Lower extremity gait kinematics outcomes after knee replacement demonstrate arthroplasty-specific differences between unicondylar and total knee arthroplasty: A pilot study

Long-term gait analysis in patients after total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Gait abnormalities have been described in patients after total knee arthroplasty (TKA), leading to the development of inter-joint coordination abnormalities and increased risk of falling. Such impairments have been reported to persist in the long-term, although the majority of studies assessed gait pattern especially in the first months after TKA.

RESEARCH QUESTION

What are the long-term gait impairments in patients after TKA compared to healthy age-matched subjects?

METHODS

A systematic search was conducted on MEDLINE/PubMed, EMBASE, CENTRAL and Scopus databases. Observational studies or randomized controlled trials investigating gait spatial-temporal, kinematic and kinetics parameters in a time-window longer than 6 months in patients with TKA compared to healthy age-matched subjects were included. Methodological quality was assessed using the modified Downs and Black (D&B) checklist and participants' characteristics, surgical procedures details and outcome measures were extracted. Pooled or un-pooled findings were categorized into "6 months - 1 year" and "more than 1 year" timepoint categories.

RESULTS

Twenty-eight studies (976 patients) were included. Overall quality was fair with a mean modified D&B score of 63.5 %. Reduced speed, stride length, cadence and longer stance phase were found in patients when compared to healthy individuals at "6 months - 1 year" follow-up. Spatial-temporal parameters deficits were also found at more than 1 year after TKA, where lower single-limb support and longer double-limb support durations were detected. These impairments occurred in concomitance with decreased knee range of motion along the sagittal and frontal planes and altered kinetic parameters. Hip kinematic and kinetic long-term impairments were also detected after TKA.

SIGNIFICANCE

These findings highlighted long-term gait pattern alterations in patients with TKA compared to age-matched healthy subjects. Future studies should identify interventions able to reduce long-term gait pattern alterations and improve function in patients after TKA.

Abnormal gait pattern in downhill hiking is related to muscular deficits of the knee flexors and extensors in active patients with total knee arthroplasty

BACKGROUND

To assess the in-field walking mechanics during downhill hiking of patients with total knee arthroplasty five to 14 months after surgery and an age-matched healthy control group and relate them to the knee flexor and extensor muscle strength.

METHODS

Participants walked on a predetermined hiking trail at a self-selected, comfortable pace wearing an inertial sensor system for recording the whole-body 3D kinematics. Sagittal plane hip, knee, and ankle joint angles were evaluated over the gait cycle at level walking and two different negative slopes. The concentric and eccentric lower extremity muscle strength of the knee flexors and extensors isokinetically at 50 and 120°/s were measured.

FINDINGS

Less knee flexion angles during stance have been measured in patients in the operated limb compared to healthy controls in all conditions (level walking, moderate downhill, steep downhill). The differences increased with steepness. Muscle strength was lower in patients for both muscle groups and all measured conditions. The functional hamstrings to quadriceps ratio at 120°/sec correlated with knee angle during level and downhill walking at the moderate slope in patients, showing higher ratios with lower peak knee flexion angles.

INTERPRETATION

The study shows that even if rehabilitation has been completed successfully and complication-free, five to 14 months after surgery, the muscular condition was still insufficient to display a normal gait pattern during downhill hiking. The muscle balance between quadriceps and hamstring muscles seems related to the persistence of a stiff knee gait pattern after knee arthroplasty. LoE: III.

Comparison of spatiotemporal, kinematic, and kinetic gait characteristics in total and unicompartmental knee arthroplasty during level walking: A systematic review and meta-analysis

PURPOSE

This meta-analysis was performed to compare the spatiotemporal, kinematic, and kinetic gait characteristics during level walking between total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA).

METHODS

An electronic database literature search was performed to screen clinical trials which were included the studies evaluating not only spatiotemporal, kinematic, and kinetic gait parameters, but also knee range of motion and knee score (Knee Society Score and Oxford Knee Score, i.e., KSS and OKS). The data analysis was performed using statistical software Stata 14.0 and Review Manager 5.4.

RESULTS

Thirteen studies (369 knees) that met the criteria were eventually included in this meta-analysis. The results revealed significant differences between UKA and TKA with regard to walking speed (P = 0.04), stride length (P = 0.02), maximum knee flexion at loading (P = 0.001), the 1st peak of vert-GRF (P = 0.006), the 1st valley of vert-GRF (P = 0.007), knee internal rotational moment (P = 0.04), knee extension (P < 0.00001), and KSS Function score (P = 0.05). In contrast, there were no statistical differences in the remaining spatiotemporal, kinematic, and kinetic gait parameters.

CONCLUSION

Medial UKA design is superior to TKA design with regard to walking speed, stride length, maximum knee flexion at loading, the 1st peak and the 1st valley of vert-GRF, knee internal rotational moment, knee extension, and KSS Function score. And it could provide a stronger basis for physicians to make clinical decisions.

No difference of gait parameters in patients with image-free robotic-assisted medial unicompartmental knee arthroplasty compared to a conventional technique: early results of a randomized controlled trial

PURPOSE

In recent studies, robotic-assisted surgical techniques for unicompartmental knee arthroplasty (UKA) have demonstrated superior implant positioning and limb alignment compared to a conventional technique. However, the impact of the robotic-assisted technique on clinical and functional outcomes is less clear. The aim of this study was to compare the gait parameters of UKA performed with conventional and image-free robotic-assisted techniques.

METHODS

This prospective, single-center study included 66 medial UKA, randomized to a robotic-assisted (n = 33) or conventional technique (n = 33). Gait knee kinematics was assessed on a treadmill at 6 months to identify changes in gait characteristics (walking speed, each degree-of-freedom: flexion-extension, abduction-adduction, internal-external rotation, and anterior-posterior displacement). Clinical results were assessed at 6 months using the IKS score and the Forgotten Joint Score. Implants position was assessed on post-operative radiographs.

RESULTS

Post-operatively, the whole gait cycle was not significantly different between groups. In both groups, there was a significant improvement in varus deformity between the pre- and post-operative gait cycle. There was no significant difference between the two groups in clinical scores, implant position, revision, and complication rates.

CONCLUSION

No difference of gait parameters could be identified between medial UKA performed with image-free robotic-assisted technique or with conventional technique.

LEVEL OF EVIDENCE

Prospective randomized controlled trial.

LEVEL OF EVIDENCE I

Impact of Proximal Tibial Varus Anatomy on Survivorship After Medial Unicondylar Knee Arthroplasty

BACKGROUND

Precise indications for medial unicondylar knee arthroplasty (UKA) continue to be defined. It is unclear if patients who have proximal tibia vara should be considered candidates for UKA. The purpose of this study was to evaluate the impact of proximal tibial varus alignment on outcomes after UKA.

METHODS

A retrospective review identified 2,416 patients (3,029 knees) who underwent mobile-bearing medial UKA with 2-year minimum follow-up or revision. Preoperative radiographs were evaluated, and medial proximal tibial angle (mPTA) was measured. Patients were grouped into two groups as follows: mPTA <80 degrees and mPTA ≥80 degrees. Analyses were performed on the impact of mPTA on clinical outcomes, all-cause revisions, and tibial failures.

RESULTS

At a mean follow-up of 5 years (range, 0.5 years to 12.8 years), there was not a statistically significant difference in clinical outcomes nor increased risk for all-cause revision or tibial failure in patients who had an mPTA <80°. Mean mPTA in patients who had tibial failures was 82.5° and not significantly different than those who did not have a tibial failure (82.9°) (P = .289). Tibial failure rate in knees with an mPTA <80° was 2.2% and not significantly different than knees with an mPTA ≥80° at 1.4% (P = .211). The all-cause revision rate in knees with an mPTA <80° was 5.8% and was not significantly different than knees with an mPTA ≥80° at 4.9% (P = .492).

CONCLUSION

Patients who have tibia vara are not at increased risk for tibial related or all-cause failure in medial UKA. This data may allow surgeons to increase their indications for medial UKA.

SYSTEMATIC PHYSICAL TRAINING IN FIGURE SKATING ATHLETES

ABSTRACT Introduction: Youngsters are an important source of reserve strength among short-speed skaters, so it is necessary to perform special strength training for young lower limb muscles while improving athletes’ endurance and physical function. Objective: Study the systematic development of physical training of speed skating athletes. Methods: The author uses the method of experimentation and mathematical statistics, the first level male athletes were selected as experimental objects, and the double-blind test method was used to conduct a comparative study through experiments. Results: Statistically, the T-test considerations of the control and experimental groups in the unipodal take-off stand and bilateral sliding jump tests showed statistical differences (P>0.05). The comparison of the experimental group pre and post-intervention indicates that the experimental group's performance in this test item increased significantly after training(P<0.05). Conclusion: The adaptation of the entry-level trainers to the scientific training concept played an auxiliary role in the results by increasing the emphasis on small muscle group training. Level of evidence II; Therapeutic studies - investigation of treatment outcomes.

Combined application of adductor canal block and local infiltration anesthesia in primary total knee arthroplasty: an updated meta-analysis of randomized controlled trials

BACKGROUND

Perioperative pain after total knee arthroplasty (TKA) may seriously affect the rapid recovery of patients. The purpose of this study was to assess whether the combined use of adductor canal block (ACB) and local infiltration anesthesia (LIA) can further reduce postoperative pain and improve early functional recovery.

MATERIALS AND METHODS

PubMed, Web of Science, EMBASE, and Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) comparing ACB + LIA and LIA alone in primary TKA. The primary outcomes were visual analog scale (VAS) scores at rest and walking, morphine consumption, range of motion (ROM) at 24 and 48 h postoperatively and distance walked. The secondary outcomes were the length of stay, the incidence of nausea and vomiting, and the total complications. Subgroup analyses were performed on the VAS at rest and walking, morphine consumption, and distance walked at 24, 48, and 72 h postoperatively.

RESULTS

A total of 10 RCTs involving 797 patients were enrolled in this meta-analysis. The results demonstrated that the combined application of ACB + LIA had a lower resting VAS at 24 h postoperatively (p = 0.02) and the walking score at 24 (p = 0.0002) and 48 h (p = 0.02) postoperatively compared with LIA alone. Similarly, the combined ACB + LIA group also had less morphine consumption at 48 h postoperatively (p = 0.0005) and had a higher ROM score at 24 h (p = 0.01) postoperatively compared to the LIA group. There were no statistical differences in length of stay, distance walked, and incidence of nausea and vomiting.

CONCLUSION

The current meta-analysis showed that ACB + LIA significantly reduced postoperative walking pain and morphine consumption and promoted rapid recovery in the early postoperative period. There is no statistical difference in the length of stay and ROM after 72 h in the two groups.

Trunk control, motion and alignment after total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Trunk control improves mobility, balance and quality of life early after total knee arthroplasty (TKA) and is therefore considered an important parameter during the recovery process. However, little is known about trunk control, motion and alignment after TKA. Increasing our understanding aids in optimizing treatment strategies to enhance functional mobility after TKA.

RESEARCH QUESTION

Does trunk control, motion and alignment return to normal after TKA and is this related to functional mobility?

METHODS

Five scientific databases were searched until July 2021. Eligibility criteria consisted of outcomes assessing trunk control and alignment in a population of adults undergoing TKA. Two reviewers independently screened studies and risk of bias was assessed by Mixed Methods Appraisal Tool (MMAT). Meta-analysis was performed for subgroups gait and alignment.

RESULTS

Of the 362 studies retrieved, 24 were included. Study designs were cohorts with mixed methods (pre-post treatment, case-control and case-case) and three randomized controlled trials. The mean MMAT score was 75%, corresponding to low bias. In total 1178 patients and 197 controls were included. Results showed that pre-operative trunk motion was characterized by increased amplitudes in all three planes and altered alignment which did not all return to normal after TKA. Frontal plane motion and alignment recovered faster than the sagittal and transversal plane. Although pelvic tilt improved after surgery, sagittal imbalance (anteriorly shifted trunk position) was still present.

SIGNIFICANCE

Recovery of trunk motion after TKA is time-, speed- and technique-dependent. The observed differences in trunk motion with the healthy controls persisted after TKA. This indicates that incorporating a full biomechanical chain approach, including trunk motion and gait-retraining exercises with a strong focus on postural alignment could improve functional mobility after TKA. Limited studies are available assessing trunk control and trunk motion during functional tasks besides walking which warrant further investigation.

Comparison of Pain, Muscle Strength, and Functional Status Following Unicompartmental Knee Arthroplasty, Total Knee Arthroplasty, and Conservative Management of Gonarthrosis

BACKGROUND

Treatment options and surgical decision for grade 3-4 gonarthrosis remains controversial. We aimed to compare the pain level, muscle strength, physical performance, lower extremity functions, and other physical activity levels between patients who underwent arthroplasty and those who received conservative management for grade 3-4 gonarthrosis.

METHODS

This prospective analytical observational study was conducted in a tertiary referral hospital. A total of 30 unicompartmental knee arthroplasty (UKA) and 30 total knee arthroplasty (TKA) patients as two different study groups and 30 patients were treated conservatively as the control group were included. The rehabilitation and complication rates were recorded. The values of the range of motion, quadriceps diameter, were measured and also the isokinetic muscle strength, pick-up, repeated sit-to-stand, stair ascending and descending, straight-line walking, timed up and go, and 20-m walk tests, the knee injury and osteoarthritis-outcome-score (KOOS), the hospital for special-surgery-knee-score (HSS), and Oxford-Knee-Score (OKS) were performed.

RESULTS

Postoperative rehabilitation and complication rates were significantly higher in the TKA group compared to the UKA group (p = 0.029 and p = 0.026, respectively). Six months after the treatment, the knee extension muscle strength value at 180°/s, knee flexion degree, total work flexion, stair ascending, VAS at night, all KOOS symptom, pain and daily function and total scores in the UKA group was significantly different than the TKA and the control groups (p < 0.001). Total work extension values, knee flexion degree, in the control group were found to be significantly higher than the TKA group (p = 0.033, p < 0.001, respectively).

CONCLUSIONS

The UKA was significantly superior to TKA and conservative treatment concerning pain, muscle strength, and quality of life.

LEVEL OF EVIDENCE

IIa.

Patient-specific musculoskeletal models as a framework for comparing ACL function in unicompartmental versus bicruciate retaining arthroplasty

Unicompartmental knee arthroplasty has been shown to provide superior functional outcomes compared to total knee arthroplasty and have motivated development of advanced implant designs including bicruciate retaining knee arthroplasty. However, few validated frameworks are available to directly compare the effect of implant design and surgical techniques on ligament function and joint kinematics. In the present study, the subject-specific lower extremity models were developed based on musculoskeletal modeling framework using force-dependent kinematics method, and validated against in vivo telemetric data. The experiment data of two subjects who underwent TKA were obtained from the SimTK "Grand Challenge Competition" repository, and integrated into the subject-specific lower extremity model. Five walking gait trials and three different knee implant models for each subject were used as partial inputs for the model to predict knee biomechanics for unicompartmental, bicruciate retaining, and total knee arthroplasty. The results showed no significant differences in the tibiofemoral contact forces or angular kinematic parameters between three groups. However, unicompartmental knee arthroplasty demonstrated significantly more posterior tibial location between 0% and 40% of the gait cycle (p < 0.017). Significant differences in range of tibiofemoral anterior/posterior translation and medial/lateral translation were also observed between unicompartmental and bicruciate retaining arthroplasty (p < 0.017). Peak values of anterior cruciate ligament forces differed between unicompartmental and bicruciate retaining arthroplasty from 10% to 30% of the gait cycle. Findings of this study indicate that unicompartmental and bicruciate retaining arthroplasty do not have identical biomechanics and point to the complementary role of anterior cruciate ligament and articular geometry in guiding knee function. Further, the patient-specific musculoskeletal model developed provides a reliable framework for assessing new implant designs, and effect of surgical techniques on knee biomechanics following arthroplasty.

Factors characterizing gait performance of patients before and soon after knee arthroplasty

[Purpose] For monitoring patients with knee osteoarthritis undergoing knee arthroplasty, the Timed Up and Go and maximum walking speed tests are commonly used. To provide appropriate peri-surgical rehabilitation, we evaluated the factors associated with postsurgical changes in Timed Up and Go and maximum walking speed results. [Participants and Methods] We enrolled 545 knee osteoarthritis patients undergoing either of the following knee arthroplasties: conventional total knee arthroplasty, minimally invasive total knee arthroplasty, and unicompartmental knee arthroplasty. Comfortable Timed Up and Go, maximum Timed Up and Go, and maximum walking speed were measured 2 weeks before and soon after surgery. Factors (gender, age, and surgical mode) that might influence changes in test results were evaluated by multiple regression analysis and a two-factor stratification diagram. [Results] Multiple regression analysis revealed that postsurgical changes in comfortable/maximum Timed Up and Go and maximum walking speed results were associated with age and surgical mode after adjustment for preoperative values. Two-factor diagrams showed that the older the patient, the greater was the slowdown in the Timed Up and Go test performed postoperatively. The levels of slowdown in the postoperative Timed Up and Go and maximum walking speed tests were the smallest in those who underwent conventional total knee arthroplasty, followed by those who underwent minimally invasive and unicompartmental knee arthroplasty. Among patients whose preoperative Timed Up and Go and maximum walking speed were slow, slowdown in Timed Up and Go was pronounced with age, and slowdown in maximum walking speed was higher in conventional total knee arthroplasty. [Conclusion] The changes in Timed Up and Go and maximum walking speed results 2 weeks after knee arthroplasty depended on age and surgical modes. These findings are relevant for the implementation of appropriate peri-surgical rehabilitation.

Effect of knee arthroplasty on sports participation and activity levels: a systematic review and meta-analysis

Objective

Desires and expectations of patients in regard to resume participation in sport activities after knee arthroplasty strongly increased in recent years. Therefore, this review systematically reviewed the available scientific literature on the effect of knee arthroplasty on sports participation and activity levels.

Design

Systematic review and meta-analysis.

Data sources

PubMed, Embase, SPORTDiscus and reference lists were searched in February 2019.

Studies eligibility criteria

Inclusion of knee osteoarthritis patients who underwent total knee arthroplasty (TKA) and/or unicondylar knee arthroplasty. Studies had to include at least one preoperative and one postoperative measure (≥1 year post surgery) of an outcome variable of interest (ie, activity level: University of California, Los Angeles and/or Lower Extremity Activity Scale; sport participation: type of sport activity survey).

Results

Nineteen studies were included, consisting data from 4074 patients. Knee arthroplasty has in general a positive effect on activity level and sport participation. Most patients who have stopped participating in sport activities in the year prior to surgery, however, do not seem to reinitiate their sport activities after surgery, in particular after a TKA. In contrast, patients who continue to participate in sport activities until surgery appear to become even more active in low-impact and medium-impact sports than before the onset of restricting symptoms.

Conclusions

Knee arthroplasty is an effective treatment in resuming sports participation and physical activity levels. However, to achieve the full benefits from knee arthroplasty, strategies and guidelines aimed to keep patients capable and motivated to participate in (low-impact or medium-impact) sport activities until close before surgery are warranted.

Lower limb kinematics of unicompartmental knee arthroplasty individuals during stair ascent

Objective

Purpose of the study was to compare lower-limb kinematics and interlimb asymmetry during stair ascent in individuals post-medial or lateral unicompartmental knee arthroplasty (UKA).

Methods

60 patients (20 medial; 10 lateral) post-UKA and 30 matched healthy controls performed stair ascent. Spatio-temporal, lower-limb kinematics and interlimb asymmetries during stair ascent were compared.

Results

Medial-UKA group displayed 5° less knee extension of the UKA limb than controls (p = 0.005) and 2° less than the contralateral limb during stance phase. No interlimb asymmetries were found for lateral-UKA.

Conclusion

Patients post-UKA demonstrate satisfactory lower-limb kinematics and minimal interlimb asymmetry during stair ascent compared to healthy individuals.