Acute effects of different orthotic interventions on knee loading parameters in knee osteoarthritis patients with varus malalignment.

BACKGROUND: Knee osteoarthritis (KOA) is the most common form of arthritis with an estimated lifetime prevalence of 45%. The use of orthotic devices is a generally accepted conservative therapy in KOA. A new conservative treatment is an ankle-foot orthosis (AFO); however, studies on the biomechanical effects are limited. The aim of this study was to examine the acute effects of different orthotic devices (AFO, knee brace and wedged shoes) on (un)loading parameters in subjects with KOA. METHODS: Fifty-two medial KOA patients (mean age 59 (standard deviation (SD) 10) years and mean body mass index 27.5 (SD 4.9) kg/m2) were recruited. Three-dimensional gait analysis was undertaken with different interventions in a randomized order: control (own shoes), new AFO, conventional unloader brace and laterally wedged shoes (six degrees). RESULTS: Significant decreases of 27% and nine percent in first peak knee adduction moment (KAM) were observed for the AFO and wedged shoes, respectively, in comparison with the control. Significant decreases of 21%, seven percent and 18% in the KAM impulse were observed for the AFO, brace and wedged shoes, respectively, compared to the control. The knee flexion moment (KFM) increased compared to the control for all conditions, but only significantly while using the AFO, showing an increase of 26% as compared to the control. CONCLUSIONS: The AFO and wedged shoes were more effective in unloading the medial compartment of the knee compared to the unloader brace. However, the effect of an increased KFM on KOA remains unclear and requires further investigation.

Acute and mid-term (six-week) effects of an ankle-foot-orthosis on biomechanical parameters, clinical outcomes and physical activity in knee osteoarthritis patients with varus malalignment.

BACKGROUND: Knee osteoarthritis (KOA) is a painful disease commonly caused by high loads on the articular cartilage. Orthotic interventions aim to reduce mechanical loading, thereby alleviating pain. Traditional orthotics appear effective, but high drop-out rates have been reported over prolonged periods. RESEARCH QUESTION: The aim of this study was to examine the effect of a novel ankle-foot orthosis (AFO) on gait parameters, physical function and activity of KOA patients. METHODS: 29 clinically diagnosed KOA patients with varus malalignment wore an AFO for 6 weeks. Prior to and after the intervention period, 3D gait analysis, physical function tests and the KOOS questionnaire were administered. Physical activity was objectively assessed with accelerometers. RESULTS: The AFO immediately reduced the first peak of the knee adduction moment (KAM) and the KAM impulse by 41% and 19%. The knee flexion moment (KFM) was increased by 48%. After six weeks, the first KAM peak and KAM impulse were decreased by 27% and 19% while using the AFO. The KFM was increased by 71%. Furthermore, patients completed the functional tests faster (1.4-2.6%). The KOOS scores decreased significantly. No significant differences were found in physical activity parameters. SIGNIFICANCE: The six-week AFO application significantly reduced the KAM. The patients' physical function appeared improved; yet these improvements were only minor and therefore arguably clinically irrelevant. The KFM appeared to be negatively affected after six weeks, as were the scores on the KOOS subscales. In summary, even though the AFO reduced the KAM and improved physical function, the clinical benefit for KOA patients with varus malalignment after the 6-week AFO application is debatable.

Long-term Outcomes of Operative and Nonoperative Treatment of Congenital Coxa Vara.

BACKGROUND: Congenital coxa vara (CCV) is a rare hip condition with few long-term studies. The purpose of this study was to assess clinical, radiographic, and functional outcomes after operative and nonoperative treatment of CCV, assess reliability of radiographic parameters, and investigate risk factors for recurrence after surgery. METHODS: Retrospective review was performed of all CCV patients treated at 1 institution from 1980 to 2010. In addition, patients were recalled for additional follow-up x-rays, modified Harris Hip Score (mHHS), and gait analysis. Radiographic measurements [neck-shaft angle (NSA), head-shaft angle (HSA), Hilgenreiner-epiphyseal angle (HEA), and femoral neck length (FNL)] were assessed for reliability using intraclass correlation coefficients. Multivariate analysis was performed to identify risk factors for recurrence after surgery. RESULTS: Forty-six hips in 32 patients were reviewed. Mean age at presentation was 5.4±4.9 years. Mean follow-up was 11.8±5.8 years. Valgus proximal femoral osteotomy was performed in 27 hips (20 patients). Initial deformity was greater in the operative group (NSA 90±17 degrees, HEA 68±19 degrees) versus nonoperative patients (NSA 122±19 degrees, HEA 34±14 degrees) (P<0.0001), but radiographic outcomes were similar at follow-up. Most nonoperative hips had normal FNL growth rates (80%), but resolution of varus NSA occurred in only 21%. In contrast, 56% of operative hips showed decreased FNL growth rates. Interobserver reliability was excellent for HEA (0.98), NSA (0.90), and FNL (0.89), and good for HSA (0.79). Repeat osteotomy was performed in 6 cases (22%). No significant predictors for recurrence were identified. At long-term follow-up for recalled patients, 72% had significantly abnormal gait, and 50% had fair-poor functional outcomes (mHHS<79). CONCLUSIONS: Valgus osteotomy corrects severe deformity in CCV with improved clinical and radiographic outcomes. HEA and NSA are the most reliable radiographic measurements of proximal femoral deformity in CCV. Recurrence is not uncommon, but no predictors were identified. Many patients have persistent gait abnormalities and functional impairment at long-term follow-up, regardless of prior treatment. LEVEL OF EVIDENCE: Level III-retrospective cohort.

[Crooked legs- just an aesthetic problem]. / Krumme Beine - mehr als ein ästhetisches Problem?

Because the lower extremities are weight bearing, malalignment plays a key role in the development of degenerative disease of the joints. This is particularly true as degenerative arthropathy is of mechanical and not inflammatory cause. Deviation of the axis has been shown to alter the load and force distribution in the joint and thereby causing excessive wear. Whether or not a deformity is clinically relevant or not depends on the symptoms, the amount of the deformity and the location of the deformity. Relevant deformities can be treated with orthotics or corrective osteotomies in early stages. In late stages fusions or joint replacement is the mainstay of treatment.

Parce que les extrémités inférieures portent un poids, un mauvais alignement de ces dernières joue un rôle clé dans le développement des atteintes dégénératives des articulations. Cela est particulièrement vrai puisque l'arthropathie dégénérative est d'origine mécanique et non pas inflammatoire. Une déviation axiale a été montrée modifier la répartition des charges et des forces dans l'articulation et provoquer ainsi un poids excessif. Qu'une déformation soit significative ou non sur le plan clinique dépend des symptômes, de l'importance et de la localisation de la déformation. Les déformations significatives peuvent être traitées dans des stades précoces par des ostéotomies orthotiques ou correctrices. Dans les stades tardifs des fusions ou des remplacements articulaires représentent les options thérapeutiques principales.