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Wang X, Liu H, Dong Z, Chen X, Xu C, Ji G, Kang H, Wang F. Contact area and pressure changes of patellofemoral joint during stair ascent and stair descent. BMC Musculoskelet Disord 2023; 24:767. [PMID: 37770867 PMCID: PMC10537124 DOI: 10.1186/s12891-023-06882-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023] Open
Abstract
PURPOSE To investigate the differences of patellofemoral joint pressure and contact area between the process of stair ascent and stair descent. METHODS The finite element models of 9 volunteers without disorders of knee (9 males) to estimate patellar cartilage pressure during the stair ascent and the stair descent. Simulations took into account cartilage morphology from magnetic resonance imaging, joint posture from weight-bearing magnetic resonance imaging, and ligament model. The three-dimension models of the patella, femur and tibia were developed with the medical image processing software, Mimics 11.1. The ligament was established by truss element of the non-linear FE solver. The equivalent gravity direction (-z direction) load was applied to the whole end of femur (femoral head) according to the body weight of the volunteers, and the force of patella was observed. A paired-samples t-test or Wilcoxon rank sum test to make comparisons between stair ascent and stair descent. Statistical analyses were performed using SPSS 22.0 using a P value of 0.05 to indicate significance. RESULTS During the stair descent (knee flexion at 30°), the contact pressure of the patella was 2.59 ± 0.06Mpa. The contact pressure of femoral trochlea cartilage was 2.57 ± 0.06Mpa. During the stair ascent (knee flexion at 60°), the contact pressure with patellar cartilage was 2.82 ± 0.08Mpa. The contact pressure of the femoral trochlea cartilage was 3.03 ± 0.11Mpa. The contact area between patellar cartilage and femoral trochlea cartilage was 249.27 ± 1.35mm2 during the stair descent, which was less than 434.32 ± 1.70mm2 during the stair ascent. The area of high pressure was located in the lateral area of patella during stair descent and the area of high pressure was scattered during stair ascent. CONCLUSION There are small change in the cartilage contact pressure between stair ascent and stair descent, indicating that the joint adjusts the contact pressure by increasing the contact area.
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Affiliation(s)
- Xiaomeng Wang
- Foot and Ankle Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Huixin Liu
- Ultrasound medicine department, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhenyue Dong
- Department of Joint Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaobo Chen
- Department of Joint Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chenyue Xu
- Department of Joint Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Gang Ji
- Department of Joint Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Huijun Kang
- Department of Joint Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Fei Wang
- Department of Joint Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China.
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Liao TC, Bird A, Samaan MA, Pedoia V, Majumdar S, Souza RB. Persistent underloading of patellofemoral joint following hamstring autograft ACL reconstruction is associated with cartilage health. Osteoarthritis Cartilage 2023; 31:1265-1273. [PMID: 37116856 DOI: 10.1016/j.joca.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 03/31/2023] [Accepted: 04/14/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE To determine the longitudinal changes of patellofemoral joint (PFJ) contact pressure following anterior cruciate ligament reconstruction (ACLR). To identify the associations between PFJ contact pressure and cartilage health. DESIGN Forty-nine subjects with hamstring autograft ACLR (27 males; age 28.8 [standard deviation, 8.3] years) and 19 controls (12 males; 30.7 [4.6] years) participated. A sagittal plane musculoskeletal model was used to estimate PFJ contact pressure. A combined T1ρ/T2 magnetic resonance sequence was obtained. Assessments were performed preoperatively, at 6 months, 1, 2, and 3 years postoperatively in ACLR subjects and once for controls. Repeated Analysis of Variance (ANOVA) was used to compare peak PFJ contact pressure between ACLR and contralateral knees, and t-tests to compare with control knees. Statistical parametric mapping was used to evaluate the associations between PFJ contact pressure and cartilage relaxation concurrently and longitudinally. RESULTS No changes in peak PFJ contact pressure were found within ACLR knees over 3 years (preoperative to 3 years, 0.36 [CI, -0.08, 0.81] MPa), but decreased over time in the contralateral knees (0.75 [0.32, 1.18] MPa). When compared to the controls, ACLR knees exhibited lower PFJ contact pressure at all time points (at baseline, -0.64 [-1.25, -0.03] MPa). Within ACLR knees, lower PFJ contact pressure at 6 months was associated with elevated T2 times (r = -0.47 to -0.49, p = 0.021-0.025). CONCLUSIONS Underloading of the PFJ following ACLR persists for up to 3 years and has concurrent and future consequences in cartilage health. The non-surgical knees exhibited normal contact pressure initially but decreased over time achieving limb symmetry.
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Affiliation(s)
- Tzu-Chieh Liao
- Department of Physical Therapy, University of Michigan-Flint, Flint, MI, USA; Department of Radiology, University of Michigan, Ann Arbor, MI, USA.
| | - Alyssa Bird
- Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco, San Francisco, CA, USA
| | - Michael A Samaan
- Department of Kinesiology and Health Promotion, University of Kentucky, Lexington, KY, USA
| | - Valentina Pedoia
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Sharmila Majumdar
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Richard B Souza
- Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco, San Francisco, CA, USA; Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
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Schranz C, Sperl M, Kraus T, Guggenberger B, Kruse A, Habersack A, Svehlik M. Different gait pattern in adolescence with patellofemoral instability. Clin Biomech (Bristol, Avon) 2023; 108:106067. [PMID: 37633176 DOI: 10.1016/j.clinbiomech.2023.106067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Patellofemoral instability influences the gait pattern and activity level in adolescents. However, gait biomechanics to cope with recurrent patella instability and its relation to radiological findings has hardly been studied. METHODS We retrospectively analyzed kinematic and kinetic gait analysis data, magnetic resonance images and X-ray of 32 adolescents with unilateral recurrent patellofemoral instability aged 12 to 18 years. Subjects were assigned to 3 groups based on their sagittal knee moment in the loading response and mid stance phase. Kinematic and kinetic differences among the groups were analyzed using a one-way ANOVA. A multinomial logistic regression model provided a further analysis of the relationship between gait biomechanics and MRI as well as X-ray parameters. FINDINGS All three groups showed different characteristics of the knee kinematics during loading response and single stance: while the patella-norm-loading group showed a slightly reduced knee flexion (p 〈0,01), the patella-unloading group kept the knee nearly extended (p < 0,01) and patella-overloading group showed an increased knee flexion (p = 0,01) compared to the other groups. In single stance the patella-overloading group maintained increased knee flexion (p < 0,01) compared to patella-unloading group and patella-norm-loading group. None of the radiological parameters proved to be related to gait patterns. INTERPRETATION The paper describes different gait coping strategies and their clinical relevance in subjects with patellofemoral instability. However, we did not find any relation of gait biomechanics to skeletal morphology.
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Affiliation(s)
- Christian Schranz
- Paediatric Orthopaedic Unit, Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria.
| | - Matthias Sperl
- Paediatric Orthopaedic Unit, Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Tanja Kraus
- Paediatric Orthopaedic Unit, Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Bernhard Guggenberger
- Paediatric Orthopaedic Unit, Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria; Institute of Physiotherapy, JOANNEUM University of Applied Sciences, Alte Poststraße 154, 8020 Graz, Austria
| | - Annika Kruse
- Institute of Human Movement Science, Sport and Health, University of Graz, Mozartgasse 14, 8010 Graz, Austria
| | - Andreas Habersack
- Paediatric Orthopaedic Unit, Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria; Institute of Human Movement Science, Sport and Health, University of Graz, Mozartgasse 14, 8010 Graz, Austria
| | - Martin Svehlik
- Paediatric Orthopaedic Unit, Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
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Ling M, Liang Z, Wang Y, Cheng M, Lu S, Pan Y, Hu H, Chen B, Ding J. Elbow Kinematics and Function Following Treatment with Open Arthrolysis and Hinged External Fixator. Orthop Surg 2023; 15:2102-2109. [PMID: 37052066 PMCID: PMC10432452 DOI: 10.1111/os.13714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 02/24/2023] [Accepted: 03/02/2023] [Indexed: 04/14/2023] Open
Abstract
OBJECTIVE Open arthrolysis (OA) combined with hinged external fixator (HEF) is a promising surgical option for patients with elbow stiffness. This study aimed to investigate elbow kinematics and function following a combined treatment with OA and HEF in elbow stiffness cases. METHODS Patients treated with OA with or without HEF due to elbow stiffness were recruited between August 2017 and July 2019. Elbow flexion-extension motion and function (Mayo elbow performance scores, MEPS) were recorded and compared between patients with and without HEF during a 1-year follow-up period. Additionally, those with HEF were assessed by dual fluoroscopy at week 6 postoperatively. Flexion-extension and varus-valgus motions, as well as ligament insertion distances of the anterior medial collateral ligament (AMCL) and lateral ulnar collateral ligament (LUCL), were compared between the surgical and intact sides. RESULTS This study included 42 patients, of which 12 with HEF demonstrated a similar flexion-extension angle and range of motion (ROM) and MEPS as the other patients. In patients with HEF, the surgical elbows showed limitations in flexion-extension (maximal flexion, 120.5° ± 5.3° vs 140.4° ± 6.8°; maximal extension, 13.1° ± 6.0° vs 6.4° ± 3.0°; ROM, 107.4° ± 9.9° vs 134.0° ± 6.8°; all Ps < 0.01) compared with the contralateral sides. During elbow flexion, a gradual valgus-to-varus transition of the ulna, increase in the AMCL insertion distance, and steady change in the LUCL insertion distance were observed, with no significant differences between the bilateral sides. CONCLUSIONS Patients treated with OA and HEF demonstrated similar elbow flexion-extension motion and function to those treated with OA alone. Although the use of HEF could not restore an intact flexion-extension ROM and might result in some minor but not significant changes in kinematics, it contributed to clinical outcomes comparable to that of the treatment with OA alone.
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Affiliation(s)
- Ming Ling
- Biomechanical Laboratory of Orthopaedic Surgery DepartmentShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
- Department of OrthopaedicsHuadong Hospital Affiliated to Fudan UniversityShanghaiChina
| | - Zhenming Liang
- Orthopaedic CenterAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
| | - Yanmao Wang
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Mengqi Cheng
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Shengdi Lu
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Yao Pan
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Hai Hu
- Biomechanical Laboratory of Orthopaedic Surgery DepartmentShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Bin Chen
- Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Jian Ding
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
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Wang B, Mao Z, Guo J, Yang J, Zhang S. The non-invasive evaluation technique of patellofemoral joint stress: a systematic literature review. Front Bioeng Biotechnol 2023; 11:1197014. [PMID: 37456733 PMCID: PMC10343958 DOI: 10.3389/fbioe.2023.1197014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction: Patellofemoral joint stress (PFJS) is an important parameter for understanding the mechanism of patellofemoral joint pain, preventing patellofemoral joint injury, and evaluating the therapeutic efficacy of PFP rehabilitation programs. The purpose of this systematic review was to identify and categorize the non-invasive technique to evaluate the PFJS. Methods: Literature searches were conducted from January 2000 to October 2022 in electronic databases, namely, PubMed, Web of Science, and EBSCO (Medline, SPORTDiscus). This review includes studies that evaluated the patellofemoral joint reaction force (PJRF) or PFJS, with participants including both healthy individuals and those with patellofemoral joint pain, as well as cadavers with no organic changes. The study design includes cross-sectional studies, case-control studies, and randomized controlled trials. The JBI quality appraisal criteria tool was used to assess the risk of bias in the included studies. Results: In total, 5016 articles were identified in the database research and the citation network, and 69 studies were included in the review. Discussion: Researchers are still working to improve the accuracy of evaluation for PFJS by using a personalized model and optimizing quadriceps muscle strength calculations. In theory, the evaluation method of combining advanced computational and biplane fluoroscopy techniques has high accuracy in evaluating PFJS. The method should be further developed to establish the "gold standard" for PFJS evaluation. In practical applications, selecting appropriate methods and approaches based on theoretical considerations and ecological validity is essential.
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Chokhandre S, Schwartz A, Klonowski E, Landis B, Erdemir A. Open Knee(s): A Free and Open Source Library of Specimen-Specific Models and Related Digital Assets for Finite Element Analysis of the Knee Joint. Ann Biomed Eng 2023; 51:10-23. [PMID: 36104640 PMCID: PMC9832097 DOI: 10.1007/s10439-022-03074-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/04/2022] [Indexed: 01/28/2023]
Abstract
There is a growing interest in the use of virtual representations of the knee for musculoskeletal research and clinical decision making, and to generate digital evidence for design and regulation of implants. Accessibility to previously developed models and related digital assets can dramatically reduce barriers to entry to conduct simulation-based studies of the knee joint and therefore help accelerate scientific discovery and clinical innovations. Development of models for finite element analysis is a demanding process that is both time consuming and resource intensive. It necessitates expertise to transform raw data to reliable virtual representations. Modeling and simulation workflow has many processes such as image segmentation, surface geometry generation, mesh generation and finally, creation of a finite element representation with relevant loading and boundary conditions. The outcome of the workflow is not only the end-point knee model but also many other digital by-products. When all of these data, derivate assets, and tools are freely and openly accessible, researchers can bypass some or all the steps required to build models and focus on using them to address their research goals. With provenance to specimen-specific anatomical and mechanical data and traceability of digital assets throughout the whole lifecycle of the model, reproducibility and credibility of the modeling practice can be established. The objective of this study is to disseminate Open Knee(s), a cohort of eight knee models (and relevant digital assets) for finite element analysis, that are based on comprehensive specimen-specific imaging data. In addition, the models and by-products of modeling workflows are described along with model development strategies and tools. Passive flexion served as a test simulation case, demonstrating an end-user application. Potential roadmaps for reuse of Open Knee(s) are also discussed.
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Affiliation(s)
- Snehal Chokhandre
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH USA
| | - Ariel Schwartz
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH USA
| | - Ellen Klonowski
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH USA
| | - Benjamin Landis
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH USA
| | - Ahmet Erdemir
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH USA
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Cartilage thickness and bone shape variations as a function of sex, height, body mass, and age in young adult knees. Sci Rep 2022; 12:11707. [PMID: 35810204 PMCID: PMC9271066 DOI: 10.1038/s41598-022-15585-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 06/27/2022] [Indexed: 11/22/2022] Open
Abstract
The functional relationship between bone and cartilage is modulated by mechanical factors. Scarce data exist on the relationship between bone shape and the spatial distribution of cartilage thickness. The aim of the study was to characterise the coupled variation in knee bone morphology and cartilage thickness distributions in knees with healthy cartilage and investigate this relationship as a function of sex, height, body mass, and age. MR images of 51 knees from young adults (28.4 ± 4.1 years) were obtained from a previous study and used to train a statistical shape model of the femur, tibia, and patella and their cartilages. Five multiple linear regression models were fitted to characterise morphology as a function of sex, height, body mass, and age. A logistic regression classifier was fitted to characterise morphological differences between males and females, and tenfold cross-validation was performed to evaluate the models’ performance. Our results showed that cartilage thickness and its distribution were coupled to bone morphology. The first five shape modes captured over 90% of the variance and described coupled changes to the bone and spatial distribution of cartilage thickness. Mode 1 (size) was correlated to sex (p < 0.001) and height (p < 0.0001). Mode 2 (aspect ratio) was also correlated to sex (p = 0.006) and height (p = 0.017). Mode 4 (condylar depth) was correlated to sex only (p = 0.024). A logistic regression model trained on modes 1, 2, and 4 could classify sex with an accuracy of 92.2% (95% CI [81.1%, 97.8%]). No other modes were influenced by sex, height, body mass, or age. This study demonstrated the coupled relationship between bone and cartilage, showing that cartilage is thicker with increased bone size, diaphysis size, and decreased femoral skew. Our results show that sex and height influence bone shape and the spatial distribution of cartilage thickness in a healthy young adult population, but body mass and age do not.
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Zimmermann F, Milinkovic DD, Balcarek P. Outcomes After Deepening Trochleoplasty and Concomitant Realignment in Patients With Severe Trochlear Dysplasia With Chronic Patellofemoral Pain: Results at 2-Year Follow-up. Orthop J Sports Med 2021; 9:23259671211010404. [PMID: 34164556 PMCID: PMC8191084 DOI: 10.1177/23259671211010404] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/05/2021] [Indexed: 01/26/2023] Open
Abstract
Background Abnormal patellofemoral joint stress appears to have major relevance in a subgroup of patients with patellofemoral pain (PFP). Purpose To evaluate whether patients with chronic PFP and trochlear dysplasia-induced patellofemoral joint malalignment benefit from a deepening trochleoplasty procedure with the aim of improving patellotrochlear congruence. Study Design Case series; Level of evidence, 4. Methods Included were 15 patients (male/female, 1/14; mean age, 30.3 years [range, 19-51 years]) with 8.8 years (range, 1-20 years) of chronic PFP and severe trochlear dysplasia. All patients underwent correction of patellotrochlear malalignment with deepening trochleoplasty and concomitant realignment procedures. The Kujala score and a numerical analog scale (0-10) for intensity of pain were used to assess symptoms preoperatively and at 12 and 24 months postoperatively. Pre- and postoperative magnetic resonance imaging (MRI) scans from the patients were compared with the MRI scans of age- and sex-matched controls regarding the patellotrochlear contact area and contact ratio, patellar tilt, patellotrochlear index, and lateral trochlear inclination (LTI) angle. Results The Kujala score increased from a mean of 55 (range, 15-81) preoperatively to 82.5 (range, 53-98) after 12 months (95% CI, -42.56 to -12.37; P < .001) and to 84.2 (range, 59-99) after 24 months (95% CI, -44.29 to -14.11; P < .001). The intensity of PFP decreased from 5.7 (range, 3-10) preoperatively to 1.4 (range, 0-4) after 12 months (95% CI, 2.57 to 5.96; P < .001) and had a mean of 1.6 (range, 0-6) after 24 months (95% CI, 2.44 to 5.75; P < .001). Preoperatively, parameters in the study group indicated significant patellotrochlear malalignment, which improved and normalized (except for the LTI angle) postoperatively compared with the values of the control group (P > .05). Conclusion In a subgroup of patients with chronic PFP due to severe trochlear dysplasia, deepening trochleoplasty and concomitant realignment procedures significantly reduced pain and improved knee joint function while normalizing patellotrochlear congruence.
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Affiliation(s)
| | | | - Peter Balcarek
- Arcus Sportklinik, Pforzheim, Germany.,Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Göttingen, Germany
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Yu L, Mei Q, Mohamad NI, Gu Y, Fernandez J. An exploratory investigation of patellofemoral joint loadings during directional lunges in badminton. Comput Biol Med 2021; 132:104302. [PMID: 33677166 DOI: 10.1016/j.compbiomed.2021.104302] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 10/22/2022]
Abstract
Anterior knee pain is a commonly documented musculoskeletal disorder among badminton players. However, current biomechanical studies of badminton lunges mainly report kinetic profiles in the lower extremity with few investigations of in-vivo loadings. The objective of this study was to evaluate tissue loadings in the patellofemoral joint via musculoskeletal modelling and Finite Element simulation. The collected marker trajectories, ground reaction force and muscle activation data were used for musculoskeletal modelling to compute knee joint angles and quadricep muscle forces. These parameters were then set as boundary conditions and loads for a quasistatic simulation using the Abaqus Explicit solver. Simulations revealed that the left-forward (LF) and backward lunges showed greater contact pressure (14.98-29.61%) and von Mises stress (14.17-32.02%) than the right-forward and backward lunges; while, loadings in the left-backward lunge were greater than the left-forward lunge by 13-14%. Specifically, the stress in the chondral layer was greater than the contact interface, particularly in the patellar cartilage. These findings suggest that right-side dominant badminton players load higher in the right patellofemoral joint during left-side (backhand) lunges. Knowledge of these tissue loadings may provide implications for the training of badminton footwork, such as musculature development, to reduce cartilage loading accumulation, and prevent anterior knee pain.
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Affiliation(s)
- Lin Yu
- Loudi Vocational and Technical College, Loudi, China; Faculty of Sports Sciences and Coaching, Sultan Idris Education University, Tanjong Malim, Malaysia; Faculty of Sports Science, Ningbo University, Ningbo, China
| | - Qichang Mei
- Faculty of Sports Science, Ningbo University, Ningbo, China; Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.
| | - Nur Ikhwan Mohamad
- Faculty of Sports Sciences and Coaching, Sultan Idris Education University, Tanjong Malim, Malaysia
| | - Yaodong Gu
- Faculty of Sports Science, Ningbo University, Ningbo, China; Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.
| | - Justin Fernandez
- Faculty of Sports Science, Ningbo University, Ningbo, China; Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand; Department of Engineering Science, University of Auckland, Auckland, New Zealand
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Waiteman MC, de Oliveira Silva D, Azevedo FM, Pazzinatto MF, Briani RV, Bazett-Jones DM. Women with patellofemoral pain and knee crepitus have reduced knee flexion angle during stair ascent. Phys Ther Sport 2020; 48:60-66. [PMID: 33373904 DOI: 10.1016/j.ptsp.2020.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 12/12/2020] [Accepted: 12/15/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To compare trunk and knee biomechanics of women with and without patellofemoral pain (PFP) and knee crepitus during stair ascent. DESIGN Cross-sectional. SETTING Laboratory-based study. PARTICIPANTS 29 women with PFP and knee crepitus (PFPCrepitus); 28 women with PFP and no knee crepitus (PFPNOCrepitus); 17 pain-free women with knee crepitus (Pain-freeCrepitus); and 29 pain-free women without knee crepitus (Pain-freeNOCrepitus). MAIN OUTCOME MEASURES Peak trunk flexion, peak knee flexion, mean knee angular velocity, knee extensor moment at peak knee flexion, peak and impulse of the knee extensor moment. RESULTS PFPCrepitus group performed the stair ascent task with reduced peak knee flexion compared to Pain-freeCrepitus (p = 0.04; Effect size = -0.85) and Pain-freeNOCrepitus (p = 0.03; Effect size = -0.75). No significant differences among groups were found for peak trunk flexion (p = 0.979), knee angular velocity (p = 0.420), knee extensor moment at peak knee flexion (p = 0.933), peak (p = 0.290) and impulse (p = 0.122) of the knee extensor moment. CONCLUSION Women with concomitant PFP and knee crepitus demonstrated reduced knee flexion during stair ascent, but no significant differences for trunk flexion and knee extensor moment variables were found.
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Affiliation(s)
- Marina Cabral Waiteman
- Sao Paulo State University (UNESP), School of Science and Technology, Physical Therapy Department, Presidente Prudente, Brazil; University of Toledo, School of Exercise and Rehabilitation Sciences, Toledo, OH, USA.
| | - Danilo de Oliveira Silva
- Sao Paulo State University (UNESP), School of Science and Technology, Physical Therapy Department, Presidente Prudente, Brazil; La Trobe Sports and Exercise Medicine Research Centre (LASEM), School of Allied Health, La Trobe University, Bundoora, Victoria, Australia.
| | - Fábio M Azevedo
- Sao Paulo State University (UNESP), School of Science and Technology, Physical Therapy Department, Presidente Prudente, Brazil.
| | - Marcella F Pazzinatto
- Sao Paulo State University (UNESP), School of Science and Technology, Physical Therapy Department, Presidente Prudente, Brazil; La Trobe Sports and Exercise Medicine Research Centre (LASEM), School of Allied Health, La Trobe University, Bundoora, Victoria, Australia.
| | - Ronaldo V Briani
- Sao Paulo State University (UNESP), School of Science and Technology, Physical Therapy Department, Presidente Prudente, Brazil; La Trobe Sports and Exercise Medicine Research Centre (LASEM), School of Allied Health, La Trobe University, Bundoora, Victoria, Australia.
| | - David M Bazett-Jones
- University of Toledo, School of Exercise and Rehabilitation Sciences, Toledo, OH, USA.
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De Oliveira Silva D, Willy RW, Barton CJ, Christensen K, Pazzinatto MF, Azevedo FM. Pain and disability in women with patellofemoral pain relate to kinesiophobia, but not to patellofemoral joint loading variables. Scand J Med Sci Sports 2020; 30:2215-2221. [DOI: 10.1111/sms.13767] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/03/2020] [Accepted: 07/03/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Danilo De Oliveira Silva
- La Trobe Sport and Exercise Medicine Research Centre (LASEM) School of Allied Health, Human Services and Sport La Trobe University Bundoora Australia
- Department of Physiotherapy School of Science and Technology Sao Paulo State University (UNESP) Presidente Prudente Brazil
| | - Richard W. Willy
- School of Physical Therapy and Movement Sciences University of Montana Missoula MT USA
| | - Christian J. Barton
- La Trobe Sport and Exercise Medicine Research Centre (LASEM) School of Allied Health, Human Services and Sport La Trobe University Bundoora Australia
- Department of Surgery St Vincent's Hospital University of Melbourne Melbourne Australia
| | - Kelly Christensen
- School of Physical Therapy and Movement Sciences University of Montana Missoula MT USA
| | - Marcella F. Pazzinatto
- La Trobe Sport and Exercise Medicine Research Centre (LASEM) School of Allied Health, Human Services and Sport La Trobe University Bundoora Australia
- Department of Physiotherapy School of Science and Technology Sao Paulo State University (UNESP) Presidente Prudente Brazil
| | - Fábio M. Azevedo
- Department of Physiotherapy School of Science and Technology Sao Paulo State University (UNESP) Presidente Prudente Brazil
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Holyoak DT, Chlebek C, Kim MJ, Wright TM, Otero M, van der Meulen MCH. Low-level cyclic tibial compression attenuates early osteoarthritis progression after joint injury in mice. Osteoarthritis Cartilage 2019; 27:1526-1536. [PMID: 31265883 PMCID: PMC6814162 DOI: 10.1016/j.joca.2019.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 06/02/2019] [Accepted: 06/06/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Mechanical loading and joint health have a unique relationship in osteoarthritis (OA) onset and progression. Although high load levels adversely affect cartilage health, exercise that involves low to moderate load levels can alleviate OA symptoms. We sought to isolate the beneficial effects of mechanical loading using controlled in vivo cyclic tibial compression. We hypothesized that low-level cyclic compression would attenuate post-traumatic OA symptoms induced by destabilization of the medial meniscus (DMM). METHODS 10-week-old C57Bl/6J male mice underwent DMM surgery (n = 51). After a 5-day post-operative recovery period, we applied daily cyclic tibial compression to the operated limbs at low (1.0N or 2.0N) or moderate (4.5N) magnitudes for 2 or 6 weeks. At the completion of loading, we compared cartilage and peri-articular bone features of mice that underwent DMM and loading to mice that only underwent DMM. RESULTS Compared to DMM alone, low-level cyclic compression for 6 weeks attenuated DMM-induced cartilage degradation (OARSI score, P = 0.008, 95% confidence interval (CI): 0.093 to 0.949). Low-level loading attenuated DMM-induced osteophyte formation after 2 weeks (osteophyte size, P = 0.033, 95% CI: 3.27-114.45 μm), and moderate loading attenuated subchondral bone sclerosis after 6 weeks (tissue mineral density (TMD), P = 0.011, 95% CI: 6.32-70.60 mg HA/ccm) compared to limbs that only underwent DMM. Finally, loading had subtle beneficial effects on cartilage cellularity and aggrecanase activity after DMM. CONCLUSION Low-level cyclic compression is beneficial to joint health after an injury. Therefore, the progression of early OA may be attenuated by applying well controlled, low-level loading shortly following joint trauma.
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Affiliation(s)
| | - C Chlebek
- Cornell University, Ithaca, NY, USA.
| | - M J Kim
- Cornell University, Ithaca, NY, USA.
| | - T M Wright
- Cornell University, Ithaca, NY, USA; Hospital for Special Surgery, New York, NY, USA; Weill Cornell Medicine, New York, NY, USA.
| | - M Otero
- Hospital for Special Surgery, New York, NY, USA.
| | - M C H van der Meulen
- Cornell University, Ithaca, NY, USA; Hospital for Special Surgery, New York, NY, USA.
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Fatima M, Scholes CJ, Zhong E, Kohan L. Towards a Dynamic Model of the Kangaroo Knee for Clinical Insights into Human Knee Pathology and Treatment: Establishing a Static Biomechanical Profile. Biomimetics (Basel) 2019; 4:biomimetics4030052. [PMID: 31349696 PMCID: PMC6784414 DOI: 10.3390/biomimetics4030052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/19/2019] [Accepted: 07/23/2019] [Indexed: 12/23/2022] Open
Abstract
There is limited understanding of how patella realignment or patellectomy to surgically manage patellofemoral pain (PFP) affects knee biomechanics. By analysing marsupials like kangaroos that lack an ossified patella, actionable biomimetic insight for the management of end-stage PFP could be gained. This study aimed to provide the foundation of a multi-stage approach, by establishing a static biomechanical profile of the kangaroo stifle that informs the inputs and factors requiring consideration for future dynamic analyses. Volumetric CT and MRI sequences were obtained for four hindlimbs from two Macropus giganteus specimens, from which three-dimensional models of the stifles were created. Two limbs were dissected to visualise the insertion points, origins and lines of action of the quadriceps muscles and the knee extensor mechanism. Static measurements were obtained from the three-dimensional models to establish the biomechanical profile. The results confirmed structural differences in the kangaroo stifle with lack of an ossified patella, a prominent tuberosity and a shorter femur, which functionally affect the mechanical advantage and the torque-generating capability of the joint. The data reported in this study can be used to inform the inputs and constraints of future comparative analyses from which important lessons can be learned for the human knee.
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Affiliation(s)
| | | | - Emily Zhong
- EBM Analytics, Crows Nest, NSW 2065, Australia
| | - Lawrence Kohan
- Joint Orthopaedic Centre, Bondi Junction, NSW 2022, Australia
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Bulat M, Korkmaz Can N, Arslan YZ, Herzog W. Musculoskeletal Simulation Tools for Understanding Mechanisms of Lower-Limb Sports Injuries. Curr Sports Med Rep 2019; 18:210-216. [DOI: 10.1249/jsr.0000000000000601] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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15
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Pal S, Besier TF, Gold GE, Fredericson M, Delp SL, Beaupre GS. Patellofemoral cartilage stresses are most sensitive to variations in vastus medialis muscle forces. Comput Methods Biomech Biomed Engin 2018; 22:206-216. [PMID: 30596523 DOI: 10.1080/10255842.2018.1544629] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to evaluate the effects of variations in quadriceps muscle forces on patellofemoral stress. We created subject-specific finite element models for 21 individuals with chronic patellofemoral pain and 16 pain-free control subjects. We extracted three-dimensional geometries from high resolution magnetic resonance images and registered the geometries to magnetic resonance images from an upright weight bearing squat with the knees flexed at 60°. We estimated quadriceps muscle forces corresponding to 60° knee flexion during a stair climb task from motion analysis and electromyography-driven musculoskeletal modelling. We applied the quadriceps muscle forces to our finite element models and evaluated patellofemoral cartilage stress. We quantified cartilage stress using an energy-based effective stress, a scalar quantity representing the local stress intensity in the tissue. We used probabilistic methods to evaluate the effects of variations in quadriceps muscle forces from five trials of the stair climb task for each subject. Patellofemoral effective stress was most sensitive to variations in forces in the two branches of the vastus medialis muscle. Femur cartilage effective stress was most sensitive to variations in vastus medialis forces in 29/37 (78%) subjects, and patella cartilage effective stress was most sensitive to variations in vastus medialis forces in 21/37 (57%) subjects. Femur cartilage effective stress was more sensitive to variations in vastus medialis longus forces in subjects classified as maltrackers compared to normal tracking subjects (p = 0.006). This study provides new evidence of the importance of the vastus medialis muscle in the treatment of patellofemoral pain.
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Affiliation(s)
- Saikat Pal
- a Department of Biomedical Engineering , New Jersey Institute of Technology , Newark , NJ , USA
| | - Thor F Besier
- b Auckland Bioengineering Institute & Department of Engineering Science , University of Auckland , Auckland , New Zealand
| | - Garry E Gold
- c Department of Bioengineering , Stanford University , Stanford , CA , USA.,d Department of Radiology , Stanford University , Stanford , CA , USA.,e Department of Orthopaedic Surgery , Stanford University , Stanford , CA , USA
| | - Michael Fredericson
- e Department of Orthopaedic Surgery , Stanford University , Stanford , CA , USA
| | - Scott L Delp
- c Department of Bioengineering , Stanford University , Stanford , CA , USA.,e Department of Orthopaedic Surgery , Stanford University , Stanford , CA , USA.,f Mechanical Engineering Department , Stanford University , Stanford , CA , USA
| | - Gary S Beaupre
- c Department of Bioengineering , Stanford University , Stanford , CA , USA.,g Musculoskeletal Research Laboratory , VA Palo Alto Health Care System , Palo Alto , CA , USA
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Dagneaux L, Allal R, Pithioux M, Chabrand P, Ollivier M, Argenson JN. Femoral malrotation from diaphyseal fractures results in changes in patellofemoral alignment and higher patellofemoral stress from a finite element model study. Knee 2018; 25:807-813. [PMID: 30060996 DOI: 10.1016/j.knee.2018.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 05/11/2018] [Accepted: 06/06/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Malrotation of the femur is a frequent complication in the management of a diaphyseal fracture. It is often responsible for pain and adverse functional results. Among these complications, contact stress effects on the patellofemoral joint are recognized as predictive factors of impaired results. The purpose of this study was to analyze the effect of malrotation on stress distribution on the patellofemoral joint, using radiological measurement and three-dimensional finite element models. METHODS Functional analysis of the patellofemoral joint was evaluated in eight knee pairs from patients with unilateral femoral fractures and subsequent femoral malrotation. A computed tomography-based protocol allowed patellofemoral joint analysis. A finite element model of the healthy (contralateral) knee was then created from 3D reconstruction at 30° flexion. In a finite element model, incremental rotational malalignment was simulated to observe changes in stress distribution on the patellar surface. RESULTS Femoral malrotation was associated with anomalies of patellofemoral joint rotational alignment. Internal rotation resulted in increased stress on the lateral side of the patella, and external rotation increased inferior medial side stress. CONCLUSIONS Rotational disorders of the distal femur resulted in increased stress on the patellofemoral joint and alignment changes. Malrotation in internal and external rotation might cause patellofemoral pain syndrome from rotations <10°. Care should be taken especially for internal malrotation in the management of femoral shaft fracture.
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Affiliation(s)
- Louis Dagneaux
- Aix Marseille University, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopaedics and Traumatology, Marseille, France; Department of Orthopaedic Surgery, Lower Limb Surgery Unit, Lapeyronie University Hospital, Montpellier Cedex 05, France; Aix Marseille University, CNRS, ISM, Inst Movement Sci, France.
| | - Raphael Allal
- Aix Marseille University, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopaedics and Traumatology, Marseille, France
| | - Martine Pithioux
- Aix Marseille University, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopaedics and Traumatology, Marseille, France
| | - Patrick Chabrand
- Aix Marseille University, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopaedics and Traumatology, Marseille, France
| | - Matthieu Ollivier
- Aix Marseille University, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopaedics and Traumatology, Marseille, France
| | - Jean-Noël Argenson
- Aix Marseille University, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopaedics and Traumatology, Marseille, France
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Runners With Patellofemoral Pain Exhibit Greater Peak Patella Cartilage Stress Compared With Pain-Free Runners. J Appl Biomech 2018; 34:298-305. [DOI: 10.1123/jab.2017-0229] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The primary purpose of this study is to determine whether recreational runners with patellofemoral pain (PFP) exhibit greater peak patella cartilage stress compared with pain-free runners. A secondary purpose was to determine the kinematic and/or kinetic predictors of peak patella cartilage stress during running. A total of 22 female recreational runners (12 with PFP and 10 pain-free controls) participated in this study. Patella cartilage stress profiles were quantified using subject-specific finite element models simulating the maximum knee flexion angle during the stance phase of running. Input parameters to the finite element model included subject-specific patellofemoral joint geometry, quadriceps muscle forces, and lower-extremity kinematics in the frontal and transverse planes. Tibiofemoral joint kinematics and kinetics were quantified to determine the best predictor of stress using stepwise regression analysis. Compared with the pain-free runners, those with PFP exhibited greater peak hydrostatic pressure (PFP vs control: 21.2 [5.6] MPa vs 16.5 [4.6] MPa) and maximum shear stress (PFP vs control: 11.3 [4.6] MPa vs 8.7 [2.3] MPa). Knee external rotation was the best predictor of peak hydrostatic pressure and peak maximum shear stress (38% and 25% of variances, respectively), followed by the knee extensor moment (21% and 25% of variances, respectively). Runners with PFP exhibit greater peak patella cartilage stress during running compared with pain-free individuals. The combination of knee external rotation and a high knee extensor moment best predicted the elevated peak stress during running.
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Leibbrandt D, Louw Q. Kinematic factors associated with anterior knee pain during common aggravating activities: a systematic review. PHYSICAL THERAPY REVIEWS 2017. [DOI: 10.1080/10833196.2017.1283832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Dominique Leibbrandt
- Faculty of Medicine and Health Sciences, University of Stellenbosch, Physiotherapy Division/FNB-3D Movement Analysis Laboratory , Tygerberg, South Africa
| | - Quinette Louw
- Faculty of Medicine and Health Sciences, University of Stellenbosch, Physiotherapy Division/FNB-3D Movement Analysis Laboratory , Tygerberg, South Africa
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Lee YH, Yang J, Jeong HK, Suh JS. Assessment of the patellofemoral cartilage: Correlation of knee pain score with magnetic resonance cartilage grading and magnetization transfer ratio asymmetry of glycosaminoglycan chemical exchange saturation transfer. Magn Reson Imaging 2016; 35:61-68. [PMID: 27580516 DOI: 10.1016/j.mri.2016.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 07/25/2016] [Accepted: 08/20/2016] [Indexed: 01/08/2023]
Abstract
PURPOSE Biochemical imaging of glycosaminoglycan chemical exchange saturation transfer (gagCEST) could predict the depletion of glycosaminoglycans (GAG) in early osteoarthritis. The purpose of this study was to evaluate the relationship between the magnetization transfer ratio asymmetry (MTRasym) of gagCEST images and visual analog scale (VAS) pain scores in the knee joint. MATERIALS AND METHODS This retrospective study was approved by the institutional review board. A phantom study was performed using hyaluronic acid to validate the MTRasym values of gagCEST images. Knee magnetic resonance (MR) images of 22 patients (male, 9; female, 13; mean age, 50.3years; age range; 25-79years) with knee pain were included in this study. The MR imaging (MRI) protocol involved standard knee MRI as well as gagCEST imaging, which allowed region-of-interest analyses of the patellar facet and femoral trochlea. The MTRasym at 1.0ppm was calculated at each region. The cartilages of the patellar facets and femoral trochlea were graded according to the Outerbridge classification system. Data regarding the VAS scores of knee pain were collected from the electronic medical records of the patients. Statistical analysis was performed using Spearman's correlation. RESULTS The results of the phantom study revealed excellent correlation between the MTRasym values and the concentration of GAGs (r=0.961; p=0.003). The cartilage grades on the MR images showed significant negative correlation with the MTRasym values in the patellar facet and femoral trochlea (r=-0.460; p=0.031 and r=-0.543; p=0.009, respectively). The VAS pain scores showed significant negative correlation with the MTRasym values in the patellar facet and femoral trochlea (r=-0.435; p=0.043 and r=-0.671; p=0.001, respectively). CONCLUSION The pain scores were associated with the morphological and biochemical changes in articular cartilages visualized on knee MR images. The biochemical changes, visualized in terms of the MTRasym values of the gagCEST images, exhibited greater correlation with the pain scores than the morphological changes visualized on conventional MR images; these results provide evidence supporting the theory regarding the association of patellofemoral osteoarthritis with knee pain scores.
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Affiliation(s)
- Young Han Lee
- Department of Radiology, Research Institute of Radiological Science, Medical Convergence Research Institute, and Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaemoon Yang
- Department of Radiology, Research Institute of Radiological Science, Medical Convergence Research Institute, and Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ha-Kyu Jeong
- Clinical Science, Philips Healthcare, Seoul, Republic of Korea
| | - Jin-Suck Suh
- Department of Radiology, Research Institute of Radiological Science, Medical Convergence Research Institute, and Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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