Jacquelin Perry

Energy cost of walking of amputees: the influence of level of amputation

A comparison of selected gait parameters and the energy cost of prosthetic walking was made in seventy patients with unilateral traumatic and vascular amputations. Amputations above the knee, below the knee, and at the Symes level were compared in both groups of amputees, and a control group of forty normal subjects also studied. In both groups of amputees performance was significantly better the lower the level of the amputation. When preservation of function is the chief concern, amputation should be performed at the lowest possible level.

Functional ambulation in patients with myelomeningocele.

The factors important in achieving good walking status in myelomeningocele include level of paraplegia, the additional anomalies of brain and kidney, the intelligence, and the home environment. In a group of fifty-six patients none of those with lesions of the thoracic level walked and all of those with lesions of the sacral level walked. In those with lesions at lumbar levels (twenty-one lower and nineteen upper) fourteen were community ambulators and five household ambulators. The other twenty-one were either wheel-chair (nineteen) or non-functional ambulators (two) and the level of paraplegia did not seem to matter nor did the extent of surgery. Some very young non-functional ambulators rose in functional level, but in most instances the trend was to deteriorate.

Rectus femoris transfer to improve knee function of children with cerebral palsy.

Stance phase stability and swing phase clearance, prerequisites for normal ambulation, often are lost in the gait of children with cerebral palsy. Lengthening of the hamstrings usually will improve stance‐phase knee extension but will not greatly alter swing‐phase knee flexion. This paper presents the outcome of transfer of the distal end of the rectus femoris in conjunction with hamstrings lengthening in 37 knees, and compares it with a control group of 24 knees in which only hamstrings lengthening was done. In the first group swing‐phase knee flexion was improved by 16‐0± 14‐4o, compared to 9‐5±7‐5o in the control group, and residual knee flexion in stance was reduced to 8–9±8‐1o, compared to 15. 1 ± 13‐8o in the controls. Poor outcome in the transfer‐plus‐lengthening group was associated mainly with foot rotation in excess of 8o internally or externally, or postoperative knee flexion in stance. Criteria for selection of cases and methods of improving surgical outcome are discussed.

Selective tarsal arthrodesis: An in vitro analysis of the effect on foot motion

Five different intertarsal arthrodeses were simulated in 15 fresh cadaver feet/ankles utilizing external fixation. Pin placement was verified radiographically. Range of motion measurements were performed before pin placement, after pin placement, and after simulated arthrodesis. The deficit in foot motion created by selected limited intertarsal fusions was then measured. The prearthrodesis range of motion measurements were found to be dorsiflexion (DF), 27°; plantarflexion (PF), 57°; total inversion (INVT), 29°; eversion total (EVT), 22°; hindfoot varus (VRH), 16°; hindfoot valgus (VLH), 12°. The deficits in motion after arthrodesis were as follows. Ankle (tibiotalar): DF, 50.7%; PF, 70.3%; INVT, 8.7%; EVT, 9.4%; VRH, 34.6%; VLH, 27.8%. Hindfoot arthrodesis (Tibiotalar calcaneal): DF, 53%; PF, 71.3%; INVT, 49.5%; EVT, 47.6%, VRH, 100%; VLH, 100%. Pantalar (Tibotalar calcanea cuboid navicular): DF, 62.8%; PF, 82.2%; INVT, 71.7%; EVT, 67.4%; VRH, 100%; VLH, 100%. Triple (Talocalcaneal cuboid navicular): DF, 12.5%; PF, 15.5%; INVT, 50%; EVT, 51.4%; VRH, 60.5%; VLH, 60.5%. Total tarsal arthrodesis: DF, 78.5%; PF, 90.2%, INVT, 87.5%; EVT, 83.6%; VRH, 100%; VLH, 100%.

The Relative Strength of the Hamstrings during Hip Extension

The role of the hamstrings in extension of the hip was determined in eight normal subjects by measuring maximum isometric hip extension torque in different positions of hip flexion before and after sciatic-nerve block. Total hip extensor strength increased more than twofold as the hip was flexed from zero to 90 degrees. Following sciatic-nerve block, hip extension strength was reduced approximately 50 per cent in all positions of hip flexion. The hamstrings accounted for approximately one-third of total measured extensor torque.

Relationship between foot pronation and rotation of the tibia and femur during walking.

The purpose of this study was to test the hypothesis that the magnitude and timing of peak foot pronation would be predictive of the magnitude and timing of peak rotation of tibia and femur. Thirty subjects who demonstrated a wide range of pronation participated. Three-dimensional kinematics of the foot, tibia, and femur segments were recorded during self-selected free walking trials using a six-camera VICON motion analysis system. Regression analysis demonstrated that the magnitude and timing of peak pronation was not predictive of the magnitude and timing of tibial and femoral rotation. The lack of a relationship between peak foot pronation and the rotation of the tibia and femur is contrary to the clinical hypothesis that increased pronation results in greater lower extremity rotation. It would seem, therefore, that the relationship between foot pronation and rotation of the lower extremity segments should be assessed on a patient-by-patient basis.

Translational motion of the head and trunk during normal walking

Abstract Translational motion at different levels of the head and trunk in normal human subjects was measured in three dimensions at different walking speeds. Both acceleration and displacement were directly recorded in two separate experiments. Characteristic patterns of motion were observed and are related to the basic mechanics of human locomotion.

The Orthopaedic Management of Brain-Injured Children

This survey emphasizes the important role the orthopaedic surgeon plays in the treatment of brain-damaged children. In one institution in ten years, 122 brain-damaged children were admitted and 112 were evaluated: 21 per cent walked in the first year after injury, and 83 per cent walked at the time of final evaluation; 68 per cent of the patients had joint deformities on admission, and 8 per cent had joint deformities at discharge. Scoliosis occurred in four patients, limb-length inequalities in three, and ectopic ossification in six. The problems of management of a total of sixty-nine fractures were described. Internal fixation was necessary in two of the fractured femora and would have been advisable in a third.

ASSESSMENT OF REARFOOT MOTION : PASSIVE POSITIONING, ONE-LEGGED STANDING, GAIT

Earlier studies that address assessment of the subtalar joint (STJ) by measuring rearfoot motion used a goniometer to evaluate intertester reliability. Few investigations have determined how positions of the rearfoot, assessed manually (passive range of motion) or statically in one-legged standing, compare with those occurring during walking. The purpose of this study was to determine the following: (1) the intertester reliability of positioning the STJ in neutral, maximum inversion, and maximum eversion; (2) the reliability of the rearfoot position during relaxed one-legged standing; and (3) how these positions compare to rearfoot motion during walking. An electrogoniometer attached to the lateral aspect of the lower leg and heel was used to record the position of the rearfoot during testing procedures. Ten healthy volunteers participated. Rearfoot position was recorded during relaxed one-legged standing and during free and fast walking. Additionally, rearfoot position was recorded while each of three physical therapists positioned the STJ in neutral, maximum inversion, and maximum eversion. Intertester reliability for positioning the STJ in neutral, maximum inversion, and maximum eversion yielded intraclass correlation coefficients of 0.76,0.37, and 0.39, respectively. Reliability of relaxed one-legged standing had an intraclass correlation coefficient of 0.92. The rearfoot position in relaxed one-legged standing and the maximum eversion position occurring during gait were not significantly different. These findings suggest that there is good intertester reliability in positioning the STJ in neutral. Additionally, the rearfoot position in relaxed one-legged standing may be used to approximate the maximum eversion position that occurs during gait.

Predictive Value of Manual Muscle Testing and Gait Analysis in Normal Ankles by Dynamic Electromyography

Eight muscles about the ankle of seven normal subjects were assessed by electromyography (EMG) during manual muscle testing (MMT) and walking. Three strength levels (normal, fair, trace) and three gait velocities (free, fast, slow) were tested. The muscles studied included the gastrocnemius, soleus, posterior tibialis, flexor digitorum longus, flexor hallucis longus, anterior tibialis, extensor digitorum longus, and extensor hallucis longus. Relative intensity of muscle action was quantitated visually (using an eight-point scale based on amplitude and density of the signal). The data showed that EMG activity increased directly as more muscle force was required during the different manual muscle test levels and increased walking speeds. No MMT isolated activity to the specific muscle thought being tested. Instead, there always was a synergistic response. Both the gastrocnemius and soleus contributed significantly to plantarflexion regardless of knee position. The intensity of muscle action during walking related to the manual muscle test grades. Walking at the normal free velocity (meters/min) required fair (grade 3) muscle action. During slow gait the muscle functioned at a poor (grade 2) level. Fast walking necessitated muscle action midway between fair and normal, which was interpreted as good (grade 4).