Up to 20 percent of patients remain dissatisfied after primary total knee arthroplasty (TKA) surgery. Understanding the reasons for dissatisfaction post TKA may allow for better patient selection and optimized treatment for those who remain dissatisfied. The association between function, mobility and satisfaction are not well understood. The purpose of this study was to investigate the association between post-TKA satisfaction and i) pre-operative, ii) post-operative, and iii) change in knee joint function during gait. Thirty-one patients scheduled to receive primary TKA for knee osteoarthritis (OA) diagnosis were recruited and visited the Dynamics of Human Motion laboratory for instrumented walking gait analysis (using a synchronized NDI Optotrak motion capture system and AMTI force platforms in the walkway) at two time points, first within the week prior to their surgery, and second at approximately one year after surgery. At their post-operative visit, patients were asked to indicate their satisfaction with their knee prosthesis on a scale from zero to 100, with zero being totally unsatisfied and 100 being completely satisfied. Knee joint mechanics during gait at both time points were characterized by discriminant scores, the projection of their three-dimensional knee angles and moments during gait onto an existing discriminant model that was created to optimize separation of severe knee OA and healthy asymptomatic gait patterns. This discriminant model was created using data from 73 healthy participants and 73 with severe knee OA, and includes the magnitude and pattern features (captured with principal component analysis) of the knee adduction and flexion moment, and the magnitude of the knee flexion angle during gait. Larger discriminant scores indicate improved function toward healthy patterns, and smaller scores indicate more severe function. Associations between post-operative satisfaction and pre, post and change in discriminant scores were examined using Pearson correlation analyses. We also examined associations between satisfaction and pre-operative BMI, EQ5D and Oxford 12 scores, as well as changes in these scores from pre to post-TKA. Discriminant scores representing knee joint function during gait significantly improved on average after surgery (P =0.05). While overall knee joint function improved after primary TKA surgery, the amount of improvement in function was not reflected in post-operative patient satisfaction. However, the pre-operative function of the patient was negatively associated with satisfaction, indicating that patients with higher pre-operative function are overall less satisfied with their TKA surgery, regardless of any functional improvement due to the surgery. Interestingly, the only significant association with post-operative satisfaction was knee joint function, and the relationship between function and patient satisfaction following TKA appears to relate only to the baseline functional state of the patient, and not with functional improvement. This suggests that dissatisfaction post-surgery is more likely reflecting the unmet expectations of a higher functioning patient, and has implications for the need for improved understanding of pre-operative patient functional variability in TKA triage and expectation management

Purpose of Study. In children with spastic diplegia, surgery for equinus has a high incidence of both over and under correction. We wished to determine if conservative (mainly Zone 1) surgery for equinus gait, in the context of multilevel surgery, could result in the avoidance of calcaneus and crouch gait as well as an acceptable rate of recurrent equinus, at medium term follow-up. Description of Methods. This was a retrospective, consecutive cohort study of children with spastic diplegia, between 1996 and 2006. All children had distal gastrocnemius recession or differential gastrocsoleus lengthening, on one or both sides, as part of Single Event Multilevel Surgery. The primary outcome measures were the Gait Variable Scores (GVS) and Gait Profile Score (GPS) at two time points after surgery. Summary of Results. Forty children with spastic diplegia, GMFCS Level II and III were eligible for inclusion in this study. There were 25 boys and 15 girls, mean age 10 years at surgery. The mean age at final follow-up was 17 years and the mean postoperative follow-up period was seven years. The mean ankle GVS improved from 18.5° before surgery to 8.7° at short term follow-up (P<0.005) and 7.8° at medium term follow-up. Equinus gait was successfully corrected in the majority of children with a low rate of over-correction (2.5%) but a high rate of recurrent equinus (35.0%), as determined by sagittal ankle kinematics. Conclusion. Surgery for equinus gait, in children with spastic diplegia, was successful in the majority of children, at a mean follow-up of seven years, when combined with multilevel surgery, orthoses and rehabilitation. No patients developed crouch gait and the rate of revision surgery for recurrent equinus was 12.5%. NO DISCLOSURES

Introduction. Limb deformity is usually assessed clinically assisted by long leg alignment radiographs and further imaging modalities (MRI and CT). Often decisions are made based on static imaging and simple gait interpretation in clinic. We have assessed the value of gait lab analysis in surgical decision making comparing surgical planning pre and post gait lab assessment. Materials & Methods. Patients were identified from the local limb reconstruction database. Patients were reviewed in the outpatient clinic and long leg alignment radiographs and a CT rotational limb profile were performed. A surgical plan was formulated and documented. All patients then underwent a formal gait lab analysis. The gait lab recommendations were then compared to the initial plan. Results. Twelve patients (8 female) with mean age of 14 (range 12–16) were identified. Nine were developmental torsional malalignments, one arthrogryposis, one hemiparesis secondary to spinal tumour resection and one syndromic limb deficiency. The gait lab recommended conservative management in four patients and agreed with eight surgical plans with one osteotomy level changing. Five patients are post-operative: two bilateral distal tibial osteotomies, two de-rotational femoral osteotomy with de-rotational tibial osteotomies and one bilateral femoral de-rotational osteotomies. Conclusions. Limb deformity correction is major surgery with long rehabilitation and recovery period. Gait lab analysis can identify who would benefit from conservative management rather than surgery with our study showing changes to surgical planning in one third of patients. The gait lab analysis helps to identify patients with functional and neuromuscular imbalances where correcting the bony anatomy may not actually benefit the patient

Advances in algorithms developed with sensor data from smart phones demonstrates the capacity to passively collect qualitative gait metrics. The purpose of this feasibility study was to assess the recovery of these metrics following joint reconstruction. A secondary data analysis of an ethics approved global, multicenter, prospective longitudinal study evaluating gait quality data before and after primary total knee arthroplasty (TKA, n=476), partial knee arthroplasty (PKA, n=139), and total hip arthroplasty (THA, n=395). A minimum 24 week follow-up was required (mean 45±12, range 24 - 78). Gait bouts and gait quality metrics (walking speed, step length, timing asymmetry, and double support percentage) were collected from a standardized smartphone operating system. Pre- and post-operative values were compared using paired-samples t-tests (p<0.05). A total of 595 females and 415 males with a mean age of 61.9±9.3 years and mean BMI of 30.2±6.1 kg/m. 2. were reviewed. Walking speeds were lowest at post-operative week two (all, p<.001). Speeds exceeded pre-operative means consistently by week 21 (p=0.015) for PKA, and week 13 (p=0.007) for THA. The average weekly step length was lowest in post-operative week two (all, p<0.001). PKA and THA cases achieved pre-operative step lengths by week seven (p=0.064) and week 9 (p=0.081), respectively. The average weekly gait asymmetry peaked at week two post-operatively (all, p <0.001). Return to pre-operative baseline asymmetry was achieved by week 11 (p=0.371) for TKA, week six (p=0.541) for PKA, and week eight (p=.886) for THA. Double limb support percentages peaked at week two (all, p<0.001) and returned to pre-operative levels by week 24 (p=0.089) for TKA, week 12 (p=0.156) for PKA, and week 10 (p=0.143) for THA. Monitoring gait quality in real-world settings following joint reconstruction using smartphones is feasible, and may provide the advantage of removing the Hawthorne effect related to typical gait assessments and in-clinic observations

Aims. To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population. Methods. In all, 73 children with idiopathic club foot were included: 31 children treated with the Ponseti method (mean age 8.3 years; 24 male; 20 bilaterally affected, 13 left and 18 right sides analyzed), and 42 treated with primary surgical correction (mean age 11.6 years; 28 male; 23 bilaterally affected, 18 left and 24 right sides analyzed). Foot function data was collected during walking gait and included Oxford Foot Model kinematics (Foot Profile Score and the range of movement and average position of each part of the foot) and plantar pressure (peak pressure in five areas of the foot). Oxford Ankle Foot Questionnaire, Disease Specific Index for club foot, Paediatric Quality of Life Inventory 4.0 were also collected. The gait data were compared between the two club foot groups and compared to control data. The gait data were also correlated with the data extracted from the questionnaires. Results. Our findings suggest that symptomatic children with club foot deformity present with similar degrees of gait deviations and perceived disability regardless of whether they had previously been treated with the Ponseti Method or surgery. The presence of sagittal and coronal plane hindfoot deformity and coronal plane forefoot deformity were associated with higher levels of perceived disability, regardless of their initial treatment. Conclusion. This is the first paper to compare outcomes between Ponseti and surgery in a symptomatic older club foot population seeking further treatment. It is also the first paper to correlate foot function during gait and perceived disability to establish a link between deformity and subjective outcomes. Cite this article: Bone Joint Open 2020;1-7:384–391

Introduction. Wearable sensors are promising tools for fast clinical gait evaluations in individuals with osteoarthritis (OA) of the knee and hip. However, gait assessments with wearable sensor are often limited to relatively simple straight-ahead walking paradigms. Parameters reflecting more complex and relevant aspects of gait, including dual-tasking, turning, and compensatory upper body motion are often overlooked in literature. The aim of this study was to investigate turning, dual-task performance, and upper body motion in individuals with knee or hip OA in addition to spatiotemporal gait parameters, taking shared covariance between gait parameters into account. Methods. Gait was compared between individuals with unilateral knee (n=25) or hip (n=26) OA scheduled for joint replacement, and healthy controls (n=27). For 2 minutes, subjects walked back-and-forth a 6 meter trajectory making 180 degree turns, with and without a secondary cognitive task. Gait parameters were collected using four inertial measurement units on feet, waist, and trunk. To test if turning, dual-tasking, and upper body motion had added value above common spatiotemporal parameters, a factor analysis was conducted. Standardized mean differences were computed for the comparison between knee or hip OA and healthy controls. One gait parameter was selected per gait domain based on factor loading and effect size for the comparison between OA groups and healthy controls. Results. Four independent domains of gait were obtained: speed-spatial, speed-temporal, dual task cost, and upper body motion. Turning parameters were part of the speed-temporal domain. From the gait domains that were obtained, stride length (speed-spatial) and cadence (speed-temporal) had the strongest factor loadings and effect sizes for both knee and hip OA, and lumbar sagittal range of motion (upper body motion) for hip OA only. Although dual-task cost was an independent domain, it was not sensitive to knee or hip OA. Conclusions. Stride length, cadence, and lumbar sagittal range of motion were non-redundant and sensitive gait parameters, representing (compensatory) gait adaptations in individuals with knee or hip OA. Turning or dual-task parameters had limited additional value for evaluating gait in knee and hip OA, although dual-task cost constituted a separate gait domain. These findings hold promise for objective gait assessments in the clinic using wearable sensors. Future steps should include testing responsiveness of these gait domains to interventions aiming to improve mobility, including knee and hip arthroplasty

For many years, achieving a neutral coronal Hip-Knee-Ankle angle (HKA) measured on radiographs has been considered a factor of success for total knee arthroplasty (TKA). Lower limb HKA is influenced by the acquisition conditions, and static HKA (sHKA) may not be representative of the dynamic loading that occurs during gait. The primary aim of the study was to see if the sHKA is predictive of the dynamic HKA (dHKA). A secondary aim was to document to what degree the dHKA changes throughout gait. We analysed the 3-D knee kinematics during gait of a cohort of 90 healthy individuals (165 knees) with the KneeKG™ system. dHKA was calculated and compared with sHKA values. Knees were considered “Stable” if the dHKA remained positive or negative – i.e. in valgus or varus – for greater than 95% of the corresponding phase and “Changer” otherwise. Patient characteristics of the Stable and Changer knees were compared to find contributing factors. The dHKA absolute variation during gait was 10.9±5.3° [2 .4° – 28.3°] for the whole cohort. The variation was greater for the varus knees (10.3±4.8° [2.4° – 26.3°]), than for the valgus knees (12.8±6.1° [2.9° – 28.3°], p=0.008). We found a low to moderate correlation (r = 0.266 to 0.553, p < 0 .001) between sHKA and the dHKA values for varus knees and no correlation valgus knees. Twenty two percent (36/165) of the knees demonstrated a switch in the dHKA (Changer). Proportion of Changer knees was 15% for varus sHKA versus 39% for valgus sHKA (p < 0.001). Lower limb radiographic measures of coronal alignment have limited value for predicting dynamic measures of alignment during gait

Background. Achieving a neutral static Hip-Knee-Ankle angle (sHKA) measured on radiographs has been considered a factor of success for total knee arthroplasty (TKA). However, recent studies have shown that sHKA seems to have no effect on TKA survivorship. sHKA is not representative of the dynamic loading occurring during gait, unlike the dynamic HKA (dHKA). Research question. The primary objective was to see if the sHKA is predictive of the dynamic HKA (dHKA). A secondary objective was to document to what degree the dHKA changes during gait. Methods. We analysed 3D knee kinematics during gait of a cohort of 90 healthy individuals with the KneeKG™ system. dHKA was calculated and compared with sHKA. Knees were considered “Stable” if the dHKA remained in valgus or varus for greater than 95% of the corresponding phase, and “Changer” otherwise. Patient characteristics of the Stable and Changer knees were compared to find associated factors. Results. dHKA absolute variation during gait was 10.9±5.3° for the whole cohort. The variation was less for the varus knees (10.3±4.8°), than for the valgus knees (12.8±6.1°, p=0.008). We found low to moderate correlations (r=0.266 to 0.553, p<0.001) between sHKA and dHKA values for varus knees and no significant correlation for valgus knees. Twenty two percent (36/165) of the knees were considered Changers. The proportion of knees that were Changers was 15% of the varus versus 39% of the valgus (p < 0.001). Significance. Lower limb radiographic measures of coronal alignment have limited value for predicting dynamic measures of alignment during gait

Introduction. Recent advances in algorithms developed with passively collected sensor data from smart phones and watches demonstrate new, objective, metrics with the capacity to show qualitative gait characteristics. The purpose of this feasibility study was to assess the recovery of gait quality following primary total hip and knee arthroplasty collected using a smartphone-based care platform. Methods. A secondary data analysis of an IRB approved multicenter prospective trial evaluating the use of a smartphone-based care platform for primary total knee arthroplasty (TKA, n=88), unicondylar knee arthroplasty (UKA, n=28), and total hip arthroplasty (THA, n=82). Subjects were followed from 6 weeks preoperative to 24 weeks postoperative. The group was comprised of 117 females and 81 males with a mean age of 61.4 and BMI of 30.7. Signals were collected from the participants' smartphones. These signals were used to estimate gait quality according to walking speed, step length, and timing asymmetry. Post-operative measures were compared to preoperative baseline levels using a Signed-Rank test (p<0.05). Results. Mean walking speeds were lowest at postoperative week 2 for all three procedures (p<.001). The TKA population stabilized to preoperative speeds by week 17. For UKA cases, mean walking speeds rebounded to preoperative speed consistently by week 9 (p>.05). THA cases returned to preoperative walking speeds with a stable rebound starting at week 6 (p>.05), and improvement was seen at week 14 (p=.025). The average weekly step length was lowest in postoperative week 2 for both TKA and UKA (p<.001), and at week 3 for THA (p<.001). The TKA population rebounded to preoperative step lengths at week 9 (p=0.109), UKA cases at week 7 (p=.123), and THA cases by week 6 (p=.946). For TKA subjects, the change in average weekly gait asymmetry peaked at week 2 postoperatively (p <0.001), returning to baseline symmetry by week 13 (p=.161). For UKA cases, mean gait asymmetry also reached its maximum at week 2 (p =.006), returning to baseline beginning at week 7 (p=0.057). For THA cases mean asymmetry reached its maximum in week 2 (p <0.001) and was returned to baseline values at week 6 (p=.150). Discussion and Conclusion. Monitoring gait quality in real-world patient care following hip and knee arthroplasty using smart phone technology demonstrated recovery curves similar to previously reported curves captured by traditional gait analysis methods and patient reported outcome scores. Capturing such real-world gait quality metrics passively through the phone may also provide the advantage of removing the Hawthorne effect related to typical gait assessments and in-clinic observations, leading to a more accurate picture of patient function

The Step Holter is a software and mobile application that can be used to easily study gait analysis. The application can be downloaded for free on the App Store and Google Play Store for iOS and Android devices. The software can detect with an easy calibration the three planes to detect the movement of the gait. Before proceeding with the calibration, the smartphone can be placed and fixed with a band or stowed into a long sock with its top edge at the height of the joint line, in the medial side of the tibia. The calibration consists in bending the knee about 20 to 30 degrees and then making a rotation movement, leaving the heel fixed to the ground as a rotation fulcrum. After calibration, the program records data related to lateral flexion, rotation, and bending of the leg. This data can be viewed directly from the smartphone screen or transmitted via a web link to the Step Holter web page . www.stepholter.com. by scanning a personal QR code. The web page allows the users to monitor the test during its execution or view data for tests done previously. By pressing the play button, it is possible to see a simulation of the patient's leg and its movement. With the analyze button, the program is capable of calculating the swing and stance phase of every single step, providing a plot with time and percentages. Finally, with the Get Excel button, test data can be conveniently exported for more in-depth research. The advantage of this application is not only to reduce the costs of a machine for the study of gait analysis but also being able to perform tests quickly, without expensive hardware or software and be used in specific spaces, without specialized personnel. Furthermore, the application can collect important data concerning rotation that cannot be highlighted with the classic gait analysis. The versatility of a smartphone allows tests to be carried out not only during walking but also by climbing or descending stairs or sitting down or getting up from a chair. This software offers the possibility to easily study any kind of patients; Older patients, reluctant to leave their homes for a gait analysis can be tested at home or during an office control visit. Step Holter could be one small step for patients, one giant leap for gait study simplicity. For any figures or tables, please contact authors directly

Aims. A flexed knee gait is common in patients with bilateral spastic cerebral palsy and occurs with increased age. There is a risk for the recurrence of a flexed knee gait when treated in childhood, and the aim of this study was to investigate whether multilevel procedures might also be undertaken in adulthood. Patients and Methods. At a mean of 22.9 months (standard deviation 12.9), after single event multi level surgery, 3D gait analysis was undertaken pre- and post-operatively for 37 adult patients with bilateral cerebral palsy and a fixed knee gait. Results. There was a significant improvement of indices and clinical and kinematic parameters including extension of the hip and knee, reduction of knee flexion at initial contact, reduction of minimum and mean knee flexion in the stance phase of gait, improved range of movement of the knee and a reduction of mean flexion of the hip in the stance phase. Genu recurvatum occurred in two patients (n = 3 legs, 4%) and an increase of pelvic tilt (> 5°) was found in 12 patients (n = 23 legs, 31%). Conclusion. Adult patients with bilateral cerebral palsy and a flexed knee gait benefit from multilevel surgery including hamstring lengthening. The risk of the occurence of genu recurvatum and increased pelvic tilt is lower than has been previously reported in children. Cite this article: Bone Joint J 2017;99-B:1256–64

Introduction. The objective of our study was to determine the extent to which the quality of the biomechanical reconstruction when performing hip replacement influences gait performances. We aimed to answer the following questions: 1) Does the quality of restoration of hip biomechanics after conventional THR influence gait outcomes? (question 1), and 2) Is HR more beneficial to gait outcomes when compared with THR? (question 2). Methods. we retrospectively reviewed 52 satisfied unilateral prosthetic hip patients (40 THRs and 12 HRs) who undertook objective gait assessment at a mean follow-up of 14 months. The quality of the prosthetic hip biomechanical restoration was assessed on standing pelvic radiograph by comparison to the healthy contralateral hip. Results. We were unable to detect any statistically significant correlation between the radiographical parameters and the gait data, for THR patients. In stress conditions (inclination or declination of the ramp), the gait was more symmetric in the HR group, compared to the THR group. Discussion/Conclusions. We found that slight variations in the quality of the hip biomechanical restoration had little effect on gait outcomes of THR patients, and HR generated a more physiological gait under stress conditions than well-functioning THR

Background. The cruciate ligaments are important structures for biomechanical stability of the knee. For total knee arthroplasty (TKA), understanding of the exact function of the (PCL) and anterior (ACL) cruciate ligament during walking is important in the light of recent designs of bicruciate TKAs. However, studies evaluating in vivo function of the PCL during daily activities such as walking are scarce. We aimed to assess the role of the PCL during gait by measuring kinematics and kinetics of individuals with PCL deficiency and compare them with individuals with ACL deficiency and healthy young adults. Methods. Individuals with unilateral PCL deficiency (PCLD; n=9), unilateral ACL deficiency (n=10) and healthy young adults performed (n=10) 10 walk trials (5 for each leg) in which they walked over a force platform. Motion analysis (Vicon Motion Capture System) was used to calculate joint angles and internal moments around the knee, hip and ankle in the sagittal plane. Joint angles and moments of the injured knee (in PCLD and ACLD) or left knee (in HYA) were compared between groups at weight acceptance, mid-stance and push-off phases (see Fig. 1). Clinical assessment included passive knee laxity (Kneelax) for anterior (in 20–30° knee flexion) and posterior tibia translation (in 70–90° knee flexion) and Lysholm questionnaires. Results. Lysholm scores were significantly lower in PCLD and ACLD individuals compared to HYA (p's ≤ .001). PCLD subjects had more passive anterior (p = .001) and posterior tibia translation (p = .041) compared to HYA, but no significant differences were found in both directions between ACLD and HYA (p's > .10). During gait, knee angles at weight acceptance, late stance and around toe-off were not significantly different between the PCLD and HYA, and between ACLD and HYA (all p's > .06). However, the knee extension moment during mid-stance was significantly lower in the PCLD group when compared to the HYA group (p = .001; Fig. 2). Interestingly, the knee moment in the PCLD group remained positive (i.e. extension moment) throughout the stance phase, whereas HYA and ACLD groups created a substantial flexion moment around the knee at this instant. We did not observe any significant differences in hip and ankle joint angles and moments between groups. Discussion. We observed a difference in gait pattern in individuals with PCL deficiency compared to HYA, that was confined to an absence of knee flexion moments during the mid-stance phase. We hypothesize that this difference reflects a compensation strategy employed by individuals with PCL deficiency to avoid external knee (hyper)extension moments. Gait adaptations related to PCL deficiency might also have implications for design of total knee prosthesis and calls for careful evaluation of gait patterns after TKA with a specific focus on the role of the PCL. For any figures or tables, please contact the authors directly

Background. Hip resurfacing arthroplasty (HRA) and total hip arthroplasty (THA) are treatments of end-stage hip disease. Gait analysis studies comparing HRA and THA have demonstrated that HRA results in a more normal gait than THA. The reasons may include the larger, more anatomic head diameter or the preservation of the neck of the femur with restoration of the anatomical position of the hip centre and normal proprioception. This study investigated (1) whether femoral head size diameter affects gait; (2) whether gait still differs between THA and HRA patients even with comparable head diameters. Methods. We retrospectively analysed the gait of 33 controls and 50 patients with a unilateral hip replacement, operated by the same surgeon. Follow-up ranged from 9–68 months. In 27 hips a small femoral head size was used (≤ 36mm); in 23 hips a large head size (>36mm). The small size group consisted of 11 long femoral stem THA and 16 short-stem THA and the large group of 5 long-stem THA, 8 short-stem THA and 10 HRA patients. There were 14 females/19 males in the control group; 22 females/5 males in the small size group; 13 females/10 males in the large size group. Results. (1) We found a significant difference in the step-length between the small head size group and the controls (p<0.01) at speeds ranging from 4.0 to 5.5 km/h but no difference between the larger head size and the controls. There was no significant difference in maximum speed, weight acceptance, push-off, mid-stance, impulse and cadence between the groups. (2) Analysis between THA and HRA in the large head size group revealed that there was a significant difference in the maximum speed (p=0.021) between the long-stem THA (6.338 km/h± 1.542) and HRA (7.756km/h± 0.7604) patients. At 5.5 km/h there was a significantly better weight acceptance (p=0.009) and mid-stance (p=0.041) of the HRA compared to short-stems. Impulse was significantly higher for HRA compared to long-stem THA (p<0.05) at all speeds ranging 4 to 5.5 km/h. (3) Males (7.1972 km/h ± .9700) had significantly higher maximum speeds compared to females (6.6524km/h± 1.019) (p=0.017) and lower gait impulse (p<0.01) at speeds ranging from 4 to 5.5km/h. (4) There was no significant difference in the Oxford Hip Score (OHS) and EQ-5D of patients in the small compared to the large head size group. Conclusions. Gait analysis demonstrated a significant difference in step length between THA patients with head size ≤ 36mm and normal controls. There was no difference in step length between normal controls and THA patients with larger head sizes. Compared to larger head size THA, the HRA still revealed higher maximum speeds and better weight acceptance. Males had significantly higher maximum speeds compared to females (controls and hip replacement patients). We could not demonstrate a correlation between better gait and Oxford scores or EQ-5D scores but these scores are known to have a ceiling effect. In a former study, better gait parameters such as longer step length and higher maximum speed have been associated with higher patient satisfaction

Total knee arthroplasty (TKA) has been shown to improve knee joint function during gait post-operatively. However, there is considerable patient to patient variability, with most gait mechanics metrics not reaching asymptomatic levels. To understand how to target functional improvements with TKA, it is important to identify an optimal set of functional metrics that remain deficient post-TKA. The purpose of this study was to identify which combination of knee joint kinematics and kinetics during gait best discriminate pre-operative gait from postoperative gait, as well as post-operative from asymptomatic. Seventy-three patients scheduled to receive a TKA for severe knee osteoarthritis underwent 3D gait analysis 1 week before and 1 year after surgery. Sixty asymptomatic individuals also underwent analysis. Eleven discrete gait parameters were extracted from the gait kinematic and kinetic waveforms, as previously defined (Astephen et al., J Orthop Res., 2008). Stepwise linear discriminant analyses were used to determine the sets of parameters that optimally separated pre-operative from post-operative gait, and post-operative from asymptomatic gait. Cross-validation was used to quantify group classification error. Knee flexion angle range, knee adduction moment first peak, and gait velocity were included in the optimal discriminant function between the pre- and post-operative groups (P<0.05), with relatively equal standardised canonical coefficients (0.567, −0.501, 0.565 respectively), and a total classification rate of 74%. A number of metrics were included in the discriminant function to optimally separate post-operative and asymptomatic gait function, including the knee flexion angle range, peak stance knee flexion angle, minimum late stance knee extension moment, minimum mid-stance knee adduction moment, and peak knee internal rotation moment (P<0.05). The mid-stance knee adduction moment had the largest standardised canonical coefficients in the function, and 89.5% of cases were correctly classified. Separation of pre and post-operative gait patterns included only three parameters, suggesting that current standard of care TKA significantly improves only walking velocity, knee flexion angle range, and the peak value of the knee adduction moment. A number of gait metrics, which were included in the discriminant function between post-operative and asymptomatic gait, could benefit from further improvement either through rehabilitation or design. With almost 90% classification, separation of post-operative gait function from asymptomatic levels is significant. The consolidation of knee joint function during gait into single, discrete discriminant scores allows for an efficient summary representation of patient-specific (or implant-specific) improvement in gait function from TKA surgery

Background. The patients with high hip dislocation due to the sequelae of septic hip or neglected Developmental Dysplasia of the Hip (DDH) show severely impaired gait pattern. Total hip arthroplasty (THA) for these patients are expected to restore gait pattern by establishing better joint stability and biomechanics. To our knowledge, no study have investigated about objective change in gait parameters after total hip arthroplasty (THA) for these patients. So, we are to prospectively evaluate change in gait patterns after THA. Methods. Between 2012 and 2013, 11 patients with highly dislocated hip underwent unilateral THA with subtrochanteric osteotomy. There was 6 patients with DDH sequelae and 5 patients with septic hip sequelae. Spatio-temporal gait analysis was performed preoperatively and at 12 months after THA. We followed the patient 3, 6, 12 months and then annually postoperatively. The gait patterns were analyzed by several parameters such as cadence, speed, stride length, step length, step time, initial double support (IDS), terminal double support (TDS), stance phase and swing phase by a three-dimensional (3D) high-speed motion-capturing system (eight Eagle® cameras; Motion Analysis, Santa Rosa, CA, USA). Also dynamic range of motion (ROM) of hip joint and ground-reaction forces (GFR) were recorded. Clinical outcome was evaluated by using the Harris Hip Score (HHS). Radiographic assessments were evaluated for the changes in leg length discrepancy (LLD). Results. For operated limb, the mean period of TDS significantly increased from 8.6 % to 11.3 % respectively (p=0.038). As IDS, single support and TDS improved, mean period of stance phase increased from 54.4 % to 60.1 % of gait cycle and swing phase was relatively reduced from 45.4% to 39.9% (p=0.005) On the other hand, there were decrease in cadence, speed, step length on the affected limb postoperatively (p>0.05). In force graph, all patients showed significant increase of the peak force postoperatively. The first peak force (Fz1) was improved from 0.76 N (0.60 – 0.98) to 0.95 N (0.79 – 1.16) (p=0.007). The second peak force (Fz2) was improved from 0.70 N (0.44–0.96) to 0.94 N (0.85 – 1.14) (p=0.007). For the dynamic ROM, there were increase in sagittal plane motion and decrease in transverse and coronal plane. All of the changes were significantly not difference than preoperatively. Clinically, mean HHS was improved from 57.2 (range, 43–67) to 79.6 (range, 61–88) at last follow-up (p<0.05). In radiographic assessment, the patients showed 9.8 mm (range, 2.1 – 22.1) residual LLD at last follow-up. Conclusions. In the present study, patients with high hip dislocation who underwent primary THA showed improvement of gait pattern closer to that of normal hip joint. Although the patients showed improvement in gait analysis and clinical outcomes, but do not reach normal hip joint level and showed little residual antalgic gait pattern after THA

Introduction. Total Hip Arthroplasty (THA) devices are now increasingly subjected to a progressively greater range of kinematic and loading regimes from substantially younger and more active patients. In the interest of ensuring adequate THA solutions for all patient groups, THA polyethylene acetabular liner (PE Liner) wear representative of younger, heavier, and more active patients (referred to as HA in this study) warrants further understanding. Previous studies have investigated HA joint related morbidity [1]. Current or past rugby players are more likely to report osteoarthritis, osteoporosis, and joint replacement than a general population. This investigation aimed to provide a preliminary understanding of HA patient specific PE liner tribological performance during Standard Walking (SW) gait in comparison to IS0:14242-1:2014 standardized testing. Materials and Methods. Nine healthy male subjects volunteered for a gait lab-based study to collect kinematics and loading profiles. Owing to limitations in subject selection, five subjects wore a weighted jacket to increase Body Mass Index ≥30 (BMI). An induced increase in Bodyweight was capped (<30%BW) to avoid significantly effecting gait [3] (mean=11%BW). Six subjects identified as HA per BMI≥30, but with anthropometric ratios indicative of lower body fat as previously detailed by the author [2] (Waist-to-hip circumference ratio and waist circumference-to-height ratio). Three subjects identified as Normal (BMI<25). Instrumented force plate loading profiles were scaled (≈270%BW) in agreement with instrumented hip force data [4]. A previously verified THA (Pinnacle® Marathon® 36×56mm, DePuy Synthes) Finite Element Analysis wear model based on Archard's law and modified time hardening model [5] was used to predict geometrical changes due to wear and deformation, respectively (Figure 1). Subject dependent kinematic and loading conditions were sampled to generate, for both legs, 19 SW simulation runs using a central composite design of response surface method. Results. HA group demonstrated comparable SW gait characteristics and Range of Motion (RoM) to the Normal group (p>0.1) (Figure 2) but statistically greater SW peak loads, PE liner wear rates, deformation, and penetration after 3Mc (Million cycles) of SW (p<0.01). HA group demonstrated comparable RoM (p>0.4) and peak loading to ISO-14242-1:2014 (p>0.1) although, up to 8° increase in flexion-extension angle was observed. The HA group demonstrated statistically greater wear rates (mean 7.5% increase) to ISO-14242-1:2014 (p<0.05) (Figure 3). No difference in PE liner deformation or penetration was observed (p>0.4). Discussion. This study detailed only a 19. th. percentile within a broader HA population (BW=91kg, n=485) [6] however, were statistically worst-case compared to a Normal group and ISO-14242-1:2014. A 95. th. percentile HA population (BW=127kg) may produce lower PE liner tribological performance than reported in this investigation and therefore, warrants further investigation. Further studies would be beneficial to determine whether the increase in PE liner wear rate for HA patients is predictable based on kinematics and loading alone, or whether influences exist in design inputs and surgical factors. Conclusion. The HA population detailed in this study (representative of a 19. th. percentile) demonstrated statistically greater SW PE liner wear rates compared to ISO-14242-1:2014. This study may have implications for the test methods considered appropriate to verify novel designs. For any figures or tables, please contact the authors directly

Introduction. Total hip arthroplasty (THA) is the most effective treatment modality for severe arthritis of the hip. Patients report excellent clinical and functional outcomes following THA, including subjective improvement in gait mechanics. However, few studies in the literature have outlined the impact of THA, as well as surgical approach, on gait kinetics and kinematics. Purpose. The purpose of this study was to determine the impact of surgical approach for THA on quantitative gait analysis. Methods. Thirty patients undergoing THA for primary osteoarthritis of the hip were assigned to one of three surgical approaches (10 anterior, 10 posterior, and 10 lateral). A single surgeon performed each individual approach. Each patient received standardized implants at the time of surgery (cementless stem and acetabular component, cobalt chrome femoral head, highly cross-linked liner). Patients underwent 3D gait analysis pre-operatively, and at 6- and 12-weeks following the procedure. At each time point, temporal gait parameters, kinetics, and kinematics were compared. Statistical analysis was performed using one-way analysis of variance. Results. All three groups were similar with respect to age (p=0.27), body mass index (p=0.16), and the Charlson Comorbidity Index (p=0.66). Temporal parameters including step length, stride length, gait velocity, and percent stance and swing phase were similar between the groups at all time points. The lateral cohort had higher pelvic tilt during stance on the affected leg than the anterior cohort at 6-weeks (p=0.033). Affected leg ipsilateral trunk lean during stance was higher in the lateral group at 6-weeks (p=0.006) and 12-weeks (p=0.037) compared to the other cohorts. The anterior and posterior groups demonstrated an increased external rotation moment at 6-weeks (p=0.001) and 12-weeks (p=0.005) compared to the lateral group. Discussion. Although temporal parameters were similar across all groups, some differences in gait kinematics and kinetics exist following THA using different surgical approaches. However, the clinical relevance based on the small magnitude of the differences remains in question

Medial knee OA effects approximately 4.1 million people in England. Non-surgical strategies to lower knee joint loading is commonly researched in the knee OA literature as a method to alleviate pain and discomfort. Medial knee OA is much more prevalent than lateral knee OA due to the weight bearing line passing medial to the knee causing an external knee adduction moment (KAM). Numerous potential gait retraining strategies have been proposed to reduce either the first and/or the second peak KAM, including: toe-in gait, toe-out gait, lateral trunk lean and medial thrust gait. Gait retraining has been researched with little regard to the biomechanical consequences at the hip and ankle joints. This systematic review aimed to establish whether gait retraining can reduce medial knee loading as assessed by first and second peak KAMs, establish what are the biomechanical effects a reduced KAM has on other lower limb joint biomechanics and outline patient/participant reported outcomes on how easy the gait retraining style was to implement. The protocol for this systematic review was registered with PROSPERO on the 23rd January 2018 (registration ID: CRD42018085738). 13 databases were searched by one author (J.B.B). Additionally, PROSPERO was searched for ongoing or recently completed systematic reviews. Risk of bias was assessed using the Downs and Black quality index. Search: Group one consisted of keywords “walk” OR “gait”. Keywords “knee” OR “adduction moment” built up the second group. Group three consisted “osteoarthriti” OR “arthriti” OR “osteo arthriti”, OR “OA”. Group four included “hip” OR “ankle”. the searched results of each group were combined with conjunction “AND” in all fields. Out of the eight different gait retraining strategies identified, trunk lean reduced first peak KAM the most, which was evaluated in 3 studies, reducing first peak KAM by 20%-65%. There was a lack of collective pelvic, hip and/or ankle joint biomechanical variables reported across all 11 studies. Of eight gait retraining styles identified, the strategy that reduced first peak KAM the most was an increased lateral trunk lean, which was evaluated in 3 different studies. This is the first systematic review that has highlighted that there is limited evidence of the biomechanical consequences of a reduced knee joint load has on the pelvic, hip and/or ankle joints when undertaking gait retraining protocols. Future studies assessing gait retraining strategies should provide biomechanical outputs for other lower limb joints other than the knee joint, as well as providing participant perceptions on the level of difficulty the gait style is to perform

Total hip arthroplasty (THA) is the most effective treatment modality for severe arthritis of the hip. Patients report excellent clinical and functional outcomes following THA, including subjective improvement in gait mechanics. However, few studies in the literature have outlined the impact of surgical approach on gait kinetics and kinematics. The purpose of this study was to determine the impact of surgical approach for THA on quantitative gait analysis. Thirty patients undergoing THA for primary osteoarthritis of the hip were assigned to one of three surgical approaches (10 anterior, 10 posterior, and 10 lateral). A single surgeon performed each individual approach. Each patient received standardised implants at the time of surgery (cementless stem and acetabular component, cobalt chrome femoral head, highly cross-linked liner). Patients underwent 3D gait analysis pre-operatively, and at 6- and 12-weeks following the procedure. At each time point, temporal gait parameters, kinetics, and kinematics were compared. Statistical analysis was performed using one-way analysis of variance. All three groups were similar with respect to age (p=0.27), body mass index (p=0.16), and the Charlson Comorbidity Index (p=0.66). Temporal parameters including step length, stride length, gait velocity, and percent stance and swing phase were similar between the groups at all time points. The lateral cohort had higher pelvic tilt during stance on the affected leg than the anterior cohort at 6-weeks (p=0.033). Affected leg ipsilateral trunk lean during stance was higher in the lateral group at 6-weeks (p=0.006) and 12-weeks (p=0.037) compared to the other cohorts. The anterior and posterior groups demonstrated an increased external rotation moment at 6-weeks (p=0.001) and 12-weeks (p=0.005) compared to the lateral group. Although temporal parameters were similar across all groups, some differences in gait kinematics and kinetics exist following THA using different surgical approaches. However, the clinical relevance based on the small magnitude of the differences remains in question