Correction to at Least Neutral Alignment during High Tibial Osteotomy is Sufficient in Reducing the Knee Adduction Moment 

Correction to at Least Neutral Alignment during High Tibial Osteotomy is Sufficient in Reducing the Knee Adduction Moment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Correction to at Least Neutral Alignment during High Tibial Osteotomy is Sufficient in Reducing the Knee Adduction Moment Kee Soo Kang, Na-Kyoung Lee, Kyoung Min Lee, Chong Bum Chang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4670770/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Apr, 2025 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract High tibial osteotomy (HTO) for varus knee osteoarthritis traditionally aims to overcorrect the mechanical tibiofemoral angle (mTFA) to become valgus. However, valgus overcorrection in HTO increases problems such as knee joint line abnormality, hinge fracture, and patellar height change. Thus, there is a trend to avoid overcorrection, but biomechanical basis for abandoning the overcorrection is lacking. From a dynamic perspective, medial-to-lateral knee joint load distribution during gait can be reflected by knee adduction moment (KAM), and the main purpose of HTO is to reduce the KAM increased during gait due to varus alignment. We tried to reveal the association between the KAM obtained from three-dimensional gait analysis and various static alignment parameters, including mTFA, measured from the standing whole limb anteroposterior radiograph and through this, to suggest a dynamically optimal target for HTO. When grouped according to the alignment by the interval of 1°, lower extremities with 3° to 8° of varus had greater KAM values than those with 0° to 5° of valgus. However, within groups of 0° to 5° of valgus, there were no significant differences. Therefore, the varus must be corrected to at least neutral alignment during HTO, but valgus overcorrection does not further reduce the KAM. Health sciences/Medical research Physical sciences/Physics/Biological physics Alignment High tibial osteotomy Knee adduction moment 3D Gait analysis Figures Figure 1 Introduction According to a systematic analysis, the global prevalence of knee osteoarthritis (OA) is 16.0% and its incidence is 203 per 10,000 person-years 1 . OA of the knee refers to the degenerative joint disease of the medial and lateral tibiofemoral and the patellofemoral compartments. It more frequently involves the medial tibiofemoral compartment than the others. The treatment of medial knee OA consists of operative managements such as alignment-correcting osteotomies and arthroplasty as well as conservative managements including laterally wedged shoes or insoles, toe-out gait, and valgus unloader knee braces 2 . Before treatment decisions, thorough radiographic assessments are necessary. Although expensive and time-consuming, dynamic study such as gait analysis is additionally performed in some orthopedic centers to provide biomechanical perspective to the patient’s knee. Among several variables measured during gait analysis, knee adduction moment (KAM) has widely received attention. The KAM is defined as the ground reaction force multiplied by its lever arm which is the perpendicular distance from the ground reaction force vector to the knee joint center 23 . The KAM acts to adduct the knee into a varus position 4 . It serves as a surrogate marker for loading of the medial compartment 5 and OA progression 6 . Moreover, several studies have reported that the KAM increases with the severity of knee OA 4 7 . In a previous study from our group, the relationships between the KAM variables, namely, the KAM-time integral (KAM impulse) and the maximum KAM at stance phase measured with the three-dimensional (3D) gait analysis and the radiographic alignment parameters were analyzed. Both mechanical tibiofemoral angle (mTFA) and ankle joint line orientation (AJLO) relative to the ground independently explained the KAM. However, the study included only OA patients with varus knee alignment 8 . The relationship, therefore, could not be extrapolated to a general population or those with valgus knee alignment. ​ Because the medial compartment OA is known to aggravate with more varus alignment 9 , high tibial osteotomy (HTO) could be performed preferably in patients younger than 65 years old in order to unload the medial compartment. Miniaci’s and Dugdale’s methods have been traditionally used to preoperatively estimate the amount of correction needed in the HTO operation 10 . They usually locate the weight-bearing line at 62.5% of the tibial width, as measured from the medial to lateral edge of the tibial plateau, thus correcting the pre-existing varus alignment to 3° to 5° of mechanical valgus 11 . However, these preoperative surgical plannings were derived only from the radiological perspective based on static images. Although Yasuda et al. reported favorable long-term results in HTO with corrected mTFA of 12° to 16° 12 , valgus overcorrection might lead to problems such as knee joint line abnormality 13 , lateral hinge fracture 14 , leg length difference 15 , patellar height change 16 , 17 , patellar maltracking 17 , 18 , and decreased functional outcome 13 , 18 . Because of these problems, there is a trend to avoid overcorrection during HTO 19 – 22 , but there is a lack of dynamic perspective for abandoning the conventional overcorrection. Equipped with the 3D gait analysis, the planning of HTO can also be approached from the biomechanical viewpoint. The KAM is reported to decrease following HTO 23 , 24 and some researchers emphasized that the preoperative KAM could influence the outcome of the operation 23 while others highlighted the effect of the postoperative alignment on the KAM 24 . Analysis of the KAM derived from subjects with different limb alignment would provide more insight to the amount of correction needed to achieve significant reduction in the KAM following the HTO. In this study, our purpose was to analyze factors associated with the KAM-time integral and the maximum KAM values by reviewing the 3D gait analysis and radiographic alignment parameters of 500 randomly-selected volunteers from an urban area in Korea. Moreover, by categorizing each lower extremity according to its alignment, we aimed to compare the KAM-time integral and the maximum KAM according to the alignment groups. We intended to extend the understanding of the radiographic alignment parameters associated with the KAM and the relationship of the KAM with the degree of the lower limb alignment, providing background for the amount of alignment correction needed in the HTO. Results Population characteristics The mean positive KAM-time integral, negative KAM-time integral, and maximum KAM were 0.13±0.05 Nms/kg, 0.0039±0.010 Nms/kg, and 0.36±0.12 Nm/kg, respectively. The characteristics of the study population are summarized in Table 1. Male lower extremities had greater values of the positive KAM-time integral (male vs. female, 0.14±0.06 vs. 0.13±0.05 Nms/kg), the maximum KAM (0.37±0.12 vs. 0.35±0.12 Nm/kg), mTFA (1.70±2.43° vs. 0.61±2.46°), knee joint line orientation (KJLO) (1.88±2.16° vs. 1.03±2.18°), AJLO (-2.00±3.86° vs. -2.89±4.00°), and joint line convergence angle (JLCA) (0.64±1.27° vs. 0.41±1.52°). They had lower values of medial proximal tibial angle (MPTA) (85.8±2.16° vs. 86.6±2.16°) (Table 2). Table 1 Characteristics of the lower extremities included in the analysis Data summary of lower extremities No. 937 Age (years) 36.8 (SD, ±16.5) Sex (men:women) 471:466 (50.3%:49.7%) Side (right:left) 470:467 (49.8%:50.2%) Height (cm) 165.8 (SD, ±8.9) Weight (kg) 64.0 (SD, ±12.8) BMI (kg/m2) 23.1 (SD, ±3.4) Kinetic data Maximum KAM (Nm/kg) 0.36 (SD, ±0.12) Positive KAM-time integral (Nms/kg) 0.13 (SD, ±0.05) Negative KAM-time integral (Nms/kg) 0.0039 (SD, ±0.010) Radiographic measurements Medial K-L grade (0/I/II/III/IV) 780/139/17/1/0 (83.2%/14.8%/1.8%/0.1%/0%) Lateral K-L grade (0/I/II/III/IV) 856/77/4/0/0 (91.4%/8.2%/0.4%/0%/0%) mTFA (°) 1.16 (SD, ±2.50) MPTA (°) 86.2 (SD, ±2.19) LDFA (°) 86.8 (SD, ±2.05) KJLO (°) 1.46 (SD, ±2.21) AJLO (°) -2.44 (SD, ±3.96) JLCA (°) 0.53 (SD, ±1.40) Tibiofemoral translation 3.24 (SD, ±2.50) SD, standard deviation; BMI, body mass index; KAM, knee adduction moment; K-L, Kellgren-Lawrence; mTFA, mechanical tibiofemoral angle; MPTA, medial proximal tibial angle; LDFA, lateral distal femoral angle; KJLO, knee joint line orientation; AJLO, ankle joint line orientation; JLCA, joint line convergence angle Table 2 Characteristics of the lower extremities according to sex Characteristics of lower extremities Male (n=471) Female (n=466) P value Age (years) 36.4 (SD, ±16.7) 37.3 (SD, ±16.3) 0.389 Side (right:left) 237:234 (50.3%:49.7%) 233:233 (50%:50%) 0.922 Height (cm) 172.3 (SD, ±6.4) 159.3 (SD, ±5.8) <0.001 Weight (kg) 71.2 (SD, ±11.5) 56.6 (SD, ±9.3) <0.001 BMI (kg/m2) 23.9 (SD, ±3.2) 22.3 (SD, ±3.5) <0.001 Kinetic data Maximum KAM (Nm/kg) 0.37 (SD, ±0.12) 0.35 (SD, ±0.12) 0.008 Positive KAM-time integral (Nms/kg) 0.14 (SD, ±0.06) 0.13 (SD, ±0.05) <0.001 Negative KAM-time integral (Nms/kg) 0.0033 (SD, ±0.0083) 0.0046 (SD, ±0.0119) 0.642 Radiographic measurements Medial K-L grade (0/I/II/III/IV) 403/64/4/0/0 (85.6%/13.6%/0.8%/0%/0%) 377/75/13/1/0 (80.9%/16.1%/2.8%/0.2%/0%) 0.039 Lateral K-L grade (0/I/II/III/IV) 432/37/2/0/0 (91.7%/7.9%/0.4%/0%/0%) 424/40/2/0/0 (91.0%/8.6%/0.4%/0%/0%) 0.896 mTFA (°) 1.70 (SD, ±2.43) 0.61 (SD, ±2.46) <0.001 MPTA (°) 85.8 (SD, ±2.16) 86.6 (SD, ±2.16) <0.001 LDFA (°) 86.8 (SD, ±1.95) 86.7 (SD, ±2.15) 0.448 KJLO (°) 1.88 (SD, ±2.16) 1.03 (SD, ±2.18) <0.001 AJLO (°) -2.00 (SD, ±3.86) -2.89 (SD, ±4.00) <0.001 JLCA (°) 0.64 (SD, ±1.27) 0.41 (SD, ±1.52) 0.012 Tibiofemoral translation 3.36 (SD, ±2.40) 3.11 (SD, ±2.60) 0.125 SD, standard deviation; BMI, body mass index; KAM, knee adduction moment; K-L, Kellgren-Lawrence; mTFA, mechanical tibiofemoral angle; MPTA, medial proximal tibial angle; LDFA, lateral distal femoral angle; KJLO, knee joint line orientation; AJLO, ankle joint line orientation; JLCA, joint line convergence angle Correlation study between the KAM and other variables The results of the correlation analyses between the KAM and other variables are shown in Table 3. mTFA had the strongest correlation with both the positive KAM-time integral and the maximum KAM (r=0.376 and 0.383, respectively) followed by AJLO (r=-0.258 and -0.269). Both the positive KAM-time integral and the maximum KAM had positive correlation with age (r=0.145 and 0.103), medial Kellgren-Lawrence (K-L) grade (r=0.140 and 0.106), and lateral distal femoral angle (LDFA) (r=0.184 and 0.199) but negative correlation with MPTA (r=-0.240 and -0.250). Male lower extremities had positive correlation with the positive KAM-time integral and the maximum KAM (r=0.125 and 0.087, respectively). Lateral K-L grade had significant positive correlation with only the positive KAM-time integral (r=0.088), but not with the maximum KAM or the negative KAM-time integral. The negative KAM-time integral had negative and positive correlation with mTFA (r=-0.095) and MPTA (r=0.076), respectively. Among the KAM variables, the positive KAM had strong positive correlation with the maximum KAM (r=0.924) and negative correlation with the negative KAM (r=-0.374). The maximum KAM also had negative correlation with the negative KAM (r=-0.442). Multiple regression analysis for the KAM variables Multiple regression analyses for the positive and negative KAM-time integral and the maximum KAM that include variables which were significantly correlated in the correlation study except the KAM variables themselves were performed. Final models were obtained after backward elimination steps. Sex, medial K-L grade, mTFA, MPTA, and AJLO comprised the final model for the positive KAM-time integral while only mTFA and AJLO were included in the model for the maximum KAM. When more backward eliminations from the final model for the positive KAM-time integral were performed to compare the adjusted R 2 values, both mTFA and AJLO independently explained the variance of the positive KAM-time integral the most while mTFA was the main explanatory parameter of the maximum KAM. The model for negative KAM-time integral included only mTFA (Table 4). Positive KAM-time integral = 0.295 + (-0.009) x Sex + 0.012 x medial K-L grade + 0.006 x mTFA + (-0.002) x MPTA + (-0.003) x AJLO (R 2 = 0.1917, adjusted R 2 = 0.1874) (1 and 2 for male and female, respectively) Maximum KAM = 0.330 + 0.017 x mTFA + (-0.006) x AJLO (R 2 = 0.1843, adjusted R 2 = 0.1825) Negative KAM-time integral = 0.0044 + (-0.0004) x mTFA (R 2 = 0.0091, adjusted R 2 = 0.0081) Table 4 Factors associated with the KAM variables in the multiple regression analysis ( a ) Non-standardized Standardized β t P-value VIF β Standard error Sex Male: 1 Female: 2 -0.009 0.003 -0.087 -2.806 0.005 1.097 Medial K-L grade 0.012 0.004 0.096 3.123 0.002 1.084 mTFA 0.006 0.001 0.256 6.736 <0.001 1.663 MPTA -0.002 0.001 -0.076 -2.099 0.036 1.498 AJLO -0.003 0.000 -0.206 -6.736 <0.001 1.077 Intercept 0.295 0.078 3.794 <0.001 R 2 =0.1917, adjusted R 2 =0.1874 ( b ) Non-standardized Standardized β t P-value VIF β Standard error mTFA 0.017 0.001 0.342 11.329 <0.001 1.686 AJLO -0.006 0.001 -0.198 -6.558 <0.001 1.064 Intercept 0.330 0.004 75.473 <0.001 R 2 = 0.1843, adjusted R 2 =0.1825 ( c ) Non-standardized Standardized β t P-value β Standard error mTFA -0.0004 0.0001 -0.0955 -2.9330 0.0034 Intercept 0.0044 0.0004 11.9840 <0.001 R 2 = 0.0091, adjusted R 2 = 0.0081 ( d ) Adjusted R 2 for Positive KAM-time integral 0.1874 Sex + medial K-L grade + mTFA + MPTA + AJLO 0.1814 Medial K-L grade + mTFA + MPTA + AJLO 0.1844 Sex + medial K-L grade + mTFA + AJLO 0.1797 Sex + mTFA + + MPTA + AJLO 0.1487 Sex + medial K-L grade + mTFA + MPTA 0.1487 Sex + medial K-L grade + MPTA + AJLO Adjusted R 2 for Maximum KAM 0.1825 mTFA + AJLO 0.1458 mTFA 0.0712 AJLO (a) Positive KAM-time integral (b) maximum KAM (c) Negative KAM-time integral (d) adjusted R 2 for predictors of the positive KAM-time integral and maximum KAM; VIF, variance inflation factor; K-L, Kellgren-Lawrence; mTFA, mechanical tibiofemoral angle; MPTA, medial proximal tibial angle; KJLO, knee joint line orientation; AJLO, ankle joint line orientation Analysis according to mTFA by the interval of 1° To investigate the relationship between the KAM values and limb alignment, the lower extremities were grouped according to mTFA by the interval of 1°. There was a tendency that the positive KAM-time integral and the maximum KAM increased as mTFA increased (P <0.001, Table 5). The positive KAM-time integral and the maximum KAM of alignment groups which showed significant difference in the post-hoc analysis of ANOVA are shown in Table 6. The positive KAM-time integral values of lower extremities of varus alignment groups with 3°≤mTFA<8° were significantly greater than those of neutral or valgus alignment groups with -5°≤mTFA<0°. Similar relationship was observed in the post-hoc analysis of the maximum KAM among those with 3°≤mTFA<8° and -5°≤mTFA<0°, except that the P-value of the post-hoc analysis of the maximum KAM between the alignment groups -1°≤mTFA<0° and 5°≤mTFA<6° was slightly greater than 0.05 (P=0.088). Although the positive KAM-time integral and the maximum KAM showed decreasing tendency in alignment groups of -5°≤mTFA<0°, there was no significant difference of the positive KAM-time integral and the maximum KAM within these groups (Table 6). There was no increasing tendency of the negative KAM as the amount of valgus increased (Table 5). Every alignment group with 3° to 7° of mTFA included more male than female extremities whereas female lower extremities were more prevalent in alignment groups with -4° to 0° of mTFA (P<0.001). Table 5 The positive and negative KAM-time integral, and the maximum KAM values according to the alignment groups of one-degree interval No. Male No. Female No. Age (years) Positive KAM-time integral (Nms/kg) Negative KAM-time integral (Nms/kg) Maximum KAM (Nm/kg) mTFA≥10 1 (0.1%) 0 1 59.0 0.266 0.000 0.656 9≤mTFA<10 1 (0.1%) 1 0 61.0 0.194 0.000 0.492 8≤mTFA<9 1 (0.1%) 1 0 61.0 0.254 0.000 0.658 7≤mTFA<8 9 (1.0%) 3 6 49.6 0.193 (SD, ±0.071) 0.001 (SD, ±0.002) 0.478 (SD, ±0.145) 6≤mTFA<7 18 (1.9%) 14 4 48.7 0.181 (SD, ±0.062) 0.002 (SD, ±0.003) 0.479 (SD, ±0.139) 5≤mTFA<6 15 (1.6%) 11 4 43.7 0.174 (SD, ±0.062) 0.007 (SD, ±0.019) 0.441 (SD, ±0.115) 4≤mTFA<5 73 (7.8%) 50 23 42.2 0.164 (SD, ±0.051) 0.003 (SD, ±0.006) 0.429 (SD, ±0.101) 3≤mTFA<4 103 (11.0%) 65 38 39.8 0.153 (SD, ±0.054) 0.003 (SD, ±0.006) 0.407 (SD, ±0.120) 2≤mTFA<3 131 (14.0%) 67 64 36.7 0.142 (SD, ±0.055) 0.003 (SD, ±0.007) 0.383 (SD, ±0.115) 1≤mTFA<2 138 (14.7%) 84 54 39.9 0.136 (SD, ±0.051) 0.003 (SD, ±0.013) 0.373 (SD, ±0.121) 0≤mTFA<1 141 (15.0%) 67 74 36.0 0.128 (SD, ±0.047) 0.005 (SD, ±0.011) 0.350 (SD, ±0.103) -1≤mTFA<0 121 (12.9%) 50 71 33.2 0.119 (SD, ±0.043) 0.005 (SD, ±0.012) 0.334 (SD, ±0.105) -2≤mTFA<-1 86 (9.2%) 29 57 32.8 0.108 (SD, ±0.042) 0.004 (SD, ±0.009) 0.308 (SD, ±0.099) -3≤mTFA<-2 59 (6.3%) 12 47 30.4 0.104 (SD, ±0.045) 0.006 (SD, ±0.014) 0.293 (SD, ±0.121) -4≤mTFA<-3 22 (2.3%) 8 14 26.8 0.097 (SD, ±0.037) 0.007 (SD, ±0.010) 0.289 (SD, ±0.089) -5≤mTFA<-4 13 (1.4%) 7 6 29.8 0.096 (SD, ±0.074) 0.006 (SD, ±0.011) 0.265 (SD, ±0.121) -6≤mTFA<-5 2 (0.2%) 1 2 41.0 0.156 (SD, ±0.066) 0.001 (SD, ±0.001) 0.397 (SD, ±0.146) -7≤mTFA<-6 1 (0.1%) 1 1 23.0 0.328 0.000 0.600 -8≤mTFA<-7 2 (0.2%) 1 1 23.5 0.078 (SD, ±0.046) 0.004 (SD, ±0.005) 0.221 (SD, ±0.100) Total 937 471 466 SD, standard deviation; KAM, knee adduction moment; mTFA, mechanical tibiofemoral angle Interobserver reliability test Table 7 shows ICCs for each variable. Every coefficient value was greater than 0.8, implying good to excellent interobserver reliability 25 . Table 7 Interobserver reliability of radiographic measurements Interobserver reliability of radiographic measurements ICC Medial K-L grade (0/I/II/III/IV) 0.823 (95% CI, 0.671-0.909) Lateral K-L grade (0/I/II/III/IV) 1 mTFA (°) 0.996 (95% CI, 0.991-0.998) MPTA (°) 0.949 (95% CI, 0.898-0.974) LDFA (°) 0.98 (95% CI, 0.96-0.99) KJLO (°) 0.966 (95% CI, 0.93-0.984) AJLO (°) 0.987 (95% CI, 0.974-0.994) JLCA (°) 0.879 (95% CI, 0.763-0.94) Tibiofemoral translation 0.986 (95% CI, 0.97-0.993) ICC, intraclass correlation coefficient; CI, confidence interval; K-L, Kellgren-Lawrence; mTFA, mechanical tibiofemoral angle; MPTA, medial proximal tibial angle; LDFA, lateral distal femoral angle; KJLO, knee joint line orientation; AJLO, ankle joint line orientation; JLCA, joint line convergence angle Discussion In the analysis of 937 lower extremities of randomly-selected individuals of Seongnam, Korea, the positive KAM-time integral could be independently explained by sex, medial K-L grade, mTFA, MPTA, and AJLO. The variance in maximum KAM were independently explained by mTFA and AJLO. There was a tendency of increasing positive KAM-time integral and maximum KAM as the amount of varus alignment increased. When the lower extremities were categorized into alignment groups of 1° interval, lower extremities with 3° to 8° of varus had greater values of the positive KAM-time integral and the maximum KAM than those with 0° to 5° of valgus. However, within the alignment groups of 0° to 5° of valgus, there was no significant difference in the positive KAM-time integral and the maximum KAM. In our study population, older participants and more male than female individuals had more varus limb alignment. In a landmark study conducted by Bellemans et al., the constitutional varus group were composed of older participants and its proportion of K-L grade 2 was higher than that of either the neutral or valgus alignment groups 26 . Colyn et al. reported increase in varus alignment during the arthritic progression when comparing consecutive full-length X-rays of the same patients over mean 2 years 27 . Despite the cross-sectional nature of our study, lower extremities with varus alignment belonged more to the older individuals, which was in agreement with the progression of varus alignment as one ages. Interestingly, significantly more male lower extremities belonged to the varus alignment group. Male lower extremities had greater mean varus alignment (1.70° vs. 0.61°) and had lower mean MPTA (85.8° vs. 86.6°) than those of female while there was no significant difference in LDFA between the sexes. This may be the reason why male population had positive correlation with the positive KAM-time integral and the maximum KAM. Moreover, the final model for the positive KAM-time integral in the multiple regression analysis also included male sex as an independent explanatory variable though its net contribution was less than 1%. The trends that there are more males than females with varus limb alignment due to the smaller MPTA in males have been reported in a healthy Korean population 28 and other ethnic groups as well 26,29 . Hueter-Volkmann law partly explains this phenomenon 28,30 because men are tended to be more physically active than women in younger populations. mTFA and AJLO had the strongest correlation with the positive KAM-time integral and the maximum KAM in the correlation study. The following multiple regression analyses revealed the quantitative relationship between the positive KAM-time integral and sex, medial K-L grade, mTFA, MPTA, and AJLO. Although they only explained less than 1% of the variance of the positive KAM-time integral when other variables were included, grade of OA in the medial compartment and tibia vara increased the positive KAM-time integral but not the maximum KAM. The KAM-time integral was noted to be more sensitive at distinguishing between K-L grades than the maximum KAM 7 . However, when backward eliminations were performed from the final model for the positive KAM-time integral, mTFA and AJLO were the main explanatory variables. This relationship between the KAM variables and mTFA and AJLO was demonstrated in the previous study of our group which only included patients with varus knee OA 8 . Our study extends this relationship to a general population including participants with valgus limb alignments. The correlation between the maximum KAM and the ankle inversion moment was reported 31 32 . The varus position of the ankle in the stance phase of the gait cycle produces adduction force to the knee joint probably by laterally shifting the center of the knee joint. This association provides biomechanical grounds for laterally wedged shoes or insoles as means of conservative management for the medial knee OA. The magnitude of R 2 values is less than 20% in all of our multiple regression analyses. There may be other factors not considered in our study such as foot progression angle, and walking speed 33 34 32 . Since mechanical axis was reported to account for about 50% of the variation in the peak KAM in patients with OA 33 , R 2 values seem too small even if we had considered other factors which are known to influence the KAM. This difference might be attributed to the fact that randomly-selected volunteers instead of known OA patients were enrolled in our study. The correlation coefficient between alignment and the maximum KAM was 0.383 in our study, smaller than those calculated from studies with knee OA patients (0.751 33 . 0.59 24 , and 0.543 8 ). Coronal tibiofemoral translation did not have significant correlation with the positive KAM-time integral and the maximum KAM in our study probably due to relatively competent collateral ligament status in general but not osteoarthritic population setting. The positive KAM-time integral and the maximum KAM of lower extremities with 3° to 8° of varus were greater than those of 0° to 5° of valgus alignment, respectively. It can be inferred that in order to reduce the KAM-time integral and the maximum KAM significantly, the amount of correction should at least reach neutral alignment when performing HTO. Wada et al., comparing the low and high adduction moment group that underwent HTO, advocated valgus overcorrection to prevent varus recurrence 24 . In a 10- to 15-year follow-up study, Yasuda et al. addressed that mTFA of 12° to 16° should be attained to ensure good long-term outcome 12 . However, there was no significant difference of the positive KAM-time integral and the maximum KAM within the alignment groups of 0° to 5° of valgus in our study, implying that valgus overcorrection seems to offer no additional benefit in reducing the KAM values. According to a meta-analysis investigating the amount of knee adduction moment loss after medial open wedge HTO, KAM after the operation decreased to 60% of the preoperative level. The authors also reported that there was no significant association between alignment correction amount and difference in the KAM before and after the operation 35 . Our findings support their conclusion though our study could only compare the KAM values of lower extremities cross-sectionally. While the alignment group of 6° to 7° of valgus showed significant difference in the positive KAM-time integral with alignment groups of 0° to 5° and 7° to 8° of valgus, there was only one limb with the 6° to 7° valgus alignment, which could be interpreted as bias due to small sample size in the group. In conjunction with recent trend to avoid valgus overcorrection in HTO 19,21,22 which might cause problems such as knee joint line abnormality 13 , lateral hinge fracture 14 , and patellar maltracking 17,18 , our study advocates correction to at least neutral alignment when performing HTO but excessive valgus correction provides no significant reduction in the KAM values. Further studies are needed to validate whether this amount of reduction in the KAM values has clinically significant effects. Peak knee joint moments are reported to be strongly correlated with both peak medial and lateral knee joint contact forces in knees with valgus malalignment 36 . The negative KAM-time integral among the alignment groups did not show increasing trend as the amount of valgus increased. This might be due to the small absolute value of the negative KAM-time integral and to the relatively small number of participants with valgus alignment. Moreover, only 0.8% of the variations of the negative KAM were explained by the mechanical alignment in the multiple regression analysis. Further research enrolling more subjects with valgus alignment would reveal the relationship between the amount of valgus and the negative KAM-time integral. Our study has several limitations. First, though we explored the relationship between the KAM-time integral and the maximum KAM and the radiographic alignment variables, no causality relation could be directly inferred due to the cross-sectional nature of the study. Second, because randomly-selected volunteers were enrolled in the study, our findings may not be directly applicable to the patients with knee OA whose cartilage status should also be taken into account when deciding the correction amount in HTO 37 . Third, R 2 values in our multiple regression analyses were too small. Inclusion of more factors such as foot progression angle, stride length, and walking speed might have improved the explanatory power of the regression model. Fourth, there were some inherent problems during radiographic assessments because the study was retrospective. Since radiographs such as the lateral and the Rosenberg view were not taken, K-L grade of tibiofemoral joint of each knee could be assessed merely from the full-lower limb standing anteroposterior (AP) radiograph, which could have underestimated the degree of OA. Moreover, in some radiographs, X-ray beam was not orthogonal to the tibiofemoral joint space, which made it difficult to assign the K-L grades properly and measure angles for some lower extremities. In spite of its limitations, our study presented the associations between the positive KAM-time integral and the maximum KAM and radiographic alignment variables, namely, mTFA and AJLO in randomly-selected individuals. Moreover, we demonstrated the difference of the positive KAM-time integral and the maximum KAM in lower extremities with 3° to 8° of varus and 0° to 5° of valgus while there was no significant difference of the KAM within the latter alignment groups. We believe these findings would provide biomechanical evidence to correction to at least neutral alignment when performing HTO while valgus overcorrection provides no additional benefit in reducing the KAM. Methods Participants This study was performed by retrospectively reviewing the data from a previously-conducted prospective cohort study 38 . 500 participants with the age of 10 to 75 years were randomly selected from the city of Seongnam, Gyeonggi province, South Korea. All subjects gave informed consent about data collection. They underwent 3D gait analysis and standing full-lower limb AP radiograph was taken for each individual from February 2016 to December 2019. The present study was approved by the institutional review board of Seoul National University Bundang Hospital (B-2308-847-102) and was performed according to the international ethical guidelines of human subject research. Of 1000 lower extremities from total 500 participants, 937 were included in the final analysis. Since the position of the patella relative to the center of the knee joint could substantially affect radiographic parameters such as mTFA, MPTA, and mechanical LDFA 39 , quality of each full-lower limb AP radiograph was evaluated in relation to the degree of patellar rotation relative to the adjacent femur. The relative amount of patellar rotation was categorized into 4 grades in the following way. When the patella was located at the center of the tibiofemoral joint, it was defined as "patella facing forward" or grade 0. If the edge of the patella crossed either the medial or lateral margin of the adjacent femur, it was termed grade 3 internal or external rotation, respectively. Grade 1 was assigned to those with only slight rotation from the center and grade 2 to those in which the patellar margin was just on but not past the boundary of the adjoining femur. 57 lower extremities with grade 3 patellar rotation were excluded from the analysis. Gait analysis data from 3 participants (6 lower extremities) were excluded due to marker mismatch error. Anthropometric parameters Age, sex, and anthropometric parameters such as height, weight, and body mass index (BMI) were collected from each participant. Radiographic measurements All full-lower limb standing AP radiograph images were uploaded to a picture archiving and communication system (PACS), and radiographic measurements were conducted with the PACS softwares (INFINITT, Seoul, Korea and Medixant. RadiAnt DICOM Viewer. Version 2023. 1.). The degree of knee OA in the medial and lateral compartments of the tibiofemoral joint was evaluated using the K-L grade. For fear of ambiguity of the original definition and interobserver disagreement, we categorized less than 50% narrowing of the original joint space as K-L grade II and more than 50% narrowing of the joint space as K-L grade III 8 . The following radiographic alignment parameters were measured for each lower extremity in the standing full-lower limb AP radiograph: mTFA, MPTA, mechanical LDFA, knee joint line orientation (KJLO) relative to the horizontal plane, ankle joint line orientation (AJLO) to the horizontal plane, and JLCA. The mTFA, defined as the angle between the mechanical axis of the femur and the tibia, was measured in the following manner using the PACS softwares. The mechanical axis of the femur was depicted as the line from the center of the femoral head to the center of the intercondylar notch of the femur. Initially, a closest-fit circle was drawn to match the margin of the femoral head. The femoral head center was then determined as the intersection of the two crossing lines each with the length of the diameter of the circle. The mechanical axis of the tibia was referred to as the line connecting the center of the intercondylar eminences of the tibial plateau and the center of the talar dome. Positive and negative values of the mTFA were assigned to the knees with varus and valgus mechanical alignments, respectively. The MPTA was measured as the medial angle between the mechanical axis of the tibia and the tangential line to the tibial plateau. The mechanical LDFA was measured as the lateral angle between the mechanical axis of the femur and the tangential line to both the medial and lateral femoral condyles. The KJLO was measured in the following two steps. Initially, the midline of the tangential line to the tibial plateau and the tangential line to the femoral condyles was drawn. Then, the angle between this midline and a horizontal line parallel to the ground was defined as the KJLO. Positive and negative values were given when the midline was inclined to the medial and lateral sides of the corresponding tibiofemoral joint, respectively. The AJLO was defined as the angle between the tangential line to the talar dome and a horizontal line parallel to the ground. Positive and negative values were given when the tangential line was inclined to the medial and lateral sides of the corresponding tibiotalar joint, respectively. The JLCA was measured as the angle between the tangential line to the tibial plateau and the tangential line to the femoral condyles (Figure 1). Positive and negative values were given when the intersection of the lines was located medial and lateral to the joint, respectively. Tibiofemoral translation was measured using coronal tibiofemoral subluxation. It is known to impair the load transmission across the medial compartment of the knee 40 and to be caused by a difference in the medial and lateral soft tissue laxity 41 . It is defined as the distance between a line perpendicular to the ground and passing through the most lateral point of the lateral femoral condyle and a line perpendicular to the ground and passing through the most lateral point of the lateral tibial condyle. This distance was normalized by dividing it with the width of the corresponding tibial plateau 40 (Figure 1). Positive and negative values were conferred when the lateral-most point of the femoral condyle was located medial and lateral to the lateral-most point of the tibial plateau, respectively. Interobserver reliability was tested by two orthopaedic surgeons with 8 and 5 years of clinical experience in the orthopaedic department. To achieve adequate power, 33 lower extremities were randomly selected from the study population and assigned to each surgeon. They independently evaluated the K-L grade and measured the radiographic alignment parameters, being blinded to each other’s measurements. 3D gait analysis Participants underwent 3D gait analysis using a motion analysis system (Motion Analysis Corporation, Santa Rosa, California, USA) with 10 cameras at 120 frames per second and two force plates. Photo-reflective skin markers in accordance with Helen marker set were installed by an operator having 9 years of experience in the field. The participants walked barefoot on a ten-meter-long track at their self-selected speed after 10 walking trials. Joint moments were calculated using the inverse dynamic model and the global coordination system 38 . The values of the KAM-time integral and the maximum KAM in the stance phase were obtained. Although there can be the second peak KAM as well as the first peak KAM, the appearance of the second peak KAM is reported to be inconsistent 33 . Therefore, only the maximum KAM was used in our study. The KAM-time integral or KAM impulse which was reported to be more sensitive at distinguishing disease severities than the maximum KAM 7 was calculated by integrating the KAM relative to time during the stance phase, representing accumulation of the KAM according to time. The positive and negative KAM-time integral values were calculated separately to represent the adduction and abduction moment, respectively 42 . Average values of 3 repetitive measurements of both the KAM-time integral and the maximum KAM were used in the analysis. The KAM-time integral and the maximum KAM were calculated in the units of N∙m∙s/kg and N∙m/kg, respectively. Statistical analysis Descriptive statistical analyses were conducted first to depict the population characteristics. Normality was checked using the Kolmogorov-Smirnov test. Inferential statistical analyses were then performed using chi-square tests or Fisher’s exact tests for categorical variables and one-way analyses of variance (ANOVA) and t-tests or Mann-Whitney test for continuous variables which belong to each alignment category and either sex, respectively. Subgroup analyses for ANOVA were performed using Bonferroni post-hoc test. The correlation analyses between the KAM values and other variables were performed to obtain Pearson’s product-moment correlation coefficient. Interobserver reliability was tested with intraclass correlation coefficients (ICCs) with the assumption of single measurement and absolute agreement. The multiple linear regression analyses for the KAM values were conducted with variables which were significantly related to the KAM values in the correlation analyses. Then, backward elimination of variables was performed so that only variables with independent explanatory ability wound remain in the final model. Multi-collinearity was evaluated with variance inflation factors (VIFs). All statistical analyses were done using R software (version 4.2.3; R Foundation for Statistical Computing, Vienna, Austria), RStudio 2023.12.0+369 "Ocean Storm" Release (33206f75bd14d07d84753f965eaa24756eda97b7, 2023-12-17) for Windows. In every analysis, P-values less than 0.05 were considered as statistically significant. Declarations Acknowledgements The authors thank Misun Yoo for helping with the processing of 3D gait analysis. Author contributions K.S.K. contributed to radiographic measurements, data analysis, data interpretation, and drafting of the work. N.L. contributed to the design of the work, data analysis and data interpretation. K.M.L. contributed to data acquisition. C.B.C. contributed to the design of the work, data acquisition, and data interpretation. S.K. contributed to data interpretation. Additional information Competing interests The authors declare no competing interests. Data availability The data that support the findings of this study are not openly available because the study participants did not consent to public sharing of their data. Moreover, the institutional review board of Seoul National University Bundang Hospital did not approve sharing of the participants' data publicly. The data are available from the corresponding author only upon reasonable request. Data are located in controlled access data storage at Seoul National University Bundang Hospital. References Cui, A. et al. Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies. EClinicalMedicine 29-30 , 100587 (2020). https://doi.org:10.1016/j.eclinm.2020.100587 Reeves, N. D. & Bowling, F. L. Conservative biomechanical strategies for knee osteoarthritis. Nat Rev Rheumatol 7 , 113-122 (2011). https://doi.org:10.1038/nrrheum.2010.212 Foroughi, N., Smith, R. & Vanwanseele, B. The association of external knee adduction moment with biomechanical variables in osteoarthritis: a systematic review. The Knee 16 , 303-309 (2009). Sharma, L. et al. Knee adduction moment, serum hyaluronan level, and disease severity in medial tibiofemoral osteoarthritis. Arthritis & Rheumatism 41 , 1233-1240 (1998). Zhao, D. et al. 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Arthroscopy 34 , 3073-3079 (2018). https://doi.org:10.1016/j.arthro.2018.06.041 Lee, O. S., Ahn, S. & Lee, Y. S. Comparison of the Leg-Length Change between Opening- and Closing-Wedge High Tibial Osteotomy: A Systematic Review and Meta-Analysis. J Knee Surg 32 , 372-379 (2019). https://doi.org:10.1055/s-0038-1641176 Bin, S. I., Kim, H. J., Ahn, H. S., Rim, D. S. & Lee, D. H. Changes in Patellar Height After Opening Wedge and Closing Wedge High Tibial Osteotomy: A Meta-analysis. Arthroscopy 32 , 2393-2400 (2016). https://doi.org:10.1016/j.arthro.2016.06.012 Gaasbeek, R., Welsing, R., Barink, M., Verdonschot, N. & van Kampen, A. The influence of open and closed high tibial osteotomy on dynamic patellar tracking: a biomechanical study. Knee Surg Sports Traumatol Arthrosc 15 , 978-984 (2007). https://doi.org:10.1007/s00167-007-0305-0 Lee, S. S. et al. Predictive Factors for Patellofemoral Degenerative Progression After Opening-Wedge High Tibial Osteotomy. Arthroscopy 35 , 1703-1710 (2019). https://doi.org:10.1016/j.arthro.2019.01.032 Heijens, E., Kornherr, P. & Meister, C. The coronal hypomochlion: a tipping point of clinical relevance when planning valgus producing high tibial osteotomies. Bone Joint J 98-b , 628-633 (2016). https://doi.org:10.1302/0301-620x.98b5.33394 Martay, J. L. et al. A preliminary modeling investigation into the safe correction zone for high tibial osteotomy. Knee 25 , 286-295 (2018). https://doi.org:10.1016/j.knee.2017.12.006 Kuriyama, S. et al. Large medial proximal tibial angles cause excessively medial tibiofemoral contact forces and abnormal knee kinematics following open-wedge high tibial osteotomy. Clin Biomech (Bristol, Avon) 80 , 105190 (2020). https://doi.org:10.1016/j.clinbiomech.2020.105190 Atkinson, H. F. et al. High tibial osteotomy to neutral alignment improves medial knee articular cartilage composition. Knee Surg Sports Traumatol Arthrosc 30 , 1065-1074 (2022). https://doi.org:10.1007/s00167-021-06516-9 Prodromos, C. C., Andriacchi, T. P. & Galante, J. O. A relationship between gait and clinical changes following high tibial osteotomy. JBJS 67 , 1188-1194 (1985). Wada, M. et al. Relationship Between Gait and Clinical Results After High Tibial Osteotomy. Clinical Orthopaedics and Related Research® 354 , 180-188 (1998). Koo, T. K. & Li, M. Y. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr Med 15 , 155-163 (2016). https://doi.org:10.1016/j.jcm.2016.02.012 Bellemans, J., Colyn, W., Vandenneucker, H. & Victor, J. The Chitranjan Ranawat award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res 470 , 45-53 (2012). https://doi.org:10.1007/s11999-011-1936-5 Colyn, W. et al. Changes in coronal knee-alignment parameters during the osteoarthritis process in the varus knee. J isakos 8 , 68-73 (2023). https://doi.org:10.1016/j.jisako.2022.12.002 Hwang, D. et al. Age and sex differences in coronal lower extremity alignment in a healthy Asian population. The Knee 45 , 198-206 (2023). https://doi.org:https://doi.org/10.1016/j.knee.2023.09.009 Khattak, M. J., Umer, M., Davis, E. T., Habib, M. & Ahmed, M. Lower-Limb Alignment and Posterior Tibial Slope in Pakistanis: A Radiographic Study. Journal of Orthopaedic Surgery 18 , 22-25 (2010). https://doi.org:10.1177/230949901001800105 Stokes, I. A. Mechanical effects on skeletal growth. J Musculoskelet Neuronal Interact 2 , 277-280 (2002). Wang, J. W., Kuo, K. N., Andriacchi, T. P. & Galante, J. O. The influence of walking mechanics and time on the results of proximal tibial osteotomy. J Bone Joint Surg Am 72 , 905-909 (1990). Andrews, M., Noyes, F. R., Hewett, T. E. & Andriacchi, T. P. Lower limb alignment and foot angle are related to stance phase knee adduction in normal subjects: a critical analysis of the reliability of gait analysis data. J Orthop Res 14 , 289-295 (1996). https://doi.org:10.1002/jor.1100140218 Hurwitz, D. E., Ryals, A. B., Case, J. P., Block, J. A. & Andriacchi, T. P. The knee adduction moment during gait in subjects with knee osteoarthritis is more closely correlated with static alignment than radiographic disease severity, toe out angle and pain. J Orthop Res 20 , 101-107 (2002). https://doi.org:10.1016/s0736-0266(01)00081-x Andriacchi, T. P., Ogle, J. A. & Galante, J. O. Walking speed as a basis for normal and abnormal gait measurements. Journal of Biomechanics 10 , 261-268 (1977). https://doi.org:https://doi.org/10.1016/0021-9290(77)90049-5 Kim, J.-H., Kim, H.-J., Celik, H., Kim, J.-H. & Lee, D.-H. Change in adduction moment following medial open wedge high tibial osteotomy: a meta-analysis. BMC Musculoskeletal Disorders 20 , 102 (2019). https://doi.org:10.1186/s12891-019-2472-9 Holder, J. et al. Peak knee joint moments accurately predict medial and lateral knee contact forces in patients with valgus malalignment. Scientific Reports 13 , 2870 (2023). https://doi.org:10.1038/s41598-023-30058-4 Jakob, R. P. & Jacobi, M. Die zuklappende Tibiakopfosteotomie in der Behandlung der unikompartimentären Arthrose. Der Orthopäde 33 , 143-152 (2004). https://doi.org:10.1007/s00132-003-0600-5 Park, G., Lee, K. M. & Koo, S. Uniqueness of gait kinematics in a cohort study. Scientific Reports 11 , 15248 (2021). https://doi.org:10.1038/s41598-021-94815-z Burghardt, R. D., Hinterwimmer, S., Bürklein, D. & Baumgart, R. Lower limb alignment in the frontal plane: analysis from long standing radiographs and computer tomography scout views: an experimental study. Archives of Orthopaedic and Trauma Surgery 133 , 29-36 (2013). https://doi.org:10.1007/s00402-012-1635-z Ogawa, H., Matsumoto, K. & Akiyama, H. Coronal tibiofemoral subluxation is correlated to correction angle in medial opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 26 , 3482-3490 (2018). https://doi.org:10.1007/s00167-018-4948-9 Greif, D. N., Epstein, A. L., Hodgens, B. H., Jose, J. & Baraga, M. G. Current Measurement Strategies of Coronal Tibiofemoral Subluxation: A Systematic Review of Literature. American Journal of Roentgenology 216 , 1183-1192 (2021). https://doi.org:10.2214/AJR.20.23503 Hinman, R. S., Hunt, M. A., Simic, M. & Bennell, K. L. Exercise, Gait Retraining, Footwear and Insoles for Knee Osteoarthritis. Current Physical Medicine and Rehabilitation Reports 1 , 21-28 (2013). https://doi.org:10.1007/s40141-012-0004-8 Table Table 6 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table6.docx Cite Share Download PDF Status: Published Journal Publication published 03 Apr, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 01 Oct, 2024 Reviews received at journal 29 Sep, 2024 Reviews received at journal 22 Sep, 2024 Reviewers agreed at journal 20 Sep, 2024 Reviewers agreed at journal 09 Sep, 2024 Reviewers invited by journal 07 Sep, 2024 Editor assigned by journal 02 Sep, 2024 Editor invited by journal 03 Jul, 2024 Submission checks completed at journal 03 Jul, 2024 First submitted to journal 01 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4670770","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":329488858,"identity":"5e65d4dc-4147-4754-990d-d5623a30d6af","order_by":0,"name":"Kee Soo Kang","email":"","orcid":"","institution":"College of Medicine, Seoul National University, Seoul","correspondingAuthor":false,"prefix":"","firstName":"Kee","middleName":"Soo","lastName":"Kang","suffix":""},{"id":329488859,"identity":"90107103-c760-4a1e-b623-a6e60ca287b5","order_by":1,"name":"Na-Kyoung Lee","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, National Medical Center, Seoul","correspondingAuthor":false,"prefix":"","firstName":"Na-Kyoung","middleName":"","lastName":"Lee","suffix":""},{"id":329488860,"identity":"01f2059b-5b01-4863-a920-db4af8c23aa5","order_by":2,"name":"Kyoung Min Lee","email":"","orcid":"","institution":"College of Medicine, Seoul National University, Seoul","correspondingAuthor":false,"prefix":"","firstName":"Kyoung","middleName":"Min","lastName":"Lee","suffix":""},{"id":329488861,"identity":"ee3b974f-7b31-4f3a-aa27-efaa802e44f7","order_by":3,"name":"Chong Bum Chang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtklEQVRIiWNgGAWjYFACHmYQKQciDjwgRYsxWEsCKVoSG0AkUVr4288eNi6osEmfH3b4IdAWOzndBgJaJM7kJSfPOJOWu/F2mgFQS7Kx2QECWgwkeIwP87Ydzt04OwGk5UDiNuK0/Pufbjg7/QPxWpJ5Gw4kyEvnEGkLyC/GPMeSDTdI5xQcSDAgwi+gEJPmqbGTl5+dvvnDhwo7OYJaEC4EqzQgVjkIyDeQonoUjIJRMApGFAAAR+RB0N/HuGMAAAAASUVORK5CYII=","orcid":"","institution":"College of Medicine, Seoul National University, Seoul","correspondingAuthor":true,"prefix":"","firstName":"Chong","middleName":"Bum","lastName":"Chang","suffix":""},{"id":329488862,"identity":"94781ca5-bed5-4924-95d5-6c3cb5837212","order_by":4,"name":"Seung-Baik Kang","email":"","orcid":"","institution":"College of Medicine, Seoul National University, Seoul","correspondingAuthor":false,"prefix":"","firstName":"Seung-Baik","middleName":"","lastName":"Kang","suffix":""}],"badges":[],"createdAt":"2024-07-02 01:59:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4670770/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4670770/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-024-80161-3","type":"published","date":"2025-04-03T15:56:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61057743,"identity":"60451f3f-17f7-4f46-afc7-c9abbff7d8d2","added_by":"auto","created_at":"2024-07-25 05:53:33","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40968,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurement of mTFA, MPTA, LDFA, KJLO, AJLO, JLCA, and tibiofemoral translation\u003c/p\u003e\n\u003cp\u003e(a) mTFA (b) MPTA (c) LDFA (d) KJLO (e) AJLO (f) JLCA (g) Tibiofemoral translation\u003c/p\u003e\n\u003cp\u003emTFA, mechanical tibiofemoral angle; MPTA, medial proximal tibial angle; LDFA, lateral distal femoral angle; KJLO, knee joint line orientation; AJLO, ankle joint line orientation; JLCA, joint line convergence angle\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4670770/v1/c1845f36972dd1c059c508cc.jpg"},{"id":80083052,"identity":"502bfc7b-c1f7-4b3c-b360-37aaac314a3e","added_by":"auto","created_at":"2025-04-07 16:09:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1287442,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4670770/v1/6106796f-9f6a-42c1-a578-3d533b3b35a8.pdf"},{"id":61057744,"identity":"dee6281b-a3c1-4b39-a7df-99bdd1ba7608","added_by":"auto","created_at":"2024-07-25 05:53:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":51186,"visible":true,"origin":"","legend":"","description":"","filename":"Table6.docx","url":"https://assets-eu.researchsquare.com/files/rs-4670770/v1/3a0a8becebec1077d891e5ad.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Correction to at Least Neutral Alignment during High Tibial Osteotomy is Sufficient in Reducing the Knee Adduction Moment ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAccording to a systematic analysis, the global prevalence of knee osteoarthritis (OA) is 16.0% and its incidence is 203 per 10,000 person-years \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. OA of the knee refers to the degenerative joint disease of the medial and lateral tibiofemoral and the patellofemoral compartments. It more frequently involves the medial tibiofemoral compartment than the others. The treatment of medial knee OA consists of operative managements such as alignment-correcting osteotomies and arthroplasty as well as conservative managements including laterally wedged shoes or insoles, toe-out gait, and valgus unloader knee braces \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Before treatment decisions, thorough radiographic assessments are necessary. Although expensive and time-consuming, dynamic study such as gait analysis is additionally performed in some orthopedic centers to provide biomechanical perspective to the patient\u0026rsquo;s knee. Among several variables measured during gait analysis, knee adduction moment (KAM) has widely received attention. The KAM is defined as the ground reaction force multiplied by its lever arm which is the perpendicular distance from the ground reaction force vector to the knee joint center \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The KAM acts to adduct the knee into a varus position \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. It serves as a surrogate marker for loading of the medial compartment \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e and OA progression \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Moreover, several studies have reported that the KAM increases with the severity of knee OA \u003csup\u003e4 7\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn a previous study from our group, the relationships between the KAM variables, namely, the KAM-time integral (KAM impulse) and the maximum KAM at stance phase measured with the three-dimensional (3D) gait analysis and the radiographic alignment parameters were analyzed. Both mechanical tibiofemoral angle (mTFA) and ankle joint line orientation (AJLO) relative to the ground independently explained the KAM. However, the study included only OA patients with varus knee alignment \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. The relationship, therefore, could not be extrapolated to a general population or those with valgus knee alignment.\u003c/p\u003e \u003cp\u003e​ Because the medial compartment OA is known to aggravate with more varus alignment \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, high tibial osteotomy (HTO) could be performed preferably in patients younger than 65 years old in order to unload the medial compartment. Miniaci\u0026rsquo;s and Dugdale\u0026rsquo;s methods have been traditionally used to preoperatively estimate the amount of correction needed in the HTO operation \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. They usually locate the weight-bearing line at 62.5% of the tibial width, as measured from the medial to lateral edge of the tibial plateau, thus correcting the pre-existing varus alignment to 3\u0026deg; to 5\u0026deg; of mechanical valgus \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. However, these preoperative surgical plannings were derived only from the radiological perspective based on static images. Although Yasuda et al. reported favorable long-term results in HTO with corrected mTFA of 12\u0026deg; to 16\u0026deg; \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, valgus overcorrection might lead to problems such as knee joint line abnormality \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, lateral hinge fracture \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, leg length difference \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, patellar height change \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, patellar maltracking \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, and decreased functional outcome \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Because of these problems, there is a trend to avoid overcorrection during HTO \u003csup\u003e\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, but there is a lack of dynamic perspective for abandoning the conventional overcorrection.\u003c/p\u003e \u003cp\u003eEquipped with the 3D gait analysis, the planning of HTO can also be approached from the biomechanical viewpoint. The KAM is reported to decrease following HTO \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e and some researchers emphasized that the preoperative KAM could influence the outcome of the operation \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e while others highlighted the effect of the postoperative alignment on the KAM \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Analysis of the KAM derived from subjects with different limb alignment would provide more insight to the amount of correction needed to achieve significant reduction in the KAM following the HTO.\u003c/p\u003e \u003cp\u003eIn this study, our purpose was to analyze factors associated with the KAM-time integral and the maximum KAM values by reviewing the 3D gait analysis and radiographic alignment parameters of 500 randomly-selected volunteers from an urban area in Korea. Moreover, by categorizing each lower extremity according to its alignment, we aimed to compare the KAM-time integral and the maximum KAM according to the alignment groups. We intended to extend the understanding of the radiographic alignment parameters associated with the KAM and the relationship of the KAM with the degree of the lower limb alignment, providing background for the amount of alignment correction needed in the HTO.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePopulation characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean positive KAM-time integral, negative KAM-time integral, and maximum KAM were 0.13\u0026plusmn;0.05 Nms/kg, 0.0039\u0026plusmn;0.010 Nms/kg, and 0.36\u0026plusmn;0.12 Nm/kg, respectively. The characteristics of the study population are summarized in Table 1. Male lower extremities had greater values of the positive KAM-time integral (male vs. female, 0.14\u0026plusmn;0.06 vs. 0.13\u0026plusmn;0.05 Nms/kg), the maximum KAM (0.37\u0026plusmn;0.12 vs. 0.35\u0026plusmn;0.12 Nm/kg), mTFA (1.70\u0026plusmn;2.43\u0026deg; vs. 0.61\u0026plusmn;2.46\u0026deg;), knee joint line orientation (KJLO) (1.88\u0026plusmn;2.16\u0026deg; vs. 1.03\u0026plusmn;2.18\u0026deg;), AJLO (-2.00\u0026plusmn;3.86\u0026deg; vs. -2.89\u0026plusmn;4.00\u0026deg;), and joint line convergence angle (JLCA) (0.64\u0026plusmn;1.27\u0026deg; vs. 0.41\u0026plusmn;1.52\u0026deg;). They had lower values of medial proximal tibial angle (MPTA) (85.8\u0026plusmn;2.16\u0026deg; vs. 86.6\u0026plusmn;2.16\u0026deg;) (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1 Characteristics of the lower extremities included in the analysis\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"577\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eData summary of lower extremities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e937\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Age (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e36.8 (SD, \u0026plusmn;16.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Sex (men:women)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e471:466 (50.3%:49.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Side (right:left)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e470:467 (49.8%:50.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Height (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e165.8 (SD, \u0026plusmn;8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Weight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e64.0 (SD, \u0026plusmn;12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;BMI (kg/m2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e23.1 (SD, \u0026plusmn;3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eKinetic data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Maximum KAM (Nm/kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e0.36 (SD, \u0026plusmn;0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Positive KAM-time integral (Nms/kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e0.13 (SD, \u0026plusmn;0.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Negative KAM-time integral (Nms/kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e0.0039 (SD, \u0026plusmn;0.010)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRadiographic measurements\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Medial K-L grade (0/I/II/III/IV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e780/139/17/1/0 (83.2%/14.8%/1.8%/0.1%/0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Lateral K-L grade (0/I/II/III/IV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e856/77/4/0/0 (91.4%/8.2%/0.4%/0%/0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;mTFA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e1.16 (SD, \u0026plusmn;2.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;MPTA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e86.2 (SD, \u0026plusmn;2.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;LDFA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e86.8 (SD, \u0026plusmn;2.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;KJLO (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e1.46 (SD, \u0026plusmn;2.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;AJLO (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e-2.44 (SD, \u0026plusmn;3.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;JLCA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e0.53 (SD, \u0026plusmn;1.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.393414211438476%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Tibiofemoral translation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.606585788561524%\" valign=\"top\"\u003e\n \u003cp\u003e3.24 (SD, \u0026plusmn;2.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD, standard deviation; BMI, body mass index; KAM, knee adduction moment; K-L, Kellgren-Lawrence; mTFA, mechanical tibiofemoral angle; MPTA, medial proximal tibial angle; LDFA, lateral distal femoral angle; KJLO, knee joint line orientation; AJLO, ankle joint line orientation; JLCA, joint line convergence angle\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 Characteristics of the lower extremities according to sex\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics of lower extremities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale (n=471)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale (n=466)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Age (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e36.4 (SD, \u0026plusmn;16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e37.3 (SD, \u0026plusmn;16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e0.389\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Side (right:left)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e237:234 (50.3%:49.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e233:233 (50%:50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e0.922\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Height (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e172.3 (SD, \u0026plusmn;6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e159.3 (SD, \u0026plusmn;5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Weight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e71.2 (SD, \u0026plusmn;11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e56.6 (SD, \u0026plusmn;9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;BMI (kg/m2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e23.9 (SD, \u0026plusmn;3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e22.3 (SD, \u0026plusmn;3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eKinetic data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Maximum KAM (Nm/kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e0.37 (SD, \u0026plusmn;0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e0.35 (SD, \u0026plusmn;0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Positive KAM-time integral (Nms/kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e0.14 (SD, \u0026plusmn;0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e0.13 (SD, \u0026plusmn;0.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Negative KAM-time integral (Nms/kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e0.0033 (SD, \u0026plusmn;0.0083)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e0.0046 (SD, \u0026plusmn;0.0119)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e0.642\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRadiographic measurements\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Medial K-L grade (0/I/II/III/IV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e403/64/4/0/0 (85.6%/13.6%/0.8%/0%/0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e377/75/13/1/0 (80.9%/16.1%/2.8%/0.2%/0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Lateral K-L grade (0/I/II/III/IV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e432/37/2/0/0 (91.7%/7.9%/0.4%/0%/0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e424/40/2/0/0 (91.0%/8.6%/0.4%/0%/0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e0.896\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;mTFA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e1.70 (SD, \u0026plusmn;2.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e0.61 (SD, \u0026plusmn;2.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;MPTA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e85.8 (SD, \u0026plusmn;2.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e86.6 (SD, \u0026plusmn;2.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;LDFA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e86.8 (SD, \u0026plusmn;1.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e86.7 (SD, \u0026plusmn;2.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e0.448\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;KJLO (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e1.88 (SD, \u0026plusmn;2.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e1.03 (SD, \u0026plusmn;2.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;AJLO (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e-2.00 (SD, \u0026plusmn;3.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e-2.89 (SD, \u0026plusmn;4.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;JLCA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e0.64 (SD, \u0026plusmn;1.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e0.41 (SD, \u0026plusmn;1.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Tibiofemoral translation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e3.36 (SD, \u0026plusmn;2.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e3.11 (SD, \u0026plusmn;2.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11%\" valign=\"top\"\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD, standard deviation; BMI, body mass index; KAM, knee adduction moment; K-L, Kellgren-Lawrence; mTFA, mechanical tibiofemoral angle; MPTA, medial proximal tibial angle; LDFA, lateral distal femoral angle; KJLO, knee joint line orientation; AJLO, ankle joint line orientation; JLCA, joint line convergence angle\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation study between the KAM and other variables\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results of the correlation analyses between the KAM and other variables are shown in Table 3. mTFA had the strongest correlation with both the positive KAM-time integral and the maximum KAM (r=0.376 and 0.383, respectively) followed by AJLO (r=-0.258 and -0.269). Both the positive KAM-time integral and the maximum KAM had positive correlation with age (r=0.145 and 0.103), medial Kellgren-Lawrence (K-L) grade (r=0.140 and 0.106), and lateral distal femoral angle (LDFA) (r=0.184 and 0.199) but negative correlation with MPTA (r=-0.240 and -0.250). Male lower extremities had positive correlation with the positive KAM-time integral and the maximum KAM (r=0.125 and 0.087, respectively). Lateral K-L grade had significant positive correlation with only the positive KAM-time integral (r=0.088), but not with the maximum KAM or the negative KAM-time integral. The negative KAM-time integral had negative and positive correlation with mTFA (r=-0.095) and MPTA (r=0.076), respectively. Among the KAM variables, the positive KAM had strong positive correlation with the maximum KAM (r=0.924) and negative correlation with the negative KAM (r=-0.374). The maximum KAM also had negative correlation with the negative KAM (r=-0.442).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMultiple regression analysis for the KAM variables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMultiple regression analyses for the positive and negative KAM-time integral and the maximum KAM that include variables which were significantly correlated in the correlation study except the KAM variables themselves were performed. Final models were obtained after backward elimination steps. Sex, medial K-L grade, mTFA, MPTA, and AJLO comprised the final model for the positive KAM-time integral while only mTFA and AJLO were included in the model for the maximum KAM. When more backward eliminations from the final model for the positive KAM-time integral were performed to compare the adjusted R\u003csup\u003e2\u003c/sup\u003e values, both mTFA and AJLO independently explained the variance of the positive KAM-time integral the most while mTFA was the main explanatory parameter of the maximum KAM. The model for negative KAM-time integral included only mTFA (Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePositive KAM-time integral = 0.295 + (-0.009) x Sex + 0.012 x medial K-L grade + 0.006 x mTFA + (-0.002) x MPTA + (-0.003) x AJLO (R\u003csup\u003e2\u003c/sup\u003e = 0.1917, adjusted R\u003csup\u003e2\u003c/sup\u003e = 0.1874)\u003c/p\u003e\n\u003cp\u003e(1 and 2 for male and female, respectively)\u003c/p\u003e\n\u003cp\u003eMaximum KAM = 0.330 + 0.017 x mTFA + (-0.006) x AJLO (R\u003csup\u003e2\u003c/sup\u003e = 0.1843, adjusted R\u003csup\u003e2\u003c/sup\u003e = 0.1825)\u003c/p\u003e\n\u003cp\u003eNegative KAM-time integral = 0.0044 + (-0.0004) x mTFA (R\u003csup\u003e2\u003c/sup\u003e = 0.0091, adjusted R\u003csup\u003e2\u003c/sup\u003e = 0.0081)\u003c/p\u003e\n\u003cp\u003eTable 4 Factors associated with the KAM variables in the multiple regression analysis\u003c/p\u003e\n\u003cp\u003e(\u003cstrong\u003ea\u003c/strong\u003e)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" rowspan=\"2\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.192371475953564%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-standardized\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24709784411277%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eStandardized\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026beta;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVIF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.11764705882353%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.88235294117647%\"\u003e\n \u003cp\u003e\u003cstrong\u003eStandard error\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMale: 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFemale: 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e-0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24709784411277%\"\u003e\n \u003cp\u003e-0.087\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e-2.806\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e1.097\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedial K-L grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24709784411277%\"\u003e\n \u003cp\u003e0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e3.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e1.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003emTFA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24709784411277%\"\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e6.736\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e1.663\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMPTA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e-0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24709784411277%\"\u003e\n \u003cp\u003e-0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e-2.099\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e1.498\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAJLO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e-0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24709784411277%\"\u003e\n \u003cp\u003e-0.206\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e-6.736\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e1.077\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntercept\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e0.295\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24709784411277%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e3.794\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e=0.1917, adjusted R\u003csup\u003e2\u003c/sup\u003e=0.1874\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(\u003cstrong\u003eb\u003c/strong\u003e)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"603\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.096185737976782%\" rowspan=\"2\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"31.011608623548923%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-standardized\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5787728026534%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eStandardized\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026beta;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.437810945273633%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVIF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.784946236559136%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"60.215053763440864%\"\u003e\n \u003cp\u003e\u003cstrong\u003eStandard error\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.119601328903654%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003emTFA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29235880398671%\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.6046511627907%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.60797342192691%\"\u003e\n \u003cp\u003e0.342\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.458471760797343%\"\u003e\n \u003cp\u003e11.329\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.458471760797343%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.458471760797343%\"\u003e\n \u003cp\u003e1.686\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.119601328903654%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAJLO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29235880398671%\"\u003e\n \u003cp\u003e-0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.6046511627907%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.60797342192691%\"\u003e\n \u003cp\u003e-0.198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.458471760797343%\"\u003e\n \u003cp\u003e-6.558\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.458471760797343%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.458471760797343%\"\u003e\n \u003cp\u003e1.064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.119601328903654%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntercept\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29235880398671%\"\u003e\n \u003cp\u003e0.330\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.6046511627907%\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.60797342192691%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.458471760797343%\"\u003e\n \u003cp\u003e75.473\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.458471760797343%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.458471760797343%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e = 0.1843, adjusted R\u003csup\u003e2\u003c/sup\u003e=0.1825\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(\u003cstrong\u003ec\u003c/strong\u003e)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.586151368760063%\" rowspan=\"2\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"33.17230273752013%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-standardized\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.06924315619968%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eStandardized\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026beta;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.586151368760063%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.586151368760063%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eStandard error\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.586151368760063%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003emTFA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.586151368760063%\"\u003e\n \u003cp\u003e-0.0004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.586151368760063%\"\u003e\n \u003cp\u003e0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.06924315619968%\"\u003e\n \u003cp\u003e-0.0955\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.586151368760063%\"\u003e\n \u003cp\u003e-2.9330\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.586151368760063%\"\u003e\n \u003cp\u003e0.0034\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.586151368760063%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntercept\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.586151368760063%\"\u003e\n \u003cp\u003e0.0044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.586151368760063%\"\u003e\n \u003cp\u003e0.0004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.06924315619968%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"16.586151368760063%\"\u003e\n \u003cp\u003e11.9840\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.586151368760063%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e = 0.0091, adjusted R\u003csup\u003e2\u003c/sup\u003e = 0.0081\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(\u003cstrong\u003ed\u003c/strong\u003e)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"431\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted R\u003csup\u003e2\u0026nbsp;\u003c/sup\u003efor Positive KAM-time integral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.13888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e0.1874\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.86111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSex + medial K-L grade + mTFA + MPTA + AJLO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.13888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e0.1814\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.86111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eMedial K-L grade + mTFA + MPTA + AJLO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.13888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e0.1844\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.86111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSex + medial K-L grade + mTFA + AJLO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.13888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e0.1797\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.86111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSex + mTFA + + MPTA + AJLO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.13888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e0.1487\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.86111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSex + medial K-L grade + mTFA + MPTA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.13888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e0.1487\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.86111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSex + medial K-L grade + MPTA + AJLO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted R\u003csup\u003e2\u0026nbsp;\u003c/sup\u003efor Maximum KAM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.13888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e0.1825\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.86111111111111%\" valign=\"top\"\u003e\n \u003cp\u003emTFA + AJLO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.13888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e0.1458\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.86111111111111%\" valign=\"top\"\u003e\n \u003cp\u003emTFA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.13888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e0.0712\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.86111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eAJLO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e(a) Positive KAM-time integral (b) maximum KAM (c) Negative KAM-time integral (d) adjusted R\u003csup\u003e2\u003c/sup\u003e for predictors of the positive KAM-time integral and maximum KAM; VIF, variance inflation factor; K-L, Kellgren-Lawrence; mTFA, mechanical tibiofemoral angle; MPTA, medial proximal tibial angle; KJLO, knee joint line orientation; AJLO, ankle joint line orientation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis according to mTFA by the interval of 1\u0026deg;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo investigate the relationship between the KAM values and limb alignment, the lower extremities were grouped according to mTFA by the interval of 1\u0026deg;. There was a tendency that the positive KAM-time integral and the maximum KAM increased as mTFA increased (P \u0026lt;0.001, Table 5). The positive KAM-time integral and the maximum KAM of alignment groups which showed significant difference in the post-hoc analysis of ANOVA are shown in Table 6. The positive KAM-time integral values of lower extremities of varus alignment groups with 3\u0026deg;\u0026le;mTFA\u0026lt;8\u0026deg; were significantly greater than those of neutral or valgus alignment groups with -5\u0026deg;\u0026le;mTFA\u0026lt;0\u0026deg;. Similar relationship was observed in the post-hoc analysis of the maximum KAM among those with 3\u0026deg;\u0026le;mTFA\u0026lt;8\u0026deg; and -5\u0026deg;\u0026le;mTFA\u0026lt;0\u0026deg;, except that the P-value of the post-hoc analysis of the maximum KAM between the alignment groups -1\u0026deg;\u0026le;mTFA\u0026lt;0\u0026deg; and 5\u0026deg;\u0026le;mTFA\u0026lt;6\u0026deg; was slightly greater than 0.05 (P=0.088). Although the positive KAM-time integral and the maximum KAM showed decreasing tendency in alignment groups of -5\u0026deg;\u0026le;mTFA\u0026lt;0\u0026deg;, there was no significant difference of the positive KAM-time integral and the maximum KAM within these groups (Table 6). There was no increasing tendency of the negative KAM as the amount of valgus increased (Table 5). Every alignment group with 3\u0026deg; to 7\u0026deg; of mTFA included more male than female extremities whereas female lower extremities were more prevalent in alignment groups with -4\u0026deg; to 0\u0026deg; of mTFA (P\u0026lt;0.001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;5\u0026nbsp;The positive and negative KAM-time integral, and the maximum KAM values according to the alignment groups of one-degree interval\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"608\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive KAM-time integral (Nms/kg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eNegative KAM-time integral (Nms/kg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaximum KAM\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Nm/kg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003emTFA\u0026ge;10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e59.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.656\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e9\u0026le;mTFA\u0026lt;10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e61.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.492\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u0026le;mTFA\u0026lt;9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e61.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.254\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.658\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u0026le;mTFA\u0026lt;8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e9 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e49.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.193 (SD, \u0026plusmn;0.071)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.001 (SD, \u0026plusmn;0.002)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.478 (SD, \u0026plusmn;0.145)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u0026le;mTFA\u0026lt;7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e18 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e48.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.181 (SD, \u0026plusmn;0.062)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.002 (SD, \u0026plusmn;0.003)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.479 (SD, \u0026plusmn;0.139)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u0026le;mTFA\u0026lt;6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e15 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e43.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.174 (SD, \u0026plusmn;0.062)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.007 (SD, \u0026plusmn;0.019)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.441 (SD, \u0026plusmn;0.115)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u0026le;mTFA\u0026lt;5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e73 (7.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e42.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.164 (SD, \u0026plusmn;0.051)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.003 (SD, \u0026plusmn;0.006)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.429 (SD, \u0026plusmn;0.101)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u0026le;mTFA\u0026lt;4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e103 (11.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e39.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.153 (SD, \u0026plusmn;0.054)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.003 (SD, \u0026plusmn;0.006)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.407 (SD, \u0026plusmn;0.120)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n 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(SD, \u0026plusmn;0.099)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e-3\u0026le;mTFA\u0026lt;-2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e59 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e30.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.104 (SD, \u0026plusmn;0.045)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.006 (SD, \u0026plusmn;0.014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n 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colspan=\"2\"\u003e\n \u003cp\u003e0.289 (SD, \u0026plusmn;0.089)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e-5\u0026le;mTFA\u0026lt;-4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e13 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e29.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.096 (SD, \u0026plusmn;0.074)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.006 (SD, \u0026plusmn;0.011)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.265 (SD, \u0026plusmn;0.121)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e-6\u0026le;mTFA\u0026lt;-5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e2 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e41.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.156 (SD, \u0026plusmn;0.066)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.001 (SD, \u0026plusmn;0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.397 (SD, \u0026plusmn;0.146)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e-7\u0026le;mTFA\u0026lt;-6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e23.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.328\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.600\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e-8\u0026le;mTFA\u0026lt;-7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e2 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.078 (SD, \u0026plusmn;0.046)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.004 (SD, \u0026plusmn;0.005)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\" colspan=\"2\"\u003e\n \u003cp\u003e0.221 (SD, \u0026plusmn;0.100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.330049261083744%\"\u003e\n \u003cp\u003e937\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e471\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\n \u003cp\u003e466\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.747126436781609%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD, standard deviation; KAM, knee adduction moment; mTFA, mechanical tibiofemoral angle\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterobserver reliability test\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 7 shows ICCs for each variable. Every coefficient value was greater than 0.8, implying good to excellent interobserver reliability \u003csup\u003e25\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTable 7 Interobserver reliability of radiographic measurements\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.9134775374376%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterobserver reliability of radiographic measurements\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.0865224625624%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eICC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.08319467554077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Medial K-L grade (0/I/II/III/IV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.91680532445923%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.823 (95% CI, 0.671-0.909)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.08319467554077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Lateral K-L grade (0/I/II/III/IV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.91680532445923%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.08319467554077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;mTFA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.91680532445923%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.996 (95% CI, 0.991-0.998)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.08319467554077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;MPTA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.91680532445923%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.949 (95% CI, 0.898-0.974)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.08319467554077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;LDFA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.91680532445923%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.98 (95% CI, 0.96-0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.08319467554077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;KJLO (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.91680532445923%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.966 (95% CI, 0.93-0.984)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.08319467554077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;AJLO (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.91680532445923%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.987 (95% CI, 0.974-0.994)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.08319467554077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;JLCA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.91680532445923%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.879 (95% CI, 0.763-0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.08319467554077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Tibiofemoral translation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.91680532445923%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.986 (95% CI, 0.97-0.993)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eICC, intraclass correlation coefficient; CI, confidence interval; K-L, Kellgren-Lawrence; mTFA, mechanical tibiofemoral angle; MPTA, medial proximal tibial angle; LDFA, lateral distal femoral angle; KJLO, knee joint line orientation; AJLO, ankle joint line orientation; JLCA, joint line convergence angle\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the analysis of 937 lower extremities of randomly-selected individuals of Seongnam, Korea, the positive KAM-time integral could be independently explained by sex, medial K-L grade, mTFA, MPTA, and AJLO. The variance in maximum KAM were independently explained by mTFA and AJLO. There was a tendency of increasing positive KAM-time integral and maximum KAM as the amount of varus alignment increased. When the lower extremities were categorized into alignment groups of 1\u0026deg; interval, lower extremities with 3\u0026deg; to 8\u0026deg; of varus had greater values of the positive KAM-time integral and the maximum KAM than those with 0\u0026deg; to 5\u0026deg; of valgus. However, within the alignment groups of 0\u0026deg; to 5\u0026deg; of valgus, there was no significant difference in the positive KAM-time integral and the maximum KAM.\u003c/p\u003e\n\u003cp\u003eIn our study population, older participants and more male than female individuals had more varus limb alignment. In a landmark study conducted by Bellemans et al., the constitutional varus group were composed of older participants and its proportion of K-L grade 2 was higher than that of either the neutral or valgus alignment groups \u003csup\u003e26\u003c/sup\u003e. Colyn et al. reported increase in varus alignment during the arthritic progression when comparing consecutive full-length X-rays of the same patients over mean 2 years \u003csup\u003e27\u003c/sup\u003e. Despite the cross-sectional nature of our study, lower extremities with varus alignment belonged more to the older individuals, which was in agreement with the progression of varus alignment as one ages. Interestingly,\u0026nbsp;significantly more male lower\u0026nbsp;extremities\u0026nbsp;belonged to the varus alignment group. Male lower extremities had greater mean varus alignment (1.70\u0026deg;\u0026nbsp;vs. 0.61\u0026deg;) and had lower mean MPTA (85.8\u0026deg; vs. 86.6\u0026deg;)\u0026nbsp;than those of female while there was no significant difference in LDFA between the sexes.\u0026nbsp;This may be the reason why male population had positive correlation with the positive KAM-time integral and the maximum KAM. Moreover, the final model for the positive KAM-time integral in the multiple regression analysis also included male sex as an independent explanatory variable though its net contribution was less than 1%. The trends that there are more males than females with varus limb alignment due to the smaller MPTA in males have been reported in a healthy Korean population \u003csup\u003e28\u003c/sup\u003e and other ethnic groups as well\u0026nbsp;\u003csup\u003e26,29\u003c/sup\u003e. Hueter-Volkmann law partly explains this phenomenon \u003csup\u003e28,30\u003c/sup\u003e because men are tended to be more physically active than women in younger populations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003emTFA and AJLO had the strongest correlation with the positive KAM-time integral and the maximum KAM in the correlation study. The following multiple regression analyses revealed the quantitative relationship between the positive KAM-time integral and sex, medial K-L grade, mTFA, MPTA, and AJLO. Although they only explained less than 1% of the variance of the positive KAM-time integral when other variables were included, grade of OA in the medial compartment and tibia vara increased the positive KAM-time integral but not the maximum KAM. The KAM-time integral was noted to be more sensitive at distinguishing between K-L grades than the maximum KAM \u003csup\u003e7\u003c/sup\u003e. However, when backward eliminations were performed from the final model for the positive KAM-time integral, mTFA and AJLO were the main explanatory variables. This relationship between the KAM variables and mTFA and AJLO was demonstrated in the previous study of our group which only included patients with varus knee OA\u0026nbsp;\u003csup\u003e8\u003c/sup\u003e. Our study extends this relationship to a general population including participants with valgus limb alignments. The correlation between the maximum KAM and the ankle inversion moment was reported \u003csup\u003e31\u003c/sup\u003e \u003csup\u003e32\u003c/sup\u003e. The varus position of the ankle in the stance phase of the gait cycle produces adduction force to the knee joint probably by laterally shifting the center of the knee joint. This association provides biomechanical grounds for laterally wedged shoes or insoles as means of conservative management for the medial knee OA. The magnitude of R\u003csup\u003e2\u003c/sup\u003e values is less than 20% in all of our multiple regression analyses. There may be other factors not considered in our study such as foot progression angle, and walking speed \u003csup\u003e33\u003c/sup\u003e \u003csup\u003e34\u003c/sup\u003e \u003csup\u003e32\u003c/sup\u003e. Since mechanical axis was reported to account for about 50% of the variation in the peak KAM in patients with OA\u0026nbsp;\u003csup\u003e33\u003c/sup\u003e, R\u003csup\u003e2\u003c/sup\u003e values seem too small even if we had considered other factors which are known to influence the KAM. This difference might be attributed to the fact that randomly-selected volunteers instead of known OA patients were enrolled in our study. The correlation coefficient between alignment and the maximum KAM was 0.383 in our study, smaller than those calculated from studies with knee OA patients (0.751 \u003csup\u003e33\u003c/sup\u003e. 0.59\u0026nbsp;\u003csup\u003e24\u003c/sup\u003e, and 0.543 \u003csup\u003e8\u003c/sup\u003e). Coronal tibiofemoral translation did not have significant correlation with the positive KAM-time integral and the maximum KAM in our study probably due to relatively competent collateral ligament status in general but not osteoarthritic population setting.\u003c/p\u003e\n\u003cp\u003eThe positive KAM-time integral and the maximum KAM of lower extremities with 3\u0026deg; to 8\u0026deg; of varus were greater than those of 0\u0026deg; to 5\u0026deg; of valgus alignment, respectively. It can be inferred that in order to reduce the KAM-time integral and the maximum KAM significantly, the amount of correction should at least reach neutral alignment when performing HTO. Wada et al., comparing the low and high adduction moment group that underwent HTO, advocated valgus overcorrection to prevent varus recurrence \u003csup\u003e24\u003c/sup\u003e. In a 10- to 15-year follow-up study, Yasuda et al. addressed that mTFA of 12\u0026deg;\u0026nbsp;to 16\u0026deg;\u0026nbsp;should be attained to ensure good long-term outcome \u003csup\u003e12\u003c/sup\u003e. However, there was no significant difference of the positive KAM-time integral and the maximum KAM within the alignment groups of 0\u0026deg; to 5\u0026deg; of valgus in our study, implying that valgus overcorrection seems to offer no additional benefit in reducing the KAM values. According to a meta-analysis investigating the amount of knee adduction moment loss after medial open wedge HTO, KAM after the operation decreased to 60% of the preoperative level. The authors also reported that there was no significant association between alignment correction amount and difference in the KAM before and after the operation \u003csup\u003e35\u003c/sup\u003e. Our findings support their conclusion though our study could only compare the KAM values of lower extremities cross-sectionally. While the alignment group of 6\u0026deg; to 7\u0026deg; of valgus showed significant difference in the positive KAM-time integral with alignment groups of 0\u0026deg; to 5\u0026deg; and 7\u0026deg; to 8\u0026deg; of valgus, there was only one limb with the 6\u0026deg; to 7\u0026deg; valgus alignment, which could be interpreted as bias due to small sample size in the group. In conjunction with recent trend to avoid valgus overcorrection in HTO \u003csup\u003e19,21,22\u003c/sup\u003e which might cause problems such as knee joint line abnormality \u003csup\u003e13\u003c/sup\u003e, lateral hinge fracture \u003csup\u003e14\u003c/sup\u003e, and patellar maltracking \u003csup\u003e17,18\u003c/sup\u003e, our study advocates correction to at least neutral alignment when performing HTO but excessive valgus correction provides no significant reduction in the KAM values. Further studies are needed to validate whether this amount of reduction in the KAM values has clinically significant effects.\u003c/p\u003e\n\u003cp\u003ePeak knee joint moments are reported to be strongly correlated with both peak medial and lateral knee joint contact forces in knees with valgus malalignment \u003csup\u003e36\u003c/sup\u003e. The negative KAM-time integral among the alignment groups did not show increasing trend as the amount of valgus increased. This might be due to the small absolute value of the negative KAM-time integral and to the relatively small number of participants with valgus alignment. Moreover, only 0.8% of the variations of the negative KAM were explained by the mechanical alignment in the multiple regression analysis. Further research enrolling more subjects with valgus alignment would reveal the relationship between the amount of valgus and the negative KAM-time integral.\u003c/p\u003e\n\u003cp\u003eOur study has several limitations. First, though we explored the relationship between the KAM-time integral and the maximum KAM and the radiographic alignment variables, no causality relation could be directly inferred due to the cross-sectional nature of the study. Second, because randomly-selected volunteers were enrolled in the study, our findings may not be directly applicable to the patients with knee OA whose cartilage status should also be taken into account when deciding the correction amount in HTO\u0026nbsp;\u003csup\u003e37\u003c/sup\u003e. Third, R\u003csup\u003e2\u003c/sup\u003e values in our multiple regression analyses were too small. Inclusion of more factors such as foot progression angle, stride length, and walking speed might have improved the explanatory power of the regression model. Fourth, there were some inherent problems during radiographic assessments because the study was retrospective. Since radiographs such as the lateral and the Rosenberg view were not taken, K-L grade of tibiofemoral joint of each knee could be assessed merely from the full-lower limb standing anteroposterior (AP) radiograph, which could have underestimated the degree of OA. Moreover, in some radiographs, X-ray beam was not orthogonal to the tibiofemoral joint space, which made it difficult to assign the K-L grades properly and measure angles for some lower extremities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn spite of its limitations, our study presented the associations between the positive KAM-time integral and the maximum KAM and radiographic alignment variables, namely, mTFA and AJLO in randomly-selected individuals. Moreover, we demonstrated the difference of the positive KAM-time integral and the maximum KAM in lower extremities with 3\u0026deg; to 8\u0026deg; of varus and 0\u0026deg; to 5\u0026deg; of valgus while there was no significant difference of the KAM within the latter alignment groups. We believe these findings would provide biomechanical evidence to correction to at least neutral alignment when performing HTO while valgus overcorrection provides no additional benefit in reducing the KAM.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed by retrospectively reviewing the data from a previously-conducted prospective cohort study \u003csup\u003e38\u003c/sup\u003e. 500 participants with the age of 10 to 75 years were randomly selected from the city of Seongnam, Gyeonggi province, South Korea. All subjects gave informed consent about data collection. They underwent 3D gait analysis and standing full-lower limb AP radiograph was taken for each individual from February 2016 to December 2019. The present study was approved by the institutional review board of Seoul National University Bundang Hospital (B-2308-847-102) and was performed according to the international ethical guidelines of human subject research.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Of 1000 lower extremities from total 500 participants, 937 were included in the final analysis. Since the position of the patella relative to the center of the knee joint could substantially affect radiographic parameters such as mTFA, MPTA, and mechanical LDFA \u003csup\u003e39\u003c/sup\u003e, quality of each full-lower limb AP radiograph was evaluated in relation to the degree of patellar rotation relative to the adjacent femur. The relative amount of patellar rotation was categorized into 4 grades in the following way. When the patella was located at the center of the tibiofemoral joint, it was defined as \u0026quot;patella facing forward\u0026quot; or grade 0. If the edge of the patella crossed either the medial or lateral margin of the adjacent femur, it was termed grade 3 internal or external rotation, respectively. Grade 1 was assigned to those with only slight rotation from the center and grade 2 to those in which the patellar margin was just on but not past the boundary of the adjoining femur. 57 lower extremities with grade 3 patellar rotation were excluded from the analysis. Gait analysis data from 3 participants (6 lower extremities) were excluded due to marker mismatch error.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnthropometric parameters\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAge, sex, and anthropometric parameters such as height, weight, and body mass index (BMI) were collected from each participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRadiographic measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll full-lower limb standing AP radiograph images were uploaded to a picture archiving and communication system (PACS), and radiographic measurements were conducted with the PACS softwares (INFINITT, Seoul, Korea and Medixant. RadiAnt DICOM Viewer. Version 2023. 1.).\u003c/p\u003e\n\u003cp\u003eThe degree of knee OA in the medial and lateral compartments of the tibiofemoral joint was evaluated using the K-L grade. For fear of ambiguity of the original definition and interobserver disagreement, we categorized less than 50% narrowing of the original joint space as K-L grade II and more than 50% narrowing of the joint space as K-L grade III \u003csup\u003e8\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The following radiographic alignment parameters were measured for each lower extremity in the standing full-lower limb AP radiograph: mTFA, MPTA, mechanical LDFA, knee joint line orientation (KJLO) relative to the horizontal plane, ankle joint line orientation (AJLO) to the horizontal plane, and JLCA. The mTFA, defined as the angle between the mechanical axis of the femur and the tibia, was measured in the following manner using the PACS softwares. The mechanical axis of the femur was depicted as the line from the center of the femoral head to the center of the intercondylar notch of the femur. Initially, a closest-fit circle was drawn to match the margin of the femoral head. The femoral head center was then determined as the intersection of the two crossing lines each with the length of the diameter of the circle. The mechanical axis of the tibia was referred to as the line connecting the center of the intercondylar eminences of the tibial plateau and the center of the talar dome. Positive and negative values of the mTFA were assigned to the knees with varus and valgus mechanical alignments, respectively. The MPTA was measured as the medial angle between the mechanical axis of the tibia and the tangential line to the tibial plateau. The mechanical LDFA was measured as the lateral angle between the mechanical axis of the femur and the tangential line to both the medial and lateral femoral condyles. The KJLO was measured\u0026nbsp;in the following two steps. Initially, the midline of the tangential line to the tibial plateau and the tangential line to the femoral condyles was drawn. Then, the angle between this midline and a horizontal line parallel to the ground was defined as the KJLO. Positive and negative values were given when the midline was inclined to the medial and lateral sides of the corresponding tibiofemoral joint, respectively. The AJLO was defined as the angle between the tangential line to the talar dome and a horizontal line parallel to the\u0026nbsp;ground. Positive and negative values were given when the tangential line was inclined to the medial and lateral sides of the corresponding tibiotalar joint, respectively. The JLCA was measured as the angle between the tangential line to the tibial plateau and the tangential line to the femoral condyles (Figure 1).\u0026nbsp;Positive and negative values were given when the intersection of the lines was located medial and lateral to the joint, respectively.\u003c/p\u003e\n\u003cp\u003eTibiofemoral translation was measured using coronal tibiofemoral subluxation. It is known to impair the load transmission across the medial compartment of the knee \u003csup\u003e40\u003c/sup\u003e and to be caused by a difference in the medial and lateral soft tissue laxity \u003csup\u003e41\u003c/sup\u003e. It is defined as the distance between a line perpendicular to the ground and passing through the most lateral point of the lateral femoral condyle and a line perpendicular to the ground and passing through the most lateral point of the lateral tibial condyle. This distance was normalized by dividing it with the width of the corresponding tibial plateau \u003csup\u003e40\u003c/sup\u003e (Figure 1). Positive and negative values were conferred when the lateral-most point of the femoral condyle was located medial and lateral to the lateral-most point of the tibial plateau, respectively.\u003c/p\u003e\n\u003cp\u003eInterobserver reliability was tested by two orthopaedic surgeons with 8 and 5 years of clinical experience in the orthopaedic department. To achieve adequate power, 33 lower extremities were randomly selected from the study population and assigned to each surgeon. They independently evaluated the K-L grade and measured the radiographic alignment parameters, being blinded to each other\u0026rsquo;s measurements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3D gait analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants underwent 3D gait analysis using a motion analysis system (Motion Analysis Corporation, Santa Rosa, California, USA) with 10 cameras at 120 frames per second and two force plates. Photo-reflective skin markers in accordance with Helen marker set were installed by an operator having 9 years of experience in the field. The participants walked barefoot on a ten-meter-long track at their self-selected speed after 10 walking trials. Joint moments were calculated using the inverse dynamic model and the global coordination system \u003csup\u003e38\u003c/sup\u003e. The values of the KAM-time integral and the maximum KAM in the stance phase were obtained. Although there can be the second peak KAM as well as the first peak KAM, the appearance of the second peak KAM is reported to be inconsistent \u003csup\u003e33\u003c/sup\u003e. Therefore, only the maximum KAM was used in our study. The KAM-time integral or KAM impulse which was reported to be more sensitive at distinguishing disease severities than the maximum KAM \u003csup\u003e7\u003c/sup\u003e was calculated by integrating the KAM relative to time during the stance phase, representing accumulation of the KAM according to time. The positive and negative KAM-time integral values were calculated separately to represent the adduction and abduction moment, respectively \u003csup\u003e42\u003c/sup\u003e. Average values of 3 repetitive measurements of both the KAM-time integral and the maximum KAM were used in the analysis. The KAM-time integral and the maximum KAM were calculated in the units of N∙m∙s/kg and N∙m/kg, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistical analyses were conducted first to depict the population characteristics. Normality was checked using the Kolmogorov-Smirnov test. Inferential statistical analyses were then performed using chi-square tests or Fisher\u0026rsquo;s exact tests for categorical variables and one-way analyses of variance (ANOVA) and t-tests or Mann-Whitney test for continuous variables which belong to each alignment category and either sex, respectively. Subgroup analyses for ANOVA were performed using Bonferroni post-hoc test. The correlation analyses between the KAM values and other variables were performed to obtain Pearson\u0026rsquo;s product-moment correlation coefficient. Interobserver reliability was tested with intraclass correlation coefficients (ICCs) with the assumption of single measurement and absolute agreement. The multiple linear regression analyses for the KAM values were conducted with variables which were significantly related to the KAM values in the correlation analyses. Then, backward elimination of variables was performed so that only variables with independent explanatory ability wound remain in the final model. Multi-collinearity was evaluated with variance inflation factors (VIFs). All statistical analyses were done using R software (version 4.2.3; R Foundation for Statistical Computing, Vienna, Austria), RStudio 2023.12.0+369 \u0026quot;Ocean Storm\u0026quot; Release (33206f75bd14d07d84753f965eaa24756eda97b7, 2023-12-17) for Windows. In every analysis, P-values less than 0.05 were considered as statistically significant.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Misun Yoo for helping with the processing of 3D gait analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eK.S.K. contributed to radiographic measurements, data analysis, data interpretation, and drafting of the work. N.L. contributed to the design of the work, data analysis and data interpretation. K.M.L. contributed to data acquisition. C.B.C. contributed to the design of the work, data acquisition, and data interpretation. S.K. contributed to data interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are not openly available because the study participants did not consent to public sharing of their data. Moreover, the institutional review board of Seoul National University Bundang Hospital did not approve sharing of the participants\u0026apos; data publicly. The data are available from the corresponding author only upon reasonable request. Data are located in controlled access data storage at Seoul National University Bundang Hospital.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCui, A.\u003cem\u003e et al.\u003c/em\u003e Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies. \u003cem\u003eEClinicalMedicine\u003c/em\u003e \u003cstrong\u003e29-30\u003c/strong\u003e, 100587 (2020). https://doi.org:10.1016/j.eclinm.2020.100587\u003c/li\u003e\n\u003cli\u003eReeves, N. D. \u0026amp; Bowling, F. L. Conservative biomechanical strategies for knee osteoarthritis. \u003cem\u003eNat Rev Rheumatol\u003c/em\u003e \u003cstrong\u003e7\u003c/strong\u003e, 113-122 (2011). https://doi.org:10.1038/nrrheum.2010.212\u003c/li\u003e\n\u003cli\u003eForoughi, N., Smith, R. \u0026amp; Vanwanseele, B. 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Exercise, Gait Retraining, Footwear and Insoles for Knee Osteoarthritis. \u003cem\u003eCurrent Physical Medicine and Rehabilitation Reports\u003c/em\u003e \u003cstrong\u003e1\u003c/strong\u003e, 21-28 (2013). https://doi.org:10.1007/s40141-012-0004-8\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 6 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Alignment, High tibial osteotomy, Knee adduction moment, 3D Gait analysis","lastPublishedDoi":"10.21203/rs.3.rs-4670770/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4670770/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHigh tibial osteotomy (HTO) for varus knee osteoarthritis traditionally aims to overcorrect the mechanical tibiofemoral angle (mTFA) to become valgus. However, valgus overcorrection in HTO increases problems such as knee joint line abnormality, hinge fracture, and patellar height change. Thus, there is a trend to avoid overcorrection, but biomechanical basis for abandoning the overcorrection is lacking. From a dynamic perspective, medial-to-lateral knee joint load distribution during gait can be reflected by knee adduction moment (KAM), and the main purpose of HTO is to reduce the KAM increased during gait due to varus alignment. We tried to reveal the association between the KAM obtained from three-dimensional gait analysis and various static alignment parameters, including mTFA, measured from the standing whole limb anteroposterior radiograph and through this, to suggest a dynamically optimal target for HTO.\u003c/p\u003e \u003cp\u003eWhen grouped according to the alignment by the interval of 1\u0026deg;, lower extremities with 3\u0026deg; to 8\u0026deg; of varus had greater KAM values than those with 0\u0026deg; to 5\u0026deg; of valgus. However, within groups of 0\u0026deg; to 5\u0026deg; of valgus, there were no significant differences. Therefore, the varus must be corrected to at least neutral alignment during HTO, but valgus overcorrection does not further reduce the KAM.\u003c/p\u003e","manuscriptTitle":"Correction to at Least Neutral Alignment during High Tibial Osteotomy is Sufficient in Reducing the Knee Adduction Moment ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-25 05:53:28","doi":"10.21203/rs.3.rs-4670770/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-01T05:06:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-29T13:36:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-22T10:41:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168986197580435339824676289796969596122","date":"2024-09-20T04:19:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"111169936070876787517258105826360126377","date":"2024-09-09T08:32:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-08T00:36:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-02T13:26:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-03T17:30:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-03T11:01:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-07-02T01:57:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fd5ef4a1-61c3-4216-96b8-4ca1abf5e819","owner":[],"postedDate":"July 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":34881327,"name":"Health sciences/Medical research"},{"id":34881328,"name":"Physical sciences/Physics/Biological physics"}],"tags":[],"updatedAt":"2025-04-07T16:09:02+00:00","versionOfRecord":{"articleIdentity":"rs-4670770","link":"https://doi.org/10.1038/s41598-024-80161-3","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-04-03 15:56:54","publishedOnDateReadable":"April 3rd, 2025"},"versionCreatedAt":"2024-07-25 05:53:28","video":"","vorDoi":"10.1038/s41598-024-80161-3","vorDoiUrl":"https://doi.org/10.1038/s41598-024-80161-3","workflowStages":[]},"version":"v1","identity":"rs-4670770","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4670770","identity":"rs-4670770","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}