The effect on gait of lengthening of the medial hamstrings in cerebral palsy

The purpose of this study was to analyze the effect of lengthening of the medial hamstrings on the gait of patients who had spastic cerebral palsy. Thirty-one patients had preoperative and postoperative gait analyses. Standard parameters, such as velocity, cadence, and stride length, were evaluated, as were motion graphs of the hip, knee, and ankle. There was little difference between the preoperative and postoperative mean values for velocity, cadence, and stride length, which were expressed as percentages of normal for the patient's age. The contours of the postoperative motion graphs of the knees changed very little compared with those of the preoperative graphs; when a graph showed restricted motion preoperatively, it did so postoperatively. Although extension of the knee in stance phase improved postoperatively, the improvement was accompanied by decreased flexion of the knee during swing phase. When spasticity of both the hamstrings and the quadriceps was noted on the preoperative electromyogram, motion of the knee in the sagittal plane was markedly restricted.     

Comparison of rectus femoris transposition with traditional transfer for treatment of stiff knee gait in patients with cerebral palsy

Purpose To assess the outcome of children with cerebral palsy following reposition of the distal rectus femoris tendon for treatment of stiff knee gait. Methods Children with cerebral palsy with stiff knee gait who underwent rectus femoris transfer were studied retrospectively. Inclusion criteria were cerebral palsy of diplegic or quadriplegic type, preoperative and 1 year postoperative three-dimensional motion analysis, and no other surgery except rectus femoris transfer at the time of study. The patients were separated into two groups: in group I, the rectus femoris was transferred to the distal medial hamstring tendons, either the gracilis or the semitendinosus; in group II, the distal tendon of the rectus femoris was transposed laterally and attached to the iliotibial band/intermuscular septum. Results Peak knee flexion during swing phase, total dynamic knee range of motion, knee range of motion during swing phase, and time to peak knee flexion during swing phase were all improved in both groups. Hip and pelvic kinematics were not influenced by the surgery. Velocity, stride length, and cadence were all improved following the surgery. There was no difference between the transfer group and the transposition group. Conclusion These findings suggest that distal transfer of the rectus femoris is effective in improving swing phase knee function by diminishing the mechanical effect of the dysphasic swing phase activity of the rectus femoris, not by converting the rectus femoris to an active knee flexor. No financial support was received for this study.     

Single event multilevel surgery to improve gait in diplegic cerebral palsy - a prospective controlled trial]

AIM: To evaluate prospectively the outcome of gait-improvement surgery in children with spastic diplegia. METHOD: Three-dimensional gait analysis was performed in twenty children with spastic diplegia. Ten children underwent single event multilevel surgery for gait improvement. Indications for individual procedures followed a fixed set of selection criteria. The other ten children continued with their physiotherapy programme and served as a control group. A second gait analysis was performed in all children after 1.5 years. Time-distance parameters and kinematics of the pelvis, hip, knee and ankle joints in the sagittal plane served as main outcome measures RESULTS: The patients walked faster with an increased stride length after surgery in comparison to the conservatively treated controls. The average pelvic tilt increased slightly and the range of motion of the knee joint increased considerably after multilevel surgery. The motion at the ankle remained unchanged over the study period in both the groups. An improved knee extension during the stance phase of gait served to improve stance limb stability and facilitated an unhindered swing phase of the opposite limb. CONCLUSION: This prospective trial showed favourable changes in gait function after multilevel surgery in spastic diplegic children.     

Cerebral palsy and rhizotomy. A 3-year follow-up evaluation with gait analysis

A recent increase in the popularity of selective rhizotomy for reduction of spasticity in cerebral palsy has led to a demand for more objective studies of outcome and long-term follow-up results. The authors present the results of gait analysis on 14 children with spastic cerebral palsy, who underwent selective posterior rhizotomy in 1985. Sagittal plane gait patterns were studied before surgery and at 1 and 3 years after surgery using a digital camera system. The parameters measured included the range of motion at the knee and thigh, stride length, speed of walking, and cadence. The range of motion at the knee was significantly increased at 1 year after surgery and further improved to a nearly normal range at 3 years after surgery. In contrast, postoperative measurements of thigh range exceeded normal values at 1 year, but decreased toward normal range at 3 years. While improvements in range of motion continued between Years 1 and 3, the children developed a more extended thigh and knee position, which indicated a more upright walking posture. Stride length and speed of walking also improved, while cadence remained essentially unchanged. This 3-year follow-up study, the first to examine rhizotomy using an objective approach, has provided some encouraging results regarding early functional outcome.     

Kinematic and kinetic analysis of the knee joint before and after a PCL retaining total knee replacement during gait and single step ascent

The objective of this study was to capture and analyze the kinetics and kinematics and determine the functional performance of the osteoarthritic knee after a posterior cruciate ligament (PCL) retaining total knee arthroplasty. Kinematic and kinetic gait analysis of level walking was performed in 20 subjects (12 female and 8 male) with knee ostoarthritis. These patients were free of any neurological diseases that could affect their normal gait. Mean age was 69.6 ± 6.6 years; mean height was 157.6 cm ± 7.6 cm; and mean weight was 77.2 ± 12.1 kg. Full body gait analyses were performed using the BIOKIN 3D motion analysis system before and 9 months after total knee arthroplasty procedures. Single-step ascending kinetic analyses and plantar pressure distribution analyses were also performed for all subjects. International Knee Society Scores (IKSSs) were also assessed pre- and postoperatively. Significant increases were noted postoperatively in average cadence (preoperative mean = 99.26, postoperative mean = 110.5; p < 0.004), step length (preoperative mean = 0.49, postoperative mean = 0.54; p < 0.01) , and walking velocity (preoperative mean = 0.78, preoperatively, postoperative mean = 0.99; p < 0.001). Decreases in stance duration percentage and knee adduction moment were also reported postoperatively. All patients showed a significant improvement of knee kinetics and kinematics after a PCL retaining total knee arthroplasty. Significant differences were found in the cadence, step length, stride length, and walk velocity postoperatively. IKSSs also significantly improved. Further research is warranted to determine the clinical relevance of these findings.     

Knee motion following multiple soft-tissue releases in ambulatory patients with cerebral palsy.

Multiple soft-tissue releases (MSTRs) in cerebral palsy have been advocated to improve knee motion during gait. Forty-five extremities underwent MSTRs as recommended by preoperative gait analysis. Pre- and postoperative analyses were evaluated in relation to knee motion and foot progression angle. Maximum knee flexion during swing and the foot progression angle showed no significant change postoperatively. The total knee ROM and minimum knee flexion in stance improved significantly towards normal. The timing of maximum knee flexion and slope of the knee flexion curve at toe off improved with respect to age and number of previous surgeries. MSTRs increased knee ROM and improved the sequential timing and event progression during gait.     

Quantitative gait analysis after bilateral total knee arthroplasty with two different systems within each subject

The functional behavior of two kinematically different knee arthroplasty systems within each subject was studied by gait analysis (three-dimensional kinematics, kinetics, dynamic electromyography) in five elderly patients, 2 to 5 years after bilateral surgery. Clinical results were good, yet gait velocity was reduced (range, 0.57–1.1 m/s), with a shortened stride length and a decreased duration of single-limb stance in all subjects. Force plate recordings revealed an undynamic gait with slow loading, reduced modulation of the vertical forces, and poor fore/aft shears. Sagittal plane knee motion during gait was reduced in all subjects, with trunk and pelvic compensation patterns for foot clearance. Muscle activity around the knee was prolonged bilaterally, with activity modulation related to the motion pattern. Although the stride parameters were quite symmetric, there was a marked asymmetry of the motion pattern, with a side-to-side difference of peak knee flexion during stance and swing phase of up to 15°. This finding, however, was not clearly related to the type of prosthesis. Even within one subject, significant side-to-side variability may persist, which leads to asymmetry of the motion pattern, unrelated to the kinematic design of the implant. Other factors, such as the patella-extensor mechanism, ligament balancing, leg-length discrepancy, proprioception, continuation of a preoperative habit, or a contralateral influence, may explain part of the asymmetry seen in these subjects.     

Rectus and hamstring surgery in cerebral palsy: a gait analysis study of results by functional ambulation level

The purpose of this study is to determine if children more severely involved with cerebral palsy respond as well to rectus transfer and hamstring surgery as those with less severe involvement. Ninety-nine children were classified as independent community ambulators, crutch/walker-dependent community ambulators, or household/exercise ambulators. Maximum knee extension in stance and total range of knee motion in gait increased following surgery in all groups. Peak knee flexion in swing was maintained in the independent group only, but timing of knee flexion in swing improved in all groups. All groups showed increases in stride length, and the household/exercise group also showed an increase in walking speed. Four of 39 crutch/walker-dependent community ambulators and 13 of 21 household/exercise ambulators progressed to the next higher functional ambulation group.     

Natural progression of gait in children with cerebral palsy

Twenty-eight children with cerebral palsy had two gait analyses an average of 4.4 years apart with no surgical intervention between the tests. The effects of growth and age were examined using three-dimensional kinematics, temporal and stride parameters, and clinical examination measures. Kinematic changes showed decreases in hip, knee, and ankle sagittal plane ranges of motion (ROM), peak hip flexion in swing, and peak knee flexion over time. Temporal and stride parameters showed declines in timing of toe off, cadence, and walking velocity. Clinical measures showed declines in hip abduction ROM (knees flexed and extended), popliteal angle, and sagittal plane ankle ROM (knees flexed and extended). Overall results showed that gait function in these individuals with cerebral palsy decreased longitudinally with respect to temporal/stride measures, passive ROM, and kinematic parameters compared with a group of individuals who had had orthopaedic intervention.     

Effects of surgical lengthening of the hamstrings without a concomitant distal rectus femoris transfer in ambulant patients with cerebral palsy

Eighteen ambulant patients (32 legs) who had undergone fractional lengthening of the medial and lateral hamstrings without rectus femoris transfer underwent pre- and postoperative gait analysis. A significant increase in the amount of knee extension and a decrease in the amount of peak knee flexion in swing were observed. This decrease in knee flexion signified a change towards more normal speed-related values. Dorsiflexion at initial contact decreased significantly for patients who did not undergo a gastrocnemius lengthening (n = 24). Absolute cadence was significantly lower after surgery, but the change in dimensionless cadence was not significantly different. This difference in the outcome between dimensionless and absolute stride parameters can be attributed to the increase in body height after surgery. The clinical significance of these findings is that it is important to recognize that postoperative effects of surgery on gait in children may, in part, be explained by changes in height and not surgery alone.     

Temporal-spatial gait adaptations during stair ascent and descent in patients with knee osteoarthritis

Knee osteoarthritis (OA) accounts for more functional disability of the lower extremity than any other disease. We recruited 18 patients with knee OA and 18 healthy age-, height-, mass-, and gender-matched control subjects to investigate the effects knee OA has on select spatial and temporal gait variables during a stair climbing task. No group-by-direction interaction was observed; however, significant effects did occur for group and direction. Specifically, patients with knee OA demonstrated less time in single support, greater time in double support, decreased step length, greater step width, less stride length, decreased total gait velocity, greater total time in support, and less total time in swing, compared with controls. Early-stage knee OA directly influences specific temporal and spatial gait characteristics during stair climbing.     

Case Reports: The Influence of Selective Voluntary Motor Control on Gait After Hamstring Lengthening Surgery

Background  

Preliminary evidence suggests selective voluntary motor control (SVMC), defined as performance of isolated voluntary joint movement on request, may be an important factor affecting functional movement tasks. Individuals with poor SVMC are unable to dissociate hip and knee synergistic movement during the swing phase of gait and have difficulty extending their knee while the hip is flexing during terminal swing regardless of hamstring length. This pattern may limit their ability to take advantage of hamstring-lengthening surgery (HLS) and may explain a lack of improved stride length postoperatively.     

Kinetic and kinematic characteristics of gait in patients with medial knee arthrosis

We compared the mechanics of gait in 13 patients with early medial arthrosis (OA) of the knee and 13 normal controls, by measuring gait events, kinematic and kinetic parameters. In the OA group, walking velocity, cadence and stride length were reduced and stride time and double support time accordingly increased on both sides, the overall stance phase was prolonged in the OA group, but the stance phase and swing phase peak flexion were reduced. The varus in the stance phase and the valgus in the swing phase were increased. The extensor moment in the loading response was increased and the flexor moment at late stance reduced in the OA group. Patients with OA had a greater valgus (abductor) and internal rotation moment during the stance phase. The times to second vertical force peak (VFP) were similar in the two groups. Values of VFP1 and VFP2 were lower in the OA group. Our findings indicate that computerized gait analysis can be used to reveal various mechanical abnormalities accompanying arthrosis of the knee joint at an early stage. Some of these abnormalities may have etiologic implications, but others may represent secondary changes developed in part as a compensatory mechanism in knee OA.     

Kinetic and kinematic characteristics of gait in patients with medial knee arthrosis

We compared the mechanics of gait in 13 patients with early medial arthrosis (OA) of the knee and 13 normal controls, by measuring gait events, kinematic and kinetic parameters. In the OA group, walking velocity, cadence and stride length were reduced and stride time and double support time accordingly increased on both sides, the overall stance phase was prolonged in the OA group, but the stance phase and swing phase peak flexion were reduced. The varus in the stance phase and the valgus in the swing phase were increased. The extensor moment in the loading response was increased and the flexor moment at late stance reduced in the OA group. Patients with OA had a greater valgus (abductor) and internal rotation moment during the stance phase. The times to second vertical force peak (VFP) were similar in the two groups. Values of VFP1 and VFP2 were lower in the OA group. Our findings indicate that computerized gait analysis can be used to reveal various mechanical abnormalities accompanying arthrosis of the knee joint at an early stage. Some of these abnormalities may have etiologic implications, but others may represent secondary changes developed in part as a compensatory mechanism in knee OA.     

Antalgic maneuvers during walking in men with unilateral knee disability

The gait of men with unilateral knee disability has not been quantified previously. Interrupted-light photography was used to quantify the gait abnormalities of 35 men whose major disability was unilateral knee pain. The following antalgic maneuvers were found to be common to the gait of these patients: slow and uneven forward progression with lateral lurching toward the painful side, asymmetry in stride and temporal components, and abnormalities in the displacement patterns of most body segments. Subnormal knee motion was found during the stance and swing phases. Because treatment of patients with knee problems is usually directed toward pain relief, an understanding of how pain affects walking performance is important to the clinician when assessing a patient's problem.     

Current applications of gait analysis after total knee arthroplasty: A scoping review

IntroductionThe biomechanics of the knee do not return to normal after knee replacement. The purpose of this scoping review is to summarize the current use of gait analysis in total knee arthroplasty and to identify the preoperative motion analysis parameters for which a systematic review aimed at determining the reliability and validity may be warranted.Materials and methodsThis IRB-exempt scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. The 279 articles from the five search engines underwent a title/abstract and full-text screening. Included articles were categorized as either: the role of gait analysis as a research tool for operative decisions, other research applications for motion analysis in total knee arthroplasty, gait analysis as a tool in predicting radiologic outcomes, or gait analysis as a tool in predicting clinical outcomes.ResultsEleven articles studied gait analysis as a research tool in studying operative decisions. Five articles studied other research applications for motion analysis in total knee arthroplasty. Other research applications for motion analysis currently include studying the role of the unicompartmental knee arthroplasty and novel physical therapy protocols aimed at optimizing post-operative care. Two articles studied motion analysis as a tool for predicting radiographic outcomes. 15 articles studied motion analysis in conjunction with clinical scores.ConclusionsThere is a broad range of research applications for motion analysis in knee reconstruction. Current limitations include vague definitions of ‘gait analysis’ or ‘motion analysis’ and a limited number of articles with preoperative and postoperative outcomes. Knee adduction moment, knee adduction impulse, total knee range of motion, varus angle, cadence, stride length, and velocity have the potential for integration into composite clinical scores. A systematic review to determine the psychometric properties of these variables is warranted.     

Guided growth for correction of knee flexion deformity: a series of four cases

Fixed knee flexion deformity can present as an insidious and significant problem in diverse etiologies, most commonly in cerebral palsy. Traditional surgical intervention has included posterior capsulotomy and supracondylar femoral osteotomy, both of which carry significant associated morbidity and risks. In the skeletally immature patient, guided growth may be used to correct or substantially diminish the deformity. We are presenting our early experience encompassing four subjects who completed instrumented gait analysis both prior to and after distal femoral anterior guided growth (hemiepiphysiodesis). Changes in gait and function resulting from surgery in each individual are reported. Outcomes indicate improved knee range of motion and alleviation of crouch at the knee with secondary improvements in the ankle, hip and pelvis. Three subjects with initially slow gait velocity improved to within normal limits by demonstrating increased stride length. A measure of overall gait kinematics showed improvements in all limbs. Anterior guided growth (hemiepiphysiodesis) of the distal femur resulted in positive quantitative changes in all four patients, though degree and types of changes were variable in this small series. Encouraged by these findings, we now prefer guided growth to extension supracondylar osteotomy for the skeletally immature patient with fixed knee flexion deformity.     

Functional outcome of patients with rotationplasty about the knee

Rotationplasty is a surgical procedure designed to achieve a durable reconstruction after the resection of tumors about the knee. However, because of the recent advances with expandable prostheses, rotationplasty has been less popular in the skeletally immature patient, particularly in the United States. We assessed the functional outcome of patients who had rotationplasty to allow better comparison with other operative techniques in this patient population. Seven patients, who were operated on at our institution at an average age of 9.4 years (range, 5-14 years), had a followup of at least 4 years and were evaluated in the Motion Analysis Laboratory. The gait analysis included kinetic, kinematic and temporal-distance parameters to evaluate the patient's functional performance. The data also were compared with measurements of a population of 25 able-bodied subjects and with four subjects with distal above-knee amputation. All patients had the ability to weightbear fully. All patients ambulated without assistive devices. Gait analysis of patients with rotationplasty revealed only slight asymmetry regarding stride duration, stride length, cadence, velocity and stance-swing ratio compared with healthy subjects. Although the gait was similar to subjects with distal above-knee amputation, knee motion was superior in patients who had rotationplasty. Rotationplasty offers a durable reconstruction. Rotationplasty allows the patient to actively control the knee, which results in a coordinated gait pattern, which is similar to the gait of the able-bodied population, and better than in subjects with distal-knee amputation.     

Early changes in gait and maximum knee torque following knee arthroplasty

Fourteen knees in 11 individuals were studied before knee arthroplasty and at three and six months following surgery. Eleven of these knees were further evaluated at 12 months following surgery. At each evaluation, kinematic, electromyographic, and force plate data were gathered during level walking. Maximum knee extension and flexion torques were also determined. The greatest improvement in gait was noted in the first three postoperative months when velocity increased 13% and stride length increased 14%. After six months gait changes were negligible. Maximum knee torques in the osteoarthritic population were decreased at three months, then returned to preoperative levels at six months. In the rheumatoid population, maximum knee torques steadily increased up to six months following surgery. Gait abnormalities that persist at six months and beyond following knee arthroplasty appear to be most related to the presence of arthritis in joints other than in the operated knee(s).     

Does Bilateral Total Knee Arthroplasty Affect Gait in Women?: Comparison of Gait Analyses Before and After Total Knee Arthroplasty Compared with Normal Knees

We performed gait analysis of 24 patients with bilateral knee osteoarthritis (OA) before, 1 year, and 2 years after bilateral total knee arthroplasty and compared these results to 12 normal controls. Cadence was significantly decreased in OA patients when compared with controls. Step and stride lengths were significantly different preoperatively (shorter) and postoperatively (P < .05), but postoperative results showed no significant difference when compared with normal controls (P < .05). Step and stride times were significantly different (P < .05) between the preoperative OA group and controls, but no difference was seen with the postoperative measurements when compared with controls. In the OA group, the mean vertical component of the ground reaction forces expressed as percent body weight was significantly lower when compared with controls and postoperative results. No correlation was found between the preoperative and postoperative clinical scores and objective data obtained from gait analysis. Our results demonstrate that gait analysis is not a useful tool in evaluating the success of total knee arthroplasty patient.