Functional outcomes following surgery for spastic hip adductor muscles in ambulatory and non-ambulatory adults.

OBJECTIVE: To evaluate functional outcomes of surgery of spastic hip adductor muscles (obturator neurotomy with or without adductor longus tenotomy) in ambulatory and non-ambulatory patients, using preoperatively defined personalized goals. DESIGN: Retrospective observational descriptive study. PATIENTS: Twenty-three patients with adductor spasticity who underwent obturator neurotomy between May 2016 and May 2021 at the Clinique des Cèdres, Cornebarrieu, France, were included. METHODS: Postoperative functional results were evaluated in accordance with the Goal Attainment Scaling method. Patients were considered "responders" if their score was ≥ 0. Secondary outcomes included spasticity, strength, hip range of motion and change in ambulatory capacity. When data were available, a comparison of pre- and postoperative 3-dimensional instrumented gait analysis was also performed. RESULTS: Among the 23 patients only 3 were non-walkers. Seventeen/22 patients achieved their main goal and 14/23 patients achieved all their goals. Results were broadly similar for both walking goals (inter-knee contact, inter-feet contact, fluidity, walking perimeter, toe drag) and non-walking goals (intimacy, transfer, pain, posture, dressing). CONCLUSION: Surgery of spastic hip adductor muscles results in functional improvement in ambulation, hygiene, dressing and posture and can be offered to patients with troublesome adductor overactivity. The use of a motor nerve block is recommended to define relevant goals before the surgery.

Changes in gait patterns after anterior cruciate ligament reconstruction in children.

PURPOSE: Anterior cruciate ligament reconstruction (ACLR) in children is indicated to reduce recurrent knee instability and further damage to the joint. Postoperative modified gait pattern was reported in the adult population after ACLR. The aim of this study was to analyse gait abnormalities, and especially knee and ankle adaptations during gait in children after ACLR. METHODS: A prospective study was performed between 2018 and 2022 on 50 children, aged nine to 15 years with unilateral ACL deficiency. Changes in gait pattern were evaluated by gait analysis before surgery and at the latest follow-up of 24 months. Kinematic data of ACL-deficient limb were compared to contralateral limb and to those of a matched control group of healthy children. RESULTS: Compared to control group, knee flexion was decreased for both ACL-deficient and contralateral knee before surgery. Decreased knee flexion during gait cycle persisted at latest follow-up. Ankle kinematics showed decreased dorsal flexion for both ACL-deficient and contralateral limb before surgery. At latest follow-up, ankle kinematics were modified for ACL-reconstructed limbs only at initial contact and showed no significant difference for contralateral limb compared to the control group. CONCLUSION: In children with ACL injury, abnormal gait patterns persist two years after ligament reconstruction, in spite of extensive rehabilitation and no clinical complaints. These findings might guide neuromuscular training to improve clinical outcomes and reduce the rerupture rate.

ToulGaitViz: a tool for the systematic description of lower limb clearance during the swing phase of hemiparetic gait after stroke. A cohort study.

BACKGROUND: In post-stroke hemiparetic subjects, a systematic and quantified description of the shortening default and compensatory movements during the swing phase of gait is essential to guide treatments and assess the impact of therapeutic interventions. However, such a systematic approach does not exist in the current clinical practice. AIM: The aim of this study was to present a method improving the quantification and visualization of the kinematics of both lower limbs during the swing phase of gait, more specifically the origin of shortening default and the weight of compensations, based on a tool specifically developed: ToulGaitViz. DESIGN: Observational cohort study. SETTING: Three-dimensional kinematic gait analyses of outpatients evaluated in Toulouse university hospital. POPULATION: ToulGaitViz was applied to 151 post-stroke hemiparetic participants and 48 healthy control participants. METHODS: ToulGaitViz is a standalone software allowing to compute 1) limb clearance as the sum of the shortening related to hip, knee and ankle flexion in the sagittal plane; 2) compensations related to the abduction of the limb and hip hiking at mid-swing. Both centimetric and angular values of the clearance were reported as well as their correlations with walking speed. RESULTS: Overall, the contribution of compensations in clearance was higher in post-stroke hemiparetic subjects than in healthy control participants with both centimetric (130% vs. 33%; P<0.001) and angular methods (23% vs. 1.4%; P<0.001). The centimetric method better represents the specific contribution of each segment to the clearance than the angular method. Symbolically, mean kinematic data from the cohort supports the claim that 2° of pelvic obliquity is equivalent to 10° of knee flexion to increase clearance by 1 cm, emphasizing the non-proportionality between the angular values and the actual contribution to the shortening. ToulGaitViz allows visualization of clearance, segmental shortening and compensation evolution before and after any therapeutic intervention with quantitative and comprehensive data. CONCLUSIONS: The ToulGaitViz could be systematically used in clinical practice to extract relevant kinematic data from the origin of shortening default and the weight of compensations. CLINICAL REHABILITATION IMPACT: This tool allows better understanding of the mechanisms of action of treatments to better link them to the subjects' needs.

Comparison between a novel helical and a posterior ankle-foot orthosis on gait in people with unilateral foot drop: a randomised crossover trial.

BACKGROUND: Neuromuscular disease and peripheral neuropathy may cause drop foot with or without evertor weakness. We developed a helical-shaped, non-articulated ankle-foot orthosis (AFO) to provide medial-lateral stability while allowing mobility, to improve gait capacity. Our aim was to evaluate the effect of the helical AFO (hAFO) on functional gait capacity (6-min walk test) in people with peripheral neuropathy or neuromuscular disease (NMD) causing unilateral drop foot and compare with a posterior leaf spring AFO (plsAFO). Secondary aims were to compare functional mobility, 3D kinematic and kinetic gait variables and satisfaction between the AFOs. METHODS: Single centre, randomised crossover trial from January to July 2017 in 20 individuals (14 with peripheral neuropathy and 6 with NMD, 12 females, mean age 55.6 years, SD 15.3); 10 wore the hAFO for the first week and 10 wore the plsAFO before switching for the second week. The 6-min walk test (6MWT), Timed Up and Go (TUG) test and 3D gait analysis were evaluated with the hAFO, the plsAFO and shoes only (noAFO) at inclusion and 1 week after wearing each orthosis. Satisfaction was evaluated with the Quebec user evaluation of satisfaction with assistive technology (QUEST). RESULTS: Median [interquartile range] 6MWT distance was greater with the hAFO (444 m [79]) than the plsAFO (389 m [135], P < 0.001, Hedge's g = 0.6) and noAFO (337 m [91], P < 0.001, g = 0.88). TUG time was shorter with the hAFO (8.1 s [2.8]) than the plsAFO (9.5 s [2.6], P < 0.001, g = - 0.5) and noAFO (10.0 s [2.6]), P < 0.001, g = - 0.6). The plsAFO limited plantarflexion during the loading response (plsAFO - 7.5 deg [6.0] vs. noAFO -13.0 deg [10.0], P = 0.0007, g = - 1.0) but the hAFO did not (- 11.0 deg [5.1] vs. noAFO, P = 0.05, g = - 0.5). Quasi-stiffness was lower for the hAFO than plsAFO (P = 0.009, g = - 0.7). The dimensionless eversion moment was higher (though not significantly) with the hAFO than noAFO. Neither orthosis reduced ankle power (P = 0.34). Median total QUEST score was higher for the hAFO (4.7 [0.7]) than the plsAFO (3.6 [0.8]) (P < 0.001, g = 1.9). CONCLUSIONS: The helical orthosis significantly and considerably improved functional gait performance, did not limit ankle mobility, increased lateral stability, though not significantly, and was associated with greater patient satisfaction than the posterior leaf spring orthosis. Trial registration The trial began before registration was mandatory.

Respective Contributions of Instrumented 3D Gait Analysis Data and Tibial Motor Nerve Block on Presurgical Spastic Equinus Foot Assessment: A Retrospective Study of 40 Adults.

Spastic equinus foot is a common deformity in neurologic patients who compromise walking ability. It is related to the imbalance between weak dorsiflexion and overactive plantar flexor muscles. To achieve the best functional results after surgical management, the challenge is to identify the relevant components involved in the deformity using several methods, namely, examination in the supine position, motor nerve blocks allowing transient anesthesia of suspected overactive muscles, and kinematic and electromyographic data collected during an instrumented 3D gait analysis. The procedure is not standardized; its use varies from one team to another. Access to gait analysis laboratories is limited, and some teams do not perform motor nerve blocks. When both examinations are available, instrumental data from the instrumented 3D gait analysis can be used to specify muscle targets for motor blocks, but data collected from both examinations are sometimes considered redundant. This retrospective cohort analysis compared examination in the supine position, temporary motor nerve blocks, and instrumented 3D gait analysis data in 40 adults after brain or spinal cord injuries. Clinical data collected before motor nerve block was not associated with instrumental data to assess calf muscle's overactivity and tibialis anterior function. Improvement of ankle dorsiflexion in the swing phase after tibial motor nerve block was associated with soleus spastic co-contraction during this phase corroborating its involvement in ankle dorsiflexion defects. This study showed the relevance of tibial motor nerve block to remove spastic calf dystonia and facilitate the assessment of calf contracture. It also underlined the need for complementary and specific analyses of the tibialis anterior abnormal activation pattern after motor nerve block to confirm or deny their pathological nature.

Foot and ankle compensation for anterior cruciate ligament deficiency during gait in children.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are common in adults and cause knee instability, pain, and an increased risk of osteoarthritis. Previous studies demonstrated changed gait patterns in adult patients with ACL deficiency. In paediatric patients, ACL injuries were once thought to be rare but are being increasingly diagnosed due to greater involvement of children in contact sports and to the introduction of more effective diagnostic tools such as magnetic resonance imaging (MRI). However, little is known about gait adaptation in children with ACL deficiency. The objective of this study was to look for compensatory foot and ankle behaviours during gait in paediatric patients with symptomatic ACL deficiency. HYPOTHESIS: Compensation for ACL deficiency during gait occurs at the foot and ankle in children, because compensation at the hip and pelvis would require greater energy expenditure. MATERIAL AND METHODS: We included 47 patients, 33 males and 14 females, ranging in age from 9 to 17 years (mean, 14.1 years). The patients had a history of unilateral ACL injury documented by MRI and initially treated by immobilisation and physical therapy. They were allowed to walk with full weight-bearing on the affected limb and were not taking medications at the time of the study. All patients had pain, knee instability, or functional limitation. The physical examination showed joint laxity indicating surgical ACL reconstruction. None had neurological conditions, congenital musculoskeletal abnormalities, or a history of knee surgery. Gait analysis (GA) was performed using a Vicon 460 system. Kinematic data for the ankle and foot were compared to those in a control group of 37 healthy children. Ankle angular positions were calculated for each group at the following stance time points: initial contact (0% of gait cycle [GC]), mid-stance (25% GC), terminal stance (60% GC), and swing (83% GC). Foot progression data were recorded at mid-stance (25% GC) and swing (70% GC). Student's t test was applied to compare the results to reference values obtained at our laboratory and to data from the control group. RESULTS: Compared to the reference values, the ankle was in plantar flexion at initial contact in 41 patients, and ankle dorsiflexion during the stance phase was diminished in 39 patients. The external foot progression angle was increased in 23 patients during the stance phase and 38 patients during the swing phase. Compared to the control group (mean age, 9.1 years), the patients had plantar flexion of the ankle at initial contact (3.43°±3.5° vs. 0.74°±3.6°, p<0.05) and decreased dorsiflexion during the stance phase (3.43°±3.5° vs. 0.74°±3.6°, p<0.05). No significant differences were found for any of the other parameters. DISCUSSION: Children with ACL deficiency developed compensatory foot and ankle behaviours during gait that improved knee stability. Understanding these compensations may guide treatment optimisation. LEVEL OF EVIDENCE: III, retrospective comparative study.