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The Journal of Arthroplasty Vol. 21 No.

2 2006

Tibial Forces Measured In Vivo After


Total Knee Arthroplasty

Darryl D. D’Lima, MD, Shantanu Patil, MD, Nikolai Steklov, BS,


John E. Slamin, and Clifford W. Colwell Jr., MD

Abstract: An instrumented tibial prosthesis was developed to measure forces in vivo


after total tibial arthroplasty. This prosthesis was implanted in a 67-kg, 80 -year-old
man. The prosthesis measured forces at the 4 quadrants of the tibial tray. Tibial
forces were measured postoperatively during rehabilitation, rising from a chair,
standing, walking, and climbing stairs. By the sixth postoperative week, the peak
tibial forces during walking averaged 2.2 times body weight (BW). Stair climbing
increased from 1.9 times BW on day 6 to 2.5 times BW at 6 weeks. This represents
the first direct in vivo measurement of tibial forces, which should lead to refined
surgical techniques and enhanced prosthetic designs. Technical design improve-
ments will enhance function, quality of life, and longevity of total knee arthroplasty.
Key words: tibiofemoral forces, telemetry, electronic knee, instrumented prosthe-
sis, total knee arthroplasty, in vivo forces.
n 2006 Elsevier Inc. All rights reserved.

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

hip forces during controlled activities of daily living


were relatively low, higher forces (5.5 times BW)
have been reported during a period of instability
during a single leg stance [8]. Brand et al [6]
reported that calculated peak hip forces were
consistently higher (0.5 times BW) than those
measured in the same patient.
The aforementioned reports provide evidence
that telemetry can be a safe and accurate method
of measuring both in vivo bone and joint forces. The
reports also reveal a disparity between commonly
reported estimates of forces in the hip and in the
femur, and direct measurements in vivo. The knee is
much more complex than the hip, and theoretical
estimates of tibiofemoral forces have varied between
3 and 6 times BW, depending on the mathematical
models used and on the type of activity analyzed
[23 -30]. A major problem with mathematical pre-
dictions is the high degree of mechanical redundan-
cy due to the numerous muscles involved in
locomotion. Several optimization techniques have
been reported to address this problem [25,27-29,31-
Fig. 1. Cross section of the implant. The tibial tray is
34]. However, laboratory validation has not dem-
composed of upper and lower halves separated by posts,
onstrated an agreement between predicted muscle
which lie on load transducers. The microtransmitter and
forces and those measured directly [35]. An im- the internal coil are housed in the stem. The transmitting
plantable telemetry system was therefore developed antenna is located at the tip of the stem and is protected
to directly measure tibiofemoral compressive forces by a polyethylene cap.
in vivo.
to the transmitting antenna. A detailed description
Methods of the microtransmitter and antenna has been
previously reported [37]. Because radio-frequency
Transducers
signals do not pass through the sealed titanium shell,
A titanium alloy revision tibial prosthesis design a single-pin hermetic feed-through transmitting
was instrumented with force transducers, a micro- antenna is located at the distal tip of the stem and
transmitter, and an antenna. The tibial force trans- is connected to the microtransmitter. The pulse code
ducers have been previously described [1] and have modulated receiver contains a receiving antenna, a
been used in cadaveric studies [36,37]. The tibial matched radio-frequency surface acoustic wave
tray consists of upper and lower halves separated by oscillator, and a level converter to generate RS-232
support posts, below which lie the load cells. The signals from the pulse code modulated data stream.
load cells are located at the 4 quadrants of the tibial The data acquisition and display were done using
tray. By measuring the force on each load cell, the LabView 6.0 (National Instruments, Niagara Falls,
total axial load, and the location of center of pressure NY, USA), and data processing was done in Matlab
can be determined. In addition, the distribution of 7.0 (National Instruments, Niagara Falls, NY, USA).
forces between the medial and the lateral compart- Remote powering was achieved with the use of mag-
ments can be calculated. If the tibiofemoral contact netic near-field coupling. Approximately 40 mW of
points are known, moments along the anteroposte- power could be generated in the internal coil, which
rior and the mediolateral axes can also be deter- was adequate to power the telemetry system.
mined. Fig. 1 displays a cross-sectional diagram
demonstrating the location of the multichannel In Vitro Testing
transmitter and the hermetic feed-through antenna.
The prosthesis was calibrated several times and
Telemetry checked for thermal drift between 158C and 458C.
The accuracy was tested in a multiaxial testing ma-
The microtransmitter receives the analog signal chine with and without a polyethylene insert
through leads from the load cells and is connected (Force 5; Advanced Medical Technologies, Inc.
Tibial Forces ! D’Lima et al 257

(AMTI), Watertown, Mass) [37]. Extensive testing of


the accuracy and integrity of the signal was also
performed with the prosthesis implanted in cadaver
knees under static and dynamic conditions [37].

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

raise averaged 0.84 (F0.06) times BW on postop-


erative day 3.

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

The peak flexion angle achieved during stair


climbing with a rise of 20 cm was 68.58. The tibia
showed a general trend toward increased internal
rotation with knee flexion. Tibial forces peaked at
2.5 times BW between 358 and 508 of knee flexion

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.

between the tibial rotation and posterior transla-


tion of the center of pressure. This suggests that the 0.69 (F0.11), indicating that the patient still
posterior translation of center of pressure was more favored his right knee. The center of pressure
likely associated with posterior femoral translation followed a similar pattern as that seen during stair
rather than femoral rotation on the tibia. climbing, but the posterior translation was sub-
stantially greater (Fig. 7).
Chair rise
The peak flexion angle achieved during rising Discussion
from a chair was 107.48. Peak tibial forces recorded
reached 1.5 times BW at 100.78 knee flexion. The This report represents the first in vivo measure-
vertical ground reaction force under the right foot ments of forces directly at the tibial tray after total
was less than 0.5 times BW for almost the entire knee arthroplasty. Tibial forces have been mea-
chair-rise activity (Fig. 8), whereas the average sured in vitro using a tibial plate connected to an
ground reaction force under his left foot was instrumented shaft [38]. Singerman et al [39] also
measured forces in cadaver knees using a force
transducer design based on 2 concentric cylinders.
Kaufman et al [1] reported on a tibial prosthesis
instrumented with load cells that could measure
the magnitude of compressive force and the center
of application in vitro. The same instrumented
prosthesis that measured the effect of joint-line
elevation on tibiofemoral forces after total knee
arthroplasty was subsequently used in cadaver
studies [36]. The force-sensing portion of the
instrumented prosthesis used in the present study
was based on the same design reported by Kauf-
man et al [1].
Attempts have also been made to measure knee
forces in vivo. Lu et al [18] measured femoral
shaft axial forces in a massive proximal femoral
Fig. 7. The center of pressure moved posteriorly with arthroplasty prosthesis. Sagittal plane modeling
knee flexion during stair climbing until approximately underestimated forces by 30% compared with
508, then moved anteriorly with further flexion. A those directly measured in the proximal femoral
similar pattern of posterior translation was noted during shaft. A significant increase in the ratio of mea-
the chair-rise activity. sured forces to externally applied forces was found
260 The Journal of Arthroplasty Vol. 21 No. 2 February 2006

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

to study the effect of postoperative physical spinal internal fixators in a patient with degenerative
therapy, overall rehabilitation, bracing, and the instability. Spine 1995;20:2683.
use of corrective orthotics. 15. Lu TW, O’ Connor JJ, Taylor SJ, et al. Validation of
a lower limb model with in vivo femoral forces
telemetered from two subjects. J Biomech 1998;
Acknowledgments 31:63.
16. Taylor SJ, Walker PS, Perry JS, et al. The forces in the
This study was funded in part by OREF research distal femur and the knee during walking and other
grant 02-021, a research grant from the Knee activities measured by telemetry. J Arthroplasty
Society, and the Weingart-Price Fund. 1998;13:428.
17. Taylor SJ, Perry JS, Meswania JM, et al. Telemetry of
forces from proximal femoral replacements and
relevance to fixation. J Biomech 1997;30:225.
References 18. Lu TW, Taylor SJ, O’ Connor JJ, et al. Influence of
muscle activity on the forces in the femur: an in vivo
1. Kaufman KR, Kovacevic N, Irby SE, et al. Instru- study. J Biomech 1997;30:1101.
mented implant for measuring tibiofemoral forces. 19. Rydell NW. Forces acting on the femoral head–
J Biomech 1996;29:667. prosthesis. A study on strain gauge supplied pros-
2. Graichen F, Bergmann G, Rohlmann A. Hip endo- theses in living persons. Acta Orthop Scand 1966;
prosthesis for in vivo measurement of joint force and 37(5 Suppl 88):1.
temperature. J Biomech 1999;32:1113. 20. English TA, Kilvington M. In vivo records of hip
3. Bergmann G, Graichen F, Siraky J, et al. Multichan- loads using a femoral implant with telemetric
nel strain gauge telemetry for orthopaedic implants. output (a preliminary report). J Biomed Eng 1979;
J Biomech 1988;21:169. 1:111.
4. Bassey EJ, Littlewood JJ, Taylor SJ. Relations be- 21. Rohrle H, Scholten R, Sigolotto C, et al. Joint forces
tween compressive axial forces in an instrumented in the human pelvis-leg skeleton during walking.
massive femoral implant, ground reaction forces, and J Biomech 1984;17:409.
integrated electromyographs from vastus lateralis 22. Crowninshield RD, Johnston RC, Andrews JG, et al.
during various bosteogenicQ exercises. J Biomech A biomechanical investigation of the human hip.
1997;30:213. J Biomech 1978;11:75.
5. Kotzar GM, Davy DT, Berilla J, et al. Torsional loads 23. Lutz GE, Palmitier RA, An KN, et al. Comparison of
in the early postoperative period following total hip tibiofemoral joint forces during open-kinetic-chain
replacement. J Orthop Res 1995;13:945. and closed-kinetic-chain exercises. J Bone Joint Surg
6. Brand RA, Pedersen DR, Davy DT, et al. Comparison Am 1993;75A:732.
of hip force calculations and measurements in the 24. Nisell R, Ericson MO, Nemeth G, et al. Tibiofemoral
same patient. J Arthroplasty 1994;9:45. joint forces during isokinetic knee extension. Am J
7. Bergmann G, Graichen F, Rohlmann A. Hip joint Sports Med 1989;17:49.
loading during walking and running, measured in 25. Collins JJ. The redundant nature of locomotor
two patients. J Biomech 1993;26:969. optimization laws. J Biomech 1995;28:251.
8. Kotzar GM, Davy DT, Goldberg VM, et al. Telemeter- 26. Wilk KE, Escamilla RF, Fleisig GS, et al. A compar-
ized in vivo hip joint force data: a report on two patients ison of tibiofemoral joint forces and electromyo-
after total hip surgery. J Orthop Res 1991;9:621. graphic activity during open and closed kinetic chain
9. Graichen F, Bergmann G. Four-channel telemetry exercises. Am J Sports Med 1996;24:518.
system for in vivo measurement of hip joint forces. 27. Li G, Kawamura K, Barrance P, et al. Prediction of
J Biomed Eng 1991;13:370. muscle recruitment and its effect on joint reaction
10. Davy DT, Kotzar GM, Brown RH, et al. Telemetric forces during knee exercises. Ann Biomed Eng
force measurements across the hip after total arthro- 1998;26:725.
plasty. J Bone Joint Surg Am 1988;70A:45. 28. Li G, Kaufman KR, Chao EY, et al. Prediction of
11. Hodge WA, Carlson KL, Fijan RS, et al. Contact antagonistic muscle forces using inverse dynamic
pressures from an instrumented hip endoprosthesis. optimization during flexion/extension of the knee.
J Bone Joint Surg Am 1989;71A:1378. J Biomech Eng 1999;121:316.
12. Calisse J, Rohlmann A, Bergmann G. Estimation of 29. Seireg A, Arvikar RJ. A mathematical model for
trunk muscle forces using the finite element method evaluation of forces in lower extremities of the
and in vivo loads measured by telemeterized internal musculo-skeletal system. J Biomech 1973;6:313.
spinal fixation devices. J Biomech 1999;32:727. 30. Ellis MI, Seedhom BB, Wright V. Forces in the knee
13. Wilke HJ, Neef P, Caimi M, et al. New in vivo joint whilst rising from a seated position. J Biomed
measurements of pressures in the intervertebral disc Eng 1984;6:113.
in daily life. Spine 1999;24:755. 31. Kaufman KR, An KN, Litchy WJ, et al. Dynamic joint
14. Rohlmann A, Bergmann G, Graichen F, et al. Tele- forces during knee isokinetic exercise. Am J Sports
meterized load measurement using instrumented Med 1991;19:305.
262 The Journal of Arthroplasty Vol. 21 No. 2 February 2006

32. An KN, Kwak BM, Chao EY, et al. Determination of 38. Perry J, Antonelli D, Ford W. Analysis of knee-joint
muscle and joint forces: a new technique to solve the forces during flexed-knee stance. J Bone Joint Surg
indeterminate problem. J Biomech Eng 1984; Am 1975;57:961.
106:364. 39. Singerman R, Berilla J, Archdeacon M, et al. In vitro
33. Crowninshield RD, Brand RA. A physiologically forces in the normal and cruciate-deficient knee
based criterion of muscle force prediction in locomo- during simulated squatting motion. J Biomech Eng
tion. J Biomech 1981;14:793. 1999;121:234.
34. Pedersen DR, Brand RA, Cheng C, et al. Direct 40. Taylor SJ, Walker PS. Forces and moments te-
comparison of muscle force predictions using linear lemetered from two distal femoral replace-
and nonlinear programming. J Biomech Eng 1987; ments during various activities. J Biomech 2001;
109:192. 34:839.
35. Herzog W, Leonard TR. Validation of optimization 41. Taylor WR, Heller MO, Bergmann G, et al. Tibio-
models that estimate the forces exerted by synergistic femoral loading during human gait and stair climb-
muscles. J Biomech 1991;(Suppl 1):31. ing. J Orthop Res 2004;22:625.
36. Grady-Benson J, Kaufman KR, Irby SE, et al. The 42. Banks SA, Hodge WA. Accurate measurement of
influence of joint line location on tibiofemoral forces three-dimensional knee replacement kinematics us-
after total knee arthroplasty. Trans 38th Orthop Res ing single-plane fluoroscopy. IEEE Trans Biomed Eng
Soc 1992;18:324. 1996;43:638.
37. D’Lima DD, Townsend CP, Arms CW, et al. An 43. Dennis DA, Komistek RD, Hoff WA, et al. In vivo
implantable telemetry device to measure intra- knee kinematics derived using an inverse perspective
articular tibial forces. J Biomech 2005;38:299. technique. Clin Orthop 1996;331:107.

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