.I.

Biomrchanics
Vol.26.No. 8.pp.969-990,1993. 0021-9290/93
$6.00.t.a)
Printedin Grecaf
Bnrain n-31993PergamonPressLtd

HIP JOINT LOADING DURING WALKING AND RUNNING,

MEASURED IN TWO PATIENTS

G. BERGMANN, F. GRAICHEN and A. ROHLMANN

Oskar-Helene-Heim, Biomechanics-Laboratory. Orthopaedic Hospital of the Free University Berlin,

Clayallee 229, D-1000 Berlin 33, F.R.G.

Abstract-- The resultant hip joint force, its orientation and the moments were measured in two patients
during walking and running using telemetering total hip prostheses. One patient underwent bilateral joint
replacement and a second patient, additionally suffering from a neuropathic disease and atactic gait
patterns. received one instrumented hip implant. The joint loading was observed over the first 30 and 18
months, respectively, following implantation. In the first patient the median peak forces increased with the
walking speed from about 280% of the patients body weight (BW) at 1 km h- 1to approximately 480% BW
at 5 km h- I. Jogging and very fast walking both raised the forces to about 550% BW; stumbling on one
occasion caused magnitudes of 720% BW. In the second patient median forces at 3 km h- were about
410% BW and a force of 870% BW was observed during stumbling. During all types of activities, the
direction of the peak force in the frontal plane changed only slightly when the force magnitude was high.
Perpendicular to the long femoral axis, the peak force acted predominantly from medial to lateral. The
component from ventral to dorsal increased at higher force magnitudes. In one hip in the first patient and in
the second patient the direction of large forces approximated the average anteversion of the natural femur.
The torsional moments around the stem of the implant were 40.3 N m in the first patient and 24 N m in the
second.

INTRODUCTION especially for the second half of the stance phase. This
may he due to the applied optimization strategies and
Detailed knowledge about the in viva loading of hip to the employed anatomic and physiologic assump-
prostheses is needed for further improvement in tions and simplifications.
prosthesis design, computer simulation of bone In order to expand the data base on hip loading,
remodelling, stress calculations and mechanical tes- inductively powered, telemetering total hip implants
ting of hip implants. It may also help to refine were developed for long-term in oivo studies of three-
operative goals and guide postoperative physiother- dimensional hip joint forces. They allow one to meas-
apy. Patients with implants or arthritis need informa- ure the magnitudes, directions and moments of the
tion about activities which might cause excessive joint force in real time. Two patients currently have tele-
loading. Measured load data can also help to improve metrized hip prostheses implanted. The first patient is
analytical methods for the calculation of forces at a very active and healthy individual. Data from his
other locations in the body. bilateral implants are reported here for walking, jogg-
The first measurements of hip joint forces in two ing and stumbling (single event). They are probably
patients were performed by Rydell (1966a,b) and typical for healthy patients. The second patient has a
HiiggstrBm (1974). English determined one compon- neurologic disorder and similar forces reported as for
ent of the joint force in one patient (English, 1977; the same activities may also occur in other patients
English and Kilvington, 1979; Goodman et al., 1980). with abnormal gait patterns. Some additional results
A group from the Case Western Reserve University have already been reported (Bergmann et a[., 1990 a,
(CWRU) took measurements on two patients c+ 1991, 1992a,b).
( Brown et al., 1985; Davy et al., 1988, 1990; Goldberg
et al., 1988; Kotzar et al., 1988). All experimental data
DEFINITIONS
(Table 1) were achieved shortly after the implantation
or, on one occasion, six months postoperatively and
The coordinate system x-pz of this paper (Fig. 1) is
were mostly restricted to walking.
based on the following definitions of the femoral axis z
Hip joint forces have also been calculated ( Brand
and the knee axis: the long femoral axis z is defined by
et nl., 1989; Brown et al., 1984; Calderale and Scelfo, connecting the point where the curved femoral midline
1987; Crowninshield et al., 1978; Paul, 1964, 1967,
crosses the neck axis with the point where it intersects
1974, 1975: Pauwels, 1935; Rahrle et al., 1984; Seireg
with the cortical bone of the intercondylar notch. If the
and Arvikar, 1975). The analytical results (Table 2 )
dorsal aspects of the two femoral condyles in a lateral
mostly led to higher joint forces than measured,
view are approximated as half circles, a connection of
their centers defines the knee axis. The parallel shifted
knee axis and z define the frontal plane. The other axes
Received in final form20 November 1992. and planes of the femur-based coordinate system
 970 G. BERGMANNet al

Table 1. Measured hip joint forces during walking and running

Load
Postoperative Angles
Time -F, -F, -F, R F T
Author Activity Remark (week) (% BW) (dee.)

Rydell Patient 1 6 mon;hsaq;o. (1) 26

3.2 kmh- 42 21 143 151 16 27
2.Max. 42 15 152 159 15 20
4.7 kmh- l.Max. 43 34 173 182 14 38
2.Max. 42 20 170 176 14 25
Rydell patient 2 6 months p.o. (1) 26
4.0 kmh- LMax 96 92 264 269 21 20
2.max 64 45 207 222 17 17
5.0kmh- l.Max 107 98 293 327 19 20
2.Max 64 45 207 222 17 17
9.0 km h- 1 (running) 1. =Z.Max. 149 123 388 433 20 21
English 42 days p. o.
1.6 kmh- l.Max. (2) 1.7 242-256
2.Max. 120
2.6kmh- l.Max. 270
CWRU patient 1 31 days p. o. (3)
1 step, 1.8 km h- l.Max. (5) 4.5 47 33 265 211 10 35
2.Max. 23 11 225 221 6 36
1 step, 1.8 kmh- l.Max. (5) 47 39 256 263 10 40
2.Max. 35 15 246 248 8 23
5 steps, av., 1.8 km h- l.Max. 264
Initial step l.Max. 320
CWRU patient 2 44 days p.o. (3)
1 step, 4.3 km h- 1 l.Max. (4) 6.3 310
slow l.Max. (4) 6.3 270
Very slow l.Max. (4) 4.4 260

Maximum resultant hip joint force (R), is components (-F,, -F,, -F,) and orientation in the frontal (F) and transverse
(r) plane (Fig. I). Measurements by different authors. Average values in percent of body weight (BW). LMax.: first maximum
after heel strike; 2.Max.: second maximum before toe-off. Components and angles were transformed into the coordinate
system x-y-z used in this paper. Required average angles A (CWRU) and S(Rydel1, CWRU) possibly led to inaccuracies.
Remarks. (1) From Rydell (1966a). Patient 1: male, 51 yr, 736 NBW, patient 2:56yr, 441 N BW. (2) From English et al.
(1977, 1979). Force measured in the direction of prosthetic neck. (3) Case Western Reserve University, Cleveland. (4) From
Kortzar et al. (1988). Patient 1: 67 yr, 545 N, 169cm; patient 2: 620N, 169 cm. (5) From Davy et al. (1988). (6) From Goldberg
et al. (1988).

x-y-z are described in Fig. 1 and in Bergmann et al.
(1985, 1990b).
The force components - F,, -F,, - F, have mostly
positive values, the resultant force R points towards
the prosthetic head. If not otherwise stated, the ex-
pressions joint force and force refer to the resultant
R, and maximum force or peak force R,,, stand for
the highest magnitude R,,, during one step or exercise
maneuver. The term absolute maximum is used for
the highest magnitude of forces observed from a series
of steps. The force magnitudes are not normally
distributed, especially at low walking speeds. There-
fore, and because of their insensitivity to extreme
values, median values instead of arithmetic means are
used. The ranges of forces, moments and angles are
reported as maximum and minimum values.
The frontal force angle is calculated from F = arctan
(-FJ-F,) and the transverse force angle from
T= arctan (- F,,/ - F,). When speaking of statistical
values, the expressions F or T mean the median angles
of the peak force R,,, from a series of steps, and the
terms F,,, or T,,,,, denote the absolute maxima of F or
T from that series.
For the transformation of the measured joint forces
into the system x-y-z the neck-stem angle N, the
stem-femur angle S and the anteversion angle A were
used (Fig. 1). S was measured from a lateral X-ray and
A from X-rays with the Rippstein technique (Ripp-
stein, 1955) with an accuracy of about 5 (Otte and
Schlegel, 1973). In the frontal plane the stem axis z did
not exactly coincide with the femoral axis z, but the
difference of 1-2 was neglected.
In order to compare our results with data from the
literature, mathematical transformations to our
coordinate system had to be performed, sometimes
requiring the assumption of average values A = 13.5
and S=8 (Backman, 1957). If during walking the
femur passes through the vertical and forces are given
in a ground-based system, they can be recalculated
relative to the long femoral axis if the frontal shaft
angle (not shown in Fig. 1) between the femur and the
vertical direction is known. According to Pauwels
(1935) finding in one patient, V=9 was used.
The frontal bending moment M, and the transverse
torsional moment M, were calculated in the x-y/-z
system (Figs 1 and 2). Applied to moments, the ex-
pression frontal plane stands for the plane x-z and
transverse plane means the plane x-y. The largest
 Hip joint loading 971

Table 2. Calculated hip joint forces during walking and running

Resultant load
(% BW)

Author activity Remark l.Max 2.Max

Pauwels (1) 444 360

Paul (2) 580 3801470

(3) 425 442
(4) 296 450
4.0 kmh- (4) 411 480
5.3 km h- (4) 675 736
7.2 kmh- (5) 554 585
5.4 km h- (mean range) (5) 298-753 44-697
(5) 687 771
7.4 km h - (mean range) (5) 572-1032 572-1012
(5) 590 582
Up ramp (mean range) (5) 325--169 436782
(5) 479 526
Down ramp (mean range) (5) 359--790 308-820

Brown et al.
Normal subjects (6) 417 477
Patients Charnley (6) 263 329
Patients Muller (6) 343 440
Seireg and Arvikar (7) 532 464
Crowninshield et al.
3.4kmh- (8) 360 190
13.8 kmh- (8) 562 292
1 km h old persons (9) 331+118
3 km h _ 1 old persons 381k118
5 km h - old persons I;; 442+118
1 km h young persons (9) 344 + 140
3 km h- young persons (9) 429+134
5 km h- young persons (9) 585+ 151
Riihrle et al. (10)
2.5 kmh- 260+ 165 360+ 165
4.5 kmh- 440+165 555+165
6.3 kmh- 620+ 165 755 + 165
Brand et al. 111) 400-500
Improved model 310-430
Measured 18@-310
Calderale and Scelfo (12) 330 280

Maximum resultant hip joint force (R). Calculations by different authors. Values in percent of
body weight (BW). i.Max.: first maximum after heel strike; 2.Max.: second maximum before toe-off.
Remarks. From Pauwels (1935). One young test person, 576N BW. (2) From Paul (1964). Double
maximum during push-off phase. (3) From Paul (1967). (4) From Paul (1975). (5) From Paul and
Paulson (1974), 3-5 test persons. (6) From Brown et al. (1984), individual speed, different implants.
(7) From Seireg and Arvikar (1975). (8) From Crowninshield et al. (1978b), 25 yr, 69 kg. (9) From
Crowninshield et al. (1978a). Average *95% confidence range, Young:11 subjects, 24 yr; old: 15
subjects, 15 yr mean. (10) From Rijhrle et al. (1984). Average i 80% confidence range, 22 subjects, 30
yr mean. (11) From Brand et al. (1989). (12) From Calderale and Scelfo (1987a,b).

moment Mfmax or M,,,, during one step did not patients body weight (6.5 N for EB, 4.7 N for JB).
always temporally coincide with the maximum R,,, However, some changes of magnitude are directly
(Fig. 4, bottom, third step; Fig. 3, bottom, second given in percent instead of % BW.
step). For the statistical evaluation of M, or M, during
a series of steps, the median of all M, or M, were used,
observed at the same time as R,,,, and the absolute METHODS
maximum Mfmax or M,,,, from all steps.
The forces are given in percent of the patients body Details of the instrumented implants, external
weight (% BW) and the moments in % BW m. To measurement equipment, employed mathematics, cal-
obtain the joint force values in N or the moment in ibration procedures and measurement accuracy have
Nm, the values have to be multiplied by 1% of the been described in Bergmann et al. (1990b).
972
c ~e4oMECH.
Coordinate System
,_i,_ -- .. ,_._,,,.
Y :L...,
/1:
i .._.
-FY t
: .
-Fx
Fig. 1. Coordinate systems and forces at the left hip joint.
The axes x, y, z are femur-based and define a right-handed
system for the left hip and a left-handed system for the right
joint. The long femoral axis +z points upwards, the axis +x
points medially and the axis + y is directed anteriorly. The
force components -F,, -F,, -F, act in the negative
directions of these axes and point towards the head of the
implant. The resultant R is the vectorial sum of all compo-
nents. The frontal force angle F describes the orientation of
R relative to + .z,as seen in the frontal plane x-z of the femur.
The transverse force angle T is the angle between R and the
axis +x, as seen in the transverse plane x-y. The neck-stem
angle N lies in the symmetry plane of the implant but is
drawn here in the frontal plane. The anteversion angle A is
measured against the axis +x in the transverse plane. The
stem of the implant is inclined against -z by the stem-femur
angle S, measured in the sag&al plane y-z. The moments (fig.
2) are calculated in the implant-based x-y-z system, which is
rotated by S around the axis +x against the x-y-z system. S
normally is about 8.
The instrumented hip implant (Bergmann et al.,
1988,199Ob) was a modification of a cemented stand-
ard titanium implant (type Uni-Hip, Mecron, angle N
=45, neck length= 50 mm) with a cemented poly-
ethylene cup. The arrangement of the telemetry and
the three semiconductor strain gauges inside the hol-
low neck was the same as that used earlier for sheep
implants (Bergmann et al., 1985, 1987). The neck was
sealed by a laser-welded plate that contained the
antenna inside the ceramic head (32 mm).
Many safety tests were performed on the implants
and the welding parameters were extensively optim-
ized. The mechanical safety of the instrumented neck
G. BERGMANN et al.
OH SERUNPg
Moments Mt and Mf
Mt:
InTransv. Plane X ~1 Around Stem Axis -2 l
Mf: In Frontal Plane X Z I Around Axis +Y 1
k
4
Neck Axis
.
Fig. 2. Moments acting on the implant. In the x-y-z system
(Fig. I), used to calculate the moments, the z/-axis is the
implants stem axis and not the femoral long axis. The
bending moment M, acts around +y and rotates the
prosthesis inwards and downwards against the femur. The
torsional moment M, acts around -z and tries to rotate the
implant backwards.
was calculated and verified by fatigue tests with 10
million cycles at 9300N maximum force, which was
three times larger than that required by IS0 7206-7.
All welds were then examined microscopically with
fluorescence dye and tested with pressurized air (un-
published test setup). The corrosion behavior of the
prosthetic neck was tested using standard laboratory
corrosion experiments and the biocompatibility by
implantation in the soft tissue of rabbits.
A specially designed, compact electrical telemetry
circuit (Bergmann et al., 1988, 1990b; Graichen, 1990;
Graichen and Bergmann, 1991) transmitted the force-
dependent deformations of the prosthetic neck, meas-
ured by three strain gauges, and additionally the
implant temperature. The inductive power supply
permitted an unrestricted measuring time. Each of the
four pulse-interval-modulated signals was transmitted
at a signal-dependent rate of about 250 Hz. High-
magnitude accelerations, three-month burn-in tests
and temperature shocks were used to guarantee the
reliability of the electronic circuit. Instrumented hip
endoprostheses were then implanted in three sheep
and measurements were taken for three years (not
published).
By applying the matrix method (Bergmann et al.,
1979, 1981a,b, 1982), the three components of the
spatial joint force were calculated from the signals of
the three strain gauges. This method increases the
accuracy by minimizing the cross-talk between the
force components and allows an easy instrumentation.
Depending upon force direction and magnitude, the
accuracy of the components differed from 0.5% for
small forces to 1.5% for large ones (Bergmann et al.,
1990b). These values were determined experimentally
relative to the different calibration ranges in the three
directions, The dependency of the relative errors on
the force magnitudes was mainly due to the nonlinear
relation between signals and forces. The force angles F
 Hip joint loading
and T became more inaccurate for smaller forces. For
a patient of 650 N BW, typical errors of F and T were
around 4 at 50% BW and 1 at 200% BW.
The external equipment consisted of an inductive
power supply, a RF receiver, a personal computer and
a video system (Graichen, 1990; Graichen and
Bergmann, 1991). An induction coil was placed
around the patients hip and the telemetry was activa-
ted by the generated magnetic field. The antenna was
arranged close to the hip and the TV tuner transmitted
the received signals to a specially built data acquisi-
tion board in an IBM-AT-compatible computer. Here
the strain- and temperature-dependent signals were
determined from the time between the received pulses.
Temperature compensation and mathematical line-
arization of the signals as well as the matrix calcu-
lation of the components and their transformation
into the system x-y-2 (Bergmann et al., 1990b) were
performed in real time.
The patients were filmed with two video cameras
and the images were recorded together with the four
telemetry signals on one tape. After the sessions, the
videos and the corresponding force components could
be displayed repeatedly to analyze the forces, force
directions and moments. The display and analysis
software was specially written for the different appli-
cations.*
For sitting and lying relaxed the forces were very
small and reproducible throughout the first 8-12
months. Then a slowly increasing offset was observed
in the signals from both patients. Therefore, an offset
compensation was performed for all measurements
after this time so that the forces during lying and
sitting were set to the initial postoperative values. This
drift also occurred in nonimplanted, unloaded prost-
heses. Because the amplification of the strain gauge
signals and the temperature data were not affected, the
offset seemed to be due to aging and creep of the strain
gauge adhesive, although the glue (MBond 610, Micro
Measurements) had proved to be the best in an earlier,
long-term test.
The stresses in implant and bone are influenced not
only by the magnitude and direction of the joint force
that acts at the head of the implant but also by the
moments that these forces cause (Fig. 2). These mo-
ments are influenced by geometric and anatomic
parameters such as the neck length L, neck-shaft angle
N and anteversion angle A. With regard to the stresses
in the prosthesis and surrounding bone, the moments
are possibly critical. Bending moments M, in the
frontal plane and torsional moments M, in the trans-
verse plane are, therefore, well suited to characterize
the severity of implant loading by a limited number of
parameters and were additionally analyzed.
Instrumented prostheses were implanted in the left
and right hips of an 82-year-old male patient (abbrevi-
ation EBI BW = 650 N, height = 168 cm) with severe
*Display program and data of this paper available from
the authors.
913
arthritis in May and August of 1988 (EBL: left joint.
4 = lo, 5= 10; EBR: right joint, A = 5, 5 = lo). In
the frontal plane the preoperative location of the left
femur relative to the pelvis was restored by the
prosthesis with an accuracy of 3 mm. In the right hip
the femur was 1.3 cm more lateral and 1 cm more
distal after the implantation. EB has been an active
swimmer and sky diver all his life and is in excellent
physical condition. Six months after the first implanta-
tion he was able to run at 6.0 km h- and after 30
months even up to 8 km h- . Starting with the first
postoperative day, more than 80 h of different phys-
ical activities have been recorded, If not mentioned
otherwise, data in this paper were obtained when EB
walked or ran on a treadmill 30 months postopera-
tively. One measurement from the 24 th month, when
EB stumbled while walking upstairs, is included. EB
wore sport shoes during the investigations.
In March 1990, a 69-year-old female patient (ab-
breviation JB, BW = 470 N, height = 160 cm) with uni-
lateral idiopathic femoral head necrosis received an
instrumented implant in the right hip (A= 15,
S= 10). This patient additionally suffered from
cerebellar atropathy and axonal polyneuropathy in
the right leg, which caused atactic gait patterns. She
was able to walk at 4 km h- I, get up from a chair and
go up and down the stairs with minimal hand support
(fingertip of another person), but always felt unsteady.
After several minutes of walking, she would feel
muscular pain in the right thigh and could usually
walk for only 15 min. This patient was chosen because
her clinical symptoms were predicted to cause in-
creased joint forces. About 15 h of measurements have
been taken during physiotherapy and the previously
mentioned activities. The data were obtained from
walking on level ground eight months postoperatively.
One measurement from the 18th month, when JB
stumbled during walking, is included. This patient
used walking shoes with flat soles.
RESULTS
Typical diagrams from the three hips show the
patterns of forces, angles and moments vs time from
three steps of treadmill walking and jogging at differ-
ent speeds (Figs 3-10). For the instants of maximum
joint force the median and maximum values of the
peak force, the force directions and the peak moment
were calculated from 20 to 40 consecutive steps. The
parameters were walking speed (Figs 11 and 13-16)
and the postoperative time (Fig. 12). Because only two
patients were investigated, statistical methods were
not applicable to determine whether the intluence of
these parameters on the loading was significant or not.
Force characteristics
The overall shape of R and its components was very
similar between EBL (Fig. 4), EBR (Fig. 8) and JB
(Fig. 9). The patterns showed a first maximum force
(Fig. 4, top, second step) at the instant when the leg
914 G. BERGMANN
et al.

RBSULTnNT HIP JOINT FORCE 6ND COMPONENTS

BIOWECH. OHH BERLIN

0.0 .s 1.0 1.5 a.8 2.5 3.8 3.5 4.0

TIME CSECONDSl
RESULTnNT -Ix <MED > LAT> -Fy (UENT > DORS) -Fz (PROX > DIST>
______________________
--------

XRLXINC. TRMDXILL 2 XX/H

ATIBNT E.B.. LEFT SIDE, 30 MONTHS P.O. m EBL2746

KXBXI RESULTnNT H:;W4T FORCE 6ND ORIENTATION [DEC. 3

. OHH BERLIN
4w-

359 -

e 1 3 1 I I -30
1 I
0.e .s 1.0 1.S 2.0 2.5 3.0 3.5 4.0
TIME CSECOMDSJ
RESULTANT llNCLE F <FRONT. PL.1 ANGLE T <TRnNSU. PL.)
__---_----

.wALXINC. TREADXILL 2 XX/H

IITIENT E.B., LEFT SIDE. 30 MONTHS P.O. m EBL2744

txBu3 RESULTnNT HIP JOINT FORCE LND MOMENTS C %BY - METER1

RESULTANT nfmtbt<n= 10) ntl.ans<a= 10) tttrandn=-s>

------ ____________

WLXINC. TREnDMILL 2 XX/H

ATIBNT E.B., LEFT SIDE, 30 MONTHS P.O. - EBL2741
 Hip joint loading
was about 5 before passing through the vertical
position. This peak force R,,, increased with the
walking speed (Figs 3-7). The second maximum,
sometimes observed during the push-off phase of the
gait cycle, decreased at higher walking speeds (Figs 3
and 4) but stayed about the same for fast walking and
jogging at any speed (Figs 5-7). In both patients the
second force peak often varied in magnitude. When
EB was told to hit a force plate, for example, the
second maxima were generally larger and more dis-
tinct than if he was allowed to walk without coaching.
The shapes of the curves for -F, and -FZ from
measurements at increasing speed (Figs 3-7) were
similar (Fig. 7), especially at higher speeds and when R
was large. This implies that F changed only slightly at
high force levels. Between the absolute values of the
components -F, and - F,, the correlation was less
strict and the force direction Tin the transverse plane,
therefore, varied more.
From the shapes of R or the force component - FZ
the moments of heel strike and toe-off could not be
reliably identified (Figs 3-7. top) because no or only
negligible force peaks were superimposed on the cur-
ves at this point in the gait cycle. However, the
moments of heel strike and toe-off, marked in the
middle diagrams of these figures, could be determined
from single-frame video images of the foot. In both
patients the force levels at heel strike and toe-off
ranged between 50 and 200% BW.
During the swing phase the minimum forces of both
patients were typically between 10 and 40% BW for all
speeds (Figs 3-7). However, during the first weeks the
force patterns were more irregular and minimum
values of 60-80% BW were measured occasionally.
Peak forces
The largest forces observed during walking or jogg-
ing were 584% BW (EBL, 7 km h-l, 12 months
Fig. 3. Slow walking at 2 km h-l: patient EB (left hip), hip
joint forces, force directions and moments 30 months postop-
eratively. Three typical steps on a treadmill. Upper diagram:
forces. Coordinate system ~-y-z of Fig. I. Resultant force R
(thick solid line) and the three force components -F, (thin
solid line), -F, (long dashed line) and -F, (short dashed
line). Scale in percent of the patients body weight (% BW).
Middle diagramforce directions. Coordinate system x-y-z of
the Fig. 1. Resultant force R (thick solid line, left scale). Force
angle F in the frontal plane (thin solid line, right scale and
dashed zero line); positive values indicate a force from
proximal and medial. Force angle T in the transverse plane
(long dashed line, right scale); positive values indicate a force
from medial and ventrial. Directions for forces R smaller
than 40% BW are not charted because they are relatively
inaccurate. Lower diagram: moments. Coordinate system of
Fig. 2. Resultant force R (thick solid line, left scale), Bending
moment M, in the plane x-z (thin solid line, right scale and
dashed zero line), +M, bends the implant inwards/down-
wards. Torsional moment M, in the plane x-y (long dashed
line. right scale), +M, rotates the implant backwards. The
short dashed line shows the (hypothetical) torsional moment
M, if the anteversion angle A were 15 smaller than it is in the
patient. Right scale: relative dimension (% BWm) for the
moments.
975
postoperatively), 558% BW (EBR, 7 km h- ,
17 months) and 467% BW (JB, 3 km h- , 18 months).
When the patients stumbled, extreme forces of 720%
BW (EBL) and 870% BW (JB, Fig. 10) were observed.
Tests with EB showed that he was unable to willingly
create similar large forces by any kind of exercise.
In EB the peak forces during walking increased with
the walking speed (Fig. 1 I and Table 3). Typically, the
peak force in the right hip of EB was larger than in the
left. A maximum difference of 60% BW in the median
values occurred at 5 km h- , but at a high walking
speed of 6 km h-i the difference vanished. A trend
towards larger force variations at higher speed was
observed. The median peak forces of JB were about
20-30% larger than those in EB at the same speed.
The forces during slow jogging (Fig. 11 and Table 3)
were not generally larger than those during fast walk-
ing. In contrast to walking, the forces during running
were nearly the same in EBs left and right joints. For
both hips, the increase of forces with the speed was less
pronounced for running than for walking. When EBL
was jogging in place on level ground (about 0.7 s per
step, toes raised l&15 cm), the peak forces averaged
450% BW, a value comparable to fast walking and
running. JB was unable to run.
The changes in peak forces versus the time after
implantation were not uniform. In EBL the maxima of
R,,, (Fig. 12) stayed nearly constant during the first
four months for walking at 1 and 2 km h-i on level
ground. R,,, was largest in the eighth month and then
decreased by 16% (average of walking at l-5 km h _ )
until the 30th month. A similar trend was observed in
EBR. The forces kept constant until the ninth month,
then increased by 13% (average of walking and jogg-
ing) until the 17th month and decreased again by 9%,
on an average, to the values given in Fig. 11. In JB the
median and maximum forces both increased by 8%
between the fifth and the 18th month.
In general, the peak forces during walking on level
ground varied less than during walking on a treadmill
(EB), but the shape of the curves and their maxima
were the same.
Walking continuously for 20 min at 2.5 km h- 1 on
the treadmill did not change the peak forces (EBL,
eight months). When the treadmill slope was varied
form zero to + 15 at 2.5 km h-i, R increased by 30%
BW (EBL, eight months). The influence of the walking
behavior on the joint forces was investigated by
having EBL run at 6 km h - 1normally and then telling
him to either move very softly and harmonically or to
take hard steps (20 months). These two abnormal gait
patterns were trained for several minutes before the
measurements were taken. They resulted in 8% smal-
ler forces for the soft steps and 8% larger forces for
hard jogging. On other occasions, smaller differences
were observed.
The influence of the step length on the peak forces at
a constant speed was also investigated. EB first walked
at 3 km h- without advice and then was asked to
take longer steps. With normal steps (average stride
976 GBERGMANN et&

RESULTllNT HIP JOINT FORCE 6ND COMPONENTS

BIOMECH. OHH BERLIN

-50 1 I 1 I , I
0.0 .5 1.0 1.5 2.8 2.5 3.9
TIME ISECONDS
RESULTRNT -Fr CMED > LA11 -Fy (VENT
_______- > DORS) -Fz CPROX > DIET)
_______:______--------
UALKINC. TREfiDMILL. 4 XIUH
'ATIENT E.B.. LEFT SIDE, 38 MONTHS P.O. - EBL277E

CZBWI RESULTaNT H;;O;gi;T FORCE nND ORIENTATION CDEG. 1

. OHH BERLIN
4ee- . 45

0.0 .5 I.0 1.5 2.0 2.5 3.0

TIME [SECONDS1
RESULIIIANT ONCLE F (FRONT. PL.> I)NGLE T <TRINSU. PL.1
------es--

W~LKlNC. TREADMILL, 4 KM/H

'PATIENT E.B., LEFT SIDE, 30 MONTHS P.O. m EBL277B

C%BU.METERl

TIME [SECONDS3
RESULTANT Nfront<fi= la> Mtrans(R= 183, Mtrms<A=-s~
------ __________--

WaLI(INC. TREIIDMILL. 4 KM/H

'lTIENT E.B., LEFT SIDE, 38 NONTWS P.O. - EBL277B
 Hip joint loading
length 53 cm), EBL had a force of (median/max.)
3 15/340% BW acting at the hip, which increased only
slightly to 3211357% BW when he took longer steps
(64 cm). Data for EBR were 370/405% BW (52 cm),
4001449% BW (60cm) and 3951428% BW (70cm).
Here the strides with a length of 70 cm caused even
smaller forces than those with 60cm. All forces in
these trials were larger than during normal walking
(Fig. 11 and Table 3).
During simulated limping, JB shifted the upper
body over the affected hip during the stance phase.
The forces at the hip varied widely because this kind of
walking had not been trained previously. When the
physiotherapist judged her walking as severe limping,
the measured forces (median/max.) were 326/356%
BW (2.S2.5 km h- , eight months). This was about
17% less as compared to normal walking at the same
speed for both the median and maximum. In EB a
similar reduction of forces during limping was
observed.
Force directions
In both joints of EB the direction F in the frontal
plane at the instant of the peak force was nearly
independent of the speed (Fig. 4), both for walking and
jogging (Fig. 13 and Table 3). The median value of F
averaged over all speeds of walking and jogging was
25 (EBL, range 21-27), 22.5 (EBR, range 21-25)
and 17.5 (JB, range 15-24).
In EBL the angle F increased by 4 between the first
and the 12th month (2 km h-) and then fell again by
2 (average of I-7 km h ) to the values given in Fig.
13. Only small changes were observed in EBR. In JB
the angle F was 34 smaller in the eighth month (Fig.
13) than in the fifth and the 18th month. No differences
of F were found in EB between walking on level
ground and on the treadmill.
When stumbling, the angle F at the moment of
maximum force was 19 in EBL, which was 6 smaller
than the median and 2 smaller than the minimum
during regular walking (Table 3). In JB the angle F
<
Fig. 4. Normal walking at 4 km h-: patient EB (left hip),
hip joint forces, force directions and moments 30 months
postoperatively. Three steps on a treadmill. Stance phase and
swing phase are separated by the events of heel strike (HS)
and toe-off (TO). During the stance phase two relative force
maxima exist with an intermediate relative minimum (top,
second step). During the swing phase the forces are low. The
statistical evaluation of force R (top, third step) and the force
directions F and T (middle, third step) is performed for the
moment of the first force maximum R,,, (peak force). Two
values of the moments M, and M, are evaluated (shown for
M,, bottom, first and third step): the median of M, (R,,,) at
the moment of peak force (denoted in the text as M,) and the
largest moment Mfmar which can occur at different instants of
time (bottom, third and first step and Fig. 3). The instants of
heel strike and toe-off (top, second step) can hardly be
detected from the force patterns but they correlate with
typical turns in the shape of F or T for most steps (middle,
second step). For additional explanations see Fig. 3.
911
during stumbling was 21 (Fig. 10) and, thus, within
the normal range. For simulated limping the value of
F was the same as during normal walking.
Throughout the gait cycle the direction F was
relatively constant at high force magnitudes (Figs 3-9,
middle), but at lower magnitudes it varied more. Even
in those cases where the instants of heel strike and toe-
off could hardly be detected from the force curves
because of their smooth shape (Fig. 4, top), they could
mostly be determined by characteristic changes in the
curves of F and/or T(Fig. 4, middle). The shapes of the
F-curves during the stance phase were very similar for
all three investigated joints as long as the joint force
was large.
When EB walked at l-5 km h- a nearly linear
relationship existed between the load direction 7 in
the transverse plane at the instant of the peak force
and the speed (Fig. 14 and Table 3). However, the
values for EBR were up to 14 larger than those for
EBL, especially at lower walking speeds. At walking
speeds of more than 4 km h-, and for jogging, T
stayed nearly constant in EB. The average of T for all
jogging speeds was 19.5 (EBL, range 15-24) and
25.5 (EBR, range 21-30). The values for JB for slow
walking stayed between those for EBL and EBR.
When stumbling, the angle T was 15 (EBL) and 17
(JB, Fig. 10). This corresponds approximately to the
values during normal walking in EB but was larger in
JB by a few degrees. Walking on level ground and on
the treadmill resulted in the same transverse force
directions.
The shape of the T-curves was more dependent on
the walking speed than were the patterns of F (Figs
3-7). This was already obvious from the relationship
between the force components (Fig. 7). A typical
T-curve during the stance phase had a first maximum
at the instant of the peak force and a second max-
imum, which varied its location more within the gait
cycle. The superimposed irregularities of the T-curve
during the three steps of JB (Fig. 9) reflect the appre-
hensive gait of this patient.
Bending and torsional moments
The largest bending moments Mfmaxobserved dur-
ing walking or jogging were 8.2% BWm (EBL,
8 km hh, 30 months), 10.0% BWm (EBR, 7 km h- ,
17 months) and 10.0% BWm (JB, 3.5 km h- I 8
months). When the patients stumbled, M, reached
peak values of 14.8% BW m (EBL) and 16.2% BW m
(JB, Fig. 10).
The patterns of M, (Figs 49) resembled that of R,
but had more distinct second maxima at low and
medium walking speeds. The first maximum increased
with the speed while the second maximum was less
dependent on the speed. While the first maximum of
M, was observed at nearly the same time as that of R
(Fig. 4), the time shift between the peak values of M,
and R varied more for the second maximum of M,.
The pattern of M, corresponded best to the shape of
978 G. BERGMANN et al.

C%BWI RESULTflNI HIP JOINT FORCE AND COllPONENTS

688 , BIOMECH. OHH BERLIN ,

5563

500 . .
i
450

489

350

300

258

208 _
150

100

58

I I I I 1

a.0 .5 1.0 1.5 2.0

TI::SECONDS,
RESULTANT -Fx <RED > L&T) -FY <UENT > DORS) -Fz <PROX > DIST)
______________________
_---_--_

WRLKING, TREADIIILL, 6 KNAi

LTIENT E-B., LEFT SIDE, 30 MONTHS P-0. m EEL28211

cXBWI RESIILTRNT HIP JOINT FORCE RND ORIENTATION CDEC. I

BI OMECH . OHH BERLIN
600

550 -

0.8 .5 1.0 1.5 2.0

TIM:*:SECONDS,
RESULTANT ANGLE F <FRONT. PL.> lNCLE
-_--__---_
T <TRINSU. PL. >

CIALKING, TREhDMILL, 6 KM/H

?BTIENT E.B., LEFT SIDE, 38 WONTHS P.O. - EBL2821

C %BWl RESULTRNT HIP JOINT FORCE 8ND MOMENTS C %BW - METER3

BI ONECH . OHH BERLIN
608,

7
450
6
400
5
358

388 4

250 3

208
2
150
1
lee
9
se

B -1

a.0 .5 1.0 1.5 2.0 TIN::SECONDS,

RESULTANT nfront<A= 1e, Ntrans(fi= 10) ntransca=-5)
-_-_-- ----__---___

WRLKING, TREIIDNILL, 6 KN/H

RTIENT E.B.. LEFT SIDE, 30 NONTHS P.O. - EBL2828

Fig. 5. Fast walking at 6 km h-l: patient EB (left hip), 30 months postoperatively. Force scale different from
Figs 3 and 4 (for explanations see Figs 3 and 4).
 Hip joint loading 919

CZBUI RESULTRNT HIP JOINT FORCE fiND COMPONENTS

BIOMBCH. OHH BERLIN

..,,......,..... ,.

0.0 .5 1.0 1.5

1% tSECONDS3
RESULTANT -Fx (NED > LIIT> -FM (VENT > DORS> -Fr <PROX > DIST>
-___-_-- _____________ -__-_____

JOGGING, IRERDRILL. 6 RR/H

PRIIENT E.B.. LEFT SIDE, 38 MONTHS P.O. - EBL28ln

t XBU3 RESULTtiNT HIP JOINT FORCB RND 0RIENTI)TION [DEG. 3

350 -

3w-

a5e -

2W-

a.0 .s 1.0 1.5

T:iIi ISECONDSI
RESULTA?tT RNCLE F <FRONT. PL.> &ffiLE 1 (TRANSU. PL.>
----__-_--

JOGGING, TRERDMLL, 6 RM0ll

PRTIENT E.B., LEFT SIDE, 39 NONIHS P.O. u-x-m EBL281h

I XBWl RESULTANT HIP JOINT FORCE RND MONENTS C ZBU - NEIERI

BIOMECH. OHH BRRLIN
688

558

5BB

458

4laB

358

388

250

2BB

158

lee
-- ---_ _- __ __ -- -- -- __ __ __ _ ___.._ _ _______
52

0
0.0 .5 1.e 1.5
T:li: C SECONDS 1
RESULTANT Nfmont<n= 121 Ntrmr<n= lo) Nt,rms<A=-53
------ ____________

JOGGING. TREADMILL. 6 WH
PllTIENT E.B., LEFT SIDE, 39 MONTHS P.O. m EBL28lA

Fig. 6. Slow jogging at 6 km h- I: patient EB (left hip), 30 months postoperatively (for explanations see Figs
3 and 4).
 RESIJLIIINT HIP JOINT FORCE *ND COMPONENTS
BIOUECH. OHH BERLIN

----_
-50 ! I I I
0.0 .5 1.2 1.5 -----&
TIME CSECONDSI
RESULTaNT -Fx <NED > LIIT> -FY (WENT > DORS> -Fz CPROX > DIST1
-------- _--________ __ ______ ___

JOGGING, TREADMILL. 8 KM/H

PIllTIENT E.B.. LEFT SIDE, 30 MONTHS P.O. - EBL2790

RESULTLNT HIP JOINT FORCE (IND ORIENIlTION [DEG. 1

BIOMECH. OHH BERLIN
45

0 I I I

0.0 .5 1.0 1.5 TIME CSEC:t&

RESULTfbNT ANGLE F (FRONT. PL.) ANGLE 1 CTRdNSU. PL. >
----------

JOGGING, TRE6DWILL. 8 KM/H

nTIENT E.B.. LEFT SIDE, 30 MONTHS P.O. m EBL2790

CZBWI RESULTANT HIP JOINT FORCE AND MOMENTS CxBW-METER1

BI OMECH . OWH BERLIN
600 9

550

500

450

400

350

300

250

200

150

100

50
- - - __ _. - - __ _ ______________ _ _- __ _. - - __ _.
I 1 I -1

8.8 .5 1.0 1.5 TIME CSEC%&,

RESULTI)NT Mfront<(l= 10, Mtrans<A= 10, r(trans<ri=-5)
------ ------______

JOGGING, TREADMILL, 8 KM/H

RTIENT E.B.. LEFT SIDE, 30 MONTHS P.O. - EBL279A

Fig. 7. Normal jogging at 8 km h-: patient EB (left hip), 30 months postoperatively. The shapes of the
components are very similar, especially those of -F, and -F,. This is most pronounced at large force levels
and indicates a relatively invariable force direction for F and T (for explanations see Figs 3 and 4).
 HIP joint loading

RESULTANT RIIPOMJO$NT FORCE llND COMPONENTS

t%BUI
. OHH BERLIN
488 -

-58 I I I 1 r I
0.0 .5 1.0 1.5 2.0 2.5 3.8
TIME tSECONDS3
RESULIBNT -Fx CMED > LAT> -Fy <VENT > DORS> -Fz <PROX > DIST)
_ - _- - - _ _ ----------------------

YALKINC, TREADMILL. 4 RN/H

I aTlENT E.B., RIGHT SIDE, 30 MONTHS P.O. m EBRiZOB

CZBUI RESULT(\NT HIP JOINT FORCE nND ORIENTI\TION

9.e .5 1.0 1.5 2.8 2.5 TIME CSE:i:DSI

RESULTaNT ANGLE F (FRONT. PL.> ANGLE T (TRfiNSU. PL.>
----------

WILHING. TREIIDWILL, 4 KW/H

ATIENT E.B., RIGHT SIDE, 30 MONTHS P.O. m EBRlZaB

t%BWI RESULTANTB;;;EJC;INT FORCE IND MONENTS I %BW NETERI

. OHH BERLIN
4cN3

350

380

258

58 _ __ ___ __ . __

I 1 f 1 1 I -1

0.0 .5 1.0 1.5 2.8 2.5 TIUE ISE&:DSI

RESULTANT Mtront~a= 5) ntrans<fi= 5, Mtrans<A=-lE)
------ _-__--_---_-

WnLWING. TREIIDMILL, 4 HN/H

t I bTIENT E.B.. RIGHT SIDE, 30 MONTHS P.O. - EBRlZt3B

Fig. 8. Normal walking at 4 km h- : patient EB (right hip), 30 months postoperatively (for explanations see
Figs 3 and 4).
982 G.BERGMANN~~~[.

CXBWI RESULTINI Hl,FO~J~~HN FORCE IND COMPONENTS

OHH BERLIN
488-j ...fi... ..,.._......,. ,...........: .._... ~... .,..........

-50 : 1 1 , I I I I
0.0 .5 1.0 1.5 2.0 2.5 3.0 3.5
TIME ISECONDSI
RESULTIINT -Fx <MEZD > LfiIl -Fy (UENT > DORS) -Fz <PROX > DIST)
_------- _________----_______--

WIILKING. LEVEL FLOOR, F&ST SPEED, 3.8 KM/H

IITIENT J.B.. 8 ?lONTHS P.O. - JBBE

LXBWI RESULI~NT HIP JOINT FORCE RND ORIENTATION [DEC. 3

Y_.. OHH BERLIN
BI0nr.a.n.
seeq , n

350

250

280

159

ima

50

I 8 I I I , -38
0.8 .5 1.a 1.5 2.0 2.5
T&i: CSECOt%s:
RESULTRNT ANGLE F (FRONT. PL.> llNCLE T <TRfiNSU. PL. >
----------

WfiLXING, LEUEL FLOOR, F&ST SPEED. 3.8 RU/H

I\TIENT J.B., 8 MONTHS P.O. m JBOB

I ZBWI RESULTANTBy;;E;;INT FORCE IND MOMENTS C%BW -METER1

. OHH BERLIN
4063, A

358

250

50 __
63 i
.5
8.0 .5 1.0 1.5 2.8 2.5 T%t: CSECO: DSI
RESULTRNT Nfront<ll= 15) ntrans<n= 15) MtranscA= la>
____-_ ------------

WALRING, LEUEL FLOOR, FAST SPEED, 3.8 KM/H

?fiTIENT J.B., 8 RONTHS P.O. - JBBB

Fig. 9. Normal walking at 4 km h- : patient JB, 8 months postoperatively (for explanations see Figs 3
and 4).
 Hip joint loading 983

I%Bu1 RESULTllNI HIP JOINT FORCE RND COMPONENTS

RIOMECH. OHH BERLIN
see

809 . . . . .. . . . . . . . . . .,.,._._._...__...........,..,,.,,,..................

709

CBB

see

488 ,.,,.,,..................

300

0.0 .s 1.0 1.5 2.8 2.5 3.0 3.5 4.0 s.O

IIlm A&w4DS,
RESULTANT -FK <NED > LA?) -FY <VENT > DORF) -Fz (PROX > DISIB
--__--__ ____________________--

1 STEP LEVEL GROUND, STUMBLING YITHOUI FfiLLINC (3 STEPS>. 1 STEP FOORCIARDS

PIITIENT J.B.. 18 MONTHS P.O. m JB4i

C%BW RESULTANT H;:,=;;;T FORCE llND ORIENTnTION [DEG.3

. ORH BERLIN
see 4s
II h Al

Ct! 1 8 I I I I t I 1 f -38
8.0 .!i 1.0 1.5 2.0 2.5 3.0 3.5 4.8 C:J%ONDS JQ
TIME i
RESULTnNT nNCLE F <FRONT. PL.) nNCLE T CTRANSU. PL.>
___---_---

1 STEP LEVEL GROUND, STUMBLING CIfTHOUT FnLLINC <3 STEPS>. 1 STEP FORWnRDS
PATIENT J.B., 18 MONTHS P.O. m JB41

f. %BWI RESULTnNTB;;;Ri;INT FORCE llND MOMENTS C%BW -METER3

. OHH BERLIN 18

16

U.O .5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 5.8

I I ME L+i&ONDS 1
RESULTnNT n*r0ntcn= 15) Nt~mrcn= 15) ntrmrcn= 0)
------ _______----_

1 STEP LEUEL GROUND, STUMBLING WITHOUT FALLING (3 STEPS). 1 STEP FORCIARDS

PnTIENT J.B., 18 MONTHS P.O. m JB41

Fig. IO. Stumbling: patient JB, 18 months postoperatively. The patient was stumbling after the first step on
level ground, but did not fall. She made three fast steps to regain her balance and then a nearly normal step.
984 G. BERGMANN
et al.

p --+4mm OHH Bal!kc-

Result. Hip Joint Force Rmax (Peak Values) Transverse Force Angle T at Rmax

2 3 4 5 1 2 3 4 5
&ed Tkrn,hi &wd Tkm/h;
Activity: Walking I Jogging Activity: Walking I Jogging
/ L

Fig. 11. Joint force R,,, vs walking and jogging speed:
patients EB (EBL: left hip; EBR: right hip) and JB, EBL and
EBR: 30 months postoperatively; JB: 8 months postoper-
atively. Median (thin lines) and maximum (thick lines) of the
peak force R,,, (Figs 1 and 4) from 20 to 40 steps. Scale in
percent of the patients body weight (% BW). The peak force
is always the first maximum during the stance phase (Fig. 4).
Fig. 14. Force direction T of the peak force R,,, vs walking
and jogging speed: patients EB (EBL: left hip; EBR: right hip)
and JB. Median angle Tin the transverse plane (Figs 1 and 4)
at the instants of peak force R,,, (thick lines) and absolute
maximum M,,,, (thin lines). With increasing magnitude at
higher walking speeds the peak force does not act from the
medial side (T=O) but has an increasing component from the
ventral side (T> 0).

) p
Resultant Hip Joint Force Rmax (Peak Values) km I h Frontal Bending Moment Mf
-12, :

lp 8m.p.c.J
I )I
.I5
2 j i . . . . . . . . . . . ..i i . . . ..__.......

@ao) (0-1 - HdlYI~RRYX) -YUlhW

5 10 15 20 25 30
-1 2 3 4 3
PostapratlveTime [ Months
I ssped ;km,h;
Actlvlty: Walking and Jogglng Actidy: Walking/Jogging

Fig. 12. Joint force R,,, vs posto~rative time: patient EB
(left hip), walking and jogging on a treadmill at different
speeds. Data before the sixth month were obtained during
level walking.
Fig. 15. Bending moment M, vs walking and jogging speed:
patients EB (EBL: left hip; EBR: right hip) and JB, EBL and
EBR: 30 months postoperatively; JB: 8 months postoper-
atively. Median of M, (Figs 2 and 4) at the instants of peak
force R,,, (thin lines) and absolute maximum MfmsXfrom all
steps (thick lines).

Frontal Force Angle F at Rmax

<-. OHH Bwhii

Transverse Tonional Moment Mt

-I
1 2 3 4 5
&eed ikm/hy 1
Activity: Walking I Jogging
n
"1 2 3 4 3
&wed ;km/h:
Fig. 13. Force direction F of the peak force R,,. vs walking Activity: Walking /Jogging
and jogging speed: patients EB (EBL: left hip; EBR: right hip)
and JB, EBL and EBR: 30 months postoperatively; JB: 8
months postoperatively. Median angle F in the frontal plane Fig. 16. Torsional moment M, vs walking and jogging speed:
(Figs 1 and 4) at the instants of peak force R,,, (thick lines) patients EB (EBL: left hip; EBR: right hip) and JB. Median of
and absolute maximum Mfmlr (thin lines). The force acts from M, (Figs 2 and 4) at the instants of peak force R,, (thin lines)
proximal and medial. and maximum M,,,, from all steps (thick lines).
 Hip joint loading 985

Table 3. Force. force directions and moments acting on the hip joint during walking, jogging and stumbling,
Patients EB (ELB: left hip; EBR: right hip) and JB

Patient EB Patient EB
left Hip right Hip Patient JB

Value (km h _ )/Activity Median Max. Median Max. Median Max.

%a,(1% BW)
1 Walking 273 293 282 293
3 Walking 307 330 324 352 409 464
5 Walking 369 394 429 471
5 Jogging 475 522 484 509
7 Jogging 491 550 496 540
Max. Walk & Jog 539(l) 584(l) 536 (4) 558 (4) 415(5) 467 (5)
Stumbling 720(7) 870 (8)

f(L,) (deg.)
1 Walking 23 23 23 23
3 Walking 25 26 23 24 16 21
5 Walking 25 25 23 24
5 Jogging 26 27 23 24
7 Jogging 26 27 22 23
Av. Walk & Jog 25 26 22.5 23 17.5 21
Av. Jogging 25 26.5 23 23
Stumbling 19 21

TUG,,,) (deg.)
1 Walking -6.5 0 6.5 14
3 Walking 9 14 18.5 22 8.5 14
5 Walking 20 23 24 26
5 Jogging 19 21 24.5 27
7 Jogging 20 24 26.5 30
Av. Walk & Jog 13.5 17 21.5 25 7.5 12.5
Av. Jogging 19.5 22 25.5 29
Stumbling 15 17
M, (% BW m)
1 Walking 5.1 5.3 5.2 5.3
3 Walking 4.8 5.2 5.6 6.0 8.7 10.0
5 Walking 5.8 6.5 7.4 8.2
5 Jogging 7.0 7.9 8.1 8.9
7 Jogging 7.2 7.9 8.7 9.9
Max. Walk & Jog 1.5 (2) 8.2 (2) 10.0 (4) 10.0 (4) 8.8 (6) 10.0 (6)
Stumbling 14.8 (7) 16.2 (8)
M, (% BW m)
I walking 0.5 1.3 0.9 1.4
3 Walking 1.6 2.1 2.5 2.8 1.8 2.4
5 Walking 2.9 3.5 3.9 4.2
5 Jogging 3.6 4.4 4.3 4.8
7 Jogging 4.0 5.1 4.7 5.3
Max. Walk & Jog 4.4 (3) 5.1 (3) 5.7 (4) 6.2 (4) 1.8 (6) 2.4 (6)
Stumbling 5.4 (7) 5.1 (8)

R,,,: peak values of the resultant joint force R; F(R,,J: direction of peak force in the frontal plane (Fig. 1);
T(R,,,):direction of peak force in the transverse plane (Fig. 1); M,: bending moment (Fig. 2), Median: M, at R,,,,
Max.: Mfmnrduring all steps; M,: torsional moment (Fig. 2), Median: M, at R,,, during all steps.
Av.=arithmetic mean, Walk=walking at ld km h- (EBL and EBR) or 2.5-3.5 km h- (JB), jogging at
5-8 km h- (EBL) or 4-8 km h- % BW=percent of body weight, 1% BW: 6.5 N (EBL and EBR) or 4.7 N (JB).
All data achieved from 20 to 40 consecutive steps, except for stumbling (single events).
Remarks.
Without number, postoperative months: EBL: 30 EBR: 30 JB: 8
With number, km h- /postoperative months: (1) 7112 (2) 8130 (3) 7130 (4) 7117
(5) 2.5/18 (6) 3.518 (7) slow/24 (8) slow/l 8

the R-curve when the walking or jogging speed was and this difference increased with the speed. JB show-
high. For all three hips the characteristics of the ed larger moments M, than those found in both hips of
patterns of M, were very similar. EB at the same speed.
M rmar was up to 20% larger than M, (EBL, The largest torsional moments M,,,, observed in
2 km h-l, Fig. 15 and Table 3). Both showed a speed- the patients during walking and jogging were 5.1%
dependent increase during walking (EB and JB) and BWm (EBL, 7kmh-, 30 months), 6.2% BWm
nearly constant values for all jogging speeds (EB). In (EBR, 7 km h-l, 17 months) and 2.5% BW m (JB,
EBR the moment M, was generally larger than in EBL 3 km h- I, eight months). When stumbling, M,,,, was
986 G. BERGMANNet al.
5.4% BWm (EBL) and 5.1% BW (JB, Fig. 10). In
absolute numbers, the largest Mtmaxduring walking at
up to 5 km h-r was 22.7 Nm (EBL), 32.5 N m (EBR)
and 11.7 N m (JB). During jogging, M,,,, of 33.1 N m
(EBL) and 40.3 Nm (EBR) were noted, while
stumbling caused M,,,, of 35.1 Nm (EBL) and
24.0 N m (JB).
The shape of the pattern of M, resembled that of M,
with respect to the location of maxima and minima
(Figs 3-9). The increase of M, with the walking speed
(Fig. 16) was more pronounced than that of M,. In
contrast to M,, which stayed nearly constant at in-
creasing jogging speeds, the torsional moment was
also slightly higher at higher speeds. The difference
between M,,,, and M, (Fig. 16 and Table 3) was larger
than that observed in M, (Fig. 15) and reached 27%
(EBL, 7 km h-l). This implies that the torsional mo-
ment varied more from one step to the next than the
bending moment. At low walking speeds the minima
and maxima of M,, which are not charted, sometimes
even had negative values. M, was larger in EBs right
hip than in the other joint and this difference was more
pronounced than that in M,. In JB the torsional
moments stayed between those of EBL and EBR at the
same speed.
M rmaldid not change much postoperatively in EBL,
but in EBR it became 13% larger between the fourth
and the 17th month (average of walking and jogging)
and then fell by 13% again. No differences were noted
when EB walked on level ground and on the treadmill
at the same speed.
The torsional moment was also calculated for a
theoretical scenario (Figs 3-10, bottom, lines with
short dashes) where 15 less anteversion was assumed
(- 5 instead of + lo for EBL, for example). This
hypothetical decrease in anteversion led to torsional
moments which rose by 30-100% with a typical
increase of 4&50%.
DISCUSSION
The detailed long-term data about the loading of
hip endoprostheses can be used for further design
improvements, refining surgical techniques, guiding
postoperative physical therapy and to detect the activ-
ities which the patients should avoid so as not to
overload the implant. Only two patients have been
investigated so far, but these two patients are extremes
with regard to their physical activities and conditions.
Patient EB is very active and represents a patient with
hip implants who is in excellent condition. Patient JB
is more representative of elderly patients. Her neuro-
pathic disease also provides an insight into how
disturbed muscle functions possibly affect the forces
acting at the hip joint. Further implantations are
required, however, and will be performed to develop a
normal range of joint forces.
When the hip joint has been restored to its pre-
operative position by an implant, the magnitudes and
directions of the joint force should nearly return to the
values that existed prior to the onset of the joint
disease that necessitated the implantation. But even
long after surgery, when the patient has regained
normal walking ability, his gait patterns can be differ-
ent from those of healthy persons (Stauffer and Smidt,
1974). The presented results can, therefore, be gen-
eralized to normal individuals only with caution.
The median and maxima of the peak hip forces and
the maximum moments during walking, running and
stumbling are presumably most relevant for the stabil-
ity of hip implant, as they represent the worst-case
scenario for the loosening and failure of the interface
between prosthesis and bone. The data and discussion,
therefore, concentrate on these values. The depend-
ence of the loads and directions from the walking
speed and the postoperative time could not be proved
statistically, since only one patient was investigated in
a wider speed range. The comparison of our results
with data from the literature can help, however, to
estimate to what extent they might be typical for other
patients. The long-term trends may indicate to what
extent short-term studies are relevant for long-term
implantations.
Most loads stayed nearly constant for some months
postoperatively, followed by a temporary increase for
several months and then a succeeding decrease. This
can possibly be interpreted as an increase due to
improved walking abilities after the operation, follow-
ed by a decrease caused by training effects. The overall
shape of the force curves did not change throughout
the observation time. During the first months some
superimposed irregularities were found in EBs force
curves. Such noise was also found in JB for 18 months
and indicates painful or apprehensive walking.
The force magnitudes in JBs hip joint were higher
than those in EB, possibly due to disturbed muscle
function. But the overall shape of the force curves was
comparable in both patients and similar to the find-
ings of other authors ( Brown et al., 1985; Davy et al.,
1988, 1990; Goldberg et al., 1988; Kotzar et al., 1988;
Rydell 1966). This supports the assumption that sim-
ilar hip forces as in EB will also be found in future
investigations on additional patients.
Nearly all analytical studies (Table 2) showed a
distinct second peak force during the push-off phase of
the gait cycle,which usually exceeded the first max-
imum. In previously measured data (Table 1) this
second peak was less pronounced or was absent. Such
a second force peak was now observed in EBs right
hip joint only, predominantly at median walking
speeds. Some of the differences might be caused by
different walking patterns of healthy subjects and
patients with hip implants (Brown et al., 1984). The
height of the second force maximum probably de-
pends on the flexion angle at toe-off (Brown et al.,
1984) and it has not been demonstrated that this angle
was within the normal range in our patients. But even
in hip patients Brown et al. calculated higher second
 Hip joint loading
than first maxima. The differences between measured
and calculated joint forces with regard to the second
maximum, therefore, indicate that the mathematical
models might not describe accurately the second half
of the stance phase.
The second force maximum typically changed its
value when EB concentrated on how he walked, such
as when he had to hit a force plate. This shows that test
conditions can bias the obtained results.
The nearly invariable peak loads of EB at all
running speeds and the small differences between
jogging and very fast walking were not expected. It
seems that the maximum joint loads at higher speeds
can be limited by adapted gait patterns, but an extra-
polation of our results to hip forces in sports is not
possible.
The forces in EBs right joint were larger than in his
other hip. This may be due to the position of the right
femur, which was more lateral and distal than its
preoperative location. When using Pauwels (1935)
mechanical model of hip mechanics, a lateralization of
the femur such as in EBR should indeed increase the
magnitude of the joint force. At the same speed the
peak forces were larger in JB than in EB. From a
mechanical point of view. such a neurologic disease
could contribute to the initiation of a necrosis as it
possibly increases the joint forces by uncoordinated or
antagonistic muscle activity. The femoral head nec-
rosis of JB was indeed diagnosed only in the right hip
and the neurologic lesion on the same side preceded
the necrosis by several years.
The peak force data obtained for walking and
running are similar to the results of Rydell in his
second patient, but are much larger than the forces
measured in his first patient (Table 1). This may be due
to the fact that the prosthetic head of his first patient
did not fit the acetabulum exactly. The force magnitu-
des are also comparable to Englishs measurements.
Large forces were observed by English during the
swing phase, possibly because he took the measure-
ments early after the implantation. This was not found
in our patient. The data from the CWRU group show
nearly the same magnitudes as our results.
Except for Rydells first patient and JB with her
additional neuropathic disease, the hip joint forces
measured by us and other authors in different patients
have very uniform force magnitudes and patterns.
Normal walking seems to exist for most patients and
differences between individuals may not be too large.
Therefore, it seems justified to compare calculated
joint forces (Table 2) to values measured by us (Table
3) and other authors (Table 1). This comparison leads
to several observations:
(I) The calculated first force peaks were often larger
than the measured values and the variation ranges
exceeded the experimental results.
(2) The measured second peak was found to be
smaller than the first or was even absent, while most
mathematical models predicted larger values.
987
(3) The analytical procedures showed a more pro-
nounced speed-dependent increase in the peak forces
than was measured.
(4) The complexity of mathematical models does
not necessarily increase the relevance of the results.
These findings and the differences found by Brand
et al. (1989) between measured and calculated forces in
the same patient lead us to conclude that analytical
models need to be improved to deliver realistic results.
We did not find a pronounced influence of the stride
length on the force magnitudes, but this only shows
that walking with other than the normal, individual
step length at a given speed cannot reduce the hip
forces. Varying speeds and, thus, peak forces are
probably associated with different step lengths, but
this has not been evaluated.
Walking with hard and soft heel contact caused
only small differences in the force maxima. This is
consistent with the observation that the stiffness of
shoe materials hardly influences the loads (Bergmann
et al., 1990e). The instrumented implants can detect
peak values with a much faster speed increase than
really observed. At the instant of heel strike only
extremely small superimposed force peaks were ob-
served occasionally (Bergmann et al., 1990e). This
means that impact forces from the floor are damped
before they reach the hip joint and that the damping
properties of different implant materials do not influ-
ence the forces at the hip joint.
When the patients stumbled, the peak forces and
moments were much larger than ever measured during
walking or running. Because such situations are com-
mon, it can be assumed that most patients will occa-
sionally load their implants much more than can be
measured during planned activities. What role acci-
dental forces may play in the initiation of prosthetic
loosening must, therefore, be considered.
The frontal force angles F of the peak forces for all
speeds were nearly the same in EBL (average 25) and
EBR (22.5) and only a few degrees smaller in JB
(17.5). Even when the patients stumbled, F did not
differ much from the regular values. Rydell (Table 1)
measured 19-21 for F in his second patient, but his
angle variations during the stance phase were larger
than those we observed. With 10 or 11 for the lirst
maximum and 6 or 8 for the second one, smaller force
angles were measured by the CWRU group. But these
authors also mention a very constant direction of large
hip forces. Pauwels found nearly the same angle (27)
as in our study. Inman (1974) calculated 19-24 in the
frontal plane. The calculations of Paul (see Bergmann
et al., 1985) showed similar force directions for the first
maximum. However, the variations during the stance
phase were much greater. Brown et al. (1984) calcu-
lated angles F of the peak forces which were by up to
12 smaller in patients with different implants than in
healthy subjects, where they were about 17. Most of
these results, therefore, confirm frontal angles of the
peak forces in the same range as those found in our
988 G. BERGMANNer al.
patients and some of them support the finding that
this angle is more or less invariable.
The very low variation in the force direction Fin the
frontal plane at the moment of peak loading raises
several questions:
(1) Does the force in the frontal plane have a
direction which is optimal because it limits the
stresses created in any part of the natural femur?
(2) If a constant angle F also occurs in the native-
disease-free joint, does this automatically imply an
invariable area of contact pressure at the head?
(3) Does a small area of pressure transfer contribute
to accelerated cartilage destruction?
(4) Why do some models of femoral bone re-
modelling require variable force directions for predic-
ting reasonable results (Huiskes et al., 1989; Orr et al.,
1988)?
(5) Test specifications for hip prostheses often ask
for a direction of F= 10 (IS0 7206-7). Can larger
angles F be permitted to allow less rigid stems and,
therefore, new designs and materials?
In the transverse plane the joint force predomin-
antly acts from the medial or even from the medial and
dorsal side during slow walking, but more from the
ventral side at higher walking speeds and any jogging
speed. In EBL and JB its direction Tapproximates the
anteversion plane of the implant for walking at
medium speed and for stumbling. The deviation be-
tween T and the anteversion angle A has a strong
influence on the torsional moment around the stem
axis. Therefore, the increase of Tat raised force levels
can minimize torsion at hip implants and natural
femurs and could be a protective mechanism aimed at
reducing stresses in the natural bone.
When comparing the observed transverse load an-
gles with the results of other authors (Table 1), one has
to note that its values are very sensitive to measuring
errors, as the force component -F, is small. Rydell
found the angle T of the peak force to be 20. During
the course of the stance phase, T varied between about
zero and 90 (Bergmann et al., 1985). Paul found a
wide variation of -45 to +45 during the stance
phase (Bergmann et al., 1985). The CWRU group
measured Tin the range 3540 for the first peak force.
However, the performed data transformation may
have a large amount of error because some angles had
to be set to average values. Pauwels calculated a value
of only 2 for T. The angles T which we determined
were smaller and much more constant than in most
previous reports; however, they are similar to Rydells
data. The observation that the force acts more from
the ventral side at high magnitudes has not been
reported previously. Further, detailed analyses in
more patients will show whether this tendency can be
generalized.
If the deviation between A and T and the force
magnitude in the transverse plane were the only
factors that influenced the torsional moment, this load
would become very small as T approximates A. In
EBL and JB both angles are indeed close together at
medium walking speeds but the torsional moment
does not vanish. This is due to the choice of the system
x-$-z for the calculation of M,. It implies that not
only the force components -F, and -F, determine
the magnitude of M, but -F, has a large component
acting in the direction --y, too (Figs 1 and 2).
Torsional moments can lead to high bone stresses
and large motion between implant and bone, thus
placing the fixation in jeopardy (Walker et al., 1987).
In EB the component -F, often exceeded the a-p
force used in that study. Phillips et al. (1991) demon-
strated in vitro that cyclic torsional moments of
33 Nm (average, range 19-52 Nm) led to loosening of
cementless, porous coated hip implants. In EB M,
reached this average limit during walking and ex-
ceeded it for very fast walking, jogging and stumbling.
In JB 60% of the lower limit was observed during
walking. This indicates that prostheses, if implanted
without cement, are highly endangered by torsion.
The mathematical simulation of a changed antever-
sion of the implant showed a strong rise in the
torsional moment with decreasing anteversion angles.
But this calculation can only reveal possible trends
because a different orientation of the prosthesis would
change the direction of the muscle forces and this
would influence the magnitude and direction of the
joint force and herewith change the moments. No
information is available on the possible extent of this
compensation effect, but the obtained data indicate
that an increase of the torsional moments with a
smaller anteversion angle is probable. Therefore, im-
plant anteversion must be carefully considered by the
surgeon.
Acknowfedqements-We greatly appreciate the enthusiastic
cooperation of the two pa&e& H. Jendrzynski, G.
GroBhans. J. Sirakv. C. Voigt. H. Francke and F. HBussler
from our laboratory have worked diligently for many years
on this project. Many other individuals, institutes and com-
panies helped us in the development, fabrication and im-
plantation of the prosthesis, with training the patients,
performing the measurements and evaluations, and with
proof reading the manuscript. We acknowledge with thanks
their help and inspiration. The German Research Society has
supported these investigations financially.
REFERENCES
Backman, S. (1957) The proximal end of the femur. Acta
Radial. (suppl.) 146, 29.
Bergmann, G. (1981b) Ein Dreikomponenten-Kraftaufneh-
mer und seine Anwendung fiir die Messung von Gelenk-
krlften am Tier. Ph.D. thesis, Techn. Univ. Berlin.
Bergmann, G., Graichen, F., Jendrzynski, H. and Rohlmann,
A. (1987) Lone. term animal test with instrumented hip
implants. In &mechanics, Basic and Applied Research
(Edited by Bergmann, G., Ktilbel, R. and Rohlmann, A.),
pp. 317-324. Nijhoff, Dordrecht.
Bergmann, G., Graichen, F. and Rohlmann, A. (1990b)
Instrumentation of a hip joint prosthesis. In Implantable
Telemetry in Orthopaedics-(Editdd by Bergmann, G., Grai-
then, F. and Rohlmann, A.), pp. 35-63. Forschungsver-
mittlung der Freien Univ. Berlin, Berlin.
 Hip joint loading 989

Bergmann, G.. Graichen. F. and Rohlmann. A. (1991) In uiuo Western Reserve University. In Implantable Telemetry in
measurement of temperature rise in a hip implant. Trans. Orthopaedics (Edited by Bergmann, G., Graichen, F. and
37111 Ann. Meet. Orthop. Res. Sot., p. 223, Los Angeles. Rohlmann, A.), pp. 205-220. Forschungsvermittlung der
Bergmann, G.. Graichen. F. and Rohlmann, A. (1992a) Freien Univ. Berlin, Berlin.
Loading of hip implants by torsional moments. Trans. 38th Davy, D. T., Kotzar, G. M.. Brown, R. H., Heiple, K. G. Sr,
.4nn. Meet. Orthop. Res. Sot., p. 19, Washington. Goldbere. V. M.. HeiDle, K. G. Jr, Berilla, J. and Burstein,
Bergmann, G.. Graichen. F. and Rohlmann, A. (1992b) Load A. H. (19;s) Telemetric force measurements across the hip
reduction of hip joint implants by forearm crutches. Proc. after total arthroplasty. J. Bone Jt Surg. 70A, 45-50.
8th Meet. Europ. Sot. Biomech., p. 300, Rom. English, T. A. (1977) Recording dynamic loads on a femoral
Bergmann. G., Graichen. F.. Siraky, J., Jendrzynski, H. and hip implant using a telemetric method. First Europ. Con{:
Rohlmann, A. (1988) Multichannel strain gauge telemetry Euuluating of Biomut., Strasbourg.
for orthopaedic implants. J. Biomechanics 21, 169-176. English, T. A. and Kilvington, M. (1979) In uivo records of hip
Bergmann. G., Kniggendorf. H., Rohlmann, A., Graichen, F. loads using a femoral implant with telemetric output.
and Jendrzynski, H. (1990e) The influence of floor mater- J. biomed. Engng 1, 111-115.
ials on the hip joint loading. Proc. 7th Meet. Europ. Sot. Fick, A. (1903) Statische Betrachtung der Muskulatur des
Biomech., p. A40 Aarhus. Oberschenkels. In Gesammelte Schri)en (Edited by Fick,
Bergmann. G.. Kiilbel. R. and Rohlmann, A. (1979) Die A.). Staherl, Wiirzburg.
Messung van Gelenkkriften in ~litro. In Funktionelle Dia- Fischer, 0. (1899) Der Gang des Menschen. Teubner, Leipzig.
ynosrik in der Orthopiidie (Edited by Morscher, E.), pp. Goldberg, V. M., Davy, D. T., Kotzar, L., Heiple. K. G. Sr.
214-218. Enke, Stuttgart. Brown, R. H., Heiple, K. G. Jr, Berilla, J. and Burstein. A.
Bergmann. G., Kiilbel, R.. Siraky, J. and Rohlmann, A. (1981) H. (1988) In uivo hip forces. In Non Cemented Total Hip
Measurement of hip joint forces in sheep. In Biomech. VII- Arthroplusty (Edited by Fitzgerald, R. H.), pp. 251--256.
B (Edited by Morecki. A., Fidelius. K.. Kedzior, K. and Raven Press, New York.
Wit. A.). pp. 106-l I I. University Park Press, Baltimore, Goodman, R. M. F.;English, T. A. and Kilvington, M. (1980)
MD. An implantable FM telemetry system for measuring forces
Bergmann. G.. Neff. G., Rohlmann, A. and Graichen, F. on prosthetic hip joints. In A Handbook on Biotelemetry
( 1990~) Influence of orthotic devices on the forces at the hip and Radio Tracking (Edited by Amlaner. C. J. Jr). pp.
Joint. Trans. 36th Ann. Meet. Orthop. Res. Sot., p, 1, New 297-306. Pergamon, Oxford.
Orleans. Graichen, F. (1990)Implantierbares telemetrisches iibertray-
Bergmann, G.. Rohlmann, A. and Graichen, F. (1989) In ciuo ungssystem zur in uivo Messung der Belastung kiinstlicher
Messung der Hiiftgelenkbelastung 1. Teil Krankengym- Hiiytyelenke. Schiele & SchBn, Berlin.
nastik. Z. Orthop. 127, 672-79. Graichen, F. and Bergmann, G. (1991) Four-channel tele-
Bergmann, G.. Rohlmann. A. and Graichen, F. (1990a) In metry system for in &o measurement of hip joint forces.
t:iro hip joint force measurements in one patient. In J. biomed. Engng 13, 37G-374.
Clinical Imp/am Muter& Adrances in Biomuterials. Vol. 9 HHggstriim, R. P. (1974) A transducer for the measurement of
(Edited bv Heimke, G.. SoltCsz, U. and Lee, A. J. C.). pp. forces and moments in the hip joint of the living human
639-644. Elsevier, Amsterdam. body. VDI-Berichte 212, 93.
Beremann. G.. Rohlmann. A. and Graichen. F. 11990d) Hin Huiskes, R., Weinans, H. and Dalstra, M. (1989) Adaptive
j&t forces during physical therapy after joint redlace- bone remodeling and biomechanical design considera-
ment. Truns. Jtith Ann. Meef. Orthop. Res. SOP., p. 2, New tions. Orthopaedics 12, 1255-l 267.
Orleans. Inman, T. (1947) Functionat aspects of the abductor muscles
Bergmann, G.. Siraky, J.. Rohlmann. A. and KCilbel. R. (1982) of the hip. J. Bone Jt Surg. 29. 607-619.
Measurement of spatial forces by the Matrix-method. Kotzar, G. M.. Davy, D. T., Goldberg, V. M., Heiple, K. G.
Proc. Y1i7 World Congr. IMEKO, pp. 395404, Berlin. Sr, Berilla. J., Heinle. K. G. Jr. Brown. R. H. and Burstein.
Bergmann. G., Siraky. J., Rohlmann, A. and Klilbel, R. (1985) A. H. (1988) Co&parison of early telemetrized hip pros:
A comparison of hip joint force in sheep, dog and man. J. thesis data in two patients. Proc. 6th Meet. Europ. Sot.
&mechanics 17, 907-:92 I. Biomech.. p. 27B, Bristol.
Brand. R. A., Pedersen. D. T.. Davy, D. T.. Helple, K. G. and McLeish, R. D. and Charnley, J. (1970) Abduction forces in
Goldberg, V. M. (1989) Comparison of hip force calcu- the one-legged stance. .I. Biomechanics 3, 191-209.
lations and measurements in the same patient. Trans. 35th Orr, T. E., BeauprB, G. S. and Carter, D. R. (1989) Femoral
.Ann. Meet. Orthop. Res. Sot., p. 96. Las Vegas. bone architecture computed from 3-D models relating
Brown. R. H.. Davy. D. T.. Heiple, K. G. Sr, Kotzar, G. M., bone remodeling to stress histories. Proc. XII. Int. Cnnyr.
Heiple. K. G. Jr. Berilla. .I.. Goldberg, V. M. and Burstein, Biomech., abstr. # 167.
A. H. (1985) In-viro load measurements on a total hip Otte, P. and Schlegel, K.-F. (1973) Der Antetorsions- und
prosthesis. Trans. 31st Ann. Meet. Orthop. Rex Sot., p. 283, Schenkelhalsschaftwinkel des Femur. In Biicherei der Or-
Las Vegas. thopiiden, Band 10 (Edited by Kiinig, G. and Schult. W.).
Brown, T. R. M.. Nicol, A. C. and Paul. J. P. (1984) Enke, Stuttgart.
Comparison of loads transmitted by Charnley and CAD Paul, J. P. (1964) Bioengineering studies of the forces trans-
Muller total hip arthroplasties. Proc. Cant Engineering mitted by joints. II. Engineering studies. Proc. Symp.
and Clinical Aspects of Endoprosthetic Fixation, Inst. Biomech. and Related Bioengng Topics, pp. 369-380. Glas-
Mech. Enyny, pp. 63-68, London. gow.
Calderale. P. M. and Scelfo. G. (1987) Mathematical models Paul, J. P. (1967) Forces transmitted by joints in the human
of the musculo-skeletal systems. Engng Med. 16, 131-146. body. Proc. Inst. Mech. Engng 181, S-15.
Calderale. P. M. and Scelfo. G. (1987)A mathematical model Paul, J. P. (1974) The analysis of forces transmitted by joints
of the locomotor apparatus. Enyng Med. 16, 147-161. in the human body. Proc. 5th Int. Conf Stress Analysis, pp.
Crownmshield, R. D., Brand, R. A. and Johnston, R. C. 3.34-3.42.
(1978a) The effect of walking velocity and age on hip Paul, J. P. (1975) Force actions transmitted by ioints in the
kinematics and kinetics. C/in. Orthop. 132, 14c-144. human body. Proc. R. Sot. Med. 192, pp. 163-172.
Crowninshield, R. D.. Johnston, R. C., Andrews, J. G. and Pauwels, F. (1935) Der Schenkelhalsbruch-ein mechanis-
Brand, R. A. (1978b) A biomechanical investigation of the ches Problem. Beil. Z. orthop. Chir. 63, l-138 (Reprint
human hip. J. Biomechunics 11, 75-85. Gesammelte Abhandlungen zur funktionellen Anatomie
Davy. D. T.. Kotzar. G. M., Berilla, J. and Brown, R. H. des Bewegungsapparates. Springer, Heidelberg).
(1990) Telemetrired orthopaedic implant work at Case Phillips, T. W.. Nguyen, L. T. and Munro. S. D. (1991)
990 G. BERGMANNet al

Loosening of cementless femoral stems: biomechanical
analysis of immediate fixation with loading vertical femur
horizontal. J. Biomechanics 24, 37118.
Rippstein, J. (1955) Zur Bestimmung der Antetorsion des
Schenkelhalses mittels zweier Riintgenaufnahmen. Z. Or-
thop. 86, 345-360.
Riihrle, H., Scholten. R., Sigolotto, C., Sollbach, W. and
Kellner, H. (1984) Joint forces in the human pelvis-leg
skeleton during walking. J. Biomechanics 17, 409424.
Rydell, N. W. (1966a) Forces acting in the femoral head-
prosthesis Acta orthop. stand. (Suppl.) 88, 37.
Rydell, N. W. (1966b) Intravital measurements of forces
acting on the hip joint. In Studies an the Anatomy and
Function ofBone and Joints (Edited by Evans, F. G.), pp.
52-68. Springer, Berlin.
Seireg, A. and Arvikar, R. J. (1975) The prediction of muscu-
lar load sharing and joint forces in the lower extremities
during walking. .I. Biomechanics 8, 89-102.
Stauffer, R. N. and Smidt, G. L. (1974) Clinical and bio-
mechanical analysis of gait following Charnley total hip
replacement. Clin. Orthop. Rel. Res. 99, 7&77.
Walker, P. S., Schneeweis, D., Murphy, S. and Nelson, P.
(1987) Strains and micromotions of press-fit femoral stem
prostheses. J. Biomechanics 20, 693-702.