Elsevier

The Knee

Volume 21, Issue 6, December 2014, Pages 994-1008
The Knee

Review
Longitudinal changes in knee kinematics and moments following knee arthroplasty: A systematic review

https://doi.org/10.1016/j.knee.2014.09.009Get rights and content

Highlights

  • We systematically reviewed longitudinal changes following knee arthroplasty

  • 19 articles describing three-dimensional gait analysis were included

  • Maximum knee adduction angle and external knee adduction moment decreased

  • In the sagittal plane, the peak knee flexion moment increased

  • Further research is needed to determine if arthroplasty restores gait patterns to normal

Abstract

Background

Knee arthroplasty (KA) is recognized as an effective treatment of knee joint osteoarthritis and up to 90% of patients experience substantial pain relief. There has been no systematic review synthesizing the longitudinal changes in gait following KA. The aims of this systematic review were to determine the effects of KA on (i) frontal plane and (ii) sagittal plane kinematic and kinetic parameters during the stance phase of gait.

Methods

MEDLINE (PubMed), CINAHL, SPORTdiscus (EBSCO), and Cochrane Library (Wiley) were searched until April 10th, 2014. 1,765 articles were identified, of which 19 studies describing 3-dimensional gait analysis pre- and post-KA were included. Study quality was evaluated by two reviewers independently using the Downs and Black checklist.

Findings

Following KA, in the frontal plane, the maximum knee adduction angle and external knee adduction moment (KAM) tended to decrease. In the sagittal plane, findings suggest that the maximum knee flexion moment is increased. From the ten studies that included a healthy reference group, it was unclear whether gait variables returned to normal following KA.

Interpretation

Overall, it appears that KA results in a decreased peak KAM and maximum knee adduction angles, an increased peak knee flexion moment and inconsistent changes in the peak knee flexion angle. Knowledge gaps remain due to methodological inconsistencies across studies, limited statistical analysis, and largely heterogeneous sample populations. More research is needed to determine whether KA restores gait patterns to normal, or if additional rehabilitation may be needed to optimize gait following surgery for osteoarthritis.

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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