Journal Pre-proofs

Direct Measurement of Three-Dimensional Forces at the Medial Meniscal

Root: A Validation Study

Justin R. Brown, Justin F. Hollenbeck, Bradley W. Fossum, Heath Melugin,

Scott Tashman, Armando F. Vidal, Matthew T. Provencher

PII: S0021-9290(22)00470-5
DOI: https://doi.org/10.1016/j.jbiomech.2022.111429
Reference: BM 111429

To appear in: Journal of Biomechanics

Received Date: 12 March 2022

Revised Date: 22 December 2022
Accepted Date: 29 December 2022

Please cite this article as: J.R. Brown, J.F. Hollenbeck, B.W. Fossum, H. Melugin, S. Tashman, A.F. Vidal, M.T.
Provencher, Direct Measurement of Three-Dimensional Forces at the Medial Meniscal Root: A Validation Study,
Journal of Biomechanics (2023), doi: https://doi.org/10.1016/j.jbiomech.2022.111429

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 Direct Measurement of Three-Dimensional Forces at the Medial Meniscal Root: A
Validation Study
Justin R. Brown, MD1, Justin F. Hollenbeck, MS1, Bradley W. Fossum, BA1, Heath Melugin,
MD1,2, Scott Tashman, PhD1, Armando F. Vidal, MD1,2, and Matthew T. Provencher, MD,
CAPT1,2
1- Steadman Philippon Research Institute
181 W Meadow Dr.
Vail, CO 81657
2- The Steadman Clinic
180 W Meadow Dr.
Vail, CO 81657
All future correspondence should be addressed to Matthew T. Provencher, MD, CAPT,
Steadman Philippon Research Institute, 181 W. Meadow Dr. Ste 400, Vail, CO 81657. The
phone number is 970-479-5806 and the fax number is 970-672-0861. Email to both addresses
would be greatly appreciated: mprovencher@thesteadmanclinic.com and
jbrown@thesteadmanclinic.com
Key words: biomechanics, meniscal root, validation, meniscal root force, 3D forces
Word count Introduction through Discussion: 3730 words

1
Direct Measurement of Three-Dimensional Forces at the Posterior Medial Meniscal Root: A Validation Study

2
Abstract

The posterior medial meniscal root (PMMR) experiences variable and multiaxial forces during loading.

Current methods to measure these forces are limited and fail to adequately characterize the loads in all three

dimensions at the root. Our novel technique resolved these limitations with the installation of a 3-axis sensing

construct that we hypothesized would not affect contact mechanics, would not impart extraneous loads onto the

PMMR, would accurately measure forces, and would not deflect under joint loads. Six cadaveric specimens were

dissected to the joint capsule and a sagittal-plane, femoral condyle osteotomy was performed to gain access to the

root. The load sensor was placed below the PMMR and was validated across four tests. The contact mechanics test

demonstrated a contact area precision of 44 mm2 and a contact pressure precision of 5.0 MPa between the pre-

installation and post-installation states. The tibial displacement test indicated an average bone plug displacement of

< 1mm in all directions. The load validation test exhibited average precision values of 0.7 N in compression, 0.5 N

in tension, 0.3 N in anterior-posterior shear, and 0.3 N in medial-lateral shear load. The bone plug deflection test

confirmed <2 mm of displacement in any direction when placed under a load. This is the first study to successfully

validate a technique for measuring both magnitude and direction of forces experienced at the PMMR. This validated

method has applications for improving surgical repair techniques and developing safer rehabilitation and

postoperative protocols that decrease root loads.

3
INTRODUCTION

Meniscal tears are the most common indication for orthopedic surgery. As many as 1% of active people

suffer a meniscal injury, with the medial side being affected three times as often as the lateral (Gee et al., 2020;

Wilson et al., 2018). The outcomes of posterior medial meniscal root (PMMR) tears are well documented, although

the forces experienced at the root are only understood at a rudimentary level (Daney et al., 2019). The ability to

comprehensively characterize forces at the PMMR can guide the position of surgical techniques to withstand the

magnitude and direction of stress that results in injury. This also applies to making safer rehabilitation and

postoperative protocols that minimize loads on the root.

Meniscal root tears occur due to a variety of factors (Bahr et al., 2005). Tears are typically seen during

sudden movements at high flexion angles while weightbearing, such as descending stairs or pivoting during athletics

(Furumatsu et al., 2019; Song et al., 2017; Wang et al., 2021). Along with knee position, internal factors such as

advanced age, BMI, and varus alignment are all significant risk factors for PMMR tears (Hwang et al., 2012).

Higher flexion angles generate greater postero-medial pressure, leading many groups to hypothesize that PMMR

tears are caused by elevated compression and shear forces at the root (Habata et al., 2004; Vedi et al., 1999).

However, many of these hypotheses remain speculative due to the inability to measure PMMR loads in more than

one direction.

Previous methods have successfully estimated meniscal root force under various joint loading conditions.

However, the majority of these findings have focused on recording tension force leaving shear and compressive

forces to be discovered in future studies (Markolf et al., 2012; Stärke et al., 2013; Seitz 2012; Seitz et al., 2021).

Other methods have generated computational models to estimate three-dimensional (3D) root forces further

expanding the ways to measure root forces (Guess et al., 2017; Yao et al., 2006). Freutel et al. measured 3D forces

in a porcine meniscal root model making cadaveric specimens the next setting to record these forces (Freutel et al.,

2015). Fujie et al. used a cadaveric model that paired a force transformation scheme with an external sensor to take

the field another step closer to determining comprehensive forces in ligaments (Fujie et al., 1995). The current body

of literature surrounding root force measurements has laid the groundwork for an intact cadaveric model utilizing

the latest sensor technology to finally obtain comprehensive force measurements at the meniscal root.

Utilizing an established 3-axis force sensor (TR3D-B-250 Three Axis Load Cell, Michigan Scientific

Corporation, Charlevoix, MI), we have developed a novel method to measure the 3D magnitude and direction of

4
force transmitted to the PMMR in an intact knee joint. The objective of this study was to validate the accuracy of

this method for capturing PMMR loading conditions without influencing the native biomechanics of the knee joint.

We hypothesized that installation of the 3-axis sensing construct would not significantly affect the contact area of

the knee joint, would not significantly affect the average contact pressure of the knee joint, would not impart

significant extraneous loads onto the PMMR, would accurately measure forces applied to the PMMR, and would not

significantly deflect under joint loads. Successful validation has potential applications for tendon or ligament studies

that can guide clinicians towards surgical repairs better positioned to decrease forces and help develop safer

rehabilitation and postoperative protocols with minimal root loads.

5
Methods

Specimen Preparation

Six male, fresh-frozen cadaveric knees (mid femur to mid tibia-fibula) with a mean age of 59.3 (Range: 53-

65 years) and no history of arthritis, previous surgery, or malignancy were used for this study. The skin,

subcutaneous tissue, and muscles down to the joint capsule were carefully dissected and removed, leaving all

ligaments intact (Figure 1). Each specimen was screened for meniscal pathology under direct visualization. The tibia

and fibula were potted in a cylindrical mold with polymethyl methacrylate (PMMA, Fricke Dental, Streamwood, IL)

15 cm distal to the joint line. Two holes were drilled into the femur in order to mount the specimen to a custom

fixture capable of changing flexion angles (fixture seen in Figure 2). Next, a medial condyle osteotomy was

performed with a micro-oscillating saw and k-wires for complete visualization of the medial meniscus (Figure 1B).

The osteotomy was secured with a removable steel plate and bicortical screws (Figure 1).

Sensor Installation

A high-grade stainless steel, environmentally sealed three-axis sensor (25.4 mm x 25.4 mm x 12.7 mm)

was acquired from Michigan Scientific Corporation that determines force measurements in three orthogonal

directions. The sensor consists of 3 four-arm strain gauge bridges, each with a full-scale output of 3.5 mV/V and

maximum load of 1.1 kN (250 lbs). Sensor non-linearity and hysteresis is reported to be less than 0.5% of full-scale

output. Sensor calibration was performed within one month of experimental testing. Manufacturer sensor calibration

was performed within one month of experimental testing. The sensor construct (Figure 1A) consisted of the 3-axis

load cell, a directional mounting bracket, and plastic potting cup. A section of bone was removed from the posterior

tibia via oscillating saw 2 cm inferior to the PMMR, maintaining 2 mm margins (Figure 1C). A bone plug was cut

out inferior to the PMMR via k-wire, carefully protecting and excluding the meniscus and footprint of the cruciate

ligaments protected by army navy retractors. This plug was made with 20⁰ of medial angulation in relation to the

tibial plateau to replicate the insertion angle of the meniscal root fibers (Haut Donahue et al., 2022). PMMA potting

material was used to cement the bone plug to the sensor and then secured by three converging screws. Once

preliminary testing for surface biomechanics concluded, final cuts were made to separate the bone plug from the

tibial plateau with 2 mm margins by a micro-oscillating saw and k-wires.

Force Transformation

6
 Two coordinate systems were defined to standardize 3D forces to a tibial coordinate system across

specimens using a three-dimensional coordinate digitizer (Romer Absolute Arm, Hexagon Manufacturing

Intelligence, Cobham, Surrey, Great Britain). One system was positioned and oriented at the load cell, and the other

to the tibial plateau (Figure 3). A transformation matrix was calculated between the two coordinate systems such

that the forces measured in the sensor coordinate system could be transformed and reported with respect to the tibial

coordinate frame (Appendix A).

Biomechanical Validation Testing

Four validation tests were performed: a contact mechanics test, a tibial plateau displacement test, a load validation

test, and a bone plug deflection test. Together, these tests ensured that the proposed method for measuring 3D forces

at the PMMR is accurate and does not affect the native biomechanics of the knee joint.

Contact Mechanics Test:

This test evaluated the hypothesis that the installation of the 3-axis sensing construct (independent variable) would

insignificantly affect the contact area and average contact pressure of the knee joint (dependent variables). Each

fully dissected specimen was measured in two states: before sensor installation and after. The specimen was

mounted to a materials testing system (Instron Electropuls 10,000, Norwood, MA, USA) via a custom fixture that

oriented the specimen so that each compartment was loaded evenly and applied load to the femoral epicondyles.

Equilibrated electronic pressure sensors (K-scan Model 4000, 1500 psi; Tekscan Inc, South Boston, MA) were

calibrated by performing Tekscan-defined calibrations at 20% of the expected maximum pressure (188.5 N) and

80% of the expected maximum pressure (754 N). At each loading value, cork (3 mm thickness) cylinder with a

contacting surface area of 314 mm2 and capped with a layer of silicone 30 was applied to the pressure sensor, and a

power calibration was performed per manufacturer’s specifications. The pressure-mapping sensors were installed

under the meniscus in the lateral and medial compartments, and the position of the sensors relative to the tibia was

marked. The specimen was loaded to 1000 N, and the total contact area, medial compartment contact pressure, and

lateral compartment pressure for the pre-installation state were recorded (Figure 2). The specimen was unloaded,

and the pressure-mapping sensor in the medial compartment was removed to install the 3-axis load cell via the steps

described above. Final cuts on the tibial bone plug were then performed. The pressure mapping sensors were then

reinstalled, and the loading protocol and pressure measurements were repeated for the post-installation state. Bias,

precision, and intra-class correlation coefficients (ICCs) were calculated from all outcome measures to compare the

7
pre-installation and post-installation testing states (Koo and Li 2015). Bias for contact area and average contact

pressure was calculated as the mean of the differences between states (Equation 1). Precision was calculated by first

squaring the difference between the pre-installation state with the bias subtracted and the post-installation state with

the bias subtracted. Then, the square root of the mean of these squared differences was calculated to obtain a

precision value (Equation 2) (Dahl et al., 2020, ASTM, 1996).

(∑ 𝑛
𝑥
𝑖 = 1 𝑝𝑟𝑒𝑖
― 𝑥𝑝𝑜𝑠𝑡𝑖 )
(1) 𝐵𝑖𝑎𝑠, 𝐵 = 𝑛, for 𝑖 : length(𝑛) where 𝑛 is the number of specimens and 𝑥 is the

outcome of the dependent variable (average contact pressure or contact area).

(2) 𝑃𝑟𝑒𝑐𝑖𝑠𝑖𝑜𝑛 =
(∑ ((𝑥
𝑛
𝑖=1 𝑝𝑟𝑒𝑖 ― 𝑥𝑝𝑜𝑠𝑡𝑖) ― 𝐵)
2
) for 𝑖 : length(𝑛) where 𝑛 is the number of specimens and 𝑥
𝑛

is the outcome of the dependent variable (average contact pressure or contact area).

A custom-MATLAB script was used to calculate intraclass correlation coefficients based on a two-way mixed

effects model, using single measures, and absolute agreement as outlined by Koo and Li (2015). Agreement between

pre-installation state and post-installation state, based on the 95% confidence intervals of the ICC estimates, was

classified as poor (0–0.49), moderate (0.50–0.74), good (0.75–0.89), or strong (0.90–1.00).

Tibial Plateau Displacement Test:

This test determined how the installation of the 3-axis sensing construct (independent variable) affected the position

and orientation of the tibial plateau bone plug (dependent variables).

Each specimen was recorded in two states: before sensor installation and after. Prior to sensor installation, the

locations of seven fiducial markers on the tibia and five fiducial markers on the bone plug were determined using a

3D digitizer (Romer Absolute Arm, Hexagon Manufacturing Intelligence, Cobham, Surrey, Great Britain) (Figure

4). These measurements were repeated following final installation of the sensor system. The displacement and

change in orientation of the bone plug from pre to post sensor installation was determined by calculating the

transformation matrix between the bone plugs in each state relative to the tibial location (Ellman et al., 2014).

Load Validation Test:

This test served as a verification test of the 3-axis load cell and evaluated whether the applied load (independent

variable) was equivalent to the load output from the 3-axis load cell (dependent variable). The bone plug was

removed from the specimen by excising the medial meniscus from the tibia and unscrewing the bracket from the

tibia. The bone plug specimen was mounted to a materials testing system (Instron) via a custom fixture that oriented

8
the end effector of the tensile testing machine to the sensor’s coordinate system (Figure 5). Three-dimensional loads

from the sensor were recorded as the bone plug was loaded in compression (0 to 50 N in 10-N increments), in

tension (0 to 40 N in 10-N increments), in anterior-posterior (AP) shear (0 to 15 N in 5-N increments), and in

medial-lateral (ML) shear (0 to 15 N in 5-N increments) (Figure 5). Loads were selected based on previous studies

in addition to what forces this group was seeing in piloting (Markolf et al., 2012; Stärke et al., 2013; Seitz 2012;

Seitz et al., 2021). The percent difference, bias, precision, and ICCs were calculated to compare the measured loads

to the applied loads and each applied loading state (e.g. 15 N of AP shear force) was calculated to compare the

measured loads to the applied loads. (Bias and precision were calculated with the same equations and methodology

as The Contacts Mechanics Test.)

Bias and precision were calculated for each load value (e.g. 0 N, 10 N, 20N, … 50 N) for each loading direction

(compression, tension, anterior-posterior shear, medial-lateral shear). A mean bias and mean precision were

calculated across all applied load values for each loading direction, and box-and-whisker plots were generated to

visualize the distribution of bias and precision values across load values for each loading direction (Figure 7). ICCs

were calculated in the same way as specified in the Contact Mechanics Test.

Bone Plug Deflection Test:

This test determined how shear load applied to the cortical layer of the bone plug (independent variable) affected

deflection in the bone plug (dependent variable). The specimen was mounted to a materials testing system via a

custom fixture that oriented the specimen in its neutral alignment with symmetric loads on the joint. A 1000 N

compression load was applied to the femoral epicondyles along the anatomical axis, and shear loads at the meniscal

root were recorded. Once removed, the bone plug was mounted to a materials testing system via a custom fixture

that oriented the end effector of the tensile testing machine to the sensor’s coordinate system. End effector

displacement was recorded as the shear loads, recorded earlier, were applied to the bone plug at the root attachment

site (Figure 5). As the gap distance between bone plug and tibia was standardized to 2 mm during installation, the

criterion for success was defined as an end effector displacement of less than or equal to 2 mm at maximal shear

load force.

9
Results

Contact Mechanics Test:

The average difference in contact area from pre to post sensor installation was 2 mm2 (-93 mm2 to 97 mm2 95%

confidence interval) for bias and 44 mm2 (13 mm2 to 63 mm2 95% confidence interval) for precision (Figure 6). An

ICC of 0.99 indicated strong agreement in contact area between the two testing states (Figure 6). In the lateral

compartment the average difference in contact pressure from pre to post sensor installation was -10.9 MPa (-40.0

MPa to 18.2 MPa 95% confidence interval) for bias and 13.6 MPa (2.7 MPa to 19.6 MPa 95% confidence interval)

for precision with an ICC of 0.97 (Figure 6). In the medial compartment the average difference in contact pressure

from pre to post sensor installation was -5.5 MPa for bias (-16.9 MPa to 27.9 MPa 95% confidence interval) and

10.4 MPa (0.9 MPa to 15.3 MPa 95% confidence interval) for precision with an ICC of 0.98 (Figure 6).

Load Validation Test:

The average difference between the applied and the measured compression load was 0.5 N for bias (-0.3 N to 1.4 N

95% confidence interval) and 0.7 N (-0.2 N to 1.6 N 95% confidence interval) for precision (Table 1, Figure 7). The

average difference between the applied and the measured tensile load was -0.1 N for bias (-0.3 N to 0.1 N 95%

confidence interval) and 0.5 N (-0.4 N to 1.3 N 95% confidence interval) for precision (Figure 7). The average

difference between the applied and the measured AP shear load was -0.2 N for bias (-0.8 N to 0.3 N 95% confidence

interval) and 0.3 N (-0.8 N to 1.5 N 95% confidence interval) for precision (Figure 7). The average difference

between the applied and the measured ML shear load was -0.5 N for bias (-1.5 N to 0.5 N 95% confidence interval)

and 0.3 N (-1.1 N to 1.7 N 95% confidence interval) for precision (Figure 7). ICCs indicated very strong agreement

(r > 0.998) between the applied and measured loads in all loading directions.

Tibial Plateau Displacement Test:

Across all specimens, the bone plug displaced 0.4 ± 0.3 mm in the AP direction, 0.4 ± 0.3 mm in the ML direction

and 0.2 ± 0.1 mm in the SI direction (Table 1). The bone plug changed orientation 1.0° ± 0.7° about the AP axis,

1.3° ± 1.4° about the ML axis, and 2.7° ± 2.1° about the SI axis (Table 1).

Bone Plug Deflection Test:

Under AP shear, the bone plug deflected 0.90 mm ± 0.60 mm in the AP direction (Table 1). Under ML shear, the

bone plug deflected 0.67 mm ± 0.20 mm in the ML direction (Table 1).

10
Discussion

The most significant finding of this study was that a 3-axis load cell could be placed under the PMMR

without disrupting native joint mechanics and could accurately measure magnitude and direction of force. The

installation was validated by the contact mechanics test demonstrating a contact area precision of 44 mm2 and a

contact pressure precision of 5 MPa between the pre-installation and post-installation states, the tibial displacement

test indicating an average bone plug displacement of < 1mm in all directions, the load validation test exhibited

average precision values of 0.7 N in compression, 0.5 N in tension, 0.3 N in anterior-posterior shear, and 0.3 N in

medial-lateral shear load, and the bone plug deflection test that confirmed <2 mm of displacement in any direction

when placed under a load.

The method validated in this study offers a new approach towards understanding detailed biomechanical

injury mechanisms of the PMMR. Etiological mechanisms for injury to the root carry complex three-dimensional

forces that to this point have only been characterized in theory, but never quantified (Bahr et al., 2005; Kennedy et

al., 2020; Stärke et al., 2013). Flexion angle, increased age, BMI, activity level, posterior tibial slope, varus

alignment, and meniscal extrusion are known risk factors for meniscal injury that place strain and can alter the three-

dimensional forces on the meniscus (Krych et al., 2020). Previous studies have assessed uniaxial PMMR forces by

measuring tension along an assumed axis of force transmission and do not decompose this force into its orthogonal

components (Stärke et al., 2013). As PMMR strength varies along each dimension, these prior studies are non-

specific in drawing conclusions related to PMMR injury and injury prevention. Markolf et al. (2012) reported force

measurements at the PMMR recorded before and after ACL removal ranging from 11 N to 60 N in magnitude. The

study, however, measured only tensile force along an arbitrary orientation towards the PMMR, and was unable to

discern force components in shear or compression. It is well documented that the PMMR exhibits anisotropic load

tolerances (Ellman et al., 2014), so force measurements of the PMMR that fail to discern directional magnitudes

provide, at best, an incomplete assessment of injury risk. Measuring PMMR forces without significantly altering

mechanics of the joint has also been a challenge in previous studies. In their study of PMMR shear forces in a

porcine model, Freutel et al. (2015) failed to acknowledge that, in modifying the contact mechanics of the medial

compartment, meniscal function is altered and the relevance of their force measurements to PMMR injury risk

assessment is therefore significantly compromised.

11
 The ability to comprehensively characterize forces in three dimensions at the PMMR can guide the

development of surgical techniques. Knowing the magnitude and direction of force on the root will allow surgical

repairs to be positioned to best resist these strains. Specific procedures that may be guided by this biomechanical

study include PMMR repair, medial meniscus allograft transplantation, medial meniscus repair, and meniscal

centralization or meniscotibial ligament repair. Additionally, the measurement of forces at the PMMR may allow a

better understanding of how coronal and sagittal lower extremity alignment impact forces at the PMMR. For

example, it may be found that tibial osteotomies are required in some circumstances with concomitant meniscal

allograft transplantation or PMMR repair to decrease the forces experienced at the PMMR. Increased posterior tibial

slope has been found to increase forces on the ACL and has changed clinical practice as an anterior closing wedge

osteotomy is required in some circumstances to decrease the rate of ACL re-tear. This has yet to be studied in the

meniscus, but the development of this new force measurement technique at the PMMR will allow this.

An additional benefit of this study is its application to rehabilitation and postoperative protocols. Future

studies can take specimens through various motions and measure which movements impart the greatest loads at the

root. It may elucidate how much flexion is acceptable post-op day 1 or which maneuvers need to be avoided in

physical therapy. This will allow clinicians to modify protocols that can be both protective of surgically repaired

menisci while permitting earlier rehabilitation and potentially earlier return to play.

Limitations

The authors recognize that the proposed method of measuring 3D PMMR forces has limitations. Firstly,

there is a small amount of displacement that can occur within the 2 mm gap that separates the bone plug from the

tibial plateau. The gap is necessary to ensure that the force sensor only reads forces from the meniscal root, but

displacement within this space may have a small effect on force measurements. For specimen selection, all knees

were from male specimens. There were initially concerns about accommodating the size of the sensor, although the

method developed turned out to be adaptable to a wide range of tibial sizes. Furthermore, the reported forces are

based upon the anatomical reference points selected to create the coordinate frames. While the authors minimized

variability of point selection using anatomic landmarks, variation in point selection will influence variation of the

forces reported using this method.

Notably, the applied loads were low for deflection testing (~20 N at the bone plug) and load validation (~15

N - 40 N at the bone plug). Despite the PMMR load tolerance exceeding 500 N (Ellman et al., 2014) and dynamic

12
joint loading yielding higher PMMR loads, the authors intended to mimic the quasi-static load magnitudes measured

in previous studies (Freutel et al., 2015; Markolf et al., 2012). Secondly, during the piloting process, the study team

recorded shear loads that did not exceed 15 N when the joint was loaded in 500 N of compression. These selections

are not indicative of validation failure at higher loads as the manufacturer reports nonlinearity specifications as less

than 0.56 N. As with all cadaveric studies, there will be bony deformation when high loads are applied that could

potentially affect results. In addition, the femoral and tibial osteotomies needed to install the sensor may alter bony

deformation under high joint loads.

Conclusion

The current study successfully validated a method that can measure the three-dimensional forces seen at the

posterior medial meniscal root in a human cadaveric model that maintains native knee mechanics at low loads. This

force measurement methodology has potential to significantly advance repair techniques and alter protocols

postoperatively or during rehabilitation to avoid potentially damaging loads to the meniscus.

13
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24. Krych AJ, Bernard CD, Leland DP, et al., 2020. Isolated meniscus extrusion associated
with meniscotibial ligament abnormality. Knee Surg Sports Traumatol Arthrosc. 3599-
3605.

25. Ellman MB, LaPrade CM, Smith SD, et al., 2014. Structural Properties of the Meniscal
Roots. Am J Sports Med. 1881-1887.

15
Figure Legends

Figure 1. A) Sensor construct consisting of mounting bracket, 3-axis sensor, and potting cup. B)

Medial condyle osteotomy for direct visualization of the PMMR. C) Removed bone block 2 cm

below joint line. D) Sensor placement with 2 mm margins. E) Converging screw fixation and

pouring of PMMA potting material F) Final rigid fixation of sensor construct.

F – femur, T – tibia, Fb – fibula

Figure 2. Testing apparatus fixture for the contact mechanics test featuring the steel plate holding

the femoral condyle osteotomy together with 4 bicortical screws (left). Schematics of the pre-

installation (top right) and post-installation (bottom right) testing states, the TekScan sensors

were installed beneath the meniscus from anterior to posterior on the tibial plateau by making

minimal incisions to the meniscotibial ligaments.

Figure 3. Creation of sensor coordinate system, 𝑨, and tibial coordinate system, 𝑩, using a 3D

coordinate digitizer (left). Development of transformation matrix, 𝑻, from coordinate systems

(center) that is utilized to transform the force vector in the sensor coordinate system, 𝑭, to the

equivalent force vector in the standard tibial coordinate system, 𝑭′.

Figure 4. Specimen with sensor installed before final cuts made. Dashed yellow lines show

direction of final cuts and bone plug (left). Schematics before final cuts made to create bone plug

16
(top right) and after bone plug is created from final cuts with the intention to prevent bone plug

displacement once final cuts have been made (bottom right).

F – femur, T – tibia, Fb – fibula

Figure 5. Testing set up for the load validation test and bone plug deflection test (left). For both

tests, a dynamic tensile testing machine applied a known load to the cortical bone of the bone

plug (right). For the load validation test, forces were recorded from the sensor and compared to

the known applied load. For the bone plug deflection test, the displacement of the dynamic

tensile testing machine was recorded during loading.

BP – bone plug

Figure 6. Representative pressure maps in the lateral and medial condyles comparing the pre-

installation and post-installation testing states (top left). Chart of bias, upper 95% confidence

margin, lower 95% confidence margin, precision, and ICC of contact mechanics test (top right).

Confidence margins show 95% confidence margin of the difference between pre-installation and

post-installation testing states. Bland-Altman plots comparing pre-installation versus post-

installation contact area (bottom left), medial contact pressure (bottom center), and lateral

contact pressure (bottom right). Bland-Altman plots display the mean of the differences (SD), the

standard deviation of the differences (SD), and the limits of agreement (LOA).

17
Figure 7. Box and whisker plots of bias (left) and precision (right) calculated across all applied

loading values (e.g. 0 N, 10 N, 20 N, …, 50 N) for each loading direction. Within each plot, “X”

denotes the mean value.

Table Legends

Table 1. Mean values, standard deviations, and 95% confidence interval for outcomes of the

tibial plateau displacement test (top left), the bone plug deflection test (top right), the contact

mechanics test (middle), load validation test (bottom).

18
.

STEADMAN PHILIPPON RESEARCH INSTITUTE

181 West Meadow Drive • Suite 400 • Vail, CO 81657-5059
Ph 970-479-5806 • Fax 970-672-0861 • www.sprivail.org

Dear J. Biomech. Committee,

The authors of Direct Measurement of Three-Dimensional Forces at the Medial Meniscal Root: A Validation
Study present our CRediT Author contributions:
Justin Brown – Conceptualization, Methodology, Validation, Investigation, Resources, Writing – Original Draft,
Writing – Review and Editing, Visualization.

Justin Hollenbeck – Conceptualization, Methodology, Validation, Investigation, Resources, Writing – Original

Draft, Writing – Review and Editing, Visualization, Software, Formal Analysis.

Brad Fossum – Conceptualization, Validation, Investigation, Writing – Review and Editing, Visualization.

Heath Melugin – Conceptualization, Investigation, Writing – Review and editing, Supervision.

Scott Tashman – Writing – Review and editing, Supervision, Project Administration, Funding Acquisition.

Armando Vidal – Writing – Review and editing, Supervision, Project Administration, Funding Acquisition.

Matthew Provencher – Conceptualization, Writing – Review and editing, Supervision, Project Administration,
Funding Acquisition.

Thank you,
Justin Brown, MD on behalf of the author list

19
Figures

F F

T
Fb T Fb
F
F

T Fb
Figure 1. T

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Figure 2.

Figure 3.

21
Figure 4.

Figure 5.

22
Figure 6.

Figure 7.

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Tables

Table 1.

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