Computational Lower Limb Simulator Boundary Conditions to Reproduce Measured TKA Loading in a Cohort of Telemetric Implant Patients.

Recent advancements in computational modeling offer opportunities to refine total knee arthroplasty (TKA) design and treatment strategies. This study developed patient-specific simulator external boundary conditions (EBCs) using a PID-controlled lower limb finite element (FE) model. Calibration of the external actuation required to achieve measured patient-specific joint loading and motion was completed for nine patients with telemetric implants during gait, stair descent, and deep knee bend. The study also compared two EBC scenarios: activity-specific hip AP motion and pelvic rotation (that was averaged across all patients for an activity) and patient-specific hip AP motion and pelvic rotation. Including patient-specific data significantly improved reproduction of joint-level loading, reducing root mean squared error between the target and achieved loading by 28.7% and highlighting the importance of detailed patient data in replicating joint kinematics and kinetics. The principal component analysis (PCA) of the EBCs for the patient dataset showed that one component represented 77.8% of the overall variation, while the first three components represented 97.8%. Given the significant loading variability within the patient cohort, this group of patient-specific models can be run individually to provide insight into expected TKA mechanics variability, and the PCA can be utilized to further create reasonable EBCs that expand the variability evaluated.

Effect of age on ankle biomechanics and tibial compression during stair descent.

BACKGROUND: Stress fracture is a concern among older adults, as age-related decrements in ankle neuromuscular function may impair their ability to attenuate tibial compressive forces experienced during daily locomotor tasks, such as stair descent. Yet, it is unknown if older adults exhibit greater tibial compression than their younger counterparts when descending stairs. RESEARCH QUESTION: Do older adults exhibit differences in ankle biomechanics that alter their tibial compression during stair descent compared to young adults, and is there a relation between tibial compression and specific changes in ankle biomechanics? METHODS: Thirteen young (18-25 years) and 13 older (> 65 years) adults had ankle joint biomechanics and tibial compression quantified during a stair descent. Discrete ankle biomechanics (peak joint angle and moment, and joint stiffness) and tibial compression (maximum and impulse) measures were submitted to an independent t-test, while ankle joint angle and moment, and tibial compression waveforms were submitted to an independent statistical parametric mapping t-test to determine group differences. Pearson correlation coefficients (r) determined the relation between discrete ankle biomechanics and tibial compression measures for all participants, and each group. RESULTS: Older adults exhibited smaller maximum tibial compression (p = 0.004) from decreases in peak ankle joint angle and moment between 17 % and 34 % (p = 0.035), and 20-31 % of stance (p < 0.001) than young adults. Ankle biomechanics exhibited a negligible to weak correlation with tibial compression for all participants, with peak ankle joint moment and maximum tibial compression (r = -0.48 ±â€¯0.32) relation the strongest. Older adults typically exhibited a stronger relation between ankle biomechanics and tibial compression (e.g., r = -0.48 ±â€¯0.47 vs r = -0.27 ±â€¯0.52 between peak ankle joint moment and maximum tibial compression). SIGNIFICANCE: Older adults altered ankle biomechanics and decreased maximum tibial compression to safely execute the stair descent. Yet, specific alterations in ankle biomechanics could not be identified as a predictor of changes in tibial compression.

Porcine computational modeling to investigate developmental dysplasia of the hip.

While it is well-established that early detection and initiation of treatment of developmental dysplasia of the hip (DDH) is crucial to successful clinical outcomes, research on the mechanics of the hip joint during healthy and pathological hip development in infants is limited. Quantification of mechanical behavior in both the healthy and dysplastic developing joints may provide insight into the causes of DDH and facilitate innovation in treatment options. In this study, subject-specific three-dimensional finite element models of two pigs were developed: one healthy pig and one pig with induced dysplasia in the right hindlimb. The objectives of this study were: (1) to characterize mechanical behavior in the acetabular articular cartilage during a normal walking cycle by analyzing six metrics: contact pressure, contact area, strain energy density, von Mises stress, principal stress, and principal strain; and (2) to quantify the effect on joint mechanics of three anatomic abnormalities previously identified as related to DDH: variation in acetabular coverage, morphological changes in the femoral head, and changes in the articular cartilage. All metrics, except the contact area, were elevated in the dysplastic joint. Morphological changes in the femoral head were determined to be the most significant factors in elevating contact pressure in the articular cartilage, while the effects of acetabular coverage and changes in the articular cartilage were less significant. The quantification of the pathomechanics of DDH in this study can help identify key mechanical factors that restore normal hip development and can lead to mechanics-driven treatment options.

Neural-driven activation of 3D muscle within a finite element framework: exploring applications in healthy and neurodegenerative simulations.

This paper presents a novel computational framework for neural-driven finite element muscle models, with an application to amyotrophic lateral sclerosis (ALS). The multiscale neuromusculoskeletal (NMS) model incorporates physiologically accurate motor neurons, 3D muscle geometry, and muscle fiber recruitment. It successfully predicts healthy muscle force and tendon elongation and demonstrates a progressive decline in muscle force due to ALS, dropping from 203 N (healthy) to 155 N (120 days after ALS onset). This approach represents a preliminary step towards developing integrated neural and musculoskeletal simulations to enhance our understanding of neurodegenerative and neurodevelopmental conditions through predictive NMS models.

Surface, but Not Age, Impacts Lower Limb Joint Work during Walking and Stair Ascent.

Older adults often suffer an accidental fall when navigating challenging surfaces during common locomotor tasks, such as walking and ascending stairs. This study examined the effect of slick and uneven surfaces on lower limb joint work in older and younger adults while walking and ascending stairs. Fifteen young (18-25 years) and 12 older (>65 years) adults had stance phase positive limb and joint work quantified during walking and stair ascent tasks on a normal, slick, and uneven surface, which was then submitted to a two-way mixed model ANOVA for analysis. The stair ascent required greater limb, and hip, knee, and ankle work than walking (all p < 0.001), with participants producing greater hip and knee work during both the walk and stair ascent (both p < 0.001). Surface, but not age, impacted positive limb work. Participants increased limb (p < 0.001), hip (p = 0.010), and knee (p < 0.001) positive work when walking over the challenging surfaces, and increased hip (p = 0.015), knee (p < 0.001), and ankle (p = 0.010) work when ascending stairs with challenging surfaces. Traversing a challenging surface during both walking and stair ascent tasks required greater work production from the large proximal hip and knee musculature, which may increase the likelihood of an accidental fall in older adults.

Increased deformations are dispensable for cell mechanoresponse in engineered bone analogs mimicking aging bone marrow.

Aged individuals and astronauts experience bone loss despite rigorous physical activity. Bone mechanoresponse is in-part regulated by mesenchymal stem cells (MSCs) that respond to mechanical stimuli. Direct delivery of low intensity vibration (LIV) recovers MSC proliferation in senescence and simulated microgravity models, indicating that age-related reductions in mechanical signal delivery within bone marrow may contribute to declining bone mechanoresponse. To answer this question, we developed a 3D bone marrow analog that controls trabecular geometry, marrow mechanics and external stimuli. Validated finite element (FE) models were developed to quantify strain environment within hydrogels during LIV. Bone marrow analogs with gyroid-based trabeculae of bone volume fractions (BV/TV) corresponding to adult (25%) and aged (13%) mice were printed using polylactic acid (PLA). MSCs encapsulated in migration-permissive hydrogels within printed trabeculae showed robust cell populations on both PLA surface and hydrogel within a week. Following 14 days of LIV treatment (1g, 100 Hz, 1 hour/day), type-I collagen and F-actin were quantified for the cells in the hydrogel fraction. While LIV increased all measured outcomes, FE models predicted higher von Mises strains for the 13% BV/TV groups (0.2%) when compared to the 25% BV/TV group (0.1%). Despite increased strains, collagen-I and F-actin measures remained lower in the 13% BV/TV groups when compared to 25% BV/TV counterparts, indicating that cell response to LIV does not depend on hydrogel strains and that bone volume fraction (i.e. available bone surface) directly affects cell behavior in the hydrogel phase independent of the external stimuli. Overall, bone marrow analogs offer a robust and repeatable platform to study bone mechanobiology.

Pedicle Screw Placement Accuracy in Robot-Assisted Spinal Fusion in a Multicenter Study.

Pedicle screw fixation is a spinal fusion technique that involves the implantation of screws into vertebral pedicles to restrict movement between those vertebrae. The objective of this research is to measure pedicle screw placement accuracy using a novel automated measurement system that directly compares the implanted screw location to the planned target in all three anatomical views. Preoperative CT scans were used to plan the screw trajectories in 122 patients across four surgical centers. Postoperative scans were fused to the preoperative plan to quantify placement accuracy using an automated measurement algorithm. The mean medial-lateral and superior-inferior deviations in the pedicle region for 500 screws were 1.75 ± 1.36 mm and 1.52 ± 1.26 mm, respectively. These deviations were measured using an automated system and were statistically different from manually determined values. The uncertainty associated with the fusion of preoperative to postoperative images was also quantified to better understand the screw-to-plan accuracy results. This study uses a novel automated measurement system to quantify screw placement accuracy as it relates directly to the planned target location, instead of analyzing for breaches of the pedicle, to quantify the validity of using of a robotic-guidance system for accurate pedicle screw placement.

Modeling of active skeletal muscles: a 3D continuum approach incorporating multiple muscle interactions.

Skeletal muscles have a highly organized hierarchical structure, whose main function is to generate forces for movement and stability. To understand the complex heterogeneous behaviors of muscles, computational modeling has advanced as a non-invasive approach to evaluate relevant mechanical quantities. Aiming to improve musculoskeletal predictions, this paper presents a framework for modeling 3D deformable muscles that includes continuum constitutive representation, parametric determination, model validation, fiber distribution estimation, and integration of multiple muscles into a system level for joint motion simulation. The passive and active muscle properties were modeled based on the strain energy approach with Hill-type hyperelastic constitutive laws. A parametric study was conducted to validate the model using experimental datasets of passive and active rabbit leg muscles. The active muscle model with calibrated material parameters was then implemented to simulate knee bending during a squat with multiple quadriceps muscles. A computational fluid dynamics (CFD) fiber simulation approach was utilized to estimate the fiber arrangements for each muscle, and a cohesive contact approach was applied to simulate the interactions among muscles. The single muscle simulation results showed that both passive and active muscle elongation responses matched the range of the testing data. The dynamic simulation of knee flexion and extension showed the predictive capability of the model for estimating the active quadriceps responses, which indicates that the presented modeling pipeline is effective and stable for simulating multiple muscle configurations. This work provided an effective framework of a 3D continuum muscle model for complex muscle behavior simulation, which will facilitate additional computational and experimental studies of skeletal muscle mechanics. This study will offer valuable insight into the future development of multiscale neuromuscular models and applications of these models to a wide variety of relevant areas such as biomechanics and clinical research.

Computational comparison of medializing tibial tubercle osteotomy and trochleoplasty in patients with trochlear dysplasia.

Medial patellofemoral ligament reconstruction (MPFLR) has emerged as the procedure of choice for recurrent patellar dislocation. This addresses soft tissue injury but does not address underlying anatomic factors, including trochlear dysplasia, that are commonly present and increase risk of dislocation. Quantification of the stability offered by other surgical interventions, namely, medializing tibial tubercle osteotomy (mTTO) and trochleoplasty, with and without MPFLR, may provide insight for surgical choices in patients with trochlear dysplasia. We developed subject-specific finite element models based on magnetic resonance scans from a cohort of 20 patients with trochlear dysplasia and recurrent patellar dislocation. The objectives of this study were (1) to compare patella stability after mTTO and trochleoplasty procedures; (2) to evaluate whether it is necessary to perform an MPFLR in combination with the mTTO or trocheoplasty procedure; and (3) to quantify the robustness of patellar stability to variability in knee kinematics. Trochleoplasty performed better than mTTO at stabilizing the patella between 5° and 30° flexion. For both mTTO and trochleoplasty procedures, it was beneficial to also perform MPFLR-inclusion of MPFLR halved the magnitude of patellar laxity predicted in the simulations. Simulations that did not include any medial patellofemoral ligament restraint were also more sensitive to variation in tibiofemoral internal-external kinematics.

Instantaneous Generation of Subject-Specific Finite Element Models of the Hip Capsule.

Subject-specific hip capsule models could offer insights into impingement and dislocation risk when coupled with computer-aided surgery, but model calibration is time-consuming using traditional techniques. This study developed a framework for instantaneously generating subject-specific finite element (FE) capsule representations from regression models trained with a probabilistic approach. A validated FE model of the implanted hip capsule was evaluated probabilistically to generate a training dataset relating capsule geometry and material properties to hip laxity. Multivariate regression models were trained using 90% of trials to predict capsule properties based on hip laxity and attachment site information. The regression models were validated using the remaining 10% of the training set by comparing differences in hip laxity between the original trials and the regression-derived capsules. Root mean square errors (RMSEs) in laxity predictions ranged from 1.8° to 2.3°, depending on the type of laxity used in the training set. The RMSE, when predicting the laxity measured from five cadaveric specimens with total hip arthroplasty, was 4.5°. Model generation time was reduced from days to milliseconds. The results demonstrated the potential of regression-based training to instantaneously generate subject-specific FE models and have implications for integrating subject-specific capsule models into surgical planning software.

Robust automatic hexahedral cartilage meshing framework enables population-based computational studies of the knee.

Osteoarthritis of the knee is increasingly prevalent as our population ages, representing an increasing financial burden, and severely impacting quality of life. The invasiveness of in vivo procedures and the high cost of cadaveric studies has left computational tools uniquely suited to study knee biomechanics. Developments in deep learning have great potential for efficiently generating large-scale datasets to enable researchers to perform population-sized investigations, but the time and effort associated with producing robust hexahedral meshes has been a limiting factor in expanding finite element studies to encompass a population. Here we developed a fully automated pipeline capable of taking magnetic resonance knee images and producing a working finite element simulation. We trained an encoder-decoder convolutional neural network to perform semantic image segmentation on the Imorphics dataset provided through the Osteoarthritis Initiative. The Imorphics dataset contained 176 image sequences with varying levels of cartilage degradation. Starting from an open-source swept-extrusion meshing algorithm, we further developed this algorithm until it could produce high quality meshes for every sequence and we applied a template-mapping procedure to automatically place soft-tissue attachment points. The meshing algorithm produced simulation-ready meshes for all 176 sequences, regardless of the use of provided (manually reconstructed) or predicted (automatically generated) segmentation labels. The average time to mesh all bones and cartilage tissues was less than 2 min per knee on an AMD Ryzen 5600X processor, using a parallel pool of three workers for bone meshing, followed by a pool of four workers meshing the four cartilage tissues. Of the 176 sequences with provided segmentation labels, 86% of the resulting meshes completed a simulated flexion-extension activity. We used a reserved testing dataset of 28 sequences unseen during network training to produce simulations derived from predicted labels. We compared tibiofemoral contact mechanics between manual and automated reconstructions for the 24 pairs of successful finite element simulations from this set, resulting in mean root-mean-squared differences under 20% of their respective min-max norms. In combination with further advancements in deep learning, this framework represents a feasible pipeline to produce population sized finite element studies of the natural knee from subject-specific models.

Musculoskeletal adaptation of young and older adults in response to challenging surface conditions.

Over 36 million adults over 65 years of age experience accidental falls each year. The underlying neuromechanics (whole-body function) and driving forces behind accidental falls, as well as the effects of aging on the ability of the musculoskeletal system to adapt, are poorly understood. We evaluated differences in kinematics (lower extremity joint angles and range of motion), kinetics (ground reaction force), and electromyography (muscle co-contraction), due to changes in surface conditions during gait in 14 older adults with a history of falling and 14 young adults. We investigated the impact of challenging surfaces on musculoskeletal adaptation and compared the mechanisms of adaptation between age-groups. Older adults displayed greater hip and knee flexion and range of motion during gait, reduced initial vertical loading, and 13 % greater knee muscle co-contraction during early stance compared to young adults. Across age groups, the presence of an uneven challenging surface increased lower-limb flexion compared to an even surface. On a slick surface, older adults displayed 30 % greater ankle muscle co-contraction during early stance as compared to young adults. Older adults respond to challenging surfaces differently than their younger counterparts, employing greater flexion during early stance. This study underscores the need for determining lower-limb musculoskeletal adaptation strategies during gait and assessing how these strategies change with age, risk of accidental falls, and environmental surfaces to reduce the risk of accidental falls.

Integration of neural architecture within a finite element framework for improved neuromusculoskeletal modeling.

Neuromusculoskeletal (NMS) models can aid in studying the impacts of the nervous and musculoskeletal systems on one another. These computational models facilitate studies investigating mechanisms and treatment of musculoskeletal and neurodegenerative conditions. In this study, we present a predictive NMS model that uses an embedded neural architecture within a finite element (FE) framework to simulate muscle activation. A previously developed neuromuscular model of a motor neuron was embedded into a simple FE musculoskeletal model. Input stimulation profiles from literature were simulated in the FE NMS model to verify effective integration of the software platforms. Motor unit recruitment and rate coding capabilities of the model were evaluated. The integrated model reproduced previously published output muscle forces with an average error of 0.0435 N. The integrated model effectively demonstrated motor unit recruitment and rate coding in the physiological range based upon motor unit discharge rates and muscle force output. The combined capability of a predictive NMS model within a FE framework can aid in improving our understanding of how the nervous and musculoskeletal systems work together. While this study focused on a simple FE application, the framework presented here easily accommodates increased complexity in the neuromuscular model, the FE simulation, or both.

Modeling stem cell nucleus mechanics using confocal microscopy.

Nuclear mechanics is emerging as a key component of stem cell function and differentiation. While changes in nuclear structure can be visually imaged with confocal microscopy, mechanical characterization of the nucleus and its sub-cellular components require specialized testing equipment. A computational model permitting cell-specific mechanical information directly from confocal and atomic force microscopy of cell nuclei would be of great value. Here, we developed a computational framework for generating finite element models of isolated cell nuclei from multiple confocal microscopy scans and simple atomic force microscopy (AFM) tests. Confocal imaging stacks of isolated mesenchymal stem cells were converted into finite element models and siRNA-mediated Lamin A/C depletion isolated chromatin and Lamin A/C structures. Using AFM-measured experimental stiffness values, a set of conversion factors were determined for both chromatin and Lamin A/C to map the voxel intensity of the original images to the element stiffness, allowing the prediction of nuclear stiffness in an additional set of other nuclei. The developed computational framework will identify the contribution of a multitude of sub-nuclear structures and predict global nuclear stiffness of multiple nuclei based on simple nuclear isolation protocols, confocal images and AFM tests.

Applying ASTM Standards to Tensile Tests of Musculoskeletal Soft Tissue: Methods to Reduce Grip Failures and Promote Reproducibility.

Tensile testing is an essential experiment to assess the mechanical integrity of musculoskeletal soft tissues, yet standard test methods have not been developed to ensure the quality and reproducibility of these experiments. The ASTM International standards organization has created tensile test standards for common industry materials that specify geometric dimensions of test specimens (coupons) that promote valid failures within the gage section (midsubstance), away from the grips. This study examined whether ASTM test standards for plastics, elastomers, and fiber-reinforced composites are suitable for tensile testing of bovine meniscus along the circumferential fiber direction. We found that dumbbell (DB) shaped coupons based on ASTM standards for elastomers and plastics had an 80% and 60% rate of midsubstance failures, respectively. The rate of midsubstance failures dropped to 20% when using straight (ST) coupons based on ASTM standards for fiber-reinforced composites. The mechanical properties of dumbbell shaped coupons were also significantly greater than straight coupons. Finite element models of the test coupons revealed stress distributions that supported our experimental findings. In addition, we found that a commercial deli-slicer was able to slice meniscus to uniform layer thicknesses that were within ASTM dimensional tolerances. This study provides methods, recommendations, and insights that can advance the standardization of tensile testing in meniscus and other soft fibrous tissues.

Emerging Gene-Editing Modalities for Osteoarthritis.

Osteoarthritis (OA) is a pathological degenerative condition of the joints that is widely prevalent worldwide, resulting in significant pain, disability, and impaired quality of life. The diverse etiology and pathogenesis of OA can explain the paucity of viable preventive and disease-modifying strategies to counter it. Advances in genome-editing techniques may improve disease-modifying solutions by addressing inherited predisposing risk factors and the activity of inflammatory modulators. Recent progress on technologies such as CRISPR/Cas9 and cell-based genome-editing therapies targeting the genetic and epigenetic alternations in OA offer promising avenues for early diagnosis and the development of personalized therapies. The purpose of this literature review was to concisely summarize the genome-editing options against chronic degenerative joint conditions such as OA with a focus on the more recently emerging modalities, especially CRISPR/Cas9. Future advancements in novel genome-editing therapies may improve the efficacy of such targeted treatments.

Development and calibration of a probabilistic finite element hip capsule representation.

The objective of this study was to develop a probabilistic representation of the hip capsule, which is calibrated to experimental capsular torque-rotation behavior and captures the observed variability for use in population-based studies. A finite element model of the hip capsule was developed with structures composed of a fiber-reinforced membrane, represented by 2D quadrilateral elements embedded with tension-only non-linear spring. An average capsule representation was developed by calibrating ligament properties (linear stiffness, reference strain) so that torque-rotation behavior matched mean cadaveric data. A probabilistic capsule was produced by determining the ligament property variability which represented ±2 SD measured in the experiment. Differences between experimental and model kinematics across all positions had RMS error of 4.7°. Output bounds from the optimized probabilistic capsule representation were consistent with ±2 SD of experimental data; the overall RMS error was 5.1°. This model can be employed in population-based finite element studies of THA to assess mechanics in realistic scenarios considering implant design, as well as surgical and patient factors.

Center of Biomedical Research Excellence in Matrix Biology: Building Research Infrastructure, Supporting Young Researchers, and Fostering Collaboration.

The Center of Biomedical Research Excellence in Matrix Biology strives to improve our understanding of extracellular matrix at molecular, cellular, tissue, and organismal levels to generate new knowledge about pathophysiology, normal development, and regenerative medicine. The primary goals of the Center are to i) support junior investigators, ii) enhance the productivity of established scientists, iii) facilitate collaboration between both junior and established researchers, and iv) build biomedical research infrastructure that will support research relevant to cell-matrix interactions in disease progression, tissue repair and regeneration, and v) provide access to instrumentation and technical support. A Pilot Project program provides funding to investigators who propose applying their expertise to matrix biology questions. Support from the National Institute of General Medical Sciences at the National Institutes of Health that established the Center of Biomedical Research Excellence in Matrix Biology has significantly enhanced the infrastructure and the capabilities of researchers at Boise State University, leading to new approaches that address disease diagnosis, prevention, and treatment. New multidisciplinary collaborations have been formed with investigators who may not have previously considered how their biomedical research programs addressed fundamental and applied questions involving the extracellular matrix. Collaborations with the broader matrix biology community are encouraged.

Computational framework for population-based evaluation of TKR-implanted patellofemoral joint mechanics.

Differences in patient anatomy are known to influence joint mechanics. Accordingly, intersubject anatomical variation is an important consideration when assessing the design of joint replacement implants. The objective of this study was to develop a computational workflow to perform population-based evaluations of total knee replacement implant mechanics considering variation in patient anatomy and to assess the potential for an efficient sampling strategy to support design phase screening analyses. The approach generated virtual subject anatomies using a statistical shape model of the knee and performed virtual implantation to size and align the implants. A finite-element analysis simulated a deep knee bend activity and predicted patellofemoral (PF) mechanics. The study predicted bounds of performance for kinematics and contact mechanics and investigated relationships between patient factors and outputs. For example, the patella was less flexed throughout the deep knee bend activity for patients with an alta patellar alignment. The results also showed the PF range of motions in AP and ML were generally larger with increasing femoral component size. Comparison of the 10-90% bounds between sampling strategies agreed reasonably, suggesting that Latin Hypercube sampling can be used for initial screening evaluations and followed up by more intensive Monte Carlo simulation for refined designs. The platform demonstrated a functional workflow to consider variation in joint anatomy to support robust implant design.

Computational approach to correcting joint instability in patients with recurrent patellar dislocation.

Patellar dislocation is a debilitating injury common in active adolescents and young adults. Conservative treatment after initial dislocation is often recommended, but almost half of these patients continue to suffer from recurrent dislocation. The objective of this study was to compare preoperative patellofemoral joint stability with stability after a series of simulated procedures, including restorative surgery to correct to pre-injury state, generic tibial tubercle osteotomy, patient-specific reconstructive surgery to correct anatomic abnormality, less invasive patient-specific surgery, and equivalent healthy controls. Three-dimensional, subject-specific finite element models of the patellofemoral joint were developed for 28 patients with recurrent patellar dislocation. A 50 N lateral load was applied to the patella to assess the lateral stability of the patellofemoral joint at 10° intervals from 0° to 40° flexion. Medial patellofemoral ligament reconstruction, along with reconstructive procedures to correct anatomic abnormality were simulated. Of all the simulations performed, the healthy equivalent control models showed the least patellar internal-external rotation, medial-lateral translation, and medial patellofemoral ligament restraining load during lateral loading tests. Isolated restorative medial patellofemoral ligament reconstruction was the surgery that resulted in the most patellar internal-external rotation, medial-lateral translation, and medial patellofemoral ligament reaction force across all flexion angles. Patient-specific reconstruction to correct anatomic abnormality was the only surgical group to have non-significantly different results compared with the healthy equivalent control group across all joint stability metrics evaluated. Statement of clinical significance: This study suggests patient-specific reconstructive surgery that corrects underlying anatomic abnormalities best reproduces the joint stability of an equivalent healthy control when compared with the pre-injury state, generic tibial tubercle osteotomy, and less invasive patient-specific surgery. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:768-776, 2020.