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Tibiofemoral forces are highly significant in total and has been used to measure in vivo forces in the
knee arthroplasty. These forces help determine hip, spine, and femur [2-18].
wear and cold flow in polyethylene, stress distri- Rydell [19] was the first to measure hip forces
bution in the implant and the implant-bone in vivo with an instrumented Austin-Moore pros-
interface, and stress transfer to the underlying thesis using direct connections to subcutaneous
bone. Tibial prostheses have been instrumented leads. However, there are obvious disadvantages
with force transducers to measure tibial forces in to such a system. Subsequently, in vivo forces have
vitro [1]; however, direct measurement of tibial been successfully measured in orthopedics in the
forces in vivo has not been reported. Telemetry has hip using telemetry links [2-11], spine [12-14], and
been shown to be a safe and accurate means of femur [15-18]. The first report of a telemetered hip
obtaining force data from implanted transducers prosthesis came from English and Kilvington [20],
who reported hip forces of 2.7 times body weight
(BW) during the stance phase of level walking
From the Orthopaedic Research Laboratories, Shiley Center for
Orthopaedic Research and Education at Scripps Clinic, California. without support. Davy et al [10] implanted a
Submitted December 17, 2004; accepted July 7, 2005. femoral prosthesis with a triaxial load cell then
Benefits or funds were received in partial or total support of measured peak hip forces of 2.6 times BW during
the research material described in this article. These benefits or
support were received from the following sources: OREF both level walking and stair climbing. These mea-
research grant 02-021, a research grant from the Knee Society, sured hip forces were significantly less than prior
and the Weingart-Price Fund. No funding was received from mathematical predictions that ranged from 3.3 to
Depuy; however John Slamin is an employee.
This study has been awarded the 2004 HAP Paul Award. 6.9 times BW [21,22]. Subsequent reports of in vivo
Reprint requests: Darryl D. D’Lima, MD, 11025 N Torrey hip forces have been fairly consistent: 2.7 times BW
Pines Road, Suite 140, La Jolla, CA 92037. for walking at a normal pace [8], 2.8 to 4.8 times
n 2006 Elsevier Inc. All rights reserved.
0883-5403/06/1906-0004$32.00/0 BW for walking at faster speeds, and 2.5 to 5.5 times
doi:10.1016/j.arth.2005.07.011 BW for jogging and slow jumping [4,7]. Although
255
256 The Journal of Arthroplasty Vol. 21 No. 2 February 2006
In Vivo Implantation
Institutional review board approval and the
patient’s consent were obtained. The first electronic
knee prosthesis was implanted on February 27,
2004, in a 67-kg (148 lb), 80-year-old man with
osteoarthritis of the right knee. A preoperative
video motion analysis was obtained 2 weeks before
surgery. The number of steps the patient walked
each day was monitored for a week using a
StepWatch Activity Monitor (Cyma Corp, Seattle,
Wash). A preoperative computed tomographic scan
of the right knee was obtained. A simulated surgery
was performed on a personal computer using the
3D model generated from the computed tomo-
graphic scan and a computer-aided design model of
the electronic tibial prosthesis to ensure the pros- Fig. 2. Postoperative radiograph of the knee with the
thesis adequately fit the patient’s tibial anatomy. instrumented prosthesis (A, anteroposterior view; B,
The implantation was through a standard midvas- lateral view).
tus approach. The tibia was prepared using custom
instrumentation developed for the stem and keel. A
ground reaction forces during level walking, stair
standard cruciate-retaining Sigma PFC femoral
climbing, and rising from a chair. The kinematic
component was cemented. The tibial prosthesis
and reaction force data were synchronized with
was cemented with a 10-mm polyethylene insert
direct tibial force measurements.
(Sigma PLI). The prosthesis was remotely powered
after implantation to test function. Tibial forces
were recorded during passive flexion and extension Results
of the knee. Postoperative deep vein thrombosis
prophylaxis and rehabilitation were the same as for Preoperative and Intraoperative Results
a routine primary knee arthroplasty. Fig. 2 contains Based on ankle accelerometer measurements,
the postoperative radiographs. the patient walked an average of 1.6 million
steps per year before the surgery. Passive knee
In Vivo Force Measurement flexion demonstrated reasonable balance be-
tween the medial and lateral soft tissues intra-
On postoperative day 1, tibial forces were operatively. The mean mediolateral imbalance
recorded during active and passive knee flexion, (difference between the medial and lateral forces)
active and passive straight-leg raising, and during was 6 (F1.1) N, and the mean anteroposterior
partial weight-bearing with a walker. The patient imbalance was 11 (F2.4) N.
was able to walk a few steps with the help of a
walker on postoperative day 3. Tibial forces were Postoperative Rehabilitation
also recorded during the patient’s first few steps.
During the first 3 weeks of the patient’s postoper- The patient was able to bear weight on the
ative recovery, tibial forces were monitored during operated limb with the help of a walker on
walking, stair climbing, rising from a chair, and postoperative day 1, and peak tibial forces of
standing on both legs with and without support. At 1.17 (F0.09) times BW were recorded. Body
6 weeks postoperative, knee kinematics and kinet- weight was 659 N (148 lb). The difference between
ics were measured at the Motion Analysis Labora- total tibial forces at full extension, and those at
tory, Children’s Hospital, San Diego, Calif. Six Vicon 908 flexion was 18 N. Forces generated during a
infrared cameras and 4 force plates were used to passive straight-leg raise averaged 0.34 (F0.04)
measure the patient’s lower limb kinematics and times BW, whereas those for an active straight-leg
258 The Journal of Arthroplasty Vol. 21 No. 2 February 2006
Level Walking
On postoperative day 3, the patient was able to
walk several steps with the help of a walker; peak
tibial force averaged 1.26 (F0.09) times BW. On
postoperative day 6, tibial forces displayed the
typical double-peak characteristic of heel strike
and toe off but peaked at 1.7 (F0.05) times BW.
By 3 weeks postoperative, peak tibial forces
reached 2.13 (F0.16) times BW (Fig. 3). No
changes in peak tibial forces were noted between
the 3- and 6-week measurements of 2.17 (F0.20) Fig. 4. The center of pressure during level gait remained
close to the center of the tray during the stance phase of
times BW. The center of pressure varied during the
level walking. The X marks the center of pressure
gait cycle. Fig. 4 shows the mean location of the
measured intraoperatively with the knee in full flexion.
center of pressure recorded during heel strike,
midstance, and toe off.
The patient felt a subjective difference in gait
when tested with and without shoes on a carpeted (Fig. 6). This was substantially higher than the
floor. The presence of absence of shoes did not vertical ground reaction force recorded under the
make a difference to mean or peak tibial forces same foot, which was 0.95 times BW at the above
during the stance phase (6 representative steps flexion angles.
each; Fig. 5), but the heel-strike transient was 19% The center of pressure moved posteriorly with
higher when shoes were worn. Qualitatively, the flexion until approximately 508 and then moved
stance phase peaks had a more blunted appearance anteriorly with further flexion (Fig. 7). The center
when shoes were not worn. of pressure also moved from a more lateral position
at low flexion angles to a more central position at
Stair Climbing higher flexion angles. There was no correlation
Fig. 3. Tibial forces were recorded during level walking Fig. 5. Tibial forces were recorded over 6 representa-
at 3 days and at 3 and 6 weeks postoperative. Peak tibial tive steps with and without shoes. The heel transients
forces were averaged over 6 representative steps for each were higher when shoes were worn, and the stance
time point. Peak forces rose until the third postoperative phase peaks appeared more rounded. However, no sig-
week and then appeared to stabilize (BW, 659 N [148 lb]). nificant differences in mean or peak tibial forces could
POD indicates postoperative day. be detected.
Tibial Forces ! D’Lima et al 259
Fig. 6. Tibial forces generated during stair climbing were Fig. 8. Peak tibial forces during a chair-rise activity were
substantially higher than measured ground reaction force in general lower than peak forces during stair climbing
under the same foot. This was due to the large moments despite the higher knee flexion angles. The vertical
generated at the knee in flexion. ground reaction force under the instrumented extremity
was almost always less than 0.5 times BW.
ranging from 1.3:1 in double-leg stance to more patient was using a walker. By the third postoper-
than 20:1 during isometric contraction. This dem- ative week, tibial forces during level walking had
onstrates that muscle contraction contributes a reached a plateau (at a little N2 times BW).
significant component of the actual force in the Footwear did not appear to have a significant
shaft of the femur as opposed to that calculated impact on the magnitude of tibial forces. Wearing
from external forces alone. Therefore, appropriate shoes did increase the initial heel-strike transient,
simulation of muscle forces is necessary to accu- and the typical double peaks appeared sharper than
rately calculate forces acting on bones and joints. without shoes.
More recently, instrumented distal femoral pros- Stair climbing and rising from a chair are 2
theses have been used to measure forces in the activities that involve higher knee flexion angles
femoral shaft and to estimate tibial forces. The and generate higher knee moments than walking.
prosthesis used was a distal femoral arthroplasty Stair climbing generated the highest peak tibial
for the treatment of bone tumors [16,40]. The forces among all the activities studied (2.5 times
reported peak femoral shaft axial forces were in the BW). However, these forces were still lower than
2.2 to 2.5 times BW range and were similar to reports of predicted forces during stair climbing
the estimated tibial-axial compressive forces. These [41]. Although the knee flexed to a greater degree
previous studies represent significant advances during the chair-rise activity (1078) than the stair
toward directly measuring tibial forces. However, climbing activity (698), tibial forces were substan-
unlike a typical total knee arthroplasty, the knee tially lower. Because the chair-rise activity in-
prosthesis used was a rotating-hinge design with volved double stance, the instrumented knee was
both heads of the gastrocnemius dissected free loaded at substantially lower levels despite the
of the femur. higher knee flexion angle. Although the chair-rise
The tibial forces recorded in the present study activity produced a similar pattern of posterior
also reached about 2.2 times BW by the sixth translation of the center of pressure, the curve
postoperative week. Stair climbing generated was smoother. Again, having both feet on the
higher peaks at 2.5 times BW, whereas rising from ground probably helped extend the knee in a more
a chair produced 1.5 times BW. The measured tibial controlled manner. Because the chair rise begins
forces during level walking and stair climbing were with the knee in flexion and the muscles likely
significantly below those predicted by prior reports relaxed, this posture is often associated with
[41]. The knee is a complex joint that is difficult to significant anterior translation of the femoral
model accurately. Although significant advances component on the tibial surface. When the muscles
have been made in mathematical modeling, these fire and the patient rises, the femoral component
have yet to be successfully validated in vivo. may move rapidly posterior into midflexion and
Measurement of knee forces can lead to a better then anterior into terminal extension.
understanding of the stresses seen in total knee The center of pressure moved posteriorly with
arthroplasty. This will enable more accurate math- femoral flexion during the stair climbing and chair-
ematical and in vitro modeling of the knee, which rise activities. This was consistent with the expec-
can then be used to evaluate and to implement tation of posterior femoral translation with flexion.
relevant improvements in implant design. Because knee kinematics was measured using skin
In addition to the total tibial force, the instru- markers, femoral rollback could not be measured
mented prosthesis also measured the center of with sufficient accuracy. Plans are underway to use
pressure, which yielded valuable data regarding more accurate kinematic measurements such as
the location of the femur on the insert. During level dynamic fluoroscopy [42,43].
walking, the center of pressure was reasonably This instrumented tibial prosthesis opens excit-
stable close to the center of the tibial tray. This ing possibilities for use in measuring forces during
suggested that the knee was well aligned and was activities of daily living. We will continue
consistent with the intraoperative measurement of to monitor tibial forces during these activities.
passive soft-tissue balance. In addition, we are currently collecting data
Tibial forces were monitored during rehabilita- during more strenuous and athletic activities.
tion and physical therapy. By the first postopera- We plan to include fluoroscopic gait analysis to
tive day, the patient was able to bear the entire BW relate accurate tibiofemoral position and orienta-
on the operated limb. Active straight-leg raising tion with instantaneous tibial force measurement.
also generated forces greater than 80% of the Future applications include the ability to validate
patient’s BW. On postoperative day 3, forces mathematical models, potential improvements in
approached 2 times BW despite the fact that the total knee arthroplasty design, and the capability
Tibial Forces ! D’Lima et al 261
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This study was funded in part by OREF research distal femur and the knee during walking and other
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