Posterior cruciate ligament deficiency (PCLD) leads to structural and proprioceptive impairments of the knee, affecting the performance of daily activities including obstacle-crossing. Therefore, identifying the biomechanical deficits and/or strategies during this motor task would be helpful for rehabilitative and clinical management of such patients. A safe and successful obstacle-crossing requires stability of the body and sufficient foot clearance of the swing limb. Patients with PCLD may face demands different from normal when negotiating obstacles of different heights. The objective of this study was thus to identify the biomechanical deviations/strategies of the lower limbs in unilateral PCLD during obstacle-crossing using motion analysis techniques.

Twelve patients with unilateral PCLD and twelve healthy controls participated in the current study with informed written consent. They were asked to walk and cross obstacles of heights of 10%, 20% and 30% of their leg lengths at self-selected speeds. The PCLD group was asked to cross the obstacles with each of the affected and unaffected limb as the leading limb, denoted as PCLD-A and PCLD-U, respectively. The kinematic and kinetic data were measured with a 7-camera motion analysis system (Vicon, Oxford Metrics, U.K.) and two force plates (AMTI, U.S.A.). The angles of the stance and swing limbs (crossing angles) and the moments of the stance limbs (crossing moments) for each joint in the sagittal plane when the leading limb was above the obstacle were calculated for statistical analysis. A 3 by 2, 2-way mixed-model analysis of variance with one between-subject factor (PCLD-A vs. Control, and PCLD-U vs. Control) and one within-subject factor (obstacle height) was performed (α=0.05). Paired t-test was used to compare the variables between PCLD-A and PCLD-U (α=0.05). SAS version 9.2 was used for all statistical analysis.

When the leading toe was above the obstacle, the PCLD group showed significantly greater hip flexion in the swing limb but decreased dorsiflexion in the stance limb, both in PCLD-A and PCLD-U (P<0.05). Greater knee flexion and greater ankle dorsiflexion were found in the leading limb in PCLD-A (P<0.05). Meanwhile, the PCLD group showed significantly decreased ankle plantarflexor but increased knee extensor crossing moments in the stance limb compared with the Control (P<0.05). None of the calculated variables were found to be significantly different between PCLD-A and PCLD-U (P>0.05).

When crossing the obstacle, patients with PCLD reduced ankle plantarflexor moments that were mainly produced by the gastrocnemius. This may help reduce the posterior instability of the affected knee. Greater knee extensor crossing moments may also help reduce the posterior instability of the standing knee when the leading toe was above the obstacle.

The changed joint kinetics as a result of PCLD were not only seen on the affected side but also on the unaffected side during obstacle-crossing. This symmetrical pattern may be necessary in performing functional activities that may require either the affected side or the unaffected side leading. These results suggest that rehabilitative intervention, including muscular strengthening, on both affected and unaffected sides are necessary in patients with unilateral PCLD.

Anterior cruciate ligament deficiency (ACLD) affects the performance of walking in some patients (non-copers) while copers are able to minimize the effects via proper musculoskeletal compensations. Since many daily activities are more challenging than level walking, e.g., obstacle-crossing, it is not clear whether copers are able to cope with such a challenging task. A successful and safe obstacle-crossing requires not only sufficient foot clearance of the swing limb, but also the stability of the body provided mainly by the stance limb. Failure to meet these demands may lead to falls owing to loss of balance or tripping over obstacles. The purpose of the current study was to identify the motor deficits and/or biomechanical strategies in coper and non-coper ACLD patients when crossing obstacles of different heights for a better function assessment.

Ten coper and ten non-coper ACLD patients were recruited in the current study. The non-coper ACLD subjects were those who had not been able to return to their pre-injury level activities, had at least once giving way during the last six months and their Lysholm knee scale was less than 70 [1]. Each subject walked and crossed obstacles of heights of 10%, 20% and 30% of their leg lengths at a self-selected pace. Kinematic and kinetic data were measured with a 7-camera motion analysis system (Vicon, Oxford Metrics, U.K.) and two force plates (AMTI, U.S.A.). The leading and trailing toe clearances were calculated as the vertical distances between the toe markers and the obstacle when the toe was directly above the obstacle. Joint angles of both limbs, and joint moments of the stance limb, were calculated. Peak extensor moments at the knee during stance phase and the corresponding joint angles were extracted for statistical analysis. A 3 by 2, 2-way mixed-model analysis of variance with one between-subject factor (group) and one within-subject factor (obstacle height) was performed (α=0.05). SAS version 9.2 was used for all statistical analysis.

Compared with the copers, significantly reduced leading and trailing toe clearances were found in the non-coper group (P<0.05). The non-copers showed significantly decreased peak extensor moments (P<0.05) and flexion angle at the affected knee during the stance phase before leading limb crossing (P<0.05).

Distinctive gait patterns were identified in coper and non-coper patients with unilateral anterior cruciate ligament deficiency during obstacle crossing. During the stance phase before the un-affected leading limb crossing, the non-copers showed significantly reduced flexion and peak extensor moments at the affected knee (i.e., quadriceps avoidance), primarily owing to the impaired stability at the affected knee. The significantly reduced leading and trailing toe clearances in the non-coper group indicate that the non-coper ACLD patients are at a higher risk of tripping over the obstacle, and may have difficulty in regaining balance owing to the unstable ACLD knee. Advanced rehabilitation program or reconstruction of the ACL is suggested for the non-coper group.

Identification of gait deviations and compensations in patients with total hip arthroplasty (THA) is important for the management of their fall risks. To prevent collapse of the lower limbs while balancing and supporting the body, proper combinations of joint moments are necessary. However, hip muscles affected by THA may compromise the sharing of load and thus the whole body balance. The current study aimed to quantify the control of body support in patients with THA in terms of the total support moment (Ms) and contributions of individual joint moments to Ms during walking.

Six patients who underwent unilateral THA via an anterolateral approach for at least six months at the time of the gait experiment, and six age- and gender-matched healthy controls were recruited. Twenty-eight infrared retro-reflected markers were placed on specific landmarks of the pelvis-leg apparatus to track the motion of the segments during walking. Kinematic and kinetic data were measured using an 8-camera motion analysis system (Vicon, Oxford Metrics, U.K.) and two force plates (AMTI, U.S.A.). The Ms of a limb was calculated as the sum of the net extensor moments at the hip, knee and ankle during stance phase. The contributions of the hip, knee and ankle to the first and second peaks of Ms (Ms1 and Ms2) were calculated by dividing the joint moment value by the corresponding peak values of Ms. Independent t-tests were performed to compare between groups at a significance level set at α=0.05 using SAS version 9.2 (SAS Institute Inc., NC, USA).

No significant differences in Ms1 and Ms2 were found between the THA group and normal controls (P >0.05). However, compared to the healthy controls, significantly increased hip and ankle contributions but decreased knee contributions to Ms1, and significantly increased hip contributions but decreased ankle contributions to Ms2 were found in the THA group.

Similar Ms1 and Ms2 between groups indicates that the lower limbs in the THA group were able to provide normal body supports. However, this was achieved via an altered contributions of the hip, knee and ankle. Hip and knee extensors play important roles in supporting the body when the Ms1 occurs during early stance of walking. In the THA group, greater hip and ankle contributions but lesser knee contributions for the Ms1 indicates that the function of hip extensors were not affected but compensatory mechanisms of the knee and ankle were found. For the Ms2, hip flexor and ankle plantarflexors are important for supporting the body during late stance. Decreased hip flexor (i.e., greater hip extensor contributions) and ankle plantarflexor moments in the THA patients suggests that the hip flexors and ankle plantarflexor muscles were affected by THA surgery. Hip muscles affected by the THA may compromise the sharing of load at the hip and thus the whole body balance. Further postoperative rehabilitation is suggested for the patients following THA. Further studies on the effects of different surgical approaches on the support moments is needed for improving treatment plans.

Introduction

The pathophysiology of osteonecrosis of femoral head (ONFH) is uncertain for most cases with speculation of vascular impairment and changes in cell biology due to multi-factorial etiologies including corticosteroid, alcohol, smoking, trauma, radiation or caisson disease and genetic. Extracorporeal shockwave therapy (ESWT) began with an incidental observation of osteoblastic response pattern during animal studies in the mid-1980 that generated an interest in the application of ESWT to musculoskeletal disorders. The mechanism of shockwave therapy is not fully understood but several reports showed better clinical outcomes and promoted bone remodelling and regeneration effect of the femoral head after ESWT in ONFH. Therefore, we compared the clinical results of the use of extracorporeal shock wave therapy (ESWT) on the patients with ONFH in radiographic staging.

We carried out an MRI study of the lumbar spine in 15 patients with achondroplasia to evaluate the degree of stenosis of the canal. They were divided into asymptomatic and symptomatic groups. We measured the sagittal canal diameter, the sagittal cord diameter, the interpedicular distance at the mid-pedicle level and the cross-sectional area of the canal and spinal cord at mid-body and mid-disc levels.

The MRI findings showed that in achondroplasia there was a significant difference between the groups in the cross-sectional area of the body canal at the upper lumbar levels. Patients with a narrower canal are more likely to develop symptoms of spinal stenosis than others.