Recognising features (bone and joint deformity)

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Recognising features (bone and joint deformity)

  1. 1. Recognising features due to bone and joint impairments Richard Baker Professor of Clinical Gait Analysis 1
  2. 2. 2
  3. 3. How can you visualise the supplementary data on the graphs? 3
  4. 4. Bone and Joint Impairments 4
  5. 5. Bone Impairments Deformations of whole bones: • Persistent femoral anteversion • Increased tibial torsion • Bowing of long bones Most often treated by osteotomies. 5
  6. 6. Joint Impairments Deformations of joints from local deformation of bones and/or cartilage and or pathology in ligamentous constraints. • Knee flexion contracture Tend to be treated by osteotomies or guided growth (eight plates or stapling) 6
  7. 7. Joint Impairments Excludes restrictions in joint range as a consequence of muscle shortness (which will be addressed later in course). 7
  8. 8. Bony impairments 8
  9. 9. “Lever-arm disease” All bones act mechanically as levers. “Lever-arm disease” or “dysfunction” really just means bony abnormality and is not sufficiently specific to be useful. Often used to refer to torsional malalignment but the way that this affects lever mechanisms is particularly poorly understood. “Lever-arm disease” is a phrase which is best avoided! 9
  10. 10. Femoral anteversion 10
  11. 11. Normal femoral Anteversion 11 12° Knee joint axis
  12. 12. Abnormal femoral anteversion 12 40° 40°
  13. 13. Measuring anteversion 13
  14. 14. Measuring anteversion 14 Passive range of external rotation Femoral anteversion Passive range of internal rotation
  15. 15. Post-operative? 15 Passive range of external rotation Femoral anteversion Passive range of internal rotation
  16. 16. Normal femur development 16 Von Lanz T (1953). Z Anat 117:317-45. Shands A, Steele M (1958). Journal of Bone and Joint Surgery 40-A:803. Crane L (1959).Journal of Bone and Joint Surgery 41-A:421. Fabry G, MacEwen GD, Shands AR (1973). Journal of Bone and Joint Surgery 55-A:1726-1738. 0 10 20 30 40 50 0 2 4 6 8 10 12 14 16 18 Anteversion(degrees) Age( years) Lanz Shands Crane Fabry
  17. 17. Femoral anteversion The reduction in femoral anteversion is almost certainly a consequence of bone remodelling of the whole femur and not just the femoral neck. 17
  18. 18. 0 10 20 30 40 50 0 2 4 6 8 10 12 14 16 18 Anteversion(degrees) Age( years) Bobroff (CP) CP femur development 18 Bobroff ED, Chambers HG, Sartoris DJ, Wyatt MP, Sutherland DH (1999). Clinical Orthopaedics and Related Research 364:194-204.
  19. 19. All children have anteversion Question is not, “Do they have anteversion?” but, “Is the anteversion affecting the way they walk?” 19
  20. 20. Anteversion and the abductors
  21. 21. Abductor Moment Arm
  22. 22. Anteversion (0 )
  23. 23. Anteversion (40 )
  24. 24. Anteversion (40 ) + Int. Rot.
  25. 25. Anteversion (40 ) + Int. Rot. (40 )
  26. 26. Internal rotation gait Probably a consequence of: persistent femoral anteversion and abductor weakness 26
  27. 27. 27 -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Hiprotation % gait cycleHip abductor strength 3(2) 3(2) Hip adductor tone (Ashworth) 1 1 Hip internal rotation range 57°int 61°int External rotation range 8°ext 5°ext Femoral anteversion 21°int 24°int
  28. 28. 28 a Features: Comments: a. too much int. hip rotation through cycle bilaterally Supplementary data: left right Comments: Hip internal rotation range 57° 61° Hip external rotation range 8° 5° Femoral anteversion 21° 24° Hip abductor strength 3 3 Impairment: Bilateral persistent femoral anteversion Evidence: clear Effect on walking: major Impairment: Bilateral hip abductor weakness Evidence: clear Effect on walking: major
  29. 29. Hemiplegia 29 -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Hiprotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Footprogression % gait cycle Hip abductor strength 3(1) 5(2) Hip adductor tone (Ashworth) 1 0 Hip internal rotation range 56°int 44°int External rotation range 1°ext 33°ext Femoral anteversion 31°int 15°int Features: Comments: Supplementary data: left right Comments: Impairment: Evidence: Effect on walking: Impairment: Evidence: Effect on walking: a. Increased left hip. rot. throughout a c. Increased left ext. pel. rot. throughout Compensation for internal hip rot c d d. Inc. bilat. int. foot prog. throughout On left consequence of int. hip rot On right consequence of int. pel. rot. b b. Right hip within normal limits Internal hip rot. range 56 44 External hip rot. range 1 33 Femoral anteversion 31 15 Hip abductor strength 3 5 Left femoral anteversion Left hip abductor weakness clear clear marked marked
  30. 30. Hemiplegia 30 -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Hiprotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Footprogression % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Hiprotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Footprogression % gait cycle Left femoral derotation Dobson, F., et al. J Bone Joint Surg Br, 2005. 87(4): 548-55.
  31. 31. Tibial torsion 31
  32. 32. Tibial torsion 32 Knee joint axis 12° Knee joint axis20°
  33. 33. Measuring tibial torsion 33 Compare with VICON measurement if using medial malleolar markers in static
  34. 34. Normal tibia development 34 Can be increased or decreased in CP suggesting different mechanism to anteversion Staheli, L.T., et al., J Bone Joint Surg Am, 1985. 67(1):39-47.
  35. 35. Knee forward foot out Is it in the tibia or in the foot? 35 -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Footprogression % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Anklerotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Footprogression % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Anklerotation % gait cycle Ankle rotation normal so deformity must be in tibia Ankle rotation sufficiently external to explain foot progression
  36. 36. -30° -20° -10° 0° 10° 20° 30° 1° 11° 21° 31° 41° 51° Pelvicobliquity % gait cycle 0° 10° 20° 30° 40° 50° 60° 1° 11° 21° 31° 41° 51° Pelvictilt % gait cycle -20° -10° 0° 10° 20° 30° 40° 50° 60° 70° 0° 20° 40° 60° 80° 100° Hipflexion % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° HipAdduction % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle 0° 10° 20° 30° 40° 50° 60° 1° 11° 21° 31° 41° 51° Pelvictilt % gait cycle -30° -20° -10° 0° 10° 20° 30° 1° 11° 21° 31° 41° 51° Pelvicobliquity % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle -20° -10° 0° 10° 20° 30° 40° 50° 60° 70° 0° 20° 40° 60° 80° 100° Hipflexion % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° HipAdduction % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Hiprotation % gait cycle -15° -5° 5° 15° 25° 35° 45° 55° 65° 75° 0° 20° 40° 60° 80° 100° Kneeflexion % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Kneeadduction % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Kneerotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Dorsiflexion(ankle) % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Anklerotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Footprogression % gait cycle
  37. 37. -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle 37 0° 10° 20° 30° 40° 50° 60° 1° 11° 21° 31° 41° 51° Pelvictilt % gait cycle -30° -20° -10° 0° 10° 20° 30° 1° 11° 21° 31° 41° 51° Pelvicobliquity % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle -20° -10° 0° 10° 20° 30° 40° 50° 60° 70° 0° 20° 40° 60° 80° 100° Hipflexion % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° HipAdduction % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Hiprotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Kneerotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Anklerotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Footprogression % gait cycle
  38. 38. -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle 38 -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle Pelvic rotation
  39. 39. 39 -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Hiprotation % gait cycle Hip rotation
  40. 40. 40 -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Kneerotation % gait cycle Knee rotation
  41. 41. 41 -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Anklerotation % gait cycle Ankle rotation
  42. 42. 42 -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Pelvicrotation % gait cycle -30° -20° -10° 0° 10° 20° 30° 0° 20° 40° 60° 80° 100° Footprogression % gait cycle Foot progression
  43. 43. Pelvic rotation + Hip rotation = Distal femur rotation + Knee rotation = Proximal tibia rotation + Tibial torsion = Distal tibia rotation + Ankle rotation = Foot progression 43
  44. 44. Leg length discrepancy 44
  45. 45. Leg length discrepancy Distance from anterior superior iliac spine to medial malleolus (via medial epicondyle if knee cannot be extended) 45
  46. 46. Leg length discrepancy 46 Pelvic obliquity and hip ab/adduction are consequences of leg length discrepancy
  47. 47. Compensations • Shorter leg – Vault – Toe walking • Longer leg – Increased knee flexion – Increased hip flexion • Work from ground up! 47
  48. 48. Conversion of angle to height 48 0 10 20 30 40 50 60 70 80 90 100 0° 5° 10° 15° 20° 25° 30° Differenceinhipheight(mm) Pelvic obliquity 100mm 150mm 200mm 250mm 300mm pelvic width For person with pelvic width of 250mm exhibiting 15° pelvic obliquity Difference in hip height is 47mm
  49. 49. Bowing of long bones 49 Not observable in gait analysis data
  50. 50. Joint contractures 50
  51. 51. “True” joint contractures • Consequence of focal impairment of bone, cartilage andor ligaments • Distinguish from limited joint range as a consequence of short muscles 51
  52. 52. 52 Knee flexion is probably the impairment limiting knee flexion Measured knee flexion contracture
  53. 53. 53 Measured knee flexion contracture Another impairment is limiting knee extension … … but if that is corrected then the contracture will be a problem.

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