Gait analysis and clinical outcome in patients after pilon fracture surgery

BACKGROUND

In this study kinematic parameters, radiographic findings and PROM in pilon fractures after operative treatment were compared with healthy subjects.

METHODS

16 patients treated with osteosynthesis after pilon fracture underwent kinematic analysis with the OFM. Fractures were evaluated for post-operative step-off and gap on CT-scans and PROM were collected. Results were compared to 10 healthy persons.

RESULTS

Range of motion (ROM) crural was lower in the flexion/extension for pilon fractures (10.03 vs. 13.15, p = 0.017). The ROM in the inversion/eversion was low, but ROM in the abduction/adduction was higher. Correlations were found between flexion/extension and AO-classification (r = -0.357 p < 0.05), PROM score of the AOFAS (r = 0.445 p < 0.01), post-operative gap and step-off in the tibia plafond.

CONCLUSION

Pilon fractures showed decreased ROM between the hindfoot and tibia in the sagittal and transverse plane, but increased ROM in the frontal plane during push-off phase as compensatory kinetics. ROM showed significant correlations with PROM and intra-articular step-off and gap in the tibia plafond.

Multisegment Foot Models and Clinical Application After Foot and Ankle Trauma: A Review

Since the end of the 1990s, several multisegment foot models (MSFMs) have been developed. Several models were used to describe foot and ankle kinematics in patients with foot and ankle pathologies; however, the diagnostic value for clinical practice of these models is not known. This review searched in the literature for studies describing kinematics in patients after foot and ankle trauma using an MSFM. The diagnostic value of the MSFMs in patients after foot and ankle trauma was also investigated. A search was performed on the databases PubMed/MEDLINE, Embase, and Cochrane Library. To investigate the diagnostic value of MSFMs in patients after foot and ankle trauma, studies were classified and analyzed following the diagnostic research questions formulated by Knottnerus and Buntinx. This review was based on 7 articles. All studies were published between 2010 and 2015. Five studies were retrospective studies, and 2 used an intervention. Three studies described foot and ankle kinematics in patients after fractures. Four studies described foot and ankle kinematics in patients after ankle sprain. In all included studies, altered foot and ankle kinematics were found compared with healthy subjects. No results on patient outcome using MSFMs and costs were found. Seven studies were found reporting foot and ankle kinematics in patients after foot and ankle trauma using an MSFM. Results show altered kinematics compared with healthy subjects, which cannot be seen by other diagnostic tests and add valuable data to the present literature; therefore, MSFMs seem to be promising diagnostic tools for evaluating foot and ankle kinematics. More research is needed to find the additional value for MSFMs regarding patient outcome and costs.

Gait analysis related to functional outcome in patients operated for ankle fractures

Ankle fractures are among the most common lower limb fractures. Associations between postoperative radiographic results and clinical outcome have been found, but less is known about the relevant ankle biomechanics. This study analyzed ankle kinematics, radiographic findings, and patient-reported outcome measures (PROM) in patients treated for ankle fractures. The hypothesis was that patients after ankle fracture surgery had less flexion/extension in the ankle compared to healthy subjects and that fracture severity had significant influence on kinematics and patient satisfaction. Thirty-three patients (n = 33 feet) operated for ankle fractures were recruited. Ankle kinematics were analyzed using the Oxford Foot model, and results were compared with an age-matched healthy control group (11 patients, 20 feet). In addition, patients were divided by fracture (severity) classification and kinematic results were correlated with PROM and radiographic findings. Patients treated for ankle fracture showed lower walking speed (p < 0.001) when asked to walk in preferred normal speed. When compared at equal speed, significantly less range of motion (ROM) between the hindfoot and tibia in the sagittal plane (flexion/extension) during loading and push-off phases (p = 0.003 and p < 0.001) was found in patients after ankle fractures compared to healthy subjects. Lowest ROM and poorest PROM results were found for patients with trimalleolar ankle fractures. There was a significant correlation between ROM (flexion/extension) during the push-off phase and SF-36 physical functioning (r²  = 0.403, p = 0.027) and SF-36 general health (r²  = 0.473, p = 0.008). Fracture severity was significantly correlated with flexion/extension ROM in the ankle during both loading and push-off phases (r²  = -0.382, p = 0.005, and r²  = -0.568, p < 0.001) and was also significantly correlated with PROM. This study found that patients with ankle fractures had significantly altered ankle kinematics compared to healthy subjects. The poorest results were found among patients with trimalleolar fractures. Weak to strong significant correlations were found between fracture severity, ankle kinematics, and PROM. © 2019 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 37:1658-1666, 2019.

The effect of age and speed on foot and ankle kinematics assessed using a 4-segment foot model

BACKGROUND

The effects of age and speed on foot and ankle kinematics in gait studies using foot models are not fully understood, whereas this can have significant influence. We analyzed these variables with the 4-segment Oxford foot model.

METHODS

Twenty-one healthy subjects (aged 20-65 years) were recruited for gait analysis. The effect of speed on foot and ankle kinematics was assessed by comparing results during slow walking and fast walking. To assess the effect of age, a group of 13 healthy young adults (aged 20-24 years) were compared with a group of 8 older adults (aged 53-65 years). Also, the interaction between age and speed was analyzed.

RESULTS

Regarding speed, there was a significant difference between forefoot/hindfoot motion in the sagittal plane (flexion/extension) during both loading- and push-off phase (P = .004, P < .001). Between hindfoot/tibia, there was a significant difference for all parameters except for motion in the sagittal plane (flexion/extension) during push-off phase (P = .5). Age did not significantly influence kinematics. There was no interaction between age and speed.

CONCLUSION

Our analysis found that speed significantly influenced the kinematic outcome parameters. This was more pronounced in the ankle joint. In contrast, no significant differences were found between younger and older healthy subjects.

Gait Analysis of Foot Compensation After Arthrodesis of the First Metatarsophalangeal Joint

BACKGROUND

Arthrodesis of the first metatarsophalangeal (MTP1) joint is an intervention often used in patients with severe MTP1 joint osteoarthritis and relieves pain in approximately 80% of these patients. The kinematic effects and compensatory mechanism of the foot for restoring a more normal gait pattern after this intervention are unknown. The aim of this study was to clarify this compensatory mechanism, in which it was hypothesized that the hindfoot and forefoot would be responsible for compensation after an arthrodesis of the MTP1 joint.

METHODS

Gait properties were evaluated in 10 feet of 8 patients with MTP1 arthrodesis and were compared with 21 feet of 12 healthy subjects. Plantar pressures and intersegmental range of motion were measured during gait by using the multisegment Oxford Foot Model. Pre- and postoperative X-rays of the foot and ankle were also evaluated.

RESULTS

The MTP1 arthrodesis caused decreased eversion of the hindfoot during midstance, followed by an increased internal rotation of the hindfoot during terminal stance, and ultimately more supination and less adduction of the forefoot during preswing. In addition, MTP1 arthrodesis resulted in a lower pressure time integral beneath the hallux and higher peak pressures beneath the lesser metatarsals. A mean dorsiflexion fusion angle of 30 ± 5.4 degrees was observed in postoperative radiographs.

CONCLUSION

This study demonstrated that the hindfoot and forefoot compensated for the loss of motion of the MTP1 joint after arthrodesis in order to restore a more normal gait pattern. This resulted in a gait in which the rigid hallux was less loaded while the lesser metatarsals endured higher peak pressures. Further studies are needed to investigate whether this observed transfer of load or a preexistent decreased compensatory mechanism of the foot can possibly explain the disappointing results in the minority of the patients who experience persistent complaints after a MTP1 arthrodesis.

LEVEL OF EVIDENCE

Level III, comparative series.

Outcome of Minimally Invasive Open and Percutaneous Techniques for Repair of Calcaneal Fractures: A Systematic Review

Percutaneous and minimally invasive open techniques for the treatment of calcaneal fractures are now frequently used with good results, although a comparison between these different techniques has not yet been performed. The aim of the present review was to search for studies evaluating the outcomes of patients after treatment with percutaneous and minimally invasive open techniques for calcaneal fractures. A search was performed using PubMed/MEDLINE, Embase, and the Cochrane Library. Studies from the previous 15 years in English were included. Data on the Sanders classification, operation technique, infection rate, American Orthopaedic Foot and Ankle Society ankle-hindfoot score, radiographic evaluation, and follow-up were extracted. The techniques were divided into 4 groups: minimally invasive open, percutaneous reduction and screw osteosynthesis, external fixation, and other. Forty-six studies were included, with 1776 patients and 2018 calcaneal fractures. Of the 2018 fractures, 924 (46%) were classified as Sanders II, 558 (28%) as Sanders III, and 245 (12%) as Sanders IV; the fractures of 291 patients(14%) were not classified or were classified as complete extra-articular. Of the 46 studies, 15 used a minimally invasive open technique, 19 evaluated the outcome of percutaneous reduction and screw osteosynthesis, 10 investigated the results of an external fixation system, and 2 studies used other operative techniques. The median infection rate was 3% (range 0% to 33%). The median American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 83 (range 67 to 94). The median angle of Böhler postoperatively was 24° (range 14° to 35°) and had increased after operative treatment, with a median of 16° (range 0° to 39°). The percutaneous reduction and screw osteosynthesis and minimal invasive open technique resulted in significantly better outcomes compared with external fixation and other techniques. In conclusion, percutaneous reduction and screw osteosynthesis and minimal invasive open techniques have the best outcomes for the minimal invasive open surgical treatment of calcaneal fractures.

Gait Analysis and Functional Outcome After Calcaneal Fracture

BACKGROUND

Calcaneal fractures are associated with substantial morbidity and socioeconomic impact, frequently leading to limited functional outcome and high economic costs. The Oxford foot model (OFM) has been reported as a valid addition to the biomechanical examination of the foot. The aim of our study was to analyze the gait of patients after operative repair of a calcaneal fracture in relation to functional outcome and radiographic findings.

METHODS

Thirteen patients with a calcaneal fracture underwent gait analysis with OFM at a minimum of six months after open surgery. Intersegmental range of motion was measured during gait. Results were compared with those of healthy subjects and those of patients who had undergone subtalar arthrodesis. Patient-reported questionnaires and radiographic images were also evaluated.

RESULTS

The range of motion between the hindfoot and the tibia in the push-off phase in the transverse plane was significantly correlated with the clinical outcome as reported by patients based on the Foot and Ankle Disability Index (FADI) (r(2) = 0.51; p < 0.001) and the Short Form (SF)-36 physical component summary score (r(2) = 0.52; p < 0.001). We found a significant correlation between the step-off in the subtalar joint as measured on postoperative computed tomography (CT) and range of motion (r(2) = -0.74; p = 0.004). The step-off was also correlated with the patient-reported outcome questionnaire FADI (r(2) = -0.76; p = 0.003) and the SF-36 physical component summary score (r(2) = -0.78; p = 0.002).

CONCLUSIONS

This study demonstrated that the subtalar joint range of motion of patients after a calcaneal fracture was related both to the quality of the reduction of the subtalar joint as evaluated on postoperative CT scans and patient-reported functional outcome.