Elsevier

Journal of Biomechanics

Volume 72, 27 April 2018, Pages 180-186
Journal of Biomechanics

Inter-joint coordination of kinematics and kinetics before and after total hip arthroplasty compared to asymptomatic subjects

https://doi.org/10.1016/j.jbiomech.2018.03.015Get rights and content

Abstract

While differences in joint kinematics and kinetics between control subjects and patients before and after total hip arthroplasty (THA) has often been studied, inter-joint coordination has not been fully characterized. We hypothesized that in patients undergoing THA, inter-joint coordination (i) is different from control subjects before surgery, (ii) changes from pre-operative to post-operative, and (iii) remains different from control subjects after surgery. Seventy-eight subjects underwent gait analysis before and ∼1 year after primary unilateral THA. 109 control subjects were age, sex, and BMI matched to the THA group. We selected a representative trial at each subjects’ self-selected walking speed from a motion analysis data repository. To assess kinematic coordination, we constructed sagittal plane hip-knee angle cyclograms, and calculated total, stance, and swing phase plot area (deg2). To assess kinetic coordination, we calculated the support moment (MS, %wt ∗ ht), the time-integral of support moment (MS impulse, %wt ∗ ht ∗ t), and the relative contribution of each joint to MS impulse (%Hip, %Knee, %Ankle). We used t-tests to compare groups. Total and swing-phase cyclogram area was smaller preoperatively, but improved to control values after THA. Swing-phase area was smaller than control values after THA. MS impulse was larger in THA subjects than controls both before and after surgery. While, the relative contribution of the hip to MS impulse was not different from control values, the contributions of the knee and ankle were smaller. Inter-joint coordination, as measured by hip-knee angle cyclograms and MS impulse, may be used to distinguish differences in gait mechanics between osteoarthritis and THA. Future work focusing on coordination among joints may be needed to fully restore gait function.

Introduction

Hip osteoarthritis (OA) is a degenerative joint disease that leads to pain and reduced function. Total hip arthroplasty (THA) relieves pain and restores function in most patients, but leaves functional deficits in some (Judge et al., 2010, Singh and Lewallen, 2013). Gait analysis has been used to quantitatively characterize the mechanical function of the hip before and after THA. Studies consistently show that patients with OA have smaller hip ranges of motion (ROM) and external moments during normal walking compared to healthy subjects. Moreover, while gait patterns improve (Foucher and Freels, 2015, Queen et al., 2013, Rosenlund et al., 2016), gait alterations persist after THA relative to healthy controls (Agostini et al., 2014, Foucher et al., 2011, Foucher, 2016, Queen et al., 2014, Varin et al., 2013). Despite the knowledge added by biomechanical studies over the years, gait findings based on traditional measures have been consistent over time even as new surgical approaches and new implant technologies have been developed. It is possible that conventional approaches to evaluating gait mechanics have not revealed all of the information needed to develop interventions that would improve gait and clinical outcomes.

Walking is a dynamic, complex movement, requiring a substantial degree of joint coordination within the kinetic chain. A few studies have investigated joints other than the affected hip, (Beaulieu et al., 2010, Foucher and Wimmer, 2012, Horstmann et al., 2013), however even in these cases single-joint, discrete measures (e.g. peak knee adduction moment) are reported. More comprehensive measures of dynamic movement may reveal systematic gait differences not revealed using traditional measures. For example, an analysis of joint kinematic coordination in subjects with acetabular cartilage defects revealed abnormalities that suggested motor control deficits, which in turn may be relevant for OA progression (Samaan et al., 2015).

In this study, we evaluated two methods of characterizing inter-joint coordination during walking. The first technique is a cyclogram, an angle-angle diagram of the cyclical kinematics of a coordinated system (Goswami, 1998). Cyclograms are generated by simultaneously plotting one joint variable against another joint variable. For example, a hip-knee angle cyclogram graphically shows the relationship between the angles of both joints throughout the entire gait cycle (Fig. 1). The resulting plot can provide measures of the coordinated pattern. Cyclograms have been used to detect differences in locomotion patterns during various distances, over various inclines, and among individuals with various injury diagnoses (Decker et al., 2007, Goswami, 1998, Mah et al., 1999). The second technique, support moment (MS), was developed to study total kinetics of the coordinated system (Winter, 1980). The overall moment (i.e. sum of the moments) produced about the hip, knee, and ankle results in the MS (Fig. 2). Muscle extensor moments are responsible for vertical support as well as propelling the center of gravity forward during the stance phase of walking. The MS has been used to identify abnormalities in knee OA during walking (Zeni and Higginson, 2011) and in sit-to-stand activities in femoroacetabular impingement (Samaan et al., 2017), but to our knowledge has not previously been evaluated in the setting of THA.

The purpose of this study was to explore changes in inter-joint coordination before and one year after THA surgery using both a kinematic and kinetic measure: a hip-knee angle cyclogram and the MS. The rationale is that we know that normal gait function is not completely restored after THA. We therefore postulate that inter-joint coordination is compromised before and possibly after surgery. This information could provide new approaches to ultimately optimize rehabilitation. We hypothesized that in patients undergoing THA, inter-joint coordination measures (i) are worse than control subjects before surgery, (ii) improve from preoperative to postoperative, but (iii) remain worse compared to control subjects after surgery.

Section snippets

Methods

We queried an institutional review board-approved data repository of participants of a motion analysis laboratory study to identify subjects for this retrospective cohort study. Original subjects participated in studies of pre- and postoperative THA gait biomechanics. There were no restrictions on age, functional ability, operated-hip pain level or disease severity for any of the original studies. However, all original studies excluded patients with pain or prior joint replacements in the

Results

Total cyclogram area (Table 2) was 572.2 ± 307.8 deg2 in the pre-THA subjects compared to 1292.1 ± 301.4 deg2 in control subjects (55% lower in pre-THA subjects, p < 0.001) (Fig. 3). Cyclogram area increased by 70% from pre- to post-THA to 973.3 ± 309.7 deg2 (p < 0.001), but remained 20% lower than controls (p < 0.001). When we analyzed stance-phase separately (Table 2), we found stance-phase area was 43% lower at pre-THA compared to control values (p < 0.001). Stance-phase area increased by

Discussion

The purpose of our study was to explore changes in inter-joint coordination during walking before and one year after THA using a kinematic and kinetic measure: a hip-knee angle cyclogram and MS impulse. We hypothesized that inter-joint coordination would be abnormal before THA and would not return to normal following THA, based, in part, on previous findings regarding individual joints. Our hypothesis was partially supported. Total cyclogram area was reduced compared to control values before

Acknowledgements

Data were originally collected at Rush University Medical Center. Data acquisition was funded by a grant from the Rush Research Mentoring Program Young Investigators Fund. The sponsor had no involvement in the study design, conduct, or manuscript preparation. Kris Dapiton, B.S. and Kristin Tayag, B.S. participated in data analysis for the present study.

Conflict of interest statement

There are no financial or personal relationships that have influenced this work.

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