Abstract:
We
aimed to investigate the characteristics of gait pattern in the
patients with hip osteoarthritis (OA). To this end, we
performed gait analysis of 207 patients with unilateral hip OA
and on a control group of 35 healthy elderly subjects. All
the patients were analyzed during free walking along a 5-m
walkway equipped with a ground-reaction force plate. The
following spatiotemporal parameters were assessed: step length,
stride length, single support duration, cadence, and velocity.
There were significant reductions in gait parameters in the hip
OA patients compared with the control group. Hip OA
patients had a significantly lower velocity (P < 0.001),
cadence (P < 0.001), stride length (P < 0.001), step
length on both sides (P < 0.001), and single support duration
of the involved side (P < 0.001) compared with the control
group. The most evident differences between the hip OA
patients and the controls were the shorter step length and a
decreased single support duration on the involved side. We
conclude that a shorter step length and a decreased single
support duration are prominent features of gait in patients with
more severe hip OA. The findings of this study advance our
understanding of how hip OA affects gait changes in the lower
limbs.
J.Orthopaedics 2009;6(2)e14
Keywords:
gait
analysis; hip osteoarthritis; spatiotemporal parameters
Introduction:
Osteoarthritis
(OA) of the hip is one of the most common hip joint diseases.
Although different functional scores are widely used to assess
the improvement after surgery, the patients’ responses are
often subjective and the disparities between the patients’ and
doctors’ evaluations can be significant [1]. Gait
analysis assigns one continuous factor score to each patient,
and it can evaluate all patients on the same scale.
Therefore, gait analysis is a useful tool in the evaluation of
hip disease.
Many
studies have reported the use of accelerometers [2], video
cameras [3], walkways [4, 5], footswitches [6], or force plates
[7]. However, several of the techniques used are
complicated in design [4, 8], expensive, or interfere with the
patient’s gait [3, 5, 6, 7, 8]. Complicated systems are
not suitable for clinical usage. In this study, we used a
non-invasive system that makes it possible to measure gait
parameters in subjects who are simply required to walk on a
walkway. Simplified analysis using spatiotemporal
parameters is desirable for clinical usage and expands the
clinical use of gait analysis. Such systems have an
advantage in that they avoid influencing or inconveniencing the
examined patients; are easy to use, even by non-expert
operators; and provide quick, easily interpretable results.
The purpose of this study was to investigate the
characteristics of gait pattern in patients with unilateral hip
OA using a spatiotemporal gait parameter.
Materials
and Methods:
This
study was carried out on a group of 207 patients (34 males and
173 females) with severe unilateral hip OA and a control group
of 35 healthy elderly subjects (9 males and 26 females).
There were no statistically significant differences between the
ages, heights, and weights of the two groups (Table 1).
None of the patients exhibited any symptoms involving the
contralateral hip, lumbar vertebrae, knees, or ankles. We
also excluded those patients who were unable to walk unsupported
for more than 5 s. The study was approved by the local
ethics committee and written- informed consent was obtained from
all subject.
|
Patients
|
Healthy
subjects
|
Significance
|
Age
(year)
|
61.7
± 9.7
|
63.8
± 10.9
|
ns
|
Height
(cm)
|
152.6
± 6.9
|
155.0
± 6.1
|
ns
|
Weight
(kg)
|
56.0
± 8.6
|
58.1
± 8.8
|
ns
|
ns, not significant (P > 0.05
Table
1. Subject characteristics
Radiological
observations were used to classify OA into early, advanced, and
terminal stages. The early stage was characterized by a
slight narrowing of the joint space and/or abnormal subchondral
sclerosis; the advanced stage was characterized by a marked
narrowing of the joint space and/or the detection of some cystic
changes and small osteophytes in the femoral head and acetabulum;
and the terminal stage was characterized by the obliteration of
the joint space along with a marked number of osteophytes.
On the basis of this classification system, advanced-stage hip
OA was diagnosed in 41 patients and terminal-stage hip OA was
diagnosed in 166 patients. The mean preoperative leg
length discrepancy was 1.5 cm (range, 0–7 cm). The
Harris hip score [9] averaged 46.9 (range, 11–88).
For
gait analysis, all the patients and control group subjects were
analyzed during free walking along a 5-m walkway equipped with a
ground-reaction force plate (Gait Scan 8000; Nitta Inc.).
The patients’ walking was tested for 5-s periods at a sampling
rate of 60 Hz. We performed at least 3 walking trials for
each patient. Using this analysis system, we were able to
measure the distribution pattern of the anti-power and the sole
pressure in relation to the spatiotemporal parameters of the
ambulating subjects. We evaluated the step length (cm),
step length ratio (involved/uninvolved, dominant/non-dominant),
stride length (cm), stride length (% stature), single support
duration (% cycle), cadence (step/min), and velocity (m/s).
The results of this evaluation were compared with those obtained
from the control group.
Statistical
analysis was performed using SPSS version 12.0 for Windows (SPSS
III, Chicago). We used a 2-sample t test for comparing the
results of the control group with those of the patient group.
Differences associated with a probability (P) value less than
0.05 were regarded as statistically significant.
Results :
A
comparison of spatiotemporal parameters between the healthy
elderly subjects and the patients is shown in Table 2. Hip
OA patients had a significantly lower velocity (P < 0.001),
cadence (P < 0.001), stride length (P < 0.001), step
length on both sides (P < 0.001), and single support duration
of the involved side (P < 0.001) compared with the control
group. Asymmetry of the gait parameters was observed in
patients with unilateral OA of the hip during free level
walking. The step length of the involved side was
significantly shorter than that of the uninvolved side (P <
0.001). The single support duration of the involved side
was significantly lower than that of the uninvolved side (P <
0.001). The step length of the uninvolved side was
significantly shorter than that of the control group (P <
0.001). There were no significant difference between the
single support duration of the uninvolved side of the patients
and that of either side of the control group subjects.
Parameter
|
Patients
|
Healthy
subjects
|
Significance
|
Velocity (m/s)
|
0.628
± 0.189
|
0.996
± 0.242
|
P
< 0.001
|
Cadence (step/min)
|
94.0
± 15.0
|
115.7
± 13.0
|
P
< 0.001
|
Stride length (cm)
|
78.2
± 16.5
|
107.1
± 12.7
|
P
< 0.001
|
Stride length (% stature)
|
51.4
± 10.9
|
69.1
± 8.2
|
P
< 0.001
|
Step length ratio
(patients: i/u,controls: d/n)
|
0.475
± 0.066
|
0.959
± 0.150
|
P
< 0.001
|
Step length (cm):
involved side
|
37.5
± 9.9
|
52.4 ± 8.5
|
P
< 0.001
|
: uninvolved side
|
40.9±
8.8
|
P
< 0.001
|
Single support duration
(% cycle): involved side
|
34.4
± 5.7
|
42.1 ± 1.39
|
P
< 0.001
|
: uninvolved side
|
41.5
± 4.3
|
ns
|
i/u:
involved side /uninvolved side, d/n: dominant side/non-dominant
side, ns: not significant (P > 0.05)
Table
2:Values
of the spatiotemporal parameters for the hip OA patients and
control group subjects
Discussion :
This
is one of the largest series on hip OA patients to analyze the
resulting changes in functional gait patterns. Previous
studies that have considered the gait ability of hip OA patients
have generally included small patient numbers. Murray et
al. [10], for example, reported the gait patterns of a group of
26 exclusively male patients with osteoarthritis and avascular
necrosis. Similarly, Wiedmer et al. [11] reported the gait
patterns of a group of 32 patients and Brandes et al. [12]
reported gait patterns of a group of 26 patients with
osteoarthritis of the hip or knee. This study reported the
gait patterns of a large cohort of hip OA patients, facilitating
analysis across the age range of patients usually presenting for
total hip arthroplasty.
The
main results of our study indicated that hip OA patients have
significantly decreased gait parameters compared with healthy
elderly subjects. Deficits in hip OA patients were small
for the gait parameters tested (26.9% gait velocity, 18.8%
cadence, 27.0% stride length) when compared with the control
group. The decrease in these 3 parameters in hip OA
patients can be attributed to the shorter step length and the
decreased single support duration on the involved side, which
were the most evident differences between the hip OA patients
and controls (28.4% and 18.3% lower, respectively, in the OA
patients). A decrease in gait parameters limits the
ability to produce forward propulsion, but can be considered a
strategy for reducing joint pain by reducing joint load.
This suggests that hip OA patients spend a greater portion of
the gait cycle on both limbs, which represents a more stable and
safe condition. In comparison with the subjects in other
studies [10, 12, 13 ], in our series, the velocity and cadence
were lower, step and stride lengths were shorter, and single
support duration was lower, although the mean age of the
patients was not lower than that in other studies. These
differences may be attributed to the fact that we included
patients with more severe hip pain, and that we analyzed all the
patients by using simple and non-invasive techniques immediately
before surgery. This finding supports the view that levels
of disability are associated with gait parameters.
Levinger
et al. [14] described similar gait patterns in knee OA patients,
including slower velocity, lower cadence, shorter step and
stride length, and lower single support duration compared with
the control group. However, the mean values for cadence,
step length, and single support time did not differ
significantly, indicating poor discrimination between patients
and controls. Weiss et al. [15] reported that rheumatoid
arthritis (RA) patients had several decreased kinetic gait
parameters in the lower limbs compared with controls.
However, single support time in the RA patients was not
significantly shorter compared with the control group.
This finding indicates that the range of hip motion is very
important for increasing the step length, and that hip joint
loads in particular increase in the single support phase.
These results suggest that a shorter step length and a decreased
single support duration are prominent features of gait in
patients with more severe hip OA patients.
A
descriptive study of gait patterns in hip OA patients is
difficult due to the progressive nature of degenerative joint
disease and also due to the fact that patients with hip OA
rarely have only an insolated hip problem. In order to
make the present study more homogeneous, we accordingly excluded
all patients exhibiting any symptoms in joints other than the
hip. Our clinical observations led us to believe that
common deviations in hip OA patients’ gait patterns exist
despite differences in clinical signs and symptoms and despite
inter-individual differences. In conclusion, hip OA
patients experienced a shorter step length and a decreased
single support duration during free walking. The findings
of this study advance our understanding of how hip OA affects
gait changes in the lower limbs.
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