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Journal of Biomechanics
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www.JBiomech.com
Loading of the knee joint during activities of daily living measured in vivo in
ve subjects
I. Kutzner a,n, B. Heinlein a,b, F. Graichen a, A. Bender a,c, A. Rohlmann a, A. Halder d,
A. Beier d, G. Bergmann a
a
Universit
Julius Wolff Institute, Charite
atsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
ZHAW Zurich University of Applied Science, Biomechanical Engineering, Winterthur, Switzerland
c
Berlin-Brandenburg Center for Regenerative Therapies, Charite Universit
atsmedizin Berlin, Germany
d
Hellmuth-Ulrici-Kliniken, Klinik f
ur Endoprothetik, Sommerfeld, Germany
b
a r t i c l e in f o
a b s t r a c t
Article history:
Accepted 26 March 2010
Detailed knowledge about loading of the knee joint is essential for preclinical testing of implants,
validation of musculoskeletal models and biomechanical understanding of the knee joint. The contact
forces and moments acting on the tibial component were therefore measured in 5 subjects in vivo by an
instrumented knee implant during various activities of daily living.
Average peak resultant forces, in percent of body weight, were highest during stair descending
(346% BW), followed by stair ascending (316% BW), level walking (261% BW), one legged stance (259%
BW), knee bending (253% BW), standing up (246% BW), sitting down (225% BW) and two legged stance
(107% BW). Peak shear forces were about 1020 times smaller than the axial force. Resultant forces
acted almost vertically on the tibial plateau even during high exion. Highest moments acted in the
frontal plane with a typical peak to peak range 2.91% BWm (adduction moment) to 1.61% BWm
(abduction moment) throughout all activities. Peak exion/extension moments ranged between
0.44% BWm (extension moment) and 3.16% BWm (exion moment). Peak external/internal torques
lay between 1.1% BWm (internal torque) and 0.53% BWm (external torque).
The knee joint is highly loaded during daily life. In general, resultant contact forces during dynamic
activities were lower than the ones predicted by many mathematical models, but lay in a similar range
as measured in vivo by others. Some of the observed load components were much higher than those
currently applied when testing knee implants.
& 2010 Elsevier Ltd. All rights reserved.
Keywords:
Knee
Forces
Moments
Telemetry
In vivo
Measurements
Load
Implant
1. Introduction
The knee joint is loaded by external forces (ground reaction
force, masses and acceleration forces of foot and shank). Their
sum is counterbalanced by the forces acting across the joint, i.e.
the tibio-femoral contact forces, muscle forces and forces in soft
tissue structures. The net moment, caused by the external forces,
is additionally counterbalanced by the moments exerted by
muscles, soft tissues, contact forces and frictional forces. Muscle
and joint contact forces can be analysed using gait data together
with musculoskeletal modelling techniques e.g. inverse dynamics
and static optimization. However, large variations of reported
loading exist. Using gait analysis and a mathematical model,
Morrison calculated joint forces of 200400% BW (percent of
body weight) during level walking (Morrison, 1970). Whilst more
0021-9290/$ - see front matter & 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbiomech.2010.03.046
2.2. Subjects
After obtaining approval of the ethics committee and the subjects informed
consent to participate in the study and have their images published, the prosthesis
was implanted in 4 male and 1 female subjects with osteoarthritis (Table 1).
A medial parapatellar approach was used; the cruciate ligaments were sacriced.
Femoral and tibial component were cemented. The mechanical axis angles
between the tibial axis and an axis connection knee and hip joint centers were
determined by radiographs during two legged stance (Specogna et al., 2007;
Colebatch et al., 2009). No subject had further joint replacements except K2L,
whose contralateral knee had been replaced 6 months previously.
2.3. Activities investigated and data evaluation
Fz
Mz
Mx
2165
My
Fx
Fy
Eight most frequent and strenuous activities of daily living were investigated
(Table 2, Fig. 2) and are further named by their abbreviations. Every activity was
repeated 5 to 25 times by each subject. Average time courses of resultant forces
from several trials were calculated using a dynamic time warping procedure
(Wang and Gasser, 1997). During 2LegSt, StUp, SitD and KneeB ground reaction
forces were measured to control an even body weight distribution. KneeB was
performed to self-selected exion angles: K1L (901001), K2L (1001051), K3R
(90951), K4R (80851) and K5R (90951).
Ranges of forces and moments during complete loading cycles are stated by
their maximal (and minimal, if applicable) peak values. In different subjects these
peak values may occur at different time points. Peak forces during walking, for
example, can act either during the instants of contralateral toe off (CTO) or prior to
contralateral heel strike (CHS).
Individual forces or moments of each subject refer to the average peak values
from all investigated trials. Typical forces or moments are the averages of the
individual loads from all ve subjects. Absolute maxima/minima refer to the
highest/lowest value from all investigated subjects and trials.
In the following, peak forces are stated in percent of the body weight (%BW),
peak moments in percent body weight times meter (%BWm).
3. Results
3.1. Typical peak loads
During most activities (except static positions), shear forces and
moment components changed their sign during a loading cycle.
Forces in the transverse plane, for example, changed from a
laterally directed force +Fx to a medially directed force Fx. This
sign inversion becomes obvious in Fig. 3 if all large symbols are
above zero and the small symbols are below zero. In the following,
all values refer to typical peak loads if not stated otherwise.
3.1.1. Resultant forces F (Fig. 3A)
Smallest peak resultant forces of 107% BW were measured
during 2LegSt. During SitD the values were about two times higher
(225% BW). StUp, KneeB, 1LegSt and LevWalk caused nearly the
same forces (246261% BW). The highest forces acted during AscSt
(316% BW) and DesSt (346% BW). The absolute maximum of F
from all subjects and trials was 400% BW, measured in K5R during
DesSt. Peak axial forces Fz were of similar magnitude as the
stated resultant forces F.
3.1.2. Shear forces Fx and Fy (Fig. 3B and C)
Shear forces in the transverse plane were about 1020 times
smaller than the axial force Fz. In most subjects the largest shear
forces Fx and Fy were found during LevWalk, AscSt and DesSt.
Medial shear forces ( Fx) ranged between 1% and 18% BW,
forces in lateral direction (+ Fx) between + 1% and +16% BW.
Highest medial forces were mainly observed in K4R, highest
lateral forces mainly in K2L.
Shear forces Fy in posterior direction were highest for
LevWalk ( 26% BW), AscSt ( 32% BW) and DesSt ( 34% BW).
In K4R, however, high exion activities (SitD, StUp, KneeB) led to
individual posterior forces Fy of 46% BW. Shear forces in
anterior direction ( + Fy) typically lay between + 2% and + 18% BW.
During 1LegSt, Fy always acted in the posterior direction.
2166
Table 1
Subject data.
Subject
K1L
K2L
K3R
K4R
K5R
Sex
Age at implantation (years)
Body weight (kg)
Height (cm)
Time of measurement (months post-operatively)
Mechanical axis angle (deg.) preoperative
Mechanical axis angle (deg.) postoperative
Male
63
100
177
10
8 varus
3 varus
Male
71
90
171
22
8 varus
5 varus
Male
70
92
175
16
9 varus
4 varus
Female
63
97
170
7
3 varus
5 valgus
Male
60
100
175
11
11 varus
1 varus
Table 2
Activities investigated.
Activity
Abbreviation
Trials
Conditions
2LegSt
SitD
StUp
KneeB
1LegSt
LevWalk
AscSt
DesSt
5
5
5
5
5
25
10
10
Fig. 2. Subject K5R during the investigated activities. Body positions at peak resultant forces; A: one legged stance, B: standing up/sitting down, C: knee bend, D: level
walking, E: ascending stairs, F: descending stairs
2167
450
Resultant Force F
400
350
F [%BW]
300
250
K1L
200
K2L
K3R
150
K4R
K5R
100
Absolute Max
50
Absolute Min
Average
0
Two legged
stance
Sitting
down
Standing
up
Level
walking
Ascending Descending
stairs
stairs
Level
walking
Ascending Descending
stairs
stairs
Level
walking
Ascending Descending
stairs
stairs
40
Fx [%BW]
10
0
-10
-20
-30
Absolute Max
Absolute Min
Average(Max)
Average(Min)
-40
Sitting
down
Standing
up
50
40
30
20
Fy [%BW]
10
0
-10
-20
-30
-40
-50
-60
-70
Two legged
stance
Sitting
down
Standing
up
Fig. 3. Peak forces during investigated activities. Data from 5 subjects. A resultant force F, B medio-lateral force Fx, C antero-posterior force Fy. Large/small
symbols average maximum/minimum from several trials of 1 subject (individual forces). Thin lines average values from all subjects and trials (typical forces). Thick
lines absolute maximum/minimum values from all subjects and trials. Peak values of component Fz are nearly identical to those of F.
2168
Mx [%BWm]
K1L
K3R
K5R
Absolute Min
Average(Min)
K2L
K4R
Absolute Max
Average(Max)
3
2
1
0
-1
-2
-3
Two legged
stance
Sitting
down
Standing
up
Level
walking
Ascending Descending
stairs
stairs
Level
walking
Ascending Descending
stairs
stairs
Level
walking
Ascending Descending
stairs
stairs
4
3
My [%BWm]
2
1
0
-1
-2
-3
-4
-5
-6
Two legged
stance
Sitting
down
Standing
up
1.5
Mz [%BWm]
0.5
0.0
-0.5
-1.0
-1.5
Sitting
down
Standing
up
Fig. 4. Peak moments during investigated activities. Data from 5 subjects. A exion/extension moment Mx, B abduction/adduction moment My, C external/internal
rotation moment Mz. Large/small symbols average maximum/minimum from several trials of 1 subject (individual moments). Thin lines average values from all
subjects and trials (typical moments). Thick lines absolute maximum/minimum values from all subjects and trials.
300
Forces [%BW]
Fx
Fy
Fz
300
2169
Fx
Forces [%BW]
Fy
Fz
200
200
100
100
2 legs
2 legs
1 leg
Sitting down
Standing up
-100
-100
-200
-200
Time [s]
Time [s]
Mx
My
Mz
Moments [%BWm]
My
Mz
2.0
2.0
0
-2.0
Time [s]
Forces [%BW]
Fx
Fy
Fz
max.
Flexion
100
Descending
Ascending
Knee bend
-100
-200
Time [s]
Moments [%BW*m]
Mx
My
250
200
150
100
50
0
-50
-100
-150
-200
Mz
2.0
0
Time [s]
-2.0
400
Fx
Forces [%BW]
Fy
Fz
Fx
Forces [%BW]
Fy
CHS
Level Walking
Time [s]
Mx
My
Mz
Time [s]
400
Fz
-2.0
300
HS CTO
Moments [%BW*m]
2.0
Time [s]
-2.0
200
0.2
0.4
Forces [%BW]
0.6
0.8
Fx
Fy
1.2
Fz
1.4
1.6
300
200
200
CTO
CSC
100
Ascending stairs
-100
100
0
CTO
CSC
-100
-200
Descending stairs
-200
-300
4.0
Mx
Time [s]
Moments [%BWm]
Mx
My
Mz
-300
Time [s]
4.0
2.0
Moments [%BWm]
Mx
My
Mz
2.0
0
Time [s]
-2.0
0
0.25
0.5
0.75
1.25
1.5
1.75
Time [s]
-2.0
0
0.2
0.4
0.6
0.8
1.2
1.4
1.6
Fig. 5. Load patterns during investigated activities. Upper diagrams forces, lower diagrams moments. Exemplary trials from K5R. HS: heel strike; CTO: contralateral toe
off; CHS: contralateral heel strike; CSC: contralateral stair contact.
2170
Load variation within one subject was moderate. The intraindividual range of peak resultant forces F was typically around
50% BW during LevWalk (Fig. 7A), AscSt and DesSt. Smaller ranges
of about 30% BW were observed during all other activities
(Fig. 7C), which implies an overall intra-individual variation of
peak resultant forces of about 1020%.
Inter-individual variation of F was highest during KneeB
(Fig. 7D). Peak values differed between 182% BW (K4R) and
300% BW (K1L), reecting the variation of performing this
movement. With variations of about 70% BW, inter-individual
variation was moderate for StUp, SitD and LevWalk (Fig. 7B),
smaller differences of about 50% BW were observed during AscSt,
DesSt, 1LegSt and 2LegSt.
Even though the peak to peak range of shear forces and
moments were comparable between most subjects, the load
magnitudes varied considerably (Figs. 4, 5). During most activities
the highest medial shear forces Fx, posterior shear forces Fy,
extension moments Mx and abduction moments + My were
measured in K4R. Highest lateral shear forces + Fx, adduction
moments My and external rotation moments +Mz were mostly
found in K2L. Highest exion moments +Mx were measured in
K3R.
4. Discussion
The knee joint is highly loaded during daily life. For most
activities, resultant forces lay typically in the range 220350% BW.
Similar values were reported in other in vivo studies using
K2L
K3R
K4R
K5R
223
%BW
264
%BW
297
%BW
236
%BW
313
%BW
345
%BW
298
%BW
299
%BW
325
%BW
359
%BW
337
%BW
337
%BW
323
%BW
374
%BW
289
%BW
241
%BW
261
%BW
240
%BW
265
%BW
299
%BW
261
%BW
256
%BW
185
%BW
262
%BW
270
%BW
229
%BW
227
%BW
205
%BW
247
%BW
Knee bend
Descending stairs
Ascending stairs
285
%BW
Sagittal Plane
Frontal Plane
Level walking
K1L
2171
Fig. 6. Force directions during investigated activities. Selected trials from all 5 subjects. For each activity (lines) and subject (columns) the force vectors are displayed in the
frontal (left) and the sagittal (right) plane. Individual peak resultant forces are indicated. Different scales are used.
2172
350
300
Level walking (K5R)
300
250
Inter-individual range
250
Resultant Force [%BW]
Intra-individual range
200
150
100
50
200
150
K1L
K2L
K3R
K4R
K5R
100
50
0
0
20
40
60
80
0
0
100
20
Normalized time
60
80
100
80
100
350
350
Knee bend (K5R)
300
Resultant Force [%BW]
300
250
Resultant Force [%BW]
40
Normalized time
200
150
100
250
200
150
K1L (max. Flexion 90-100)
K2L (max. Flexion 100-105)
100
50
0
0
20
40
60
50
80
100
Normalized time
0
0
20
40
60
Normalized time
Fig. 7. Variation of resultant force during level walking and knee bending. Left intra-individual variation between several trials of K5R during level walking (A) and knee
bending (C). Thick line average from all trials. Right inter-individual variation between average curves of 5 subjects during level walking (B) and knee bending (D). Data
was averaged by time warping.
Acknowledgments
The authors gratefully acknowledge the voluntary collabora
tion of all subjects and the technical support of Jorn
Dymke. This
study was supported by Zimmer GmbH, Switzerland.
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