Measures of knee and gait function and radiographic severity of knee osteoarthritis - A cross-sectional study

Gait Analysis and Functional Knee Scores in Primary Knee Osteoarthritis and Their Correlation with Progression of the Disease in the Indian Population

INTRODUCTION

Osteoarthritis of the knee is a leading cause of disability and is a multi-factorial disease. Moreover, it is partly considered a mechanically driven disease in which higher abnormally disbursed forces play a prime role. With the progression of the disease, the gait function declines, so a comprehensive and objective evaluation of gait function would help in prognostic evaluation and management.

MATERIALS AND METHODS

This study included two groups: patients with primary knee osteoarthritis and a control group of healthy volunteers. Gait analysis and functional knee scores were evaluated for all the subjects. The KOOS score, temporal parameters excluding the step length, and spatial parameters excluding the stance phase percentage were evaluated for an individual as a whole. The KSS score, kinetic parameters, kinematic parameters, step length, and stance phase percentage were calculated for each knee separately. Each knee of the patient and controls was taken as 1 sample and categorized as per Kellgren-Lawrence score. An asymptomatic control group of subjects were included in group A. Symptomatic patients with KL grades 1, 2 were included in group M, and those with KL grades 3, 4 were included in group S. The kinetic and kinematic parameters and KSS score were compared among the three groups.

RESULTS

A total of 60 subjects were included of which 40 were patients and 20 were controls. In the control group, the age ranged from 22 to 48 years with a mean age of 28.6 years. In the patient group, the mean age was 60.3 years. Patients with knee osteoarthritis were significantly obese with slower walking speed, short stride length, longer stride time, and decreased cadence compared to the asymptomatic group. There was a significant difference in spatiotemporal parameters, functional scores, and kinetic and kinematic parameters among the groups.

CONCLUSION

Various spatiotemporal, kinetic, and kinematic parameters like peak knee flexion angle, abduction/adduction angle, peak knee adduction moment, range of knee flexion, peak knee flexion, and gait deviation index along with functional scores varied significantly with the progression of the disease.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-024-01103-9.

Inter-segment coordination amplitude and variability during gait in patients with knee osteoarthritis and asymptomatic adults

BACKGROUND

Inter-segment coordination examines the timing and coupling of multiple body segments and provides a complex understanding of how the neuromuscular system controls the body. Research is required to examine if inter-segment coordination during gait differs between individuals with different knee osteoarthritis (OA) severities and asymptomatic adults.

RESEARCH QUESTION

Do inter-segment coordination amplitude and between-trial variability during gait differ between individuals with varying levels of knee OA severity and asymptomatic adults?

METHODS

This observational, cross-sectional study included participants with mild/moderate knee OA (n = 38), severe knee OA (n = 24), and asymptomatic adults (n = 51). Participants ambulated overground at self-selected speeds. Data were collected with an eight-camera motion capture system and two force plates. Continuous relative phase (CRP) was used to quantify sagittal plane inter-segment coordination amplitude and between-trial variability for the thigh-shank and shank-foot pairs. Hierarchical linear models examined if CRP variables were related to the group (asymptomatic, mild/moderate OA, severe OA) after accounting for gait speed and gait phase.

RESULTS

Thigh-shank CRP amplitude was significantly associated with group variables. The severe OA group had lower CRP amplitudes than both asymptomatic (b=8.57, 95 % confidence interval=2.75-14.38) and mild/moderate OA (b=5.69, 95 % confidence interval=-0.25 to 11.62) groups. Thigh-shank CRP variability was also associated with group. The severe OA group had lower CRP variability than the asymptomatic group (b=0.45, 95 % confidence interval=0.12-0.78); there were no differences between severe and mild/moderate OA groups (p > 0.050). There were no significant associations between any of the shank-foot CRP measures and the groups.

SIGNIFICANCE

Lower thigh-shank CRP amplitude and variability in individuals with severe knee OA represents a more rigid motor system. These individuals could be attempting to stabilize their knee in response to a loss of passive stability or in response to pain. They might have difficulty adapting their gait to perturbations.

Bilateral lower extremity gait and function after unilateral total ankle arthroplasty: a case report

BACKGROUND

End-stage ankle osteoarthritis is one of the leading causes of chronic disability in North America. The main purpose of this case report was to describe the functional recovery of a person following total ankle arthroplasty (TAA) surgery using the INFINITY™ system for end stage osteoarthritis of the left ankle.

CASE DESCRIPTION

We report a case of a 55-year-old male who had attempted conservative management for end stage ankle osteoarthritis in his left ankle but ultimately elected to undergo TAA using The INFINITY™ Total Ankle System. He not only had significant left ankle pain limiting his daily function, but also had developed severe right knee pain. We performed gait analysis both before and 6 months after his TAA surgery to examine the sagittal and frontal-plane motions of bilateral ankle, knee, and hip joints during gait.

OUTCOMES

At 6 months post-surgery, the patient demonstrated a 44-point improvement in his Foot and Ankle Outcome questionnaire scores as well as an increase in both left knee and left ankle motion in the sagittal and frontal planes. Kinematic deviations in the left ankle, hip, and knee joints during gait also reduced post-surgery. Despite improvement in his left ankle and overall function, the participant's right knee pain and altered kinematics of the right limb during gait worsened after surgery.

DISCUSSION

Interventions, either before or after ankle surgery, should consider bilateral lower extremities simultaneously in order to optimize patient care and minimize future secondary complications for individuals with unilateral ankle osteoarthritis.

Retention of kinematic patterns during a 6-minute walk test in people with knee osteoarthritis

BACKGROUND

Knee osteoarthritis (OA) is a chronic condition affecting the entire joint and surrounding tissue, resulting in pain, stiffness and impaired movement. Recent studies have suggested the use of physical performance tests, such as the six-minute walk test (6MWT) to assess joint function for those with knee OA. This study assessed lower limb sagittal plane joint angles during a 6MWT for people with mild-moderate knee OA.

METHODS

Thirty-one participants (18 male, 13 female; 62.9 ± 8.4 years) with knee OA were recruited. Gait data were collected in a single session during which participants completed a 6MWT around a 20 m course. Sagittal plane joint angles for the hip, knee and ankle were calculated during the first and last minute of the 6MWT. Statistical parametric mapping (SPM) was used to investigate changes in kinematic traces over the gait cycle.

RESULTS

Mean joint angles for the hip and knee showed no significant differences between the first and last minute of the 6MWT. Ankle joint kinematic traces indicated there to be a decrease in plantarflexion approaching toe-off in the last minute of the test - a 1.5° reduction from the first minute. No significant differences were calculated for walking speed or joint range of motion.

DISCUSSION

The lack of significant change in joint kinematic parameters and walking speed suggests the relative fatigue and pain burden to the participant over the duration of the 6-minute period is insufficient to elicit any mechanical changes to walking gait.

Factors associated with self-rated difficulty to descend stairs in persons with knee osteoarthritis

BACKGROUND

Difficulty descending stairs is common in persons with knee osteoarthritis (OA). Clinically, it is important to know if and how this is explained by objectively measured difficulty to descend stairs, muscle weakness, pain, fear of movement, or knee joint status.

OBJECTIVE

To identify the potential of these factors to explain self-reported difficulty descending stairs.

DESIGN

Cross sectional, case-control.

SETTING

Hospital outpatient and physiotherapy clinic.

PARTICIPANTS

Twenty-eight men and women with knee OA (age 62.2 SD 5.9 years) and 31 controls (age 50.0 SD 8.5 years).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Using multivariate statistics, group comparisons were made for lower extremity kinematics (incorporating hip, knee, and ankle angles) and stance time in stair descent and lower extremity muscle strength. Then, a stepwise linear regression analysis was performed within the OA group to explain self-reported difficulties in stair descent where pain, kinesiophobia, radiographic signs, and outcomes that differed from controls for stair-descent kinematics and muscle strength were independent variables.

RESULTS

Multivariate statistics showed that the OA group displayed different all-over lower extremity kinematics (F_8,42 = 2.44 p = .029, η²  = 0.32) and a longer stance time (F_3,50 = 6.46; p = .001, η²  = 0.28) in stair descent and lower muscle strength (F_7,47 = 2.39; p = .035, η²  = 0.26) compared to controls. Regression analysis within the OA group to explain self-rated difficulties to descend stairs showed that the strongest association with kinesiophobia (ß = 0.607, p = .001) that combined with pain last week and radiographic signs explained almost 100% (ß = 0.972). Stair descent kinematics and strength variables that differed between groups did not explain self-rated difficulties to descend stairs.

CONCLUSION

Kinesiophobia and pain rather than stair-descent kinematics and reduced muscle-strength explained self-rated difficulties in stair descent in the OA group.

Relation of gait measures with mild unilateral knee pain during walking using machine learning

Gait alterations in those with mild unilateral knee pain during walking may provide clues to modifiable alterations that affect progression of knee pain and osteoarthritis (OA). To examine this, we applied machine learning (ML) approaches to gait data from wearable sensors in a large observational knee OA cohort, the Multicenter Osteoarthritis (MOST) study. Participants completed a 20-m walk test wearing sensors on their trunk and ankles. Parameters describing spatiotemporal features of gait and symmetry, variability and complexity were extracted. We used an ensemble ML technique ("super learning") to identify gait variables in our cross-sectional data associated with the presence/absence of unilateral knee pain. We then used logistic regression to determine the association of selected gait variables with odds of mild knee pain. Of 2066 participants (mean age 63.6 [SD: 10.4] years, 56% female), 21.3% had mild unilateral pain while walking. Gait parameters selected in the ML process as influential included step regularity, sample entropy, gait speed, and amplitude dominant frequency, among others. In adjusted cross-sectional analyses, lower levels of step regularity (i.e., greater gait variability) and lower sample entropy(i.e., lower gait complexity) were associated with increased likelihood of unilateral mild pain while walking [aOR 0.80 (0.64-1.00) and aOR 0.79 (0.66-0.95), respectively].

Contralateral advanced radiographic knee osteoarthritis predicts radiographic progression and future arthroplasty in ipsilateral knee with early-stage osteoarthritis

PURPOSE

To explore whether the severity of contralateral knee osteoarthritis (OA) is associated with OA progression in ipsilateral knee with early OA.

METHODS

Knees in early OA (Kellgren-Lawrence grade (KLG):1-2) with intact baseline demographic and clinical data were retrieved from OAI database and defined as target knees. The target knees were divided into the exposure group (contralateral knees KLG 3 to 4) and the control group (contralateral knees KLG 0 to 2). Both groups underwent propensity score matching (PSM) concerning demographic data, as well as radiographic and clinical outcomes at the baseline. The primary outcome was the upgrade of KLG in the target knee in the first 12 and 24 months. The secondary outcome was the incidence of knee arthroplasty in ipsilateral knee during the first 108 months.

RESULTS

One thousand seven hundred fifty-two knees were included, with 449 in the exposure cohort and 1276 in the control cohort. Four hundred thirty-four knees in each group were matched after PSM. Target knees in the exposure cohort showed a significantly higher rate of radiographic progression in the first 12 months (12.9% vs. 5.1%, P < 0.001) and 24 months (19.6% vs. 8.1%, P < 0.001). As for the risk of future arthroplasty, a significant difference was also found between the two groups (7.8% vs. 4.0%, P = 0.02). Kaplan-Meier analysis showed that the 108-month accumulated knee survival rate was significantly lower in the exposure group (P = 0.01).

CONCLUSION

The ipsilateral knee with early-stage OA is prone to have worse early to mid-, and long-term prognosis in the circumstance of contralateral radiographic advanced knee OA. Key Points •Identifying early knee osteoarthritis (OA) with a high risk of radiographic progression and future arthroplasty enables early personalized intervention. •This is a novel study to investigate the relationship between the risk of future arthroplasty and contralateral knee status. •Propensity score matching holds promise to minimize selection bias in observational studies. •Knees with early OA are prone to have a high risk of radiographic progression and future arthroplasty in the circumstance of contralateral advanced knee OA.

Three decades of gait index development: A comparative review of clinical and research gait indices

BACKGROUND

A wide variety of indices have been developed to quantify gait performance markers and associate them with their respective pathologies. Indices scores have enabled better decisions regarding patient treatments and allowed for optimized monitoring of the evolution of their condition. The extensive range of human gait indices presented over the last 30 years is evaluated and summarized in this narrative literature review exploring their application in clinical and research environments.

METHODS

The analysis will explore historical and modern gait indices, focusing on the clinical efficacy with respect to their proposed pathology, age range, and associated parameter limits. Features, methods, and clinically acceptable errors are discussed while simultaneously assessing indices advantages and disadvantages. This review analyses all indices published between 1994 and February 2021 identified using the Medline, PubMed, ScienceDirect, CINAHL, EMBASE, and Google Scholar databases.

FINDINGS

A total of 30 indices were identified as noteworthy for clinical and research purposes and another 137 works were included for discussion. The indices were divided in three major groups: observational (13), instrumented (16) and hybrid (1). The instrumented indices were further sub-divided in six groups, namely kinematic- (4), spatiotemporal- (5), kinetic- (2), kinematic- and kinetic- (2), electromyographic- (1) and Inertial Measurement Unit-based indices (2).

INTERPRETATION

This work is one of the first reviews to summarize observational and instrumented gait indices, exploring their applicability in research and clinical contexts. The aim of this review is to assist members of these communities with the selection of the proper index for the group in analysis.

Walking-related knee contact forces and associations with knee pain across people with mild, moderate and severe radiographic knee osteoarthritis: a cross-sectional study

OBJECTIVE

To investigate knee contact forces (KCFs), and their relationships with knee pain, across grades of radiographic knee osteoarthritis (OA) severity.

DESIGN

Cross-sectional exploratory analysis of 164 participants with medial knee OA. Radiographic severity was classified as mild (grade 2), moderate (grade 3) or severe (grade 4) using the Kellgren & Lawrence (KL) scale. Walking knee pain was assessed using an 11-point numerical rating scale. External knee adduction moment (external KAM) and internal muscle forces were used to calculate medial, lateral and total KCFs using a musculoskeletal computational model. Force-time series across stance phase of gait were compared across KL grades using Statistical Parametric Mapping. Associations between KCFs and pain across KL grades were assessed using linear models.

RESULTS

Medial KCFs during early and middle stance were higher in participants with KL3 and KL4 compared to those with KL2. In contrast, lateral KCFs were higher in those with KL2 compared to KL3 and KL4 in middle to late stance. The external loading component (i.e., KAM) of the medial KCF during middle to late stance was also greater in participants with KL3 and KL4 compared to those with KL2, whereas the internal (i.e., muscle) component was greater in those with KL3 and KL4 compared to KL3 during early stance. There were no associations between medial KCF and knee pain in any KL grade.

CONCLUSIONS

Medial and lateral KCFs differ between mild, moderate and severe radiographic knee OA but are not associated with knee pain severity for any radiographic OA grade.

Prevalence of locomotive syndrome in Japanese patients more than 10 years after total hip arthroplasty: A cross-sectional cohort study

BACKGROUND

Locomotive syndrome (LS) is a high risk condition that requires nursing care. It is important to investigate the prevalence of and factors related to LS to maintain a healthy life expectancy for patients; however, only a few reports have focused on the relationship between LS and total hip arthroplasty (THA). The purpose of this study was to evaluate the prevalence of LS and to identify factors associated with LS in patients more than 10 years after THA.

METHODS

This is a cross-sectional cohort study. Patients were assessed via a mail survey that included items regarding demographic data, cardiometabolic and motor disorders, the incidence of falls, physical activity level, and the 25-question Geriatric Locomotive Function Scale (GLFS-25) questionnaire. LS was defined as having a score ≥16 on the GLFS-25, and the respondents were categorized into two groups: an LS group and a non-LS group. The prevalence of LS was calculated in each gender and age group. Differences in variables between the groups were determined using the unpaired t-test and chi-squared test.

RESULTS

A total of 593 patients were included in the study (mean age, 70.4 years; 525/593 females). According to the GLFS-25, 164 patients (27.7%; 21.1% men and 28.8% women) were classified as having LS, which increased with age. In addition, compared with the non-LS group, the LS group had a significantly higher prevalence of motor diseases, cardiometabolic diseases, and falls and significantly lower levels of activity.

CONCLUSION

These findings suggest that the prevalence of LS in patients more than 10 years after THA is 27.7%. The result suggest that the prevalence of LS in patients more than 10 years after THA is similar to the prevalence of LS in the general elderly population. Furthermore, LS is related to not only motor diseases but also cardiometabolic diseases.

Relationship between motion, using the GaitSmartTM system, and radiographic knee osteoarthritis: an explorative analysis in the IMI-APPROACH cohort

Objectives

To assess underlying domains measured by GaitSmart^TMparameters and whether these are additional to established OA markers including patient reported outcome measures (PROMs) and radiographic parameters, and to evaluate if GaitSmart analysis is related to the presence and severity of radiographic knee OA.

Methods

GaitSmart analysis was performed during baseline visits of participants of the APPROACH cohort (n = 297). Principal component analyses (PCA) were performed to explore structure in relationships between GaitSmart parameters alone and in addition to radiographic parameters and PROMs. Logistic and linear regression analyses were performed to analyse the relationship of GaitSmart with the presence (Kellgren and Lawrence grade ≥2 in at least one knee) and severity of radiographic OA (ROA).

Results

Two hundred and eighty-four successful GaitSmart analyses were performed. The PCA identified five underlying GaitSmart domains. Radiographic parameters and PROMs formed additional domains indicating that GaitSmart largely measures separate concepts. Several GaitSmart domains were related to the presence of ROA as well as the severity of joint damage in addition to demographics and PROMs with an area under the receiver operating characteristic curve of 0.724 and explained variances (adjusted R²) of 0.107, 0.132 and 0.147 for minimum joint space width, osteophyte area and mean subchondral bone density, respectively.

Conclusions

GaitSmart analysis provides additional information over established OA outcomes. GaitSmart parameters are also associated with the presence of ROA and extent of radiographic severity over demographics and PROMS. These results indicate that Gaitsmart^TM may be an additional outcome measure for the evaluation of OA.

Increased knee flexion and varus moments during gait with high-heeled shoes: A systematic review and meta-analysis

BACKGROUND

High-heeled shoes have been thought to alter lower extremity joint mechanics during gait, however its effects on the knee remain unclear.

RESEARCH QUESTION

This systematic review and meta-analysis aimed to determine the effects of high-heeled shoes on the sagittal- and frontal-plane knee kinetics/kinematics during gait.

METHODS

1449 studies from 6 databases were screened for the following criteria: 1) healthy adult females, 2) knee joint kinematics/kinetics reported for the early stance phase during gait under varying shoe heel heights (including barefoot). Excluded studies included those mixing different shoe styles in addition to altering the heel heights. A total of 14 studies (203 subjects) met the selection criteria, resulting in 51 and 21 Cohen's d effect sizes (ESs) comparing the differences in knee sagittal- (flexion) and frontal-plane (varus) moment/angle, respectively, between shoes with higher heels and shoes with lower heels/barefoot.

RESULTS

Meta-analyses yielded a significant medium-to-large effect of higher heels compared to lower heels on increasing knee flexion moment (overall ES = 0.83; P < 0.01), flexion angle (overall ES=0.46; P < 0.01), and varus moment (overall ES=0.52; P < 0.01) during the early stance phase of gait. The results of meta-regressions used to explore factors explaining the heterogeneity among study ESs revealed that a greater ES in the knee flexion moment was associated with an elevated heel height of the high-heeled shoes (P = 0.02) and greater body mass of the individuals (P = 0.012). A greater ES in the knee varus moment during high-heeled gait was associated with a greater body height (P = 0.003) and mass (P = 0.006).

SIGNIFICANCE

Given the association between increased knee flexion/varus moments and risk of developing knee osteoarthritis (OA), women who wear high-heel shoes frequently and for a long period may be more susceptible to knee OA. Preventive treatments, such as lower extremity muscle strengthening, may help improve shock absorption to decrease knee loading in high-heel users.

Osteoarthritis year in review 2020: mechanics

The mechanical environment of the joint during dynamic activity plays a significant role in osteoarthritis processes. Understanding how the magnitude, pattern and duration of joint-specific loading features contribute to osteoarthritis progression and response to treatment is a topic of on-going relevance. This narrative review synthesizes evidence from recent papers that have contributed to knowledge related to three identified emerging subthemes: 1) the role of the joint mechanical environment in osteoarthritis pathogenesis, 2) joint biomechanics as an outcome to arthroplasty treatment of osteoarthritis, and 3) methodological trends for advancing our knowledge of the role of biomechanics in osteoarthritis. Rather than provide an exhaustive review of a broad area of research, we have focused on evidence this year related to these subthemes. New research this year has indicated significant interest in using biomechanics investigations to understand structural vs clinical progression of osteoarthritis, the role and interaction in the three-dimensional loading environment of the joint, and the contribution of muscle activation and forces to osteoarthritis progression. There is ongoing interest in understanding how patient variability with respect to gait biomechanics influences arthroplasty surgery outcomes, and subgroup analyses have provided evidence for the potential utility in tailored treatment approaches. Finally, we are seeing a growing trend in the application of translational biomechanics tools such as wearable inertial measurement units for improved integration of biomechanics into clinical decision-making and outcomes assessment for osteoarthritis.

Wearable Inertial Sensors for Gait Analysis in Adults with Osteoarthritis-A Scoping Review

Our objective was to conduct a scoping review which summarizes the growing body of literature using wearable inertial sensors for gait analysis in lower limb osteoarthritis. We searched six databases using predetermined search terms which highlighted the broad areas of inertial sensors, gait, and osteoarthritis. Two authors independently conducted title and abstract reviews, followed by two authors independently completing full-text screenings. Study quality was also assessed by two independent raters and data were extracted by one reviewer in areas such as study design, osteoarthritis sample, protocols, and inertial sensor outcomes. A total of 72 articles were included, which studied the gait of 2159 adults with osteoarthritis (OA) using inertial sensors. The most common location of OA studied was the knee (n = 46), followed by the hip (n = 22), and the ankle (n = 7). The back (n = 41) and the shank (n = 40) were the most common placements for inertial sensors. The three most prevalent biomechanical outcomes studied were: mean spatiotemporal parameters (n = 45), segment or joint angles (n = 33), and linear acceleration magnitudes (n = 22). Our findings demonstrate exceptional growth in this field in the last 5 years. Nevertheless, there remains a need for more longitudinal study designs, patient-specific models, free-living assessments, and a push for "Code Reuse" to maximize the unique capabilities of these devices and ultimately improve how we diagnose and treat this debilitating disease.

Examination of the changes in lower extremities related to progression of adult spinal deformity: a longitudinal study of over 22 years

This longitudinal observational study investigated the relationship between changes in spinal sagittal alignment and changes in lower extremity coronal alignment. A total of 58 female volunteers who visited our institution at least twice during the 1992 to 1997 and 2015 to 2019 periods were investigated. We reviewed whole-spine radiographs and lower extremity radiographs and measured standard spinal sagittal parameters including pelvic incidence [PI], lumbar lordosis [LL], pelvic tilt [PT], sacral slope [SS] and sagittal vertical axis [SVA], and coronal lower extremity parameters including femorotibial angle (FTA), hip–knee–ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA) and mechanical lateral distal tibial angle (mLDTA). Lumbar spondylosis and knee osteoarthritis were assessed using the Kellgren–Lawrence (KL) grading system at baseline and at final follow-up. We investigated the correlation between changes in spinal sagittal alignment and lower extremity alignment and changes in lumbar spondylosis. The mean age [standard deviation (SD)] was 48.3 (6.3) years at first visit and 70.2 (6.3) years at final follow-up. There was a correlation between changes in PI-LL and FTA (R = 0.449, P < 0.001) and between PI-LL and HKA (R = 0.412, P = 0.001). There was a correlation between changes in lumbar spondylosis at L3/4 (R = 0.383, P = 0.004) and L4/5 (R = 0.333, P = 0.012) and the knee joints. Changes in lumbar spondylosis at L3/4 and L4/5 were related to changes in KOA. Successful management of ASD must include evaluation of the state of lower extremity alignment, not only in the sagittal phase, but also the coronal phase.