ReviewLongitudinal changes in knee kinematics and moments following knee arthroplasty: A systematic review
Introduction
First popularized in the 1970s [1], knee arthroplasty (KA) is recognized as an effective treatment of advanced knee joint osteoarthritis (OA). Gait abnormalities and increased joint loading are associated with knee OA [2], [3], [4], and often increase as disease severity and knee pain worsen over time. In particular, frontal plane abnormalities in kinematics (joint motion) and kinetics (joint moments) are of importance in knee OA as they have been linked to disease progression [5], [6], [7]. These abnormalities include: higher external knee adduction moment (KAM) [8], [9], [10] and KAM impulse [11], as well as an increased incidence of abnormal varus-valgus motion [6] when compared to those without OA. Persistent abnormal gait biomechanics following KA may contribute to sub-optimal clinical outcomes from the procedure (such as ongoing knee pain and/or functional limitations) [12], [13], [14], patient dissatisfaction and/or prosthesis failure over the long-term.
To date, most gait analysis research following KA has tended to focus on the sagittal plane. Before KA, individuals with severe OA have been shown to walk with sagittal plane moments different to controls [4], [15]. The presence of an abnormal pre- and post-operative peak flexion moment have been associated with a higher risk of tibial component loosening [16] and the presence of anterior knee pain [12], making the case for the importance of correcting gait patterns with surgery. Although two systematic reviews [17], [18] have cross-sectionally compared post-operative sagittal plane biomechanics to those of healthy control groups, no review has synthesized the literature evaluating longitudinal changes in the sagittal plane parameters in those who undergo a KA procedure.
An understanding of how KA changes frontal plane gait biomechanics is also important. KA aims to improve the tibiofemoral loading environment, particularly by reducing the frontal plane malalignment that typically accompanies knee OA. Static knee malalignment (as measured on xray) is linked to changes in joint loading [19], and varus malalignment (most commonly observed in medial OA) directly increases parameters of the KAM, a biomechanical indicator of medial compartment load distributions [20]. Furthermore, during gait, abnormal dynamic knee varus-valgus motion can occur. This dynamic malalignment is a separate phenomenon from static knee malalignment and acutely influences load across the medial tibiofemoral compartment. Presence of this excessive varus-valgus motion after surgery could have implications for abnormal knee joint loading.
Both pre- and post-operative alignment have been shown to be important in total load in the knee joint [21] and implant survival rates [22]. Given that a major aim of KA is to mechanically correct knee malalignment and optimize joint loading, an understanding of the effects of arthroplasty on frontal plane gait biomechanics is relevant. Implant retrieval studies have suggested that medial compartment rather than lateral compartment wear is dominant after surgery, suggesting that pre-operative abnormal loading conditions may not have been corrected, or may have returned at some point post-operatively [23], [24], [25]. Although two systematic reviews have compared post-arthroplasty gait to that of healthy controls [17], [18], they did not synthesize evidence regarding longitudinal changes in frontal plane biomechanics with KA, and several gait studies have since been published in the six years since the literature search of Milner was conducted.
The purpose of this systematic review was to synthesize longitudinal biomechanical studies evaluating changes in 3-dimensional gait analysis following KA. The primary aim was to assess the effects of KA procedures on the frontal plane kinematics and kinetics in stance phase of gait. Secondary aims were to evaluate changes in the sagittal plane parameters, and to compare frontal and sagittal post-operative gait parameters to those of a healthy reference group.
Section snippets
Search strategy and criteria
The search strategy was developed, reviewed, and refined by multiple authors with expertise in systematic reviews, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [26]. Electronic searches of entire databases up until April 10th, 2014 were performed using MEDLINE (PubMed), CINAHL and SPORTdiscus (EBSCO), and Cochrane Library (Wiley). Key search terms and synonyms were searched separately in three main filters which were then
Study characteristics
Fig. 1 outlines the selection of papers. Nineteen studies [3], [4], [12], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45] satisfied the eligibility criteria (Fig. 1 and Table 1). Duration of post-operative follow-up varied between 2 and 24 months with most (12/19, 63%) studies [3], [4], [12], [30], [33], [34], [36], [38], [39], [40], [41], [43], [44], [45] evaluating patients at a single post-operative time point. Ten of the 19 studies [3], [4],
Discussion
Both pre- and post-operative gait biomechanics are relevant to KA outcomes with regards to the presence of knee pain, patient satisfaction, and implant longevity. This systematic review aimed to synthesize the effects of KA on changes in frontal and sagittal plane gait kinetics and kinematics and compare post-operative gait parameters to those of a healthy reference group where possible. The main findings of this systematic review were that KA results in a decreased peak KAM and maximum knee
Financial support
This study was supported by funding from the Australian Research Council (#LP120100019) and the National Health and Medical Research Council (#61837). Kim Bennell (FT0991413) and Rana Hinman (FT130100175) are each partly funded by an Australian Research Council Future Fellowship. Michelle Dowsey holds an NHMRC Early Career Australian Clinical Fellowship (APP1035810).
Conflict of Interest
The authors declare that this manuscript is not under consideration by any other journal and has not been published in any journal or other citable form. The authors declare that they have no competing interests. All authors have read the manuscript and agreed to its content.
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