A Smart Mobile Application to Monitor Visual Function in Diabetic Retinopathy and Age-Related Macular Degeneration: The CLEAR Study.

PURPOSE: The purpose of this study was to determine if a mobile application, the Checkup Vision Assessment System, could reliably monitor visual acuity (VA) and metamorphopsia remotely versus standard VA reference tests in the clinic. With the current COVID-19 pandemic, an even greater need for remote monitoring exists. Mobile tools enhance the ability to monitor patients virtually by enabling remote monitoring of VA and Amsler grid findings. DESIGN: Prospective, multicenter reliability analysis. METHODS: Participants: Patients (N = 108) with near corrected VA better than 20/200 and a diagnosis of age-related macular degeneration, diabetic retinopathy, or healthy patients without retinal disease (best-corrected visual acuity [BCVA] of 20/32 or better). INTERVENTION: participants were tested using the Checkup, reference VA, and Amsler tests, with the order of testing (Checkup or reference) randomized. Patients monitored their vision using Checkup at least twice a week at home between office visits. Main outcome measurements were near corrected VA and Amsler grid test results. RESULTS: Agreement was strong between Checkup and reference tests for VA (r = 0.86) and Amsler grid (sensitivity: 93%; specificity: 92%). Home versus clinic testing showed excellent agreement (r = 0.96). Patients reported successful home use. There were no serious adverse events or discontinuations. Patients rated the usability of Checkup to be excellent. CONCLUSIONS: There was good agreement between Checkup and in-clinic test results for VA and Amsler grid. The low variance of Checkup testing, agreement between in-clinic and home results, and excellent usability support Checkup as a reliable method for monitoring retinal pathology in clinic and home settings.

How does a novel monoplanar pedicle screw perform biomechanically relative to monoaxial and polyaxial designs?

BACKGROUND: Minimally invasive spinal fusions frequently require placement of pedicle screws through small incisions with limited visualization. Polyaxial pedicle screws are favored due to the difficulty of rod insertion with fixed monoaxial screws. Recently, a novel monoplanar screw became available that is mobile in the coronal plane to ease rod insertion but fixed in the sagittal plane to eliminate head slippage during flexion loads; however, the strength of this screw has not been established relative to other available screw designs. QUESTIONS/PURPOSES: We compared the static and dynamic load to failure in polyaxial, monoaxial, and monoplanar pedicle screws. METHODS: Six different manufacturers' screws (42 total) were tested in three categories (polyaxial, n = 4; monoaxial, n = 1; monopolar, n = 1) utilizing titanium rods. An additional test was performed using cobalt-chromium rods with the monopolar screws only. Screws were embedded into polyethylene blocks and rods were attached using the manufacturers' specifications. Static and dynamic testing was performed. Dynamic testing began at 80% of static yield strength at 1 Hz for 50,000 cycles. RESULTS: In static testing, monoaxial and monoplanar screws sustained higher loads than all polyaxial screw designs (range, 37%-425% higher; p < 0.001). The polyaxial screws failed at the head-screw interface, while the monoaxial and monoplanar screws failed by rod breakage in the static test. The dynamic loads to failure were greater with the monoplanar and monoaxial screws than with the polyaxial screws (range, 35%-560% higher; p < 0.001). With dynamic testing, polyaxial screws failed via screw-head slippage between 40% and 95% of static yield strength, while failures in monoaxial and monoplanar screws resulted from either screw shaft or rod breakage. CONCLUSIONS: All polyaxial screws failed at the screw-head interface in static and dynamic testing and at lower values than monoaxial/monoplanar screw designs. Monoplanar and monoaxial screws failed at forces well above expected in vivo values; this was not the case for most polyaxial screws. CLINICAL RELEVANCE: Polyaxial screw heads slip on the screw shank at lower values than monoaxial or monoplanar screws, and this results in angular change between the rod and pedicle screw, which could cause loss of segmental lordosis. The novel monoplanar screw used in this study may combine ease of rod placement with sagittal plane strength.

Comparative biomechanical analysis of human and caprine knee articular cartilage.

BACKGROUND: The goat is one of the most commonly used preclinical models for focal defect repair and regeneration. While the biomechanics of the human knee has been studied extensively, less is known about the biomechanics of the caprine knee. Differences between human and caprine knees have not been quantified and their significance is largely unknown. METHODS: We conducted a biomechanical analysis of the differences in goat and human knees to assess the validity of these preclinical in vivo models. RESULTS: CT and MRI scans revealed several differences in articular geometry: the caprine tibial plateaux were more convex and the menisci were significantly thicker and covered a larger proportion of the tibial articular surface. Caprine cartilage thickness was consistently thinner, while elastic modulus on indentation testing was consistently stiffer than human cartilage measured at eight different articular locations. Contact area and pressure were measured with electronic pressure sensors under loads normalized by multiples of body weight and at knee flexion angles reported for walking. The highest peaks in contact pressure were measured in the patellofemoral joint in goat and human knees. Peak contact pressure measured at 2 times body weight at the goat tibiofemoral joint at 70° flexion was significantly higher than for any other condition at the human tibiofemoral joint. CONCLUSION: These differences in contact conditions might explain the lower quality of local repair reported for caprine femoral condylar defects relative to trochlear defects. Further comparative analysis, including biologic response, is necessary to determine the extent to which the goat knee reproduces clinical conditions.

Anti-gravity treadmills are effective in reducing knee forces.

Lower body positive pressure (LBPP) treadmills permit significant unweighting of patients and have the potential to enhance recovery following lower limb surgery. We determined the efficacy of an LBPP treadmill in reducing knee forces in vivo. Subjects, implanted with custom electronic tibial prostheses to measure forces in the knee, were tested on a treadmill housed within a LBPP chamber. Tibiofemoral forces were monitored at treadmill speeds from 1.5 mph (0.67 m/s) to 4.5 mph (2.01 m/s), treadmill incline from -10° to +10°, and four treadmill chamber pressure settings adjusted to decrease net treadmill reaction force from 100% to 25% of the subject's body weight (BW). The peak axial tibiofemoral force ranged from 5.1 times BW at a treadmill speed of 4.5 mph (2.01 m/s) and a pressure setting of 100% BW to 0.8 times BW at 1.5 mph (0.67 m/s) and a pressure setting of 25% BW. Peak knee forces were significantly correlated with walking speed and treadmill reaction force (R(2) = 0.77, p = 0.04). The LBPP treadmill might be an effective tool in the rehabilitation of patients following lower-extremity surgery. The strong correlation between tibiofemoral force and walking speed and treadmill reaction forces allows for more precisely achieving the target knee forces desired during early rehabilitation.

Knee joint forces: prediction, measurement, and significance.

Knee forces are highly significant in osteoarthritis and in the survival and function of knee arthroplasty. A large number of studies have attempted to estimate forces around the knee during various activities. Several approaches have been used to relate knee kinematics and external forces to internal joint contact forces, the most popular being inverse dynamics, forward dynamics, and static body analyses. Knee forces have also been measured in vivo after knee arthroplasty, which serves as valuable validation of computational predictions. This review summarizes the results of published studies that measured knee forces for various activities. The efficacy of various methods to alter knee force distribution, such as gait modification, orthotics, walking aids, and custom treadmills are analyzed. Current gaps in our knowledge are identified and directions for future research in this area are outlined.

Wear of polyethylene against oxidized zirconium femoral components effect of aggressive kinematic conditions and malalignment in total knee arthroplasty.

Metallic femoral components with ceramic articulating surfaces can substantially lower polyethylene (PE) wear during walking activities under conditions of normal knee alignment. It is unknown whether these types of components can maintain low wear rates under conditions of knee malalignment and the harsher kinematics associated with younger, athletically active patients. Wear was measured in non-cross-linked, ethylene oxide-sterilized PE inserts against oxidized zirconium or cobalt-chrome femoral components in a knee wear simulator. The vertical load was modified to replicate knee varus malalignment of 3°, and the range of tibial rotation was increased to 20°. Mean gravimetric and volumetric wear rate over 5 million cycles was 55% lower in the oxidized zirconium group. An oxidized zirconium femoral component can significantly reduce PE wear under simulated conditions of athletically active patients with modestly malaligned total knee arthroplasty prostheses.

Anterior cruciate ligament changes in the human knee joint in aging and osteoarthritis.

OBJECTIVE: The development and patterns of spontaneous age-related changes in the anterior cruciate ligament (ACL) and their relationship to articular cartilage degeneration are not well characterized. This study was undertaken to investigate the types and temporal sequence of age-related ACL changes and to determine their correlation with cartilage lesion patterns at all stages of osteoarthritis (OA) development in human knee joints without prior joint trauma. METHODS: Human knee joints (n = 120 from 65 donors ages 23-92) were obtained at autopsy, and ACLs and cartilage were graded macroscopically and histologically. Inflammation surrounding the ACL was assessed separately. RESULTS: Histologic ACL substance scores and ligament sheath inflammation scores increased with age. Collagen fiber disorganization was the earliest and most prevalent change. The severity of mucoid degeneration and chondroid metaplasia in the ACL increased with the development of cartilage lesions. A correlation between ACL degeneration and cartilage degeneration was observed, especially in the medial compartment of the knee joint. CONCLUSION: Our findings indicate that ACL degeneration is highly prevalent in knees with cartilage defects and may even precede cartilage changes. Hence, ACL deficiencies may not only be important in posttraumatic OA, but may also be a feature associated with knee OA pathogenesis in general.

Effect of tibial component varus on wear in total knee arthroplasty.

INTRODUCTION: Malalignment can result in poor clinical outcomes and increased wear. However, component malalignment can occur even when overall limb mechanical axis is within the normal anatomic range. We studied the effect of component malalignment in the presence of acceptable knee alignment in knee arthroplasty. METHODS: Sixteen tibial inserts retrieved at revision surgery were laser-mapped to measure wear. Average implantation duration was 7.7 years (range, 1 to 13). Early (postprimary) and final (prerevision) radiographs were analyzed for overall alignment (limb, femoral and tibial components) and osteolysis. RESULTS: The tibial components were initially aligned in a mean of 1.3 ± 1.7° varus (range, -1.5 to 4.5°), which increased to 3.2 ± 2.9° (range, -2.0 to 8.0°) at the time of revision (p=0.05). Tibial components initially placed in greater than 3° varus were associated with almost twice the volumetric penetration rate. Anatomic knee angles were 5.4 ± 0.9° valgus (range, 4.0 to 7.0°) in the post-primary radiographs and decreased in prerevision radiographs to 3.8 ± 2.6° (range, -1.0 to 7.5°), (p=0.04). DISCUSSION: Tibial varus was associated with increased medial compartment wear and total wear, thus affecting osteolysis in addition to local destruction of the bearing surface. Varus malalignment as low as 3° may result in accelerated wear, even if overall limb alignment is nearly ideal. These results indicate that tibial component alignment is an important factor associated with tibial tray subsidence and polyethylene wear even when limb alignment is neutral.

Vimentin contributes to changes in chondrocyte stiffness in osteoarthritis.

Actin and tubulin cytoskeletal components are studied extensively in chondrocytes, but less is known about vimentin intermediate filaments. In other cell types, vimentin is a determinant of cell stiffness and disruption of vimentin networks weakens the mechanical integrity of cells. Changes in vimentin organization correlate with osteoarthritis progression, but the functional consequences of these changes remain undetermined in chondrocytes. The objective of this study was to compare the contribution of vimentin to the mechanical stiffness of primary human chondrocytes isolated from normal versus osteoarthritic cartilage. Chondrocytes were embedded in alginate and vimentin networks disrupted with acrylamide. Constructs were imaged while subjected to 20% nominal strain on a confocal microscope stage, and the aspect ratios of approximately 1,900 cells were measured. Cytosolic stiffness was estimated with a finite element model, and live-cell imaging of GFP-vimentin was used to further analyze the nature of vimentin disruption. Vimentin in normal chondrocytes formed an inner cage-like network that was substantially stiffer than the rest of the cytosol and contributed significantly to overall cellular stiffness. Disruption of vimentin reduced stiffness approximately 2.8-fold in normal chondrocytes. In contrast, osteoarthritic chondrocytes were less stiff and less affected by vimentin disruption. This 3D experimental system revealed contributions of vimentin to chondrocyte stiffness previously not apparent, and correlated changes in vimentin-based chondrocyte stiffness with osteoarthritis.

Predicting the effect of tray malalignment on risk for bone damage and implant subsidence after total knee arthroplasty.

Tibial tray malalignment has been associated with increased subsidence and failure. We constructed a finite element model of knee arthroplasty to determine the biomechanical factors involved in increasing the risk of subsidence with malalignment. Four fresh-frozen human knees were implanted with a tibial tray and subjected to forces representative of walking for up to 100,000 cycles. Cyclic displacement was measured between the tray and proximal tibia. The vertical load was shifted medially to generate a load distribution ratio of 55:45 (medial/lateral) to represent neutral alignment or 75:25 to represent varus alignment. Subjected specific geometry and material properties were obtained from qCT scans of tibia to construct a finite element model. The tray was subjected to a single load cycle representing experimental conditions. Tray displacement computed by the model matched that measured experimentally. Forces representing varus tray alignment generated greater strains in the proximal tibia and a greater volume of bone was subjected to strains higher than the fatigue threshold. Local compressive strains directly correlated with experimental subsidence and failure. Our results indicate that failure after tray malalignment is likely due to fatigue damage to the proximal tibia rather than shear across the implant-bone interface or failure of the cement mantle.

Characterization of the chondrocyte actin cytoskeleton in living three-dimensional culture: response to anabolic and catabolic stimuli.

The actin cytoskeleton is a dynamic network required for intracellular transport, signal transduction, movement, attachment to the extracellular matrix, cellular stiffness and cell shape. Cell shape and the actin cytoskeletal configuration are linked to chondrocyte phenotype with regard to gene expression and matrix synthesis. Historically, the chondrocyte actin cytoskeleton has been studied after formaldehyde fixation--precluding real-time measurements of actin dynamics, or in monolayer cultured cells. Here we characterize the actin cytoskeleton of living low-passage human chondrocytes grown in three-dimensional culture using a stably expressed actin-GFP construct. GFP-actin expression does not substantially alter the production of endogenous actin at the protein level. GFP-actin incorporates into all actin structures stained by fluorescent phalloidin, and does not affect the actin cytoskeleton as seen by fluorescence microscopy. GFP-actin expression does not significantly change the chondrocyte cytosolic stiffness. GFP-actin does not alter the gene expression response to cytokines and growth factors such as IL-1beta and TGF-beta. Finally, GFP-actin does not alter production of extracellular matrix as measured by radiosulfate incorporation. Having established that GFP-actin does not measurably affect the chondrocyte phenotype, we tested the hypothesis that IL-1beta and TGF-beta differentially alter the actin cytoskeleton using time-lapse microscopy. TGF-beta increases actin extensions, and lamellar ruffling indicative of Rac/CDC42 activation, while IL-1beta causes cellular contraction indicative of RhoA activation. The ability to visualize GFP-actin in living chondrocytes in 3D culture without disrupting the organization or function of the cytoskeleton is an advance in chondrocyte cell biology and provides a powerful tool for future studies in actin-dependent chondrocyte differentiation and mechanotransduction pathways.

Aging-related differences in chondrocyte viscoelastic properties.

The biomechanical properties of articular cartilage change profoundly with aging. These changes have been linked with increased potential for cartilage degeneration and osteoarthritis. However, less is known about the change in biomechanical properties of chondrocytes with increasing age. Cell stiffness can affect mechanotransduction pathways and may alter cell function. We measured aging-related changes in the biomechanical properties of chondrocytes. Human chondrocytes were isolated from knee articular cartilage within 48 hours after death or from osteochondral specimens obtained from knee arthroplasty. Cells were divided into two age groups: between 18 and 35 years (18 - 35); and greater than 55 years (55+) of age. The 55+ group was further subdivided based on visual grade of osteoarthritis: normal (N) or osteoarthritic (OA). The viscoelastic properties of the cell were measured using the previously described micropipette cell aspiration technique. The equilibrium modulus, instantaneous modulus, and apparent viscosity were significantly higher in the 55+ year age group than in the 18 - 35 age group. On the other hand, no differences were found in the equilibrium modulus, instantaneous modulus, or apparent viscosity between the N and OA groups. The increase in cell stiffness can be attributed to altered mechanical properties of the cell membrane, the cytoplasm, or the cytoskeleton. Increased stiffness has been reported in osteoarthritic chondrocytes, which in turn has been attributed to the actin cytoskeleton. A similar mechanism may be responsible for our finding of increased stiffness in aging chondrocytes. With advancing age, changes in the biomechanical properties of the cell could alter molecular and biochemical responses.

In vivo contact stresses during activities of daily living after knee arthroplasty.

We implanted an electronic knee prosthesis to measure tibial forces in vivo during activities of daily living after total knee arthroplasty. We used tibial forces and knee kinematic data collected in vivo to calculate contact stresses using finite element analysis. The polyethylene insert was modeled as an elastoplastic material, and predicted contact stresses were validated using pressure sensitive sensors. Peak contact stresses generated during walking were similar but about 18% lower than those calculated for International Standards Organization (ISO)-recommended wear simulation conditions. Stair climbing generated higher contact stresses (32 MPa) than walking (26 MPa). However, both high flexion activities (lunge and kneel) generated even higher contact stresses, with the lunge activity generating the highest stresses (56 MPa). The activities that generated high contact stresses also resulted in high equivalent plastic strain. However, the lunge activity generated dramatically higher plastic equivalent strain than the other activities. In vivo measurement of kinematics, forces, and contact stresses may be used to develop more clinically relevant wear simulator protocols. Contact stresses generated during high flexion activities were substantially higher and were largely due to the reduced contact area in deep flexion rather than due to an increase in contact forces. Our results support the use of "high flexion" designs that improve contact conditions and preserve contact area at high flexion angles.

The Mark Coventry Award: in vivo knee forces during recreation and exercise after knee arthroplasty.

Knee forces directly affect arthroplasty component survivorship, wear of articular bearing surfaces, and integrity of the bone-implant interface. It is not known which activities generate forces within a range that is physiologically desirable but not high enough to jeopardize the survivorship of the prosthetic components. We implanted three patients with an instrumented tibial prosthesis and measured knee forces and moments in vivo during exercise and recreational activities. As expected, stationary bicycling generated low tibial forces, whereas jogging and tennis generated high peak forces. On the other hand, the golf swing generated unexpectedly high forces, especially in the leading knee. Exercise on the elliptical trainer generated lower forces than jogging but not lower than treadmill walking. These novel data allow for a more scientific approach to recommending activities after TKA. In addition, these data can be used to develop clinically relevant structural and tribologic testing, which may result in activity-specific knee designs such as a knee design more tolerant of golfing by optimizing the conflicting needs of increased rotational laxity and conformity.

Effect of osteochondral graft insertion forces on chondrocyte viability.

BACKGROUND: Because chondrocytes are responsible for articular cartilage matrix synthesis and maintenance, reduced chondrocyte viability could compromise graft survival, healing, and clinical outcome. HYPOTHESIS: Typical forces used in osteochondral grafting reduce the viability of the chondrocytes in the graft. STUDY DESIGN: Controlled laboratory study. METHODS: Osteochondral grafting was performed in 4 fresh-frozen cadaver knees (n = 16 per knee). Impact force was measured during extrusion of the donor graft from the harvester into the recipient site, seating the graft flush with the articular surface of the surrounding cartilage using a tamp, and recessing the graft surface below the recipient articular surface. The magnitudes of forces measured during cadaver surgery (200, 400, and 800 N) were reproduced using a drop-tower apparatus on 80 fresh osteochondral grafts harvested from knee blocks provided by tissue banks. Cell viability and glycosaminoglycan release in media were measured at 48 hours after injury. RESULTS: Forces were relatively low (range, 124-356 N) during graft extrusion from the harvester into the recipient defect or during flush seating (range, 191-418 N) of the graft. Attempts to recess the graft generated significantly greater force (range, 147-685; P < .01). When the donor graft length was 2 mm longer than the depth of the recipient hole, the mean impact force generated was even higher (range, 240-1114 N) than the force seen in a donor graft of equal length. No reduction in viability was seen at 200-N and 400-N impacts. However, a significant decrease in chondrocyte viability was seen in the group impacted with 800 N (only 50% of cells were viable, compared with 91% in the sham group; P < .01). Glycosaminoglycan levels in culture media did not correlate significantly with insertion force. CONCLUSION: Typical graft insertion forces did not significantly reduce chondrocyte viability. However, increased graft length relative to the depth of the recipient hole and attempts to recess the graft generated higher forces, which reduced chondrocyte viability. CLINICAL RELEVANCE: Any theoretical benefits of cancellous bone compaction that may occur in grafts that are recessed or are longer than the recipient holes must be balanced against the potential reduction in chondrocyte viability.

An ABJS Best Paper: Dynamic intraoperative ligament balancing for total knee arthroplasty.

Complications after total knee arthroplasty, such as malalignment, instability, and excessive wear, have been attributed to poor soft tissue balance. Traditional instruments that assist in intraoperative soft tissue balancing rely on static measurements. We used a custom tibial trial, instrumented with force transducers, for dynamic measurement of soft tissue balance. Six cadaver knees and two patients were implanted with the trial tray along with a standard femoral component and a tibial insert. We recorded tibial forces during passive knee flexion, after the initial bone cuts were made, after soft tissue balancing, and after replacing the selected optimal insert with one that was 2 mm thicker. In all knees, substantial imbalance in tibial forces initially was recorded. Soft tissue balancing substantially reduced the imbalance. Although reasonable balance was achieved at 0-degree and 90-degree flexion, there was some measurable imbalance at flexion angles other than 0 degrees and 90 degrees. Increasing the thickness of the insert by 2 mm substantially increased net tibial forces. Inconsistent soft tissue balance may explain some of the wide variation in knee kinematics. Surgical navigation systems have reduced the variability in component alignment. An instrumented tibial trial can be a valuable adjunct to directly measure soft tissue balance.

In vivo knee moments and shear after total knee arthroplasty.

Tibiofemoral loading is very important in cartilage degeneration as well as in component survivorship after total knee arthroplasty. We have previously reported the axial knee forces in vivo. In this study, a second-generation force-sensing device that measured all six components of tibial forces was implanted in a 74-kg, 83-year-old male. Video motion analysis, ground reaction forces, and knee forces were measured during walking, stair climbing, chair-rise, and squat activities. Peak total force was 2.3 times body weight (BW) during walking, 2.5 x BW during chair rise, 3.0 x BW during stair climbing, and 2.1 x BW during squatting. Peak anterior shear force at the tibial tray was 0.30 x BW during walking, 0.17 x BW during chair rise, 0.26 x BW during stair climbing, and 0.15 x BW during squatting. Peak flexion moment at the tray was 1.9% BW x Ht (percentage of body weight multiplied by height) for chair-rise activity and 1.7% BW x Ht for squat activity. Peak adduction moment at the tray was -1.1% BW x Ht during chair-rise, -1.3% BW x Ht during squatting. External knee flexion and adduction moments were substantially greater than flexion and adduction moments at the tray. The axial component of forces predominated especially during the stance phase of walking. Shear forces and moments at the tray were very modest compared to total knee forces. These findings indicate that the soft tissues around the knee absorbed most of the external shear forces. Our results highlight the importance of direct measurements of knee forces.

Tibial forces measured in vivo after total knee arthroplasty.

An instrumented tibial prosthesis was developed to measure forces in vivo after total tibial arthroplasty. This prosthesis was implanted in a 67-kg, 80-year-old man. The prosthesis measured forces at the 4 quadrants of the tibial tray. Tibial forces were measured postoperatively during rehabilitation, rising from a chair, standing, walking, and climbing stairs. By the sixth postoperative week, the peak tibial forces during walking averaged 2.2 times body weight (BW). Stair climbing increased from 1.9 times BW on day 6 to 2.5 times BW at 6 weeks. This represents the first direct in vivo measurement of tibial forces, which should lead to refined surgical techniques and enhanced prosthetic designs. Technical design improvements will enhance function, quality of life, and longevity of total knee arthroplasty.

Outcome of an acetabular design with hydroxyapatite coating on a rough substrate.

UNLABELLED: Outcomes of hydroxyapatite-coated cups have not been as consistently successful as outcomes of hydroxyapatite-coated stems; therefore, we studied a newer generation acetabular design with a plasma-sprayed hydroxyapatite coating on an arc-deposited rough titanium substrate. Our objective was to determine whether clinical and radiographic outcomes would be better than reported for earlier-generation designs. Ninety consecutive hips in 85 patients implanted with this design were followed up prospectively for 2 to 5 years after surgery. Hip scores improved from a preoperative mean of 59 (+/- 12) to final followup mean of 91 (+/- 12). One hip was revised for recurrent dislocation. No hips were revised for aseptic loosening. No cup had complete continuous radiolucent lines. Incomplete lucent lines were noted on early postoperative radiographs. With followup, radiolucent line length decreased by a mean 32% and radiolucent line density increased by 9%. Mean polyethylene linear and volumetric head penetration rates were 0.17 (+/- 0.16) mm/year and 73 (+/- 70) mm/year, respectively. Head penetration rates were higher in men. No other factor (age, body weight, cup abduction, or anteversion angle) correlated with head penetration rate. Our study presents encouraging short-term results. Improvement in radiolucent lines suggests a beneficial effect of hydroxyapatite coating on osseointegration of the cup. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

The Chitranjan Ranawat Award: in vivo knee forces after total knee arthroplasty.

Tibial forces were measured in vivo during the first year after total knee arthroplasty in a 66 kg, 80-year-old man. Forces were measured during activities of daily living, rehabilitation, and exercise. Peak tibial forces recorded during walking increased up to 12 months postoperatively (2.8 times body weight). Tibial forces correlated with increasing speed during treadmill walking. Rising from a chair generated peak forces of 2.6 times body weight. Stair descent generated higher peak forces than stair ascent (3.3 versus 2.9 times body weight, respectively). Exercising on a stair-climbing machine generated forces close to two times body weight whereas stationary bicycling generated even lower forces, near one times body weight. In general, the tibial forces recorded during walking and stair climbing were lower than most predicted values. These measurements can be used to validate in vitro and mathematical models of the knee. This should lead to refined surgical techniques and to enhanced prosthetic designs that will improve patient function, patient quality of life, and longevity of total knee arthroplasty implants.