Article

Intact Hip and Knee Joint Moment in Coronal Plane with Unilateral Transfemoral Amputee

Authors:
  • Korea Orthopedics and Rehabilitation Engineering Center
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Abstract

The incidence of osteoarthritis for lower limb amputees, especially unilateral transfemoral amputees, was higher than that of transtibial amputees. Considering level of amputation and bilateral load asymmetry, we could assumed that joint moments in the coronal plane during gait were highly related to the risk of osteoarthritis. Therefore, this study aimed to examine the hip and knee adduction moments in the coronal plane in persons with unilateral transfemoral amputation during walking through gait analysis. The subjects were 12 unilateral transfemoral amputees and 21 healthy persons. Three-dimensional motion analysis was measured bilaterally from 33 persons during walking to calculate temporal-spatial parameters and joint moments. The analysis compared the prosthetic side and the intact side of the amputee group and then analyzed the moment between both the intact sides of the transfemoral amputee group and the healthy persons. The results showed that the intact knee adduction moment of amputees increased by 32% compared to the prosthetic side and more than twice compared to the control group at terminal stance. But the bilateral hip adduction moment was decreased compared to the control group (p<0.05). Therefore it is expected that the higher knee adduction moment on the intact side may cause secondary complication to unilateral transfemoral amputees, but it is difficult to make connection with hip osteoarthritis. KeywordsUnilateral transfemoral amputees–Coronal plane–Joint moment–Osteoarthritis

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... This posture, combined with increased stance time on the intact limb, may be used to improve medial/lateral stability [6]. Gait characteristics highly dependent on the intact limb tend to induce secondary disorders and may lead to degenerative arthritis at weight-bearing joints [20]. ...
... Chang and co-workers found that the intact KAM of TFA's increased by 32% compared to the prosthetic side and more than twice compared to the control group at terminal stance [20]. The peak value of the intact KAM moment was 0.41Nm/kg at terminal stance, with the matched control group having approximately 0.19Nm/kg. ...
... The peak value of the intact KAM moment was 0.41Nm/kg at terminal stance, with the matched control group having approximately 0.19Nm/kg. The most relevant finding of Chang., et al. [20] study is that the peak value of the intact hip adduction moment (HAM) was larger than that of prosthetic side but was 9% smaller than control group (0.67Nm/kg vs 0.73Nm/kg). Additionally, the peak HAM appeared in the terminal stance, which is contrary to previous studies findings. ...
... TFA have more asymmetrical gait than NA on level ground, with limb asymmetries reported for joint kinematics [10][11][12][13], ground reaction forces [14] and lower limb joint moments [15,16]. Ankle and knee motion and pelvic-drop on the prosthetic limb are also typically smaller than the intact limb [10][11][12][13] and double support time is longer on the intact limb. ...
... Discussion TFA and NA gait over level surfaces are known to differ [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]. This study investigated differences in the adaptations of NA and TFA participants used to maintain dynamic stability when walking over a variety of non-level conditions. ...
Article
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Purpose: Describe and quantify how people with transfemoral amputations (TFA) maintain stable gait over a variety of surfaces; including, downhill and uphill, top and bottom-cross-slopes, medial-lateral translations, rolling hills and simulated rocky surfaces. Methods: Ten TFA and ten matched people without amputations (NA) walked in a virtual environment with level, sloped and simulated uneven surfaces on a self-paced treadmill. Stability was quantified using medial-lateral margin of stability (ML-MoS), step parameters, and gait variability (standard deviations for speed, temporal-spatial parameters, foot clearance and root-mean-square of medial-lateral trunk acceleration). Results and conclusions: TFA and NA adapted to non-level conditions by changing their walking speed, step width, and foot clearance. Variability for most parameters increased across conditions, compared to level. TFA walked slower than NA with shorter, wider and longer duration steps (most differences related to speed). ML-MoS did not change compared to level; however, ML-MoS was greater on the prosthetic side than both intact side and NA limbs. Foot clearance and root-mean-square of medial-lateral trunk acceleration were greater on the prosthetic side than the intact side and NA limbs. This research provides a comprehensive analysis of the different adaptations made by people without amputations compared to people with transfemoral amputations over non-level conditions and establishes significant differences between slopes and simulated uneven surfaces for TFA. • Implications for Rehabilitation • Transfemoral amputation and no amputation groups adapted walking biomechanics when traversing non-level surfaces. • Greatest temporal-spatial gait adaptations were walking speed, step width and foot clearance. • Gait parameter variability typically increased from the level condition in both groups. • Transfemoral amputation group walked slower than no amputation group with shorter, wider steps and longer duration steps. This was related to speed. • Transfemoral amputation group had more trunk motion variability on the prosthetic side than no amputation group; could be related to prosthetic fit.
... Il a été observé que le moment articulaire d'abduction dans la hanche résiduelle est inférieur à celui mesuré dans la hanche controlatérale et dans la hanche des sujets contrôles. Ce résultat, qui est cohérent avec les observations de Chang et al. (Chang, et al., 2011 Pendant la phase oscillante du membre appareillé, les courbes cinématiques du bassin dans le plan frontal montrent le phénomène de « l'élévation du bassin » (Cappozzo, et al., 1982 Est appelée pente une surface plane qui est inclinée par rapport à l'horizontale du repère de mesure dans l'axe de progression de la marche. La locomotion en pente demande de produire l'ascension du centre de masse à la montée et de le freiner à la descente. ...
... En ce qui concerne les moments articulaires dans le plan frontal dans les articulations du genou et de la hanche, on montre que ceux-ci sont plus faibles à plat chez les sujets amputés du côté appareillé que chez les sujets asymptomatiques, ce qui est cohérent avec la littérature (Chang, et al., 2011) (Rueda, et al., 2013). Les hypothèses, pouvant expliquer cette différence, sont la réduction des capacités musculaires des sujets amputés consécutives à l'atrophie musculaire en particulier chez le sujet amputé transfémoral (Jaegers, et al., 1996) ou la nécessité de maintenir des moments dans l'emboîture d'un niveau le plus faible possible (Beyaert, et al., 2008) (Grumillier, et al., 2008). ...
Article
Gait analysis of lower limb amputee locomotion in limiting situations of daily livingABSTRACT : Project deals with disability and particularly lower limb amputation. Fitting and rehabilitation restore part of locomotor system functions and allow lower limb amputee people to recover autonomy in motion. However, this autonomy is restricted due to more limiting situations than level walking (inclined surfaces, stairs, cross-slopes) patients have to face in everyday life. Developing new prosthetic components and rehabilitation protocols could reduce lower limb amputee people difficulties in these situations. In this aim, it is essential to understand the behavior of the osteo-articular system and of the prosthetic components while walking in limiting situations of daily living. Quantified gait analysis served this objective of locomotion characterization. PhD work is part of a three years project funded by ANR (French National Research Agency) in partnership with two clinical research centers, INI-CERAH and IRR, and an industrial, Proteor prosthetic components manufacturer. A protocol was set. It allows to study locomotion and locomotion adaptations of lower limb amputee people between five different daily living situations. A large and unique database, with regards to the literature, was created. It gathers parameters describing gait of 22 transfemoral amputee subjects, 21 transtibial amputee people and 30 control subjects, who followed the same protocol. Biomechanical parameters were identified to characterize amputee people locomotion adaptations between level walking and slopes and cross-slopes walking by comparing to locomotion adaptations of control subjects between flat surface and these situations. This innovative analysis method enables to analyze the locomotion of a group of people taking into account the gait pattern of each individual in the group. This work provides a protocol, a database and complementary analyses of mechanisms occurring during slope and cross-slopes locomotion.Keywords : Amputation, Biomechanics, Cross-slopes, Locomotion, Prosthetic fitting, Slopes
... The data on each marker were smoothed by Butterworth filters at 6 Hz using gait analysis software (Orthotrak 6.5; Motion Analysis). 18,19 Gait cycle ranging from heel-strike to toe-off was identified by frame analysis and normalized from 0% to 100%. ...
... The participants were tested barefoot in a static position, and then walked with the FWW at a self-selected walking speed along a 10-m walkway. 18 At that time, handgrip height was set as 48% or 55% of the participant's body height. Before these tests, the participants walked without the FWW at a self-selected walking speed along a 10-m walkway to evaluate whether there were differences in gait parameters between the GB and PB groups. ...
Article
Numerous elderly individuals use the four-wheeled walker (FWW) as a gait-assistive device. The walker's handgrip height is important for correct use. However, few clinical studies have investigated the biomechanical effects of the FWW's handgrip height on balance. Therefore, the present study assessed kinematic features of the gait, torso and pelvis during use of the FWW at two levels of handgrip height (48% vs 55% of the subject's height) while assessing balance in older adults. A total of 20 older adults were allocated into two groups according to the Berg Balance Scale (BBS): good balance (GB; BBS ≥46) versus poor balance (PB; BBS <45). Participants walked with the FWW at 48% or 55% handgrip height for 10 m. Our study showed that the double-support period and stance phase significantly increased at 55% handgrip height, but the swing phase significantly decreased in the GB group. In the PB group, velocity and stride length significantly increased at 55% handgrip height. Tilt angle of the torso in the GB group was significantly lower at 55% than at 48% handgrip height, but no differences were observed in the PB group. In the pelvis, initial contact and toe-off angles of tilt were lower in the GB group at 55% handgrip height, but no differences were observed in the PB group. These results showed that kinematic features of the gait, torso, and pelvis in older adults using the FWW might be dependent on the handgrip height of the FWW and the patient's balance. Additionally, greater than 48% of the body height might be appropriate for older adults with poor balance. Geriatr Gerontol Int 2014; ●●: ●●-●●.
... This shift may be attributed to the faster walking speed [36]. Individuals with transfemoral amputations often widen their step width during gait to better mechanically recruit the abductor muscles, enhance stability and power production capabilities [17,38], also accommodating the bulky socket. It was expected that after socket removal, the step width would decrease [16], as seen in UTF1. ...
Article
Full-text available
Background Direct skeletal fixation, a surgical technique enabling the attachment of an external prosthesis directly to the bone through a percutaneous implant, offers an enticing solution for patients with lower limb amputations facing socket-related issues. However, understanding of its impact on musculoskeletal function remains limited. Methods This study compares pre- and 1-year post-osseointegration surgery outcomes, focusing on patient-reported measures and musculoskeletal system function during level-ground walking. Two participants with unilateral transfemoral amputations and two participants with bilateral transfemoral amputations completed the questionnaire for transfemoral amputations (Q-TFA) and underwent gait analysis. Musculoskeletal modelling simulations were conducted. Results Results showed improved Q-TFA scores for all participants. Participants showed reduced amputated limb peak hip extension angles, flexion torques and contact forces at the push-off phase of the gait cycle. Post-operatively, hip adduction angles and abduction moments increased, indicating more natural gait patterns. Whilst one participant demonstrated increased post-operative walking speed, others walked more slowly. Conclusions The study revealed diverse adaptation patterns after one year in individuals with transfemoral amputations transitioning to bone-anchored prostheses. Additional longer-term data is necessary to enable generalization and clinical implications of these results.
... BTF walked with larger step widths than AB, in accordance with previous literature on BTF gait with fulllength articulated prostheses [17]. Increasing the step width reduces the hip adduction moment at full hip extension to better mechanically recruit the abductor muscles, and increases stability and power production capabilities [34]. Metabolic cost has been strongly correlated to the adopted step width [35], which might explain how the use of prosthetic devices may increase metabolic energy expenditure and reduce efficiency if used for walking long distances and periods of time, as presented in previous literature data [17]. ...
Article
Full-text available
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... BTF gluteus medius was the largest of all the subject groups (p = 0.023, 10% larger than CS). BTF have been shown to adopt a larger stride width than persons without amputation (Chang et al. 2011, Whittle 2014, Jarvis et al. 2017. Walking with wider steps is known to increase gluteus medius activity during stance (Kubinski et al. 2014) for stability and power production. ...
Article
Full-text available
Amputation of a major limb, and the subsequent return to movement with a prosthesis, requires the development of compensatory strategies to account for the loss. Such strategies, over time, lead to regional muscle atrophy and hypertrophy through chronic under or overuse of muscles compared to uninjured individuals. The aim of this study was to quantify the lower limb muscle parameters of persons with transtibial and transfemoral amputations using high resolution MRI to ascertain muscle volume and to determine regression equations for predicting muscle volume using femur- and tibia-length, pelvic-width, height, and mass. Twelve persons with limb loss participated in this study and their data were compared to six matched control subjects. Subjects with unilateral transtibial amputation showed whole-limb muscle volume loss in the residual-limb, whereas minor volume changes in the intact limb were found, providing evidence for a compensation strategy that is dominated by the intact-limb. Subjects with bilateral-transfemoral amputations showed significant muscle volume increases in the short adductor muscles with an insertion not affected by the amputation, the hip flexors, and the gluteus medius, and significant volume decreases in the longer adductor muscles, rectus femoris, and hamstrings. This study presents a benchmark measure of muscle volume discrepancies in persons with limb-loss, and can be used to understand the compensation strategies of persons with limb-loss and the impact on muscle volume, thus enabling the development of optimised intervention protocols, conditioning therapies, surgical techniques, and prosthetic devices that promote and enhance functional capability within the population of persons with limb loss.
... The loss of muscles is not sufficiently substituted by the artificial limb, but partially compensated by the non-amputated limb or other body parts (Schaarschmidt et al., 2012). This compensatory mechanism improves gait coordination to a certain extent, but at the cost of an increased burden and deviant load on the non-amputated limb, especially affecting the joint moment (Chang et al., 2011). Joint moment has frequently been used to evaluate gait performance but is insufficient for this purpose if muscle forces are not considered: similar joint moments can be induced with various levels of muscle co-contraction. ...
Article
Unilateral transfemoral amputees rely heavily on non-amputated limb muscles to regulate the prosthetic gait. In this study, we compared the non-amputated limb muscle coordination of eight unilateral transfemoral amputees to eight able-bodied controls. Inverse dynamics approach was conducted via a musculoskeletal model to obtain lower limb joint moments and muscle forces. In addition to the muscle forces at the instants of peak joint moments and the maximum muscle forces, the peak joint moments of the lower limbs were also investigated. The results showed that there were significant differences of muscle forces between the non-amputated limbs and the controls at the instant of peak hip extension moment, although the peak hip extension moments themselves were not significantly different between the two groups. The non-amputated limbs had significantly smaller peak hip flexion moment and peak knee extension moment, with significant differences between the muscle forces of non-amputated limbs and controls at the two instants. There was no significant difference between the muscle forces of the non-amputated limbs and controls at the peak knee flexion moment instant, despite the fact that the non-amputated limbs had significantly higher peak knee flexion moments. In addition, the non-amputated limbs had significantly smaller maximum muscle forces than the controls. These results demonstrate that amputees modify their muscle coordination to adapt to the specific joint requirements of the prosthetic gait. Our findings suggest the possibility of non-amputated limb muscle atrophy due to the decrease in the peak muscle forces during walking.
... Nineteen 10-mm reflective markers were bilaterally attached as following Helen Hayes marker set. 5,6 The kinematic data of all the markers and the analog signals of the force plates were sampled at 120 Hz using a real-time software program (Cortex ver1.3.0.675, Motion Analysis Corp., Santa Rosa, USA) and smoothened by Butterworth filters at 6 Hz. ...
Article
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When applying prosthetic gait training to patients with lower limb amputation, monitoring the gait change process is crucial for establishing and modifying rehabilitation training plans. In addition, since human gait involves complex movement of several joints, it is necessary to analyze the organic movement of adjacent joints rather than a single joint in the lower extremities for understanding the process of gait change. Therefore, this study aimed to analyze changes in spatiotemporal parameters and lower limb coordination during prosthetic gait training in unilateral transfemoral amputees (TFAs). This retrospective case–control study included 10 unilateral TFAs and 10 healthy individuals as controls. TFAs received prosthetic gait training for 12 weeks and gait changes were analyzed every 2 weeks using a 3D motion analysis system. The measured variables were spatiotemporal parameters and the continuous relative phase between hip and knee joints. The highest improvement in walking speed was seen at week 4 of training, and the continuous relative phase was most symmetric at week 8. The lower limb coordination pattern was more in-phase in the TFAs than in the controls, and the coordination variability was also lower for the TFAs than for the controls. In addition, the rate of change in lower limb coordination of TFAs was lower than that of spatiotemporal parameters and was significantly different from that of the controls even after training. Considering that the decrease in lower limb coordination is related to gait efficiency, balance, and risk of fall, there is a need to develop therapeutic strategies that can further improve the coordination of TFAs.
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Background: Prosthetic alignment directly affects the biomechanical loading in individuals with lower-limb amputation, and improper alignment may be contribute to the high incidence of hip and knee osteoarthritis (OA). The biomechanical changes caused by different alignments should be considered in prosthetic fitting. However, the quantitative effect of alignment on the kinetic features of individuals with transfemoral amputation remains unclear. Research question: As important kinetics indexes, how are the hip and knee joint moments affected by prosthetic alignment in individuals with transfemoral amputation? Methods: Gait tests of ten individuals with transfemoral amputation and fifteen individuals without amputation (control group) were performed. Several prosthetic alignment conditions were used, including the so-called "initial" alignment and eight malalignments. The hip and knee joint moments of the individuals with amputation under various alignments were analysed and compared with those of the control group. Statistical analyses were performed by one-way ANOVA, repeated measure multivariate ANOVA, and paired t tests. Results: The peaks and impulses of the hip abductor and external rotator moments on the residual side were significantly smaller than those of the control group (P < 0.0056). The peaks of the hip extensor, adductor and external rotator moments on the intact side were significantly larger than those on the residual side (P < 0.05). Alignment significantly affected the intact hip and knee joint moments for each individual with amputation (P < 0.00625), but there was no consistent effect among individuals. Significance: The significantly larger hip joint moment on the intact side of individuals with transfemoral amputation may be associated with the higher incidence of hip OA on the intact side. Alignment significantly affects the hip and knee joint moments of each individual with transfemoral amputation, but the individual responses to alignment changes are different. This situation may imply that the method for optimizing alignment should be personalized.
Article
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The prevalence of knee osteoarthritis was higher people with lower limb amputation. This was identified that transfemoral amputees have a greater external knee adduction moment than ablebodied subjects by biomechanical studies. Therefore, they need rehabilitative intervention for prevention and reduction of knee osteoarthritis. The purpose of this study was to determine the effect of lateral wedge insole used in the treatment of knee osteoarthritis. This study was participated in fourteen unilateral transfemoral amputees and we were analyzed the difference gait variables between without lateral wedge insole and with 5^{\circ} and 10^{\circ} lateral wedge insole during gait. Our results showed that step length ratio was more symmetrical and, hip adduction and ankle inversion angle were more close to normal value, and knee adduction moment was decreased as the wedge angle increases. We proposed that these data would be utilized conservative treatment of knee osteoarthritis in lower limb amputees.
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The analysis of knee kinematics and kinematics during high-risk movements associated with anterior cruciate ligament (ACL) injury is essential to studying the mechanism of ACL injury. Motion capture at low frame rates may not always detect the actual peak values during high-speed movements. However, the knee kinetic differences between various frame rate measurements during high-risk movements have not been reported. The purpose of this study was to investigate whether 3D knee kinetics would be measured differently between frame rates such as a high frame rate (1200 Hz), 400 Hz, 240 Hz and the popular low frame rate (120 Hz). Knee kinetics during a single-leg drop landing and side-step cutting under different frame rates were repeatedly measured and statistically compared. Peak knee valgus and tibial internal rotation moments measured at a popular low frame rate were significantly lower than those measured at the other frame rates of 400 Hz and 1200 Hz. The peak anterior and superior forces measured at the highest (1200 Hz) frame rate were significantly higher than those measured at any other frame rates. In addition, the variations in the peak kinetic values were significantly larger at the lowest frame rate capture and trended toward being smaller at the higher frame rates. In conclusion, significant differences in the knee kinetics between the frame rates suggest that the high frequency capturing increases the accuracy of the knee kinetics measurement for high risk maneuvers for the study of ACL injury.
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The intact knee adduction moment of unilateral transfemoral amputees was in general higher than that of able-bodied subjects and it can be related to prevalence of knee osteoarthritis. Although high knee adduction moment was affected by ankle inversion in amputee gait, biomechanical study for that was rare. This study aimed to analyze the correlation between ankle inversion in gait parameters and the intact knee adduction moment in transfemoral amputees by gait analysis. For 13 transfemoral amputees and 14 healthy persons, kinematical and kinetic data including spatio-temporal parameters, joint angles, and moments on the coronal plane were calculated by 3D motion analysis during level walking. Bilateral hip abduction, the intact ankle inversion and knee abduction angles in transfemoral amputees were larger than that in normal subjects. Knee adduction moment in the terminal stance phase was 26% higher than that in the normal group. As ankle inversion angle and ankle power in the intact side of transfemoral amputees were increased, hip and knee adduction moments were also increased. Increased ankle inversion angle was related to slow walking speed, wider step width and longer stance time of the intact limb. Gait abnormalities by increased ankle inversion affected the intact hip and knee adduction moment of transfemoral amputees. Appropriate rehabilitation intervention like lateral wedge insole should be required to correct these abnormal gait patterns.
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Objectives: To investigate the association between amputation, osteoarthritis and osteopenia in male war veterans with major lower limb amputations. Specific questions were to determine whether lower limb amputees following trauma are at subsequent risk of developing osteoarthritis (OA) and osteoporosis of the hip on both the amputated and nonamputated sides. Design: Retrospective cohort study in British Male Second World War veterans with major unilateral lower limb amputations. Subjects: Seventy-five male Second World War veterans with major lower limb amputations known to be alive were invited to participate from a subregional rehabilitation centre. After exclusions, 44 agreed to attend for examination and radiological screening. Methods: The presence of hip OA was determined from a single anterior posterior pelvic X-ray using two approaches: minimum joint space and the Kellgren and Lawrence (K&L) scoring system. Bone mineral density (BMD) was measured by a dual energy X-ray absorptiometry (DXA) scan and prosthetic rehabilitation outcome measures were recorded. Results: Twenty-seven (61%) hips on the amputated side and 10 (23%) on the nonamputated side were positive for OA (based on Kellgren and Lawrence grade of >2). Using a minimum joint space threshold of below 2.5 mm, 24 (55%) hips on the amputation side and 8 (18%) on the nonamputated side were also positive for OA. There was a threefold increased risk of OA for those with above-knee compared to a below-knee amputation. By contrast, from published general population surveys only 4 (11%) cases of hip OA would have been expected on both the amputated and nonamputated hips. There was a significant decrease in femoral neck BMD in the amputated side (p <0.0001) and significantly lower BMD in above-knee amputees than in below-knee amputees (p = 0.0027) as compared to normal age and sexmatched population.
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To determine the prevalence of osteoarthritis (OA) in the knee and/or hip of the intact leg among traumatic leg amputees compared with the general population and its relationship with amputation level, time since amputation, age, and mobility. Cross-sectional observational study. Outpatient population of 2 Dutch rehabilitation centers. Patients (N=78) with a unilateral traumatic transtibial amputation, knee disarticulation, or transfemoral amputation of at least 5 years ago; ability to walk with a prosthesis; older than 18 years of age; and able to understand Dutch. Patients were excluded if they had bilateral amputations, other pathologies of the knee or hip, or central neurologic pathologies. Not applicable. The prevalence of OA. The prevalence of knee OA was 27% (men 28.3%, women 22.2%) and hip OA was 14% (men 15.3%, women 11.1%). This was higher compared with the general population (knee OA men 1.58%, women 1.33%, hip OA men 1.13%, women 0.98%, age adjusted). No significant relationships between the prevalence of OA and level of amputation, time since amputation, mobility, and age were found. The prevalence of OA is significantly greater for both the knee and hip in the traumatic leg amputee population. No specific risk factors were identified. Although no specific risk factors in this specific population could be identified, it might be relevant to apply commonly known strategies to prevent OA as soon as possible after the amputation.
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The aim of this study was to describe the gait of persons with a unilateral transfemoral amputation by means of a questionnaire, gait analysis and measurement of energy expenditure, and to find correlations among the variables studied. The study included 29 transfemoral amputees amputated for other reasons than a chronic vascular disease. The patients were assessed using the following methods: 1) A questionnaire rating the walking distance and walking difficulty in different circumstances. 2) Gait analysis measuring temporal variables and goniometry of hips and knees. 3) Measurement of energy expenditure during sitting and walking. Scores on the questionnaire showed a correlation with socket design, a negative correlation with age and energy expenditure, and a positive correlation with fast speed. The gait of transfemoral amputees was asymmetrical as far as temporal variables were concerned, and for most amputees also for the range of motion of hip and knee. The walking speed of the amputees was lower than that of non-amputees and showed a positive correlation with hip extension-flexion range of motion and a negative correlation with age and stride time. The energy expenditure of the amputees during ambulation was higher than that of non-amputees, and seemed to correlate with residual limb length and the hip abduction-adduction range of motion.
Article
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Increased joint loading and elevated bone density may be involved in the initiation or progression of osteoarthritis. Here, we provide an introduction to the literature on this topic and describe recent studies from our laboratories on several cohorts of subjects who had or were scheduled to have a total hip replacement for unilateral end-stage osteoarthritis. This population is very useful for studying the development and progression of osteoarthritis because of the known higher incidence of osteoarthritis in the contralateral hip than in a normal population. Separate studies of the asymptomatic contralateral hip in these subjects have shown that radiographic signs of early osteoarthritis are associated with increased bone mineral density and some of the gait adaptations typically found in subjects with end-stage osteoarthritis. We have also shown in separate studies of similar populations that elevated bone mineral density is associated with a subsequent accelerated joint space narrowing rate and that elevated hip joint loads during gait are similarly associated with an accelerated narrowing rate. Major questions yet to be answered are how joint loading and bone density interact in the development and progression of joint degeneration.
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To test the hypothesis that dynamic load at baseline can predict radiographic disease progression in patients with medial compartment knee osteoarthritis (OA). During 1991-93 baseline data were collected by assessment of pain, radiography, and gait analysis in 106 patients referred to hospital with medial compartment knee OA. At the six year follow up, 74 patients were again examined to assess radiographic changes. Radiographic disease progression was defined as more than one grade narrowing of minimum joint space of the medial compartment. In the 32 patients showing disease progression, pain was more severe and adduction moment was higher at baseline than in those without disease progression (n=42). Joint space narrowing of the medial compartment during the six year period correlated significantly with the adduction moment at entry. Adduction moment correlated significantly with mechanical axis (varus alignment) and negatively with joint space width and pain score. Logistic regression analysis showed that the risk of progression of knee OA increased 6.46 times with a 1% increase in adduction moment. The results suggest that the baseline adduction moment of the knee, which reflects the dynamic load on the medial compartment, can predict radiographic OA progression at the six year follow up in patients with medial compartment knee OA.
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To determine the effects of two different prosthetic feet on the three-dimensional kinetic patterns of both the prosthetic and sound limbs during unilateral trans-tibial amputee gait. Eleven individuals with a unilateral trans-tibial amputation participated in two walking sessions: once while using the conventional SAFE foot, the other while using the dynamic Flex foot. Despite the wide variation in the design of prosthetic feet, the benefits of these prostheses remain unclear. During each test session, peak joint moments and powers in the sagittal, transverse and frontal planes were examined, as subjects walked at a comfortable speed. The majority of the kinetic differences that occurred due to the changing of prosthetic foot type were limited to ankle joint variables in the sagittal plane with greater peak moments and power during propulsion for the Flex foot compared to the SAFE foot. However, effects were also found at joints proximal to the prosthesis (e.g. knee) and differences were also found in the kinetics of the sound limb. The dynamic Flex foot allowed subjects to rely more heavily on the prosthetic foot for propulsion and stability during walking with minimal compensations at the remaining joints. Determining the biomechanical differences between the conventional and dynamic prosthetic feet may advocate the use of one prosthetic foot type over another. This information, when used in conjunction with subjective preferences, may contribute to higher functioning and greater satisfaction for individuals with a lower limb amputation.
Article
Increased joint loading and elevated bone density may be involved in the initiation or progression of osteoarthritis. Here, we provide an introduction to the literature on this topic and describe recent studies from our laboratories on several cohorts of subjects who had or were scheduled to have a total hip replacement for unilateral end-stage osteoarthritis. This population is very useful for studying the development and progression of osteoarthritis because of the known higher incidence of osteoarthritis in the contralateral hip than in a normal population. Separate studies of the asymptomatic contralateral hip in these subjects have shown that radiographic signs of early osteoarthritis are associated with increased bone mineral density and some of the gait adaptations typically found in subjects with end-stage osteoarthritis. We have also shown in separate studies of similar populations that elevated bone mineral density is associated with a subsequent accelerated joint space narrowing rate and that elevated hip joint loads during gait are similarly associated with an accelerated narrowing rate. Major questions yet to be answered are how joint loading and bone density interact in the development and progression of joint degeneration.
Article
The aim of this project was to explore the nature of gait accommodations by unilateral below-knee amputees during walking. Lower extremity kinematic and kinetic data for two groups of subjects, 6 below-knee amputees (both prosthetic and intact limbs) and 6 able-bodied individuals (a single limb), were computed as subjects walked at 1.2 and 1.6 m/s. Kinematic profiles were similar for all three limb conditions. The largest difference between limbs occurred late in stance at the ankle joint when the prosthetic limb displayed substantially less planter flexion because of its passive response to unloading. Joint kinetic differences between limbs were most apparent at the knee. Whereas the net ankle and hip moments were similar for all three limb conditions, the net knee moment for the prosthetic leg deviated from the amputee intact and non-amputee limbs by remaining flexor throughout the stance phase. This response was attributed to an effort to reduce loading on and about the knee joint and stump of the prosthetic limb. Despite the absence of an extensor contribution from the prosthetic knee, the overall support moment on the prosthetic side was sufficient to provide a normal support function.
Article
The joint is an organ and functions as a mechanical bearing created of biological materials. In the joint, as in all connective tissues, there is a relationship between mechanical factors and tissue behavior. Therefore, it is not surprising that joint health and osteoarthrosis are reflections of both mechanical and biological factors. Osteoarthrosis is not a disease, but organ failure caused initially by mechanical factors. The biological changes follow. There is no habitual pathophysiological cascade. Osteoarthrosis is best thought of not as a common final pathway, but as a common end stage. The hypotheses that in osteoarthrosis substructural disorganization of the matrix proceeds chondrocytic enzyme production, that impulsive loading is an essential factor in the progressive cartilage destruction, and that tidemark advancement and horizontal cartilage splitting are the primary mechanisms in progressive cartilage loss are discussed.
Article
The prosthetic gait of unilateral transfemoral amputees. Case series. Laboratory of Gait Analysis (GIGA-system of K-lab) in the Department of Rehabilitation of a university hospital. Eleven men with transfemoral amputation (mean age 35.7 years) participated. The amputation was performed at least 2 years ago and was caused by trauma or osteosarcoma. Stride parameters as well as the patterns of motion of the trunk, hip, and knee joint. The amputees walked with a 29% lower vcomf than normal subjects. The amputees compensate the vrapid with their stride length rather than with their step rate. The amputees showed an asymmetrical walking pattern; the amputees stood a little longer on their intact leg than on their prosthetic leg. Four amputees showed an extreme lateral bending of the trunk toward the prosthetic side during the stance phase of the prosthetic leg. The rebound of the hip at the amputated side at heel strike was very small or absent. The intact knee was flexed at heel strike and remained in a flexed position during the entire stance phase. The amount of asymmetry of the walking pattern is related to the stump length. The amputees with highly atrophied hip-stabilizing muscles walked with an extreme lateral bending of the trunk toward the prosthetic side. There is no correlation between stride width and lateral bending of the trunk. Amputees with a short and medium stump length showed a fast transition from hip extension to hip flexion.
Article
This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses normal gait, the influence of prosthetic alignment on amputee function, and the effects of prosthetic components on the metabolic costs and the biomechanical function of the amputee. The biomechanics of normal ambulation are presented as a background to enable the practitioner to gain an understanding of the typical gait adaptations that occur in below-knee and above-knee amputees. The effects of newer prosthetic components and socket designs on the biomechanical adaptations are reviewed. The metabolic costs of amputee ambulation are significantly greater than normal. The theoretical mechanisms for this are discussed, and the effects of newer socket designs, ultra-light-weight components, and energy-storing prosthetic components are presented.
Article
A five-camera Vicon (Oxford Metrics, Oxford, England) motion analysis system was used to acquire foot and ankle motion data. Static resolution and accuracy were computed as 0.86 +/- 0.13 mm and 98.9%, while dynamic resolution and accuracy were 0.1 +/- 0.89 and 99.4% (sagittal plane). Spectral analysis revealed high frequency noise and the need for a filter (6 Hz Butterworth low-pass) as used in similar clinical situations. A four-segment rigid body model of the foot and ankle was developed. The four rigid body foot model segments were 1) tibia and fibula, 2) calcaneus, talus, and navicular, 3) cuneiforms, cuboid, and metatarsals, and 4) hallux. The Euler method for describing relative foot and ankle segment orientation was utilized in order to maintain accuracy and ease of clinical application. Kinematic data from a single test subject are presented.
Article
To quantify the muscular adaptations of above-knee amputee patients' ambulation using an experimental and modeling approach. Nonrandomized controlled study. A referral center for treatment of veterans with amputation. Eight normal ambulators and 8 nondysvascular above-knee amputee subjects wearing the same lightweight prostheses were studied with a gait analysis system, walking at self-selected speeds. Using an inverse dynamics linked segment model, the mechanical torque, power output, and work done were calculated at the hip, knee, and ankle joints. The mean concentric ankle plantarflexor work done was much greater for the normal subjects compared to the prosthetic limb in pushoff (25.2 +/- 3.7 J vs 4.9 +/- 2.1 J), but greatest for the intact limb of the amputee subjects (34.2 +/- 6.6 J). Also, the concentric hip extensor work done in early stance was greater for the intact limb of the amputee subjects than for normal subjects (9.9 +/- 5.5 J vs 3.6 +/- 2.6 J), presumably compensating for the coincident decreased pushoff of the prosthetic limb. Other compensatory mechanisms are also discussed. Increased joint torques and power outputs of the amputee subjects' intact limb compared to normal ambulation may be viewed as providing additional gait progression and upright stance during parts of the gait cycle when the amputated limb lacks needed active muscle support.
Article
This study related mechanisms of gait compensations to the level of pain and to limitations in passive motion in patients with osteoarthritis of the hip. Joint motion, moments, and intersegmental forces were calculated for 19 patients with unilateral osteoarthritis of the hip (12 men and seven women) and for a group of normal subjects (12 men and seven women) with a similar age distribution. The patients who had osteoarthritis walked with a decreased dynamic range of motion (17 +/- 4 degrees) of the hip and with a hesitation or reversal in the direction of the sagittal plane motion as they extended the hip. The patients with a hesitation or reversal in motion had a greater loss in the range of motion of the hip during gait (p < 0.004) and a greater passive flexion contracture (p < 0.022) than those with a smooth pattern of hip motion. This alteration in the pattern of motion was interpreted as a mechanism to increase effective extension of the hip during stance through increased anterior pelvic tilt and lumbar lordosis. The patients who had osteoarthritis of the hip walked with significantly decreased external extension, adduction, and internal and external rotation moments (p < 0.008). The decreased extension moment was significantly correlated with an increased level of pain (R = 0.78; p < 0.001). This finding suggests that decreasing muscle forces (hip flexors) may be one mechanism used to adapt to pain.
Article
The present study examined the loads at the hip joint during gait and the bone mineral density of the proximal femur in 25 patients with end-stage hip osteoarthritis. Dual energy X-ray absorptiometry was used to determine the bone mineral density of the greater trochanter, femoral neck and Ward's triangle of the osteoarthritic group. The bone mineral density was normalized for the patient's age, gender, weight and ethnic origin (Z score). Gait analysis was used to determine the external hip joint moments and motion during walking for the osteoarthritic group and a control group of 21 normal subjects. The gait parameters of the osteoarthritic group which were significantly diminished compared to the normal group (p < 0.001) accounted for as much as 42% (p < 0.001) of the variation in the normalized bone mineral density. Specifically, the dynamic sagittal plane hip motion during gait (maximum flexion minus maximum extension) and peak external rotation and adduction moments were significantly correlated with greater trochanter (R = 0.429-0.648, p = 0.032-0.0001) and Ward's triangle (R = 0.418-0.532, p = 0.038-0.006) normalized bone mineral density while the adduction moment was also significantly correlated with the femoral neck normalized bone mineral density (R = 0.5394, p = 0.005). The normalized bone mineral density of the femoral neck and Ward's triangle was elevated while that of the greater trochanter was decreased as compared to normal reference values. The significant correlation between the hip joint moments during gait and femoral bone mineral density indicate that hip joint loads need to be included when explaining local variation in bone mineral density in hip osteoarthritis.
Article
Although treatments for osteoarthritis of the knee are often directed at relieving pain, pain may cause patients to alter how they perform activities to decrease the loads on the joints. The knee-adduction moment is a major determinant of the load distribution between the medial and lateral plateaus. Therefore, the interrelationship between pain and the external knee-adduction moment during walking may be especially important for understanding mechanical factors related to the progression of medial tibiofemoral osteoarthritis. Fifty-three subjects with symptomatic radiographic evidence of osteoarthritis of the knee were studied. These subjects were a subset of those enrolled in a double-blind study in which gait analysis and radiographic and clinical evaluations were performed after a 2-week washout of anti-inflammatory and analgesic treatment. The subjects then took a nonsteroidal anti-inflammatory drug, acetaminophen, or placebo for 2 weeks, and the gait and clinical evaluations were repeated. The change in the peak external adduction moment between the two evaluations was inversely correlated with the change in pain (R = 0.48, p < 0.001) and was significantly different between those whose pain increased (n = 7), decreased (n = 18), or remained unchanged (n = 28) (p = 0.009). Those with increased pain had a significant decrease in the peak external adduction (p = 0.005) and flexion moments (p = 0.023). In contrast, the subjects with decreased pain tended to have an increase in the peak external adduction moment (p = 0.095) and had a significant increase in the peak external extension moment (p = 0.017). The subjects whose pain was unchanged had no significant change in the peak external adduction (p = 0.757), flexion (p = 0.234), or extension (p = 0.465) moments. Thus, decreases in pain among patients with medial tibiofemoral osteoarthritis were related to increased loading of the degenerative portion of the joints. Additional long-term prospective studies are needed to determine whether increased loading during walking actually results in accelerated progression of the disease.
Article
To assess the prevalence of osteoarthritis (OA) of the contralateral knee of men with traumatic amputation who do and do not participate in regular, vigorous physical activity. Three groups of patients were assessed. Group 1 consisted of 8 male amputee volleyball players. Group 2 consisted of 24 male amputees who do not play volleyball, and Group 3 was made up of 24 healthy controls matched by age and weight to Group 2. The prevalence of contralateral knee OA in Groups 1 and 2 was assessed by questionnaire, physical examination, and radiographs, and was compared with findings for Group 3. The rate of OA in all amputees (Groups 1 and 2 together) was 65.6%, which was significantly higher than among the controls (p < 0.05). The most common findings among the amputees were patellar and medial osteophytosis of the tibiofemoral joint, with a tendency to medial narrowing of the tibiofemoral joint space. Traumatic amputees have a higher prevalence of OA in the knee of the nonamputated leg than matched healthy controls.
Article
To investigate the relationships among bone mineral density (BMD), static alignment and the adduction moment of the knee in patients with tibiofemoral osteoarthritis (OA). Sixty-nine patients with medial compartment knee OA underwent radiographic evaluation, gait analysis and BMD measurements at the proximal tibia and lumbar spine. The bone mineral distribution of the medial to lateral part of the proximal tibia correlated significantly with the peak knee adduction moment and the mechanical axis. Furthermore, the adduction moment correlated significantly with the mechanical axis. However, the BMD of the lumbar spine and the bone mineral distribution of the posterior to anterior part of the proximal tibia did not correlate with any other measurement. Our results suggest that the bone mineral distribution of the proximal tibia is directly affected but lumbar BMD is not influenced by the local mechanical stress around the knee with medial compartment OA.
Article
This study tested whether the peak external knee adduction moments during walking in subjects with knee osteoarthritis (OA) were correlated with the mechanical axis of the leg, radiographic measures of OA severity, toe out angle or clinical assessments of pain, stiffness or function. Gait analysis was performed on 62 subjects with knee OA and 49 asymptomatic control subjects (normal subjects). The subjects with OA walked with a greater than normal peak adduction moment during early stance (p = 0.027). In the OA group, the mechanical axis was the best single predictor of the peak adduction moment during both early and late stance (R = 0.74, p < 0.001). The radiographic measures of OA severity in the medial compartment were also predictive of both peak adduction moments (R = 0.43 to 0.48, p < 0.001) along with the sum of the WOMAC subscales (R = -0.33 to -0.31, p < 0.017). The toe out angle was predictive of the peak adduction moment only during late stance (R = -0.45, p < 0.001). Once mechanical axis was accounted for, other factors only increased the ability to predict the peak knee adduction moments by 10 18%. While the mechanical axis was indicative of the peak adduction moments, it only accounted for about 50% of its variation, emphasizing the need for a dynamic evaluation of the knee joint loading environment. Understanding which clinical measures of OA are most closely associated with the dynamic knee joint loads may ultimately result in a better understanding of the disease process and the development of therapeutic interventions.
Article
This study tests the hypothesis that the peak external knee adduction moment during gait is increased in a group of ambulatory subjects with knee osteoarthritis (OA) of varying radiographic severity who are being managed with medical therapy. Tibiofemoral knee OA more commonly affects the medial compartment. The external knee adduction moment can be used to assess the load distribution between the medial and lateral compartments of the knee joint. Additionally, this study tests if changes in the knee angles, such as a reduced midstance knee flexion angle, or reduced sagittal plane moments previously identified by others as load reducing mechanisms are present in this OA group. Thirty-one subjects with radiographic evidence of knee OA and medial compartment cartilage damage were gait tested after a 2-week drug washout period. Thirty-one normal subjects (asymptomatic control subjects) with a comparable age, weight and height distribution were also tested. Significant differences in the sagittal plane knee motion and peak external moments between the normal and knee OA groups were identified using t tests. Subjects with knee OA walked with a greater than normal peak external knee adduction moment (P=0.003). The midstance knee flexion angle was not significantly different between the two groups (P=0.625) nor were the peak flexion and extension moments (P> 0.037). Load reducing mechanisms, such as a decreased midstance knee flexion angle, identified by others in subjects with endstage knee OA or reduced external flexion or extension moments were not present in this group of subjects with knee OA who were being managed by conservative treatment. The finding of a significantly greater than normal external knee adduction moment in the knee OA group lends support to the hypothesis that an increased knee adduction moment during gait is associated with knee OA.
Article
The effect of increased walking speed on temporal and loading asymmetry was investigated in highly active trans-femoral and trans-tibial amputees. With increasing walking speed, temporal gait variables reduced in duration, particularly on the prosthetic limb, while vertical ground reaction force (vGRF) increased in magnitude, particularly on the intact limb. Thus, temporal asymmetry reduced and loading asymmetry increased with walking speed. The greater force on the intact limb may reflect the method by which the amputees achieve greater temporal symmetry in order to walk fast, and could possibly account for greater instances of joint degeneration in the intact limb reported in the literature.
Article
To determine whether amputees have an increased risk of knee pain or symptomatic osteoarthritis (OA) compared with nonamputees. Retrospective cohort study. Veterans Administration Patient Treatment and Outpatient Care files. All male unilateral (transtibial or transfemoral) traumatic amputee patients and a random sample of male nonamputees. Patients were excluded if they were younger than 40 years, had sustained a significant injury to their knee(s), or had a rheumatic disease. Not applicable. The prevalence of knee pain and symptomatic knee OA. The age and average weight-adjusted prevalence ratio of knee pain among transtibial amputees, compared with nonamputees, was 1.3 (95% confidence interval [CI], 0.7-2.1) for the knee of the intact limb and 0.2 (95% CI, .05-0.7) for the knee of the amputated limb. The standardized prevalence ratio of knee pain in the intact limb and symptomatic OA among transfemoral amputees, compared with nonamputees, was 3.3 (95% CI, 1.5-6.3) and 1.3 (95% CI, 0.2-4.8), respectively. Stresses on the contralateral knee of amputees may contribute to secondary disability. Possible explanations include gait abnormalities, increased physiologic loads on the knee of the intact limb, and the hopping and stumbling behavior common in many younger amputees.
Article
Persons with unilateral, lower-extremity amputation are at risk of developing osteoarthritis in their intact limb. Among persons without amputation, knee osteoarthritis disease severity has been linked to elevated frontal plane knee moments. Therefore, the purpose of this study was to examine knee and hip frontal plane moments in persons with unilateral, trans-tibial amputation. We hypothesized that knee and hip internal abduction moments are greater in the intact limb compared to the prosthetic side. Three-dimensional gait mechanics were measured bilaterally from 10 persons with unilateral, trans-tibial amputation during walking to calculate lower-extremity joint moments. The intact limb knee and hip peak internal abduction moments were 46% and 39% greater, respectively, than on the prosthetic side. The intact side knee and hip peak internal abduction moments were 17% and 6% greater, respectively, than normal. Larger moments suggest joint loading is of higher magnitude on the intact side, which may be predisposed to premature joint degeneration, particularly knee osteoarthritis.
Article
Persons with unilateral, lower-extremity amputation sometimes develop osteoarthritis in the intact limb. The purpose of this study was to investigate gait mechanics and bone mineral density in unilateral, trans-tibial amputees to test the hypotheses that the intact limb knee and hip will have larger frontal plane net joint moments and bone mineral density than the prosthetic side and the limbs of control subjects. Proximal tibia and femoral neck bone mineral density and gait mechanics were measured from nine subjects with a unilateral, trans-tibial amputation and from age, gender, and mass matched control subjects. The amputee intact proximal tibia bone mineral density and peak knee internal abduction moment were 45% (P=0.001) and 56% (P=0.028) greater, respectively, than the prosthetic side. The intact limb femoral neck bone mineral density and peak hip internal abduction moment were 12% (P=0.095) and 33% (P=0.03) greater, respectively, than the prosthetic side. The intact knee frontal plane moment and bone mineral density were moderately larger than the control knee, while the intact and control hip were similar. Elevated frontal plane net joint moments and bone mineral density suggest the potential exists for premature knee joint degradation. Measuring frontal plane joint mechanics and bone mineral density may be important tools for assessing joint health in persons with unilateral, trans-tibial amputation.
Proceedings and reports of universities, colleges, councils and associations
  • British Orthopaedic Association
British Orthopaedic Association, " Proceedings and reports of universities, colleges, councils and associations, " J. Bone Joint Surg. Br., Vol. 57B, pp. 111-123, 1975.