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Dowling A.V.,Stanford University | Fisher D.S.,Rose - Hulman Institute of Technology | Andriacchi T.P.,Stanford University | Andriacchi T.P.,Bone and Joint Center
Journal of Biomechanical Engineering | Year: 2010

The purpose of this study was to introduce a simple gait training method using real-time gait modification to reduce the peak knee adduction moment during walking by producing a subtle weight bearing shift to the medial side of the foot. The hypothesis of this study was that this weight shift could be achieved via either verbal instruction or an active feedback system, and that the weight shift would result in a reduction in the first peak knee adduction moment compared with the control tests. Nine individuals were tested during walking using two intervention methods: verbal instruction and an active feedback system placed on the right shoe. The first peak of the knee adduction moment for each condition was assessed using a motion capture system and force plate. The active feedback system significantly reduced (14.2%) the peak knee adduction moment relative to the control. This study demonstrated that a subtle weight bearing shift to the medial side of the foot produced with an active feedback system during walking reduced the first peak of the knee adduction moment and suggests the potential application of this method to slow the rate of progression of medial compartment knee osteoarthritis. Copyright © 2010 by ASME.


Scanlan S.F.,Stanford University | Donahue J.P.,Sports Orthopedic and Rehabilitation Medicine Associates SOAR | Andriacchi T.P.,Stanford University | Andriacchi T.P.,Bone and Joint Center
Knee | Year: 2014

Background: Restoration of anterior tibial stability while avoiding knee extension deficit are a common goal of anterior cruciate ligament (ACL) reconstruction. However, achieving this goal can be challenging. The purpose of this study was to determine whether side-to-side differences in anterior tibial neutral position and laxity are correlated with knee extension deficit in subjects 2. years after ACL reconstruction. Methods: In the reconstructed and contralateral knees of 29 subjects with transtibial reconstruction, anterior tibiofemoral neutral position was measured with MRI and three-dimensional modeling techniques; terminal knee extension at heel strike of walking and during a seated knee extension were measured via gait analysis; and anterior laxity was measured using the KT-1000. Results: Knees that approached normal anterior stability and anterior tibial position had increased extension deficit relative to the contralateral knee. On average the reconstructed knee had significantly less (2.1. ±. 4.4°) extension during active extension and during heel strike of walking (3.0. ±. 4.3o), with increased anterior neutral tibial position (2.5. ±. 1.7. mm) and anterior laxity (1.8. ±. 1.0. mm). There was a significant correlation between side-to-side difference in anterior neutral tibial position with both measures of knee extension (walking, r. = - 0.711, p. <. 0.001); active knee extension, r. = - 0.544, p. = 0.002). Conclusion: The results indicate a relationship between the loss of active knee extension and a change in anterior neutral tibial position following non-anatomic transtibial ACL reconstruction. Given the increasing evidence of a link between altered kinematics and premature osteoarthritis, these findings provide important information to improve our understanding of in vivo knee function after ACL reconstruction. © 2013 Elsevier B.V.


Scanlan S.F.,Stanford University | Lai J.,Stanford University | Donahue J.P.,Sports Orthopedic and Rehabilitation Medicine Associates SOAR | Andriacchi T.P.,Stanford University | Andriacchi T.P.,Bone and Joint Center
Journal of Orthopaedic Research | Year: 2012

Recent reports have indicated that anatomical placement of the anterior cruciate ligament (ACL) graft is an important factor for restoration of joint function following ACL reconstruction. The objective of this study was to address a need for a better understanding of anatomical variations in ACL position and orientation within the joint. Specifically, variations in the ACL anatomy were assessed by testing for side-to-side ACL footprint location symmetry in a healthy population relative to the operative and contralateral knee in a patient population after traditional transtibial single-bundle ACL reconstruction. MRI and three-dimensional modeling techniques were used to determine the in vivo tibiofemoral ACL footprint centers and the resulting ACL orientations in both knees of 30 healthy subjects and 30 subjects after transtibial ACL reconstruction. While there were substantial inter-subject variations in ACL anatomy, the side-to-side RMS differences in the ACL footprint center were 1.20 and 1.34 mm for the femur and tibia, respectively, for the healthy subjects and no clinically meaningful intra-subject differences were measured. However, there were large intrasubject side-to-side differences after transtibial ACL reconstruction, with ACL grafts placed 5.63 and 7.64 mm from the center of the contralateral femoral and tibial ACL footprint centers, respectively. Grafts were placed more medial, anterior, and superior on the femur and more posterior on the tibia; producing grafts that were more vertical in the sagittal and coronal planes. Given the large variation among subjects, these findings advocate the use of the contralateral ACL morphology for retrospectively evaluating patient-specific anatomic graft placement. © 2011 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.


Dowling A.V.,Stanford University | Dowling A.V.,Bone and Joint Center | Favre J.,Stanford University | Andriacchi T.P.,Stanford University | Andriacchi T.P.,Bone and Joint Center
American Journal of Sports Medicine | Year: 2012

Background: The incidence of anterior cruciate ligament (ACL) injury can be decreased through the use of intervention programs. However, the success of these programs is dependent on access to a skilled trainer who provides feedback; as such, these programs would benefit from a simple device with the capacity to provide high-quality feedback.Hypothesis: Feedback based on kinematic measurements from a simple inertial sensor-based system can be used to modify key ACL injury risk metrics (knee flexion angle, trunk lean, knee abduction moment) during jump landing.Study Design: Controlled laboratory study.Methods: Seventeen subjects (7 male) were tested during drop jump tasks. Their movements were measured simultaneously with inertial, optoelectronic, and force platform systems. Feedback provided to the subjects was based only on measurements from the inertial sensor-based system (knee flexion angle, trunk lean, and thigh coronal velocity). The subjects conducted a baseline session (without landing instructions), then a training session (with immediate feedback), and finally an evaluation session (without feedback). The baseline and evaluation sessions were then tested for changes in the key risk metrics.Results: The subjects increased their knee flexion angle (16.2°) and trunk lean (17.4°) after the training. They also altered their thigh coronal angular velocity by 29.4 deg/s and reduced their knee abduction moment by 0.5 %BW•Ht. There was a significant correlation (R2 = 0.55) between the change in thigh coronal angular velocity and the change in knee abduction moment.Conclusion: Subjects reduced key risk metrics for ACL injury after training with the system, suggesting the potential benefit of instrumented feedback for interventional training.Clinical Relevance: Interventional training for reducing the risk of ACL injury could be improved with a simple device that provides immediate feedback. © 2012 The Author(s).


Deneweth J.M.,Bone and Joint Center | Deneweth J.M.,Ford Motor Company | Bey M.J.,Bone and Joint Center | McLean S.G.,Ford Motor Company | And 3 more authors.
American Journal of Sports Medicine | Year: 2010

Background: Abnormal 3-dimensional tibiofemoral joint kinematics have been identified in anterior cruciate ligament-reconstructed knees during functional gait tasks, which is suggested to directly affect risk of knee osteoarthritis. However, the extent to which similar high-risk abnormalities are present during more demanding maneuvers, such as single-legged hopping, is largely unknown. Hypothesis: When performing a single-legged forward hop landing, the reconstructed knee will demonstrate altered sagittal, frontal, and transverse plane kinematics compared with the contralateral limb. Study Design: Controlled laboratory study. Methods: High-speed biplane radiography was used to quantify bilateral 3-dimensional tibiofemoral joint kinematics in 9 subjects with unilaterally reconstructed anterior cruciate ligaments (mean time after surgery, 4 months) during 3 single-legged, forward hop landing trials. Mean subject-based initial foot contact and maximum stance (0-250 ms) values were calculated for each kinematic variable. Two-tailed paired t tests were subsequently applied to examine for the main effect of limb (reconstructed vs contralateral). Results: The reconstructed knees exhibited significantly greater extension (P 5 .04), external tibial rotation (P 5 .006), and medial tibial translation (P 5 .02) than the contralateral knees at initial contact. Reconstructed knees underwent significantly greater maximum flexion (P 5 .05), maximum external tibial rotation (P 5 .01), and maximum anterior tibial translation (P 5 .02). No significant differences existed between limbs for initial contact (P 5 .65) or maximum adduction-abduction (P 5 .55). Conclusion: Tibiofemoral joint kinematics of the anterior cruciate ligament-reconstructed knee are significantly different from those of the uninjured contralateral limb during a single-legged hop landing. This altered kinematic profile, in conjunction with the large impact loads associated with hopping, may further contribute to the risk of posttraumatic knee osteoarthritis. Clinical Relevance: Returning to sports involving dynamic single-legged landings at 4 months after anterior cruciate ligament reconstruction surgery may contribute to accelerated knee joint degeneration. © 2010 The Author(s).


Koo S.,Chung - Ang University | Rylander J.H.,Stanford University | Rylander J.H.,Bone and Joint Center | Andriacchi T.P.,Stanford University | Andriacchi T.P.,Bone and Joint Center
Journal of Biomechanics | Year: 2011

The regional adaptation of knee cartilage morphology to the kinematics of walking has been suggested as an important factor in the evaluation of the consequences of alteration in normal gait leading to osteoarthritis. The purpose of this study was to investigate the association of spatial cartilage thickness distributions of the femur and tibia in the knee to the knee kinematics during walking. Gait data and knee MR images were obtained from 17 healthy volunteers (age 33.2±9.8 years). Cartilage thickness maps were created for the femoral and tibial cartilage. Locations of thickest cartilage in the medial and lateral compartments in the femur and tibia were identified using a numerical method. The flexion-extension (FE) angle associated with the cartilage contact regions on the femur, and the anterior-posterior (AP) translation and internal-external (IE) rotation associated with the cartilage contact regions on the tibia at the heel strike of walking were tested for correlation with the locations of thickest cartilage. The locations of the thickest cartilage had relatively large variation (SD, 8.9°) and was significantly associated with the FE angle at heel strike only in the medial femoral condyle (R2=0.41, p<0.01). The natural knee kinematics and contact surface shapes seem to affect the functional adaptation of knee articular cartilage morphology. The sensitivity of cartilage morphology to kinematics at the knee during walking suggests that regional cartilage thickness variations are influenced by both loading and the number of loading cycles. Thus walking is an important consideration in the analysis of the morphological variations of articular cartilage, since it is the dominant cyclic activity of daily living. The sensitivity of cartilage morphology to gait kinematics is also important in understanding the etiology and pathomechanics of osteoarthritis. © 2010 Elsevier Ltd.


Jacobs C.R.,Columbia University | Temiyasathit S.,Stanford University | Castillo A.B.,Bone and Joint Center
Annual Review of Biomedical Engineering | Year: 2010

An impressive range of tissues and cells are regulated by mechanical loading, and this regulation is central to disease processes such as osteoporosis, atherosclerosis, and osteoarthritis. However, other than a small number of specialized excitable cells involved in hearing and touch, cellular mechanosensing mechanisms are generally quite poorly understood. A lack of mechanistic understanding of these processes is one of the primary foci of the nascent field of mechanobiology, which, as a consequence, enjoys enormous potential to make critical new insights into both physiological function and etiology of disease. In this review we outline the process in bone by tracing mechanical effects from the organ level to the cellular and molecular levels and by integrating the biological response from molecule to organ. A case is made that a fundamental roadblock to advances in mechanobiology is the dearth of Information in the area of pericellular mechanics. © 2010 by Annual Reviews. All rights reserved.


Wagner D.W.,Bone and Joint Center | Lindsey D.P.,Bone and Joint Center | Beaupre G.S.,Bone and Joint Center
Bone | Year: 2011

Tissue level density and elastic modulus are intrinsic properties that can be used to quantify bone material and analyses incorporating those quantities have been used to evaluate bone on a macroscopic scale. Micro-computed tomography (microCT) technology has been used to construct tissue level finite element models to simulate macroscopic fracture strength, however, a single method for assigning voxel-specific tissue density and elastic modulus based on those data has not been universally accepted. One method prevalent in the literature utilizes an empirical relationship that derives tissue stiffness as a function of bone calcium content weight fraction. To derive calcium content weight fraction from microCT scans, a measure of tissue density is required and a constant value is traditionally used. However, experimental data suggest a non-trivial amount of tissue heterogeneity suggesting a constant tissue density may not be appropriate. A theoretical derivation for determining the relationship between voxel-specific tissue density and microCT scan data (i.e., microCT derived tissue mineral density (TMD), mgHA/cm 3) and bone constituent properties is proposed. Constant model parameters used in the derivation include the density of water, ash, and organics (i.e., bone constituents) and the volume fraction of the organics constituent. The effect of incorporating the theoretically derived tissue density (instead of a constant value) in determining voxel-specific elastic modulus resulted in a maximum observed increase of 12GPa (5.9GPa versus 17.9GPa, for the constant value and derived tissue density formulations, respectively) for a measured TMD of 1.02gHA/cm 3. Average and bounding quantities for the four constant model parameters were defined from the literature and the influence of those values on the derived tissue density and elastic modulus relationships were also evaluated. The theoretical relationships of tissue density and elastic modulus, with the average constant model parameters applied, were consistent with previously published empirical relationships derived from experimental data. Tissue density as a function of microCT TMD was formulated as a linear relationship and the density of water and ash was shown to solely influence the proportionality (i.e., slope) between those values. The density of water and organics (i.e., collagen) and the volume fraction of the organics constituent were shown to influence the constant offset (intercept) between tissue density and TMD with no influence from ash density. Incorporating tissue density heterogeneity into the derivation of elastic modulus resulted in a significant increase in predicted modulus (for microCT TMD ranges observed for healthy tissue) as compared to when a constant tissue density was used. The presented approach provides a novel method for deriving tissue-level bone material properties and quantifies the effect of assuming tissue homogeneity when calculating elastic modulus (when using a prevalent method in the literature) from microCT scan data. © 2011.


Zabala M.E.,Stanford University | Favre J.,Stanford University | Scanlan S.F.,Stanford University | Donahue J.,Sports Orthopedic and Rehabilitation SOAR | And 2 more authors.
Journal of Biomechanics | Year: 2013

Changes in knee mechanics following anterior cruciate ligament reconstruction (ACLR) have been implicated as a contributor to the development of premature osteoarthritis (OA). However, changes in ambulatory loading in this population have not been well documented. While the magnitude of the external knee moment vector is a major factor in loading at the knee, there is not a comprehensive understanding of the changes in the individual components of the vector following ACL reconstruction. The purpose of this study was to test for differences in the three components of the external knee moment during walking and stair locomotion between ACLR, contralateral and healthy control knees. Forty-five ACLR and 45 healthy control subjects were tested during walking, stair ascent and descent. ACLR knees had a lower first peak adduction moment than contralateral knees during all three activities. Similarly, additional cases of significant differences between ACLR and contralateral knees consisted of lower peak moments for the ACLR than the contralateral knees. These differences were due to both ACLR and contralateral knees as the ACLR knees indicated lower and the contralateral knees greater peak moments compared to healthy control knees. The results suggest a compensatory change involving greater loading in the contralateral knee, perhaps due to lower loading of the ACLR knee. Further, lower knee moments of the ACLR knee suggest that increased joint loading may not be the initiating factor in the development of OA following ACL reconstruction; but rather previous described kinematic or biological changes might initiate the pathway to knee OA. © 2012 Elsevier Ltd.


Scanlan S.F.,Stanford University | Favre J.,Stanford University | Andriacchi T.P.,Stanford University | Andriacchi T.P.,Bone and Joint Center
Journal of Biomechanics | Year: 2013

Reports that knee cartilage health is sensitive to kinematic changes, combined with reports of extension loss following ACL reconstruction, underscores the importance of restoring ambulatory knee extension in the context of preventing premature osteoarthritis. The purpose of this study was to test the relationship between individual variations in peak knee extension at heel-strike of walking and the anterior-posterior location of thickest cartilage in the medial and lateral femoral condyles of healthy contralateral and ACL reconstructed knees. In vivo gait analysis and knee MR images were collected from 29 subjects approximately 2 years after unilateral ACL reconstruction. Knee extension was measured at heel-strike of walking and 3-D femoral cartilage thickness models were reconstructed from MR images. The ACL reconstructed knees had significantly reduced knee extension (-1.5±4.2°) relative to the contralateral knees (-4.6±3.4°) at heel-strike of walking but did not have side-to-side differences in the anterior-posterior location or magnitude of thickest medial and lateral femoral cartilage. The anterior-posterior location of the thickest medial femoral cartilage was correlated with knee extension at heel-strike in both the healthy contralateral (R2=0.356, p<0.001) and reconstructed (R2=0.234, p=0.008) knees. These results suggest that ACL reconstruction can impair terminal extension at periods of ambulatory loading known to be related to cartilage morphology in healthy joints. The fact that the femoral cartilage thickness distribution had not changed at 2 years post-op, even in the subset of subjects with extension loss, suggests that loads may be shifted to thinner cartilage regions, which could have important implications on long-term joint health. © 2013 Elsevier Ltd.

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