 3, cartilage thickness and transverse relaxation time (T2) were computed from 24-month (baseline) and 48-month magnetic resonance images. Cumulative load was the interaction term of the Physical Activity Scale for the Elderly (PASE) and body mass index (BMI). Serum cartilage oligomeric matrix protein (COMP) and the nitrated form of type II collagen (Coll2-1 NO2) were collected at baseline. Multiple regressions (adjusted for baseline age, KL grade, cartilage measures, pain, comorbidity) evaluated the relationships of cumulative load and biomarkers with 2-year changes. In 406 participants (63.7 (8.7) years), interactions of biomarkers with cumulative load weakly predicted 2-year cartilage changes: (i) COMP × cumulative load explained medial tibia thickness change (R2 increased 0.062 to 0.087, p < 0.001); (ii) Coll2-1 NO2 × cumulative load explained central medial femoral T2 change (R2 increased 0.177 to 0.210, p < 0.001); and (iii) Coll2-1 NO2 × cumulative load explained lateral tibia T2 change (R2 increased 0.166 to 0.188, p < 0.001). Moderate COMP or Coll2-1 NO2 at baseline appeared protective. High COMP or Coll2-1 NO2, particularly with high BMI and low PASE, associated with worsening cartilage. Moderate serum concentrations of cartilage turnover biomarkers, at high and low physical activity, associated with maintained cartilage outcomes over 2 years. In conclusion, high concentrations of cartilage turnover biomarkers, particularly with high BMI and low physical activity, associated with knee cartilage thinning and increasing T2 over 2 years. Key Points • Higher quality cartilage may be better able to tolerate a larger cumulative load than poor quality cartilage. • Among participants enrolled in the Osteoarthritis Initiative Biomarkers Consortium Project, a representation of cumulative load exposure and its interaction with cartilage turnover biomarkers were weakly related with 2-year change in knee cartilage. • These findings suggest that cartilage turnover is a factor that modifies the relationship between loading exposure and cartilage loss in knee OA.

Improving muscle capacity utilization with a 12-week strengthening program for females with symptomatic knee osteoarthritis

BACKGROUND

Strengthening exercise improves symptoms in knee osteoarthritis (OA), but it remains unclear if biomechanical mechanisms contribute to this improvement. Muscle capacity utilization, which reflects the proportion of maximum capacity required to complete tasks, may provide insight into how strengthening exercise improves clinical outcomes in painful knee OA.

PURPOSE

The purpose of this secondary analysis was to determine if a 12-week strengthening intervention reduced muscle capacity utilization during walking, squat and lunge tasks in females with painful knee OA.

METHODS

Data from 28 females (age 59.6 ± 6.2 years old; body mass index 29.1 ± 4.7 kg/m2) with clinical knee OA were included. Participants completed a strengthening intervention 3 times per week for 12 weeks. Knee extensor isometric torque was measured on a commercial dynamometer; peak values from three exertions were averaged. Peak KFM was extracted and averaged from five walking trials. Mean KFM was extracted and averaged from three trials for each of static lunges and squats. Muscle capacity utilization was the ratio of mean peak KFM to peak extensor torque for walking; and mean KFM to peak extensor torque for squats and lunges. Paired t-tests determined differences between peak extensor torque, peak KFM and muscle capacity utilization from pre to post intervention (p < 0.05).

RESULTS & SIGNIFICANCE

Peak extensor torque increased at follow up (p = 0.02). Peak KFM during walking decreased (p = 0.005). Muscle capacity utilization during walking (p = 0.008) and squat (p = 0.002) decreased. Mean KFM and muscle capacity utilization during lunge remained unchanged from pre to post intervention. The reduction in muscle capacity utilization at follow up indicates the strengthening intervention produced a decrease in proportion of the maximal capacity a participant used to complete walking and squat tasks. Strengthening both increases maximal muscle capacity and decreases the net moment required during daily tasks in knee OA.

Relation of Temporal Asymmetry During Walking to Two-Year Knee Pain Outcomes in Those With Mild-to-Moderate Unilateral Knee Pain: An Exploratory Analysis From the Multicenter Osteoarthritis Study

OBJECTIVE

We aimed to explore the cross-sectional relation of unilateral knee pain severity and temporal asymmetry during walking and to determine relations of temporal asymmetry during walking to 2-year changes in ipsilateral and contralateral knee pain in those with mild-to-moderate unilateral knee pain.

METHODS

The Multicenter Osteoarthritis Study is a prospective cohort study of adults with or at risk for knee osteoarthritis. The current study included participants with unilateral knee pain. Gait was assessed during self-selected and fast walking at baseline. Knee pain was assessed at baseline and 2 years. We calculated limb symmetry indices (LSIs; nonpainful limb/painful limb × 100) for stance, single-limb support time, and double-limb support time, then examined their relations to unilateral knee pain severity, incident contralateral knee pain, and persistent ipsilateral knee pain.

RESULTS

Unilateral knee pain severity was not associated with temporal asymmetry during self-selected or fast walking. At 2 years, 17.1% of participants had incident contralateral knee pain and 51.4% had persistent ipsilateral knee pain. For self-selected walking, greater LSIs (i.e., longer time on the nonpainful limb) for stance and single-limb support time were associated with decreased odds of incident contralateral knee pain. Measures of temporal asymmetry were not associated with persistent ipsilateral knee pain, except for single-limb support time during fast walking.

CONCLUSION

For those with unilateral knee pain, temporal asymmetry during walking is not associated with pain severity. However, select measures of stance and single-limb support time during self-selected and fast walking relate to longitudinal knee pain outcomes.

Integrating MR imaging with full-surface indentation mapping of femoral cartilage in an ex vivo porcine stifle

The potential of MRI to predict cartilage mechanical properties across an entire cartilage surface in an ex vivo model would enable novel perspectives in modeling cartilage tolerance and predicting disease progression. The purpose of this study was to integrate MR imaging with full-surface indentation mapping to determine the relationship between femoral cartilage thickness and T2 relaxation change following loading, and cartilage mechanical properties in an ex vivo porcine stifle model. Matched-pairs of stifle joints from the same pig were randomized into either 1) an imaging protocol where stifles were imaged at baseline and after 35 min of static axial loading; and 2) full surface mapping of the instantaneous modulus (IM) and an electromechanical property named quantitative parameter (QP). The femur and femoral cartilage were segmented from baseline and post-intervention scans, then meshes were generated. Coordinate locations of the indentation mapping points were rigidly registered to the femur. Multiple linear regressions were performed at each voxel testing the relationship between cartilage outcomes (thickness change, T2 change) and mechanical properties (IM, QP) after accounting for covariates. Statistical Parametric Mapping was used to determine significance of clusters. No significant clusters were identified; however, this integrative method shows promise for future work in ex vivo modeling by identifying spatial relationships among variables.

Prediction of knee adduction moment using innovative instrumented insole and deep learning neural networks in healthy female individuals

BACKGROUND

The knee adduction moment, a biomechanical risk factor of knee osteoarthritis, is typically measured in a gait laboratory with expensive equipment and inverse dynamics modeling software. We aimed to develop a framework for a portable knee adduction moment estimation for healthy female individuals using deep learning neural networks and custom instrumented insole and evaluated its accuracy compared to the standard inverse dynamics approach.

METHODS

Feed-forward, convolutional, and recurrent neural networks were applied to the data extracted from five piezo-resistive force sensors attached to the insole of a shoe.

RESULTS

All models predicted knee adduction moment variables during walking with high correlation coefficients, r > 0.72, and low root mean squared errors (RMSE), ranging from 0.5% to 1.2%. The convolutional neural network is the most accurate predictor of average knee adduction moment (r = 0.96; RMSE = 0.5%) followed by the recurrent and feed-forward neural networks.

CONCLUSION

These findings and the methods presented in the current study are expected to facilitate a cost-effective clinical analysis of knee adduction moment for healthy female individuals and to facilitate future research on prediction of other biomechanical risk factors using similar methods.

Effect of lower limb orthoses on cartilage in patients with knee osteoarthritis: A narrative review

The objective of this review was to infer how the use of an orthosis affects cartilage in patients with knee osteoarthritis. A search was performed in four different databases (Web of Science, Scopus, EMBASE, and PubMed) up to the 21st of November of 2020 to evaluate how the patient's condition was monitored. The parameters chosen for this review were medial tibial cartilage volume, x-ray evaluation, Lequesne Index, pain visual analog scale score, Western Ontario and McMaster Universities Arthritis Index pain score, and Knee Injury and Osteoarthritis Outcome Score pain subscale score. The initial search yielded a total of 12,622 documents. After thoroughly screening them, 38 were selected for analysis. Of the resulting data, only two objectively evaluated the cartilage (medial tibial cartilage volume, n = 1; x-ray evaluation, n = 1), with the remainder evaluating subjective symptoms (Lequesne Index, n = 8; pain visual analog scale score, n = 18; Western Ontario and McMaster Universities Arthritis Index pain score, n = 10; Knee Injury and Osteoarthritis Outcome Score pain subscale score, n = 10). The data did not converge toward any general outcome. The articles read demonstrated a great tendency to evaluate qualitative parameters pertinent to the symptoms of this condition or quantitative parameters related to the biomechanics of the knee. However, these parameters are not ideal because they are ambiguous. As such, a shift toward more objective quantitative parameters that directly assess the cartilage volume of the knee should be considered in future clinical trials.

Relationship Between Knee Biomechanics and Pain in People With Knee Osteoarthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

Our primary aim was to determine the cross-sectional relationship between knee biomechanics during gait and pain in people with medial knee osteoarthritis. Our secondary aim was to evaluate differences in knee biomechanics between symptomatic and asymptomatic participants with medial knee osteoarthritis.

METHODS

Four online databases were searched from inception to July 2021. Eligible studies included people with medial/nonspecific knee osteoarthritis and a reported relationship between knee biomechanics during gait and pain or biomechanics of symptomatic and asymptomatic participants. Two reviewers independently extracted data and evaluated risk of bias. Random-effects meta-analyses were performed when three or more studies reported the same biomechanical variable for pooling (knee adduction moment [KAM], KAM impulse, varus thrust, and peak knee flexion moment [KFM]).

RESULTS

Forty studies were included. Methodological quality ranged from 4 to 9/10. Forty-seven unique biomechanical variables were reported. For the KAM, there was no correlation with pain for peak values pooled (early stance and overall) (r = 0.00, 95% confidence interval [95% CI]: -0.12, 0.11, k = 16), a small negative correlation for early stance peak alone (r = -0.09, 95% CI -0.18, -0.002, k = 12), and a medium positive correlation for the overall peak during stance (r = 0.30, 95% CI 0.17, 0.42, k = 4). Metaregression identified that body mass index moderated the peak KAM-pain relationship (P < 0.001). KAM impulse had a small positive correlation with pain (r = 0.23, 95% CI 0.04, 0.40, k = 5), and people with varus thrust had 3.84 greater odds of reporting pain compared with people without (95% CI 1.72, 8.53, k = 3). Meta-analyses for the peak KFM and pain correlation and secondary aim were nonsignificant.

CONCLUSION

Some knee gait biomechanics were associated with pain in this cohort. Longitudinal studies are required to determine causality.

The relationship between muscle capacity utilization during gait and pain in people with symptomatic knee osteoarthritis

BACKGROUND

Muscle capacity utilization reflects the percentage of maximal knee extensor strength required to complete physical activities.

RESEARCH QUESTION

Is pain associated with muscle capacity utilization during walking in older adults with knee osteoarthritis? Secondarily, is muscle capacity utilization in older adults with knee osteoarthritis sex-specific?

METHODS

Twenty-three participants (15 females) with symptomatic knee OA completed this study [age 67 ( ± 8) years, body mass index 29.7 ( ± 3.9) kg/m², gait speed during the Six Minute Walk test 1.25 ( ± 0.25) m/s]. Pain was measured using the Knee injury and Osteoarthritis Outcome Score. Muscle capacity utilization was quantified as the peak external knee flexor moment during level walking normalized to knee extensor maximum voluntary isometric contraction. The knee flexor moment was calculated from kinematic and kinetic data during barefoot level walking at a self-selected speed and at 1.1 m/s. Knee extensor maximum voluntary isometric contraction was measured on a dynamometer. Multiple linear regressions were used to determine the relationship between pain and muscle capacity utilization after adjusting for age, sex, body mass index, and gait speed. Independent sample t-tests examined sex differences.

RESULTS

Pain was not associated with muscle capacity utilization during self-selected and standardized walking speeds (p = 0.38 and p = 0.36, respectively). Females did not require a greater muscle capacity utilization than males to complete gait at self-selected and standardized speeds (p = 0.28, and p = 0.40, respectively).

SIGNIFICANCE

Muscle capacity utilization was not associated with pain during walking in people with knee osteoarthritis. Future work should explore more challenging activities of daily living in knee OA.

Variable Stiffness Shoes for Knee Osteoarthritis: An Evaluation of 3-Dimensional Gait Mechanics and Medial Joint Contact Forces

The study aim was to quantify the impact of a commercially available variable stiffness shoe (VSS) on 3-dimensional ankle, knee, and hip mechanics and estimated knee contact forces compared with a control shoe. Fourteen participants (10 females) with knee osteoarthritis completed gait analysis after providing informed consent. Shoe conditions tested were control shoe (New Balance MW411v2) and VSS (Abeo SMART3400). An OpenSim musculoskeletal model with static optimization was used to estimate knee contact forces. There were no differences in joint kinematics or in the knee adduction or flexion moments (P = .06; P = .2). There were increases in the knee internal and external rotation (P = .02; P = .03) and hip adduction and internal rotation moments for VSS versus control (P = .03; P = .02). The estimated contact forces were not different between shoes (total P = .3, medial P = .1, and lateral P = .8), but contact force changes were correlated with changes in the knee adduction moment (medial r2 = .61; P < .007). High variability in knee flexion moment changes and increases in the internal rotation moment combined with small decreases in the knee adduction moment did not lead to decreases in estimated contact forces. These results suggest that evaluation of VSS using only the knee adduction moment may not adequately capture its impact on osteoarthritis.

Are biomechanics during gait associated with the structural disease onset and progression of lower limb osteoarthritis? A systematic review and meta-analysis

OBJECTIVE

To evaluate if gait biomechanics are associated with increased risk of structurally diagnosed disease onset or progression of lower limb osteoarthritis (OA).

METHOD

A systematic review of Medline and Embase was conducted from inception to July 2021. Two reviewers independently screened records, extracted data and assessed risk of bias. Included studies reported gait biomechanics at baseline, and either structural imaging or joint replacement occurrence in the lower limb at follow-up. The primary outcome was the Odds Ratio (OR) (95% confidence interval (CI)) of the association between biomechanics and structural OA outcomes with data pooled for meta-analysis.

RESULTS

Twenty-three studies reporting 25 different biomechanical metrics and 11 OA imaging outcomes were included (quality scores ranged 12-20/21). Twenty studies investigated knee OA progression; three studies investigated knee OA onset. Two studies investigated hip OA progression. 91% of studies reported a significant association between at least one biomechanical variable and OA onset or progression. There was an association between frontal plane biomechanics with medial tibiofemoral and hip OA progression and sagittal plane biomechanics with patellofemoral OA progression. Meta-analyses demonstrated increased odds of medial tibiofemoral OA progression with greater baseline peak knee adduction moment (KAM) (OR: 1.88 [95%CI: 1.08, 3.29]) and varus thrust presence (OR: 1.97 [95%CI: 1.32, 2.96]).

CONCLUSION

Evidence suggests that certain gait biomechanics are associated with an increased odds of OA onset and progression in the knee, and progression in the hip.

REGISTRATION NUMBER

PROSPERO CRD42019133920.

Physical therapy and orthopaedic equipment-induced reduction in the biomechanical risk factors related to knee osteoarthritis: a systematic review and Bayesian network meta-analysis of randomised controlled trials

OBJECTIVE

Are physical therapy or orthopaedic equipment efficacious in reducing the biomechanical risk factors in people with tibiofemoral osteoarthritis (OA)? Is there a better therapeutic intervention than others to improve these outcomes?

DESIGN

Systematic review with network meta-analysis (NMA) of randomised trials.

DATA SOURCES

PubMed, Web of Science, Cochrane Library, Embase and MEDLINE were searched through January 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included randomised controlled trials exploring the benefits of using physical therapy or orthopaedic equipment in reducing the biomechanical risk factors which included knee adduction moment (KAM) and knee adduction angular impulse (KAAI) in individuals with tibiofemoral OA.

DATA EXTRACTION AND SYNTHESIS

Two authors extracted data independently and assessed risk of bias. We conducted an NMA to compare multiple interventions, including both direct and indirect evidences. Heterogeneity was assessed (sensitivity analysis) and quantified (I2 statistic). Grading of Recommendations Assessment, Development and Evaluation assessed the certainty of the evidence.

RESULTS

Eighteen randomised controlled trials, including 944 participants, met the inclusion criteria, of which 14 trials could be included in the NMA. Based on the collective probability of being the overall best therapy for reducing the first peak KAM, lateral wedge insoles (LWI) plus knee brace was closely followed by gait retraining, and knee brace only. Although no significant difference was observed among the eight interventions, variable-stiffness shoes and neuromuscular exercise exhibited an increase in the first peak KAM compared with the control condition group. And based on the collective probability of being the overall best therapy for reducing KAAI, gait retraining was followed by LWI only, and lower limb exercise.

CONCLUSION

The results of our study support the use of LWI plus knee brace for reducing the first peak KAM. Gait retraining did not rank highest but it influenced both KAM and KAAI and therefore it was the most recommended therapy for reducing the biomechanical risk factors.

Knee biomechanics and contralateral knee osteoarthritis progression after total knee arthroplasty

BACKGROUND

Despite the success rate of Total Knee Arthroplasty (TKA), many patients undergo contralateral TKA. It is possible that altered gait mechanics after unilateral TKA play a role in the progression of contralateral OA progression.

RESEARCH QUESTION

The purpose of this study was to identify biomechanical predictors of radiographic OA progression in the contralateral (non-surgical) knee after unilateral (primary/initial) TKA. In addition, this study quantified for patients who had contralateral OA progression.

METHODS

Biomechanical outcomes were collected 6-24 months after unilateral primary TKA and were used to predict changes in contralateral OA severity at follow-up. Participants were divided into "Progressor" and "Non-Progressor" groups based on changes in Kellgren-Lawrence (KL) OA grade and Joint Space Width (JSW) between baseline and follow-up testing sessions. Biomechanical factors during walking were peak knee adduction moment, knee flexion/extension excursions, knee angle at initial foot contact, and peak knee flexion/extension. Multiple independent t-tests were used to examine the magnitude of differences in biomechanical variables between the groups. Logistic regression was used to examine the association between the biomechanical predictors and change in KL scores and JSW.

RESULTS

The mean time between surgery and follow-up x-rays was 8.8 (2.4) years. Of 40 participants, 62.5-78% had contralateral radiographic knee OA progression by follow-up. There were no significant differences in the biomechanical variables between groups. For the regression analysis, none of the biomechanical variables were found to be predictors for contralateral OA progression.

SIGNIFICANCE

Although abnormal biomechanics are known risk factors for primary knee OA, it is possible that the mechanisms that result in OA progression of the contralateral limb are different than primary knee OA progression. Future work should evaluate other objective measures of OA progression and determine if cumulative measures of joint loading are related to OA worsening.

Gait risk factors for disease progression differ between non-traumatic and post-traumatic knee osteoarthritis

OBJECTIVE

To examine if relationships between knee osteoarthritis (OA) progression with knee moments and muscle activation during gait vary between patients with non-traumatic and post-traumatic knee OA.

DESIGN

This longitudinal study included participants with non-traumatic (n = 17) and post-traumatic (n = 18) knee OA; the latter group had a previous anterior cruciate ligament rupture. Motion capture cameras, force plates, and surface electromyography measured knee moments and lower extremity muscle activation during gait. Cartilage volume change were determined over 2 years using magnetic resonance imaging in four regions: medial and lateral plateau and condyle. Linear regression analysis examined relationships between cartilage change with gait metrics (moments, muscle activation), group, and their interaction.

RESULTS

Measures from knee adduction and rotation moments were related to lateral condyle cartilage loss in both groups, and knee adduction moment to lateral plateau cartilage loss in the non-traumatic group only [β = -1.336, 95% confidence intervals (CI) = -2.653 to -0.019]. Generally, lower levels of stance phase muscle activation were related to greater cartilage loss. The relationship between cartilage loss in some regions with muscle activation characteristics varied between non-traumatic and post-traumatic groups including for: lateral hamstring (lateral condyle β = 0.128, 95%CI = 0.003 to 0.253; medial plateau β = 0.199, 95%CI = 0.059 to 0.339), rectus femoris (medial condyle β = -0.267, 95%CI = -0.460 to -0.073), and medial hamstrings (medial plateau; β = -0.146, 95%CI = -0.244 to -0.048).

CONCLUSION

Findings indicate that gait risk factors for OA progression may vary between patients with non-traumatic and post-traumatic knee OA. These OA subtypes should be considered in studies that investigate gait metrics as risk factors for OA progression.

Association of Low Physical Activity Levels With Gait Patterns Considered at Risk for Clinical Knee Osteoarthritis Progression

Objective

Although gait analysis provides an estimate of joint loading magnitude and patterns during a typical step, accelerometry provides information about loading frequency. Understanding the relationships between these components of loading and knee osteoarthritis (OA) progression may improve conservative management, as gait interventions may need to account for physical activity levels or vice versa. The primary objective was to examine relationships between gait patterns that have previously been associated with OA progression and accelerometer‐derived metrics of loading frequency. The secondary objective examined the association of accelerometer‐derived metrics and total knee arthroplasty (TKA) at a mean follow‐up of 3.5 years.

Methods

Fifty‐seven individuals with knee OA underwent gait analysis and 1 week of accelerometer wear. Spearman correlations were calculated between accelerometer‐derived metrics and gait patterns. Differences across quartiles of step count were examined with Jonckheere‐Terpstra tests. In a subsample, baseline differences between TKA and no TKA groups were examined with Mann‐Whitney U‐tests.

Results

Gait variables previously related to progression were correlated to both step count and moderate‐ to vigorous‐intensity, but not lower‐intensity, physical activity. Individuals in the lowest quartile (~4000 steps/day) exhibited gait patterns previously related to progression. There were no differences in any baseline accelerometer‐derived metrics between those that did and did not undergo TKA at follow‐up.

Conclusion

Complex relationships exist between gait, physical activity, and OA progression. Accelerometer‐derived metrics may contribute unique information about overall loading for individuals above a certain activity threshold, but for those with lower activity levels, gait may be sufficient to predict clinical progression risk, at least over the short term.

Relationship between radiographic measurements and knee adduction moment using 3D gait analysis

BACKGROUND

Radiographic factors estimate the state of the static knee joint, and it is questionable how well these parameters reflect the dynamic knee condition. The external knee adduction moment (KAM) during gait is known to be a kinetic variable contributing to osteoarthritis progression. This study aims to investigate the effects of static radiographic parameters on the dynamic KAM during gait.

METHODS

Overall, 123 patients (mean age, 65.7 years; standard deviation, 8.1 years; 34 men and 89 women) were included. Seven radiographic parameters including the mechanical tibiofemoral angle (mTFA), Kellgren-Lawrence grade, and ankle joint line orientation (AJLO) were measured on radiographs, and the maximum KAM and KAM-time integral in the stance phase were obtained using three-dimensional gait analysis. The correlation and multiple regression analyses were performed for identifying significant radiographic measurements associated with the KAM.

RESULTS

Most of the radiographic measurements correlated with the maximum KAM and KAM-time integral. As a result of multiple regression analysis, the mTFA (p < 0.001) and AJLO (p = 0.003) were identified as significant factors associated with the KAM-time integral (R² = 0.450); the mTFA (p < 0.001) and AJLO (p = 0.003) were identified as a significant factor associated with the maximum KAM (R² = 0.352) in multiple regression analysis. The discriminant validity of KAM was highest at varus 5.7 degree of the mTFA and 7.5 degree of the AJLO.

SIGNIFICANCE

The mTFA and AJLO were significantly associated with the KAM. However, to be used as a surgical indication for corrective osteotomy, a longitudinal study is needed to validate whether the mTFA and AJLO values directly cause osteoarthritis progression as we have suggested.

LEVEL OF EVIDENCE

III.

Gait Adaptations at 8 Years After Reconstruction of Unilateral Isolated and Combined Posterior Cruciate Ligament Injuries

BACKGROUND

It remains unclear how posterior cruciate ligament (PCL) reconstruction influences long-term lower extremity joint biomechanics.

PURPOSE

To determine whether patients who underwent PCL reconstruction exhibited long-term alterations in lower limb gait mechanics.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 26 patients underwent gait analyses at 8.2 ± 2.6 years after primary unilateral PCL reconstruction. Sex- and age-matched healthy controls were analyzed for comparison. Gait data were collected using motion capture and force plates. Hip, knee, and ankle angles and moments were compared during initial contact, early stance, and late stance for the reconstructed and uninjured contralateral limbs of patients who underwent PCL reconstruction (PCL group) as well as the limbs of healthy control participants (CON group).

RESULTS

No side-to-side kinematic differences were noted between the reconstructed and contralateral limbs of the PCL group; some trivial differences were noted in knee and hip moments. However, major differences between the PCL and CON groups occurred at the knee. Reconstructed and contralateral limbs of the PCL group exhibited larger knee flexion angles during initial contact (Δ = 7.0° [P < .001] and Δ = 6.9° [P < .001], respectively), early stance (Δ = 5.8° [P = .003] and Δ = 6.7° [P < .001], respectively), and late stance (Δ = 7.9° [P < .001] and Δ = 8.0° [P < .001], respectively) compared with the CON group. During early stance, contralateral limbs of the PCL group displayed larger knee flexion moments (Δ = 0.20 N·m/kg; P = .014) compared with the CON group, and both reconstructed (Δ = 0.05 N·m/kg; P = .027) and contralateral (Δ = 0.07 N·m/kg; P = .001) limbs of the PCL group exhibited larger knee external rotation moments compared with the CON group. During late stance, reconstructed and contralateral limbs of the PCL group exhibited smaller knee extension moments (Δ = 0.24 N·m/kg [P < .001] and Δ = 0.26 N·m/kg [P < .001], respectively) and knee internal rotation moments (Δ = 0.06 N·m/kg [P < .001] and Δ = 0.06 N·m/kg [P < .001], respectively) compared with the CON group. No discrepancies were observed at the hip; minimal differences were noted in sagittal-plane ankle mechanics.

CONCLUSION

Patients who underwent PCL reconstruction generally exhibited bilateral gait symmetry at 8 years after surgery. However, they exhibited important biomechanical deviations in both knees compared with healthy controls. These modifications likely reflect adaptive gait strategies to protect the PCL after reconstruction.

CLINICAL RELEVANCE

Long-term follow-up analyses of patients who underwent PCL reconstruction should not use the uninjured contralateral limb as a "healthy" reference, as it also exhibits mechanical differences compared with controls. Results could inform the development of neuromuscular and strength training programs targeting the restoration of knee biomechanics similar to healthy controls to prevent early-onset degeneration that is frequently associated with altered biomechanics.

Effects of an Exercise Therapy Targeting Knee Kinetics on Pain, Function, and Gait Kinetics in Patients With Knee Osteoarthritis: A Randomized Clinical Trial

In this study, the effects of an exercise therapy comprising yoga exercises and medial-thrust gait (YogaMT) on lower-extremity kinetics, pain, and function in patients with medial knee osteoarthritis were investigated. Fifty-nine patients were randomly allocated to three treatment groups: (a) the YogaMT group practiced yoga exercises and medial thrust gait, (b) the knee-strengthening group performed quadriceps- and hamstring-strengthening exercises, and (c) the treadmill walking group practiced normal treadmill walking in 12 supervised sessions. The adduction and flexion moments of the hip, knee, and ankle; pain intensity; and 2-min walking test were assessed before and after treatment and at 1-month follow-up. The YogaMT group experienced a significant reduction in knee adduction moment. All groups showed significant improvement in pain and function. The YogaMT may reduce medial knee load in patients with knee osteoarthritis in the short term. A larger clinical trial is required to investigate the long-term outcomes of this intervention.

Daily cumulative load and body mass index alter knee cartilage response to running in women

BACKGROUND

It is unknown whether a greater accumulation of knee load over a typical day is related to how cartilage responds to an acute bout of loading. This information may clarify the role of habitual activity on cartilage function.

RESEARCH QUESTION

Is there a relationship between change in tibial and femoral cartilage thickness, volume, and T2 relaxation time following running with daily cumulative knee load in women? Secondarily, is there a relationship between cartilage change following running and the statistical interaction of body mass index (BMI) and daily steps?

METHODS

Participants (n = 15) completed gait analyses and wore an accelerometer over a week. Daily cumulative knee load was the statistical interaction between tibial compressive joint reaction force (JRF) impulse with the average number of daily steps measured using accelerometry. Magnetic resonance imaging scans were acquired before and immediately after 15-min of treadmill running. Changes in tibial and femoral cartilage thickness, volume, and T2 relaxation time were calculated. Multiple linear regressions tested the associations of cartilage change outcomes with: baseline (thickness, volume, T2), JRF impulse, steps, and the interaction JRF impulse*steps. Secondarily, BMI was substituted for JRF impulse.

RESULTS AND SIGNIFICANCE

Tibial volume change was explained by baseline volume, JRF impulse, steps, and JRF impulse*steps (R² = 0.50, p = 0.013). Additionally, tibial volume change was explained by baseline volume, BMI, steps, and BMI*steps (R² = 0.43, p = 0.002). Those who were more physically active with lower JRF impulse (or lower BMI) showed less change in tibial cartilage after a running exposure. This may suggest cartilage conditioning.

Longitudinal changes in tibial and femoral cartilage thickness are associated with baseline ambulatory kinetics and cartilage oligomeric matrix protein (COMP) measures in an asymptomatic aging population

OBJECTIVE

To address the need for early knee osteoarthritis (OA) markers by testing if longitudinal cartilage thickness changes are associated with specific biomechanical and biological measures acquired at a baseline test in asymptomatic aging subjects.

DESIGN

Thirty-eight asymptomatic subjects over age 45 years were studied at baseline and at an average of 7-9 year follow-up. Gait mechanics and knee MRI were measured at baseline and MRI was obtained at follow-up to assess cartilage thickness changes. A subset of the subjects (n = 12) also had serum cartilage oligomeric matrix protein measured at baseline in response to a mechanical stimulus (30-min walk) (mCOMP). Baseline measures, including the knee extension (KEM), flexion (KFM), adduction (KAM) moments and mCOMP, were tested for associations with cartilage thickness changes in specific regions of the knee.

RESULTS

Cartilage change in the full medial femoral condyle (p = 0.005) and external medial femoral region (p = 0.041) was negatively associated with larger early stance peak KEM. Similarly, cartilage change in the full medial femoral region (p = 0.009) and medial femoral external region (p = 0.043) was negatively associated with larger first peak KAM, while cartilage change in the anterior medial tibia was positively associated with larger first peak KAM (p = 0.003). Cartilage change in the anterior medial tibia was also significantly associated (p = 0.011) with mCOMP levels 5.5-h post-activity (percentage of pre-activity levels).

CONCLUSIONS

Interactions found between gait, mechanically-stimulated serum biomarkers, and cartilage thickness in an at-risk aging asymptomatic population suggest the opportunity for early detection of OA with new approaches that bridge across disciplines and scales.

Association of Machine Learning-Based Predictions of Medial Knee Contact Force With Cartilage Loss Over 2.5 Years in Knee Osteoarthritis

OBJECTIVE

The relationship between in vivo knee load predictions and longitudinal cartilage changes has not been investigated. We undertook this study to develop an equation to predict the medial tibiofemoral contact force (MCF) peak during walking in persons with instrumented knee implants, and to apply this equation to determine the relationship between the predicted MCF peak and cartilage loss in patients with knee osteoarthritis (OA).

METHODS

In adults with knee OA (39 women, 8 men; mean ± SD age 61.1 ± 6.8 years), baseline biomechanical gait analyses were performed, and annualized change in medial tibial cartilage volume (mm³ /year) over 2.5 years was determined using magnetic resonance imaging. In a separate sample of patients with force-measuring tibial prostheses (3 women, 6 men; mean ± SD age 70.3 ± 5.2 years), gait data plus in vivo knee loads were used to develop an equation to predict the MCF peak using machine learning. This equation was then applied to the knee OA group, and the relationship between the predicted MCF peak and annualized cartilage volume change was determined.

RESULTS

The MCF peak was best predicted using gait speed, the knee adduction moment peak, and the vertical knee reaction force peak (root mean square error 132.88N; R² = 0.81, P < 0.001). In participants with knee OA, the predicted MCF peak was related to cartilage volume change (R² = 0.35, β = -0.119, P < 0.001).

CONCLUSION

Machine learning was used to develop a novel equation for predicting the MCF peak from external biomechanical parameters. The predicted MCF peak was positively related to medial tibial cartilage volume loss in patients with knee OA.

Osteoarthritis year in review 2020: mechanics

The mechanical environment of the joint during dynamic activity plays a significant role in osteoarthritis processes. Understanding how the magnitude, pattern and duration of joint-specific loading features contribute to osteoarthritis progression and response to treatment is a topic of on-going relevance. This narrative review synthesizes evidence from recent papers that have contributed to knowledge related to three identified emerging subthemes: 1) the role of the joint mechanical environment in osteoarthritis pathogenesis, 2) joint biomechanics as an outcome to arthroplasty treatment of osteoarthritis, and 3) methodological trends for advancing our knowledge of the role of biomechanics in osteoarthritis. Rather than provide an exhaustive review of a broad area of research, we have focused on evidence this year related to these subthemes. New research this year has indicated significant interest in using biomechanics investigations to understand structural vs clinical progression of osteoarthritis, the role and interaction in the three-dimensional loading environment of the joint, and the contribution of muscle activation and forces to osteoarthritis progression. There is ongoing interest in understanding how patient variability with respect to gait biomechanics influences arthroplasty surgery outcomes, and subgroup analyses have provided evidence for the potential utility in tailored treatment approaches. Finally, we are seeing a growing trend in the application of translational biomechanics tools such as wearable inertial measurement units for improved integration of biomechanics into clinical decision-making and outcomes assessment for osteoarthritis.

Body mass index moderates the association between gait kinetics, body composition, and femoral knee cartilage characteristics

This study compared femoral cartilage characteristics between age- and sex-matched individuals with (n = 48, age = 22.8 ± 3.5 years; body mass index [BMI] = 33.1 ± 4.1 kg/m² ) and without obesity (n = 48 age = 22.0 ± 2.6 years; BMI = 21.7 ± 1.7 kg/m² ) and evaluated the associations between body composition, quadriceps function, and gait kinetics with femoral cartilage characteristics. Medial and lateral femoral cartilage thickness, medial:lateral thickness ratio and medial and lateral cartilage echo intensity were measured using ultrasound imaging. Body composition was assessed using air displacement plethysmography. Quadriceps function was assessed via maximal isometric knee extension. Three-dimensional gait biomechanics were recorded to extract peak external knee flexion and adduction moments, and peak loading rate of the vertical ground reaction force. Cartilage outcomes were compared between groups using one-way multivariate analysis of variance. Stepwise moderated regression evaluated the association between body composition, quadriceps function, and gait kinetics with femoral cartilage outcomes in individuals with and without obesity. Medial (75.24 vs 65.84; P < .001, d = 1.02) and lateral (58.81 vs 52.22; P < .001, d = 0.78) femoral cartilage echo intensity were higher in individuals with compared with those without obesity. A higher body fat percentage was associated with higher medial and lateral cartilage echo intensity (ΔR²  = 0.09-0.12) in individuals with obesity. A higher knee adduction moment was associated with a larger medial:lateral thickness ratio (ΔR²  = 0.09) in individuals without obesity. No associations were found between quadriceps function and cartilage outcomes. These findings suggest that high body fat in adults with obesity is associated with cartilage echo intensity. The obese body mass index was also associated with a lack of a positive relationship between cartilage thickness and joint loading during walking.

Medial knee cartilage is unlikely to withstand a lifetime of running without positive adaptation: a theoretical biomechanical model of failure phenomena

Runners on average do not have a high risk of developing knee osteoarthritis, even though running places very high loads on the knee joint. Here we used gait analysis, musculoskeletal modeling, and a discrete-element model of knee contact mechanics to estimate strains of the medial knee cartilage in walking and running in 22 young adults (age 23 ± 3 years). A phenomenological model of cartilage damage, repair, and adaptation in response to these strains then estimated the failure probability of the medial knee cartilage over an adult lifespan (age 23-83 years) for 6 km/day of walking vs. walking and running 3 km/day each. With no running, by age 55 the cumulative probability of medial knee cartilage failure averaged 36% without repair and 13% with repair, similar to reports on incidence of knee osteoarthritis in non-obese adults with no knee injuries, but the probability for running was very high without repair or adaptation (98%) and remained high after including repair (95%). Adaptation of the cartilage compressive modulus, cartilage thickness, and the tibiofemoral bone congruence in response to running (+1.15 standard deviations of their baseline values) was necessary for the failure probability of walking and running 3 km/day each to equal the failure probability of walking 6 km/day. The model results suggest two conclusions for further testing: (i) unlike previous findings on the load per unit distance, damage per unit distance on the medial knee cartilage is greater in running vs. walking, refuting the "cumulative load" hypothesis for long-term joint health; (ii) medial knee cartilage is unlikely to withstand a lifetime of mechanical loading from running without a natural adaptation process, supporting the "cartilage conditioning" hypothesis for long-term joint health.

Using Cumulative Load to Explain How Body Mass Index and Daily Walking Relate to Worsening Knee Cartilage Damage Over Two Years: The MOST Study

OBJECTIVE

Knee cartilage damage is often linked to mechanical overloading. However, cartilage requires mechanical load to remain healthy, suggesting that underloading may be detrimental. This study was undertaken to examine knee overloading and underloading by defining cumulative load as the joint effects of body mass index (BMI) and daily walking, and examine the relationship between cumulative load and worsening cartilage damage over 2 years.

METHODS

We used data from the Multicenter Osteoarthritis Study. Steps/day, measured by accelerometry, and BMI were calculated at the 60-month visit. Cartilage damage on magnetic resonance imaging was semiquantitatively scored using the Whole-Organ Magnetic Resonance Imaging Score (WORMS) at the 60-month and 84-month visits; worsening damage was defined as increased WORMS between visits. Risk ratios (RRs) and 95% confidence intervals (95% CIs) were calculated using binomial regression, with adjustment for potential confounders.

RESULTS

Our study included 964 participants, 62% of whom were female, with a mean ± SD age of 66.9 ± 7.5 years. Participants had a mean ± SD BMI of 29.7 ± 4.8 kg/m² and walked a mean ± SD of 7,153 ± 2,591 steps/day. Participants who walked a moderate number of steps/day (6,000-7,900) or a high number of steps/day (>7,900) and had a high BMI (>31 kg/m² ) had a greater risk of worsening medial tibiofemoral (TF) damage (RR 2.83 [95% CI 1.46-5.48] and RR 2.61 [95% CI 1.50-4.54], respectively) compared with those who walked similar steps/day and had a low BMI (18-27 kg/m² ). Participants with a low number of steps/day (<6,000) and a low BMI had a greater risk of worsening medial TF and lateral patellofemoral (PF) damage (RR 2.03 [95% CI 1.06-3.92] and RR 2.28 [95% CI 1.06-4.85], respectively) compared with those who walked a high number of steps/day and had a low BMI. Effect estimates for other compartments of the knee did not reach statistical significance.

CONCLUSION

This study provides preliminary evidence that both overloading and underloading may be detrimental to medial TF cartilage, and underloading may be detrimental to lateral PF cartilage.

Differences in Baseline Joint Moments and Muscle Activation Patterns Associated With Knee Osteoarthritis Progression When Defined Using a Clinical Versus a Structural Outcome

Both structural and clinical changes can signify knee osteoarthritis progression; however, these changes are not always concurrent. A better understanding of mechanical factors associated with progression and whether they differ for structural versus clinical outcomes could lead to improved conservative management. This study examined baseline gait differences between progression and no progression groups defined at an average of 7-year follow-up using 2 different outcomes indicative of knee osteoarthritis progression: radiographic medial joint space narrowing and total knee arthroplasty. Of 49 individuals with knee osteoarthritis who underwent baseline gait analysis, 32 progressed and 17 did not progress using the radiographic outcome, while 13 progressed and 36 did not progress using the arthroplasty outcome. Key knee moment and electromyography waveform features were extracted using principal component analysis, and confidence intervals were used to examine between-group differences in these metrics. Those who progressed using the arthroplasty outcome had prolonged rectus femoris and lateral hamstrings muscle activation compared with the no arthroplasty group. Those with radiographic progression had greater mid-stance internal knee rotation moments compared with the no radiographic progression group. These results provide preliminary evidence for the role of prolonged muscle activation in total knee arthroplasty, while radiographic changes may be related to loading magnitude.

Residual varus alignment after total knee arthroplasty increases knee adduction moment without improving patient function: A propensity score-matched cohort study

BACKGROUND

Targeting residual varus alignment in total knee arthroplasty may be functionally beneficial to preoperative varus patients.

METHODS

Bilateral TKA patients were enrolled. According to the postoperative hip-knee-ankle axis, patients were allocated into residual varus (3° ± 1°) alignment group or neutral (0° ± 1°) alignment group. Then, 1:2 propensity score matching was used to match preoperative variables. Finally, matched neutral (n = 45) and varus groups (n = 32) were followed-up for two years and compared. The primary outcome was the Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were range of motion (ROM), Knee Society knee score and function score, spatiotemporal gait parameters, dynamic alignment, knee flexion angle, knee adduction moment (KAM) and internal knee extension moment.

RESULTS

At two years after surgery, the mean difference of WOMAC score was 0.3 (95% CI, [-3.1, 3.7]) between the two groups. All secondary outcomes, except KAM and dynamic alignment, showed no significant difference between the two groups. Residual varus alignment group showed increased KAM and maximum KAM was 19% higher (P = 0.006).

CONCLUSIONS

Residual varus alignment showed no clinical benefits, and both groups of patients had a functionally identical knee gait biomechanics, except for increased KAM and varus alignment. The authors consider that even in patients with varus alignment, the first principle is still achieving neutral alignment, which is helpful for reducing the KAM.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Association between gait mechanics and ultrasonographic measures of femoral cartilage thickness in individuals with ACL reconstruction

BACKGROUND

Individuals with anterior cruciate ligament reconstruction (ACLR) are at greater risk for knee osteoarthritis, which may be in part due to altered gait biomechanics. Articular cartilage thickness is typically imaged using magnetic resonance imaging, which is costly and lacks portability. Ultrasonography may provide an alternative imaging method for articular cartilage. It is unclear if ultrasonographic measurements of cartilage thickness are associated with gait biomechanics in individuals with ACLR.

RESEARCH QUESTION

To evaluate the association between sagittal and frontal plane knee mechanics during gait and resting femoral cartilage thickness from ultrasonography.

METHODS

Twenty-five females with ACLR (age = 21.7 ± 2.6 years, time since ACLR = 60.6 ± 24.8 months) completed assessments of walking biomechanics and resting femoral cartilage thickness. Linear regression examined the association between gait biomechanics and cartilage thickness at the medial (MC) and lateral (LC) femoral condyles, and intercondylar notch (IC) after accounting for time since ACLR, meniscal injury, and gait speed.

RESULTS

In the ACLR limb, larger vertical ground reaction force (ΔR² = 0.21, pΔ = 0.03), knee flexion angle (ΔR² = 0.15, pΔ = 0.05), knee flexion excursion (KFE) (ΔR² = 0.16, pΔ = 0.04), and knee flexion impulse (KFI) (ΔR² = 0.23, pΔ = 0.02) were associated with thicker MC cartilage. A larger knee adduction angle (ΔR² = 0.20, pΔ = 0.03) and knee adduction moment (KAM) (ΔR² = 0.20, pΔ = 0.03) were associated with thinner MC thickness. Larger KFE (ΔR² = 0.20, pΔ = 0.03) was associated with thicker LC cartilage. Gait biomechanics were not associated with IC cartilage thickness. After accounting for co-variates, the combination of KFI and KAM was predictive of MC thickness (ΔR² = 0.37, pΔ = 0.01; Total R² = 0.52, p = 0.02). Meniscal injury, KAM, and KFI were significant predictors in the model. In the contralateral limb, KFE was associated with thicker MC cartilage (ΔR² = 0.16, pΔ = 0.05).

SIGNIFICANCE

Sagittal and frontal plane knee mechanics during gait are uniquely associated with ultrasonographic measurements of femoral cartilage thickness in individuals with ACLR. Furthermore, concomitant medial meniscal injury was associated with thinner MC cartilage.

Kinematically aligned total knee arthroplasty reduces knee adduction moment more than mechanically aligned total knee arthroplasty

PURPOSE

Knee adduction moment (KAM) has been recognized as a good clinical surrogate for medial tibiofemoral joint loading and is associated with implant durability after total knee arthroplasty (TKA). This study aimed to examine the effects of joint line obliquity in kinematically aligned TKA (KA-TKA) on KAM during gait.

METHODS

The study enrolled 21 knees from 18 patients who underwent cylindrical axis reference KA-TKA and a matched group of 21 knees from 18 patients who underwent mechanically aligned (MA)-TKA as controls. Gait analyses were performed the day before TKA and at an overall mean of 2.6 years postoperatively. First peak KAM and variables associated with frontal knee kinetics were determined and compared between groups.

RESULTS

In KA-TKA, the proximal tibia was resected with 3.4° ± 1.5° of varus in relation to the mechanical axis, and the final femorotibial shaft axis was 176.7° ± 3.8° with KA-TKA and 174.4° ± 3.0° with MA-TKA. KAM was significantly smaller with KA-TKA than with MA-TKA (p < 0.032). Regarding variables affecting KAM, significant differences were evident between the two TKAs for knee adduction angle (p = 0.0021), lever arm (p = 0.028), and Δlever arm (p = 0.0001).

CONCLUSIONS

In KA-TKA, joint line obliquity reduced peak KAM during gait, despite slight varus limb alignment, and this reduced KAM in KA-TKA can tolerate constitutional varus alignment. In clinical settings, KA-TKA thus represents a promising technical option for patients with large coronal bowing of the shaft carrying a risk of increased KAM after TKA.

LEVEL OF EVIDENCE

III.

Relationship between movement time and hip moment impulse in the sagittal plane during sit-to-stand movement: a combined experimental and computer simulation study

Background

The association between repetitive hip moment impulse and the progression of hip osteoarthritis is a recently recognized area of study. A sit-to-stand movement is essential for daily life and requires hip extension moment. Although a change in the sit-to-stand movement time may influence the hip moment impulse in the sagittal plane, this effect has not been examined. The purpose of this study was to clarify the relationship between sit-to-stand movement time and hip moment impulse in the sagittal plane.

Methods

Twenty subjects performed the sit-to-stand movement at a self-selected natural speed. The hip, knee, and ankle joint angles obtained from experimental trials were used to perform two computer simulations. In the first simulation, the actual sit-to-stand movement time obtained from the experiment was entered. In the second simulation, sit-to-stand movement times ranging from 0.5 to 4.0 s at intervals of 0.25 s were entered. Hip joint moments and hip moment impulses in the sagittal plane during sit-to-stand movements were calculated for both computer simulations.

Results and conclusions

The reliability of the simulation model was confirmed, as indicated by the similarities in the hip joint moment waveforms (r = 0.99) and the hip moment impulses in the sagittal plane between the first computer simulation and the experiment. In the second computer simulation, the hip moment impulse in the sagittal plane decreased with a decrease in the sit-to-stand movement time, although the peak hip extension moment increased with a decrease in the movement time. These findings clarify the association between the sit-to-stand movement time and hip moment impulse in the sagittal plane and may contribute to the prevention of the progression of hip osteoarthritis.

MRI UTE-T2* profile characteristics correlate to walking mechanics and patient reported outcomes 2 years after ACL reconstruction

OBJECTIVE

Quantitative magnetic resonance imaging (MRI) ultrashort echo time (UTE) T2* is sensitive to cartilage deep tissue matrix changes after anterior cruciate ligament reconstruction (ACLR). This study was performed to determine whether UTE-T2* profile analysis is a useful clinical metric for assessing cartilage matrix degeneration. This work tests the hypotheses that UTE-T2* depthwise rates of change (profile slopes) correlate with clinical outcome metrics of walking mechanics and patient reported outcomes (PRO) in patients 2 years after ACLR.

DESIGN

Thirty-six patients 2 years after ACLR completed knee MRI, gait analysis, and PRO. UTE-T2* maps were generated from MRI images and depthwise UTE-T2* profiles were calculated for weight-bearing cartilage in the medial compartment. UTE-T2* profiles from 14 uninjured subjects provided reference values. UTE-T2* profile characteristics, including several different measures of profile slope, were tested for correlation to kinetic and kinematic measures of gait and also to PRO.

RESULTS

Decreasing UTE-T2* profile slopes in ACLR knees moderately correlated with increasing knee adduction moments (r = 0.41, P < 0.015), greater external tibial rotation (r = 0.44, P = 0.007), and moderately negatively correlated with PRO (r = -0.36, P = 0.032). UTE-T2* profiles from both ACLR and contralateral knees of ACLR subjects differed from that of uninjured controls (P < 0.015).

CONCLUSIONS

The results of this study suggest that decreasing UTE-T2* profile slopes reflect cartilage deep tissue collagen matrix disruption in a population at increased risk for knee osteoarthritis (OA). That UTE-T2* profiles were associated with mechanical and patient reported measures of clinical outcomes support further study into a potential mechanistic relationship between these factors and OA development.

Baseline varus deformity is associated with increased joint loading and pain of non-operated knee two years after unilateral total knee arthroplasty

BACKGROUND

The goals of this study were (1) to document the gait pattern of patients with unilateral knee osteoarthritis (OA), (2) to determine the knee adduction moment (KAM) changes in the non-operated knee, and (3) to identify the predictors of change in KAM in the non-operated knee.

METHODS

The study recruited 23 patients with advanced unilateral knee OA. The preoperative Kellgren-Lawrence (KL) grade of the non-operated knee was one or two; non-operated knee pain, rated using a numeric rating scale (NRS), was less than three out of 10 points. We used a commercial gait analysis system to evaluate kinetics and kinematics. Radiological and gait measurements at the two-year follow-up were compared with baseline data.

RESULTS

The preoperative asymmetrical gait cycle characterized by elongation of the stance phase of the non-operated knee became symmetrical after TKA. The average KAM of the non-operated knee increased (P=0.010) and it was best predicted by the baseline mechanical axis of the non-operated knee. If the baseline mechanical axis was varus four degrees or above (varus group), the average KAM increased by 0.64 (% body weight×height, P=0.015), while for varus less than four degrees (non-varus group), KAM was unchanged. The KL grade was increased in the varus group (P=0.020) but it was unchanged in the non-varus group. Average pain NRS score was also higher (P=0.044) in the varus group.

CONCLUSIONS

Close follow-up is necessary for patients with a baseline varus deformity of the non-operated knee because of the higher possibility of developing pain, subsequent arthritis and increased joint loading of the non-operated knee.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Biomechanical Response to Osteoarthritis Pain Treatment May Impair Long-Term Efficacy

Pain has an important physiologic role and acts with or stimulates motor system adaptations to protect tissue from threats of damage. Although clinically beneficial, removing the protective pain response may have negative consequence in osteoarthritis, a mechanically mediated disease. We hypothesize motor system adaptations to joint pain and its treatment may impact osteoarthritis progression, thereby limiting efficacy of pain therapies.

Identifying changes in gait waveforms following a strengthening intervention for women with knee osteoarthritis using principal components analysis

Lower limb strengthening exercise is pivotal for the management of symptoms related to knee osteoarthritis (OA). Though improvement in clinical symptoms is well documented, concurrent changes in gait biomechanics are ill-defined. This may occur because discrete analyses miss changes following an intervention, analyses limited to the knee undermine potential mechanical trade-offs at other joints, or strengthening interventions not been designed based on biomechanical principles. The purpose of this study was to characterize differences in entire gait waveforms for sagittal plane ankle, knee, and hip angles and external moments; the knee adduction moment; and frontal plane hip angle and moment following 12-weeks of a previously designed novel lower limb strengthening program. Forty women with knee OA completed two laboratory visits: one at baseline and one immediately following intervention (follow-up). Self-report measures, strength, and gait analyses were completed at each visit. Principal components analyses were completed for sagittal angles and external moments at the ankle, knee, and hip joints, as well as frontal plane angle and moment for the hip. Participants improved self-report and strength (p≤0.004). Two significant, yet subtle differences in principal components were identified between baseline and follow-up waveforms (p<0.05) pertaining to the knee and hip sagittal external moments. The subtle changes in concert with the lack of differences in other joints and planes suggest the lower limb strengthening program does not translate to changes in the gait waveform. It is likely this program is improving symptoms without worsening mechanics.

Application of autofluorescence robotic histology for quantitative evaluation of the 3-dimensional morphology of murine articular cartilage

Murine models of osteoarthritis (OA) are increasingly important for understating pathogenesis and for testing new therapeutic approaches. Their translational potential is, however, limited by the reduced size of mouse limbs which requires a much higher resolution to evaluate their articular cartilage compared to clinical imaging tools. In experimental models, this tissue has been predominantly assessed by time-consuming histopathology using standardized semi-quantitative scoring systems. This study aimed to develop a novel imaging method for 3-dimensional (3D) histology of mouse articular cartilage, using a robotic system-termed here "3D histocutter"-which automatically sections tissue samples and serially acquires fluorescence microscopy images of each section. Tibiae dissected from C57Bl/6 mice, either naïve or OA-induced by surgical destabilization of the medial meniscus (DMM), were imaged using the 3D histocutter by exploiting tissue autofluorescence. Accuracy of 3D imaging was validated by ex vivo contrast-enhanced micro-CT and sensitivity to lesion detection compared with conventional histology. Reconstructions of tibiae obtained from 3D histocutter serial sections showed an excellent agreement with contrast-enhanced micro-CT reconstructions. Furthermore, osteoarthritic features, including articular cartilage loss and osteophytes, were also visualized. An in-house developed software allowed to automatically evaluate articular cartilage morphology, eliminating the subjectivity associated to semi-quantitative scoring and considerably increasing analysis throughput. The novelty of this methodology is, not only the increased throughput in imaging and evaluating mouse articular cartilage morphology starting from conventionally embedded samples, but also the ability to add the third dimension to conventional histomorphometry which might be useful to improve disease assessment in the model.