Focusing on functional knee parameter determination to develop a better clinical gait analysis protocol.

BACKGROUND: Attempts to improve protocol standards of marker-based clinical gait analysis (CGA) have been one of the main focuses of research to enhance robustness and reliability outcomes since the 1990s. Determining joint centres and axes constitutes an important aspect of those protocols. Although the hip joint is more prominent in such studies, knee joint center (KJC) and axis (KJA) directly affect all outcomes. RESEARCH QUESTION: What recommendations arise from the study of the scientific literature for determining knee joint parameters (KJP) for protocols of CGA? METHODS: A systematic, electronic search was conducted on November 2018 using three databases with the keyword combination ("functional approach" OR "functional method" OR "functional calibration") AND ("hip joint" OR "knee joint" OR "ankle joint") and analyzed by four reviewers. Given the existence of a recent review about the hip joint and the lack of material about the ankle joint, only papers about the knee joint were kept. The references cited in the selected papers were also screened in the final round of the search for these publications. The quality of the selected papers was assessed and aspects regarding accuracy, repeatability, and feasibility were thoroughly considered to allow for a comparison between studies. Technical aspects, such as marker set choice, KJP determination techniques, demographics, and functional movements, were also included. RESULTS: Thirty-one papers were included and on average received a rating of about 75 % according to the quality scale used. The results showed that functional methods are superior or equivalent to predictive methods to estimate the KJA, while a regression method was slightly better for KJC prediction. SIGNIFICANCE: Calibration methods should be applied to CGA whenever feasibility is reached. No study to date has focused on evaluating the in vivo RoM required to obtain reliable and repeatable results and future work should aim in this direction.

[Expert assessment of lower extremity prosthetics]. / Begutachtung von Prothesenversorgungen der unteren Extremität.

Although the number of major amputations is declining throughout Germany, more than 57,000 surgical procedures for amputation still take place. As a consequence of high prosthetic care costs, these often lead to disputes before the social court in which expert medical opinions are required. With knowledge of the legal norms, the remit of the expert opinion can be fulfilled. The expert begins with evaluation of the patient's file and a search of the contested parts. The investigation includes a medical history, in addition to a physical examination, in order to be able to comment on the disputed beneficial use of the therapeutic appliance and respond to questions of proof. Questionnaires may be helpful.

Prosthetic restoration of the forefoot lever after Chopart amputation and its consequences onto the limb during gait.

BACKGROUND: In subjects with Chopart amputation the foot lever is clearly diminished. Usually high or low profile prostheses are routinely utilized to re-establish the lost forefoot lever. RESEARCH QUESTION: The aim of this study was to investigate to what extent the proposed prostheses were able to replace the forefoot lever in chopart-amputees. METHODS: An instrumented 3D gait analysis, including plantar and socket pressure measurements, was performed in thirteen subjects with Chopart amputation using a clamshell and/or a Bellmann prosthesis including an ankle foot orthosis during level ground walking. RESULTS: The largest range of motion (p < 0.05) in the ankle joint was seen for the Bellmann prosthesis (32 ±â€¯3°) followed by the Bellmann prosthesis with ankle-foot orthosis (22 ±â€¯6°) whereas in the clamshell prosthesis (10 ±â€¯4°) almost no ankle motion was seen. Conversely, the highest ankle joint moment (p < 0.05) was seen for the clamshell prosthesis (1.04 ±â€¯0.24Nm/kg) followed by the Bellmann prosthesis with ankle-foot orthosis (0.66 ±â€¯0.14Nm/kg) and, finally, the Bellmann (0.37 ±â€¯0.11Nm/kg) alone offering the lowest joint moment. CONCLUSION: High-profile prostheses with ventral shell are more suitable to reacquire the lost forefoot lever after Chopart amputation. However, the issue of restricted range of motion in the ankle joint with the clamshell prosthesis needs to be addressed.

The added value of orthotic management in the context of multi-level surgery in children with cerebral palsy.

BACKGROUND: Treatment of cerebral palsy includes an interdisciplinary concept and in more severe cases the well-established multi-level surgery (MLS). Different kinds of orthoses are typically part of postoperative treatment but there is a lack of knowledge about their additional benefit. RESEARCH QUESTION: Do ankle foot orthoses lead to an additional, measurable improvement of gait after MLS? METHODS: 20 children with bilateral spastic cerebral palsy (9 retrospective, 11 in a postoperative clinical routine) were included. All had a preoperative gait analysis before MLS. Postoperatively, they were fitted with different ankle foot orthoses (AFO), depending on their individual needs. Dynamic ankle foot orthoses (DAFO), combined DAFO with additional dynamic, elastic shank adaptation (DESA) and ground reaction force AFOs (GRAFO) were used. Patients underwent a second gait analysis 1.5 (± 0.6) years postoperatively barefoot and with orthoses. Data analysis included testing for normal distribution (Shapiro-Wilk-Test) and further nonparametric statistical testing on basis of a Wilcoxon Single-Rank Test. RESULTS: The operation produced changes in the hip, knee and ankle joint, and the pelvis. Spatiotemporal parameters showed significant changes due to additional use of the orthoses. Further, additional kinematic changes occurred at the hip, knee and ankle joint as well as the foot. The Gillette Gait Index (GGI) improved significantly by supplementary orthoses, but not by surgery alone. The Gait Profile Score (GPS) and Gait Deviation Index (GDI) rather showed changes due to the surgery. SIGNIFICANCE: MLS significantly improves GPS and GDI more than a year after surgery, which can be interpreted as an improvement in gait pattern. In contrast, the GGI is improved by additional postoperative orthotic treatment, which implies that walking ability itself has improved, rather than the gait pattern. Orthoses show a positive additional effect on surgical results at different anatomical levels. Spatiotemporal parameters are positively influenced solely by additional orthotic support.

Structural changes in the thigh muscles following trans-femoral amputation.

INTRODUCTION: Early ambulation is the principal objective in trans-femoral amputees. Postamputation modifications complicate the rehabilitation process due to a reduced control at the interface between stump and prosthesis. The aim of this study is to determine whether magnetic resonance imaging depicts the amount of fatty degeneration of the thigh muscles after trans-femoral amputation (TFA). METHODS: A total of 12 patients following a TFA on the basis of a bone neoplasm or metastasis with an evaluable postoperative MRI were identified. Using the Goutallier classification, the fatty degeneration of the thigh muscles was analyzed in the middle (M) and at the distal end (E) of the residual limb at T1 (10.6 months) and T2 (25.6 months). RESULTS: Analysis at two different levels showed different grades of fatty degeneration of thigh muscles after TFA at T1 and T2. Comparing fatty degeneration at both levels of the stump, the quadriceps femoris revealed a significant change (p = 0.01) at T1 and M. sartorius and adductor (p = 0.02) at T2. CONCLUSIONS: MRI is an excellent diagnostic tool to evaluate fatty degeneration after TFA. The highest amount of fatty degeneration of the quadriceps muscle was monitored within the first 10 months. Early physiotherapy is important to strengthen the remaining stump muscles during rehabilitation.

[Femoral Derotation in Children with Cerebral Palsy - Does the Result Depend on the Age at Operation and the Kind of Surgery?]. / Derotation des Femurs bei Patienten mit infantiler Zerebralparese - ist das Ergebnis abhängig vom Alter zum Zeitpunkt der Operation und der OP-Technik?

INTRODUCTION: Patients with spastic cerebral palsy GMFCS I-III often develop gait dysfunctions. One of the most prevalent gait dysfunctions is the intoeing gait. Femoral derotation osteotomy is the common treatment for internal rotation gait in cerebral palsy. We now present 3D-gait analysis data of the hip rotation in gait before and after femoral derotation osteotomy. We analysed the influence of the age at the index operation on the risk of recurrence and the surgical technique. METHODS: We included 48 patients treated with femoral derotation osteotomy during a single event of multi-level surgery. Mean hip rotation in standing was measured before and after femoral derotation osteotomy (FDO). The patients were divided into two groups of different age and in a second analysis into two groups with the osteotomy in different locations, either inter-trochanteric (DO proximal) or supracondylar (DO distal). RESULTS: Age at FDO and surgical technique had no influence on the results. However, the variance of the results was very high. Differences were found in the walking speed between the DO proximal and DO distal groups. The walking speed in the group of distal femoral osteotomy was higher. This difference was not significant, but there was a trend to proximal osteotomy in slower walkers. Significant improvements in IRG after FDO were found in our investigation. Our results indicate that FDO as a part of single-event multilevel surgery SEMLS provides a satisfactory mean overall correction of IRG. The results were independent of the age at the index operation and the location of the osteotomy.