Medial and lateral knee contact forces during walking, stair ascent and stair descent are more affected by contact locations than tibiofemoral alignment in knee osteoarthritis patients with varus malalignment

Introduction: Knee OA progression is related to medial knee contact forces, which can be altered by anatomical parameters of tibiofemoral alignment and contact point locations. There is limited and controversial literature on medial-lateral force distribution and the effect of anatomical parameters, especially in motor activities different from walking. We analyzed the effect of tibiofemoral alignment and contact point locations on knee contact forces, and the medial-lateral force distribution in knee OA subjects with varus malalignment during walking, stair ascending and stair descending.Methods: Fifty-one knee OA subjects with varus malalignment underwent weight-bearing radiographs and motion capture during walking, stair ascending and stair descending. We created a set of four musculoskeletal models per subject with increasing level of personalization, and calculated medial and lateral knee contact forces. To analyze the effect of the anatomical parameters, statistically-significant differences in knee contact forces among models were evaluated. Then, to analyze the force distribution, the medial-to-total contact force ratios were calculated from the fully-informed models. In addition, a multiple regression analysis was performed to evaluate correlations between forces and anatomical parameters.Results: The anatomical parameters significantly affected the knee contact forces. However, the contact points decreased medial forces and increased lateral forces and led to more marked variations compared to tibiofemoral alignment, which produced an opposite effect. The forces were less medially-distributed during stair negotiation, with medial-to-total ratios below 50% at force peaks. The anatomical parameters explained 30%-67% of the variability in the knee forces, where the medial contact points were the best predictors of medial contact forces.Discussion: Including personalized locations of contact points is crucial when analyzing knee contact forces in subjects with varus malalignment, and especially the medial contact points have a major effect on the forces rather than tibiofemoral alignment. Remarkably, the medial-lateral force distribution depends on the motor activity, where stair ascending and descending show increased lateral forces that lead to less medially-distributed loads compared to walking.