**6. Significance of the three-dimensional gait analysis in therapy of patients with gonarthrosis before and after arthroplasty**

Degenerative changes in the knee joint lead to its deformation resulting in genu varum or genu valgum. They also cause changes in intra- and peri-articular soft tissues. Cruciate ligaments, collateral ligaments, the quadriceps femoris and other lower extremity muscles influencing the joint function under incorrect conditions. Compensation mechanisms are developed to make it possible for the system to function under normal conditions. All this causes nerve impulses from the end organs of the ligaments of the joint capsule, and especially those responsible for the proper position of the joint surface and joint kinematics reach the central nervous system from damaged locations or from locations which do not function properly. In this way, the stimuli reaching the central nervous system consolidate incorrect patterns of motion.

During the knee replacement procedure, the cruciate ligaments are removed, fat is removed from the joint capsule, the condyles of the femur and tibia are trimmed together with the subcartilage layer. Main end organs informing the central nervous system about the position of the joint are removed. A prosthesis without nerve connections is implanted.

After the surgical procedure, the central nervous system is not properly informed about the position of the individual elements of the joint, so, during gait, it uses the patters consolidated during the disease.

It is important to capture all deviations caused by the developing disease in the gait analysis performed before the procedure. As both legs are used for walking, changes occurring in the affected joint often influence the function of the healthy joint.

Al-Zahrani et al. (2002) performed a gait analysis in patients suffering from degenerative knee disease which showed that the length of the cycle and the walking speed were reduced

After the procedure the values of time and space parameters improved only slightly, which may be corroborated by a study by Bőrjessona et al. (2005) who found that patients suffering from degenerative knee disease walk at a lower speed, with lower step frequency and the single support phase is shortened. Despite good results they continue to walk more slowly

Similar results, pointing to slight changes in time and space parameters before and after the

Fantozzi et al. (2003) studied locomotion in two groups – endoprosthesi with PCL retention and with PCL removal. The extension of the DS period and a reduced walking speed were

The results obtained by these authors confirm the results of the authors' own research

Wu et al. (2007) found in their study of patient locomotion after knee replacement that the walking speed is reduced, which is connected with the reduction of the length of the cycle and a reduction in step frequency, especially in the operated leg. The DS period was

However, the results were not compared before and after the procedure. Such an analysis presented in this study shows a clear improvement of these parameters after the procedure

**6. Significance of the three-dimensional gait analysis in therapy of patients** 

Degenerative changes in the knee joint lead to its deformation resulting in genu varum or genu valgum. They also cause changes in intra- and peri-articular soft tissues. Cruciate ligaments, collateral ligaments, the quadriceps femoris and other lower extremity muscles influencing the joint function under incorrect conditions. Compensation mechanisms are developed to make it possible for the system to function under normal conditions. All this causes nerve impulses from the end organs of the ligaments of the joint capsule, and especially those responsible for the proper position of the joint surface and joint kinematics reach the central nervous system from damaged locations or from locations which do not function properly. In this way, the stimuli reaching the central nervous system consolidate

During the knee replacement procedure, the cruciate ligaments are removed, fat is removed from the joint capsule, the condyles of the femur and tibia are trimmed together with the subcartilage layer. Main end organs informing the central nervous system about the position

After the surgical procedure, the central nervous system is not properly informed about the position of the individual elements of the joint, so, during gait, it uses the patters

It is important to capture all deviations caused by the developing disease in the gait analysis performed before the procedure. As both legs are used for walking, changes occurring in the

of the joint are removed. A prosthesis without nerve connections is implanted.

affected joint often influence the function of the healthy joint.

for such persons while the support phase is extended.

and do not regain the correct gait stereotype after the procedure.

observed in both groups, compared to the control group.

and their values become close to the control group.

**with gonarthrosis before and after arthroplasty** 

presented in this study.

incorrect patterns of motion.

consolidated during the disease.

lengthened.

procedure were observed in research conducted by Sukru Solak et al. (2005).

All deviations captured in the gait analysis performed before the procedure should be used for the planning of rehabilitation treatment to eliminate them after the operation.

Kinezytherapy planning should emphasize the use of end organs in the remaining joint structures which are responsible for proprioception to open a new rout for information flowing from these elements to the central nervous system.

Selection of appropriate exercises may help eliminate motion patterns consolidated before the procedure to achieve the correct gait pattern. Without being familiar with locomotion patterns before the procedure it will be difficult, which is confirmed by results of research conducted even two years after the procedure.

The patients taking part in the study were rehabilitated for only two weeks after the procedure and the results of locomotion examination show that changes consolidated in the gait stereotype resulting from the progressive nature of the disease were not considerably improved after the procedure. Thus, on the basis of the research conducted it should be concluded that physiotherapeutic procedures should include changes in the gait pattern and should be conducted until normal values are reached in follow-up examinations. The rehabilitation program should include elements of correct gait learning, dominated by exercises teaching the correct function of the pelvis and the lower extremity joints. This will make it possible to reconstruct the biomechanical locomotion pattern changed as a result of the disease. This will also extend the endoprothesis life.

Compensation mechanisms developing in the locomotor system due to disease make it possible to reduce pain, however, they cause strain changes in other locomotor segments with time - in the pelvis, ankle and hip joints. Knee replacement reduces articular pain, however, it will not reverse these mechanisms. It will be possible only by proper rehabilitation based on three-dimensional gait analysis.

The gait analysis presented in this study may be an example of locomotor disturbance examination in a group of patients before and after knee replacement. Thus, the application of more and more accurate measuring instruments in gait analysis becomes a necessity to achieve the best clinical results. On the basis of the presented three-dimensional gait analysis, a change in the locomotor pattern in patients after joint replacement can be noticed and the degree and scope of these dysfunctions can be determined. So one of the possibilities offered by the method is the monitoring of the treatment after surgical procedures. The results obtained can be used to evaluate and verify the effectiveness of the treatment methods used.

Owing to the application of three-dimensional gait analysis it is possible to adjust the therapeutic programme to individual changes in the locomotor stereotype and to monitor the direction of the rehabilitation as well as walking reeducation processes.

Advanced gonarthrosis affects significantly gait stereotype with a limitations in function of a patients. Knee arthroplasty is a method of therapy which allows to improve the gait pattern, although it demands time and proper rehabilitation to record correct pattern. A detailed analysis of gait cycle is necessary of optimal results, since it illustration and presents various disturbances in individual gait pattern. This can be reached in 3D notion analysis, which presents spatial arrangement of body segments in three planes of motion

Application of more and more exact hardware for motion analysis is necessary to obtain best clinical results. Changes in gait pattern is apparent in 3D analysis of patients motion after arthroplasty of knee join, estimation of these changes and range of dysfunction can thus be measured. As so, one of applications of the presented method is monitoring of the

Gait Analysis in Patients with Gonarthrosis Treated by Total Knee Arthroplasty (TKA) 67

Childs J., Sparto P., Fitzgerald K., Bizzini M., Irrgang J. (2004). *Alterations in lower extremity* 

Dorr L.D., Ochsner J.L., Gronley J., Perry J. (1988). *Functional comparsion of posterior cruciate-*

Fantozzi S., Benedetti M.G., Leardini A., Banks S.A., Cappello A. (2003). *Fluoroscopic and gait* 

Gök H., Ergin S., Yavuzer G. (2002). *Kinetic and kinematic characteristics of gait in patients with* 

Ishii Y., Terajima K., Koga Y., Takahashi H.E., Bechtold J.E. (1998). *Gait analysis after total knee* 

Kaufman K.R., Huges C., Morrey B.F., Morrey M., An K – N. (2001). *Gait characteristics of* 

Kramers-de Quervain A., Stussi E., Muller R., Drobny T., Munzinger U. (1997). *Quantitative* 

*subject.* Journal of Arthroplasty, Vol.12, No.2, pp. 168-179, ISSN 1532-8406 Kwiatkowski K., Płomiński J. (2004) *Choroba zwyrodnieniowa stawu kolanowego –* 

Manetta J., Franz L.H., Moon C., Perell K.L., Fang M. (2002). *Comparison of hip and knee muscle* 

Marks R., Quiney H., Wessel J. (1993). *Proprioceptive sensibility in woman with normal and* 

McClelland J., Webster K., Feller J. (2006). *A comparison of gait patterns in patients following* 

McClelland J., Webster K., Feller J. (2007). *Gait analysis of patients following total knee replacement: A systematic review.* The Knee, No.14, pp. 253-263, ISSN 0968-0160 Minns R.J. 2005. *The role of gait analysis in the management of the knee*. The Knee, Vol.12, No.3,

Ogrodzka K., Chwała W., Niedźwiedzki (2007). T. *Three-dimensional pattern of the knee* 

Ogrodzka K., Niedźwiedzki T. (2008). *The variability of kinematic parameters of the lower limb* 

Biomechanics, No.19, pp. 44-49, ISSN 0268-0033.

and Posture, No.17, pp. 225-234, ISSN 0966-6362

ISSN 0001-6470

0021-9290

– 419, ISSN 1426-9686

139-140, ISSN 0966-6362

pp. 157-162, ISSN 0968-0160

No.6, pp. 605-614, ISSN 1509-3492

ISSN 0966-6362

ISSN 1436-2023

Related Research, No.336, pp. 36-45, ISSN 0009-921X

Orthopaedic Science No.3, pp. 310-317, ISSN 1436-2023

*movement and muscle activation patterns in individuals with knee osteoarthritis.* Clinical

*retained versus cruciate-sacrificed total knee arthroplasty*. Clinical Orthopaedics and

*analysis of functional performance i stair ascent of two total knee replacement designs*. Gait

*medial knee arthrosis.* Acta Orthopaedica Scandinavica, Vol.73, No.6, pp. 647-652,

*arthroplasty. Comparison of posterior cruciate retention and substitution*. The Journal of

*patients with knee osteoarthritis*. Journal of Biomechanics, No. 34, pp. 907-915, ISSN:

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

*patomechanizm i rozpoznawanie*, Polski Merkuriusz Lekarski, Vol.17, No.100, pp. 415

*moment in subject with and without knee pain*. Gait and Posture, No.16, pp. 249-254,

*osteoarthritic knee joints*. Clinical Rheumatology, No.12, pp. 170-175, ISSN 0770-3198

*total and unicompartmental knee replacement surgery* Gait and Posture, No.24S, pp.

*movement of subjects with gonarthrosis*. Ortopedia Traumatologia Rehabilitacja, Vol.9,

*joints of subjects before and after total knee replacement.* The Journal of Orthopaedics Trauma Surgery and Related Research, Vol.1, No.9, pp. 25-30, ISSN 1897-2276 Otsuki T., Nawata K., Okuno M. (1999). *Quantitative evaluation of gait pattern in patients with* 

*osteoarthrosis of the knee before and after total knee arthroplasty. Gait analysis using a pressure measuring system.* The Journal of Orthopaedic Science, No.4, pp. 99-105,

patients after the surgery. The obtained result can be used for validation and verification of the efficacy of applied therapy.

### **7. References**


patients after the surgery. The obtained result can be used for validation and verification of

Al-Zahrani K., Bakheit A. (2002). *A study of the gait characteristics of patients with chronic* 

Andriacchi T.P., Galante J., Fermier R. (1982). *The influence of total knee-replacement design on* 

Andriacchi T.P., Hurwitz D.E. (1997). *Gait biomechanics and the evolution of total joint* 

Andriacchi T.P., Alexander E. J. (2000). *Studies of human locomotion: past, present and future,*

Astephen J.L., Deluzio K.J. (2005). *Changes in frontal plane dynamics and the loading response* 

Astephen J.L., Deluzio K.J., Caldwell G.E., Hubley-Kozey C.L., Dunbar M.J. (2007). *Gait and* 

Baliunas A.J., Hurwitz A.B., Ryal A.B., Karrar A., Case J.P. (2002). *Increased knee joint loads* 

Barret D., Cobb A., Bentley G. (1991). *Joint proprioception in normal, osteoarthritic and replaced knees*. The Journal of Bone & Joint Surgery, No. 73, pp. 53-56, ISSN: 1535-1386 Basmajian JV (1976) The human bicycle. In: Biomechanics V-A (Komi PV, ed), pp 297-302,

Bejek Z., Paróczai R., Illyés Á., Kocsis L., Kiss R. (2006a) *Gait parameters of patients with* 

Bejek Z., Paróczai R., Illyés Á., Kiss R. (2006b). *The influence of walking speed on gait parameters* 

Bőrjesson M., Weidenhielm L., Mattsson E., Olsson E. (2005). G*ait and clinical measurements in* 

Cash R., Gonzales M., Garst J., Barmada R., Stern S. (1996)*. Proprioception after arthroplasty*. Clinical Orthopaedics and Related Research, No.331, pp. 172-178, ISSN 0009-921X Chao E., Laughman R., Stauffer R. (1980). *Biomechanical gait evaluation of pre and postoperative* 

Traumatology, Arthroscopy, Vol. 14, No.7, pp. 612-622, ISSN 0942-2056 Benedetti M.G., Catani F., Bilotta T.W., Marcacci M., Mariani E. (2003). *Muscle activation* 

Bober T. (1987). *Biomechanika chodu i biegu*, ISBN 83-89156-38-5, AWF Wrocław

*replacement,* Gait and Posture, No.5, pp. 256-264, ISSN 0966-6362

Journal of Biomechanics, No.33, pp. 1217-1224, ISSN 0021-9290

*osteoarthritis of the knee.* Disability and Rehabilitation, Vol.24, No.5, pp.275-280, ISSN

*walking and stair climbing*. The Journal of Bone & Joint Surgery. Vol.64A, pp. 1328-

*phase of the gait cycle are characteristic of severe knee osteoarthritis application of a multidimensional analysis technique.* Clinical Biomechanics, No. 20, pp. 209-217,

*neuromuscular changes associated with knee OA severity.* Journal of Biomechanics,

*during walking are present in subjects with knee osteoarthritis*, Osteoarthritis and

*osteoarthritis of the knee joint*. Facta Universitatis: Physical Education and Sport,

*in healthy people and in patients with osteoarthritis.* Knee Surgery, Sports

*pattern and gait biomechanics after total knee replacement.* Clinical Biomechanics, No.13,

*patients with knee osteoarthritis after surgery: a prospective 5 – year follow – up study.* The

*total knee replacement patients.* Archives of Orthopaedic and Trauma Surgery, No.97,

the efficacy of applied therapy.

0963-8288

1335, ISSN: 1535-1386

ISSN 0268-0033.

*No.*40(S2), pp. 287-294, ISSN: 0021-9290

University Park Press: Baltimore

pp. 871-876, ISSN 0268-0033.

pp. 309, ISSN 1434-3916

Vol.4, No.1, pp. 9-16, ISSN 1451 740X

Knee, No.12, pp. 121-127, ISSN 0968-0160

Cartilage, No. 10, pp. 573-579, ISSN 1063-4584

**7. References** 


**5** 

*France* 

**Hip-Spine Relations: An Innovative** 

*1Department of Orthopaedic Surgery, Hôpital Pitié Salpétrière Assistance Publique - Hôpitaux de Paris (AP-HP), Paris* 

*Scientifique (CNRS), Unités Mixtes de Recherche (UMR), Paris* 

Jean Yves Lazennec1,2, Adrien Brusson1 and Marc-Antoine Rousseau1,2

The sagittal balance of the trunk is considered to be a key point for spinal fusion and disc replacement. This balance is the manifestation of a postural strategy conditioned by anatomic and functional characteristics that can differ greatly from one person to another (Duval-Beaupere et al., 1992). The role of the pelvic area is evident for spinal surgeons in their planning and analyses; they pay special attention to the sacral slope, which is closely related to the pelvic tilt (Chanplakorn et al., 2011; Dorr et al., 1983; Jackson & McManus, 1994; Kobayashi et al., 2004; Murray, 1993; Vialle et al., 2005). Dubousset underlined this concept as early as 1984, in treating the pelvis as a "pelvic vertebra" (Dubousset, 1984). Although the concept of spinopelvic balance is well accepted today (Lazennec et al., 2004), conventional imagery underestimates the influence of the coxofemoral joint and explains it inadequately. The EOS imaging system (Dubousset et al., 2008), by optimizing radiologic data in functional situations, is revolutionizing our understanding of hip-spine relations

These anatomic and functional considerations often remain foreign to hip surgeons, who focus on the bone landmarks of the pelvis for their navigation, individualized adjustments, and failure analyses (Woo & Morrey, 1982; Woolson & Rahimtoola, 1999). Although the hip is a highly mobile joint, surgical concepts are still based on the static AP view of the pelvis in standing or supine position to assess cup orientation, which is an essential risk factor for prosthesis instability and wear (Kennedy et al., 1998). Influenced by the classic anatomic culture of cross-sectional slices, they consider the CT scan a reference tool for the "horizontal" assessment of the coxofemoral joints (Ackland et al., 1986; Dorr et al., 1983; Kennedy et al., 1998; Murray, 1993; Seki et al., 1998; Wan et al., 2009). Nonetheless, as this chapter will show, lateral views of the hips and the evaluation of sitting position provide

The concept of cumulative anteversion between the acetabular cup and the femur is considered a key factor in the stability of the hip prosthesis. This concept, however, is based on the measurements taken by computed tomography in a supine position, which do not

new information about "normal" hip function and THR failures.

take into account the functional dimension of the problem.

**1. Introduction** 

(Lazennec et al., 2011b).

*2Biomechanics Lab, Arts et Métiers ParisTech, Centre National de la Recherche* 

**Paradigm in THR Surgery** 

