Assessing the knee joint biomechanics and trunk posture according to medial osteoarthritis severity

doi:10.21203/rs.3.rs-2522164/v1

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Assessing the knee joint biomechanics and trunk posture according to medial osteoarthritis severity

https://doi.org/10.21203/rs.3.rs-2522164/v1

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Background

During progression of knee osteoarthritis (KOA), coronal, sagittal, and horizontal biomechanical parameters are dramatically altered. The purpose of this study is to assess the three-dimensional knee joint biomechanics and trunk posture according to KOA severity.

Methods

Seventy-five patients (95 knees) with medial knee osteoarthritis and 19 young healthy controls (38 knees) were enrolled in this study. The Kellgren-Lawrence classification was used for radiographic evaluation. There were 20 patients with 24 knees with grade 2, 25 with 28 knees with grade 3, and 30 with 43 knees with grade 4. All patients walked at a self-selected speed using an optical motion capture system. Additionally, six-degrees-of-freedom kinematics of the knee joint were calculated using the point cluster technique. The three moment components of the knee joint were calculated using inverse dynamics.

Results

In grade 2 KOA, the relative contribution of knee adduction moment (KAM) increased significantly, and that of knee flexion moment (KFM) decreased at the first peak of total joint moment prior to significant progression of varus knee deformity. Grade 3 KOA showed significant exacerbation of varus knee deformity and increased KA. Maximum knee extension angle decreased and trunk flexion increased during gait in grade 4 KOA.

Conclusions

We showed that kinetic conversion occurred in grade 2 KOA prior to varus deformity appearance as in grade 3. Knee flexion contracture and trunk flexion during gait occurred in grade 4 KOA. The relative contribution of KAM increased significantly, and that of KFM decreased prior to progression of varus knee deformity.

Trial registration:

Not applicable

gait analysis

biomechanics

external knee moment

knee osteoarthritis

severity

trunk flexion

relative contribution

Knee osteoarthritis (KOA) is a degenerative disease affecting more than 300 million patients worldwide. In severe KOA cases, dysfunction, malalignment, joint stiffness, deformity, and flexion contracture occur. This leads to chronic pain, reduction of activities of daily living, and disability, especially in older adults [1–3]. The knee joint is responsible for one-joint motion that enables whole-body movement, by interlocking with other joints, and rotation of the trunk. Maintaining a standing posture is achieved through the interaction and compensatory mechanisms of the knee motion, spinal column, and pelvis. When the compensatory function of pelvic retroversion reaches maximum due to limited hip joint extension, knee flexion is mobilized [4]. This pathology, as a consequence of progression of KOA, is known to cause frailty and affects healthy life expectancy [1, 5].

Knee biomechanics are important parameters for understanding KOA pathology. The external knee joint moment can be divided into the knee adduction moment (KAM), knee flexion moment (KFM), and knee rotation moment (KRM), which are important concepts in understanding the mechanical environment of the knee joint [6, 7]. Many studies on gait analysis in patients with KOA have been performed. Moreover, increased KAM due to varus alignment has been reported to be associated with rapid progression of KOA [6–9]. Asay et al. also assessed the relationship between KOA progression and changes in gait analysis after five years in 19 patients with medial KOA [10]. The results proved that as KOA progressed, the relative contribution, the new concept in kinetics, of KAM to the total joint moment (TJM) increased and KFM decreased. However, the knee biomechanics according to each severity of KOA is still unknown.

Recently, it has been reported that not only changes in coronal parameters, but also variations in sagittal and horizontal parameters occurred in the kinematics and kinetics of KOA. These parameters have been used for gait analysis for a better understanding of KOA [11, 12]. Additionally, external knee joint moments were found to be strongly influenced by the position of the center of body weight [13, 14]. Therefore, analysis of trunk posture is necessary for understanding three-dimensional joint dynamics. Determining the onset and causal relationship between knee moment imbalance, knee flexion contracture, and trunk flexion is critical for establishing systematic treatment strategies for the knee joint and spine. However, regarding comprehensive understanding of KOA pathology, the relationship between three-dimensional joint biomechanics and trunk posture according to KOA severity remains unknown.

In this study, we hypothesized that the onset of knee moment imbalance, knee flexion contracture, and trunk flexion depends on osteoarthritis (OA) severity. This study aimed to evaluate the relationship between three-dimensional joint biomechanics and trunk posture according to KOA severity.

Participants

From November 2014 to October 2018, a total of 4,450 patients (6,786 knees) were diagnosed with KOA at our medical facility. Patients: over 40 years of age, radiographically diagnosed with medial compartment KOA with Kellgren-Lawrence (KL) grade ≥ 2 in at least one knee, and who were randomly chosen to undergo gait analysis were enrolled in the current study. Patients with OA of the hip or ankle, disability preventing walking without support, predominantly lateral compartment OA, neurological deficits, or previous spinal fractures were excluded from the study. Patients who underwent any previous orthopedic surgery were also excluded from this study. Then, 75 patients (93 knees) were eligible for participating in the study, including 20 patients with 24 grade 2 KOA (group G-2), 25 with 28 grade 3 KOA (group G-3), and 30 with 43 grade 4 KOA (group G-4) in the OA groups. As normal controls, 19 young healthy volunteers (38 knees aged 22–39 years old, including 15 men and five women, were allocated to group C.

Physical and radiological evaluation

Knee range of motion (ROM) was measured for physical evaluation. Regarding radiological evaluation, the K-L classification was used to assess knee OA severity [15]. Radiological evaluation was performed using anteroposterior radiographs. Radiographic parameters included hip-knee-ankle angle (HKA) in full length bilateral standing anteroposterior radiographs, and posterior tibial slope angle in the lateral view.

Gait analysis

The participants performed three sets of walking trials at their self-selected normal walking speeds. Gait data were collected as described previously [10, 16, 17]. Gait motion data were captured using a three-dimensional motion analysis system with eight infrared light cameras (ProReflex Qualisys AB Inc., Gothenburg, Sweden). Ground reaction force (GRF) was measured using two multi-component force plates (OR6, Advanced Mechanical Technology Inc., Watertown, NY, USA) embedded in an 8-m walkway. Motion and force data were synchronized and collected at 120 Hz. Three-dimensional motion data were processed using Qualisys Track Manager (Qualisys Track Manager 3D; Qualisys AB Inc., Gothenburg, Sweden). Force data were used for identifying heel strike time in each gait cycle. The gait cycle was defined as the interval between heel strikes on the ipsilateral side.

Kinematic data were collected using the point cluster technique (PCT) as previously described[18]. Fifty-two 14 mm diameter light-reflective markers were placed by physical therapists well-trained in localizing the anatomical landmarks of the limbs and used to calculate knee motion in six degrees of freedom with no constraints, as previously described [19]. Fifty-eight 14 mm diameter light-reflective markers were arranged on two limb segments, creating separate cluster groups of 13 markers on the thigh and 15 on the shank [20]. The software application BioMove (Stanford University, Stanford, CA, USA) was used to calculate the joint kinematics and trunk flexion during walking. External joint moments were calculated using standard inverse dynamics and normalized to each participant’s body weight and height [21]. The angle of trunk flexion was calculated as the angle between the vertical axis and line segment connecting the midpoints of both acromion markers and obliques in the sagittal plane of the global coordinate system [22]. Each gait cycle was time-normalized to 100% of the gait cycle, where the initial contact of a limb inside a force plate was defined as 0%, and the following ground contact of the same limb was defined as 100%.

The values extracted from three walking trials were averaged. The extracted moments included KAM, KFM, and KRM. Similar to the knee index, the total joint moment (TJM; TJM = √ (KAM² + KFM² + KRM²) was calculated during each frame of the stance phase by taking the square root of the sum of the squares of the KFM, KAM, and KRM. The first peak of TJM (TJM1) was defined as the maximum TJM during the first half of the stance, and the second peak TJM (TJM2) was defined as the maximum TJM during the second half of the stance. At the time of the TJM peaks, the proportions of KFM (%KFM), KAM (%KAM), and KRM (%KRM) contribution to the total joint moment were calculated as the square of the planar moment at the time of the peak over the square of the total moment at the time of the peak, multiplied by 100 (%KAM = KAM²/TJM²*100) [10].

Statistical Analysis

Statistical tests for comparing the patients’ demographic data, joint moments, and kinetics among each KL grade and normal control were assessed by one-way analysis of variance followed by the Bonferroni test. All analyses were performed with the JMP software (SAS, Cary, NC, USA). P-values < 0.05 were considered statistically significant. All figures were made by Adobe Illustrator CC 2020 (Adobe, CA, USA).

Demographics of the patients and healthy controls

The demographic and radiographic data of the participants are shown in Table 1. The mean age was significantly high and low in groups G-4 and C, respectively. The height and body mass index were low and high, respectively, in group G-4. However, there was no significant difference in weight between the groups. Gait speed was significantly slower and HKA was significantly lower in group G-4. Knee flexion, extension angle, and total range of motion were significantly smaller in group G-4. No significant differences were observed in the posterior tibial slope angle.

Table1. Background and radiographic data of normal control and the patients in each Kellgren-Lawrence grade.

Kinetics

External knee moments

KAM showed bimodal peak patterns in the early and late stance phases in all groups (Fig. 1A). At the first peak of adduction moment (KAM1), KAM was higher in groups G-3 (rho = 0.66, CI = (0.04, 1.28), P = 0.03) and G-4 (rho = 1.57, CI = (1.01, 2.13), P < 0.0001) than that in group C. Furthermore, KAM in group G-4 was higher than in groups G-2 (rho = 1.38, CI = (0.74, 2.02), P < 0.0001) and G-3 (rho = 0.91, CI = (0.3, 1.52), P = 0.0006). At the second peak of adduction moment (KAM2), KAM was higher in group G-4 than in groups C (rho = 1.04, CI = (0.43, 1.65), P < 0.0001), G-3 (rho = 0.70, CI = (0.04, 1.37), P < 0.0) and G-2 (rho = 1.28, CI = (0.58, 1.98), P = 0.03).

According to KFM, group C showed a moment peak during the loading response phase and then decreased and was converted to an extension moment in the midstance phase, followed by the second peak in the late stance phase (Fig. 1B). KFM was low in the OA groups compared with group C (with significant difference between group C and group G-3 (rho = -1.28, CI = (-2.33, -0.23), P = 0.009) and G-4 (rho = -1.26, CI = (-2.22, -0.31), P = 0.003)) at the first peak (KFM1). However, KFM showed no significant difference among the OA groups at both KFM1 and second peak (KFM2). A decrease in KFM was observed and showed a negative value in groups C, G-2, and G-3 in the midstance phase (from the peak at 12–13% and reached a minimum value at around 38% of the gait phase). However, translation of KFM into an extension moment was not observed in group G-4. KFM was significantly higher in groups G-4 compared with group C (rho = 1.01, CI = (0.32, 1.71), P = 0.001).

KRM showed a bimodal peak pattern in groups C, G-2 and G-3, not in group G-4, which showed a peak only in the late stance phase (Fig. 1C). KRM showed a transition from a positive value (internal rotation) in the early stance phase to a negative value (external rotation) in the late stance phase. KRM was significantly lower in the severe group (group C vs. groups G-3 (rho = -0.27, CI = (0, -0.05), P = 0.007) and G-4 (rho = -0.37, CI = (-0.57, -0.17), P < 0.0001)) in the early stance phase.

TJM and the relative contributions of each moment component

TJM showed a bimodal peak pattern throughout the stance phase in all groups (Fig. 1D). There was no significant difference in TJM at the first peak (TJM1). However, TJM was remarkably higher in group G-4 than in group C (rho = 0.92, CI = (0.38, 1.46), P < 0.0001) and G-2 (rho = 1.17, CI = (0.56, 1.79), P < 0.0001) at the second peak (TJM2).

Regarding the relative contribution, the normal controls showed high %KFM, followed by %KAM and %KRM. However, %KAM and %KFM were significantly high (rho = 39.8, CI = (23.8, 55.7), P < 0.0001) and low (rho = -38.1, CI = (-54.4, -21.9), P < 0.0001), respectively, in groups G-4 at TJM1 (Fig. 2A). At TJM2, the same tendency was observed, without significant difference (Fig. 2B). No significant difference was observed in %KRM among the grades at either TJM peak.

Kinematics

Knee flexion angle showed similar pattern during gait cycle in all the groups. Group C showed smaller knee flexion angle than other groups at initial contact (P < 0.01) (Fig. 3A). Changes in knee flexion angle were significantly lower in group G-4 than other groups at both initial contact to first peak (P < 0.01) and first peak to the midstance (P < 0.01). Knee varus angle was significantly higher in group G-4 than in other groups (P < 0.01) during the stance phase (Fig. 3B). Group G-3 showed large knee varus angle than group C (P < 0.01) and G-2 (P < 0.05) in the mid to terminal stance phase.

Trunk flexion

Trunk flexion showed a negative peak in the early stance phase and a positive peak in the late stance phase in all groups (Fig. 3C). This late stance phase was almost the same as the maximum knee extension phase. Trunk flexion significantly increased in patients with grade 4 KOA, not in the other groups, throughout the entire gait cycle (P < 0.01).

In the present study, the severe KOA group showed more severe varus deformity, larger KAM, and smaller KFM. The relative contribution converted from %KFM dominance into %KAM dominance in patients with severe KOA at TJM1. In addition, knee flexion contracture and trunk flexion were observed in group G-4. We evaluated knee alignment, ROM, and trunk flexion, and clarified the pathogenesis and mechanism of OA progression from a biomechanical perspective with regard to kinematics and kinetics characteristics in each group. This is the first study to identify differences in kinematics and kinetics, including the relative contributions of each moment component according to OA severity.

Regarding the relationship between varus deformity and KAM, significant varus deformity and increases in KAM occurred in groups G-3 and G-4. This may be the result of increases in the lever arm of KAM as well as severity of varus deformity. However, there was a significant increase and decrease in the relative contributions of KAM and KFM, respectively, in grade 2 knees, with little difference between grades 2 and 3 KOA. This suggests that the conversion of relative contribution of each moment from KAM to KFM had already occurred in grade 2 KOA prior to varus deformity appearance.

Group G-4 was found to have a significantly higher %KAM and lower %KFM compared with groups G-2 and G-3, showing further drastic kinetic changes in severe KOA. Additionally, significant flexion contractures and trunk flexion were observed, indicating that grade 4 differed from grade 3 KOA. In addition to varus deformity, severe KOA was reported to have pathology of apparent sagittal imbalance [23–25]. Ohkoshi et al reported that trunk flexion, which leads to elongation of the moment arm of the trunk toward the center of gravity, reduced quadriceps muscle activity in the squat movement [26]. The same effect of reducing KFM may occur during gait. Our results suggest that grade 4 KOA has the potential to increase not only the risk of quadriceps muscle weakness [27] and patellofemoral arthropathy exacerbation [28] due to knee flexion contracture, but also the risk of erector spinae muscles weakness [29, 30] and vertebral fractures. Our data support and provide an explanation of the mechanism of the previous biomechanical study of vertebral fractures associated with KOA [31].

The results of this study showed that a change in the relative moment contribution occurred in grade 2 KOA, with significant constructive varus deformity in grade 3. The KOA progression leads to a conversion of the knee flexion moment (KFM) to the knee adduction moment (KAM). This change in moment balance subsequently exacerbates knee flexion contracture during gait, resulting in trunk flexion (Fig. 4). These outcomes suggest clinical relevance that conservative treatment, such as orthotic treatment [32] and muscle strength training [33] may particularly be effective in grade 2 KOA before constructive changes occur. This is consistent with the results of previous studies of therapeutic interventions with rehabilitation [34, 35]. It has been reported that quadriceps strength weakens with age and pain even in mild cases of KOA [35]. On the other hand, in patients with grade 3, prevention of flexion contracture and maintenance of quadriceps muscle strength are important to prevent progression to grade 4. This may indicate the need for surgical intervention (alignment surgery) to correct constructive varus deformity. In addition, patients with grade 4 KOA had trunk flexion, which also affected sagittal imbalance. Therefore, more aggressive surgical treatment of grade 4 KOA should be considered to improve overall function and prevent frailty.

The KOA progression leads to a conversion of the knee flexion moment (KFM) to the knee adduction moment (KAM). This alteration in moment balance subsequently exacerbates knee flexion contracture during gait, eventually leading to trunk flexion.

The present study has several limitations. First, this study has a relatively small number of patients. The purpose of this study was to clarify the pathophysiology of KOA by subdividing patients with KOA, including healthy participants, into grades. Thus, the number of cases in each group of grades was small. However, new findings were obtained based on this grouping, and this study is considered meaningful and relevant. Furthermore, considering the pathophysiology of KOA, the findings of the present study might be significant depending on the viewpoint that it is a comparative study of grades of KOA and healthy participants were included as controls. Second, our data are cross-sectional, and whether the result is primary or secondary to disease status is unknown. The course of the disease is also unclear. However, it is feasible to compare the characteristics of each grade at the same time. Variations in the disease status among grades may be the result of another study, but our study mainly targeted differences among grades and had an advantage at this point. This new concept comparing the changes in kinetics, including the relative contribution of moments, and kinematics data simultaneously among different severity groups, provides new insights into OA knee pathogenesis. Third, gait speed was not adjusted among groups. Generally, it is well known that it is preferable to match gait speed for comparison. However, in order to assess the natural history of KOA pathology, we have chosen to use self-selected normal walking speeds as previous studies have performed [36, 37]. Additionally, there was no difference in body weight which may have influence on biomechanics among groups.

In conclusion, the present study assessed the kinematics and kinetics according to severity of medial KOA and its relationship with trunk flexion. The relative contribution of each moment component changed from KFM to KAM dominance, and flexion contracture and trunk flexion was observed in patients with severe KOA.

GRF

ground reaction force

HKA

hip-knee-ankle angle

KAM

knee adduction moment

KFM

knee flexion moment

K-L

Kellgren-Lawrence

KOA

knee osteoarthritis

KRM

knee rotation moment

osteoarthritis

PCT

point cluster technique

ROM

range of motion

TJM

total joint moment

Ethics approval and consent to participate

This retrospective study was produced in accordance with our institutional ethics policy. The institutional review board approved this study (No. HOC-C01). The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000

Consent for publication

Informed written consent was obtained from all patients for providing patients information and any accompanying supplements.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing Interests

The authors declare that they have no competing interests.

Funding

This research report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors’ contributions

KS, SC and KU performed data collection of gait analysis. YO and TM performed the clinical assessment. YS, KK, KS, CS, KU and YO analyzed the data. YS, YO, TO and KI mainly wrote the manuscript, and the study was supervised by YO, KK, SS, KI, TO, EK and NI. All authors have made substantial contributions for (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be submitted.

Acknowledgements

The authors have no financial or proprietary interest in the subject matter of this article. Special thanks to our healthcare members for their efforts on valuable helps.

Authors’ information

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No competing interests reported.

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Assessing the knee joint biomechanics and trunk posture according to medial osteoarthritis severity

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Trial registration:

Figures

Introduction

Material And Methods

Participants

Physical and radiological evaluation

Gait analysis

Statistical Analysis

Results

Demographics of the patients and healthy controls

Kinetics

External knee moments

TJM and the relative contributions of each moment component

Kinematics

Trunk flexion

Discussion

Abbreviations

Declarations

References

Additional Declarations

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