REVIEW ARTICLE

Computational Modeling: An Alternative Approach for Investigating Patellofemoral Mechanics

John J. Elias, PhD* and Andrew J. Cosgarea, MDw

Abstract: Computational modeling is commonly used in all engineering disciplines to represent complex systems. A computational model of the patellofemoral joint is a graphical representation of joint anatomy that can be manipulated to simulate knee function. Current models are typically reconstructed from magnetic resonance imaging scans of knees. Force vectors are applied to the patella to represent the quadriceps muscles, while the patella tendon is modeled with force vectors or deformable elements. Although the femur, tibia, and patella are typically modeled as rigid structures, the cartilage is represented with springs or modeled using nite element analysis. Computational models can be created to represent individual patients or general pathologic conditions. The quadriceps muscles and patella tendon can be manipulated to simulate patellofemoral pathology or surgical or nonsurgical treatment methods. The models can be used to characterize patellofemoral loading during knee exion and characterize the distribution of force and pressure within the patellofemoral joint. Key Words: patellofemoral joint, computational model, cartilage, pressure (Sports Med Arthrosc Rev 2007;15:8994)

COMPUTATIONAL MODELING
Computational models are used in all engineering disciplines to represent complex systems. Structural analyses that characterize deformations, internal forces, and stresses are vital for cost eective analysis of buildings and vehicles used for transportation. Computational modeling techniques used for other engineering disciplines are commonly incorporated into biomechanical engineering studies to assess loads and pressures applied to tissues of the musculoskeletal system. The primary parameters characterized during studies focused on patellofemoral biomechanics are patellofemoral loading due to the muscles of the quadriceps
From the *Medical Education and Research Institute of Colorado, Colorado Springs, CO; and wDepartment of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD. Funding for this work has been provided by the Patellofemoral Foundation and the Colorado Institute for Technology. Reprints: John J. Elias, PhD, MERIC, 3920 North Union Blvd, Suite 210, Colorado Springs, CO 80907 (e-mail: elias@meric.info). Copyright r 2007 by Lippincott Williams & Wilkins

group, the patella tendon and the retinacular structures, patellofemoral kinematics, and pressure applied to patellofemoral cartilage. Numerous studies have been performed with live subjects and cadaveric specimens to investigate the parameters of interest. Data that can be collected directly from live subjects is primarily limited to electromyographic (EMG) assessment of quadriceps muscle activity13 and magnetic resonance imaging (MRI) based assessment of patellofemoral kinematics4,5 and areas of contact.46 Cadaveric studies allow measurement of additional output parameters, such as the distribution of force and pressure within the patellofemoral joint.7,8 Cadaveric studies also allow controlled manipulation of variables of interest, such as the orientation and magnitude of forces applied by the quadriceps muscles and the patella tendon. Because cadaveric studies are typically performed with normal knees, the anatomy and alignment are usually externally manipulated to represent patients with patellofemoral disorders. In addition, because the loads that can be applied to cadaveric tissues are limited, subphysiologic loads are often applied. Tissue degradation also limits the number of parametric variations that can be performed with a single specimen. The expense and time required to perform cadaveric studies also hinders the progress of patellofemoral biomechanics studies. One way to address these limitations is to computationally model the patellofemoral joint and simulate knee function. A computational model of the patellofemoral joint is a graphical representation of joint anatomy that can be manipulated to simulate joint function. Threedimensional representations of joint anatomy are typically constructed from imaging data obtained from knees. Forces acting on the patella represent the quadriceps muscles, the patella tendon, and any other retinacular structures included in the model. Joint cartilage is represented as a deformable material, and motion of the patella with respect to the femur and the force and pressure distributions within the cartilage are determined by governing equations developed to simulate function. The primary advantage of computational modeling is the ability to manipulate the model. Previous computational studies have focused on the inuence of the patella tendon orientation,912 the quadriceps extension moment,13 the force distribution among the quadriceps muscles,11,12 and the properties of the retinacular structures14 on the distribution of force and pressure within the patellofemoral joint. Other parameters that can be manipulated include the properties of patellofemoral

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cartilage, patellofemoral alignment, and patellofemoral anatomy. In addition to characterizing the patellofemoral force and pressure distributions, the forces applied by all soft tissues that are not input to the model can be calculated. The resultant force and moment acting on the patella owing to the forces applied by the quadriceps muscles, the patella tendon, and the retinacular structures can also be calculated. Patellofemoral kinematics can also be quantied. Models can be created to represent knees with patellofemoral disorders or normal knees, and physiologically realistic loading levels can be applied. For most models, the governing equations and tissue representations provide rapid calculation of the patellofemoral pressure distribution, allowing relatively inexpensive studies including a wide range of parametric variations in input parameters. The primary concern related to computational modeling of patellofemoral biomechanics is the accuracy of the computational output. The accuracy of the computational output is inuenced by all the data input to the model. Approximated parameters that can dramatically inuence computational output include the magnitude and orientation of the forces used to represent the quadriceps muscles and the patella tendon and the properties assigned to the retinacular structures and the joint cartilage. The accuracy of the computational output is also inuenced by the governing equations used to simulate knee function. Studies comparing computational output with in vitro or in vivo experimental measurements should be performed for all computational models to assess the accuracy of the modeling techniques. The accuracy of computational models developed to date has been assessed by comparing experimental measurements of patellofemoral kinematics,15,16 contact area,16,17 force distribution,18 and maximum cartilage pressure18 to computational predictions.

MODELING TECHNIQUES
Graphical representations of knees are currently constructed from imaging data. Although computed tomography images have commonly been used to construct representations of bone surfaces,12,15,18 MRI scans allow reconstruction of the bones and cartilage without exposing subjects to radiation. Multiple techniques have been described for obtaining MRI images that highlight the bones and cartilage of the patellofemoral joint.6,10,17,19 Several software programs and custom written computer codes are available to convert outlines of bones and cartilage on sequential MRI images into 3dimensional representations of bones and cartilage. MRI images can also be used to help locate the origin and insertion points of the quadriceps muscles and patella tendon on the models,17 although previously published anatomic data are necessary to represent the orientations of the individual muscles of the quadriceps group.20,21 Anatomic data can also be used to identify insertion points for retinacular structures, such as the medial patellofemoral ligament (MFPL).14

The primary loading inputs to computational models of the patellofemoral joint are the forces applied by the quadriceps muscles. The quadriceps force has typically been divided among the muscles of the quadriceps group on the basis of the physiologic crosssectional area of each muscle.21,22 The quadriceps force distribution can be individualized for patients by replicating simulated activities in a laboratory while recording EMG data from the quadriceps muscles. When the EMG data are combined with kinematic data, the quadriceps muscle forces can be estimated using a modied Hill-type muscle model.17 The force applied by the patella tendon can be determined on the basis of previously dened relationships between quadriceps and patella tendon forces23,24 or the patella tendon can be modeled with extendable elements that deform in response to applied quadriceps loads.1517 Multiple theoretical methods have been developed to simulate knee function with patellofemoral models. Quasi-static analyses are typically performed to quantify the patellofemoral force and pressure distributions. For a quasi-static analysis, the initial position of the patella with respect to the femur is prescribed at each exion angle, although 6 degrees of freedom of movement are allowed for the patella in response to patellofemoral loading.10,12,17,18 The bones of the patellofemoral joint are typically considered rigid surfaces in comparison with the deformable cartilage.12,1618 Deformable bands can also be included to represent retinacular structures, although the contribution of these structures to the computational output can be assumed to be minimal for some applications.10,14,17 At each exion angle, the joint cartilage deforms to provide reaction forces and moments to balance those applied by the quadriceps muscles, the patella tendon, and any retinacular structures modeled. The distribution of force and pressure is determined by the cartilage deformation and the properties assigned to the cartilage.

PATIENT-SPECIFIC MODELING
The authors have been developing a technique for simulating knee function in computational models representing patients with patellofemoral disorders. Development of the modeling technique has been approved by the Institutional Review Board of the Medical Education and Research Institute of Colorado. Models are constructed using 2 sets of MRI images. One MRI scan highlights both the patellofemoral cartilage and the bones (Fig. 1), whereas the second highlights the bones with the knee exed. To highlight the cartilage, the knee is scanned in the sagittal plane using a 3-dimensional spoiled gradient echo sequence with fat suppression (repetition time = 55 ms, echo time = 5 ms, ip angle = 40 degrees, eld of view = 14 cm), with a slice thickness of 1.5 mm.10,19 The knee is imaged while fully extended using an extremity coil. The second scan uses the full body coil, with the knee passively exed to approximately 45 degrees. The images with the knee exed are T1-weighted
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Computational Modeling

FIGURE 1. MRI image used to construct a patient-specific model of the patellofemoral joint. The outlines of the femur, tibia, and patella are shown in white, as are the outlines of the cartilage on the patella and femur.

(repetition time = 550 ms, echo time = 15 ms, eld of view = 25 cm), with a 3-mm slice thickness. Surface models of the bones and cartilage are created from the rst set of MRI images. Triangulated surface meshes representing each bone and cartilage surface are combined to give a representation of the extended knee (Fig. 2). The cartilage thickness distributions on the articular surfaces of the femur and patella are determined from the reconstructed cartilage surfaces. By plotting the cartilage thickness distribution, areas of local cartilage thinning corresponding to cartilage lesions can be identied. Attachment points for the vastus medialis obliquus (VMO), vastus medialis longus (VML), rectus femoris, vastus intermedius, vastus lateralis and patella tendon on the femur, patella, and tibia are identied on the basis of anatomic landmarks and previously published data.20,21 Kinematic data are input to the model to simulate passive knee exion from 30 to 90 degrees of exion. Near full extension, the patella is not suciently constrained by the trochlear groove for the analysis. To reproduce patellofemoral alignment of the patient with the knee exed, the reconstructed femur from the extended MRI scan is aligned with a femur reconstructed from the exed MRI scan. The patella from the extended knee is also aligned with the patella from the exed knee, while focusing on reproducing the position of the patella apex within the trochlear groove and the orientation of the lateral facet with respect to the lateral ridge of the trochlear groove for the exed knee (Fig. 3). The patellar exion at 45 degrees is quantied. The patellar exion is
r

FIGURE 2. Computational model of a knee at full extension, showing the orientations of the vectors representing the patella tendon, the VMO, the VML, the rectus femoris, the vastus intermedius, and the vastus lateralis.

set to 0 degree at full extension, and a linear variation in patellar exion with tibiofemoral exion is assumed. As the tibia is rotated about the approximate center of rotation of the distal condyles to simulate knee exion, the patella tracks within the trochlear groove without altering the shift of the patella apex with respect to the deepest part of the groove or the tilt with respect to the lateral ridge of the trochlea, on the basis of previous in vivo imaging data for normal knees.25 A proximal-distal line tangent to the apex of the patellar cartilage is kept parallel to a tangent line to the trochlear cartilage. The passive patellofemoral kinematics is kept constant when other input conditions are varied, unless the simulated

FIGURE 3. Computational model of a knee at 45 degrees of flexion, showing the alignment of the patella within the trochlear groove. A representation of the springs used to model cartilage is shown in the enlarged portion of the figure.

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change would be expected to alter passive kinematics. As an example, when simulating anteromedialization (AMZ) of the tibial tuberosity, the patellofemoral exion at each tibiofemoral exion angle is decreased by determining the eective reduction in the tibiofemoral exion angle due to anteriorizing the patella tendon attachment site. Simulated physiologic loading conditions are applied to the patella, which alters the position of the patella within the trochlear groove. The forces applied by the quadriceps muscles are represented by vectors oriented along the line of action of each muscle. The muscle forces representing a quadriceps force distribution for patients with pain and malalignment are based on a combination of 2 sets of previous EMG measurements that relied on electrical stimulation to normalize the data.1,3 The previous studies characterized relative contributions of the quadriceps muscles to the quadriceps extension moment for symptomatic and asymptomatic knees. The moment arm about the exion axis and the applied moment for each muscle are used to quantify the force applied by each muscle for each simulated exion angle. The patella tendon force is divided into 5 force vectors oriented from the distal patella to the tibial tuberosity. The patella tendon force at each exion angle is determined from the quadriceps force and the exion angle.24 Retinacular structures, when modeled, are represented by tension-only springs. Retinacular structures have an origin on the femur, wrap around the condyles and insert on the patella. A resting length is assigned to each spring based on previously published anatomic data for the structure being modeled and the length at full extension. The spring force as a function of spring elongation is also assigned on the basis of previously published data for the structure being modeled. As the knee exes, the change in length of each spring is quantied, which determines the spring force. The spring forces are incorporated into patellofemoral loading. When representing passive knee exion, large forces can develop within retinacular structures and dramatically alter the force and pressure distributions, as shown previously for grafts used to reconstruct the MFPL.14 To avoid overestimating the inuence of retinacular structures on the computational output, a step-wise analysis accounts for unloading of the retinacular structures as the position of the patella changes within the trochlear groove. To characterize the patellofemoral force and pressure distributions for each simulation, the femur and patella are treated as rigid bodies, with a surface of approximately 2000 compressive springs created midway between the cartilage on the femur and the patella to represent the patellofemoral cartilage (Fig. 3). The pressure within each spring is assumed to increase nonlinearly according to the equation26: p E1 vln1 d=h 1 v1 2v

where E is the elastic modulus (4 MPa),16 n is the Poissons ratio (0.45),26 h is the combined thickness of the cartilage on the femur and patella, and d is the compression of the spring. Each spring element is also assigned a shear stiness equal to 2% of the compressive stiness to represent the relatively small contribution of joint friction and cartilage shear stiness. To allow nonlinear deformation, patellofemoral loading is applied in 5 steps, with the deformation following one step used to determine the stiness of each spring for the next step. For each loading step, the patella translates and rotates with respect to the femur, with the nal position of the patella producing equilibrium and minimizing the total potential energy within the springs representing the cartilage and any retinacular structures.

CLINICAL APPLICATIONS
The computational model allows for a wide range of parametric variations to the input parameters. The quadriceps force distribution can be varied to represent patients with pain and malalignment or asymptomatic subjects to characterize how weakness or training of the vastus medialis inuences the patellofemoral force and pressure distributions. The patella tendon attachment site on the tibia can be manipulated to simulate surgical realignment of the tibial tuberosity. Proximal realignment techniques, such as reconstruction of the MFPL, can also be simulated. Cartilage lesions can also be represented within the model by decreasing the stiness of springs at the site of a lesion. Representing cartilage lesions allows characterization of the inuence of lesions on the pressure applied to the surrounding cartilage and characterization of how lesions inuence the biomechanical benet of simulated treatment methods. With further development, the surface models representing the patella and femur could also be manipulated, allowing characterization of the inuence of parameters such as the sulcus angle and the Wiberg classication on the force and pressure distributions. Several output parameters are calculated for each simulation. Output parameters that are commonly used to characterize patellofemoral biomechanics include the maximum pressure applied to cartilage on the medial and lateral facet, the lateral force percentage, and the mean pressure. The lateral force percentage is the percentage of the total compressive force applied to the cartilage on the lateral facet of the patella. The mean pressure is the total compressive force divided by the contact area. The compressive force applied to degenerated cartilage is also quantied when investigating treatment strategies designed to unload cartilage lesions. The 6 components of the resultant force and moment applied to the patella by the quadriceps muscles and the patella tendon are also quantied for each simulation. Variations in the components of resultant force and moment show how treatment strategies inuence patellofemoral loading during simulated knee function.
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Computational Modeling

SIMULATION OF TIBIAL TUBEROSITY AMZ AND QUADRICEPS STRENGTHENING

The computational modeling technique is being used to characterize how AMZ of the tibial tuberosity and quadriceps strengthening inuence the patellofemoral force and pressure distributions. Computational models are being created to represent the anatomy of individual patients with patellofemoral pain and malalignment that has persisted after a minimum of 4 months of physical therapy. The models are being used to simulate preoperative knee function and function after simulated treatments. A quadriceps extension moment of 30 Nm is being applied at all exion angles. The preoperative condition is being simulated with a quadriceps force distribution representing patients with patellofemoral pain and malalignment on the basis of the previously published EMG measurements.1,3 Approximately 4% and 9% of the total quadriceps force is applied by the VMO and VML, respectively. AMZ of the tibial tuberosity is being simulated by shifting the patella tendon attachment on the tibia 7 mm medially and 7 mm anteriorly. Quadriceps strengthening that focuses on the vastus medialis is being simulated by altering the quadriceps force distribution to represent asymptomatic subjects. For the strengthened quadriceps, approximately 9% and 12% of the total quadriceps force is applied by the VMO and VML, respectively. Computational output from one of the patientspecic models developed to date shows that AMZ of the tibial tuberosity and quadriceps strengthening decrease the lateral force acting on the patella. AMZ of the tibial tuberosity also decreases joint compression. The anteriorization component of AMZ increased the moment arm of the patella tendon, which decreased the force applied by the quadriceps muscles by 12% to 27% over the exion angles simulated. The decreased quadriceps force and the change in the orientation of the patella tendon combined to decrease the joint compression at all exion angles (Table 1). The decreased quadriceps force also decreased the other components of the resultant force and moment applied to the patella by the quadriceps muscles and the patella tendon. The decrease in the lateral force acting on the patella and the moments acting to tilt the patella laterally and rotate the distal patella laterally was particularly large owing to the medialization component of AMZ. The increased force applied by the VMO and VML for simulated quadriceps
TABLE 1. Components of the Resultant Force and Moment Averaged ( Standard Deviation) Over All Flexion Angles
Compression (N) Preoperative AMZ Strengthened 561 93 454 81 564 87 Lat Force (N) 64 3 18 9 51 3 Lat Tilt Moment (Nm) 1.399 0.256 0.769 0.259 0.749 0.240 Lat Rotation Moment (Nm) 0.303 0.160 0.436 0.037 0.131 0.166

strengthening decreased the lateral force and lateral rotation moment acting on the patella, although the changes were not as large as those recorded for AMZ. The decrease in the lateral tilt moment acting on the patella was larger for simulated strengthening than for AMZ owing to the posterior orientation of the VMO and the medial oset on the patella. Altering the quadriceps force distribution had minimal inuence on the joint compression. Although both simulated treatments unloaded the lateral cartilage of the patellofemoral joint and decreased the maximum and mean cartilage pressures, AMZ had a greater inuence on the computational output than quadriceps strengthening (Fig. 4). The initial analysis does not consider the inuence of cartilage lesions. Because of the constant quadriceps extension moment, the variation in the computational output with the exion angle was relatively small. From 30 to 90 degrees of exion, the average lateral force percentage ( standard deviation) for the knee in the preoperative condition was 75 4%, and decreased to 67 2% and 69 2% following simulated AMZ of the tibial tuberosity and quadriceps strengthening, respectively. The decrease in the lateral force percentage was primarily because of the decreases in the lateral force and lateral tilt moment acting on the patella. The decreases in the lateral force and tilt moment acting on the patella also contributed to a decrease in the maximum cartilage pressure. From 30 to 90 degrees of exion, the average maximum cartilage pressure for the knee in the preoperative condition was 1.9 0.8 MPa, and decreased to 1.2 0.5 MPa and 1.5 0.7 MPa after simulated AMZ and quadriceps strengthening, respectively. The decreases in the lateral rotation moment and the joint compression also contributed to the maximum pressure decrease. The changes

Lat indicates lateral.

FIGURE 4. The patellofemoral pressure distribution superimposed over the patella mesh for the knee in the preoperative condition and following simulated tibial tuberosity AMZ at 30 and 90 degrees of flexion.

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in the resultant force and moment acting on the patella also contributed to a decrease in the mean cartilage pressure. From 30 to 90 degrees of exion, the average mean cartilage pressure for the knee in the preoperative condition was 0.68 0.18 MPa, and decreased to 0.42 0.08 MPa and 0.61 0.16 MPa after simulated AMZ and quadriceps strengthening, respectively.

9. 10. 11. 12. 13. 14.

CONCLUSIONS
Computational modeling is a powerful tool for investigating patellofemoral biomechanics. Computational models can provide answers to questions that cannot be adequately addressed through other means of investigation. Computational models can be used to characterize the biomechanical benet of surgical and nonsurgical methods for treating patellofemoral disorders. An initial evaluation of AMZ of the tibial tuberosity and quadriceps strengthening indicates that both treatment methods tend to decrease the pressure applied to patellofemoral cartilage. With further development, computational models could also be used to evaluate the treatment methods for individual patients. Any developments in computational modeling techniques should be accompanied by a validation study to characterize the accuracy of the computational output. REFERENCES
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