Results of dynamic pedobarography following surgically treated intra-articular calcaneal fractures

Dynamic and Stabilometric Analysis After Syndesmosis Injuries

BACKGROUND

Distal tibiofibular syndesmosis contributes to dynamic stability of the ankle joint and thereby affects gait cycle. The purpose of this study was to evaluate the grade of syndesmosis injury on plantar pressure distribution and dynamic parameters of the foot.

METHODS

Grade of syndesmosis injury was determined by preoperative plain radiographic evaluation, intraoperative hook test, or external rotation stress test under fluoroscopic examination, and two groups were created: group 1, patients with grade III syndesmosis injury (n = 17); and group 2, patients with grade II syndesmosis injury (n = 10). At the last visit, radiologic and clinical assessment using the Foot and Ankle Outcome Score was performed. Dynamic and stabilometric analysis was carried out at least 1 year after surgery.

RESULTS

The mean age of the patients was 48.9 years (range, 17-80 years), and the mean follow-up was 16 months (range, 12-24 months). No statistically significant difference was noted between two groups regarding Foot and Ankle Outcome Score. The comparison of stabilometric and dynamic analysis revealed no significant difference between grade II and grade III injuries (P > .05). However, comparison of the data of patients with grade III syndesmosis injury between injured and healthy feet showed a significant difference for dynamic maximum and mean pressures (P = .035 and P = .49, respectively).

CONCLUSIONS

Syndesmosis injury does not affect stance phase but affects the gait cycle by generating increased pressures on the uninjured foot and decreased pressures on the injured foot. With the help of pedobarography, processing suitable orthopedic insoles for the injured foot and interceptive measures for overloading of the normal foot may prevent later consequences of ankle trauma.

Gait analysis - Available platforms for outcome assessment

Movement or gait analysis has become a viable assessment tool not only used in sports science or basic biomechanical research, but has also expanded to be a very valuable instrument in clinical diagnostics, monitoring functional recovery and musculoskeletal rehabilitation. In this context, this method has long been an integral part solely in neurological disorders such as cerebral palsy. However, in the meantime the benefits have also become apparent in other medical areas, such as foot surgery, orthopaedic technology, or in patients after lower limb amputation. These procedures proved to better understand, objectify and quantify the individual causes of gait and movement disorders in order to optimize patient-specific therapy. Currently we are able to rely on a multitude of available measurement systems. These can either be used in everyday life for simple monitoring of one's own activity or to complement therapeutic approaches in the clinical and scientific environment. The following review highlights the various fields of movement analysis, including markerless motion capture, marker-based analysis, pedobarography and wearable sensors. Each of these areas presents its own field of application and potential usage as well as the advantages and disadvantages arising in this context. The following article will give an overview of the type of measurement technology used, the respective fields of application, and the selected parameters and their interpretation possibilities for each of the areas mentioned.

What is the added value of pedobarography for assessing functional outcome of displaced intra-articular calcaneal fractures? A systematic review of existing literature

BACKGROUND

Displaced intra-articular calcaneal fractures often result in permanent disability, reduced quality of life and high socio-economic costs. Since they often result in a change in geometry of the foot, pedobarography may be useful in predicting outcome at an early stage. The aim of this study was to examine whether a correlation exists between pedobarography and functional outcomes in patients with a displaced intra-articular fracture.

METHODS

In this systematic review, studies were included when they investigated the correlation between pedobarography and functional outcome in displaced intra-articular calcaneal fractures. Excluded were studies on <10 patients or on animals/cadavers. Collected were baseline patient/treatment characteristics, pedobarographic data (peak pressures, maximum force and centre of pressure) and functional outcome scores.

FINDINGS

Out of 153 abstracts, 40 remained for full text screening and 9 were included. Pedobarographic measurements (pressure plate or insoles) showed a lateralization of centre of pressure, decreased pressures underneath the hindfoot, first and second toe and increased pressure underneath the midfoot and forefoot. Correlations with functional outcome were found in some combined pedobarographic results (entire foot/multiple measurements), but hardly in pressures underneath specific foot areas.

INTERPRETATION

Even though increased or decreased pressures in specific areas of the foot may not be directly related to functional outcome, combined scores often did. For pedobarography to serve as a prediction tool, it should be more standardised. However, assessing centre of pressure and altered peak pressures underneath the foot, may be useful in developing customized aids such as insoles, aiming for a more individualized improvement.

[A new continuous gait analysis system for ankle fracture aftercare]

BACKGROUND

Correct aftercare following lower extremity fractures remains a controversial issue. Reliable, clinically applicable weight-bearing recommendations have not yet been defined. The aim of the current study was to establish a new gait analysis insole during physical therapy aftercare of ankle fractures to test patients' continuous, long-term compliance to partial weight-bearing restrictions and investigate whether patients can estimate their weight-bearing compliance.

MATERIALS AND METHODS

The postoperative gait of 14 patients after operative treatment of Weber B-type ankle fractures was monitored continuously for six weeks (OpenGO, Moticon GmbH, Munich). All patients were instructed and trained by physical therapists on how to maintain partial weight-bearing for this time. Discontinuous (three, six and twelve weeks) clinical (patient questionnaire, visual analogue pain score [VAS]) and radiographic controls were performed.

RESULTS

Despite the set weight-bearing limits, individual ranges for overall weight-bearing (range 5-107% of the contralateral side) and patient activity (range 0-366 min/day) could be shown. A good correlation between weight-bearing and pain was seen (r_s = -0.68; p = <0.0001). Patients significantly underestimated their weight-bearing time over the set limit (2.3 ± 1.4 min/day vs. real: 12.6 ± 5.9 min/day; p < 0.01).

CONCLUSIONS

Standardized aftercare protocols and repeated training alone cannot ensure compliance to postoperative partial weight-bearing. Patients unconsciously increased weight-bearing based on their pain level. This study shows that new, individual and possibly technology-assisted weight-bearing regimes are needed. The introduced measuring device is feasible to monitor and steer patient weight-bearing during future studies.

Center of pressure in a walking boot shifts posteriorly in patients following lower leg fracture

BACKGROUND

Studies have shown that the ambulatory behavior and amount of weight bearing performed by lower leg fracture patients, increases over time. It is likely that gait features, such as center of pressure (CoP), also change over time.

RESEARCH QUESTION

The purpose of this study was to characterize changes in CoP exhibited by lower leg fracture patients wearing a walking boot during the recovery period.

METHODS

Approximately 2 weeks post-surgery, seven lower leg fracture patients were fitted with a MaxTrax walking boot which was integrated with the Ambulatory Tibia Load Analysis System, an underfoot load monitoring system. Patients wore the walking boot for 2-12 weeks resulting in continuous load data during the recovery period. Ambulation was filtered from the raw data and daily average CoP values were calculated by averaging the CoP vectors from all steps in a given day.

RESULT

In general, the CoP vector varied in both the x and y directions during the initial stages of recovery but was more uniform during the later stages of healing. In 6/7 patients, the CoP in the y direction was closer to the forefoot during the initial stages of healing but shifted posteriorly as time post-surgery increased. The single patient that did not exhibit a posterior shift in CoP was also the only patient to develop a non-union. CoP in the x direction show a less clear trend. CoP in the x direction exhibited a medial shift in 5 patients and a lateral shift in 2 patients.

SIGNIFICANCE

During lower leg fracture recovery in a walking boot, the CoP in the y direction shifts posteriorly as time post-surgery increases and CoP monitoring may become a useful tool to monitor individual patient healing progression.

Comparison of Plantar Pressure Distribution During Walking After Two Different Surgical Treatments for Calcaneal Fracture

The aim of our study was to compare gait in terms of foot loading and temporal variables after 2 different operative approaches (the extended lateral approach [ELA] and sinus tarsi approach). Twenty-two patients who sustained an intra-articular calcaneal fracture underwent plantar pressure distribution measurements 6 months after surgery. Measurements were performed while patients walked on the pedobarography platform. The values of dynamic variables were significantly lower on the operated limb in the ELA. In the sinus tarsi approach, no differences were observed between the operated and uninjured limbs (UIN) at peak pressure and at maximal vertical force. The values of temporal variables (contact time of the foot and of the heel) between the operated and UIN differed in the ELA. The hypothesis that differences in foot load between operated and UIN will be more significant in the ELA was confirmed. Our results showed that the differences in loading and temporal variables between the operated and the UIN persisted 6 months after surgery in both methods. The operated limb was less loaded, with the tendency to shift the load toward the midfoot and forefoot. After the less invasive sinus tarsi approach, the dynamic and temporal variables on the operated limb were nearly the same as those on the healthy one. The sinus tarsi surgical approach can be recommended for treatment of displaced calcaneal fractures.

The Results of Physical, Radiologic, Pedabarographic, and Quality-of-Life Assessments in Patients with Surgically Treated Intraarticular Calcaneus Fractures

Calcaneal fractures are complex injuries and have historically had a poor prognosis that results in substantial disability. However, no studies have been performed that analyze both the radiographic and plantar pressure changes after treatment of intraarticular calcaneus fracture. Patients with an intrarticular calcaneus fracture treated at our institution during the study period were identified from computerized hospital records. A total of 36 patients (34 males) completed physical examination and radiographic and dynamic pedobarographic assessments. The follow-up period was from 13 to 82 months (median 38 months). The mean pain score at rest was 3.7 and during activity was 4.0 on a 10-cm visual analogue scale. The mean range of motion of the subtalar joint was restricted. The mean American Orthopaedic Foot and Ankle Society function scale score was 68.1; the mean Short Form-36 physical score was 41.8; and the mental score was 44.9. Pedabarographic results showed that the mean maximum force in the midfoot, forefoot, and toes (p = .001; p = .04; p = .002) and peak pressure in the midfoot, forefoot (p = .001; p = .007), and contact area of the midfoot and toes (p = .038; p = .004) were significantly increased in the injured foot. Radiologic findings showed hindfoot varus, forefoot adductus, and an increase in the medial arch. Even after appropriate anatomic realignment with open reduction and internal fixation of calcaneus fractures, residual differences in plantar pressures and radiographic measures are noted compared to uninjured foot.

Foot Function After Surgically Treated Intraarticular Calcaneal Fractures: Correlation of Clinical and Pedobarographic Results of 65 Patients Followed for 8 Years

OBJECTIVES

To correlate functional deficits after surgical treatment of displaced intraarticular calcaneal fractures (DIACFs) as measured through dynamic pedobarography with clinical and radiographic long-term results.

DESIGN

Retrospective single-center study.

SETTING

Level 1 trauma center.

PATIENTS

Sixty-five patients with unilateral DIACFs, reexamined at an average of 8.1 years after surgery.

INTERVENTION

Internal fixation of DIACF with lateral plate or percutaneous screws.

MAIN OUTCOME MEASUREMENTS

Dynamic pedobarography, AOFAS, Zwipp, SF-36 scores, Foot Function Index, Böhler angle, and articular congruity.

RESULTS

When compared with the uninjured side, pedobarography of the operated foot revealed a significantly increased contact area of the hindfoot and midfoot, with a decreased contact area under first/second metatarsal (MT) and first/second toe after DIACF. Maximum pressure and pressure time integral were significantly increased at the midfoot and lateral MT with a decrease under the hindfoot and first to second MT/toe. Midfoot pressure time integral correlated with the range of plantarflexion. Fracture classification correlated with MT 1 contact time. Hindfoot and MT contact times were negatively correlated with Böhler angle. Patients with the smallest side-to-side differences in pedobarogaphy had overall highest scores and significantly greater ankle/hindfoot range of motion at follow-up.

CONCLUSIONS

Significant correlations were found between clinical and pedobarographic results. Increased contact areas and time at the midfoot indicating a lateral load shift correlated with inferior outcome and decreased subtalar motion. These results support the importance of reconstruction of the subtalar joint and overall bony morphology of the calcaneus with preservation of subtalar motion as necessary for global foot function.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Predictive value of clinical scoring and simplified gait analysis for acetabulum fractures

BACKGROUND

Fractures of the acetabulum show a high, long-term complication rate. The aim of the present study was to determine the predictive value of clinical scoring and standardized, simplified gait analysis on the outcome after these fractures.

METHODS

Forty-one patients with acetabular fractures treated between 2008 and 2013 and available, standardized video recorded aftercare were identified from a prospective database. A visual gait score was used to determine the patients walking abilities 6-m postoperatively. Clinical (Merle d'Aubigne and Postel score, visual analogue scale pain, EQ5d) and radiological scoring (Kellgren-Lawrence score, postoperative computed tomography, and Matta classification) were used to perform correlation and multivariate regression analysis.

RESULTS

The average patient age was 48 y (range, 15-82 y), six female patients were included in the study. Mean follow-up was 1.6 y (range, 1-2 y). Moderate correlation between the gait score and outcome (versus EQ5d: r_s = 0.477; versus Merle d'Aubigne: r_s = 0.444; versus Kellgren-Lawrence: r_s = -0.533), as well as high correlation between the Merle d'Aubigne score and outcome were seen (versus EQ5d: r_s = 0.575; versus Merle d'Aubigne: r_s = 0.776; versus Kellgren-Lawrence: r_s = -0.419). Using a multivariate regression model, the 6 m gait score (B = -0.299; P < 0.05) and early osteoarthritis development (B = 1.026; P < 0.05) were determined as predictors of final osteoarthritis. A good fit of the regression model was seen (R² = 904).

CONCLUSIONS

Easy and available clinical scoring (gait score/Merle d'Aubigne) can predict short-term radiological and functional outcome after acetabular fractures with sufficient accuracy. Decisions on further treatment and interventions could be based on simplified gait analysis.

The influence of monocular vision on the plantar pressure distribution

BACKGROUND

Although the influence of monocular vision to upper limb biomechanics has been well documented, data about lower extremity biomechanics are limited. The objective of the present study was to demonstrate pedobarographic differences between both feet of the individuals with monocular vision in static and dynamic conditions.

METHODS

Pedobarographic analysis of twenty-four participants with monocular vision was performed. Relative static pressure load (%) and dynamic peak plantar pressure (N/cm(2)), force (N) distributions and contact area percentages (%) were recorded under both low vision and normal vision side foot.

FINDINGS

The results showed that relative static pressure loads did not differ between low vision and normal vision foot. Under midfoot of low vision side, a significant increment was found in peak plantar pressures (2.42 (SD 1.09) N/cm(2)) and forces (136.77 (SD 64.96) N) compared to normal vision side foot (1.87 (SD 0.96) N/cm(2); 106.94 (SD 65.03) N). No difference in contact area percentages was detected.

INTERPRETATION

These results indicate that there are differences in plantar pressure measurements between feet of individuals with monocular vision. These pedobarographic differences reported here appear to support the assumption that individuals with monocular vision have adaptive gait strategies such as, decreased walking speed, limited ankle motion and postural compensations.

Proximal femoral nail shows better concordance of gait analysis between operated and uninjured limbs compared to hemiarthroplasty in intertrochanteric femoral fractures

PURPOSE

The purpose of this study was to compare the results of pedobarographic gait analysis between the patients treated by proximal femoral nail or bipolar partial hemiarthroplasty due to intertrochanteric fractures.

METHODS

Thirty-seven patients with a minimum 1-year follow-up who had been operated for intertrochanteric fractures were evaluated clinically, radiologically and with pedobarographic gait analysis. Proximal femoral nail had been performed to 21 patients (group A), whilst 16 patients had been operated by partial bipolar hemiarthroplasty (group B). Pedobarographic analysis was performed by measuring plantar pressure, force and contact area values in both static and dynamic manner. Pedobarographic results of operated limb were compared among groups. Same data's also were compared between operated and uninjured limbs in each group to determine any asymmetry on weight-bearing.

RESULTS

Average follow-up period in group A and group B was 36 (12-56) and 30 (12-48) months, respectively. There were no statistically significant differences among groups in terms of age, gender, body mass index, type and side of fracture, follow-up period, leg length discrepancy and postoperative hip scores. When the pedobarographic results of operated limb were compared, group B showed much more plantar force and pressure values than group A, on both static and dynamic evaluations. If the evaluation was taken into consideration to comparison of pedobarographic results between operated and uninjured limbs in each group, we found asymmetry in static load bearing, caused by higher load on uninjured limb in both groups. However, there was no statistically significant asymmetry between operated and uninjured limbs in respect to dynamic pedobarographic parameters for patients in group A. On the contrary, operated limbs in group B exposed much more plantar force and pressure values than uninjured limbs, which indicated asymmetric weight-bearing on dynamic evaluation.

CONCLUSIONS

Assessment of pedobarographic parameters can be another way of measuring the results of treatment in intertrochanteric fractures. Uninjured limbs of patients expose much more loading than operated limbs in postoperative static evaluation for both treatment options. However in dynamic evaluation, there is a better concordance of gait analysis between both limbs in patients operated by proximal femoral nail.

Plantar Pressure and Gait Symmetry in Individuals with Fractures versus Tendon Injuries to the Hindfoot

BACKGROUND

The intent of this study was to determine whether differences in function, walking characteristics, and plantar pressures exist in individuals after operative fixation of an intra-articular calcaneal fracture (HFX) compared with individuals with operative repair of an Achilles tendon rupture (ATR).

METHODS

Twenty patients (ten with HFXs and ten with ATRs) were recruited approximately 3.5 months after operative intervention. All of the participants completed the Lower Extremity Functional Scale and had their foot posture assessed using the Foot Posture Index. Walking velocity was assessed using a pressure mat system, and plantar pressures were measured using an in-shoe sensor. In addition to between-group comparisons, the involved foot was compared with the uninvolved foot for each participant.

RESULTS

There were no differences in age, height, weight, or number of days since surgery between the two groups. The HFX group had lower Lower Extremity Functional Scale scores, slower walking velocities, and different forefoot loading patterns compared with the ATR group. The involved limb of both groups was less pronated.

CONCLUSIONS

The results indicate that individuals with an HFX spend more time on their involved limb and walk slower than those with an ATR. Plantar pressures in the HFX group were higher in the lateral forefoot and lower in the medial forefoot and in the ATR group were symmetrically lower in the forefoot.

Pedobarography in the Assessment of Postoperative Calcaneal Fracture Pressure With Gait

The purpose of the present study was to evaluate the benefits and importance of pedobarography in the diagnosis and treatment of plantar pressure changes in the postoperative follow-up of calcaneus fractures treated with open reduction and internal fixation. The 28 patients included 23 males (82%) and 5 females (18%). The clinical evaluation was performed using the American Orthopaedic Foot and Ankle Society hindfoot scoring system. The Böhler and Gissane angles were measured on the preoperative and postoperative radiographs. In the postoperative follow-up period (mean ± standard deviation 22.25 ± 10.8 months), all the patients underwent analysis with a dynamic pedobarogram. Because the arch index of the operated feet was 29.73% and that of the nonoperated feet was 28.94%, a similar slightly low arch was seen in both feet (p = .078). When the plantar surface maximum pressures were evaluated, a significant reduction was seen in the operated feet in the second, third, fourth, and fifth metatarsals and the medial hindfoot (p < .05). Displaced intra-articular calcaneus fractures resulted in a significant reduction in maximum pressure of the second, third, fourth, and fifth metatarsals and the medial hindfoot. Also, the hindfoot pressure was lateralized. Pedobarography is a simple and useful method for the diagnosis of plantar pressure changes occurring postoperatively.

Gait and function as tools for the assessment of fracture repair - the role of movement analysis for the assessment of fracture healing

Assessment of gait and function might be as sensitive tool to monitor the progress of fracture healing. Currently available assessment tools for function use instrumented three dimensional gait analysis or pedobarography. The analysis is focused on gait or movement parameters and seeks to identify abnormalities or asymmetries between legs or arms. The additional inclusion of muscle function by electromyography can further elucidate functional performance and its temporal development. Alternative approaches abstain from directly assessing function in the laboratory but rather determine the amount of activities of daily living or the mere ability to perform defined tasks such as walking, stair climbing or running. Some of these methods have been applied to determine recovery after orthopaedic interventions including fracture repair. The combination of lab-based functional measurements and assessment of physical activities in daily live may offer a valuable level of information about the gait quality and quantity of individual patients which sheds light on functional limitations or rehabilitation of gait and mobility after a disease or injury and the respective conservative, medical or surgical treatment.