While various factors have been assumed to affect knee joint biomechanics, few data have been reported on the function of the extensor mechanism in deep flexion of the knee. This study analyzed the patellofemoral joint contact kinematics and the ratio of the quadriceps and patellar tendon forces in living subjects when they performed a single leg lunge up to 150 deg of flexion. The data revealed that in the proximal-distal direction, the patellofemoral articular contact points were in the central one-third of the patellar cartilage. Beyond 90 deg of flexion, the contact points moved towards the medial-lateral edges of the patellar surface. At low flexion angles, the patellar tendon and quadriceps force ratio was approximately 1.0 but reduced to about 0.7 after 60 deg of knee flexion, implying that the patella tendon carries lower loads than the quadriceps. These data may be valuable for improvement of contemporary surgical treatments of diseased knees that are aimed to achieve deep knee flexion.

References

1.
Mulholland
,
S. J.
, and
Wyss
,
U. P.
,
2001
, “
Activities of Daily Living in Non-Western Cultures: Range of Motion Requirements for Hip and Knee Joint Implants
,”
Int. J. Rehabil. Res.
,
24
, pp.
191
198
.10.1097/00004356-200109000-00004
2.
Weiss
,
J. M.
,
Noble
,
P. C.
,
Conditt
,
M. A.
,
Kohl
,
H. W.
,
Roberts
,
S.
,
Cook
,
K. F.
,
Gordon
,
M. J.
, and
Mathis
,
K. B.
,
2002
, “
What Functional Activities Are Important to Patients With Knee Replacements?
,”
Clin. Orthop. Relat. Res.
,
404
, pp.
172
188
.10.1097/00003086-200211000-00030
3.
Sumino
,
T.
,
Gadikota
,
H. R.
,
Varadarajan
,
K. M.
,
Kwon
,
Y. M.
,
Rubash
,
H. E.
, and
Li
,
G.
,
2011
, “
Do High Flexion Posterior Stabilised Total Knee Arthroplasty Designs Increase Knee Flexion? A Meta Analysis
,”
Int. Orthop.
,
35
, pp.
1309
1319
.10.1007/s00264-011-1228-4
4.
Hefzy
,
M. S.
,
Kelly
,
B. P.
, and
Cooke
,
T. D.
,
1998
, “
Kinematics of the Knee Joint in Deep Flexion: A Radiographic Assessment
,”
Med. Eng. Phys.
,
20
, pp.
302
307
.10.1016/S1350-4533(98)00024-1
5.
Most
,
E.
,
Li
,
G.
,
Sultan
,
P. G.
,
Park
,
S. E.
, and
Rubash
,
H. E.
,
2005
, “
Kinematic Analysis of Conventional and High-Flexion Cruciate-Retaining Total Knee Arthroplasties: An in Vitro Investigation
,”
J. Arthroplasty
,
20
, pp.
529
535
.10.1016/j.arth.2004.09.034
6.
Nagura
,
T.
,
Dyrby
,
C. O.
,
Alexander
,
E. J.
, and
Andriacchi
,
T. P.
,
2002
, “
Mechanical Loads at the Knee Joint During Deep Flexion
,”
J. Orthop. Res.
,
20
, pp.
881
886
.10.1016/S0736-0266(01)00178-4
7.
Li
,
G.
,
Zayontz
,
S.
,
Most
,
E.
,
DeFrate
,
L. E.
,
Suggs
,
J. F.
, and
Rubash
,
H. E.
,
2004
, “
In Situ Forces of the Anterior and Posterior Cruciate Ligaments in High Knee Flexion: An in Vitro Investigation
,”
J. Orthop. Res.
,
22
, pp.
293
297
.10.1016/S0736-0266(03)00179-7
8.
Most
,
E.
,
Sultan
,
P. G.
,
Park
,
S. E.
,
Papannagari
,
R.
, and
Li
,
G.
,
2006
, “
Tibiofemoral Contact Behavior is Improved in High-Flexion Cruciate Retaining TKA
,”
Clin. Orthop. Relat. Res.
,
452
, pp.
59
64
.10.1097/01.blo.0000238843.11176.42
9.
Walker
,
P. S.
,
Yildirim
,
G.
,
Sussman-Fort
,
J.
, and
Klein
,
G. R.
,
2006
, “
Relative Positions of the Contacts on the Cartilage Surfaces of the Knee Joint
,”
Knee
,
13
, pp.
382
388
.10.1016/j.knee.2006.04.011
10.
Kobayashi
,
K.
,
Sakamoto
,
M.
,
Hosseini
,
A.
,
Rubash
,
H. E.
, and
Li
,
G.
,
2012
, “
In-Vivo Patellar Tendon Kinematics During Weight-Bearing Deep Knee Flexion
,”
J. Orthop. Res.
,
30
, pp.
1596
1603
.10.1002/jor.22126
11.
Miller
,
R. K.
,
Goodfellow
,
J. W.
,
Murray
,
D. W.
, and
O'Connor
,
J. J.
,
1998
, “
In Vitro Measurement of Patellofemoral Force After Three Types of Knee Replacement
,”
J. Bone Joint Surg. Br.
,
80
, pp.
900
906
.10.1302/0301-620X.80B5.8460
12.
Hehne
,
H. J.
,
1990
, “
Biomechanics of the Patellofemoral Joint and Its Clinical Relevance
,”
Clin. Orthop. Relat. Res.
,
258
, pp.
73
85
.
13.
DeFrate
,
L. E.
,
Sun
,
H.
,
Gill
,
T. J.
,
Rubash
,
H. E.
, and
Li
,
G.
,
2004
, “
In Vivo Tibiofemoral Contact Analysis Using 3D MRI-Based Knee Models
,”
J. Biomech.
,
37
, pp.
1499
1504
.10.1016/j.jbiomech.2004.01.012
14.
Defrate
,
L. E.
,
Nha
,
K. W.
,
Papannagari
,
R.
,
Moses
,
J. M.
,
Gill
,
T. J.
, and
Li
,
G.
,
2007
, “
The Biomechanical Function of the Patellar Tendon During In-Vivo Weight-Bearing Flexion
,”
J. Biomech.
,
40
, pp.
1716
1722
.10.1016/j.jbiomech.2006.08.009
15.
Li
,
G.
,
DeFrate
,
L. E.
,
Sun
,
H.
, and
Gill
,
T. J.
,
2004
, “
In Vivo Elongation of the Anterior Cruciate Ligament and Posterior Cruciate Ligament During Knee Flexion
,”
Am. J. Sports Med.
,
32
, pp.
1415
1420
.10.1177/0363546503262175
16.
Li
,
G.
,
Wuerz
,
T. H.
, and
DeFrate
,
L. E.
,
2004
, “
Feasibility of Using Orthogonal Fluoroscopic Images to Measure in Vivo Joint Kinematics
,”
ASME, J. Biomech. Eng.
,
126
, pp.
314
318
.10.1115/1.1691448
17.
Nha
,
K. W.
,
Papannagari
,
R.
,
Gill
,
T. J.
,
Van de Velde
,
S. K.
,
Freiberg
,
A. A.
,
Rubash
,
H. E.
, and
Li
,
G.
,
2008
, “
In Vivo Patellar Tracking: Clinical Motions and Patellofemoral Indices
,”
J. Orthop. Res.
,
26
, pp.
1067
1074
.10.1002/jor.20554
18.
Van de Velde
,
S. K.
,
Gill
,
T. J.
,
DeFrate
,
L. E.
,
Papannagari
,
R.
, and
Li
,
G.
,
2008
, “
The Effect of Anterior Cruciate Ligament Deficiency and Reconstruction on the Patellofemoral Joint
,”
Am. J. Sports Med.
,
36
, pp.
1150
1159
.10.1177/0363546508314404
19.
Bingham
,
J. T.
,
Papannagari
,
R.
,
Van de Velde
,
S. K.
,
Gross
,
C.
,
Gill
,
T. J.
,
Felson
,
D. T.
,
Rubash
,
H. E.
, and
Li
,
G.
,
2008
, “
In Vivo Cartilage Contact Deformation in the Healthy Human Tibiofemoral Joint
,”
Rheumatology
,
47
, pp.
1622
1627
.10.1093/rheumatology/ken345
20.
Amis
,
A. A.
,
Senavongse
,
W.
, and
Darcy
,
P.
,
2005
, “
Biomechanics of Patellofemoral Joint Prostheses
,”
Clin. Orthop. Relat. Res.
,
436
, pp.
20
29
.10.1097/01.blo.0000171546.45718.03
21.
Li
,
G.
,
DeFrate
,
L. E.
,
Zayontz
,
S.
,
Park
,
S. E.
, and
Gill
,
T. J.
,
2004
, “
The Effect of Tibiofemoral Joint Kinematics on Patellofemoral Contact Pressures Under Simulated Muscle Loads
,”
J. Orthop. Res.
,
22
, pp.
801
806
.10.1016/j.orthres.2003.11.011
22.
Li
,
G.
,
Zayontz
,
S.
,
DeFrate
,
L. E.
,
Most
,
E.
,
Suggs
,
J. F.
, and
Rubash
,
H. E.
,
2004
, “
Kinematics of the Knee at High Flexion Angles: An in Vitro Investigation
,”
J. Orthop. Res.
,
22
, pp.
90
95
.10.1016/S0736-0266(03)00118-9
23.
Fujikawa
,
K.
,
Seedhom
,
B. B.
, and
Wright
, V
.
,
1983
, “
Biomechanics of the Patello-Femoral Joint—Part I: A Study of the Contact and the Congruity of the Patello-Femoral Compartment and Movement of the Patella
,”
Eng. Med.
,
12
, pp.
3
11
.10.1243/EMED_JOUR_1983_012_004_02
24.
Goodfellow
,
J.
,
Hungerford
,
D. S.
, and
Zindel
,
M.
,
1976
, “
Patello-Femoral Joint Mechanics and Pathology. 1. Functional Anatomy of the Patello-Femoral Joint
,”
J. Bone Joint Surg. Br.
,
58
, pp.
287
290
.
25.
Heegaard
,
J.
,
Leyvraz
,
P. F.
,
Van Kampen
,
A.
,
Rakotomanana
,
L.
,
Rubin
,
P. J.
, and
Blankevoort
,
L.
,
1994
, “
Influence of Soft Structures on Patellar Three-Dimensional Tracking
,”
Clin. Orthop. Relat. Res.
,
299
, pp.
235
243
.
26.
Nakagawa
,
S.
,
Kadoya
,
Y.
,
Kobayashi
,
A.
,
Tatsumi
, I
.
,
Nishida
,
N.
, and
Yamano
,
Y.
,
2003
, “
Kinematics of the Patella in Deep Flexion. Analysis With Magnetic Resonance Imaging
,”
J. Bone Joint Surg. Am.
,
85-A
, pp.
1238
1242
.
27.
Singerman
,
R.
,
Davy
,
D. T.
, and
Goldberg
, V
. M.
,
1994
, “
Effects of Patella Alta and Patella Infera on Patellofemoral Contact Forces
,”
J. Biomech.
,
27
, pp.
1059
1065
.10.1016/0021-9290(94)90222-4
28.
Yildirim
,
G.
,
Walker
,
P. S.
,
Sussman-Fort
,
J.
,
Aggarwal
,
G.
,
White
,
B.
, and
Klein
,
G. R.
,
2007
, “
The Contact Locations in the Knee During High Flexion
,”
Knee
,
14
, pp.
379
384
.10.1016/j.knee.2007.06.007
29.
Matsuda
,
S.
,
Ishinishi
,
T.
,
White
,
S. E.
, and
Whiteside
,
L. A.
,
1997
, “
Patellofemoral Joint After Total Knee Arthroplasty. Effect on Contact Area and Contact Stress
,”
J. Arthroplasty
,
12
, pp.
790
797
.10.1016/S0883-5403(97)90010-3
30.
Huberti
,
H. H.
, and
Hayes
,
W. C.
,
1984
, “
Patellofemoral Contact Pressures. The Influence of Q-Angle and Tendofemoral Contact
,”
J. Bone Joint Surg. Am.
,
66
, pp.
715
724
.
31.
Hsu
,
H. C.
,
Luo
,
Z. P.
,
Rand
,
J. A.
, and
An
,
K. N.
,
1996
, “
Influence of Patellar Thickness on Patellar Tracking and Patellofemoral Contact Characteristics After Total Knee Arthroplasty
,”
J. Arthroplasty
,
11
, pp.
69
80
.10.1016/S0883-5403(96)80163-X
32.
Johanson
,
N. A.
,
Cerynik
,
D. L.
, and
Pasquale
,
M.
,
2011
, “
Measuring Patellofemoral Forces and Pressures in a Simulated Operating Room Environment
,”
J. Arthroplasty
,
26
, pp.
137
143
.10.1016/j.arth.2009.09.004
33.
Omori
,
G.
,
Koga
,
Y.
,
Bechtold
,
J. E.
,
Gustilo
,
R. B.
,
Nakabe
,
N.
,
Sasagawa
,
K.
,
Hara
,
T.
, and
Takahashi
,
H. E.
,
1997
, “
Contact Pressure and Three-Dimensional Tracking of Unresurfaced Patella in Total Knee Arthroplasty
,”
Knee
,
4
, pp.
15
24
.10.1016/S0968-0160(96)00230-X
34.
Matsuda
,
S.
,
Whiteside
,
L. A.
, and
Ishinishi
,
T.
,
1998
, “
Effect of Patellar Meniscus on Patellofemoral Contact Stress in Total Knee Arthroplasty
,”
J. Arthroplasty
,
13
, pp.
722
727
.10.1016/S0883-5403(98)80020-X
35.
Xu
,
C.
,
Chu
,
X.
, and
Wu
,
H.
,
2007
, “
Effects of Patellar Resurfacing on Contact Area and Contact Stress in Total Knee Arthroplasty
,”
Knee
,
14
, pp.
183
187
.10.1016/j.knee.2007.01.005
36.
Li
,
G.
,
Most
,
E.
,
Sultan
,
P. G.
,
Schule
,
S.
,
Zayontz
,
S.
,
Park
,
S. E.
, and
Rubash
,
H. E.
,
2004
, “
Knee Kinematics With a High-Flexion Posterior Stabilized Total Knee Prosthesis: An in Vitro Robotic Experimental Investigation
,”
J. Bone Joint Surg.
,
86-A
, pp.
1721
1729
.
37.
Zelle, J., Barink, M.,
De Waal Malefijt
,
M.
, and Verdonschot, N.,
2009
, “Thigh–Calf Contact: Does It Affect the Loading of the Knee in the High-Flexion Range?,”
J. Biomech.
,
42
, pp. 587–593.10.1016/j.jbiomech.2008.12.015
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