Abstract

Accurate and reliable information about three-dimensional (3D) knee joint laxity can prevent misdiagnosis and avoid incorrect treatments. Nevertheless, knee laxity assessments presented in the literature suffer from significant drawbacks such as soft tissue artifacts, restricting the knee within the measurement, and the absence of quantitative knee ligament property information. In this study, we demonstrated the applicability of a novel methodology for measuring 3D knee laxity, combining robotics- and image-based technology. As such technology has never been applied to healthy living subjects, the aims of this study were to develop novel technology to measure 3D knee laxity in vivo and to provide proof-of-concept 3D knee laxity measurements. To measure tibiofemoral movements, four healthy subjects were placed on a custom-built arthrometer located inside a low dose biplanar X-ray system with an approximately 60 deg knee flexion angle. Anteroposterior and mediolateral translation as well as internal and external rotation loads were subsequently applied to the unconstrained leg, which was placed inside a pneumatic cast boot. Bone contours were segmented in the obtained X-rays, to which subject-specific bone geometries from magnetic resonance imaging (MRI) scans were registered. Afterward, tibiofemoral poses were computed. Measurements of primary and secondary laxity revealed considerable interpersonal differences. The method differs from those available by the ability to accurately track secondary laxity of the unrestricted knee and to apply coupled forces in multiple planes. Our methodology can provide reliable information for academic knee ligament research as well as for clinical diagnostics in the future.

References

1.
Woo
,
S. L.
,
Debski
,
R. E.
,
Withrow
,
J. D.
, and
Janaushek
,
M. A.
,
1999
, “
Biomechanics of Knee Ligaments
,”
Am. J. Sports Med.
,
27
(
4
), pp.
533
543
.10.1177/03635465990270042301
2.
Hirschmann
,
M. T.
, and
Müller
,
W.
,
2015
, “
Complex Function of the Knee Joint: The Current Understanding of the Knee
,”
Knee Surg. Sports Traumatol. Arthrosc.
,
23
(
10
), pp.
2780
2788
.10.1007/s00167-015-3619-3
3.
Kakarlapudi
,
T. K.
, and
Bickerstaff
,
D. R.
,
2001
, “
Knee Instability: Isolated and Complex
,”
West. J. Med.
,
174
(
4
), pp.
266
272
.10.1136/ewjm.174.4.266
4.
Jagodzinski
,
M.
,
Friederich
,
N. F.
, and
Müller
,
W.
,
2016
,
Untersuchung Des Verletzten Kniegelenks
,
Springer-Verlag
,
Berlin Heidelberg
.
5.
Le
,
D. H.
,
Goodman
,
S. B.
,
Maloney
,
W. J.
, and
Huddleston
,
J. I.
,
2014
, “
Current Modes of Failure in TKA: Infection, Instability, and Stiffness Predominate
,”
Clin. Orthop.
,
472
(
7
), pp.
2197
2200
.10.1007/s11999-014-3540-y
6.
Nelson
,
F.
,
Billinghurst
,
R. C.
,
Pidoux
,
I.
,
Reiner
,
A.
,
Langworthy
,
M.
,
McDermott
,
M.
,
Malogne
,
T.
,
Sitler
,
D. F.
,
Kilambi
,
N. R.
,
Lenczner
,
E.
, and
Poole
,
A. R.
,
2006
, “
Early Post-Traumatic Osteoarthritis-Like Changes in Human Articular Cartilage Following Rupture of the Anterior Cruciate Ligament
,”
Osteoarthritis Cartilage
,
14
(
2
), pp.
114
119
.10.1016/j.joca.2005.08.005
7.
Roos
,
H.
,
Adalberth
,
T.
,
Dahlberg
,
L.
, and
Lohmander
,
L. S.
,
1995
, “
Osteoarthritis of the Knee After Injury to the Anterior Cruciate Ligament or Meniscus: The Influence of Time and Age
,”
Osteoarthritis Cartilage
,
3
(
4
), pp.
261
267
.10.1016/S1063-4584(05)80017-2
8.
Sanders
,
T. L.
,
Pareek
,
A.
,
Kremers
,
H. M.
,
Bryan
,
A. J.
,
Levy
,
B. A.
,
Stuart
,
M. J.
,
Dahm
,
D. L.
, and
Krych
,
A. J.
,
2017
, “
Long-Term Follow-Up of Isolated ACL Tears Treated Without Ligament Reconstruction
,”
Knee Surg., Sports Traumatol. Arthrosc.
,
25
(
2
), pp.
493
500
.10.1007/s00167-016-4172-4
9.
Artmann
,
M.
, and
Wirth
,
C. J.
,
1974
, “
Investigation of the Appropriate Functional Replacement of the Anterior Cruciate Ligament (Author's Transl)
,”
Z. Orthop. Ihre. Grenzgeb.
,
112
(
1
), pp.
160
165
.https://pubmed.ncbi.nlm.nih.gov/4274851/
10.
Beldame
,
J.
,
Bertiaux
,
S.
,
Roussignol
,
X.
,
Lefebvre
,
B.
,
Adam
,
J.-M.
,
Mouilhade
,
F.
, and
Dujardin
,
F.
,
2011
, “
Laxity Measurements Using Stress Radiography to Assess Anterior Cruciate Ligament Tears
,”
Orthop. Traumatol. Surg. Res.
,
97
(
1
), pp.
34
43
.10.1016/j.otsr.2010.08.004
11.
LaPrade
,
R. F.
, and
Terry
,
G. C.
,
1997
, “
Injuries to the Posterolateral Aspect of the Knee: Association of Anatomic Injury Patterns With Clinical Instability
,”
Am. J. Sports Med.
,
25
(
4
), pp.
433
438
.10.1177/036354659702500403
12.
Branch
,
T. P.
,
Stinton
,
S. K.
,
Siebold
,
R.
,
Freedberg
,
H. I.
,
Jacobs
,
C. A.
, and
Hutton
,
W. C.
,
2017
, “
Assessment of Knee Laxity Using a Robotic Testing Device: A Comparison to the Manual Clinical Knee Examination
,”
Knee Surg. Sports Traumatol. Arthrosc.
,
25
(
8
), pp.
2460
2467
.10.1007/s00167-015-3935-7
13.
Peeler
,
J.
,
Leiter
,
J.
, and
MacDonald
,
P.
,
2010
, “
Accuracy and Reliability of Anterior Cruciate Ligament Clinical Examination in a Multidisciplinary Sports Medicine Setting
,”
Clin. J. Sport Med.
,
20
(
2
), pp.
80
85
.10.1097/JSM.0b013e3181ceca45
14.
Pugh
,
L.
,
Mascarenhas
,
R.
,
Arneja
,
S.
,
Chin
,
P. Y. K.
, and
Leith
,
J. M.
,
2009
, “
Current Concepts in Instrumented Knee-Laxity Testing
,”
Am. J. Sports Med.
,
37
(
1
), pp.
199
210
.10.1177/0363546508323746
15.
DeHaven
,
K. E.
,
1983
, “
Arthroscopy in the Diagnosis and Management of the Anterior Cruciate Ligament Deficient Knee
,”
Clin. Orthop. Relat. Res.
,
172
, pp.
52
56
.https://pubmed.ncbi.nlm.nih.gov/6822005/
16.
Adler
,
G. G.
,
Hoekman
,
R. A.
, and
Beach
,
D. M.
,
1995
, “
Drop Leg Lachman Test: A New Test of Anterior Knee Laxity
,”
Am. J. Sports Med.
,
23
(
3
), pp.
320
323
.10.1177/036354659502300312
17.
Arneja
,
S.
, and
Leith
,
J.
,
2009
, “
Review Article: Validity of the KT-1000 Knee Ligament Arthrometer
,”
J. Orthop. Surg. (Hong Kong)
,
17
(
1
), pp.
77
79
.10.1177/230949900901700117
18.
Forster
,
I. W.
,
Warren-Smith
,
C. D.
, and
Tew
,
M.
,
1989
, “
Is the KT1000 Knee Ligament Arthrometer Reliable?
,”
J. Bone Jt. Surg. Br.
,
71-B
(
5
), pp.
843
847
.10.1302/0301-620X.71B5.2584257
20.
Stagni
,
R.
,
Fantozzi
,
S.
,
Cappello
,
A.
, and
Leardini
,
A.
,
2005
, “
Quantification of Soft Tissue Artefact in Motion Analysis by Combining 3D Fluoroscopy and Stereophotogrammetry: A Study on Two Subjects
,”
Clin. Biomech.
,
20
(
3
), pp.
320
329
.10.1016/j.clinbiomech.2004.11.012
21.
Kuo
,
M.
,
Tsai
,
T.
,
Lin
,
C.
,
Lu
,
T.
,
Hsu
,
H.
, and
Shen
,
W.
,
2011
, “
Influence of Soft Tissue Artifacts on the Calculated Kinematics and Kinetics of Total Knee Replacements During Sit-to-Stand
,”
Gait Posture
,
33
(
3
), pp.
379
384
.10.1016/j.gaitpost.2010.12.007
22.
Tsai
,
T.
,
Lu
,
T.
,
Kuo
,
M.
, and
Hsu
,
H.
,
2009
, “
Quantification of Three-Dimensional Movement of Skin Markers Relative to the Underlying Bones During Functional Activities
,”
Biomed. Eng. Appl. Basis Commun.
,
21
(
3
), pp.
223
232
.10.4015/S1016237209001283
23.
Pedersen
,
D.
,
Vanheule
,
V.
,
Wirix-Speetjens
,
R.
,
Taylan
,
O.
,
Delport
,
H. D.
,
Scheys
,
L.
, and
Andersen
,
M. S.
,
2019
, “
A Novel Non-Invasive Method for Measuring Knee Joint Laxity in Four Dof: In Vitro Proof-of-Concept and Validation
,”
J. Biomech.
,
82
, pp.
62
69
.10.1016/j.jbiomech.2018.10.016
24.
Dzialo
,
C. M.
,
Pedersen
,
P. H.
,
Simonsen
,
C. W.
,
Jensen
,
K. K.
,
de Zee
,
M.
, and
Andersen
,
M. S.
,
2018
, “
Development and Validation of a Subject-Specific Moving-Axis Tibiofemoral Joint Model Using MRI and EOS Imaging During a Quasi-Static Lunge
,”
J. Biomech.
,
72
, pp.
71
80
.10.1016/j.jbiomech.2018.02.032
25.
Wu
,
G.
,
Siegler
,
S.
,
Allard
,
P.
,
Kirtley
,
C.
,
Leardini
,
A.
,
Rosenbaum
,
D.
,
Whittle
,
M.
,
D'Lima
,
D. D.
,
Cristofolini
,
L.
,
Witte
,
H.
,
Schmid
,
O.
, and
Stokes
,
I.
,
2002
, “
ISB Recommendation on Definitions of Joint Coordinate System of Various Joints for the Reporting of Human Joint Motion–Part I: Ankle, Hip, and Spine. International Society of Biomechanics
,”
J. Biomech.
,
35
(
4
), pp.
543
548
.10.1016/S0021-9290(01)00222-6
26.
Grood
,
E. S.
, and
Suntay
,
W. J.
,
1983
, “
A Joint Coordinate System for the Clinical Description of Three-Dimensional Motions Application to the Knee
,”
ASME J. Biomed. Eng.
,
105
(
2
), pp.
136
143
.10.1115/1.3138397
27.
Lorenz
,
A.
,
Krickl
,
V.
,
Ipach
,
I.
,
Arlt
,
E.
,
Wülker
,
N.
, and
Leichtle
,
U. G.
,
2015
, “
Practicability for Robot-Aided Measurement of Knee Stability In-Vivo
,”
BMC Musculoskeletal Disord.
,
16
(
1
), p.
373
.10.1186/s12891-015-0826-5
28.
Nielsen
,
E. S.
,
Hsu
,
A.
,
Patil
,
S.
,
Colwell
,
C. W.
, and
D'Lima
,
D. D.
,
2018
, “
Second-Generation Electronic Ligament Balancing for Knee Arthroplasty: A Cadaver Study
,”
J. Arthroplasty
,
33
(
7
), pp.
2293
2300
.10.1016/j.arth.2018.02.057
29.
Markolf
,
K. L.
,
Mensch
,
J. S.
, and
Amstutz
,
H. C.
,
1976
, “
Stiffness and Laxity of the Knee–the Contributions of the Supporting Structures. A Quantitative In Vitro Study
,”
JBJS
,
58
(
5
), pp.
583
594
.10.2106/00004623-197658050-00001
30.
Hughston
,
J. C.
, and
Jacobson
,
K.
,
1985
, “
Chronic Posterolateral Rotatory Instability of the Knee
,”
JBJS
,
67
(
3
), pp.
351
359
.10.2106/00004623-198567030-00001
31.
Colombet
,
P.
,
Jenny
,
J. Y.
,
Menetrey
,
J.
,
Plaweski
,
S.
, and
Zaffagnini
,
S.
,
2012
, “
Current Concept in Rotational Laxity Control and Evaluation in ACL Reconstruction
,”
Orthop. Traumatol. Surg. Res.
,
98
(
8
), pp.
S201
S210
.10.1016/j.otsr.2012.10.005
32.
Blankevoort
,
L.
,
Kuiper
,
J. H.
,
Huiskes
,
R.
, and
Grootenboer
,
H. J.
,
1991
, “
Articular Contact in a Three-Dimensional Model of the Knee
,”
J. Biomech.
,
24
(
11
), pp.
1019
1031
.10.1016/0021-9290(91)90019-J
33.
Delin
,
C.
,
Silvera
,
S.
,
Bassinet
,
C.
,
Thelen
,
P.
,
Rehel
,
J.-L.
,
Legmann
,
P.
, and
Folinais
,
D.
,
2014
, “
Ionizing Radiation Doses During Lower Limb Torsion and Anteversion Measurements by EOS Stereoradiography and Computed Tomography
,”
Eur. J. Radiol.
,
83
(
2
), pp.
371
377
.10.1016/j.ejrad.2013.10.026
34.
Chiron
,
P.
,
Demoulin
,
L.
,
Wytrykowski
,
K.
,
Cavaignac
,
E.
,
Reina
,
N.
, and
Murgier
,
J.
,
2017
, “
Radiation Dose and Magnification in Pelvic X-Ray: EOS™ Imaging System Versus Plain Radiographs
,”
Orthop. Traumatol. Surg. Res.
,
103
(
8
), pp.
1155
1159
.10.1016/j.otsr.2017.07.018
You do not currently have access to this content.