Clubfoot treatment with Ponseti method-parental distress during plaster casting.

BACKGROUND: Clubfoot is one of the most prevalent musculoskeletal congenital defects. Gold standard treatment of idiopathic clubfoot is the conservative Ponseti method, including the reduction of deformity with weekly serial plaster casting and percutaneous Achilles tenotomy. It is well known that parents of children with severe and chronic illnesses are mentally stressed, but in recent studies regarding clubfoot treatment, parents were only asked about their satisfaction with the treatment. Largely unknown is parental distress before and during plaster casting in clubfoot. Therefore, we want to determinate first, how pronounced the parents' worries are before treatment and if they decrease during the therapy. Second, we hypothesized that parents faced with an extreme deformity (high Pirani score), reveal more distress, than parents whose children have a less pronounced deformity (low Pirani score). Therefore, we wanted to investigate whether the Pirani score correlates with the parents' mental resilience in relation to the therapy of the child as a global distress parameter. METHODS: To answer this question, we developed a questionnaire with the following emphases: Physical capacity, mental resilience, motion score, parents score, and child score with point scores 1 (not affected) to 6 (high affected). Subsequently, we interviewed 20 parents whose children were treated with clubfeet and determined the Pirani score of the infants at the beginning (T0) and at the end (TE) of the treatment with plaster casting. RESULTS: High values were obtained in child score (Mean (M) = 3.11), motion score (M = 2.63), and mental resilience (M = 2.25). During treatment, mental resilience improved (p = 0.015) significantly. Spearman correlation coefficient between Pirani score (T0) and mental resilience (T0) is 0.21, so the initial hypothesis had to be rejected. CONCLUSION: The issues of the children are in the focus of parental worries concerning clubfoot treatment, especially the assumed future motion and the assumed ability to play with other children. Particular emphasis should be placed on educating parents about the excellent long-term results in the function of the treated feet especially as this topic shows the greatest parental distress.

Transfer of plantar pressure from the medial to the central forefoot in patients with hallux valgus.

BACKGROUND: The aim of the study was to evaluate changes in plantar pressure distribution in feet affected by hallux valgus compared with their contralateral non-affected feet and with the feet of healthy control subjects. METHODS: Thirty-six patients with unilateral hallux valgus who were indicated for surgery and 30 healthy subjects were assessed on a pedobarographic instrumented treadmill for step length and width, mean stance phase, and plantar foot pressure distribution. Plantar pressure distribution was divided into eight regions. RESULTS: Significantly higher plantar pressures were observed in hallux valgus feet under the second and third metatarsal heads (p = .033) and the fourth and fifth toes (p < .001) than in the healthy control feet. Although decreased pressures were measured under the hallux in affected feet (197 [82-467] kPa) in contrast to the contralateral side (221 [89-514] kPa), this difference failed to reach statistical significance (p = .055). The gait parameters step width, step length, and single-limb support did not show any differences between hallux valgus and control feet. CONCLUSION: Although the literature on changes in plantar pressures in hallux valgus remains divided, our findings on transferring load from the painful medial to the central and lateral forefoot region are consistent with the development of transfer metatarsalgia in patients with hallux valgus.

CLINICAL OUTCOME AFTER INFECTED TOTAL KNEE AND TOTAL HIP ARTHROPLASTY.

OBJECTIVE: Infection after total hip (THA) and knee arthroplasty (TKA) is a serious complication which typically leads to a long lasting and intensive surgical and medicamentous treatment. The aim of this study was to identify factors that influence outcome after revision surgery caused by prosthetic infection. METHODS: We retrospectively analyzed 64 patients who had revision surgery between 1989 and 2009 due to periprosthetic infection. We examined a total of 69 joints (TKA: 36%, THA: 64%), follow-up 5.1 years (0.5-21 years) after the initial surgical intervention. The mean patient age at time of surgery was 67 years old (43-79 years old). Clinical data and scores including the Western Ontario and McMaster Universities (WOMAC)-Index, the Harris Hip Score (HHS) and the Hospital for Special Surgery Score (HSS) were surveyed. RESULTS: There was no difference in clinical scores regarding treatment between a single and a multiple stage treatment regime. Infections with multiple microorganisms and Enterococcus spp. lead to a significantly higher number of interventions. Using a modified Tsukayama system we classified 24% as type I, 34% type II and 42% type III- infections, with no differences in clinical outcome. Overweight patients had a significantly lower HHS and WOMAC-score. Immunosuppression leads to a worse WOMAC and HSS-Score. An increased number of procedures was associated to a limping gait. CONCLUSION: Thorough surgical technique leads to good clinical results independent of infection-type and treatment philosophy. Level of Evidence III, Case Control Study.

CLINICAL OUTCOME AFTER INFECTED TOTAL KNEE AND TOTAL HIP ARTHROPLASTY

ABSTRACT Objective: Infection after total hip (THA) and knee arthroplasty (TKA) is a serious complication which typically leads to a long lasting and intensive surgical and medicamentous treatment. The aim of this study was to identify factors that influence outcome after revision surgery caused by prosthetic infection. Methods: We retrospectively analyzed 64 patients who had revision surgery between 1989 and 2009 due to periprosthetic infection. We examined a total of 69 joints (TKA: 36%, THA: 64%), follow-up 5.1 years (0.5-21 years) after the initial surgical intervention. The mean patient age at time of surgery was 67 years old (43-79 years old). Clinical data and scores including the Western Ontario and McMaster Universities (WOMAC)-Index, the Harris Hip Score (HHS) and the Hospital for Special Surgery Score (HSS) were surveyed. Results: There was no difference in clinical scores regarding treatment between a single and a multiple stage treatment regime. Infections with multiple microorganisms and Enterococcus spp. lead to a significantly higher number of interventions. Using a modified Tsukayama system we classified 24% as type I, 34% type II and 42% type III- infections, with no differences in clinical outcome. Overweight patients had a significantly lower HHS and WOMAC-score. Immunosuppression leads to a worse WOMAC and HSS-Score. An increased number of procedures was associated to a limping gait. Conclusion: Thorough surgical technique leads to good clinical results independent of infection-type and treatment philosophy. Level of Evidence III, Case Control Study.

Robot-aided in vitro measurement of patellar stability with consideration to the influence of muscle loading.

BACKGROUND: Anterior knee pain is often associated with patellar maltracking and instability. However, objective measurement of patellar stability under clinical and experimental conditions is difficult, and muscular activity influences the results. In the present study, a new experimental setting for in vitro measurement of patellar stability was developed and the mediolateral force-displacement behavior of the native knee analyzed with special emphasis on patellar tilt and muscle loading. METHODS: In the new experimental setup, two established testing methods were combined: an upright knee simulator for positioning and loading of the knee specimens, and an industry robot for mediolateral patellar displacement. A minimally invasive coupling and force control mechanism enabled unconstrained motion of the patella as well as measurement of patellar motion in all six degrees of freedom via an external ultrasonic motion-tracking system. Lateral and medial patellar displacement were measured on seven fresh-frozen human knee specimens in six flexion angles with varying muscle force levels, muscle force distributions, and displacement forces. RESULTS: Substantial repeatability was achieved for patellar shift (ICC(3,1) = 0.67) and tilt (ICC(3,1) = 0.75). Patellar lateral and medial shift decreased slightly with increasing flexion angle. Additional measurement of patellar tilt provided interesting insights into the different displacement mechanisms in lateral and medial directions. For lateral displacement, the patella tilted in the same (lateral) direction, and tilted in the opposite direction (again laterally) for medial displacement. With regard to asymmetric muscle loading, a significant influence (p < 0.03, up to 5 mm shift and 8° tilt) was found for lateral displacement and a reasonable relationship between muscle and patellar force, whereas no effect was visible in the medial direction. CONCLUSION: The developed experimental setup delivered reproducible results and was found to be an excellent testing method for the in vitro analysis of patellar stability and future investigation of surgical techniques for patellar stabilization and total knee arthroplasty. We demonstrated a significant influence of asymmetric quadriceps loading on patellar stability. In particular, increased force application on the vastus lateralis muscle led to a clear increase of lateral patellar displacement.

Spine radiography in the evaluation of back and neck pain in an orthopaedic emergency clinic.

BACKGROUND AND OBJECTIVES: Despite the recommendations of national and international societies for the treatment of patients with acute neck and back pain, still too many radiologic examinations were performed. The purpose of this study was to analyze and optimize diagnostics and treatment of patients with acute back pain. METHODS: The medical records of 484 patients presented to the emergency clinic with acute neck or back pain were analyzed for clinical history, physical examination, radiographic findings and therapy. RESULTS: Radiographs of the lumbar, cervical, or thoracic spine were performed in 338 cases (70%). Radiographs were normal in 142 patients (42%) and degenerative changes were identified in 123 patients (36%). Only 2 patients (0.4%) had radiographic findings that had direct therapeutic relevance: 1 patient with metastatic disease and 1 patient with posttraumatic C1-C2 instability. For most patients without sensorimotor deficits and absent specific indications for radiography ("red flags"), therapy was not affected by the results of radiography. CONCLUSIONS: Plain radiography of the spine was unnecessary in most patients initially evaluated with non-specific acute back pain and does not improve the clinical outcome. The implementation of national and international guidelines is a slow process, but helps to reduce costs and to protect patients from unnecessary ionizing radiation exposure.

Increased patellofemoral pressure after TKA: an in vitro study.

PURPOSE: Considering the discrepant results of the recent biomechanical studies, the purpose of this study was to simulate dynamic muscle-loaded knee flexion with a large number of specimens and to analyse the influence of total knee arthroplasty (TKA) without and with patellar resurfacing on the patellofemoral pressure distribution. METHODS: In 22 cadaver knee specimens, dynamic muscle-loaded knee flexion (15°-90°) was simulated with a specially developed knee simulator applying variable muscle forces on the quadriceps muscles to maintain a constant ankle force. Patellofemoral pressures were measured with flexible, pressure-sensitive sensor foils (TEKSCAN) and patellofemoral offset with an ultrasound motion-tracking system (ZEBRIS). Measurements were taken on the native knee, after total knee arthroplasty and after patellar resurfacing. Correct positioning of the patellar implant was examined radiologically. RESULTS: The maximal patellofemoral peak pressure partly increased from the native knee to the knee with TKA with intact patella (35°-90°, p < 0.012) and highly increased (twofold to threefold) after patellar resurfacing (20°-90°, p < 0.001). Concurrently, the patellofemoral contact area decreased and changed from a wide area distribution in the native knee, to a punctate area after TKA with intact patella and a line-shaped area after patellar resurfacing. Patellar resurfacing led to no increase in patellar thickness and patellofemoral offset. CONCLUSIONS: Despite correct implantation of the patellar implants and largely unchanged patellofemoral offset, a highly significant increase in pressure after patellar resurfacing was measured. Therefore, from a biomechanical point of view, the preservation of the native patella seems reasonable if there is no higher grade patellar cartilage damage.

Proximal metatarsal osteotomy for hallux valgus: an audit of radiologic outcome after single screw fixation and full postoperative weightbearing.

BACKGROUND: Proximal metatarsal osteotomy combined with a distal soft-tissue procedure is a common treatment for moderate to severe hallux valgus. Secure stabilisation of the metatarsal osteotomy is necessary to avoid complications such as delayed union, nonunion or malunion as well as loss of correction. The aim of this study was to report our results using a single screw for stabilisation of the osteotomy. METHODS: We retrospectively reviewed 151 patients with severe hallux valgus who were treated by the above mentioned way with full postoperative weightbearing in a stiff soled shoe. Mean age of patients at time of surgery was 54 years, 19 patients were male and 132 female. Assessment of clinical and radiographic results was performed after 2 days and 6 weeks. Results were also correlated to the experience of the performing surgeon. RESULTS: Mean preoperative HVA (hallux valgus angle) was 36.4 degrees, and then 3.5 degrees 2 days and 13.4 degrees 6 weeks after the procedure (p < 0.001). Mean preoperative IMA (intermetarsal angle) was 16.8 degrees, and then 6.4 degrees after 2 days and 9.8 degrees after 6 weeks (p < 0.001). Mean preoperative first metatarsal length of 56.4 mm decreased to 53.6 mm after 6 weeks. Possible non-union of the osteotomy was observed in 4 patients (2.6%) after 6 weeks. Performing residents (n = 40) operated in 65 minutes and attending surgeons (n = 111) in 45 minutes, with no significant differences in radiographic measurements between both groups. CONCLUSIONS: Single screw stabilisation of proximal chevron osteotomy is a reliable method for treating severe hallux valgus deformities with satisfactory results.

Dislocation after total hip arthroplasty: risk factors and treatment options.

OBJECTIVE: The aim of this study was to analyze the setting for dislocations and redislocations after primary and revision total hip arthroplasty (THA), identify risk factors and optimize treatment. METHODS: This study included 56 patients with a dislocated hip following THA (n=5,205) between 1984 and 2005 and a matched control group (n=55). Hospital charts and radiographs of all patients in both groups were analyzed. Thirty-one patients in the study group were followed both clinically and radiologically. RESULTS: The dislocation rate after primary THA was 1.1% (56/5,205) and the redislocation rate after a first occurrence was as high as 39%. There was a positive correlation between the time intervals from the surgery to first dislocation and from the first dislocation to second dislocation (r=0.4). Most of the primary dislocations occurred within a short period of time after surgery, thus favoring consecutive dislocations. Female gender, as well as revision arthroplasty, was associated with a higher incidence of dislocations. No relation was found between the orientation of the acetabular cup and dislocation. CONCLUSION: To prevent redislocations after the first occurrence, we suggest thorough evaluation of possible technical faults which should be addressed surgically. Considering the high redislocation rate, we also advocate a stringent conservative treatment regime especially after the first THA dislocation.

Differences in knee joint kinematics and forces after posterior cruciate retaining and stabilized total knee arthroplasty.

BACKGROUND: Posterior cruciate ligament (PCL) retaining (CR) and -sacrificing (PS) total knee arthroplasties (TKA) are widely-used to treat osteoarthritis of the knee joint. The PS design substitutes the function of the PCL with a cam-spine mechanism which may produce adverse changes to joint kinematics and kinetics. METHODS: CR- and PS-TKA were performed on 11 human knee specimens. Joint kinematics were measured with a dynamic knee simulator and motion tracking equipment. In-situ loads of the PCL and cam-spine were measured with a robotic force sensor system. Partial weight bearing flexions were simulated and external forces were applied. RESULTS: The PS-TKA rotated significantly less throughout the whole flexion range compared to the CR-TKA. Femoral roll back was greater in the PS-TKA; however, this was not correlated with lower quadriceps forces. Application of external loads produced significantly different in-situ force profiles between the TKA systems. CONCLUSIONS: Our data demonstrate that the PS-design significantly alters kinematics of the knee joint. Our data also suggest the cam-spine mechanism may have little influence on high flexion kinematics (such as femoral rollback) with most of the load burden shared by supporting implant and soft-tissue structures.

Fusion following failed total ankle replacement.

Although mid- to long-term results after total ankle replacement have improved because of available second- and third-generation devices, failure of total ankle replacement is still more common compared with total hip replacement and total knee replacement. The portfolio of available total ankle replacement revision component options is small. Furthermore, the bone stock of the tibiotalar region is scarce making it difficult and in some situations impossible to perform revision total ankle replacement. In these cases tibiotalar and tibiotalocalcaneal fusions are valuable options. This article describes which surgical procedures should be performed depending on the initial situation and gives detailed advice on surgical technique, postoperative care, and clinical results.

Gender differences in tibio-femoral kinematics and quadriceps muscle force during weight-bearing knee flexion in vitro.

PURPOSE: Females have a higher risk in terms of anterior cruciate ligament injuries during sports than males. Reasons for this fact may be different anatomy and muscle recruitment patterns leading to less protection for the cruciate- and collateral-ligaments. This in vitro study aims to evaluate gender differences in knee joint kinematics and muscle force during weight-bearing knee flexions. METHODS: Thirty-four human knee specimens (17 females/17 males) were mounted on a dynamic knee simulator. Weight-bearing single-leg knee flexions were performed with different amounts of simulated body weight (BW). Gender-specific kinematics was measured with an ultrasonic motion capture system and different loading conditions were examined. RESULTS: Knee joint kinematics did not show significant differences regarding anteroposterior and medial-lateral movement as well as tibial varus-valgus and internal-external rotation. This applied to all simulated amounts of BW. Simulating 100 N BW in contrast to AF50 led to a significant higher quadriceps overall force in female knees from 45° to 85° of flexion in contrast to BW 50 N. In these female specimens, the quadriceps overall force was about 20 % higher than in male knees being constant in higher flexion angles. CONCLUSIONS: It is indicated by our results that in a squatting movement females compared with males produce higher muscle forces, suggesting an increased demand for muscular stabilization, whereas tibio-femoral kinematics was similar for both genders.

Surgical treatment of a young patient with bilaterally destroyed first metatarsophalangeal joints suffering from gout.

The authors present an unusual case of untreated gout leading to major bony destructions in both metatarsophalangeal joints, leading to joints of enormous dimensions. If untreated, gout can cause disabling destructions with direct influence on both private and working life, even in young patients. In potentially noncompliant patients, simple surgical procedures and postoperative regimes are valuable treatment options resulting in acceptable clinical results.

The influence of asymmetric quadriceps loading on patellar tracking--an in vitro study.

BACKGROUND: In patients with anterior knee pain and patellar instability, a specific training of the quadriceps muscle - especially the vastus medialis - is often recommended, although the practicability is discussed controversially and the proof of a measurable clinical effect is difficult. Therefore, this in vitro study investigates the influence of asymmetric muscle loading on the motion of the human patella. METHODS: Seven human knee specimens were tested in a specially developed knee simulator. During simulated weight-bearing knee flexion, the kinematics of tibia, femur and patella were measured using an ultrasound motion capture system. The quadriceps forces were controlled to achieve a constant ankle force over the whole flexion range which is assumed to represent almost physiological loading. Three different force distributions of the quadriceps were tested - a central, equally distributed load as well as mainly lateral and medial loads. RESULTS: A significant influence of different quadriceps force distributions was found for patellar tilt around a proximodistal axis (up to 1.7°) and patellar rotation around an anteroposterior axis (up to 3.8°) with respect to the femur. Interestingly, the patellar mediolateral shift was influenced only marginally (<1.5mm). CONCLUSIONS: Specific muscle training might help patients with patellofemoral pain and cartilage damage by a slight modification of the kinematics, but we could show that even highly asymmetric quadriceps loads only led to a small alteration of the mediolateral shift in case of a physiologic anatomy of the trochlear groove.

Differences in tibiofemoral kinematics between the unloaded robotic passive path and a weightbearing knee simulator.

Cadaveric in vitro studies are essential to test hypotheses concerning surgical manipulations in the same individual. Robotic technologies as well as different knee-models have been developed to get an in-depth comprehension of knee joint kinematics. The purpose of this study was to compare utilization of these different established principles.Ten human cadaveric knee specimens were used to measure the kinematics during a weight-bearing flexion in a 6-degrees-of-freedom knee simulator. While flexing the knee, joint quadriceps muscle forces were dynamically simulated to reach a vertical ground reaction force of 100N. Fourteen knee specimens were mounted in 6-degrees-of-freedom robotic manipulator with a universal force sensor. The unloaded flexing motion of each specimen was measured by finding positions for each degree of flexion where all forces are minimal (passive path). The kinematic data of the knee-simulator and the robot concerning internal-external rotation, anterior-posterior translation, varus-valgus motion, and medial-lateral translation was examined.For all investigated degrees of freedom the kinematics of the robotic passive path differed from the loaded kinematics in the knee simulator.Simulated bodyweight as well as the examination method used has a substantial influence on joint kinematics during flexion which has to be considered when interpreting biomechanical studies as well as clinical tests.

Osteochondritis dissecans of both knees, both elbows, and the first metatarsophalangeal joint in a female soccer player.

A 19-year-old female soccer player presented for evaluation of pain at the base of the right hallux after a recent sports injury. She had a history of 4 operations, 1 each at both knees and both elbows, for the treatment of osteochondritis dissecans (OCD). Examination showed tenderness to palpation and limited range of motion of the first metatarsophalangeal (MP) joint, and radiographs showed stage 4 OCD of the first metatarsal head with a detached osseous fragment. Diagnostic arthroscopy confirmed the presence of OCD, and treatment included arthrotomy, excision of the loose body, and microfracture of the defect. Evaluation at 3 months after surgery showed that the first MP joint pain and limited motion had completely resolved, and the patient returned to soccer practice. Although OCD at 1 location is diagnosed frequently in athletes, involvement of 5 different joints in the same patient is uncommon.

Charcot arthropathy of the first metatarsophalangeal joint.

Charcot arthropathy is an acute or subacute, often indolent, non-infectious or tumorous osteoarticular destruction of weightbearing skeletal structures in patients with reduced pain perception due to peripheral neuropathy. The authors present a rare case of progressive Charcot arthropathy of the first metatarsophalangeal joint with accompanying ulcer and foot deformity due to peripheral neuropathy. An arthrodesis of the first metatarsophalangeal joint with resection of the hypertrophic bone and osteophytes using a locking plate was performed. Also a condylectomy of the base of the proximal phalanx digitus II and III as well as a shortening osteotomy of the third metatarsal were conducted. The ulcer was debrided and primarily closed by suture. Mobilization was performed without weightbearing in a postoperative shoe for 6 weeks, the ulcer was completely healed and the arthrodesis had fused. Owing to the complexity of Charcot arthropathy careful preoperative evaluation, timing and dimension of surgery as well as treatment of associated comorbidities and sufficient postoperative care is important to reduce the complication rate and improve long-term results.

An implant-free double-bundle reconstruction of the anterior cruciate ligament: operative technique and influence on tibiofemoral kinematics.

BACKGROUND: Reconstruction of the anterior cruciate ligament is a standard surgical procedure in sports traumatology. The widespread replacement method using hamstring tendons has an important shortcoming namely delayed or missing bony healing in contrast to patellar tendon grafts where implant-free fixation is established by using the adjacent bone blocks. The purpose of this study was to describe a new implant-free surgical procedure using hamstring tendon grafts and to analyse the influence on tibiofemoral kinematics in vitro. METHODS: Nine human knee specimens with arthroscopically transected anterior cruciate ligaments were mounted on a dynamic knee simulator and weight-bearing muscle-loaded knee flexions were simulated while a robotic universal force sensor system was used to provide external tibial loads. Three different loading conditions were simulated including partial body weight only, an additional 50 N anterior tibial force or an additional Five Nm of internal rotational torque. After reconstruction of the anterior cruciate ligament using a tibial bone block hybrid technique these three trials were repeated. The kinematics was measured with an ultrasonic measuring system and different loading and ligament conditions were examined. Graft tunnel placement was verified by computed tomography. FINDINGS: Our fixation method achieved stability to anterior tibial drawer force whereas internal tibial rotation did not change before and after the reconstruction. Computed tomography confirmed anatomical graft and tunnel placement. INTERPRETATION: The presented operative procedure is technically feasible and leads to reproducible results concerning knee joint kinematics and graft placement.

Influence of bi- and tri-compartmental knee arthroplasty on the kinematics of the knee joint.

BACKGROUND: The cruciate ligaments are important stabilizers of the knee joint and determine joint kinematics in the natural knee and after cruciate retaining arthroplasty.No in vitro data is available to biomechanically evaluate the ability of the anterior cruciate ligament (ACL) to maintain knee joint kinematics after bicruciate-retaining bi-compartmental knee arthroplasty (BKA).Therefore, the objective of the current study was to investigate the kinematics of the natural knee joint, before and after installing bicruciate-retaining BKA and posterior cruciate retaining total knee arthroplasty. Specifically, we incorporated a dynamic knee simulator to simulate weight-bearing flexions on cadaveric knee specimen before and after surgical manipulations. METHODS: In this cadaveric study we investigated rotational and translational tibiofemoral kinematics during simulated weight-bearing flexions of the intact knee, after bi-compartmental knee arthroplasty (BKA+), after resecting the ACL in BKA (BKA-), and after posterior cruciate retaining total knee arthroplasty (TKA). RESULTS: Rotation of BKA+ is closest to the intact knee joint, whereas TKA shows significant differences from 30 to 90 degree of flexion. Within the tested flexion range (15 to 90 degree of flexion), there was no significant difference in the anterior-posterior translation among intact, BKA+, and TKA knees. Resecting the ACL in BKA leads to a significant anterior tibial translation. CONCLUSIONS: BKA with intact cruciate ligaments resembles rotation and translation of the natural knee during a simulated weight-bearing flexion. It is a suitable treatment option for medial and patellofemoral osteoarthritis with advantages in rotational characteristics compared to TKA.

The effect of different quadriceps loading patterns on tibiofemoral joint kinematics and patellofemoral contact pressure during simulated partial weight-bearing knee flexion.

PURPOSE: The purpose of this in vitro study was to investigate the influence of different quadriceps loading patterns on tibiofemoral joint kinematics and patellofemoral pressure. METHODS: A dynamic muscle-loaded knee squat was simulated on eight knee specimens with an upright knee simulator while measuring tibiofemoral joint kinematics and patellofemoral pressure distribution. The quadriceps muscle was attached to three actuators simulating the three main extensor muscles, and five different quadriceps loading patterns were tested. RESULTS: Tibial axial and varus-valgus-rotation are affected most while changing quadriceps loading patterns from lateral to medial. Higher internal tibial rotation is associated with higher medial muscle load compared to the symmetrical loading condition. Contact force, contact area and maximum peak pressure rise with increasing flexion angles. Accentuating the vastus lateralis muscle induces a significant reduction in patellofemoral contact force and a 30% diminished contact area at 90° of flexion. CONCLUSION: Strengthening the vastus medialis muscle leads to increased internal tibial rotation, thus optimizing patella tracking by lowering the Q-angle. In contrast, weakness of the vastus medialis muscle causes decreased tibial internal rotation and is associated with lower patellofemoral contact pressure and contact area. Vastus medialis exercise is advisable to improve patella tracking but may not be recommended in patients with disorders due to increased patellofemoral contact pressure.