Toe-walking and its impact on first and second rocker in gait patterns with different degrees of artificially emulated soleus and gastrocnemius contracture.

BACKGROUND: Toe-walking is one of the most common gait deviations (due to soleus and/or gastrocnemius muscle contractures), compromising the first (heel rocker) and second (ankle rocker) of the foot during walking. The aim of this study is to evaluate the effect of emulated artificially gastrocnemius and soleus contractures on the first and second rocker during walking. METHOD: An exoskeleton was built to emulate contractures of the bilateral gastrocnemius and soleus muscles. Ten healthy participants were recruited to walk under the following conditions: without emulated contractures or with bilateral emulated contractures at 0°,10°, 20° and 30° of plantarflexion of the soleus or gastrocnemius in order to create an artificial restriction of dorsiflexion ankle movement. A linear regression from the ankle plantar-dorsiflexion angle pattern was performed on 0-5 % of the gait cycle (first rocker) and on 12-31 % of the gait cycle (second rocker) to compute the slope of the curve. The proportion of participants with the presence of the first and second rocker was then computed. A Statistical Parametric Mapping (SPM) analysis assessed the kinematic variations among different degrees of emulated contractures. FINDINGS: The first and second rockers are completely absent from 10° of plantarflexion emulated contracture. The data indicate there was a non-linear shift of the gait pattern of the ankle kinematics and an important shift toward plantarflexion values with the loss of the rockers. INTERPRETATION: This study suggests that toe-walking in the experimental simulation situation is not necessarily due to a high emulated contracture level and can occur with a small emulated contracture by an adaptation choice. This study may improve interpretation of clinical gait analysis and shows that the link between the level of gastrocnemius/soleus emulated contracture and progression of toe-walking (increased plantarflexion during gait) is not linear.

Kinematic alignment matches functional alignment for the extension gap: a consecutive analysis of 749 primary varus osteoarthritic knees with stress radiographs.

PURPOSE: The alignment goal in total knee arthroplasty (TKA) remains debated. Two major strategies have emerged based on recreating the native knee: kinematic and functional alignment (KA and FA). Recently a new Coronal Plane Alignment of the Knee (CPAK) classification for KA, based on bony landmarks, was described considering joint line obliquity and the arithmetic HipKneeAnkle angle (aHKA). Valgus corrected HKA medial angle (vcHKA) was measured on distractive valgus preoperative radiographs compensating for cartilage wear and ligament balance in varus osteoarthritis. The purpose of this study was to determine if aHKA accounts for differences in medial laxity for the extension gap by comparing vcHKA to aHKA. The hypothesis was that no significant difference would be observed between the two measurements. METHODS: This is a retrospective analysis of 749 knees in consecutive patients presenting to a single-centre with primary medial osteoarthritis. Patients underwent standardized weight bearing long-leg and valgus stress radiographs. Tibial mechanical angle (TMA), femoral mechanical angle (FMA) and vcHKA were measured using digital software. aHKA and vcHKA were compared to determine differences due to soft tissue balancing. RESULTS: The mean FMA was 91.3 ± 2.2° (range 82°-97°), the mean TMA was 85.7 ± 2.5° (range 75°-98°), the mean aHKA was 177.0 ± 3.0° (range 164°-185°) and the mean vcHKA was 176.6 ± 3.1° (range 165°-192°). No significant difference was observed between aHKA and vcHKA (p = 0.06). A significant correlation was found between vcHKA and TMA (ρ = 0.3; p < 0.001) and between vcHKA and FMA (ρ = 0.41; p < 0.001). CONCLUSION: This study showed that vcHKA was similar to aHKA confirming that aHKA accounts for ligamentous medial laxity. Therefore, kinematic alignment based on the CPAK classification matches the pre-arthritic coronal alignment of the knee for the extension gap. LEVEL OF EVIDENCE: IV.

The effect of ankle and hindfoot malalignment on foot mechanics in patients suffering from post-traumatic ankle osteoarthritis.

BACKGROUND: Ankle and hindfoot malalignment is a common finding in patients suffering from post-traumatic ankle osteoarthritis. However, no studies have addressed the effect of concomitant foot deformities on intrinsic foot kinematics and kinetics. Therefore, the objective of this study was to investigate the effect of ankle and hindfoot malalignment on the kinematics and kinetics of multiple joints in the foot and ankle complex in patients suffering from post-traumatic ankle osteoarthritis. METHODS: Twenty-nine subjects with post-traumatic ankle osteoarthritis participated in this study. Standardized weight-bearing radiographs were obtained preoperatively to categorize patients as having cavus, planus or neutral ankle and hindfoot alignment, based on 4 X-ray measurements. All patients underwent standard gait assessment. A 4-segment foot model was used to estimate intrinsic foot joint kinematics and kinetics during gait. Statistical parametric mapping was used to compare foot kinematics and kinetics between groups. FINDINGS: There were 3 key findings regarding overall foot function in the 3 groups of post-traumatic ankle osteoarthritis: (i) altered frontal and transverse plane inter-segmental angles and moments of the Shank-Calcaneus and Calcaneus-Midfoot joints in the cavus compared to the planus group; (ii) in cavus OA group, Midfoot-Metatarsus joint abduction sought to compensate the varus inclination of the ankle joint; (iii) there were no significant differences in inter-segmental angles and moments between the planus and neutral OA groups. INTERPRETATION: Future studies should integrate assessment of concomitant foot and ankle deformities in post-traumatic ankle osteoarthritis, to provide additional insight into associated mechanical deficits and compensation mechanisms during gait.

Increased valgus laxity in flexion with greater tibial resection depth following total knee arthroplasty.

PURPOSE: Soft tissue balancing is of central importance to outcome following total knee arthroplasty (TKA). However, there are lack of data analysing the effect of tibial bone cut thickness on valgus laxity. A cadaveric study was undertaken to assess the biomechanical consequences of tibial resection depth on through range knee joint valgus stability. We aimed to establish a maximum tibial resection depth, beyond which medial collateral ligament balancing becomes challenging, and a constrained implant should be considered. METHODS: Eleven cadaveric specimens were included for analysis. The biomechanical effects of increasing tibial resection were studied, with bone cuts made at 6, 10, 14, 18 and 24 mm from the lateral tibial articular surface. A computer navigation system was used to perform the tibial resection and to measure the valgus laxity resulting from a torque of 10 Nm. Measurements were taken in four knee positions: 0° or extension, 30°, 60° and 90° of flexion. Intra-observer reliability was assessed. A minimum sample size of eight cadavers was necessary. Statistical analysis was performed using a nonparametric Spearman's ranking correlation matrix at the different stages: in extension, at 30°, 60° and 90° of knee flexion. Significance was set at p < 0.05. RESULTS: There was no macroscopic injury to the dMCL or sMCL in any of the specimens during tibial resection. There was no significant correlation found between the degree of valgus laxity and the thickness of the tibial cut with the knee in extension. There was a statistically significant correlation between valgus laxity and the thickness of the tibial cut in all other knee flexion positions: 30° (p < 0.0001), 60° (p < 0.001) and 90° (p < 0.0001). We identified greater than 5° of valgus laxity, at 90° of knee flexion, after a tibial resection of 14 mm. CONCLUSION: Increased tibial resection depth is associated with significantly greater valgus laxity when tested in positions from 30° to 90° of flexion, despite stability in extension. Greater than 5° of laxity was identified with a tibial resection of 14 mm. When a tibial bone cut of 14 mm or greater is necessary, as may occur with severe preoperative coronal plane deformity, it is recommended to consider the use of a constrained knee prosthesis.

Kinematics can help to discriminate the implication of iliopsoas, hamstring and gastrocnemius contractures to a knee flexion gait pattern.

BACKGROUND: Excessive Knee Flexion Gait Pattern (KFGP) is a common gait deviation in many pathological conditions. The contractures of the muscles that have been identified as being responsible of KFGP are: iliopsoas, hamstring and gastrocnemius. RESEARCH QUESTION: How do isolated contractures of the iliopsoas, hamstrings and gastrocnemius impact knee flexion during gait? METHODS: Three levels of contracture (mild, moderate and severe) were simulated bilaterally using an exoskeleton on 10 healthy participants for iliopsoas, hamstring and gastrocnemius muscles. A gait analysis session was performed to evaluate the joint kinematics according to the different simulated contractures. Thirty one parameters were chosen to analyze the kinematics of the thorax, pelvis, hip, knee and ankle. A principal component analysis (PCA) was used to determine the kinematic parameters influenced by contractures. RESULTS: In addition to a permanent knee flexion observed for the three muscles with contracture: the contracture of the iliopsoas induces a large hip flexion with pronounced anterior pelvis tilt; the contracture of the hamstrings induces an ankle dorsiflexion during the support phase with a posterior pelvis tilt; the contracture of the gastrocnemius induces an absence of first and second rocker of the ankle with a slight flexion of hip and a slight anterior pelvis tilt. SIGNIFICANCE: These results support the identification of the muscles responsible for a KFGP. A better knowledge of the interactions between contractures and associated joint kinematics of the same and adjacent joints will support the interpretation of gait analyses by more precisely and faster targeting the concerned muscle.

Influence of different degrees of bilateral emulated contractures at the triceps surae on gait kinematics: The difference between gastrocnemius and soleus.

INTRODUCTION: Ankle plantarflexion contracture results from a permanent shortening of the muscle-tendon complex. It often leads to gait alterations. The objective of this study was to compare the kinematic adaptations of different degrees of contractures and between isolated bilateral gastrocnemius and soleus emulated contractures using an exoskeleton. METHODS: Eight combinations of contractures were emulated bilaterally on 10 asymptomatic participants using an exoskeleton that was able to emulate different degrees of contracture of gastrocnemius (biarticular muscle) and soleus (monoarticular muscle), corresponding at 0°, 10°, 20°, and 30° ankle plantarflexion contracture (knee-flexed and knee-extended). Range of motion was limited by ropes attached for soleus on heel and below the knee and for gastrocnemius on heel and above the knee. A gait analysis session was performed to evaluate the effect of these different emulated contractures on the Gait Profile Score, walking speed and gait kinematics. RESULTS: Gastrocnemius and soleus contractures influence gait kinematics, with an increase of the Gait Profile Score. Significant differences were found in the kinematics of the ankles, knees and hips. Contractures of soleus cause a more important decrease in the range of motion at the ankle than the same degree of gastrocnemius contractures. Gastrocnemius contractures cause greater knee flexion (during the stance phase) and hip flexion (during all the gait cycle) than the same level of soleus contractures. CONCLUSION: These results can support the interpretation of the Clinical Gait Analysis data by providing a better understanding of the effect of isolate contracture of soleus and gastrocnemius on gait kinematics.

Effects of the rider on the kinematics of the equine spine under the saddle during the trot using inertial measurement units: Methodological study and preliminary results.

Many factors associated with the saddle and the rider could produce pain in horses thus reducing performance. However, studies of horse-saddle-rider interactions are limited and determining their effects remains challenging. The aim of this study was to test a novel method for assessing equine thoracic and lumbar spinal movement under the saddle and collect data during trotting. Back movement was measured using inertial measurement units (n = 5) fixed at the levels of thoracic vertebrae T6, T12 and T16, and lumbar vertebrae L2 and L5. To compare unridden and ridden conditions, three horses were trotted in hand then at the rising trot (seated phase: left diagonal, rider seated; standing phase: right diagonal, rider standing). The protraction-retraction angles of the forelimbs and the hind limbs were also calculated in two dimensions (2D) using reflective markers. To compare conditions, linear mixed-effects regression models were used and estimated means (standard error) were calculated. The range of motion (ROM) of the caudal thoracic and thoracolumbar regions decreased respectively by -1.3 (0.4)° and -0.6 (0.2)° during the seated phase compared to the unridden condition. Concomitantly, the ROM of protraction and retraction angles increased in the ridden condition. This study demonstrated the ability of inertial measurement units to assess equine vertebral movements under the saddle. The rider, at the rising trot, affected the horse's global locomotion with measurable changes in the vertebral kinematics under the saddle.

Feasibility and reliability of using an exoskeleton to emulate muscle contractures during walking.

Contracture is a permanent shortening of the muscle-tendon-ligament complex that limits joint mobility. Contracture is involved in many diseases (cerebral palsy, stroke, etc.) and can impair walking and other activities of daily living. The purpose of this study was to quantify the reliability of an exoskeleton designed to emulate lower limb muscle contractures unilaterally and bilaterally during walking. An exoskeleton was built according to the following design criteria: adjustable to different morphologies; respect of the principal lines of muscular actions; placement of reflective markers on anatomical landmarks; and the ability to replicate the contractures of eight muscles of the lower limb unilaterally and bilaterally (psoas, rectus femoris, hamstring, hip adductors, gastrocnemius, soleus, tibialis posterior, and peroneus). Sixteen combinations of contractures were emulated on the unilateral and bilateral muscles of nine healthy participants. Two sessions of gait analysis were performed at weekly intervals to assess the reliability of the emulated contractures. Discrete variables were extracted from the kinematics to analyse the reliability. The exoskeleton did not affect normal walking when contractures were not emulated. Kinematic reliability varied from poor to excellent depending on the targeted muscle. Reliability was good for the bilateral and unilateral gastrocnemius, soleus, and tibialis posterior as well as the bilateral hamstring and unilateral hip adductors. The exoskeleton can be used to replicate contracture on healthy participants. The exoskeleton will allow us to differentiate primary and compensatory effects of muscle contractures on gait kinematics.

A simplified marker set to define the center of mass for stability analysis in dynamic situations.

The extrapolated center of mass (XCoM), a valuable tool to assess balance stability, involves defining the whole body center of mass (CoMWB). However, accurate three-dimensional estimation of the CoMWB is time consuming, a severe limitation in certain applications. In this study, twenty-four subjects (young and elderly, male and female) performed three different balance tasks: quiet standing, gait and balance recovery. Three different models, based on a segmental method, were used to estimate the three-dimensional CoMWB absolute position during these movements: a reference model based on 38 markers, a simplified 13-marker model and a single marker (sacral) model. CoMWB and XCoM estimations from the proposed simplified model came closer to the reference model than estimations from the sacral marker model. It remained accurate for dynamic tasks, where the sacral marker model proved inappropriate. The simplified model proposed here yields accurate three-dimensional estimation of both the CoMWB and the XCoM with a limited number of markers. Importantly, using this model would reduce the experimental and post-processing times for future balance studies assessing dynamic stability in humans.

Effect of the rider position during rising trot on the horse׳s biomechanics (back and trunk kinematics and pressure under the saddle).

Knowledge about the horse-saddle-rider interaction remains limited. The aim of this study was to compare the effect of the rider׳s position at rising trot on the pressure distribution, spine movements, stirrups forces and locomotion of the horse. The horse׳s back movements were measured using IMUs fixed at the levels of thoracic (T6, T12, T16) and lumbar (L2, L5) vertebrae, the pressure distribution using a pressure mat and stirrups forces using force sensors. The horse׳s and rider׳s approximated centres of mass (COM) were calculated using 2D reflective markers. To compare both trot phases (rider seated/rider standing), three horses were trotted at the rising trot by the same rider. Means±SD of each parameter for sitting and standing were compared using a Student׳s t test (p=0.05). Stirrups forces showed two peaks of equal magnitude in every stride cycle for left and right stirrups but increased during the standing phase. Simultaneously, the pressure for the whole mat significantly increased by +3.1kPa during the sitting phase with respect to standing phase. The T12-T16 and T16-L2 angular ranges of motion (ROM) were significantly reduced (-3.2° -1.2°) and the T6-T12 and L2-L5 ROM were significantly increased (+1.7° +0.7°) during sitting phase compared to standing phase. During rising trot, the sitting phase does not only increase the pressure on the horse׳s back but also reduces the back motion under the saddle compared to the standing phase. These results give new insights into the understanding of horse-rider interactions and equine back pain management.

Rigid and non-rigid geometrical transformations of a marker-cluster and their impact on bone-pose estimation.

When stereophotogrammetry and skin-markers are used, bone-pose estimation is jeopardised by the soft tissue artefact (STA). At marker-cluster level, this can be represented using a modal series of rigid (RT; translation and rotation) and non-rigid (NRT; homothety and scaling) geometrical transformations. The NRT has been found to be smaller than the RT and claimed to have a limited impact on bone-pose estimation. This study aims to investigate this matter and comparatively assessing the propagation of both STA components to bone-pose estimate, using different numbers of markers. Twelve skin-markers distributed over the anterior aspect of a thigh were considered and STA time functions were generated for each of them, as plausibly occurs during walking, using an ad hoc model and represented through the geometrical transformations. Using marker-clusters made of four to 12 markers affected by these STAs, and a Procrustes superimposition approach, bone-pose and the relevant accuracy were estimated. This was done also for a selected four marker-cluster affected by STAs randomly simulated by modifying the original STA NRT component, so that its energy fell in the range 30-90% of total STA energy. The pose error, which slightly decreased while increasing the number of markers in the marker-cluster, was independent from the NRT amplitude, and was always null when the RT component was removed. It was thus demonstrated that only the RT component impacts pose estimation accuracy and should thus be accounted for when designing algorithms aimed at compensating for STA.

Comparison between investigations of induced stepping postural responses and voluntary steps to better detect community-dwelling elderly fallers.

In this paper, we review a physiological task that is predominant in preventing humans from falling, but that simultaneously also challenges balance: taking a step. In particular, two variants of this task are presented and compared: the voluntary step versus a step induced by an external and unpredictable perturbation. We show that, while these contribute different information, it is interesting to compare these. Indeed, they both are relevant in a global balance assessment and should be included within this, at the same level as tests usually dispensed in the clinical environment such as posturography. We choose to focus on the community-dwelling elderly population, to discuss means of early detection of risk of falls, in order to prescribe an appropriate prevention. An overview of posture-movement coordination and balance recovery strategies is also provided. Finally, a working hypothesis is suggested on how "compensatory protective" steps are controlled and how their evaluation could bring additional information to the global balance assessment of risk of fall.

A model of the soft tissue artefact rigid component.

When using stereophotogrammetry and skin-markers, the reconstruction of skeletal movement is affected by soft-tissue artefact (STA). This may be described by considering a marker-cluster as a deformable shape undergoing a geometric transformation formed by a non-rigid (change in size and shape) and a rigid component (translation and rotation displacements). A modal decomposition of the STA, relative to an appropriately identified basis, allows the separation of these components. This study proposes a mathematical model of the STA that embeds only its rigid component and estimates the relevant six mode amplitudes as linear functions of selected proximal and distal joint rotations during the analysed task. This model was successfully calibrated for thigh and shank using simultaneously recorded pin- and skin-marker data of running volunteers. The root mean square difference between measured and model-estimated STA rigid component was 1.1(0.8)mm (median (inter-quartile range) over 3 subjects × 5 trials × 33 markers coordinates), and it was mostly due to the wobbling not included in the model. Knee joint kinematics was estimated using reference pin-marker data and skin-marker data, both raw and compensated with the model-estimated STA. STA compensation decreased inaccuracy on average from 6% to 1% for flexion/extension, from 43% to 18% for the other two rotations, and from 69% to 25% for the linear displacements. Thus, the proposed mathematical model provides an STA estimate which can be effectively used within optimal bone pose and joint kinematics estimators for artefact compensation, and for simulations aimed at their comparative assessments.

Gait parameters database for young children: The influences of age and walking speed.

BACKGROUND: Reference databases are mandatory in orthopaedics because they enable the detection of gait abnormalities in patients. Such databases rarely include data on children under seven years of age. In young children, gait is principally influenced by age and walking speed. The influence of the age-speed interaction has not been well established. Therefore, the objective of the present study is to propose normative values for biomechanical gait parameters in children taking into account age, walking speed, and the age-speed interaction. METHODS: Gait analyses were performed on 106 healthy children over a large age range (between one and seven years of age) during gait trials at a self-selected speed. From these gait cycles, biomechanical parameters, such as the joint angles and joint power of the lower limbs, were computed. Specific peak values and the times of occurrence of each biomechanical gait parameter were identified. Linear regressions are proposed for studying the influence of age, walking speed and the age-speed interaction. FINDINGS: Most of the regressions achieved good accuracy in fitting the curve peaks and times of occurrence, and the normal reference targets of biomechanical parameters could be deduced from these regressions. The biomechanical gait parameters of a pathological case were plotted against the normal reference targets to illustrate the relevance of the proposed targeting method. INTERPRETATION: The normal reference targets for biomechanical gait parameters based on age-speed regressions in a large database might help clinicians detect gait abnormalities in children from one to seven years of age.

Intensification of heat and mass transfer by ultrasound: application to heat exchangers and membrane separation processes.

This paper aims to illustrate the interest of ultrasound technology as an efficient technique for both heat and mass transfer intensification. It is demonstrated that the use of ultrasound results in an increase of heat exchanger performances and in a possible fouling monitoring in heat exchangers. Mass transfer intensification was observed in the case of cross-flow ultrafiltration. It is shown that the enhancement of the membrane separation process strongly depends on the physico-chemical properties of the filtered suspensions.

Gait changes of the ACL-deficient knee 3D kinematic assessment.

PURPOSE: Static, one-dimensional testing cannot predict the behaviour of the anterior cruciate ligament (ACL)-deficient knee under realistic loading conditions. Currently, the most widely accepted method for assessing joint movement patterns is gait analysis. The purpose of the study was in vivo evaluation of the behaviour of the anterior cruciate ligament-deficient (ACLD) knees during walking, using 3D, real-time assessment tool. METHODS: Biomechanical data were collected prospectively on 30 patients with ACL rupture and 15 healthy subjects as a control group, with KneeKg™ System. Kinematic data were recorded in vivo during treadmill walking at self-selected speed. Flexion/extension, abduction/adduction, anterior/posterior tibial translation and external/internal tibial rotation were compared between groups. RESULTS: The ACLD patients showed a significant lower extension of the knee joint during stance phase (p < 0.05; 13.2° ± 2.1° and 7.3° ± 2.7°, for ACLD and control group, respectively). A significant difference in tibial rotation angle was found in ACLD knees compared to control knees (p < 0.05). The patients with ACLD rotated the tibia more internally (-1.4° ± 0.2°) during the mid-stance phase, than control group (0.2° ± 0.3°). There was no significant difference in anteroposterior translation and adduction-abduction angles. CONCLUSION: Significant alterations of joint kinematics in the ACLD knee were revealed in this study by manifesting a higher flexion gait strategy and excessive internal tibial rotation during walking that could result in a more rapid cartilage thinning throughout the knee. The preoperative data obtained in this study will be useful to understand the post-ACL reconstruction kinematic behaviour of the knee. CLINICAL RELEVANCE: The findings in this study indicate that ACLD knee may adapt functionally to prevent excessive anterior-posterior translation but they fail to avoid rotational instability.