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Biomechanical Effects of Kneeling After Total Knee Arthroplasty
Kenneth J. Wilkens, MD1; Long V. Duong, BA1; Michelle H. McGarry, MS1; William C. Kim, MD1; Thay Q. Lee, PhD1
1 Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System (09/151), 5901 East 7th Street, Long Beach, CA 90822. E-mail address for T.Q. Lee: tqlee@med.va.gov
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the VA Rehabilitation Research and Development and VA Merit Review. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, and the Department of Orthopaedic Surgery, University of California, Irvine, California

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2007 Dec 01;89(12):2745-2751. doi: 10.2106/JBJS.E.01201
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Background: Kneeling following total knee arthroplasty can be a difficult task, impairing the activities of patients to varying degrees. Little is known about the biomechanical effects of kneeling following total knee replacement. The objective of this study was to quantify the effects of kneeling on patellofemoral joint contact areas and pressures, knee joint reaction force, and patellar kinematics.

Methods: Total knee arthroplasties were performed on eight fresh-frozen cadaveric knees, and they were tested with use of a custom knee jig, which permits the simulation of physiologic quadriceps loading as well as the application of an anterior force to simulate kneeling. The knees were tested at flexion angles of 90°, 105°, 120°, and 135° with no anterior force (mimicking a squatting position) and with an anterior force application simulating double-stance kneeling and single-stance kneeling. Patellofemoral joint contact areas and pressures were measured with pressure-sensitive film, and the knee joint reaction force was measured with use of a six-degree-of-freedom load cell. Patellar kinematics were assessed with use of digital photographs tracking fixed markers on the patella.

Results: Compared with the condition without kneeling, both single-stance and double-stance kneeling demonstrated significant increases in patellofemoral contact area (p < 0.05) and pressure at all flexion angles (p < 0.05), with the exception of double-stance kneeling at 135° of flexion. The resultant knee joint -reaction force increased with kneeling at all flexion angles. The compressive component of this force increased with kneeling for most conditions, while the lateral component of this force decreased significantly (p < 0.05) with kneeling only at 90°, and the anterior component of this force increased significantly at all knee flexion angles (p < 0.05). Overall, kneeling had minimal changes on patellar tilt, with significant changes in patellar tilt seen only with kneeling at 120° (p = 0.02 for double stance, and p = 0.03 for single stance).

Conclusions: The findings of this study suggest that kneeling at a higher flexion angle (135°) after total knee arthroplasty has a smaller effect on patellofemoral joint contact area and pressure than kneeling at lower flexion angles (=120°).

Clinical Relevance: These findings suggest that if greater than 120° of knee range of motion can be achieved following total knee arthroplasty, kneeling may be performed with less risk than was previously believed to be the case.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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