Perioperative gait analysis after total hip arthroplasty: Does outpatient surgery compromise patient outcomes?

Background: There has been a continuing trend toward decreasing the length of hospital stay for patients undergoing total hip arthroplasty (THA). We aimed to investigate the impact of timing of discharge on gait and patient-reported outcomes early after THA. Methods: In this prospective observational cohort study conducted from May 2014 to November 2015, we measured gait velocity, stride length, single-limb support and single-limb support symmetry in adults aged 18−75 years before direct anterior THA, at discharge from the hospital, and 2, 6 and 12 weeks postoperatively. All procedures were performed by a single surgeon. Patients were discharged on the same day as surgery (outpatient group) or stayed at least 1 night in hospital (inpatient group). Participants also completed the Timed Up and Go test (all postoperative time points) and a series of questionnaires (Western Ontario and McMaster Universities Osteoarthritis Index [6 and 12 wk], 12-Item Short Form Health Survey [2, 6 and 12 wk], Harris Hip Score [12 wk] and a pain visual analogue scale [all postoperative time points]). Results: Thirty-six participants were enrolled in the study, of whom 16 were outpatients and 20 were inpatients. The mean pain rating at the time of discharge was lower in the outpatient group than in the inpatient group (adjusted mean difference −1.5, 95% confidence interval −3.0 to 0.0). We found no other significant differences between the groups for any gait, patient-reported or surgical outcome. Conclusion: There were no statistically significant differences in gait or patient-reported outcomes after direct anterior THA between patients who stayed overnight and those who were discharged as outpatients. Patients discharged as outpatients were younger than those who stayed overnight. Our results suggest that discharging patients as an outpatient after direct anterior THA may have a similar impact on patient function and outcomes as a standard overnight stay in hospital.

Effects of Tendon Release Surgery on Inter-Limb Leg Stiffness Control in Children with Spastic Diplegic Cerebral Palsy during Gait

Impaired motor control and musculotendon tightness in the lower extremities are characteristic features of patients with diplegic cerebral palsy (CP). Tendon release surgery (TRS) helps improve joint and leg stiffness, but the effects of TRS on inter-limb coordination in terms of the total leg stiffness, and the bilateral symmetry in leg stiffness during gait, remain unknown. Ten children with spastic diplegic CP scheduled for TRS and ten healthy controls participated in this study. The inter-limb sharing of total leg stiffness during double-limb support phase and bilateral leg stiffness symmetry during stance phase of gait were calculated using the kinematic and ground reaction force data measured by a motion analysis system. Before TRS, the patients with diplegic CP walked with a decreased share of total leg stiffness during weight-acceptance (p < 0.05) and with increased bilateral leg stiffness asymmetry during single-limb support and weight-transfer during gait (p < 0.05) when compared to healthy controls. After TRS, the bilateral leg stiffness asymmetry was significantly reduced in the CP group, especially in the terminal stance phase, with inter-limb sharing of total leg stiffness becoming similar to that in controls (p > 0.05). The surgery seemed to improve the lower limb control and increased the bilateral limb symmetry during gait.

Immediate augmented real-time forefoot weight bearing using visual feedback improves gait symmetry in chronic stroke

BACKGROUND: Symmetry of gait is an important component of rehabilitation in stroke patients. Insufficient weight-bearing causes gait asymmetry. OBJECTIVE: This study aimed to identify the immediate effects of sufficient weight-bearing on the forefoot during the stance phase using visual feedback. METHODS: Twenty-seven individuals with stroke enrolled in this study. All patients were evaluated for gait parameters with and without visual feedback. Visual feedback was provided through a smart application and a beam projector screen that showed a weight shift as a change in color. Spatiotemporal gait parameters were evaluated, resulting in values for a calculated symmetry index, in addition to heel % and toe % temporal values. RESULTS: Velocity and cadence were significantly decreased when visual feedback was provided (p< 0.05). Spatiotemporal parameters, except for bilateral step length, swing time of affected side, and single-limb support of less affected side, showed significant improvement (p< 0.05). The gait pattern of subjects was more symmetrical with visual feedback compared to non-visual feedback (p< 0.05). The toe-on time significantly improved on the affected side with visual feedback (p< 0.05). CONCLUSION: This study suggests that visual feedback aids in the improvement of gait symmetry, forefoot weight-bearing on the affected side, and spatiotemporal parameters.

Assessment of hip muscles by surface EMG in gait analysis

Objectives: The rectus femoris muscle flexes the thigh, while the gluteus maximus muscle extends it. Understanding the activations of these two muscles that function in opposition to each other during walking facilitates the interpretation of gait pathologies. The aim of this study was to evaluate the activations of these muscles during walking by using the surface electromyography (EMG) technique. Methods: Twenty female volunteers aged 18–26 years participated in our study. The electrical activation of the rectus femoris and gluteus maximus muscles of the participants was simultaneously evaluated by gait analysis. At the same time, spatiotemporal parameters and phase parameters were obtained. Results: The activation pattern of both muscles was found to be similar. Both muscles reached the highest activation in the swing phase. The lowest activation was also seen in the pre-swing phase. Both muscles were observed to be active in the loading and single-limb support phases. Conclusion: The fact that these two antagonists muscles are active at the same time suggests that one is functioning concentrically, while the other eccentrically. Thus, stabilization of hip joint is provided when the body moves forward.

The utility of the single-subject method for comparison of temporal-spatial gait changes between a microprocessor and non-microprocessor prosthetic knees

Background: Despite increasing knowledge about the potential benefits of advanced user-controlled technology, the decision about switching an individual prosthesis user from a non-microprocessor prosthetic knee to a microprocessor prosthetic knee is mainly based on clinician’s experience rather than empirical evidence. Objectives: To demonstrate the utility of single-subject design and data analysis for evaluating changes in temporal-spatial gait characteristics between walking with a non-microprocessor prosthetic knee and microprocessor prosthetic knee. Study design: Single-subject ABA/BAB design. Methods: Seven non-microprocessor prosthetic knee users (all men, age 50–84 years, 3–40 years post-amputation) were transitioned through the ABA or BAB phases (A-NMPK, B-MPK, 5 weeks each). Four weekly gait evaluations were performed at three self-selected speeds with an electronic walkway. The non-microprocessor prosthetic knee–microprocessor prosthetic knee differences in stride length–cadence relationship, prosthetic weight acceptance, single-limb support, and step width were evaluated for each subject using the “non-overlap of all pairs” statistical method. Results: Most subjects improved temporal-spatial gait while on the microprocessor prosthetic knee; in only one subject, none of the 10 gait parameters were in favor of the microprocessor prosthetic knee. In the BAB group, longer use of the microprocessor prosthetic knee was associated with shorter prosthetic weight acceptance and longer single-limb support times across three speeds. Step width either improved with the microprocessor prosthetic knee or remained unchanged in most subjects. Conclusion: The evidence of individual subject improvements in gait coordination, greater reliance on the prosthetic side, and better stability with the microprocessor prosthetic knee than non-microprocessor prosthetic knee over a range of walking speeds demonstrate the practical utility of the single-subject method in clinical decision-making. Clinical relevance The results demonstrate the use of the single-subject method for examining person-specific differences in temporal-spatial gait characteristics between walking with a non-microprocessor prosthetic knee and microprocessor prosthetic knee at three self-selected speeds. The method proved feasible and reliable for documenting changes in gait at the individual level, which is relevant for clinical practice.

The effect of conjoint tendon release on gait after direct anterior total hip arthroplasty

Introduction: There has been considerable interest in the direct anterior (DA) approach to total hip arthroplasty (THA) recently. To facilitate exposure of the proximal femur it is sometimes necessary to release the conjoint tendon. Aim: To prospectively investigate whether release of the conjoint tendon has an impact on gait in the early postoperative period. Methods: We measured gait velocity, stride length, single-limb support and single-limb support symmetry preoperatively, at discharge from the hospital, and 2, 6 and 12 weeks and postoperatively. Participants also completed the Timed Up and Go and a series of questionnaires (WOMAC, SF-12, Harris Hip Score, and pain VAS) at each visit. Results: 36 participants undergoing a DA THA with a single surgeon were enrolled in this study. 22 participants had a release of the conjoint tendon during their surgery. We found no differences between the groups for any gait, patient-reported or surgical outcomes ( p < 0.05). There was a total of 3 complications reported in the release group, and 1 complication in the group that did not have a release. Conclusion: Although the conjoint tendon has an important role in the biomechanics of the hip, we found release of the conjoint tendon during the DA approach for THA to have no impact on gait or patient reported outcomes within 12 weeks post-surgery. Therefore, if the exposure of the proximal femur is limited, a low threshold for release of the conjoint tendon is recommended to improve visualisation.

A randomised trial comparing spatio-temporal gait parameters after total hip arthroplasty between the direct anterior and direct lateral surgical approaches

Introduction: Total hip arthroplasty (THA) is a successful procedure for relieving symptoms of severe osteoarthritis. Surgical approach is a key factor in early recovery and although controversial, little has been written about the direct anterior (DA) approach using objective early measures. Methods: 78 participants were prospectively enrolled to undergo a THA through either a DA or direct lateral (DL) surgical approach. Outcome measures were collected preoperatively and at discharge from the hospital, and 2-, 6- and 12-weeks. Outcome measures included the GAITRite® system to measure gait velocity, stride length, single-limb support and single-limb support symmetry. At each time point participants also completed the Timed Up and Go (TUG), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 12-Item Short-Form Survey (SF-12), Harris Hip Score, and pain visual analog scale (VAS). Results: We found statistically significant differences in gait velocity at discharge, 2-weeks and 6-weeks in favour of the DA group (all p < 0.01). We also found significant differences in favour of the DA group for single-limb support symmetry at 6-weeks ( p < 0.01) and 12-weeks ( p < 0.01). The time to complete the TUG test was also significantly shorter in the DA group at 2-weeks ( p < 0.01) and 6-weeks ( p < 0.01) compared to the DL group. However, there were no statistically significant differences in any of the patient-reported outcomes. Conclusion: The DA surgical approach was found to offer significant early advantages in function compared to the DL group, with no differences in quality of life or pain.