Biomechanics

Knee loading patterns and kinematics, focusing on injury mechanisms, cyclic loading in tendon/meniscal repairs, and biomechanical guides for osteotomies.

Overview

Personalized alignment strategies tailored to patient-specific anatomy and kinematics are crucial to optimizing outcomes in robotic total knee arthroplasty [12]. Coronal alignment at 90° of flexion impacts clinical outcomes in this era [12]. Kinematic alignment in total knee arthroplasty leads to a better restoration of patellar kinematics compared to mechanical alignment [19]. The kinematically aligned implantation technique has the potential benefit for clinical outcome by achieving better restoration of natural patellofemoral kinematics [19].

There were no clear recognizable differences in in vivo kinematics between different design parameters or prostheses [14]. Despite kinematics being generally consistent with the kinematics intended by their design, there were no clear recognizable differences in in vivo kinematics between six different types of knee prostheses [14].

Laboratory studies demonstrate improved biomechanics with bursal acromial resurfacing [15]. However, there is no consensus on indications, technique, or graft type for bursal acromial resurfacing [15]. Clinical results for bursal acromial resurfacing remain lacking [15]. More clinically relevant biomechanical and clinical studies are required to determine the best technique to address rotational instability [16].

No recommendations can be made regarding implant choice or configuration for suspensory fixation with internal brace for Rockwood grade V acromioclavicular joint injuries based on biomechanical results [17]. The biomechanical characteristics of a new rigid biodegradable anchor for meniscus refixation justify clinical use [18].

Clinical efficacy of lateral extra-articular procedures concomitant to anterior cruciate ligament reconstruction must be balanced with the risk of kinematic restriction [21]. There is a clear need for further study to define overconstraint and resolve controversies regarding osteoarthritis risk associated with lateral extra-articular procedures [21].

Force measurements on the fibular collateral ligament, popliteofibular ligament, and popliteus tendon provide a measure of the potential for failure of these structures with joint loading [23]. These force measurements provide guidelines for graft strength requirements for surgical reconstructions [23]. They also provide guidelines for postoperative rehabilitation protocols [23]. A successful graft tensioning strategy during knee ligament reconstruction requires understanding native anatomy, ligament biomechanics, graft mechanical properties, fixation methods, and the specific biomechanical goals of the reconstruction [28].

Biomechanical results regarding the safe distance between humerus shaft fracture and distal locking screws in antegrade nailing should be confirmed with clinical studies [30]. Biomechanical analysis is recommended as an adjunct to clinical decision-making for treating dysplastic hips following a triple osteotomy of the innominate bone [73].

Anatomy & Pathophysiology

Kinematics

Knee kinematics are influenced by combined flexion [1] and subtle modifications to the joint line, which contribute to widespread kinematic adaptations [10]. However, kinematics is not the only or most relevant parameter to predict or explain knee function after total knee arthroplasty (TKA) [20]. Contemporary knee implant designs do not replicate the kinematics of a healthy knee [50].

Alignment Strategies: Mechanical alignment results in more balanced load distribution and kinematics more closely resembling the native knee [56]. Kinematically aligned knees show greater multi-planar mobility, higher sagittal moments, and a more physiological gait pattern compared to mechanically aligned knees [60]. In patients with constitutional varus, the tibial cut in TKA influences varus alignment, femoral roll-back, and tibiofemoral rotation [56].

Implant Design Impact: Bi-cruciate retaining (BCS) total knee arthroplasty shows expected knee joint kinematics [24]. Medial pivot (MP) total knee arthroplasty provides a more native-like kinematic profile than cruciate-retaining (CR) design, with a more pronounced MP motion pattern and reduced quadriceps loading [63]. The morphology of the medial tibial insert produces a small but noticeable effect on knee kinematics in medial pivot prostheses [65]. Knee motion kinematic patterns during standing up from and sitting down on a chair are not similar to normal knee kinematics and are derived from the unique design of the Bi-Surface posterior-stabilized (PS) prosthesis [59]. Knee kinematics and muscle activation do not appear to change in the first 2 post-operative years after highly congruent mobile-bearing TKA [58].

ACL Reconstruction Outcomes: Neither anatomic single-bundle nor double-bundle ACL reconstruction fully restores normal knee kinematics [54]. Anatomic single-bundle and double-bundle ACL reconstructions are similarly effective for restoring near-normal dynamic knee function [54]. There are no differences in knee kinematics between anatomic double-bundle and single-bundle via central femoral tunnel ACL reconstruction techniques [61]. Knee biomechanics in the leg with ACL reconstruction are altered mainly in the sagittal plane during side-cutting compared with the contralateral leg [70]. Poor knee function after ACL reconstruction is associated with attenuated landing force and knee flexion moment during running [43]. Jump direction significantly influences knee biomechanics, with lateral jumps being the most dangerous of stop-jumps [51].

Morphologic Correlates: Morphologic measures describing the position and orientation of the femoral transcondylar axis correlate with in vivo knee translational and rotational kinematics [62].

Ligamentous

Altering superficial medial collateral ligament graft length results in measurable changes in knee kinematics and stability [68].

Meniscal

Surgical treatment of medial meniscus posterior root avulsion allows restoration of physiological knee joint biomechanics [64]. Partial weight-bearing and range of motion limitation significantly reduce loads at medial meniscus posterior root repair sutures [64].

General Pathophysiology

Knee osteoarthritis management and prevention require recognizing related mechanical overloads of the human complex motion system rather than viewing it as a localized knee disease [66].

Classification

Biomechanics combines fundamental principles of physics, engineering, and biology to describe and predict the effects of energy and various types of forces on biologic systems, aiding in the understanding of forces acting on the human body and the design of orthopaedic instruments, implants, and prostheses [36]. An understanding of hip joint biomechanics allows clinicians to assimilate the effects of motions and deformations resulting from forces acting on the joint to guide appropriate medical interventions [2]. Biomechanical studies determine the magnitude and direction of forces and moments of various tissues in and around a diarthrodial joint, as well as measure corresponding joint kinematics, to assist clinicians in assessing function and planning treatment [9]. The biomechanical shoulder model is consistent with clinical observations [8].

Acute Muscle Strain: A proposed new classification system for acute muscle strain injuries must be applied to a variety of muscle architectures and locations to determine its utility before general acceptance [45].

Anteromedial Instability: Based on present data, a new classification of anteromedial instability is proposed, which may support clinical examination and treatment decision [71].

Anterior Inferior Iliac Spine Morphology: The current radiographic classification scheme for the morphological distribution of the anterior inferior iliac spine in patients with and without hip impingement should not be used exclusively for clinical decision making [27].

Other Considerations: Subtle modifications to the knee joint line may contribute to widespread kinematic adaptations, underscoring the integrated nature of gait biomechanics [10]. There were no clear recognizable differences in in vivo kinematics between different design parameters or prostheses, despite kinematics being generally consistent with the kinematics intended by their design [14]. Both fixed- and mobile-bearing knee prostheses show typical kinematics of an anterior instability, hence they were incapable of performing physiological movement [53]. Functional alignment resulted in the highest proportion of balanced knees across all analysed subgroups compared to mechanical and kinematic alignment strategies [55]. Biology and biomechanics must be carefully balanced for a durable rotator cuff repair [22]. Subject-specific computational modeling of acromioclavicular and coracoclavicular ligaments may be useful for analyzing and assessing biomechanical stability after various types of surgical reconstruction [57]. The CLASS method demonstrated no significant difference in footprint localization compared with anatomic reference, validating patient-specific ACL footprints across variable fluoroscopic C-arm positioning [67]. Biomechanical properties were similar between suspensory and interference screw fixation for arthroscopic anterior cruciate ligament reconstruction in a translational large-animal model [69].

Clinical Presentation

Biomechanical assessment is foundational to orthopaedic practice, determining the magnitude and direction of forces and moments around diarthrodial joints to assist in assessing function and planning treatment [9]. Understanding joint biomechanics allows clinicians to assimilate the effects of motions and deformations resulting from forces acting on the joint, thereby guiding appropriate medical interventions [2]. Extensive knowledge of anatomy and normal function is critical to identifying pathologies and developing successful treatment strategies [40].

Acute Injury and Reconstruction

Landing biomechanics are altered after anterior cruciate ligament reconstruction (ACLR) but tend to recover at 3 years post-surgery [3]. However, abnormal biomechanics at 6 months after ACLR are associated with cartilage degeneration at 3 years [3]. Increasingly abnormal knee kinematics correlate with worsening clinical outcomes years later, providing a potential explanation for the incidence of posttraumatic osteoarthritis after ACLR [4]. Self-reported sport and recreational function correlated positively with biomechanical changes in former soccer players with a 16-year-old ACL injury [48].

High forces and extremes of rotation are not necessary to produce a clinically detectable pivot shift [44]. Robotic axial lower leg testing provides a level of reliability in rotational testing that allows for clinical use of test results [49].

Chronic Arthropathy and Degeneration

Knee biomechanical markers are associated with patient-reported knee function to a greater extent than X-ray grading in knee osteoarthritis patients [41]. Both knee biomechanical markers and X-ray grading provide complementary information in the assessment of osteoarthritis patients [41]. Gait analysis provides a step-by-step guide for orthopaedic surgeons and clinicians to understand and interpret key biomechanical markers relevant to common knee pathologies [39]. Personalized biomechanical treatment can improve gait patterns, pain, function, and quality of life in patients with knee osteoarthritis [11].

Patellofemoral pain may derive from a combination of physical activity in the context of pathological kinematics in female adolescents [46]. Bilateral changes in tendon structure occur in patients diagnosed with unilateral insertional or midportion Achilles tendinopathy or patellar tendinopathy [47]. The asymptomatic side should not be used as a reference in clinical practice due to these bilateral changes [47].

Surgical Planning and Alignment

Combined flexion influences knee biomechanics in robotic total knee arthroplasty, but its direct impact on clinical outcomes remains unclear [1]. Coronal alignment at 90° of flexion impacts clinical outcomes in robotic total knee arthroplasty [12]. Personalized alignment strategies tailored to patient-specific anatomy and kinematics are crucial to optimizing outcomes in robotic total knee arthroplasty [12].

The biomechanical and clinical dominance of positive buttress correlates with Pauwels type in nonanatomical reduction of femoral neck fractures; it is biomechanically stable in Pauwels types I and II but not advantageous in type III [42]. A biomechanical shoulder model is consistent with clinical observations regarding glenoid inclination and acromion index effects on humeral head translation and glenoid articular cartilage strain [8]. Updates on the thrower's shoulder, including anatomy, mechanics, pathomechanics, and treatment, are essential for clinicians and researchers treating or investigating the shoulder [37]. Conclusions regarding biomechanical advantages of triple-loaded suture anchors cannot be drawn until clinical information is available [38].

Investigations

Plain radiography: Radiographic joint space narrowing and osteophytes do not independently predict ten-year cartilage volume loss [93]. Morphologic features measurable on anteroposterior pelvic radiographs do not correlate with ultrasound-measured hip flexion in asymptomatic young adult women [95]. Radiographic measurement of medial meniscus horn position can be precisely and reproducibly defined on radiographs [85]. Different methods of measuring stress radiographs result in different levels of reliability and reproducibility [91]. Tilt-adjustment of acetabular component position based on standing preoperative imaging will likely improve functional component position in most patients undergoing total hip arthroplasty [87]. Radiographic classification of the anterior inferior iliac spine morphological distribution should not be used exclusively for clinical decision making [27].

MRI: Magnetic resonance imaging is recommended as a routine imaging method for accurate diagnosis and appropriate treatment of bone stress injuries causing exercise-induced knee pain [88]. Kinematic MRI is a reproducible method to quantify total knee rotation [78]. An MRI classification for trochlear dysplasia based exclusively on quantitative measurements has excellent interobserver agreement and high sensitivity for diagnosing objective patellar instability [94]. Conventional knee MRIs performed with the knee in slight flexion consistently underestimate tibial tuberosity–trochlear groove distance compared to full-extension whole-leg rotational MRI [92]. Additional axial plane MRI imaging at 20° of knee flexion is beneficial for symptomatic cases with inconspicuous conventional MRI findings [77]. Distinct patterns of co-existing MRI lesions have different implications for the pathogenesis of osteoarthritic knee pain occurring with or without joint loading [89]. MRI data regarding noncontact anterior cruciate ligament injuries were not consistent with the valgus collapse mechanism of injury [97].

Ultrasound: A novel ultrasound scanning approach allows similar diagnostic performance to routine MRI for knee cartilage defects [98].

Other Considerations: New biochemical imaging techniques may detect morphologic cartilaginous changes earlier than conventional MRI, although they are primarily used in research settings [79]. Clinical-grade resolution MRIs can identify the same knee anatomic factors that predict ACL injury risk as sophisticated research-grade resolution MRIs [84]. Radiolucency was greater in patients with keeled glenoid components, while pegged components exhibited greater micro-motion during biomechanical testing [80]. MRI showed abnormalities at the subchondral bone level in patients treated with a cell-free biomimetic osteochondral scaffold, with overall improvement of features over time [81]. Subchondral laminar and bone changes observed on MRI are a concern in the treatment of osteochondral lesions using a cell-free scaffold [86].

Treatment

Non-Operative Management

Personalised biomechanical interventions using non-invasive foot-worn devices improve gait patterns, pain, function, and quality of life in knee osteoarthritis [11]. Such devices significantly reduce pain and improve function [35]. Bracing improves clinical outcomes during gait in osteoarthritic patients, despite being ineffective at increasing the medial knee joint space [52]. Neuromuscular electrical stimulation is safe for knee joint biomechanics, with no pathological changes in knee function observed in professional soccer players returning to sport after ACL reconstruction [72].

Nonsurgical management, including physical therapy, is the cornerstone of treatment for first-time patellar dislocation [99]. Management of overuse injuries is stratified by risk; high-risk fractures require aggressive treatment such as absolute rest or surgery, while low-risk fractures typically heal with activity modification [105]. Nonoperative treatment for meniscal tears should consider that meniscal tear location and type likely play a crucial role in dictating the success of non-operative treatment [103]. Nonoperative treatment for isolated anterolateral bundle reconstructions of the posterior cruciate ligament should not be extended more than 1 year from injury [82]. Moderate nonprogressive coxa vara deformity in childhood often does not require surgery, whereas surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy [102].

Operative Management

Indications: Surgical release was effective in a case of vastus medialis innervation issue where nonoperative treatment failed [96]. A complete understanding of the forces and risk factors associated with noncontact anterior cruciate ligament injury should lead to the development of improved preventive strategies for this injury [100].

Surgical Approach / Technique: More clinically relevant biomechanical and clinical studies are required to determine the best technique to address rotational instability in anterior cruciate ligament reconstruction [16]. Clinical efficacy of lateral extra-articular procedures concomitant to anterior cruciate ligament reconstruction must be balanced with the risk of kinematic restriction, and further study is needed to define overconstraint and resolve controversies regarding osteoarthritis risk [21]. Anterolateral ligament (ALL) reconstruction cannot be recommended at the moment without further biomechanical investigations [75]. Conventional non-anatomic anterior cruciate ligament reconstruction techniques do not prevent early osteoarthritis nor restore normal dynamic knee function; restoring anatomy may be the key to success, but high-quality prospective randomized trials are needed to validate benefits [83].

Implant Selection: The decision for a tendon graft in coracoclavicular ligament reconstruction should be made by the necessity of a biologic substrate rather than by the assumption of a biomechanical advantage [76]. No recommendations can be made regarding implant choice or configuration for suspensory fixation with internal brace for Rockwood grade V acromioclavicular joint injuries based on current biomechanical results [17]. Bursal acromial resurfacing offers improved biomechanics in laboratory studies, but there is no consensus on indications, technique, or graft type, and clinical results are lacking [15]. The biomechanical characteristics of a new rigid biodegradable anchor for meniscus refixation justify its clinical use [18].

Alignment / Balancing Strategy: Kinematically aligned total knee arthroplasty leads to a better restoration of patellar kinematics compared to mechanical alignment [19]. Patients reporting a good outcome in knee-related quality of life one year after total knee arthroplasty show improved knee biomechanics during gait, while those with poor outcomes remain unchanged in knee biomechanics despite similar pain reduction [5].

Adjuncts: Force measurements on the fibular collateral ligament, popliteofibular ligament, and popliteus tendon provide guidelines for graft strength requirements for surgical reconstructions and postoperative rehabilitation protocols [23]. Early weight-bearing after anterior cruciate ligament reconstruction with hamstring grafts induces femoral bone tunnel enlargement, but there is no significant difference in clinical outcomes by postoperative non-weight-bearing period [106].

Other Considerations: Adequately restoring native joint biomechanics is needed for ensuring an optimal healing environment that translates into patient satisfaction and long-term stability in revision acromioclavicular joint stabilization [6]. Translational medicine must fill the gap between laboratory biomechanical studies and clinical practice, as clinical evidence supports the use of extra-articular reconstructions to improve stability and reduce failure rates despite conflicting biomechanical findings [74].

Complications

Kinematic and Biomechanical Deviations: Combined flexion in robotic total knee arthroplasty influences knee biomechanics, but its direct impact on clinical outcomes remains unclear [1]. Kinematic alignment in total knee arthroplasty does not increase failure rates at short-term follow-up, but long-term data are lacking [25]. Inadequate restoration of native joint biomechanics in revision acromioclavicular joint stabilization may compromise healing, patient satisfaction, and long-term stability [6]. Anterior-posterior glenohumeral kinematics are not fully restored after biceps rerouting for large-to-massive rotator cuff tears, and the effect on long-term clinical outcomes requires further investigation [7].

Instability and Graft Failure: Meniscal grafts undersized by more than 10% may predispose to early failure due to high hoop stresses [107]. Undiagnosed or untreated concomitant pathologies (meniscal tears, posterolateral/posteromedial corner injuries, increased coronal plane alignment, increased sagittal plane tibial slope) can lead to ACL graft overload in primary and revision ACL-reconstructed knees [109]. No reconstruction technique for posterolateral instability of the knee achieved the original strength of the native knee in cadaveric models [110]. Residual laxity after ACL reconstruction does not appear to affect short-term clinical success, but long-term effects are unknown [31].

Long-Term Outcomes and Survivorship: Short follow-up periods in robotic-assisted unicompartmental knee arthroplasty limit the assessment of complications, implant survivorship, and mid-to long-term functional outcomes [26]. Late mechanisms of failure and the effects of bone mineral density-related changes in proximally coated and tapered stems require long-term outcome studies [32]. Prospective long-term studies are needed to understand the natural history of bone bruise in ACL rupture and identify prognostic factors for joint degenerative progression [33].

Other Considerations: Abnormal landing biomechanics after anterior cruciate ligament reconstruction (ACLR) tend to recover at 3 years post-surgery [3]. Increasingly abnormal knee kinematics early after ACLR correlate with worsening patient-reported outcomes years later, potentially explaining the incidence of posttraumatic osteoarthritis [4]. Patients with poor knee-related quality of life one year after total knee arthroplasty remain unchanged in knee biomechanics during gait, despite similar pain reduction compared to those with good outcomes [5].

Recovery

Light activity (weeks): Evidence does not specify a week range for light activity or driving.

Full activity (months): Evidence does not specify a month range for full activity or sport return.

Complete recovery / outcome plateau (months): Landing biomechanics are altered after anterior cruciate ligament reconstruction (ACLR) but tend to recover at 3 years post-surgery [3]. Abnormal biomechanics at 6 months after ACLR are associated with cartilage degeneration at 3 years [3]. The correlation between increasingly abnormal kinematics and worsening clinical outcomes years later provides a potential explanation for the incidence of posttraumatic osteoarthritis after ACLR [4]. Patients reporting a good outcome in knee-related quality of life one year after total knee arthroplasty (TKA) improved in knee biomechanics during gait [5]. Patients reporting a poor outcome in knee-related quality of life one year after TKA remained unchanged in knee biomechanics despite similar reduction in pain [5]. Kinetic variables improved over time following tibial plateau fractures, but there were no improvements observed in kinematic variables [111].

Rehabilitation protocol: Evidence does not specify PT phasing, immobilisation duration, or weight-bearing progression.

Functional milestones: Adequately restoring native joint biomechanics is needed for ensuring an optimal healing environment that translates into patient satisfaction and long-term stability [6]. Anterior-posterior (A-P) glenohumeral kinematics was not fully restored after biceps rerouting (BR) for large-to-massive rotator cuff tears [7]. Kinematics is not the only or most relevant parameter to predict or explain knee function after TKA [20]. The bi-cruciate retaining (BCS) cohort showed expected knee joint kinematics [24]. Kinematic alignment restored native patellar tracking patterns more closely compared to mechanical alignment [112]. Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior patient-reported outcomes (PRO) or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up [113]. Gait biomechanics play a potential role in short-term osteoarthritis pain fluctuations [114]. Anatomic socket position in either the anteromedial or central locations provides similar time-zero biomechanics for single-bundle anterior cruciate ligament reconstruction [115].

Other Considerations: Kinematic alignment does not increase failure rates at short-term follow-up, but long-term data are still lacking [25]. The relatively short follow-up period limits the assessment of complications, implant survivorship, and mid-to long-term functional outcomes following fixed-bearing medial robotic-assisted unicompartmental knee arthroplasty in patients with severe knee varus and patellofemoral joint degeneration [26]. Studies are needed to evaluate the clinical impact of double-bundle reconstruction techniques on long-term functional outcomes [29]. Short-term clinical success appears unaffected by residual laxity in anterior cruciate ligament-reconstructed knees, but long-term effects are unknown [31]. A long-term outcome study is required to assess late mechanisms of failure and the effects of bone mineral density (BMD) related changes for proximally coated and tapered stems [32]. Prospective long-term studies are needed to better understand the natural history of bone bruise in anterior cruciate ligament rupture, identifying prognostic factors and targets of specific treatments [33]. Patients with bilateral varus gonarthrosis experience marked improvements in established biomechanical risk factors for disease progression bilaterally after staged medial opening wedge high tibial osteotomy (HTO) [34]. Long-term follow-up is essential to confirm whether repair tissue after matrix-induced autologous chondrocyte implantation has the durability required to maintain long-term patient quality of life [90].

Key Evidence

• [L3] Although combined flexion influences knee biomechanics, its direct impact on clinical outcomes remains unclear. (10.1002/ksa.12660)
• [L5] An understanding of hip joint biomechanics constitutes an important background for the diagnosis and treatment of hip disorders, allowing clinicians to assimilate the effects of motions and deformations resulting from forces acting on the joint to guide appropriate medical interventions. (10.1016/j.arthro.2010.01.027)
• [L2] Landing biomechanics are altered after ACLR but biomechanical abnormalities tend to recover at 3 years after ACLR. (10.1016/j.arthro.2018.07.033)
• [L3] The correlation between increasingly abnormal kinematics and worsening clinical outcomes years later provides a potential explanation for the incidence of posttraumatic osteoarthritis after ACLR. (10.1177/0363546516673835)
• [L3] Patients reporting a good outcome in knee-related quality of life improved in knee biomechanics during gait, while patients reporting a poor outcome, despite similar reduction in pain, remained unchanged in knee biomechanics one year after total knee arthroplasty. (10.1186/s12891-017-1479-3)
• [L5] Adequately restoring native joint biomechanics is needed for ensuring an optimal healing environment that will translate into patient satisfaction and long-term stability. (10.1007/s00167-019-05742-6)
• [L3] However, A-P glenohumeral kinematics was not fully restored after BR, and its effect on long-term clinical outcomes requires further investigation. (10.1177/03635465241301778)
• [L5] The biomechanical shoulder model is consistent with clinical observations. (10.1016/j.jse.2016.05.031)
• [L5] Biomechanical studies determine the magnitude and direction of forces and moments of various tissues in and around a diarthrodial joint, as well as measure corresponding joint kinematics, to assist clinicians in assessing function and planning treatment. (10.1177/03635465990270042301)
• [L3] These findings underscore the integrated nature of gait biomechanics and suggest that subtle modifications to the knee joint line may contribute to widespread kinematic adaptations. (10.1002/ksa.70356)
• [L4] Our results suggest that the personalised biomechanical treatment can improve gait patterns, pain, function and quality of life. (10.1186/s12891-020-03382-3)
• [L3] Personalized alignment strategies tailored to patient-specific anatomy and kinematics are crucial to optimizing outcomes. (10.1002/ksa.12648)
• [L3] Despite kinematics being generally consistent with the kinematics intended by their design, there were no clear recognizable differences in in vivo kinematics between different design parameters or prostheses. (10.1007/s00167-011-1605-y)
• [L5] While laboratory studies demonstrate improved biomechanics with bursal acromial resurfacing, there is no consensus on indications, technique, or graft type, and clinical results remain lacking. (10.1016/j.arthro.2024.07.006)
• [L5] More clinically relevant biomechanical and clinical studies are required to determine the best technique to address rotational instability, and the authors are currently in the process of performing a multicenter randomized controlled trial to validate these procedures. (10.1177/0363546515605808)
• [L5] No recommendations can be made regarding implant choice or configuration based on these biomechanical results. (10.1016/j.jse.2024.06.020)
• [L5] These biomechanical characteristics of this new implant justify clinical use. (10.1007/s00167-003-0439-7)
• [L5] The study highlights the potential benefit for clinical outcome using a kinematically aligned implantation technique to achieve better restoration of natural patellofemoral kinematics. (10.1007/s00167-018-5284-9)
• [L5] The results confirm the hypothesis that kinematics is not the only and also not the most relevant parameter to predict or explain knee function after TKA. (10.1007/s00167-015-3514-y)
• [L5] Clinical efficacy of lateral extra-articular procedures must be balanced with the risk of kinematic restriction, and there is a clear need for further study to define overconstraint and resolve controversies regarding osteoarthritis risk. (10.1016/j.arthro.2022.08.017)
• [L5] Biology and biomechanics must be carefully balanced. (10.1016/j.arthro.2020.09.049)
• [L5] These results provide a measure of the potential for failure of these structures with joint loading and guidelines for both graft strength requirements for surgical reconstructions and postoperative rehabilitation protocols. (10.1177/0363546503262694)
• [L3] The BCS cohort showed expected knee joint kinematics. (10.2106/jbjs.20.00024)
• [L5] Recent studies suggest kinematic alignment does not increase failure rates at short-term follow-up, but long-term data are still lacking. (10.5435/jaaos-d-16-00428)
• [L3] However, the relatively short follow-up period limits the assessment of complications, implant survivorship, and mid-to long-term functional outcomes. (10.1186/s13018-025-06181-5)
• [L3] The current radiographic classification scheme should not be used exclusively for clinical decision making. (10.1177/0363546516682230)
• [L5] A successful strategy requires understanding native anatomy, ligament biomechanics, graft mechanical properties, fixation methods, and the specific biomechanical goals of the reconstruction. (10.5435/jaaos-20-10-633)
• [L5] Studies are needed to evaluate the clinical impact of double-bundle reconstruction techniques on long-term functional outcomes. (10.5435/00124635-200702000-00003)
• [L5] These biomechanical results, although very promising, should be confirmed with clinical studies. (10.1186/s12891-025-08711-y)
• [L3] Short-term clinical success appears unaffected by residual laxity; however, long-term effects are unknown. (10.1177/03635465990270051101)
• [L2] A long-term outcome study is required to assess late mechanisms of failure and the effects of bone mineral density (BMD) related changes. (10.1302/0301-620x.103b4.bjj-2020-1648.r1)
• [L4] However, prospective long-term studies are needed to better understand the natural history of bone bruise, identifying prognostic factors and targets of specific treatments that should be developed in light of the overall joint derangements accompanying ACL lesions. (10.1007/s00167-018-4993-4)
• [L4] Patients with bilateral varus gonarthrosis experience marked improvements in established biomechanical risk factors for disease progression bilaterally, as well as clinically important improvements in patient-important outcomes, after staged medial opening wedge HTO. (10.1007/s00167-013-2559-z)
• [L2] The biomechanical device and treatment methodology is effective in significantly reducing pain and improving function in knee OA patients. (10.1186/1471-2474-11-179)
• [L5] Updates on the thrower's shoulder, including anatomy, mechanics, pathomechanics, and treatment, are essential for clinicians and researchers treating or investigating the shoulder. (10.1016/j.arthro.2022.02.024)
• [Letter] This is a biomechanical bench test and clinically based conclusions cannot be drawn until clinical information is available. (10.1016/j.arthro.2010.05.009)
• [L4] This narrative review aims to bridge the gap in clinical integration of gait analysis by providing a step-by-step guide for orthopaedic surgeons and clinicians to understand and interpret key biomechanical markers relevant to common knee pathologies. (10.1002/ksa.70067)
• [L2] Knee biomechanical markers are associated with patient-reported knee function to a greater extent than X-ray grading, but both provide complementary information in the assessment of OA patients. (10.1186/s12891-022-05845-1)
• [L3] The biomechanical and clinical dominance of positive buttress correlates with Pauwels type; it is biomechanically stable in Pauwels types I and II but not advantageous in type III. (10.1186/s12891-024-07802-6)
• [L3] These findings provide greater understanding of the relationship between knee biomechanics during running and clinical assessments of knee function. (10.1007/s00167-017-4810-5)
• [L5] High forces and extremes of rotation are not necessary to produce a clinical detectable pivot shift. (10.1007/s00167-011-1859-4)
• [L5] This classification system must be applied to a variety of muscle architectures and locations to determine its utility; additional studies are therefore needed prior to its general acceptance. (10.1007/s00167-012-2118-z)
• [L3] Rather, PFP may derive from a combination of physical activity in the context of pathological kinematics. (10.1177/0363546516679139)
• [L3] These results stress the importance of monitoring both symptomatic and asymptomatic tendon structures and in addition highlight that the asymptomatic side should not be used as reference in clinical practice. (10.1007/s00167-019-05495-2)
• [L2] Self-reported sport and recreational function correlated positively with the biomechanical changes supporting a clinical importance of the findings. (10.1186/1471-2474-8-35)
• [L2] These findings suggest that the device can provide a level of reliability in rotational testing that allows for clinical use of test results. (10.1007/s00167-015-3768-4)
• [L5] The knee implant designs investigated did not replicate the kinematics of a healthy knee. (10.2106/jbjs.h.00817)
• [L3] Jump direction significantly influenced knee biomechanics, suggesting that lateral jumps are the most dangerous of the stop-jumps. (10.1177/0363546505278696)
• [L4] The brace is ineffective at increasing joint space, but it is effective in improving clinical outcomes and should continue to be prescribed to patients even though the mechanism of its effectiveness remains unknown. (10.1007/s00167-013-2596-7)
• [L5] Both types of prostheses show typical kinematics of an anterior instability, hence they were incapable of performing physiological movement. (10.1007/s00167-012-1986-6)
• [L1] While neither procedure fully restored normal knee kinematics, both anatomic reconstructions were similarly effective for restoring near-normal dynamic knee function. (10.1007/s00167-021-06479-x)
• [L2] Functional alignment resulted in the highest proportion of balanced knees across all analysed subgroups. (10.1007/s00167-023-07567-w)
• [L5] Mechanical alignment seems to result in more balanced load distribution and kinematics more closely resembling the native knee. (10.1007/s00167-020-05996-5)
• [L5] These models may also be useful for analyzing and assessing biomechanical stability after various types of surgical reconstruction. (10.1016/j.jse.2022.09.004)
• [L4] Knee kinematics and muscle activation do not appear to change in the first 2 post-operative years. (10.1007/s00167-012-1936-3)
• [L4] This study demonstrated that the knee motion kinematic patterns observed in this study were not similar to normal knee kinematics and derived from the unique design of the Bi-Surface PS. (10.1186/s13018-016-0482-y)
• [L4] The kinematically aligned knee showed greater multi-planar mobility, higher sagittal moments, and a more physiological gait pattern compared to the mechanically aligned knee. (10.1186/s12891-025-09445-7)
• [L5] There were no differences in knee kinematics between the DB and SB-central techniques. (10.1177/0363546515611646)
• [L3] Correlations between knee kinematics and morphologic measures describing the position and orientation of the femoral transcondylar axis suggest that these specific measures are valuable for characterizing the influence of femur shape on dynamic knee function. (10.1007/s00167-011-1661-3)
• [L5] The MP design provides a more native-like knee kinematic profile than the CR design, with a more pronounced MP motion pattern and reduced quadriceps loading. (10.1002/ksa.12624)
• [L5] Surgical treatment of MMPRA allows restoration of physiological knee joint biomechanics. (10.1002/ksa.12465)
• [L5] The morphology of medial tibial insert was also shown to produce a small but noticeable effect on knee kinematics. (10.1007/s00167-014-3249-1)
• [L5] Knee OA management and prevention necessitate a paradigm shift from viewing it as a localized knee disease to recognizing related mechanical overloads of the human complex motion system, emphasizing the importance of understanding biomechanical risk factors and individualized interventions based on biokinetic profile analysis. (10.1016/j.jisako.2024.100381)
• [L5] The CLASS method demonstrated no significant difference in footprint localization compared with anatomic reference. (10.1002/ksa.70288)
• [L5] Altering the normal ligament length resulted in measurable changes in knee kinematics and stability. (10.1007/s00167-011-1519-8)
• [L5] Biomechanical properties were similar between groups. (10.1016/j.arthro.2015.11.026)
• [L3] Knee biomechanics in the leg with ACLR were altered mainly in the sagittal plane during side-cutting compared with the contralateral leg. (10.1177/03635465221112940)
• [L5] Based on the present data a new classification of anteromedial instability is proposed, which may support clinical examination and treatment decision. (10.1007/s00167-020-05947-0)
• [L2] The neuromuscular electrical stimulation appeared to be safe for biomechanics of knee joint with no pathological changes in knee function observed. (10.1155/2013/802534)
• [L4] The authors recommend using biomechanical analysis as an adjunct to clinical decision-making for treating dysplastic hips. (10.2106/00004623-199606000-00008)
• [L5] Translational medicine must fill the gap between laboratory biomechanical studies and clinical practice, as clinical evidence supports the use of extra-articular reconstructions to improve stability and reduce failure rates, despite conflicting biomechanical findings. (10.1016/j.arthro.2018.06.045)
• [L5] Consequently, ALL-reconstruction cannot be recommended at the moment without further biomechanical investigations. (10.1007/s00167-017-4472-3)
• [L5] Therefore the decision for a tendon graft should be made by the necessity of a biologic substrate rather than by the assumption of a biomechanical advantage. (10.1007/s00167-009-0737-9)
• [L4] In particular, symptomatic cases with inconspicuous conventional MRI imaging, additional MRI imaging only in the axial plane in a 20° of knee flexion could be beneficial and useful in clinical daily routine. (10.1186/s12891-021-04733-4)
• [L3] Kinematic MRI is a reproducible method to quantify total knee rotation. (10.1007/s00167-011-1809-1)
• [L4] New biochemical imaging techniques may help detect morphologic cartilaginous changes earlier than conventional MRI, although they have been used primarily in the research setting to date. (10.5435/00124635-201107000-00005)
• [L5] While the pegged component exhibited a greater amount of micro-motion during biomechanical testing, radiolucency was greater in patients with a keeled component. (10.1186/s12891-017-1550-0)
• [L4] MRI showed abnormalities, in particular at the subchondral bone level, but there was an overall improvement of features over time. (10.1177/0363546517737763)
• [L4] Nonoperative treatment should not be extended more than 1 year from injury. (10.1177/0363546509333479)
• [L5] Conventional non-anatomic ACL reconstruction techniques do not prevent early osteoarthritis nor restore normal dynamic knee function; restoring anatomy may be the key to success, but high-quality prospective randomized trials with precise outcome measures are needed to validate benefits. (10.1007/s00167-010-1222-1)
• [L2] Simpler methods using MRIs downgraded to a clinical-grade resolution can identify the same knee anatomic factors previously found to significantly contribute to ACL injury risk using sophisticated methods and research-grade resolution MRIs. (10.1177/03635465211024249)
• [L5] They can precisely and reproducibly be defined on radiographs. (10.1016/j.arthro.2007.12.012)
• [L4] However, subchondral laminar and bone changes observed on MRI are a concern. (10.1302/0301-620x.97b3.34555)
• [L4] Magnetic resonance imaging is recommended as a routine imaging method for accurate diagnosis and appropriate treatment. (10.1177/0363546505278699)
• [L3] Distinct patterns of co-existing MRI lesions have different implications for the pathogenesis of osteoarthritic knee pain occurring with/without joint loading. (10.1186/s12891-020-03686-4)
• [L4] Long-term follow-up is essential to confirm whether the repair tissue has the durability required to maintain long-term patient quality of life. (10.1177/0363546510390476)
• [L2] Different methods of measuring stress radiographs resulted in different levels of reliability and reproducibility. (10.1177/0363546510396182)
• [L2] Conventional knee MRIs, performed with the knee in slight flexion, are consistently smaller compared to those acquired in full extension whole-leg rotational MRI. (10.1002/ksa.70237)
• [L2] Radiographic JSN and osteophytes on the other hand are a reflection of other co-pathologies assessed on MRI and do not independently predict cartilage volume loss over 10 years. (10.1186/s12891-016-0900-7)
• [L3] This MRI classification depends exclusively on quantitative measurements, has excellent interobserver agreement, and yields high sensitivity to diagnose objective patellar instability. (10.1002/ksa.12539)
• [L4] Morphologic features that are measurable on anteroposterior pelvic radiographs do not correlate with ultrasound-measured hip flexion. (10.2106/jbjs.19.01088)
• [L4] Surgical release was effective in a case where nonoperative treatment failed. (10.1007/s00167-003-0382-7)
• [L4] The MRI data were not consistent with the valgus collapse mechanism of injury. (10.1177/0363546514527415)
• [L2] The novel US scanning approach allows similar diagnostic performance compared to routine MRI for knee cartilage defects. (10.1186/s13018-018-0887-x)
• [L5] A complete understanding of the forces and risk factors associated with noncontact ACL injury should lead to the development of improved preventive strategies for this devastating injury. (10.5435/00124635-201009000-00003)
• [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
• [L5] Meniscal tear location in addition to type likely plays a crucial role in dictating the success of non-operative treatment of the menisci. (10.1007/s00167-018-5090-4)
• [L2] There was no significant difference in clinical outcomes by postoperative non-weight-bearing period. (10.1186/s12891-019-2653-6)
• [L5] Menisci sized within ±10% of the original meniscus restore contact mechanics close to normal, while undersized grafts may predispose to early failure due to high hoop stresses. (10.1177/0363546506291404)
• [L1] This systematic review on biomechanical cadaver studies provides a rationale to systematically identify and treat pathologies in ACL-injured knees, because when undiagnosed or left untreated, these specific concomitant pathologies could lead to ACL graft overload in both primary and revision ACL-reconstructed knees. (10.1016/j.arthro.2021.11.044)
• [L5] However, the original strength of the native knee could not be achieved with any of the techniques. (10.1016/j.arthro.2009.08.010)
• [L2] While kinetic variables improved over time, there were no improvements observed in kinematic variables. (10.1186/s12891-024-07910-3)
• [L1] Kinematic alignment restored native patellar tracking patterns more closely compared to mechanical alignment. (10.1002/ksa.12335)
• [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)
• [L4] This highlights a potential role of gait biomechanics in short-term osteoarthritis pain fluctuations. (10.1186/s12891-019-2493-4)
• [L5] Anatomic socket position in either the anteromedial or central locations provides similar time-zero biomechanics. (10.1007/s00167-011-1737-0)

See Also

• Anatomy
• Anterior Cruciate Ligament
• Osteoarthritis Management

References

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[36] Chapter 57 Biomechanics. 2019.

[37] Understanding the Disabled Throwing Shoulder Requires Updated Review of Anatomy, Mechanics, Pathomechanics, and Treatment. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2022. DOI: 10.1016/j.arthro.2022.02.024

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[53] Femoro‐tibial kinematics after TKA in fixed‐ and mobile‐bearing knees in the sagittal plane. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-1986-6

[54] Anatomic single‐ and double‐bundle ACL reconstruction both restore dynamic knee function: a randomized clinical trial—part II: knee kinematics. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06479-x

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[57] Subject-specific computational modeling of acromioclavicular and coracoclavicular ligaments. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.09.004

[58] Kinematics of a highly congruent mobile‐bearing total knee prosthesis. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-1936-3

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[64] Partial weight‐bearing and range of motion limitation significantly reduce the loads at medial meniscus posterior root repair sutures in a cadaveric biomechanical model. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12465

[65] Is the posterior cruciate ligament necessary for medial pivot knee prostheses with regard to postoperative kinematics?. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3249-1

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[68] The superficial medial collateral ligament reconstruction of the knee: effect of altering graft length on knee kinematics and stability. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1519-8

[69] Suspensory Versus Interference Screw Fixation for Arthroscopic Anterior Cruciate Ligament Reconstruction in a Translational Large‐Animal Model. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2015.11.026

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[71] The superficial medial collateral ligament is the major restraint to anteromedial instability of the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-05947-0

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[73] Evaluation of the Biomechanics of the Hip following a Triple Osteotomy of the Innominate Bone. The Journal of Bone & Joint Surgery. 1996. DOI: 10.2106/00004623-199606000-00008

[74] Editorial Commentary: When Biomechanics Apparently Conflicts With Clinical Practice: The Role of Translational Medicine Regarding Combined Anterior Cruciate Ligament and Lateral Knee Reconstruction. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.06.045

[75] Function and strain of the anterolateral ligament part I: biomechanical analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4472-3

[76] Coracoclavicular ligament reconstruction: biomechanical comparison of tendon graft repairs to a synthetic double bundle augmentation. Knee Surgery, Sports Traumatology, Arthroscopy. 2009. DOI: 10.1007/s00167-009-0737-9

[77] Weight-bearing MRI with a knee flexion angle of 20°: a study on additional MRI investigation modalities to support a more accurate understanding of patellofemoral instability. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04733-4

[78] Evaluating rotational kinematics of the knee in ACL‐ruptured and healthy patients using 3.0 Tesla magnetic resonance imaging. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1809-1

[79] Advances in Magnetic Resonance Imaging of Articular Cartilage. Journal of the American Academy of Orthopaedic Surgeons. 2011. DOI: 10.5435/00124635-201107000-00005

[80] No correlation between radiolucency and biomechanical stability of keeled and pegged glenoid components. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1550-0

[81] Treatment of Knee Osteochondritis Dissecans With a Cell-Free Biomimetic Osteochondral Scaffold: Clinical and Imaging Findings at Midterm Follow-up. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517737763

[82] Long-term Results of Isolated Anterolateral Bundle Reconstructions of the Posterior Cruciate Ligament. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509333479

[83] A long journey to be anatomic. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1222-1

[84] Clinical-Grade MRI-Based Methods to Identify Combined Anatomic Factors That Predict ACL Injury Risk in Male and Female Athletes. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211024249

[85] The Reproducibility of Radiographic Measurement of Medial Meniscus Horn Position. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2007.12.012

[86] Treatment of osteochondral lesions in the knee using a cell-free scaffold. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b3.34555

[87] Pelvic_Tilt_in_Patients_Undergoing_Total_Hip_Arthroplasty_When_Does_it_Matter_S088354031400789X. n.d..

[88] Bone Stress Injuries Causing Exercise-Induced Knee Pain. The American Journal of Sports Medicine. 2006. DOI: 10.1177/0363546505278699

[89] Co-existing patterns of MRI lesions were differentially associated with knee pain at rest and on joint loading: a within-person knee-matched case-controls study. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03686-4

[90] Clinical and Magnetic Resonance Imaging–Based Outcomes to 5 Years After Matrix-Induced Autologous Chondrocyte Implantation to Address Articular Cartilage Defects in the Knee. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546510390476

[91] Comparison of 5 Different Methods for Measuring Stress Radiographs to Improve Reproducibility During the Evaluation of Knee Instability. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546510396182

[92] Underestimation of tibial tuberosity–trochlear groove distance in conventional knee magnetic resonance imaging compared to full‐extension imaging. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70237

[93] Does cartilage volume measurement or radiographic osteoarthritis at baseline independently predict ten-year cartilage volume loss?. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-0900-7

[94] Adapting the Dejour classification of trochlear dysplasia from qualitative radiograph‐ and CT‐based assessments to quantitative MRI‐based measurements. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12539

[95] Impingement-Free Hip Flexion in Asymptomatic Young Adult Women. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.19.01088

[96] A clinical case and anatomical study of the innervation supply of the vastus medialis muscle. Knee Surgery, Sports Traumatology, Arthroscopy. 2003. DOI: 10.1007/s00167-003-0382-7

[97] Comparison Between Sexes of Bone Contusions and Meniscal Tear Patterns in Noncontact Anterior Cruciate Ligament Injuries. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514527415

[98] A novel ultrasound scanning approach for evaluating femoral cartilage defects of the knee: comparison with routine magnetic resonance imaging. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-0887-x

[99] Chapter 121 Extensor Mechanism Injuries. 2019.

[100] Noncontact Anterior Cruciate Ligament Injuries: Mechanisms and Risk Factors. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201009000-00003

[102] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

[103] Predicting meniscal tear stability across knee‐joint flexion using finite‐element analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5090-4

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[106] Early weight-bearing after anterior cruciate ligament reconstruction with hamstring grafts induce femoral bone tunnel enlargement: a prospective clinical and radiographic study. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2653-6

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