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PII: S13504533(96)00031-8

ELSEVIER

Analytical

behaviors

of a knee joint

Department

Technological

Received

and dynamic

of Mechanical

Engineering

and Engineering

University,

Houghton,

MI 49931, USA

1 September

0 1997 Elsetier Science Ltd for IPEMB. All rights resewed

Printed in Great Britain

1350-4533/97

$17.00 + 0.00

1995, accepted

10 May

Mechanics,

Michigan

1996

ABSTFUCT

A knee model in the sag&al plane is established

in this Jtudy. Specafically,

the model is used to study the e&s

of

inertia, articular

surfaces of the knee joint, and patella on the behaviors

of a knee joint.

These behaviors

includt

the

joint surfnce contact point, ligament f&-es,

instantaneous

center and slide/roll

ratio between the femur

and tibia.

Model results are compawd

to experimental

cadaver studie.5 available

in the literature,

as well as between the quasi.statir and dynamic

mod&.

We found

that inertia increases the sliding ten&ncy

in the latter part of pexion,,

and

lengthens the rruciate

ligaments.

Decreasing

the curvature

of the femur surface geometry tends to reduce the ligament

forcps and moves the contact points towards the anterior

positions.

The introduction

of the patellar

ligament

in the

model seems to stabilize the behaviors

of the knee joint as reflected by the behavior

the instant

centers and the

of the external

load

contact point pattern

on the tibia surface. Furthermore,

we ,found

that diff, Prent magnitudes

applied to the tibia do not alter the qualitative

behaviors

of the knee joint. 0 1997 Elsevim Science for IPEfiiB.

,411

right,\ re.seroed.

qf

Keywords:

Knee

Med.

Phys.,

Eng.

kinematics,

1997,

Vol.

knee

dynamics,

knee

A well-defined

analytical knee model can be an

effective tool for understanding

the functionality

of the largest musculoskeletal

joint in the human

body. Statistics show that over two million

cases ofknee injury occur in the United States each year.

This model can provide a scientific explanation

as

to the causes of these injuries. Therefore,

preventive measure can be taken to avoid them. Furthermore, a well-developed

analytical

model

could

also be used efficiently to determine

the effects of

system variables on the performance

of the knee

joint,

and to guide experimental

and clinical

investigations.

However, a comprehensive

knee

model does not exist in the literature.

Analytical knee models have generally adapted

a four bar linkage methodology,

by grounding

either the tibia or femurlm4. In these models, the

two cruciates are assumed rigid links with neutral

ligament

fibers staying constant lengths during

flexion or extension.

Furthermore,

the articular

surfaces of the femur and tibia are either simplified, or their effects are ignored

completely.

Although

these models

have provided

initial

understanding

of the knee kinematics,

they can-

to: Zhi-Kui

Ling.

geometric

modeling

19, ?9-36,January

1. INTRODUCTION

Correspondence

modeling,

and

dynamic characteristics

of a knee.

a quasi-static

Other studies 5- 8 have adapted

approach

towards the modeling

of a knee.

Although

the quasi-static models compensate

for

the deficiencies

of the four bar linkage model by

allowing the cruciate ligaments

to change their

lengths, they still cannot take into account the

roles of inertia

and other ligaments

in the

behavior of a knee.

To consider the effects of inertia, three studies

have attempted

to establish the dynamic model

of a knee. The first9 proposed a two-dimensional

dynamic model of a tibiofemoral

joint. The model

was used to study the contact conditions

between

the femur and tibia as well as the characteristics

of the ligament forces. The second study investigated the role of ligaments and muscles as control

elements

for a prespecified

rolling

and slidin

pattern.

Recently,

Abdel-Rahman

and Hefzy I?

presented

a dynamic model which incorporates

additional

ligament

constraints

between

the

femur and tibia to the model by Moeinzadeh

in

describing

the tibiofemoral

joint.

However, the

entire articular surface of the femur was assumed

to be a circular arc. The contact point positions

and forces between the femur and tibia and the

ligament

forces were studied.

The

existing

dynamic models do provide further understand-

Analytical

of a knee joint:

Zhi-Kui

Ling et al.

However, deficiencies

still

exist. Specifically,

the role of the patella in the

behavior of a knee joint is usually considered separately 12*13 Furthermore,

the techniques for calculating the loci of instant centers and the roll/slide

ratio during knee motion are absent in the existing models. However, these are important

factors

in studying the kinematics

of a knee. Furthermore, the effects of the joint surface geometry on

the behaviors of the knee have not been carried

out in the literature

quantitatively.

Finally, the

role of inertia in the overall behavior of the knee

is still not quite clear.

The aim of this study is to address the abovementioned

three issues in the existing twodimensional analytical knee models. Specifically,

a two

dimensional

model shown in Figure I is introduced. Formulation

for both the quasi-static and

dynamic

models of a knee is carried out. The

implicit

Euler and Newton-Raphsons

numerical

schemes are used to solve the established

equations

of motion

and

nonlinear

equations.

Methods to determine

the loci of the instant centers and roll/slide

ratio are introduced.

In

addition,

the effect of the different articular surface geometry of the femur on the behavior of the

knee is also investigated.

Results of the quasi-static model provide the

initial values for the simulation

of the dynamic

model. Although

no experiments

are performed

in this study, results from the analytical model are

compared with the available experimental

data in

the literature.

These results include the ligament

forces, the contact conditions,

the loci of the

instant centers, and the rolling/sliding

behavior

between the femur and tibia.

The remainder

of this paper is organized into

four sections. First of all, the analytical model and

its numerical

solution

are introduced.

Secondly,

methodologies

used to determine

the iristant centers and slide/roll

ratio are described. Results and

discussions are presented next, followed by a conclusion.

2. ANALYTICAL

articulating

surface of the tibiofemoral

joint, its

effects are ignored in this study. The contours of

both the femur and the tibia in the sagittal plane

are acquired using the radiographs

of a left, unattached leg of a 6%year-old female cadaver, with

carcinoma

reported

as the cause of death. The

radiograph

conditions

include an unloaded

leg,

horizontally

positioned

with the lateral side down.

Reference axes for the model are set up with

the Y axes centred along the bones longitudinal

axes, pointed towards the knee joint contact surfaces, as shown in Figure 1. In this study, the profile of the femur is described with two segments,

as shown in equations

(1) and (2). This reflects

the actual shape of the femur14. A second-order

polynomial

in equation

(3) is also generated

to

describe the two-dimensional

profile of the tibia

in the sa ttal plane. The maximum

fit errors of

1.8 x10- P and 4.497 ~10~~ cm are found for the

two contours of the femur and the tibia, respectively. The three profiles are as follows:

~~(x_=04b0110~~~4637x-0.13492

fib(x) = 2.733 + &8144-(x

f&d)

30

A knee

+ 2.692)2

+ 0.0477~

(2)

(3)

Five major ligaments

are represented

in the

model. They are the medial collateral

(MCL) , lateral collateral (LCL) , anterior cruciate (ACL) , the

posterior

cruciate (PCL), and the patellar ligament. Both the ACL and the PCL are represented

by their anterior and posterior bundles. Their twodimensional

insertion

and origin

points

are

obtained from the literature5,

and listed in Table

1. These numbers have been adjusted to the coordinate systems discussed before.

In the following discussion, formulation

of the

analytical

model is divided

into two cases, the

quasi-static model and the dynamic model. Two

constraint

equations exist for both models. First,

the tibia surface must be in contact with the femur

surface at one point.

F3 = ACL (mhrior)

Force

F4 = PCL Qmaior)

Force

FS = ACUposterlar)

Force

F6 = PCL (~tcrtor) Force

F7 = htdlr

L@nent

Force

Fext = Externd Force

Mext = Extend

Moment

with respect to the femur, fmxc and fmyc, tibxc

and tibyc are the femur and tibia contact points,

respectively.

The second constraint

requires colinearity

of

Table

(1)

Pa:

Fii

= 21.34-0.2578x

- 0.0332

N = Normal Force

Fl = LCL Force

I -t

MODELS

i $-

model

Moving Tibia

in its sagittal

plane

Ligament

insertion

Ligament

Tibia

LCL

MCL

ACL (anterior)

ACL (posterior)

PCL (posterior)

PCL (anterior)

3.849

2.149

0.849

1.149

3.849

3.849

and origin

X

Tibia

17.579

16.079

21.079

21.079

20.579

20.579

coordinates

Y

Femur

-2.5

-2.3

-2.3

-1.9

-3.2

-1.2

(cm)

X

Femur

1.9

1.4

1.9

1.9

2.4

2.4

Analytical

Table

Ligament

k, (kg cm-

LCL

MCL

ACL

ACL

PCL

PCL

150

150

200

100

175

175

(anterior)

(posterior)

(anterior)

(posterior)

on t/w behaviors

of a knee joint:

Zhi-Kui

Ling

et al.

resistance,

a zero coefficient of friction is assumed, resulting

in only a normal force component.

The tibia is governed

by three equations

of

motion,

as shown below. In this study, the tibia

mass is estimated

at 3.45 kg, the mass for a 50

percentile malel, and the mass moment of inertia

is set to be 392.8 kg cm2.

Stiffnesses

Ligament

study

SK*)

000

000

000

000

000

000

on both the femur and tibia. This can be represented by the zero cross product of the two normals. The simplified

form of this condition

is

shown below.

muss

= (F,.),

+ W + A(nm)

(9)

(%)y

(5)

of ligament forces

for the cruciate and collateral

ligaments

is modeled with the following expression.

smagi=

kj( how,-

Istart,) * if howi

&art,)

if< lnOWj5

hart,)

(6)

different ligament.

The stiffness of the collateral

and

cruciate ligaments,

kj, are taken from the literature.16, and are listed in Table 2, and lnow is the

current length of a ligament.

In equation

(6), hart,

the taut length of the

ligament j, is calculated by multiplying

the initial

length at full extension

of the ligament

by its

strain ratio5. This is shown in equation

( { ), and

the strain ratios of the corresponding

ligaments

are shown in Table 3.

Istart, = linitial?q

(7)

is assumed

to be in the sagittal plane during flexionl.

The

magnitude

of the pate110 ligament

force is

obtained

through the ratio between patellar ligament force and quadriceps

force versus flexion

angle . The insertion

point of the patellar ligament on the tibia is specified at (-0.251,

17.779)

with respect to the tibia coordinate

system. The

angular orientation

of the patellar ligament

is referenced from the literature*.

Besides ligament

forces, a force at the contact

point exists. Because the synovial fluid present in

Table

Ligament

strain

ratio

Ligament

Strain

LCL

MCL

ACL

ACL

PCL

PCL

1.02

1.02

1.05

1.035

1.05

1.05

(anterior)

(posterior)

(anterior)

(posterior)

ratio

X[fmq$+

fma&l

of the normal contact force, and A can be either positive or negative

depending

on the curvature.

In this study, the quasi-static model constitutes

equations

(l-7),

and equations

(8-10) with the

left hand sides equal to zero. The dynamic model

consists of equations

(l-10).

For the quasi-static

model, Newton-Raphsons

method is used to solve

for the six nonlinear

equations, i.e. equations

(S10) with zero accelerations,

and equations (4) and

(5). The independent

variable in these six equations is the flexion angle, and the six unknowns

are the tibia mass center (3~0, y,J, contact point

with respect to the femur and tibia (femxc, tibxc),

the normal force (nomn), and the required external moment

(K,,).

The solutions starting from

0 with 10 increment

up to 90 are calculated.

The solution at each of these positions is found,

if the tolerance is smaller than 0.0001.

For the dynamic model, there are also six equations: the three equations

of motion,

equations

(S-10)) and three algebraic constraints, equations

(4) and (5). Smce the six equations are a mix of

nonlinear

and differential

equations,

this study

uses both

the implicit

Euler

and NewtonRaphsons in simulating

the dynamic model. The

advantage of implicit Euler is its stability, however,

the method only provides a first order accuracy.

Iterations

are performed

at each time step until

convergence

occurs. In this study, the time

increment

for the implicit

Euler method is set at

0.0001 s. The solution for each time step is achieved if the tolerance of 0.0001 is achieved.

31

Analytical

2.1. Instant

of a knee joint:

Zki-Kui

Ling et al.

ratio

The instantaneous

centers of rotation for both the

quasi-static

and dynamic

models are found by

using the instantaneous

velocities of two points on

the moving tibia. They are the tibia contact point

and the tibia mass center. For the quasi-static

model, the line representing

the velocity at the

tibia contact point is approximated

by the line

connection

between the contact point, and the

same contact point at its next position. The same

technique

is used to determine

the velocity line

at the mass center of the tibia. The instant center

is then determined

by constructing

two perpendicular lines to the two velocity lines at the contact

point and the mass center. The intersection

point

of the two perpendicular

lines is the instant center

location at that particular

instance.

For the dynamic model, the velocity at the mass

center of the tibia is known from model simulation. However, the velocity at the contact point

is unknown. In this study, the x and y components

of the

contact

point

velocity,

(dXtitml/&

df2( tibxc,)/dt),

are found by using the contact

point and the same point at the next time step.

A first order forward difference

approximation

scheme is used in the determination

of the contact point velocity. The same two perpendicular

lines to the velocities at the mass center of the

tibia and the contact point are constructed

to

determine

the corresponding

instant centers.

To calculate the slide/roll

ratio, the arc lengths

travelled on the surfaces of the tibia and femur

between two consecutive

simulation

times are

determined

with the following

numerical

integration.

(11)

For either contour surface (fi or f2), the lower and

upper limits are the X components

of two adjacent contact points. The slide/roll

ratio is defined

as the difference. between the larger distance (D)

and the smaller distance (d) travelled

on the

femur and tibia over the smaller of the two arc

lengths travelled (d) .

3. RESULTS

AND

Profun -Pnnnoz.--Plww3 - . . .. . .

KiMllUllO.0

I

x

-3.5 -4-

Figure

Femur

contact

points

arc in equation

(2) is

reduced by 0.1 cm and 0.22 cm, respectively. The

original and the two new profiles of the femur are

identified

as profile 1, 2 and 3 hereafter. Finally,

the effect of the patella on the knee behavior is

also studied with the model.

A constant impulse force with a magnitude

of

20 N is applied along the x axis of the tibia with

a duration

of 0.1 ..s in the analytical

model.

Although

the effect of different external loads on

the behavior of the knee is not the focus of this

study, a qualitative

study is performed.

In the

remainder

of this section, the results of the aforementioned

studies are presented.

The contact point with respect to the femur and

tibia travels posteriorly

with flexion as shown in

Figures 2 and 3. This is in aFeement

with the

results reported by othersgs, . In Figure 2 it can

be observed that as the curvature of the femur

surface profile becomes smaller, contact points

shift towards the anterior

direction.

The inertia

has a greater

impact

on the contact

point

behavior

towards the latter part of the knee

flexion. From Figure 2, it is also shown that the

transition

from the first to the second profile of

the femur is not perfectly smooth. This is due to

the fact that the slope at the connection

point of

DISCUSSIONS

The already-established

analytical models are used

to provide a comparison

between the kinematic

and dynamic

results in terms of the following

characteristics:

the contact points on the femur

and tibia; the ligament

forces; the instant center

locations; the slide/roll

ratio, all with respect to

the flexion angle.

The effects of the articular surface geometry on

the dynamic behavior of a knee are also investigated. This is accomplished

with the reduction

of

the curvatures of the femur surface. Specifically,

the coefficient for the linear term, 0.4637, of the

first femur profile in equation

(1) is reduced to

0.4137 and 0.3637, respectively. The second profile of the femur is also changed. In this case, the

Figure

10

Tibia

contact

30

points

40

50

Flaxion Dqrn

60

70

30

so

Analytical

continuous

in

the modeling

of the femur contour. The rest of

the results are also affected by this phenomenon.

In Figure 3, the contact point with respect to the

tibia travels posteriorly

as well with flexion. However, the contact point moves in a faster rate

towards the posterior direction

for the dynamic

model than for the kinematic

model as flexion

exceeds 40. The effect of the patellar ligament

on the contact point pattern of both the femur

and tibia is barely noticeable.

Ligament

forces in both LCL and MCL exhibit

maximum

magnitudes

at the full extension position. As flexion starts, the ligament forces start to

decrease and are faded to zero before the full

flexion of 90 is reached. It is found that the effect

of inertia on the collateral ligaments is not apparent. Furthermore,

the ligament

forces abate as the

curvature of the femur surface decreases. Introduction of the patella in this study does not make

any difference

in the behavior of the MCL, but

stretches the LCL ligaments.

This is shown in Figure 4.

to compare

the

results of the ligament

forces from the analytical

models with those of experiments

quantitatively,

since different boundary conditions

were used in

those experiments

and the analytical studies. Furthermore,

different opinions exist with regard to

the functions of ligaments20-24. Finally, most of the

experimental

studies are quasi-static

in nature.

Therefore,

the discussion here on the ligament

forces is confined to qualitative

comparison.

For

the collateral ligaments, the results from this study

using both the quasi-static and dynamic models

qualitatively

agree with those found in the exyerimental studies. The experimental

results21.2 ,24.L5

indicated

that from full extension,

the collateral

ligament

forces have the maximum

values, and

decrease as the knee flexes.

While the ligament

force of the anterior PCL

increases and then decreases with respect to the

flexion

angle, the force in the posterior

PCL

decreases very rapidly, as shown in Figure 5. Furthermore,

while the force in the anterior fiber of

the PCL from the dynamic model is larger than

300

I

250

\

h \

I\

200

liint

=-

ligament

=.-.-.(

=

tiit

=+

1

T+

0

+++&

0

Figure4

collateral

10

h~fluence

ligaments

20

30

40

50

Ftexion Degree

of the patellar

ligament

M)

over

70

80

the forces

90

in the

Figure

antrrior

of a knee joint:

The behaviours

of the PCI. ligament

and posterior

bundles

%hi-Kui

force

Ling et al.

iu terms

of in

part of flexion, the trend reverses after flexion

angle passes 42.

As the curvature of the femur declines, the ligament forces in both fibers of the PCL decrease.

While the patellar ligament

has no effect on the

posterior fiber of the PCL, it stretches the anterior

fiber of the PCL in the early part of the flexion,

and provides relief for the fiber in the later part

of the flexion. From the modeling

standpoint,

this

can be explained

with the fact that the posterior

fiber is used to provide the moment

to balance

that produced by the patellar ligament in the early

part of flexion.

The analytical

results of the PCL match with

those from experiments22.

The difference exists in

the anterior fiber, where the maximum

ligament

force occurs during the early part of flexion in the

analytical modeling.

However, the overall trend of

the ligament

forces follows the experimental

results. The effect of inertia on the posterior fiber

of PCL is difficult to observe, since the ligament

force becomes zero before 10 of flexion. The

small value of posterior PCL force was also indicated by others 26,2. The anterior portion of PCL

exhibits a decrease in the ligament force when the

inertia force is considered

in the later part of

flexion. This is probably due to the fact that the

inertia force acts along the same direction

as the

ligament force in the anterior PCL during flexion

of the knee.

While the ligament

force of the posterior ACL

increases with respect to the flexion angle, force

in the anterior ACL decreases and then increases

for the dynamic model. Yet, while the posterior

ACL increases and then decreases with respect to

the flexion angle, the anterior ACL decreases in

the kinematic

model. They are shown in Figure 6.

The difference

between

the kinematic

and

dynamic model is due to the presence of the inertia, which changes the contact pattern on both

the femur and tibia as discussed in the previous

section. Consequently,

the insertion

point of the

ACL on tibia changes its pattern of motion at the

later stage of flexion, which causes itself to be

stretched in the process. As the curvature of the

33

Analytical

on the behaviors

o?aknee joint:

Zhi-Kui

Ling et al.

350,

ACL(a)

Profile

ACL(a)

Profile

Profile

ACL(a)

250

ACL(a)

Kinematic

ACL(p)

Profile

ACL(p)

Profile

Profile

ACL(p)

.ACL(p)

it 1

Kinematic

20

30

40

Flexion

Figure

The behaviours

of the ACL

ligament

force

in terms

of its anterior

forces in both fibers of the ACL decrease.

While the patellar ligament

has little effect on

the pattern of the ligament

forces in either fiber

of the ACL, the forces in ACL increase as flexion

increases. From the modeling

standpoint,

this can

be explained

with the fact that the ACL is used

to provide the moment

to balance that produced

by the patellar

ligament

in the later part of

flexion. For the anterior cruciate ligament,

results

from the analytical model without the patella do

match with those from experiments,

such as

France et a~!. The ligament

force in the anterior

portion

of the ACL decreases from 0 to 90 of

flexion, while the posterior portion increases from

0 to 50 and then decreases towards the 90

flexion.

The instantaneous

centers obtained

from the

quasi-static model follow a circular path, beginning at around 20 of flexion anteriorly

on the

proximal

femoral condyle, and ending at 90 posteriorly closer to the joint

surface also on the

proximal

femoral

condyle. When the inertia is

considered,

the instantaneous

centers have the

same pattern as demonstrated

by the quasi-static

model, nevertheless, they are located in the posterior side of the instant centers from the kinematic model. The effect of changing

the surface

geometry of the femur on the instant centers is

minimal.

However,

the instant

centers

shift

anteriorly as the curvature of the femur decreases.

Patellar ligament

constraint

makes a big difference in the locus of the instant centers for the

dynamic model. Figure 7 demonstrates

this difference where the model without the patella locates

the instant centers in the tibia side of the joint at

the higher degrees of flexion, while the instant

centers of the model with the patella are located

on the femur side.

The loci of the instant centers from experimental studies are only available with the quasistatic approach. These instant centers were found

using X-rays at incremental

degrees of rotation**.

Therefore,

comparison

between the results from

34

50

60

70

60

90

Degree

and posterior

bundle

x am

Figure

instant

7 Influence

centres

of the patellar

(al)

ligament

over

the loci

of the

results may not

be appropriate,

as the methods used to determine

each individual

instant center are different. However, for the quasi-static

model,

the analytical

results display the trend of the instant center locus

which is similar to the experimental

results.

It can be concluded

that rolling is dominant

at

the beginning

of flexion, and sliding becomes the

dominant

factor as the flexion increases. There is

very little difference between the slide/roll

ratio

of the quasi-static and the dynamic model during

flexion from 0 to 60. However, the ratio dips

lower for the quasi-static model when the flexion

angle exceeds 60. The change of femur curvature

has very little effect on the slide/roll

ratio. Furthermore,

the patellar

ligament

facilitates

the

increase of rolling

in the latter part of knee

flexion, as illustrated

in Figure 8. Although

there

are no experimental

results

available,

the

slide/roll

ratio obtained from this study matches

with the consensus as related to the attern of sliding versus rolling in the literature r .

Although

no graphs are presented in this paper

to illustrate the behaviors of the knee joint under

Amlytiral

5

with patekr

ligament = -

liQa"Mt

= - - -

/

,

4-

3.5

,

!

1Slii<Rcdl

0.5

Or

0

Figure

ratio

10

20

Influenc?

34

of the

40

50

Flexion Degree

patellar

ligament

70

60

over

80

90

the Slide/Roll

results obtained in this study. (a) Since a majority

of the knee models and the experimental

studies

in the literature

are kinematic

and quasi-static in

nature, the results from the kinematic

model are

found to be validated

more easily with cadaver

studies, as compared

to the dynamic model. (b)

The ligament

force pattern from the analytical

study matches very well with the experimental

result, especially

that of France et aZ.*. The

smaller curvature of the femur tends to reduce

the magnitudes

of the ligament

forces. Furthermore, the inertia force does have different effects

on the behavior

of various

ligament

forces.

Finally, the patellar ligament

in general does not

have a significant effect on the ligament characteristics discussed in this paper, except in the case of

ACL. (c) A relationship

is found to exist between

the highest ligament

force and the tibia contact

point. III general, the maximum

ligament

force

pulls the two bones together, causing the contact

point to shift in the direction

of the force. This

can also be attributed

to soft tissue imbalance

caused by the surface geometry of the knee joint

as discussed by Attfield et al. (d) In general, loci

of the instantaneous

centers from both the quasistatic and dynamic models follow the pattern indicated by the quasi-static studies from the experiment. Smaller femur surface curvature causes the

movement

of instant centers in the anterior direction. Yet, the patellar ligament makes a difference

in the relative locus of the instant centers for the

dynamic simulation,

where without the consideration of the patella, the locus is located on the

tibia side for the higher degrees of flexion.

(e)

The pattern of the slide/roll

ratio conforms with

the conclusion in the literature.

Changing the cur-

on thr behavim

of n knee joint:

Zhi-Kui

Ling

et al.

little effect on the ratio, while the inertia does

increase the rolling factor a small amount in the

later part of the knee flexion. The patellar ligament also contributes

to the larger rolling/slide

ratio during the later part of knee flexion. (f) Different magnitudes

of the external load have little

impact on the behavior pattern of the characteristics discussed in this study. (g) Based on the

the following

recommenabove conclusions,

dations can be made to the prosthesis designers.

Smaller prostheses may be preferred. A well constructed patella is critical in the normal function

of a knee after total reconstruction.

The results of the study presented

here have

provided

a foundation

for a three-dimensional

study, which is being pursued by the authors.

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