In Vivo Three-dimensional Kinematics of Normal Knees During Sitting Sideways

doi:10.21203/rs.3.rs-957517/v1

Download PDF

Research Article

In Vivo Three-dimensional Kinematics of Normal Knees During Sitting Sideways

https://doi.org/10.21203/rs.3.rs-957517/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

The normal knee kinematics during asymmetrical kneeling such as the sitting sideways remains unknown. This study aimed to clarify in vivo kinematics during sitting sideways of normal knees.

Methods

Twelve knees from six volunteers were examined. Under fluoroscopy, each volunteer performed a sitting sideways. A two-dimensional/three-dimensional registration technique was used. The rotation angle, varus-valgus angle, anteroposterior translation of the medial and lateral sides of the femur relative to the tibia, and kinematic pathway in each flexion angle was evaluated.

Results

Bilateral knees during sitting sideways showed a femoral external rotation relative to the tibia with flexion. Whereas the ipsilateral knees showed valgus movement, and the contralateral knees showed varus movement. The medial side of the contralateral knees was more posteriorly located than that of the ipsilateral knees beyond 110° of flexion. The lateral side of the contralateral knees was more anteriorly located than that of the ipsilateral knees from 120° to 150° of flexion. In the ipsilateral knees, a medial pivot pattern followed by a bicondylar rollback was observed. In the contralateral knees, no significant movement followed by a bicondylar rollback was observed.

Conclusion

Even though the asymmetrical kneeling such as sitting sideways, the knees did not display asymmetrical movement.

Orthopedics

sitting sideways

kneeling

kinematics

normal knee

Many studies reported the kinematics of normal knees is activity-dependent [1-7]. Therefore, it is important to evaluate each activity.

Kneeling is one of the most common activities of daily living such as sitting on the floor, gardening, and praying. Concerning the kinematics, several studies demonstrated that a femoral external rotation with a medial pivot is observed with the knee flexion during kneeling [3, 4]. There are many kinds of sitting styles such as sitting cross-legged, seiza-sitting, and sitting sideways. In addition, the kinematics during sitting cross-legged is different from that of kneeling and squatting [4]. However, most of the sitting styles evaluated previously were symmetrical [2-4, 8]. Therefore, the kinematics during asymmetrical sitting such as the sitting sideways remains unknown.

Especially in Asian and Middle-Eastern countries, the patients after total knee arthroplasty (TKA) desire the sitting with deep-knee-bend. Several studies demonstrated that the knees after TKA during kneeling were also indicated the femoral external rotation [9-11]. Niki et al. reported that although the seiza-sitting after TKA seemed safe in terms of component dislocation [10]. Furthermore, Nakamura et al. reported that the ball-and-socket joint articulation enabled the patients to kneel safely without the incidence of any dislocation [11]. On the other hand, recently, medial pivot TKA was launched with to recreate normal knee kinematics. Additionally, many studies reported the clinical outcome was excellent or good [12-17]. In particular, for the patients after medial pivot TKA, the asymmetrical sitting such as sitting sideways tend to be avoided because the contralateral knee is capable to show the lateral pivot motion with the femoral internal rotation. However, whether the contralateral knee during sitting sideways would show the lateral pivot motion with the femoral internal rotation remain unknown. Therefore it is meaningful to evaluate the normal knee kinematics during sitting sideways.

This study aimed to clarify in vivo kinematics during sitting sideways of normal knees. The hypothesis of this study was that in vivo kinematics during sitting sideways was different between the ipsilateral knees and contralateral knees, in other words, the ipsilateral knees showed femoral external rotated, valgus, and medial pivot motion with flexion, on the other hand, the contralateral knees showed femoral internal rotated, varus, and lateral pivot motion with flexion.

Twelve knees from six volunteers were examined. All of the volunteers were Japanese males and provided written informed consent to participate in this study. Institutional review board approval was obtained, with documentation. At the time of examination, the mean age was 37.3 ± 7.6 years. The mean body height was 169.9 ± 5.2 cm. The mean body weight was 64.2 ± 5.2 kg. All of the values were expressed as mean ± standard deviation (SD).

Under fluoroscopy, each volunteer performed a sitting sideways at a natural pace (Figure 1). They practised the motion several times before recording. The right and left knee motion were separately recorded. The sequential motion was recorded as a series of digital X-ray images (1024 × 1024 × 12 bits/pixel, 7.5-Hz serial spot images as a DICOM file) using a 17-inch (43-cm) flat panel detector system. Furthermore, all images were processed by dynamic range compression, thereby enabling edge-enhanced images. To estimate the spatial position and orientation of the knee, a two-dimensional/three-dimensional (2D/3D) registration technique [4, 18] was employed.

Three-D bone models were created from computed tomography (CT) and used for the computer-aided design (CAD) models. Estimation accuracy for the relative motion between 3D bone models was ≤ 1° in rotation and ≤ 1 mm in translation [4].

A local coordinate system at the bone model was produced according to a previous study [19]. Knee rotations were described using the joint rotational convention of Grood and Suntay[20]. Femoral rotation angle relative to the tibia, varus-valgus angle, and anteroposterior (AP) translation of the medial sulcus (medial side) and lateral epicondyle (lateral side) of the femur on the plane that is perpendicular to the tibial mechanical axis in each flexion angle were evaluated [4]. AP translation was calculated as a percentage relative to the proximal AP dimension of the tibia [4]. External rotation was denoted as positive and internal rotation as negative. Valgus was denoted as positive and varus as negative. Positive and negative values of AP translation were described as anterior and posterior to the axis of the tibia, respectively.

Statistical analyses

Results were analysed using SPSS version 24 (IBM Corp., Armonk, NY, USA). Repeated measure analysis of variance (ANOVA) and post hoc pairwise comparison (Bonferroni test) was used to analyse all evaluation items. A p-value <0.05 was considered statistically significant. Moreover, a power analysis using EZR[21] indicated that 11 knees would be required for an alpha set at 0.05 and power at 0.8.

Flexion, rotation, and varus-valgus angle

Ipsilateral knees during sitting sideways were gradually flexed from 98.4 ± 6.8° to 150.8 ± 4.5°, and contralateral knees during sitting sideways were gradually flexed from 101.7 ± 6.2° to 155.2 ± 4.8°.

In the ipsilateral knees, the femurs displayed an external rotation of 13.7 ± 3.5° relative to the tibia from 110° to 150° of flexion. In the contralateral knees, the femurs displayed an external rotation of 5.8 ± 6.8° relative to the tibia from 110° to 150° of flexion (Figure 2). From 120° to 150° of flexion, the femoral external rotation of contralateral knees was significantly smaller than that of ipsilateral knees (120°: p = 0.008, 130°: p = 0.001, 140°: p < 0.001, 150°: p < 0.001).

Regarding the varus-valgus angle, the ipsilateral knees showed the valgus movement of 4.6 ± 2.5° from 130° to 150° of flexion. On the other hand, contralateral knees showed varus movement of -3.1 ± 4.4° from 110° to 150° of flexion (Figure 3). From 120° to 150° of flexion, the contralateral knees showed significantly varus position than ipsilateral knees (120°: p = 0.006, 130°: p = 0.005, 140°: p = 0.001, 150°: p < 0.001).

AP translation

The AP translation of the medial side of the ipsilateral femur indicated 10.4 ± 7.0 % posterior movement from 130° to 150° of flexion. The AP translation of the medial side of the contralateral femur indicated 11.0 ± 8.6 % posterior movement from 130° to 150° of flexion (Figure 4). Beyond 110° of flexion, the medial side of the contralateral knees was significantly more posteriorly located than that of the ipsilateral knees (p = 0.011).

The AP translation of the lateral side of the ipsilateral femur indicated 40.0 ± 6.6 % posterior movement beyond with 110° of flexion. The AP translation of the lateral side of the contralateral femur indicated 20.2 ± 4.4 % posterior movement from 130° to 150° of flexion (Figure 5). From 120° to 150° of flexion, the lateral side of the contralateral knees was significantly more anteriorly located than that of the ipsilateral knees (120°: p = 0.008, 130°: p < 0.001, 140°: p < 0.001, 150°: p < 0.001).

Kinematic pathway (Figure 6)

In the ipsilateral knees, the difference between the medial and lateral sides of the femur reflected a medial pivot pattern from 110° to 130° of flexion. From 130° to 150° of flexion, a bicondylar rollback was observed. In the contralateral knees, no significant movement was observed from 110° to 130° of flexion. From 130° to 150° of flexion, a bicondylar rollback was observed.

This is the first study to evaluate the in vivo knee kinematics of normal volunteers during asymmetrical kneeling using the CAD model of fluoroscopically captured images. Regarding the varus-valgus angle, the ipsilateral knees during sitting sideways showed valgus movement, on the other hand, the contralateral knees during sitting sideways showed varus movement. This fact was as hypothesized. Whereas, regarding rotation angle and AP translation, the result of this study was contrary to the hypothesis. In other words, the bilateral knees showed the femoral external rotation, additionally, the contralateral knees did not show a lateral pivot motion. These facts suggest that regardless of the varus-valgus movement, normal knees during asymmetrical kneeling display a femoral external rotation. Moreover, a lateral pivot motion was not observed even though the contralateral knees during asymmetrical kneeling. Namely, even though the asymmetrical kneeling, the knees did not display asymmetrical movement. However, the extent of rotation angle and AP translation was significantly different between the ipsilateral knees and contralateral knees; the femoral external rotation of contralateral knees was smaller than that of ipsilateral knees, the medial side of contralateral knees was located more posterior than that of ipsilateral knees, and the lateral side of contralateral knees was located more anterior than that of ipsilateral knees. Therefore, although the kinematics of contralateral knees during sitting sideways was not contrasted with that of ipsilateral knees perfectly during sitting sideways, it might be more laterally constrained movement.

Murakami et al reported that the knees during an asymmetrical activity such as golf swing displayed asymmetrical movement, unlike this study. The golf swing is a closed-kinetic-chain activity, whereas the sitting sideways is an open-kinetic-chain activity. This suggests that even though the asymmetrical activities, the kinematics is different depending on each activity. Moreover, in sitting sideways, the respective movement of femur and tibia may be different between the ipsilateral knees and contralateral knees.

The previous study that evaluated the knee kinematics during symmetrical kneeling has reported that the range of femoral external rotation with flexion was 14.8 ± 3.8°, and the range of lateral AP translation with flexion was 40.2 ± 10.2 % [4]. The rotation and lateral AP translation of ipsilateral knees during sitting sideways were similar to that of normal knees during symmetrical kneeling [3, 4]. On the other hand, the rotation and lateral AP translation of contralateral knees during sitting sideways were smaller than those of normal knees during symmetrical kneeling [3, 4]. These suggest that patients who underwent TKAs do not need to avoid sitting sideways. However, in particular, those who underwent guided-motion TKAs which guide medial pivot motion should take care of the sitting sideways.

Regarding the kinematic pathway, a bicondylar rollback was observed from 130° to 150° of flexion in both the ipsilateral and contralateral knees during sitting sideways. The previous studies demonstrated that normal knee kinematics showed a medial pivot pattern during kneeling [3, 4]. These suggest that the normal knee kinematics during kneeling is different between symmetrical activity and asymmetrical activity in high-flexion.

Gladnick et al reported that although from extension to 90° of flexion normal knee exhibited an increase in varus-valgus laxity as the flexion angle increase, the variability of AP translation in response to the varus and valgus load was small [22]. On the other hand, in the current study, the ipsilateral knees displayed valgus movement, whereas the contralateral knees displayed varus movement. Furthermore, the AP translation was different between the ipsilateral knees and contralateral knees. These suggest that during a high-flexion activity more than 90° of flexion, because the varus-valgus laxity increase additionally, the varus and valgus load may affect the AP translation.

This study has some limitations. First, this study analysed the knee joint kinematics of only Japanese males. The knee kinematics of females or the other races may be different. Second, in the current study, the right and left knee motion were separately recorded because it is impossible to record the bilateral knees in the flat panel. Therefore, it is capable not to be reflected in the simultaneous knee motion during sitting sideways.

Even though the contralateral knee during sitting sideways, the femoral external rotation relative to the tibia was observed. Moreover, a lateral pivot motion was not observed. In other words, the knees during asymmetrical kneeling did not display asymmetrical movement.

TKA: Total knee Arthroplasty; SD: Standard deviations; 2D/3D: 2-dimensional/3-dimensional; CT: Computed tomography; CAD: Computer-aided design; AP: anteroposterior; ANOVA: Analysis of variance

Ethics approval and consent to participate

This study was approved by Osaka University ethics committee (Number 13106). All of the volunteers in this study provided written, informed consent prior to participation.

Consent for publication

Not Applicable

Availability of data and materials

The datasets analysed 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 study was not supported by any funding.

Authors' contributions

KK, TT, and SK designed the study and the initial draft of the manuscript. KK, TT, SK, and TY contributed to analysis of the kinematic data. HI, ST, ST and KS contributed to analysis a data and manuscript preparation. All other authors have contributed to data collection and interpretation, and critically reviewed the manuscript. The final version of the manuscript was approved by all authors.

Acknowledgements

Not applicable

Komistek RD, Dennis DA, Mahfouz M: In vivo fluoroscopic analysis of the normal human knee. Clinical orthopaedics and related research 2003(410):69–81.
Hemmerich A, Brown H, Smith S, Marthandam SS, Wyss UP: Hip, knee, and ankle kinematics of high range of motion activities of daily living. Journal of orthopaedic research: official publication of the Orthopaedic Research Society 2006, 24(4):770–781.
Moro-oka TA, Hamai S, Miura H, Shimoto T, Higaki H, Fregly BJ, Iwamoto Y, Banks SA: Dynamic activity dependence of in vivo normal knee kinematics. Journal of orthopaedic research: official publication of the Orthopaedic Research Society 2008, 26(4):428–434.
Kono K, Tomita T, Futai K, Yamazaki T, Tanaka S, Yoshikawa H, Sugamoto K: In vivo three-dimensional kinematics of normal knees during different high-flexion activities. The bone & joint journal 2018, 100-b(1):50-55.
Koo S, Andriacchi TP: The knee joint center of rotation is predominantly on the lateral side during normal walking. Journal of biomechanics 2008, 41(6):1269–1273.
Kozanek M, Hosseini A, Liu F, Van de Velde SK, Gill TJ, Rubash HE, Li G: Tibiofemoral kinematics and condylar motion during the stance phase of gait. Journal of biomechanics 2009, 42(12):1877–1884.
Murakami K, Hamai S, Okazaki K, Ikebe S, Shimoto T, Hara D, Mizu-Uchi H, Higaki H, Iwamoto Y: In vivo kinematics of healthy male knees during squat and golf swing using image-matching techniques. The Knee 2016.
Acker SM, Cockburn RA, Krevolin J, Li RM, Tarabichi S, Wyss UP: Knee kinematics of high-flexion activities of daily living performed by male Muslims in the Middle East. The Journal of arthroplasty 2011, 26(2):319–327.
Hamai S, Miura H, Higaki H, Matsuda S, Shimoto T, Sasaki K, Yoshizumi M, Okazaki K, Tsukamoto N, Iwamoto Y: Kinematic analysis of kneeling in cruciate-retaining and posterior-stabilized total knee arthroplasties. Journal of orthopaedic research: official publication of the Orthopaedic Research Society 2008, 26(4):435–442.
Niki Y, Takeda Y, Udagawa K, Enomoto H, Toyama Y, Suda Y: Is greater than 145{degrees} of deep knee flexion under weight-bearing conditions safe after total knee arthroplasty?: a fluoroscopic analysis of Japanese-style deep knee flexion. The bone & joint journal 2013, 95-b(6):782-787.
Nakamura S, Sharma A, Kobayashi M, Ito H, Nakamura K, Zingde SM, Nakamura T, Komistek RD: 3D in vivo femoro-tibial kinematics of tri-condylar total knee arthroplasty during kneeling activities. The Knee 2014, 21(1):162–167.
Katchky AM, Jones CW, Walter WL, Shimmin AJ: Medial ball and socket total knee arthroplasty. The bone & joint journal 2019, 101-b(1_Supple_A):59-65.
Schmidt R, Ogden S, Blaha JD, Alexander A, Fitch DA, Barnes CL: Midterm clinical and radiographic results of the medial pivot total knee system. International orthopaedics 2014, 38(12):2495–2498.
Fitch DA, Sedacki K, Yang Y: Mid- to long-term outcomes of a medial-pivot system for primary total knee replacement: a systematic review and meta-analysis. Bone & joint research 2014, 3(10):297-304.
Atzori F, Salama W, Sabatini L, Mousa S, Khalefa A: Medial pivot knee in primary total knee arthroplasty. Annals of translational medicine 2016, 4(1):6.
Karachalios T, Varitimidis S, Bargiotas K, Hantes M, Roidis N, Malizos KN: An 11- to 15-year clinical outcome study of the Advance Medial Pivot total knee arthroplasty: pivot knee arthroplasty. The bone & joint journal 2016, 98-b(8):1050-1055.
Youm YS, Cho SD, Lee SH, Cho HY: Total Knee Arthroplasty Using a Posterior Cruciate Ligament Sacrificing Medial Pivot Knee: Minimum 5-year Follow-up Results. Knee surgery & related research 2014, 26(3):135–140.
Yamazaki T, Watanabe T, Nakajima Y, Sugamoto K, Tomita T, Yoshikawa H, Tamura S: Improvement of depth position in 2-D/3-D registration of knee implants using single-plane fluoroscopy. IEEE transactions on medical imaging 2004, 23(5):602–612.
Kawashima K, Tomita T, Tamaki M, Murase T, Yoshikawa H, Sugamoto K: In vivo three-dimensional motion analysis of osteoarthritic knees. Modern rheumatology / the Japan Rheumatism Association 2013, 23(4):646–652.
Grood ES, Suntay WJ: A joint coordinate system for the clinical description of three-dimensional motions: application to the knee. Journal of biomechanical engineering 1983, 105(2):136–144.
Kanda Y: Investigation of the freely available easy-to-use software 'EZR' for medical statistics. Bone marrow transplantation 2013, 48(3):452–458.
Gladnick BP, Boorman-Padgett J, Stone K, Kent RN, 3rd, Cross MB, Mayman DJ, Pearle AD, Imhauser CW: Primary and coupled motions of the native knee in response to applied varus and valgus load. The Knee 2016, 23(3):387–392.

No competing interests reported.

Download PDF

Editorial decision: Major revision
14 Nov, 2021
Reviews received at journal
31 Oct, 2021
Reviewers agreed at journal
20 Oct, 2021
Reviewers invited by journal
20 Oct, 2021
Editor assigned by journal
20 Oct, 2021
Editor invited by journal
07 Oct, 2021
Submission checks completed at journal
07 Oct, 2021
First submitted to journal
06 Oct, 2021

You are reading this latest preprint version

In Vivo Three-dimensional Kinematics of Normal Knees During Sitting Sideways

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Results

Discussion

Conclusions

List Of Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1