Acceleration-based joint stability parameters for total knee arthroplasty that correspond with patient-reported instability

Wearable sensor systems measure differences in knee laxity between healthy and affected knees during dynamic exercise activities: A systematic review

Purpose

Knee laxity can be experienced as knee instability which may lead to a limitation in the activity of patients. Current methods to determine knee instability are performed in a static setting, which does not always correlate with dynamic knee laxity during activities. Wearables might be able to measure knee laxity in a dynamic setting and could be of added value in the diagnosis and treatment of excessive knee laxity. Therefore, the aim of this systematic review is to provide an overview of the wearables that have been developed and their ability to measure knee laxity during dynamic activities.

Methods

The PRISMA guidelines for systematic reviews were followed. A literature search was conducted in EMBASE, PubMed and Cochrane databases. Included studies assessed patients with knee instability using a non-invasive wearable sensor system during dynamic activity, with comparison to a reference system or healthy knees. Data extraction was performed by two authors via a predefined format. The risk of bias was assessed by The Dutch checklist for diagnostic tests.

Results

A total of 4734 articles were identified. Thirteen studies were included in the review. The studies showed a great variety of patients, sensor systems, reference tests, outcome measures and performed activities. Nine of the included studies were able to measure differences in patients with knee instability, all including a tri-axial accelerometer. Differences were not measurable in all parameters and activities in these studies.

Conclusions

Wearables, including at least a tri-axial accelerometer, seem promising for measuring dynamic knee laxity in the anterior-posterior and mediolateral direction. At this stage, it remains unclear if the measured outcomes completely reflect the knee instability that patients experience in daily life.

Level of Evidence

Level III.

Comparison of difficulty in stair ascent and descent after total knee replacement

[Purpose] Although many studies have shown that patients have difficulty in climbing or descending stairs after undergoing total knee replacement, no study so far has compared the difficulty of stair ascent and descent based on objective indicators. This study compared stair ascending and descending processes based on three indicators and clarified which was more difficult. [Participants and Methods] We defined 1) movement method, 2) the necessity for handrail use, and 3) speed as objective indicators. Seventy-eight patients who underwent total knee replacement participated in this study. Three months after the surgery, we examined 1) whether the patients could ascend or descend in a step-over-step or step-by-step manner, 2) whether the patients required handrail support, and measured 3) the time required to ascend and descend for four steps. [Results] The step-by-step movement and handrail requirement rates associated with stair descent were higher than the corresponding rates associated with stair ascent. In addition, the time required for stair descent was greater than that required for ascent. [Conclusion] We found that stair descent was more challenging than stair ascent in terms of all three objective indices: movement method, handrail use, and speed. The results indicate that rehabilitation after total knee replacement should focus more on stair descent than on stair ascent.

Self-reported walking difficulty influences gait characteristics in patients with medial compartment knee osteoarthritis

BACKGROUND

To differentiate gait strategies per knee osteoarthritis and self-reported walking difficulty during self-selected regular and fast gait speeds. We hypothesize that knee osteoarthritis gait characteristics during self-selected regular and fast gait speeds will be most accentuated by the osteoarthritis and walking difficulty group, followed by osteoarthritis and no walking difficulty, and least in the control group.

METHODS

Prospective study of community-dwelling older adults (n = 39) who walk at functional speeds (≥1.0 m per second) were age and sex matched across the three groups. Gait strategies including knee excursion and moments, muscle activation and co-contraction, and limb dynamics (linear acceleration and jerk) were compared between groups during self-selected regular and fast gait speed trials. Significant group differences were defined as P < 0.05 and an effect size greater than small.

FINDINGS

Based on walking difficulty, adduction moments (P-range = 0.00-0.03; effect size range,r = 0.42-0.52) and lateral quadriceps-gastrocnemius co-activations (P = 0.01;r = 0.36) were significant during regular gait speeds; and extension (P = 0.03;d = 0.59) and adduction (P-range = 0.00-0.02;d = 0.86;r = 0.40) moments were significant during fast trials. Per knee osteoarthritis presence, adduction moment(P = 0.01;r = 0.49), medial-quadriceps (P = 0.00;d = 1.04;r = 0.61), lateral-hamstrings (P = 0.04;d = 0.55), medial-gastrocnemius (P = 0.02;r = 0.40), medial quadriceps-hamstrings (P = 0.02;r = 0.38), medial quadriceps-gastrocnemius (P = 0.00;r = 0.56), and all limb dynamics (P = 0.00-0.01;d = 1.13-1.18;r = 0.35-0.47) were significant during regular gait speeds. Extension excursion (P = 0.02;d = 0.63), adduction moment (P = 0.01;d = 0.85) and medial-quadriceps (P = 0.01;r = 0.38) were significant during fast trials.

INTERPRETATION

Many gait strategies during regular speeds that differ per walking difficulty and knee osteoarthritis attenuated at fast speeds. Perhaps gait training at fast speeds for those with knee osteoarthritis related walking difficulty is biomechanically and functionally beneficial.

Can tibio-femoral kinematic and kinetic parameters reveal poor functionality and underlying deficits after total knee replacement? A systematic review

BACKGROUND

Extensive efforts have been made to understand joint kinematics and kinetics in total knee arthroplasty (TKA) in subjects with satisfactory outcomes during daily functional activities and clinical tests, but it remains unclear whether such movement characteristics hold the potential to indicate the underlying aetiology of unsatisfactory or bad TKA outcomes.

PURPOSE

To investigate which kinematic and kinetic parameters assessed during passive clinical tests and functional activities of daily living are associated with poor functionality and underlying deficits after total knee replacement.

METHODS

We focused on studies characterizing the kinematic or kinetic parameters of the knee joint that are associated with poor clinical outcome after TKA. Seventeen articles were included for the review, and kinematic and kinetic data from 719 patients with minimal follow up of 6 months were extracted and analyzed.

RESULTS

Passive posterior translation at 90°flexionexhibited good potential for differentiating stable and unstable TKAs. Anterior-posterior (A-P) translation of the medial condyle at 0-30° and 30-60° flexion, A-P translation of the lateral condyle at 60-90°during closed chain exercises, as well asknee extension moment during stair ascent and descent, knee abduction moment during stair descent, knee internal rotation moment and plantar flexion moment during walking, 2ndpeak ground reaction force during stair ascent and walkingshowed the greatest promise as functional biomarkers for a dissatisfied/poor outcome knee after TKA.

CONCLUSION

In this study, we systematically reviewed the state-of-the-art knowledge of kinematics and kinetics associated with functional deficits, and found 11 biomechanical parameters that showed promise for supportingdecision making in TKA.

A Systematic Review of Diagnostic Accuracy and Clinical Applications of Wearable Movement Sensors for Knee Joint Rehabilitation

In clinical practice, only a few reliable measurement instruments are available for monitoring knee joint rehabilitation. Advances to replace motion capturing with sensor data measurement have been made in the last years. Thus, a systematic review of the literature was performed, focusing on the implementation, diagnostic accuracy, and facilitators and barriers of integrating wearable sensor technology in clinical practices based on a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. For critical appraisal, the COSMIN Risk of Bias tool for reliability and measurement of error was used. PUBMED, Prospero, Cochrane database, and EMBASE were searched for eligible studies. Six studies reporting reliability aspects in using wearable sensor technology at any point after knee surgery in humans were included. All studies reported excellent results with high reliability coefficients, high limits of agreement, or a few detectable errors. They used different or partly inappropriate methods for estimating reliability or missed reporting essential information. Therefore, a moderate risk of bias must be considered. Further quality criterion studies in clinical settings are needed to synthesize the evidence for providing transparent recommendations for the clinical use of wearable movement sensors in knee joint rehabilitation.

Assessing Stability of Crutch Users by Non-Contact Methods

Enhancing gait stability in people who use crutches is paramount for their health. With the significant difference in gait compared to users who do not require an assistive device, the use of standard gait analysis tools to measure movement for temporary crush users and physically disabled people proves to be more challenging. In this paper, a novel approach based on video analysis is proposed as non-contact low-cost solution to the more expensive alternative with the data collected from processed videos, two values are calculated: the Signal to Noise Ratio (SNR) of acceleration, and the Signal to Noise Ratio of the jerk (time derivative of acceleration), to assess the user’s stability while they walk with crutches. The adopted methodology has been tested on a total of 10 participants. Five are temporary users of assistive devices with one being a long-term user and the other four novice users, and five are disabled participants who use those assistive devices permanently. Preliminary results show differences between novice users, long-term users, and physically disabled users. The approach is promising and could improve the assessment of crutch user stability, allowing for the correction of gait for individuals while using an inexpensive non-contact setup and preventing unnecessary falls.

Validating Wearable Sensors Using Self-Reported Instability among Patients with Knee Osteoarthritis

BACKGROUND

Self-perceived instability among patients with knee osteoarthritis (OA) is defined as giving way, buckling, or shifting of the knee during activities, especially walking. Although instability is a leading cause of mobility decline with knee OA, methods for quantifying the symptom, determining the mechanisms, and establishing effective interventions remain unclear. Recently, data outputs (ie, linear acceleration and its time-derivative, jerk) from wearable sensors are showing strong associations with self-perceived instability among patients with other knee pathologies and may offer insight into OA-related instability.

OBJECTIVE

To examine discriminant and convergent validity of using data outputs from wearable sensors to quantify self-reported instability among patients with knee OA.

DESIGN

Secondary analysis of a cross-sectional study.

SETTING

Primary recruitment from an institutional outpatient physical therapy clinic and collection completed in an institutional research laboratory.

PATIENTS

Thirty-nine total participants. The OA group included 26 participants with radiographic evidence of moderate to severe knee OA in the medial compartment; knee pain >3 out of 10, and a walking speed of ≥1.0 m/s. The control group included 13 participants with no history of knee OA. Participants with current or history of low back, hip, or foot/ankle injury; knee replacement; skeletal realignment surgery; or comorbidities that limit walking, pregnancy, and inability to walk without an assistive device were excluded.

INTERVENTIONS

N/A MAIN OUTCOME MEASURES: Data output from wearable sensors at the tibia.

RESULTS

Midstance acceleration (P = .01) and jerk (P = .04) were significantly greater for those with than without knee OA. Acceleration was significantly associated with self-reported instability (Spearman's rho = -0.63, P < .01).

CONCLUSIONS

Data from wearable sensors are a valid measurement for exploring the mechanisms and risks of instability among patients with knee OA.

Motion Sensors-Based Machine Learning Approach for the Identification of Anterior Cruciate Ligament Gait Patterns in On-the-Field Activities in Rugby Players

Anterior cruciate ligament (ACL) injuries are common among athletes. Despite a successful return to sport (RTS) for most of the injured athletes, a significant proportion do not return to competitive levels, and thus RTS post ACL reconstruction still represents a challenge for clinicians. Wearable sensors, owing to their small size and low cost, can represent an opportunity for the management of athletes on-the-field after RTS by providing guidance to associated clinicians. In particular, this study aims to investigate the ability of a set of inertial sensors worn on the lower-limbs by rugby players involved in a change-of-direction (COD) activity to differentiate between healthy and post-ACL groups via the use of machine learning. Twelve male participants (six healthy and six post-ACL athletes who were deemed to have successfully returned to competitive rugby and tested in the 5–10 year period following the injury) were recruited for the study. Time- and frequency-domain features were extracted from the raw inertial data collected. Several machine learning models were tested, such as k-nearest neighbors, naïve Bayes, support vector machine, gradient boosting tree, multi-layer perceptron, and stacking. Feature selection was implemented in the learning model, and leave-one-subject-out cross-validation (LOSO-CV) was adopted to estimate training and test errors. Results obtained show that it is possible to correctly discriminate between healthy and post-ACL injury subjects with an accuracy of 73.07% (multi-layer perceptron) and sensitivity of 81.8% (gradient boosting). The results of this study demonstrate the feasibility of using body-worn motion sensors and machine learning approaches for the identification of post-ACL gait patterns in athletes performing sport tasks on-the-field even a number of years after the injury occurred.

Current clinical utilisation of wearable motion sensors for the assessment of outcome following knee arthroplasty: a scoping review

OBJECTIVES

Wearable motion sensors are used with increasing frequency in the evaluation of gait, function and physical activity within orthopaedics and sports medicine. The integration of wearable technology into the clinical pathway offers the ability to improve post-operative patient assessment beyond the scope of current, questionnaire-based patient-reported outcome measures. This scoping review assesses the current methodology and clinical application of accelerometers and inertial measurement units for the evaluation of patient activity and functional recovery following knee arthroplasty.

DESIGN

This is a systematically conducted scoping review following Joanna Briggs Institute methodology for scoping reviews and reported consulting the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for scoping reviews. A protocol for this review is registered with the Open Science Framework (https://osf.io/rzg9q).

DATA SOURCES

CINAHL, EMBASE, MEDLINE and Web of Science databases were searched for manuscripts published between 2008 and 2019.

ELIGIBILITY CRITERIA

We included clinical studies reporting the use of any combination of accelerometers, pedometers or inertial measurement units for patient assessment at any time point following knee arthroplasty.

DATA EXTRACTION AND SYNTHESIS

Data extracted from manuscripts included patient demographics, sensor technology, testing protocol and sensor-based outcome variables.

RESULTS

45 studies were identified, including 2076 knee arthroplasty patients, 620 patients with end-stage osteoarthritis and 449 healthy controls. Primary aims of the identified studies included functional assessment, physical activity monitoring and evaluation of knee instability. Methodology varied widely between studies, with inconsistency in reported sensor configuration, testing protocol and output variables.

CONCLUSIONS

The use of wearable sensors in evaluation of knee arthroplasty procedures is becoming increasingly common and offers the potential to improve clinical understanding of recovery and rehabilitation. While current studies lack consistency, significant opportunity exists for the development of standardised measures and protocols for function and physical activity evaluation.

The assessment of instability in the osteoarthritic knee

Patient-reported instability is a common complaint amongst those with knee arthritis.

Much research has examined the assessment of self-reported instability in the knee; however, no definitive quantitative measure of instability has been developed.

This review focuses on the current literature investigating the nature of self-reported instability in the arthritic knee and discusses the possibilities of further investigation.

Cite this article: EFORT Open Rev 2019;4:70-76. DOI: 10.1302/2058-5241.4.170079

Smoothness of the knee joint movement during the stance phase in patients with severe knee osteoarthritis

Background

Patients with knee osteoarthritis can significantly affect the function of the knee joint in terms of joint range and mobility and have a stereotypical pattern of knee stiffness during gait, caused by an increased resistance in the muscles and soft tissues during the stance phase of knee joint movement. Smoothness in movement, such as during walking and running, is assumed to be attained by adulthood; however, disruptions in gait pattern due to injury or performance enhancement can alter the smoothness of the movement, and this is often quantified in terms of "jerk". A higher jerk value is linked with a decrease in smoothness. However few have reported to evaluate the smoothness of the knee joint movement during walking in patients with knee osteoarthritis. The purpose of the present study was to quantify the smoothness of the knee joint movement during walking in people with knee osteoarthritis.

Methods

Patients were classified as having early or severe knee osteoarthritis. There were eight patients in each group (16 knees; three males, five females). The normalized angular jerk was calculated as an indicator of the walking knee joint smoothness in each of the four periods of the stance phase. Two-way ANOVA was performed to compare the smoothness of knee joint movement between groups and between each period of the stance phase.

Results

The angular change in the sagittal plane of those with severe knee osteoarthritis was smaller than that of those with early knee osteoarthritis in all periods of the stance phase. Normalized angular jerk did not significantly differ between groups in all periods. In both groups, the normalized angular jerk in the sagittal plane was significantly larger in the mid-stance and terminal stance periods than in the early stance and pre-swing periods. Only in patients with severe knee osteoarthritis, there was a significantly larger jerk in the frontal plane in the mid-stance period.

Conclusion

The present results revealed that the smoothness of joint movement decreases during the single leg supporting phase of the stance phase in the frontal plane with severe knee osteoarthritis, although there is no difference in smoothness of joint movement according to the severity of knee osteoarthritis The instability during single leg support due to increase of the knee joint load and destruction cause the impaired smoothness of the knee joint movement.

Temporomandibular joint articulations on working side during chewing in adult females with cross-bite and mandibular asymmetry

Influence of mandibular asymmetry and cross-bite on temporomandibular joint (TMJ) articulation remained unknown. This study aimed to investigate whether/how the working-side condylar movement irregularity and articular spaces during chewing differ between patients with mandibular asymmetry/cross-bite and control subjects. The cross-bite group and the control group consisted of 10 adult female patients and 10 adult female subjects, respectively. They performed unilateral gum-chewing. The mandibular movements were recorded using a video-based opto-electronic system. The 3D articular surface of the TMJ for each individual was reconstructed using CT/MRI data. For local condylar points, the normalised jerk cost (NJC) towards normal direction to the condylar surface, the angle between tangential velocity vector and condylar long axis and intra-articular space were measured. Three rotatory angles at centre of the condyle were also measured. During closing and intercuspation, (i) movements of posterior portion of the deviated side condyle showed significantly less smoothness as compared with those for the non-deviated side and control subjects, (ii) the rotations of the condyle on the deviated side induced greater intra-articular space at posterior and lateral portions. These findings suggest that chewing on the side of mandibular deviation/cross-bite may cause irregular movement and enlarged intra-articular space at posterior portion of the deviated side condyle.

Influence of balancing-side occlusal interference on smoothness of working-side condylar movement and intra-articular space in chewing efforts

Response of temporomandibular joint (TMJ) articulation adapting to occlusal alteration has been sparsely known. For 10 healthy adults with acceptably good occlusion, an artificial occlusal interference (OI) was introduced to the lower molar on the balancing side of unilateral chewing. Subjects were asked to chew a gum on their preferred side. The chewing jaw movements with/without the OI were recorded using a video-based optoelectronic system. The mandibular movements were generated in each individual's TMJ model reconstructed by magnetic resonance images. The smoothness of local condylar point movements towards the normal direction of the condylar surface and interarticular space on the working side was measured. Overall, the smoothness of condylar point movements in the closing phase was impaired immediately after introduction of the OI. In the intercuspal phase, the OI increased the joint space. After about 60 chewing cycles, the movement smoothness and joint space began to recover. These findings suggest that OI on the balancing side induced irregular stress field translation on the working-side condylar surface followed by acute recovery process.