Integrated assessment techniques for linking kinematics, kinetics and muscle activation to early migration: A pilot study

doi:10.1016/j.gaitpost.2012.03.022

Gait & Posture

Volume 36, Issue 3, July 2012, Pages 394-398

https://doi.org/10.1016/j.gaitpost.2012.03.022 Get rights and content

Abstract

The goal of this pilot study was to develop and test an integrated method to assess kinematics, kinetics and muscle activation of total knee prostheses during dynamic activities, by integrating fluoroscopic measurements with force plate, electromyography and external motion registration measurements. Subsequently, this multi-instrumental analysis was then used to assess the relationship between kinematics, kinetics and muscle activation and early migration of the tibial component of total knee prostheses. This pilot study showed that it is feasible to integrate fluoroscopic, kinematic and kinetic measurements and relate findings to early migration data. Results showed that there might be an association between deviant kinematics and early migration in patients with a highly congruent mobile-bearing total knee prosthesis. Patients that showed high levels of coactivation, diverging axial rotations of the insert and a deviant pivot point showed increased migration and might be at higher risk for tibial component loosening. In the future, to confirm our findings, the same integrated measurements have to be performed in larger patient groups and different prosthesis designs.

Highlights

► It is feasible to integrate fluoroscopic, kinematic and kinetic measurements. ► There seems to be an association between deviant kinematics and early migration. ► The insert and femoral component had comparable axial rotations up to 60° of flexion.

Introduction

In vivo functional testing is performed frequently and seems extremely useful in optimising knee implant designs for better function, better fixation and improved long-term results [1], [2]. Three dimensional (3D) fluoroscopic analysis is at the moment the most accurate measurement technique to examine the in vivo kinematics of total knee prostheses under weight-bearing activities, with an accuracy up to 0.3° for rotations and 0.3 mm for translations [3], [4], [5]. However, in single-plane fluoroscopic analysis, the out-of-plane error, which could be as high as 4 mm, is still a major limitation [6].

Electromyographic (EMG) data provides important information about co-activation, control of movements and insight into the integration of the prosthesis within the musculo-skeletal system [7], [8]. This information is particularly relevant when combined with information about the in vivo kinematics and implant design [7]. For instance, the extra degree of freedom in mobile-bearing knees might require higher muscle activity levels of the quadriceps and hamstrings muscles to stabilize the knee. However, moving with excessive muscle activations and co-activations is inefficient and large forces are transmitted to the bone-implant interface which could lead to migration of the tibial component [9].

Roentgen stereophotogrammetric analysis (RSA) can be used to accurately assess the migration of the components and gives an indication about the quality of component fixation [9], [10], [11]. Progressive migration after the first post-operative year indicates a higher risk with a predictive power of 85% for future component loosening [11]. By combining migration data and external motion registration data, Hilding et al. [12] showed a correlation between knee joint loading and an increased risk for future tibial component loosening. Unfortunately, because of problems in locating anatomical landmarks and soft tissue artefacts data acquired with external motion registration systems is less accurate compared to fluoroscopy [13], [14], [15]. Zihlmann et al. [16] improved the measurement accuracy of external motion registration by using fluoroscopic images to determine the knee centre and thereby providing a better basis for inverse dynamic calculations. They conclude that the resultant moments in the knee joint can be estimated up to seven times more accurately than in conventional instrumented motion analysis. Some studies combine fluoroscopy with a force plate or with external motion registration systems, however, in most studies the measurements are not performed simultaneously [13], [16], [17], [18], [19], [20], [21], [22].

Section snippets

Subjects

Nine rheumatoid arthritis patients [four male, five female; age 62 years (SD 12.3); BMI 29.6 (SD 4.4)] were measured simultaneously using fluoroscopy, EMG, force plate registration and external motion registration while performing three step-up and lunge motions seven months (SD 1.2) post-operatively. Inclusion criteria were the expected ability to perform a step-up and lunge motion without the help of bars and the expected ability to walk more than 1 km. All patients gave informed consent and

RSA

The precision of the RSA measurements was determined by means of double examinations at the one-year follow-up examination (Table 1). After an initial period of rapid migration, in four of the nine patients the tibial component migration slowed down and stabilized. The other components showed continuous migrations (>0.5 mm and >0.5°) in one or more directions (Fig. 4). The direction of migration was irregular. Mean Maximum Total Point Motion (MTPM) at one year was 0.87 mm (range 0.46–1.64) and at

Discussion

The goal of this pilot study was to develop and test the concept of simultaneously obtaining kinematic, kinetic and muscle activation data during dynamic activities, by integrating fluoroscopic measurements with force plate, electromyography and external motion registration measurements. This method was used to accurately assess the relationship between knee joint kinematics, kinetics and muscle activations and early migration of the tibial component of total knee prostheses. A modest

Conclusion

This pilot study showed that it is feasible to integrate fluoroscopic, kinematic and kinetic measurements and relate findings to early migration data. Results showed that there might be an association between deviant kinematics and early migration in patients with a highly congruent mobile-bearing total knee prosthesis. Patients that showed high levels of coactivation, diverging axial rotations of the insert and a deviant pivot point showed increased migration and might be at higher risk for

Conflict of interest statement

The authors declare that they have no competing interests.

Acknowledgements

The authors wish to thank Dirk Zweers, Richard Baks and Paul de Bruin from the Department of Radiology and Sander van Berloo (instrumental engineer) who have contributed to the realisation of the measurement set-up. The authors wish to thank André Prins for his help during the measurements and data analysis, Prof. Mark Taylor of the University of Southampton, Bioengineering Sciences Research Group for letting us use their force plate and Gert Kraaij for the 3D illustration.

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2023, Journal of Arthroplasty
Contact kinematics in total knee arthroplasty (TKA) has been shown to affect tibial component migration. However, previous studies correlating kinematic variables to implant migration were completed with older TKA designs. The goal of this study was to determine if there are associations between contact kinematics and tibial component migration for a cemented, bicruciate stabilized (BCS) TKA system.
A total of 54 knees implanted with a BCS TKA system were analyzed using radiostereometric analysis (RSA). Patients underwent RSA exams at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years post operation to measure tibial component migration. At 1 year, contact kinematics was evaluated during a quasi-static deep knee bend. Linear regression analyses were performed between kinematic variables and migration values.
Significant correlations were found between contact kinematics and tibial component migration. Excursion on the lateral condyle was the most consistent variable correlating with implant migration. Six patients had > 0.2 mm migrations from 1 to 2 years post operation indicating continuously migrating tibial components, and most had atypical contact kinematics.
Kinematics was shown to influence tibial component migration. Reduced lateral excursion, suggesting a more constrained lateral condyle, resulted in greater implant migration. The 6 patients who had continuously migrating tibial components had demographic factors that may limit the ability to endure unintended force transmissions caused by abnormal kinematics. These results highlight the importance of restoring knee kinematics with this BCS TKA design to minimize improper force transmissions and resultant increased implant migrations.
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A previous study correlating kinematics to implant migration found that abnormal kinematics can lead to excess tibial component migration [31]. This supported an earlier pilot study conducted by Wolterbeek et al., who also found continuous migration of components with abnormal kinematics [32]. Knee kinematics have also been shown to be related to polyethylene surface wear [28–30].
The goal was to evaluate the joint contact kinematics of total knee arthroplasties implanted using patient-specific instrumentation (PSI) compared to conventional instrumentation (CI). We hypothesized that use of PSI would not significantly alter contact kinematics.
The study was a prospective randomized controlled trial, with equal allocation of fifty patients to PSI and CI groups. At two years post-operation, patients underwent weight-bearing stereo X-ray examinations at 0°, 20°, 40°, 60°, 80°, and 100° of flexion. The shortest tibiofemoral distance on each condyle determined the contact location. Magnitude of the shortest distance was measured and condylar separation was analyzed using thresholds of 0.5 and 0.75 mm. Kinematic measurements derived from the shortest distance included anteroposterior (AP) translation, excursion, axial rotation, and paradoxical anterior motion. Pivot position and cam/post contact were also investigated.
There were no differences (p > 0.05) in medial and lateral AP contact locations, excursions, and magnitude of anterior motion, or in axial rotation, pivot patterns, frequency of cam/post engagement, frequency of medial anterior motion, and condylar separation at a 0.75 mm threshold. Significant differences were found in frequency of lateral anterior motion (p = 0.048) and condylar separation at a 0.5 mm threshold (p = 0.010). Both groups displayed typical kinematics for a fixed-bearing posterior-stabilized implant.
We found no major differences in knee kinematics between PSI and CI groups, which suggest that PSI does not provide a significant kinematic advantage over conventional instruments.
Does hamstrings co-contraction constrain knee internal rotation in patients with knee endoprosthesis during decline slope walking?
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Furthermore, the combination of relatively high knee internal rotation moments during gait, bearing geometry and high friction between the two artificial implant components transmit rotational shear forces to the bone implant interface. As a result of this interaction tibial implant rotation occurs about the longitudinal axis (Albrektsson et al., 1990; Bergmann et al., 2014; Kraemer et al., 1995; Wolterbeek et al., 2012). According to Lafortune et al. (1992) KIR is a function of knee flexion excursion during the stance phase.
Medial and lateral hamstrings are known for their capacity to promote internal or external rotation of the knee. Apart from implant geometry, increased co-contraction to a larger share of either the medial or lateral hamstrings has the potential to contribute to the restricted knee internal rotation especially under consideration of cruciate ligament substituting compared to cruciate ligament retaining knee endoprosthesis designs. Hence, the purpose of the study was to evaluate, whether increased co-contraction of the hamstrings contribute to the impaired knee internal rotation in total and unicondylar knee arthroplasty patients during level and decline walking.
Knee joint angles were calculated using an inverse kinematics model in Anybody. Muscle activity was examined of the semitendinosus and biceps femoris.
Knee internal rotation was constraint in the operated compared to the non-operated limb only in the total knee arthroplasty group during decline slope walking. Co-contraction values revealed no statistically significant differences between the operated and non-operated limb during the limited knee internal rotation period of time (59–94% of stance). Biceps femoris activity was significantly reduced (69–71% of stance) in the operated limb in the total knee arthroplasty group during decline slope walking.
Contrary to the proposed mechanism, aspects other than co-contraction between semitendinosus and biceps femoris are involved in the impaired transverse plane knee motion. These include implant congruency and probably friction. Unexpectedly, the biceps femoris did not compensate the absence of the anterior cruciate ligament with increased muscular activity in the operated limb of the total knee arthroplasty group.
Contact Kinematics Correlates to Tibial Component Migration Following Single Radius Posterior Stabilized Knee Replacement
2018, Journal of Arthroplasty
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All 4 demonstrated atypical patterns of contact on the medial condyle, lateral condyle, or both when compared to the average contact pattern of the non-migrating implants. This is consistent with the report of Wolterbeek et al [17], who found continuous migration of implants with atypical kinematics, using a different TKA implant system. Continuous migration in 4 of 26 implants has been previously reported in an RSA study of the Triathlon TKA [23], but kinematics was not assessed in that study.
Contact kinematics between total knee arthroplasty components is thought to affect implant migration; however, the interaction between kinematics and tibial component migration has not been thoroughly examined in a modern implant system.
A total of 24 knees from 23 patients undergoing total knee arthroplasty with a single radius, posterior stabilized implant were examined. Patients underwent radiostereometric analysis at 2 and 6 weeks, 3 and 6 months, and 1 and 2 years to measure migration of the tibial component in all planes. At 1 year, patients also had standing radiostereometric analysis examinations acquired in 0°, 20°, 40°, and 60° of flexion, and the location of contact and magnitude of any condylar liftoff was measured for each flexion angle. Regression analysis was performed between kinematic variables and migration at 1 year.
The average magnitude of maximum total point motion across all patients was 0.671 ± 0.270 mm at 1 year and 0.608 ± 0.359 mm at 2 years (P = .327). Four implants demonstrated continuous migration of >0.2 mm between the first and second year of implantation. There were correlations between the location of contact and tibial component anterior-posterior tilt, varus-valgus tilt, and anterior-posterior translation. The patients with continuous migration demonstrated atypical kinematics and condylar liftoff in some instances.
Kinematics can influence tibial component migration, likely through alterations of force transmission. Abnormal kinematics may play a role in long-term implant loosening.
A new technique using roentgen stereophotogrammetry to measure changes in the spatial conformation of bovine hind claws in response to external loads
2016, Veterinary Journal
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3D roentgen stereophotogrammetric analysis (RSA) (Selvik, 1989) is considered the gold standard for analysis of motions of rigid bodies (Tranberg, 2010) and joints (Kibsgård et al., 2012). The method is used in human medicine for precise measurements of displacements of prostheses such as stent grafts (Koning et al., 2006), knee implants (Wolterbeek et al., 2012), hip stems (Nelissen et al., 2002) and mandibular implants (Sarnäs et al., 2012). It is also used to determine the laxity of joints (Kärrholm et al., 2006), which helps to improve prosthesis design (Leardini, 2001), and in gait analysis to determine the accuracy of optical markers (Tranberg, 2010).
Claw and locomotion problems are widespread in ungulates. Although it is presumed that mechanical overload is an important contributor to claw tissue damage and impaired locomotion, deformation and claw injury as a result of mechanical loading has been poorly quantified and, as a result, practical solutions to reduce such lesions have been established mostly through trial and error. In this study, an experimental technique was developed that allowed the measurement under controlled loading regimes of minute deformations in the lower limbs of dissected specimens from large ungulates. Roentgen stereophotogrammetric analysis (RSA) was applied to obtain 3D marker coordinates with an accuracy of up to 0.1 mm with optimal contrast and to determine changes in the spatial conformation. A force plate was used to record the applied forces in three dimensions.
The results obtained for a test sample (cattle hind leg) under three loading conditions showed that small load-induced deformations and translations as well as small changes in centres of force application could be measured. Accuracy of the order of 0.2–0.3 mm was feasible under practical circumstances with suboptimal contrast. These quantifications of claw deformation during loading improve understanding of the spatial strain distribution as a result of external loading and the risks of tissue overload. The method promises to be useful in determining load–deformation relationships for a wide variety of specimens and circumstances.
Performance of local optimization in single-plane fluoroscopic analysis for total knee arthroplasty
2015, Journal of Biomechanics
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A standard model-based pose estimation method (Model-Based RSA 3.21, Medis Specials, Leiden, the Netherlands (Kaptein et al., 2003)) was applied to the frames from both image intensifiers and the pose calculated using this approach was used as the reference pose. Two fluoroscopic datasets (82 frames in total) were acquired with 15fps from a patient performing step-up tasks with a ROCC prosthesis (Biomet, Warsaw, IN) using a single-plane setup (15 fps, Toshiba Infinix, Toshiba, Zoetermeer, the Netherlands) (Wolterbeek et al., 2012a, 2012b). At the start of the step-up, the patient was standing with the leg of interest one step higher (18 cm) than the other leg and the movement was finished when both legs were on the same level.
Fluoroscopy-derived joint kinematics plays an important role in the evaluation of knee prostheses. Fluoroscopic analysis requires estimation of the 3D prosthesis pose from its 2D silhouette in the fluoroscopic image, by optimizing a dissimilarity measure. Currently, extensive user-interaction is needed, which makes analysis labor-intensive and operator-dependent.
The aim of this study was to review five optimization methods for 3D pose estimation and to assess their performance in finding the correct solution. Two derivative-free optimizers (DHSAnn and IIPM) and three gradient-based optimizers (LevMar, DoNLP2 and IpOpt) were evaluated. For the latter three optimizers two different implementations were evaluated: one with a numerically approximated gradient and one with an analytically derived gradient for computational efficiency.
On phantom data, all methods were able to find the 3D pose within 1 mm and 1° in more than 85% of cases. IpOpt had the highest success-rate: 97%. On clinical data, the success rates were higher than 85% for the in-plane positions, but not for the rotations. IpOpt was the most expensive method and the application of an analytically derived gradients accelerated the gradient-based methods by a factor 3–4 without any differences in success rate.
In conclusion, 85% of the frames can be analyzed automatically in clinical data and only 15% of the frames require manual supervision. The optimal success-rate on phantom data (97% with IpOpt) on phantom data indicates that even less supervision may become feasible.

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Integrated assessment techniques for linking kinematics, kinetics and muscle activation to early migration: A pilot study

Abstract

Highlights

Introduction

Section snippets

Subjects

RSA

Discussion

Conclusion

Conflict of interest statement

Acknowledgements

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