Inès A. Kramers-de Quervain

Gait Pattern in the Early Recovery Period after Stroke

The gait patterns of eighteen patients who had had a single infarct due to obstruction of the middle cerebral artery were evaluated within one week after the patients had resumed independent walking and before a gait rehabilitation program had been initiated. Gait was analyzed with use of motion analysis, force-plate recordings, and dynamic surface electromyographic studies of the muscles of the lower extremities. The patterns of motion of the lower extremity on the hemiplegic side had a stronger association with the clinical severity of muscle weakness than with the degree of spasticity, balance control, or phasic muscle activity. There was a delay in the initiation of flexion of the hip during the pre-swing phase, and flexion of the hip and knee as well as dorsiflexion of the ankle progressed only slightly during the swing phase. During the stance phase, there was decreased extension of the hip that was related to decreased muscle effort and a coupling between flexion of the knee and dorsiflexion of the ankle. The abnormal patterns of motion altered the velocity, the length of the stride, the cadence, and all phases of the gait cycle. The duration of the pre-swing phase was prolonged for the patients who had the slowest gait velocities. There also were abnormal movements of the upper extremity, the trunk, the pelvis, and the lower extremity on the unaffected side in an effort to compensate for the decreased velocity on the hemiplegic side. As velocity improved, these abnormal movements decreased. Therefore, the goal of therapy should be to improve muscle strength and coordination on the hemiplegic side, especially during the pre-swing phase.

The role of patient expectations in predicting outcome after total knee arthroplasty

IntroductionPatients expectations are variably reported to influence self-rated outcome and satisfaction after medical treatment; this prospective study examined which of the following was the most important unique determinant of global outcome/satisfaction after total knee arthroplasty (TKA): baseline expectations; fulfilment of expectations; or current symptoms and function.MethodsOne hundred and twelve patients with osteoarthritis of the knee (age, 67 ± 9 years) completed a questionnaire about their expectations regarding months until full recovery, pain, and limitations in everyday activities after TKA surgery. Two years postoperatively, they were asked what the reality was for each of these domains, and rated the global outcome and satisfaction with surgery. Multivariable regression analyses using forward conditional selection of variables (and controlling for age, gender, other joint problems) identified the most significant determinants of outcome.ResultsPatients significantly underestimated the time for full recovery (expected 4.7 ± 2.8 months, recalled actual time, 6.1 ± 3.7 months; P = 0.005). They were also overly optimistic about the likelihood of being pain-free (85% expected it, 43% were; P < 0.05) and of not being limited in usual activities (52% expected it, 20% were; P < 0.05). Global outcomes were 46.2% excellent, 41.3% good, 10.6% fair and 1.9% poor. In multivariable regression, expectations did not make a significant unique contribution to explaining the variance in outcome/satisfaction; together with other joint problems, knee pain and function at 2 years postoperation predicted global outcome, and knee pain at 2 years predicted satisfaction.ConclusionsIn this group, preoperative expectations of TKA surgery were overly optimistic. The routine analysis of patient-orientated outcomes in practice should assist the surgeon to convey more realistic expectations to the patient during the preoperative consultation. In multivariable regression, expectations did not predict global outcome/satisfaction; the most important determinants were other joint problems and the patients pain and functional status 2 years postoperatively.

Quantitative gait analysis after bilateral total knee arthroplasty with two different systems within each subject

The functional behavior of two kinematically different knee arthroplasty systems within each subject was studied by gait analysis (three-dimensional kinematics, kinetics, dynamic electromyography) in five elderly patients, 2 to 5 years after bilateral surgery. Clinical results were good, yet gait velocity was reduced (range, 0.57-1.1 m/s), with a shortened stride length and a decreased duration of single-limb stance in all subjects. Force plate recordings revealed an undynamic gait with slow loading, reduced modulation of the vertical forces, and poor fore/aft shears. Sagittal plane knee motion during gait was reduced in all subjects, with trunk and pelvic compensation patterns for foot clearance. Muscle activity around the knee was prolonged bilaterally, with activity modulation related to the motion pattern. Although the stride parameters were quite symmetric, there was a marked asymmetry of the motion pattern, with a side-to-side difference of peak knee flexion during stance and swing phase of up to 15 degrees. This finding, however, was not clearly related to the type of prosthesis. Even within one subject, significant side-to-side variability may persist, which leads to asymmetry of the motion pattern, unrelated to the kinematic design of the implant. Other factors, such as the patella-extensor mechanism, ligament balancing, leg-length discrepancy, proprioception, continuation of a preoperative habit, or a contralateral influence, may explain part of the asymmetry seen in these subjects.

Fat-pad impingement after total knee arthroplasty with the LCS A/P-Glide system.

Early follow-up (15.8 months;1–48) of 230 knee replacements with an LCS A/P Glide component indicated an increased occurrence of anterior knee pain due to a fat-pad impingement, necessitating early revision surgery. Unsatisfactory results were observed in 28 knees (12.2%). Thirteen knees (5.7%) were revised on finding the fat-pad impingement, and four knees (1.7%) were scheduled for later revision surgery; the remaining 11 subjects (4.8%) had revision surgery for a different reason. Twenty-six subjects (11.3%) complained about milder but typical symptoms of a fat-pad impingement, and 22 subjects (9.6%) had unspecific mild symptoms. 151 knees (65.7%) were free of pain and demonstrated an excellent result. The total revision rate of 10.4% (24 knees) is higher than described for other implant systems. However, the revision needed to treat the fat-pad impingement (5.7%) consisted of minor surgery only, such as exchange of the mobile bearing or reduction of the fat pad by arthroscopy. The femoral and tibial components were able to be left untouched. Resection of the Hoffa’s fat pad is recommended when such an implant system is used, and possible impingement should be investigated intraoperatively before closure.

Functional Donor-Site Morbidity During Level and Uphill Gait After a Gastrocnemius or Soleus Muscle-Flap Procedure

Background: There is only limited objective information about functional donor-site morbidity after harvest of one head of the triceps surae muscles to cover a severe soft-tissue defect of the leg. The purpose of the present study was to investigate whether a functional deficit is present during level and uphill walking after such a procedure. Methods: Five subjects who had completely recovered from the initial injury were studied with use of comprehensive gait analysis during free level, fast level, and uphill walking on a ramp at a 10° inclination. Results: Gait analysis revealed no relevant donor-site morbidity affecting level gait at a free walking speed (mean, 1.27 m/sec; range, 1.18 to 1.40 m/sec). When the subjects walked at a higher velocity (mean, 1.89 m/sec; range, 1.58 to 2.43 m/sec), an asymmetry of the ground-reaction forces was seen. The second vertical peak force during push-off was reduced by a mean of 7.3% (range, 0.94% to 12.24%), and the impulse in the direction of progression was reduced by a mean of 8.7% (range, 0.13% to 17.87%) on the affected side (p = 0.04). During uphill walking, a compensatory strategy to reduce the demand on the posterior calf muscles was seen in all subjects-that is, they shortened the length of the step on the contralateral side by a mean of 3.9 cm (range, 2.2 to 6.2 cm), which corresponded to a mean side-to-side difference of 5.6% (range, 2.18% to 6.18%) (p = 0.04). A calcaneal motion pattern, denoted as increased ankle dorsiflexion, was seen in three of the five subjects during uphill walking as a sign of decreased function of the posterior calf muscles. Two of them (both with a soleus flap) also had a calcaneal pattern during fast gait. Conclusions: We concluded from this study that the functional donor-site morbidity after harvest of one head of the triceps surae muscles is mild in subjects who have had a complete recovery from their initial injury. Normal level gait is possible. However, deficits are seen in more demanding tasks such as fast walking or uphill walking.

Infection risk after orthopedic surgery in patients with inflammatory rheumatic diseases treated with immunosuppressive drugs.

The influence of specific medications on the risk of postoperative infection in patients with rheumatoid arthritis and other inflammatory rheumatic diseases (IRDs) remains unclear. This retrospective study examined the risk of postoperative infection at the site of surgery in patients treated with immunosuppressive drugs (including biologic agents) undergoing different types of orthopedic surgery.

Quantitative gait analysis in patients with medial patellar instability following lateral retinacular release

Abstract Medial patellar instability is a known possible complication following lateral retinacular release. Insufficient passive structures, muscle imbalance and an over-release of the lateral retinaculum with resection of the vastus lateralis tendon have been implied as a major cause of this problem. We report about the findings of quantitative gait analysis consisting of video recordings, three-dimensional motion analysis, dynamic electromyography and sampling of the ground reaction forces in two patients with medial patellar subluxation. Documentation of the gait functions together with observation of the patellar translation revealed the timing of the occurrence of the instability during level gait: a normal gait pattern with a sufficient quadriceps mechanism and a centred patella was seen during loading (weight acceptance), while the quadriceps muscle was active. Abnormal medial translation of the patella was observed during unloading of the leg while the knee was bending in preparation for the swing phase. This is a phase in the gait cycle when the quadriceps muscle is silent and the patella position is guided by the passive structures only. This finding weakens the argument of muscle imbalance as a cause for the patellar instability and stresses the importance of well balanced passive structures. This explains why a muscular rehabilitation programme is likely to fail as long as the passive structures allow the instability to occur.

Prospective study of gait function before and 2 years after total knee arthroplasty.

PURPOSE To perform a prospective evaluation of gait before and 2 years after total knee arthroplasty (TKA) and examine the influence of comorbidity and other joint problems on gait characteristics and their improvement after TKA. METHODS One hundred and eleven patients scheduled for TKA took part (34 men, 65 ± 10 y; 77 women, age 68 ± 9 y). Gait velocity, cadence, and ground reaction force parameters were measured before and 2 years after surgery. Patients completed a questionnaire to rate their pain and other joint problems. Comorbidity was measured with the American Society of Anaesthesiologists (ASA) score. RESULTS Two years after TKA there were significant improvements (each p<0.05) in gait velocity and cadence and most of the ground reaction parameters, though forces during loading/unloading remained lower for the operated leg than for the contralateral leg. Higher comorbidity and other painful joints of the lower extremities/spine had a consistent, negative influence (p<0.05) on the absolute values achieved for the gait parameters although their improvement compared with baseline was independent of these factors. CONCLUSIONS Comorbidity and other joint problems negatively influenced gait performance. These confounders should be taken into account when setting realistic patient expectations and when interpreting the success of TKA in the individual patient. Improvement in gait is however still possible, within the bounds of concomitant comorbidity.

Bleeding complications after systematic switch of routine thromboprophylaxis for major orthopaedic surgery

The rate of bleeding complications after major orthopedic surgery approximates 2%. It is unclear whether a systematic switch of routine thromboprophylaxis has an impact on the rate of postoperative bleeding complications. We analyzed prospectively recorded postoperative bleeding complications and symptomatic venous thromboembolic events in 8,176 consecutive orthopedic patients at the Schulthess Clinic Zurich during a systematic switch of thromboprophylaxis from nadroparin to enoxaparin in the year 2004. Overall, 3,893 patients received nadroparin in the first nine-month observation period before the switch and 4,283 patients received enoxaparin in the second nine-month observation period after the switch. Overall, 96 (2.5%) patients in the first period and 70 (1.6%) patients in the second period suffered a postoperative bleeding complication requiring surgical revision, puncture, or transfusion (p < 0.01). Five objectively confirmed symptomatic venous thromboembolic events during hospitalization in the first period and three events in the second period were recorded. In conclusion, the switch of thromboprophylaxis in a large orthopedic clinic did not cause an increase of postoperative bleeding complications and therefore was accompanied by high patient safety.

Synovial Ganglion of the Hip as a Rare Cause of L5 Radiculopathy

Case: We report a rare case of a dorsal synovial ganglion of the left hip causing L5 radiculopathy in a 48-year-old woman. After a 12-month history of intermittent pain in the groin, left buttock, and left lower limb, magnetic resonance imaging (MRI) of the pelvis revealed a 10-cm-long cystic ganglion. The lesion originated from the posterior aspect of the hip joint capsule and extended through the sciatic notch toward the L5 nerve root, causing severe nerve compression. Open resection of the ganglion via surgical hip subluxation was performed. Conclusion: Combined presentation of symptoms attributable to intrinsic hip disease and peripheral radiculopathy should raise suspicion for a shared cause of these entities.