Abstract
Background
The aim of this study was to analyze the influence of the positioning of the components of total hip arthroplasty (THA) evaluated by the acetabular anteversion (AA) and femoral anteversion (FA) angle on postoperative gait in patients with symptomatic hip osteoarthritis secondary to hip dysplasia undergoing THA.
Methods
Between May 2023 and May 2024, patients with symptomatic hip osteoarthritis secondary to hip dysplasia (Crowe Type I and IV) who underwent THA were enrolled in the study. The AA angle and FA angle were measured by computer tomography (CT). Gait data were determined by using the Dynamic Right Gait & Posture analysis system. The relationship between FA, AA and gait data was analyzed by Pearson correlation test, subgroup Pearson correlation test, multiple linear regression.
Results
A total of 40 patients (45hips) were included in the study. Compared with preoperative, the patient’s postoperative foot progression angle, foot contact angle, plantarflexion velocity, swing foot speed, gait velocity, cadence, stride length were significantly improved. Preoperative FA is significantly different from postoperative FA (P < 0.05), while the difference between preoperative and postoperative AA is not significant. BMI, Crowe Type, AA were related to change of cadence. The less the postoperative AA of patients, and the more the cadence in the postoperative gait of patients.
Conclusion
Our study showed that THA could improve the gait function of patients with symptomatic hip osteoarthritis secondary to hip dysplasia. Adjusting AA lower could obtain a much more postoperative cadence.
Keywords: Hip prosthesis position, Postoperative gait, Femoral anteversion angle, Acetabular anteversion angle
Background
Hip dysplasia, also known as developmental dysplasia of the hip (DDH), describes the spectrum of structural abnormalities that involve the growing hip, including neonatal instability; acetabular dysplasia; hip subluxation; and true dislocation of the hip [1–3]. If left untreated, it can develop into hip osteoarthritis, which claims the top underlying diagnosis leading to total hip arthroplasty (THA) [3, 4]. Up to now, THA has achieved great success as a treatment for end-stage, symptomatic hip osteoarthritis secondary to hip dysplasia, considering its advantages in specifically pain relief, functional restoration, and overall improved quality of life [2, 5].
The key surgical goals for a successful THA are restoration of normal biomechanical functions and physiological hip restoration [6], which means surgical reconstructions of appropriate component alignments, anatomic acetabular rotation center, and equal leg length [7, 8]. Compared with patients undergoing THA for primary osteoarthritis, patients with hip dysplasia suffer the more complicated THA reconstruction and put them at a higher risk of complications due to a broad range of pathomorphological changes from both the acetabulum and femoral sides, including bony acetabular defect, a high-riding or even dislocated femoral head, and excessively anteverted femur [2, 7, 9–11]. Therefore, how to best restore the anatomical structure of the hip joint and improve the hip joint function under the condition of different pathomorphological changes, younger age of hip dysplasia patients [12], technical difficulties [13] and so on remains a challenge.
Optimum positioning of the femoral and acetabular components plays a critical role in clinical efficacy of THA, while malposition can lead to impingement, dislocation, increased polyethylene liner wear, and limited range of motion [14–16]. To ensure the precise position of implant in THA, several parameters should be considered as important evaluation of implant factors: hip center of rotation, inclination and anteversion [17]. Among them, combined anteversion, which is defined as the sum of the anteversion of the cup and that of the femoral component, is used to further illustrate the ideal orientation for the stability of prostheses [18, 19], and has great importance in the prevention of THA dislocation [20–24]. In hip dysplasia, the anatomical femoral anteversion (FA) and acetabular anteversion (AA) are excessive and often required to decrease by THA [25–27]. In practice, although different techniques used in THA of hip dysplasia (the “femur-first” technique, the “acetabular first” technique, and combined anteversion technique) were proposed to guide implant to set in the optimum position, essentially, the final goal of them is to bring the combined anteversion into the “safe zone” [26, 28–31]. However, the positioning of the components of THA often differs depending on the intraoperative situation due to acetabular defect, inadequate cup coverage, and femoral dysplasia [32]. Thus, the ideal angle of acetabular cup anteversion and FA still needs to be further investigated.
Gait analysis has been widely used in the clinical work of orthopedic and physical rehabilitation [33, 34]. Postoperative gait patterns is a reflection of biomechanical characters caused by reconstruction strategies and is closely related to clinical outcomes [35]. Understanding how positioning of the femoral and acetabular components influence postoperative gait patterns is necessary for making necessary adjustments before THA. Yi Hu et al. found significant correlations with the gait range of motion mainly in postoperative structures, including postoperative hip center positions and acetabulum and combined anteversion [36]. However, information regarding the effect of the change of acetabular and femoral anterior inclination on gait characteristics of hip dysplasia patients after THA is limited. Up to our knowledge, standard gait parameters include step and stride length, step and stride time, step width, gait velocity, cadence, support, stance phase, and swing phase [35, 37–39]. Compared with previous studies, the parameters used for gait analysis in this study are more comprehensive and multi-dimensional with addition of with addition of gait microscopic movements parameters such as foot progression angle, foot contact angle and so on, which were measured by Dynamic Right Gait & Posture (Medical 3.0 A), a dynamic gait analysis system.
Therefore, the aim of this study is to explore the correlation of gait parameters and anteversion of acetabular cup and femoral.
Methods
Ethical approval and informed consent
Ethical considerations of the research conformed to the Declaration of Helsinki. Ethical approval for this study was obtained from the ethics committee of Chinese PLA General Hospital (APPROVAL NUMBER: S2023-291-01). Written informed consent was obtained for anonymized patient information to be published in this article.
Study design and participants
Between May 2023 and May 2024, symptomatic hip osteoarthritis secondary to hip dysplasia patients with Crowe type I and IV undergoing primary THA were enrolled in this retrospective study. For the purpose of this study, inclusion criteria included the following: (1) according to the definition proposed by Wiberg [40], patients whose the lateral center-edge angle (LCEA) was less than 18° via radiography; (2) patients who had symptomatic osteoarthritis secondary to hip dysplasia, such as pain and limited hip function; (3) patients who had Crowe Type I–IV lesions in their standard anteroposterior hip radiographic; (4) patients whose the Tönnis osteoarthritis grade was in the range of 1–3; (5) patients waiting list for THA. The patients were excluded according to the following: (1) patients with other diseases affecting joint movements such as hip osteoarthritis secondary to femoroacetabular impingement (FAI); (2) patients with a history of other hip surgeries; (3) patients with Crowe Type III and iv adopting the high hip center technique and undergoing intraoperative high femoral osteotomy or subtrochanteric osteotomy during THA, leading to biomechanical changes of the lower limbs, which is different from the surgical technique used in patients with Crowe type I and IV; (4) patients with adverse events after THA such as dislocation, subluxation, or periprosthetic fractures; (5) Patients who can’t walk independently without canes, walkers, crutches, and other walking aids until gait stabilization. All participants were then followed up at 1 year after THA.
Surgical technique
THA was performed by an experienced orthopedist in our hospital using the posterolateral approach. The patient was placed in the lateral position with the affected limb on the upper side to increase the flexibility of the affected limb. A linear incision was made proximally from the greater trochanter of the femur, and the skin and subcutaneous tissue were carefully dissected in turn. Then the tensor fascia lata was bluntly separated, and part of the gluteus medius muscle was cut off along the insertion point. An osteotomy was performed along the intertrochanteric line about 1.5 cm from the lesser trochanter, and the femoral head was removed. The bottom of the acetabulum was fully exposed, the hyperplastic marginal tissue of the acetabulum was removed, the synovial membrane of the acetabular floor and the round ligament were cut off, and the acetabulum was polished from small to large with an acetabular file. The acetabular socket was washed with an anteversion Angle of 15° -25 ° and an abduction Angle of 40° from small to large. The acetabular cup was pressed and implanted. The affected hip was abducted and external rotated, the affected limb was in a figurine shape, and the proximal femur was fully exposed. The medullary opener was opened, and the medullary was expanded from small to large in turn. The range of motion and stability of the hip joint were examined, and the length discrepancy of the lower limbs was observed. After satisfactory results, the femoral head prosthesis was installed and reduced. Finally, the bleeding was stopped carefully, the equipment was counted, and the wound was rinsed and closed.
During the operation, appropriate acetabular cup and femoral stem were selected according to preoperative template measurement and intraoperative situation, and the corresponding soft tissue release was performed.
Anatomical parameter measurements
AA is measured as the angle between a line connecting the anterior acetabular margin with the posterior acetabular margin and the perpendicular to a transverse reference line either through the femoral head centers, the posterior acetabular walls or the respective posterior aspect of the ischial bones. FA is measured as the angle between the long axis of the femoral neck and a line parallel to the dorsal aspect of the femoral condyles (posterior condylar axis, or PCA) on axial slices (Fig. 1). Before and after THA, those two parameters were determined at computer tomography (CT, GE Healthcare, Chalfont St Giles, United Kingdom) using a detector slice thickness of 1 mm from the upper pelvic rim to the upper 1/3 of the tibia when the feet of patients are fixed.
Fig. 1.
Measurement of femoral anteversion angle
Gait measurements
Given that gait speed and walking asymmetry returned to baseline by 3 months [41], the gait parameters of patients in the study were measured by the Dynamic Gait and Posture Analysis system (Medical 3.0 A) (Shenzhen Hangzheng Technology Co., Ltd.) preoperatively and at more than 6 months after THA (Fig. 2a). This gait analysis system combines artificial intelligence, micro posture sensing, machine vision and thin film pressure sensing technology together with a design of wearable smart insoles, which can dynamically collect basic data of the walker’s foot and display the foot movement data in real time. The procedure of measurement: under the guide of a professional doctor, the patient wears a shoe of his/her own choice, in which placed a sensor that was embedded in a selected insole with an appropriate size. Then, the patient walks along a straight line for 1 min at a comfortable walking speed. After the patient walks, the gait parameter of the patient can be obtained through the tablet computer software system (Fig. 2b) that is connected with the insole sensor (Fig. 3). Dynamic Gait and Posture Analysis System compared with the data from three-dimensional motion capture system Vicon, and there was a 99.09% identity in core data, including stride length, gait velocity, foot-ground clearance, stance time, swing time, pitch velocity (from: https://en.xingzhengtech.com/).
Fig. 2.
Dynamic gait posture analysis system: (a) External observation of dynamic gait posture analysis system. (b) The system interface of dynamic gait posture analysis system
Fig. 3.
The result reporting interface of dynamic gait posture analysis system
This dynamic gait and posture analysis system could test gait pattern comprehensively and multi-dimensionally. By testing, fifteen gait parameters were recorded, including foot progression angle (FPA) (°)、foot contact angle (°)、toe-off angle (°)、plantarflexion velocity (°/s)、dorsiflexion velocity (°/s)、swing foot speed (m/s)、pronation angle (°)、pronation excursion (°)、maximum pronation velocity (°/s)、foot-ground clearance (cm)、foot to ground angle (°)、step width (cm)、gait velocity (m/s)、cadence (steps/m)、stride length (m). The definition of above parameters was shown in Table 1.
Table 1.
Definition of gait parameters
| Variables | Definitions |
|---|---|
| Foot progression angle (°) | the angle between the line of progression and the foot axis |
| Foot contact angle (°) | the angle between an axis connecting the toe-heel relative to the ground reference in the sagittal plane at heel contact |
| Toe-off angle (°) | the angle of toe-off the ground measured at the moment of initiation of the swing phase |
| Plantarflexion velocity (°/s) | the maximum x component of the ankle joint angular velocity in the sagittal plane expressed in the shank coordinate system at toe-off. |
| Dorsiflexion velocity (°/s) | the maximum x component of the ankle joint angular velocity in the sagittal plane expressed in the shank coordinate system at mid-stance. |
| Swing foot speed (m/s) | the maximum displacement velocity of the swing foot |
| Pronation angle (°) | the amount that the foot rolls inward toward the arch |
| Pronation excursion (°) | the total range of angular movement (in degrees) as the foot rolls inward between foot strike and the point of maximum pronation |
| Maximum pronation velocity (°/s) | the maximum angular rate at which the foot pronates between foot strike and the point of maximum pronation. |
| Foot-ground clearance (cm) | the maximum distance between the foot sole and the floor in swing phase |
| Foot to ground angle (°) | the angle between an axis connecting the toe-heel relative to the ground reference in the coronal plane at early swing |
| Step width (cm) | The mediolateral space between the two feet |
| Gait velocity (m/s) | the time one takes to walk a specified distance on level surfaces over a short distance |
| Cadence (steps/m) | the number of steps taken per minute |
| Stride length (m) | the distance between the consecutive initial contacts of the same foot |
Data collection
The demographic data were collected preoperatively, including age, sex, BMI (body mass index), Crowe type (I and IV), affected hips (bilateral and unilateral). Data of AA, FA, gait parameters were collected preoperatively and postoperatively.
Statistical analysis
Continuous variables are presented as mean ± standard deviation, median, and interquartile range (IQR), and categorical variables are presented as percentages. Statistical analyses were actualized using IBM SPSS version 26.0 (IBM, Armstrong, NewYork, USA). Paired T test was used to compare the difference of AA, FA and gait parameters between before and after THA. The correlation between change of AA, FA and change of gait parameters was analyzed by Pearson correlation test. A subgroup Pearson correlation test was conducted to analyze whether bilateral or unilateral hip affect the correlation between AA, FA and gait data. The multiple linear regression was conducted to analyze the impact of the preoperative imaging and demographic data on gait parameters. The level of significance was defined as p < 0.05.
Results
Demographic characteristics of the patients
Finally, a total of 40 symptomatic hip osteoarthritis secondary to hip dysplasia patients (45hips) who underwent primary THA were included. Among them, there were 35 females and 5 males, and 30 Crowe type I patients (33hips) and 10 Crowe type IV patients (12hips). All patients had an average height of 158.1 cm, an average weight of 61.1 kg, and an average BMI of 24.5 kg/m2. The detailed demographic characteristics of the patients were shown in Table 2.
Table 2.
Demographic characteristics of the patients
| Parameter | Value (X̅±s or n (%)) |
|---|---|
| Age | 47.9 ± 12.2 |
| Gender (number of patients) | |
| Female | 35(77%) |
| Male | 5(33%) |
| BMI | 24.5 ± 3.1 |
| Crowe type (number of patients) | |
| Crowe I | 30(75%) |
| Crowe IV | 10(25%) |
| Affected hip (number of hips) | |
| Bilateral | 10(22.22%) |
| Unilateral | 35(77.78%) |
BMI, body mass index
Comparison of AA, FA, and gait parameters preoperatively and postoperatively
The average change of AA is -0.4 degree, and the average change of FA is 2.3 degree. Preoperative FA is significantly different from postoperative FA (P < 0.05), while the difference between preoperative and postoperative AA is not significantly different. Preoperative and postoperative AA and FA were presented in Table 3.
Table 3.
Comparison of AA, FA preoperatively and postoperatively
| Preoperative | Postoperative | P value* | |
|---|---|---|---|
| Femoral anteversion (°) | 35.05 ± 6.63 | 31.18 ± 7.70 | 0.021# |
| Crowe I | 24.06 ± 9.05 | 31.60 ± 7.10 | 0.022# |
| Crowe IV | 37.10 ± 8.77 | 32.70 ± 8.99 | 0.025# |
| Acetabular anteversion (°) | 46.26 ± 5.32 | 44.45 ± 9.31 | 0.501 |
| Crowe I | 42.93 ± 8.53 | 41.22 ± 9.56 | 0.671 |
| Crowe IV | 47.06 ± 11.63 | 46.45 ± 7.26 | 0.671 |
*: P values were obtained by paired t test before and after operation
#: P value < 0.05 was considered to indicate statistical significance
Compared to preoperative gait parameters, statistically significant postoperative gait parameters include FPA, foot contact angle, plantarflexion velocity, swing foot speed, gait velocity, cadence, stride length (all P < 0.05). Preoperative and postoperative gait parameters were shown in Table 4.
Table 4.
Comparison of gait parameters preoperatively and postoperatively
| gait parameters | Preoperative | Postoperative | P value* |
|---|---|---|---|
| Foot progression angle (°) | 12.39 ± 8.22 | 5.90 ± 5.70 | 0.003# |
| Crowe I | 11.25 ± 6.45 | 6.12 ± 5.97 | 0.002# |
| Crowe IV | 10.33 ± 3.68 | 6.66 ± 4.99 | 0.032# |
| Foot contact angle (°) | 2.16 ± 10.59 | 10.56 ± 5.17 | 0.009# |
| Crowe I | 3.24 ± 9.88 | 11.67 ± 5.22 | 0.012# |
| Crowe IV | 2.24 ± 7.98 | 9.51 ± 6.45 | 0.013# |
| Toe-off angle (°) | 55.21 ± 11.24 | 57.60 ± 6.84 | 0.225 |
| Crowe I | 55.68 ± 5.14 | 54.55 ± 5.17 | 0.410 |
| Crowe IV | 60.26 ± 6.85 | 65.37 ± 6.08 | 0.341 |
| Plantarflexion velocity (°/s) | 92.81 ± 49.74 | 136.75 ± 23.38 | 0.009# |
| Crowe I | 92.56 ± 29.54 | 130.79 ± 31.14 | 0.020# |
| Crowe IV | 96.25 ± 27.64 | 147.24 ± 11.80 | 0.021# |
| Dorsiflexion velocity (°/s) | 319.42 ± 73.45 | 331.05 ± 35.49 | 0.988 |
| Crowe I | 323.58 ± 46.58 | 321.77 ± 37.65 | 0.013# |
| Crowe IV | 333.69 ± 39.55 | 344.08 ± 23.77 | 0.785 |
| Swing foot speed (m/s) | 2.67 ± 0.53 | 3.59 ± 0.25 | 0.003# |
| Crowe I | 2.87 ± 0.70 | 3.68 ± 0.31 | 0.013# |
| Crowe IV | 2.66 ± 0.64 | 3.81 ± 0.27 | 0.012# |
| Pronation angle (°) | 6.32 ± 7.23 | 10.87 ± 3.12 | 0.309 |
| Crowe I | 9.01 ± 3.51 | 12.33 ± 3.45 | 0.531 |
| Crowe IV | 10.12 ± 3.45 | 11.27 ± 3.33 | 0.554 |
| Pronation excursion (°) | 6.97 ± 5.48 | 8.43 ± 3.04 | 0.503 |
| Crowe I | 9.01 ± 4.89 | 9.33 ± 3.69 | 0.765 |
| Crowe IV | 9.22 ± 4.57 | 9.57 ± 3.57 | 0.385 |
| Maximum pronation velocity (°/s) | 184.39 ± 116.73 | 255.28 ± 115.69 | 0.344 |
| Crowe I | 239.89 ± 120.01 | 269.15 ± 141.83 | 0.325 |
| Crowe IV | 342.89 ± 120.01 | 367.88 ± 133.36 | 0.446 |
| Foot-ground clearance (cm) | 12.11 ± 2.12 | 14.07 ± 1.57 | 0.279 |
| Crowe I | 13.69 ± 3.76 | 14.59 ± 1.99 | 0.289 |
| Crowe IV | 14.88 ± 2.58 | 15.27 ± 0.58 | 0.308 |
| Foot to ground angle (°) | -1.86 ± 4.71 | -1.24 ± 6.60 | 0.473 |
| Crowe I | -2.88 ± 5.16 | -3.02 ± 5.85 | 0.567 |
| Crowe IV | -2.74 ± 4.28 | -3.90 ± 7.26 | 0.697 |
| Step width (cm) | -0.66 ± 3.25 | -0.44 ± 2.04 | 0.403 |
| Crowe I | -0.66 ± 2.21 | -0.72 ± 2.64 | 0.701 |
| Crowe IV | -0.65 ± 2.30 | -0.46 ± 2.06 | 0.654 |
| Gait velocity (m/s) | 0.66 ± 0.25 | 1.02 ± 0.09 | 0.003# |
| Crowe I | 0.70 ± 0.21 | 1.03 ± 0.09 | 0.002# |
| Crowe IV | 0.68 ± 0.22 | 1.09 ± 0.07 | 0.001# |
| Cadence (steps/m) | 104.67 ± 9.60 | 112.64 ± 4.42 | 0.001# |
| Crowe I | 103.24 ± 3.65 | 110.17 ± 4.60 | 0.003# |
| Crowe IV | 102.27 ± 3.55 | 115.53 ± 4.67 | 0.003# |
| Stride length (m) | 0.76 ± 0.26 | 1.09 ± 0.10 | 0.025# |
| Crowe I | 0.67 ± 0.22 | 1.12 ± 0.08 | 0.011# |
| Crowe IV | 0.62 ± 0.32 | 1.14 ± 0.11 | 0.010# |
*: P values were obtained by paired t test before and after operation
#: P value < 0.05 was considered to indicate statistical significance
Correlation between change of AA, FA, and change of gait parameters
After correlation analysis, there is no significantly relationship between change of AA and change of gait parameters, and between change of FA, and change of gait parameters (Table 5).
Table 5.
Correlation analysis of change of femoral anteversion and acetabular anteversion with postoperative gait parameters
| Correlation# | Change of femoral anteversion | Change of acetabular anteversion |
|---|---|---|
| Change of foot progression angle (°) | 0.114 | 0.377 |
| Change of foot contact angle (°) | 0.901 | 0.162 |
| Change of toe-off angle (°) | 0.610 | 0.286 |
| Change of plantarflexion velocity (°/s) | 0.406 | 0.900 |
| Change of dorsiflexion velocity (°/s) | 0.124 | 0.419 |
| Change of swing foot speed (m/s) | 0.298 | 0.355 |
| Change of pronation angle (°) | 0.566 | 0.589 |
| Change of pronation excursion (°) | 0.673 | 0.358 |
| Change of maximum pronation velocity (°/s) | 0.228 | 0.549 |
| Change of foot-ground clearance (cm) | 0.790 | 0.234 |
| Change of foot to ground angle (°) | 0.909 | 0.400 |
| Change of step width (cm) | 0.599 | 0.842 |
| Change of gait velocity (m/s) | 0.104 | 0.708 |
| Change of cadence (steps/m) | 0.510 | 0.235 |
| Change of stride length (m) | 0.213 | 0.675 |
#:Pearson correlation analysis was performed on the postoperative femoral anteversion Angle and postoperative acetabular anteversion Angle to obtain P values, and P values<0.05 were considered statistically significant
*: P value<0.05 was considered to indicate statistical significance
After subgroup correlation analysis, there is still no significantly relationship between change of AA and change of gait parameters in bilateral hip group, and between change of FA, and change of gait parameters in unbilateral hip group (Table 6), indicating that affected hips did not influence the relationship between change of AA, FA, and change of gait parameters.
Table 6.
The effect of affected hip on the correlation between change of femoral anteversion and acetabular anteversion and postoperative gait parameters
| Correlation# | Change of femoral anteversion | Change of acetabular anteversion | ||
|---|---|---|---|---|
| Bilateral | Unilateral | Bilateral | Unilateral | |
| Change of foot progression angle (°) | 0.235 | 0.134 | 0.863 | 0.452 |
| Change of foot contact angle (°) | 0.345 | 0.386 | 0.166 | 0.178 |
| Change of toe-off angle (°) | 0.859 | 0.321 | 0.344 | 0.374 |
| Change of plantarflexion velocity (°/s) | 0.686 | 0.461 | 0.131 | 0.563 |
| Change of dorsiflexion velocity (°/s) | 0.441 | 0.347 | 0.907 | 0.645 |
| Change of swing foot speed (m/s) | 0.123 | 0.237 | 0.561 | 0.549 |
| Change of pronation angle (°) | 0.342 | 0.456 | 0.238 | 0.544 |
| Change of pronation excursion (°) | 0.523 | 0.496 | 0.134 | 0.107 |
| Change of maximum pronation velocity (°/s) | 0.725 | 0.365 | 0.451 | 0.318 |
| Change of foot-ground clearance (cm) | 0.761 | 0.643 | 0.725 | 0.528 |
| Change of foot to ground angle (°) | 0.342 | 0.578 | 0.214 | 0.806 |
| Change of step width (cm) | 0.613 | 0.498 | 0.313 | 0.112 |
| Change of gait velocity (m/s) | 0.112 | 0.103 | 0.713 | 0.109 |
| Change of cadence (steps/m) | 0.735 | 0.145 | 0.123 | 0.634 |
| Change of stride length (m) | 0.347 | 0.231 | 0.321 | 0.432 |
#:Pearson correlation analysis was performed on the postoperative femoral anteversion Angle and postoperative acetabular anteversion Angle to obtain P values, and P values<0.05 were considered statistically significant
*: P value<0.05 was considered to indicate statistical significance
Determinants of the change in gait parameters after THA
Multiple linear regression analyses showed that cadence increased with BMI and decreased with change of AA (Table 7). In addition, Crowe type have a positive impact on cadence (Table 7).
Table 7.
Determinants of the change in gait parameters after total hip arthroplasty
| Adjusted R2 | 0.432 (P Value < 0.05) | ||
|---|---|---|---|
| B | β | P Value | |
| BMI | 0.124 | 0.623 | 0.041* |
| Crowe type | 4.513 | 0.222 | 0.022* |
| Affected hip | 0.434 | 0.049 | 0.811 |
| Change of femoral anteversion | 0.050 | 0.088 | 0.592 |
| Change of acetabular anteversion | -0.287 | -0.618 | 0.012** |
The dependent variable is Cadence (steps/m)
BMI, body mass index
* p < 0.05 ** p < 0.01
Discussion
Gait analysis is a way to assess the dynamic posture and coordination during movement. In the biomedical field, gait analysis generates valuable information regarding healthy and unhealthy gait patterns. In this study, we evaluate the gait patterns of patients with hip osteoarthritis secondary to hip dysplasia after THA, and analyze the effect of THA on gait parameters. Thus, this study could give insight into making any necessary corrections of AA and FA during THA for a smooth gait.
After THA, seven among fifteen gait parameters significantly changed, including decreasing FPA, increasing foot contact angle, increasing plantarflexion velocity, increasing swing foot speed, increasing gait velocity, increasing cadence, increasing stride length. In previous study, the normal FPA is an out-toeing angle of the foot that ranges from 5° in children [42] to 13° in adults [43]; the clinical average FPA was 10.70º in children with hip dysplasia [44]; the mean FPA was 3.3° (with a range of -9.7° (in-toeing) to a maximum of 14.3° (out-toing) in healthy adults [45]. In our study, the mean FPA was 12.39º before THA in adults with hip dysplasia, 5.90º after THA. For foot contact angle, also defined as heel-strike angle, it was 19.2º on average in healthy males in previous study [46], whereas it was 10.56º on average in adults with hip dysplasia after THA, 2.16º before THA in this study. For plantarflexion velocity, it was reported 736.5°/s on average in healthy adults [47], while it was 92.81°/s preoperatively and 136.75°/s postoperatively in this study. As for swing foot speed, it was approximately 4–6 m/s in healthy subjects during normal walking in previous study [48], while it was 3.59 m/s on average in adults with hip dysplasia after THA, 2.67 m/s before THA in this study. In previous study, the mean gait velocity was 1.22 cm/s in older adults [49]. In our study, the mean gait velocity was 0.66 cm/s preoperatively and 1.02 cm/s postoperatively. For cadence, ≥ 100 steps/min is a consistent heuristic value associated with absolutely defined moderate intensity in adults [50]. However, the mean cadence found in our study was 104.67 steps/min preoperatively and 112.64 steps/min postoperatively. As for stride length, the mean value was 1.34 m in older adults [49], and ≤ 0.64 m accurately predicted clinical events [51]. Our study demonstrated that the average stride length was 0.76 m preoperatively and 1.09 m postoperatively. Overall, our study indicated that THA significantly improved the lower limb walking function of hip dysplasia patients, which was consistent with the results of previous studies [37, 52].
FA is associated with differences in gait and is a risk factor for osteoarthritis [19]. It goes through substantial development during growth with a change from 0° in early gestation to 30° at birth, decreasing to 15° in adulthood [19]. Abnormal FA is an important factor in hip dysplasia [53]. Correction of abnormal FA in hip dysplasia patients is therefore an important goal for THA. From the perspective of kinematics, normal femur will rotate along its long axis, which is the torsion between the femur (Fig. 4a). When the FA is too large, the femoral head will rotate outward on the acetabulum. At this time, in order to promote the normal hip joint alignment, it is easy to form the gait of internal octave (Fig. 4b). On the contrary, when the FA is too small, it is easy to form the gait of external octave in order to promote the normal hip joint alignment. From the perspective of lower limb force analysis, Hans et al. [54] showed that when the femur anterior inclination angle increases, the knee contact force increases. Shull et al. [55] found that when the knee joint stress increases, a decrease in the foot deflection angle will make the vector of ground reaction force closer to the center of rotation of the knee joint and reduce the knee joint internalizing moment during limb weight-bearing. Therefore, when FA increases, the body will make the foot deflection angle decrease due to a greater stress in the knee joint, which will make the knee joint stress vector closer to the center of rotation of the knee joint, and reduce the knee joint stress. The FA of hip dysplasia patients is significantly greater than that of healthy controls (26.39°±14.74°vs 15.68°±7.95°) [56]. In this study, FA is 35.05 ± 6.63 preoperatively and 31.18 ± 7.70 postoperatively, respectively, with significance difference of change. The result suggested that FA is significantly decreased by THA. In theory, the change in FA affect that position of the rotor and thus the effect on the muscles surround this area. Torsional variation along the region of the femur also results in variation of the lever arm [57], the higher the FA, the greater the hip flexion arm [19, 58], so within a reasonable range, the greater the FA, hip joint flexion arm increases, the patient is easier to bend the hip in the process of walking, so the patient in postoperative gait step speed and stride. However, the significant difference of change of FA is not related with any significant changes of gait parameters above. More efforts should be taken to explore the effect of FA on gait, such as increasing study sample, extending the observation time.
Fig. 4.
(a) Normal femoral anteversion. (b) Excessive femoral anteversion with “in-toeing”
The normal AA was found to be 17 ± 6° [59]. In this study, AA is 46.26°±5.32°preoperatively and 44.45°±9.31° postoperatively, respectively, with no significance difference of change. The osseous AA and cartilaginous AA were both over-anteverted in hip dysplasia children [60]. AA is related to hip function. After multiple linear regression analysis, we found that AA had a negative effect on cadence. The less AA was, the more cadence was. Too excessive AA could result in a rotation for a dual mobility hip implant at both articulations [61]. Poor acetabular cup placement is a common cause of complications after THA [62–64], when the acetabular rake angle is too large, can lead to hip instability, even lead to dislocation of the hip [65]. The observed relation between AA and cadence may result from hip prosthesis position and rotation. However, the underlying mechanism of how the AA affects the cadence needs further investigation. In addition, we found both BMI and Crowe type play a positive role in cadence. The larger BMI was, the lager cadence was. It was demonstrated that BMI-defined normal weight children had higher peak 1-minute (115.5 versus 110.6 and 106.6 steps/min), 30-minute (81.0 versus 77.5 and 74.0 steps/min) and 60-minute cadence (67.1 versus 63.4 and 60.7 steps/min) than overweight and obese children (p < 0.0001), respectively [66]. Our finding was not consistent with the previous study. Plus, the cadence in Crowe IV type patients was higher than that in Crowe I type patients, indicating the more severe the disease, the higher the cadence.
Therefore, for patients undergoing primary THA because of Crowe Type I DDH and Crowe Type IV DDH, the postoperative AA should be kept within a reasonable range to ensure that the patient’s post-operative cadence is maintained within a reasonable range. Our study has several limitations: (1) We mainly studied the correlation between postoperative imaging and gait of DDH patients, and did not collect preoperative imaging data of patients, so we could not analyze the relationship between the changes of preoperative and postoperative imaging and gait data of patients. (2) Secondly, we collected the patient’s gait information after the postoperative gait was stable, and did not analyze the patient’s gait changes during the whole rehabilitation process. (3) We only analyzed the postoperative gait of patients with Crowe I DDH and Crowe IV DDH without intraoperative osteotomy. We did not analyze the postoperative gait of patients with Crowe II and Crowe III DDH, and also did not analyze the postoperative gait of patients with Crowe IV DDH who underwent intraoperative osteotomy.
Conclusions
In conclusion, our study indicated that THA could improve the gait function of patients with symptomatic hip osteoarthritis secondary to hip dysplasia. Adjusting AA lower could obtain a much more postoperative cadence.
Acknowledgements
Not applicable.
Author contributions
YMW, HY, JFY, YW and CX designed the study; LC, PX, JYL and HCR collected the data; XYL, QQQ, YW and CX analyzed and interpreted the data; YMW, HY and JFY were major contributors in writing the manuscript. KX was major contributor in revising the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable.
Data availability
The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The study was approved by the ethics committee of General Hospital of PLA. Ethics approval number is S2023-291-01. Informed consent was obtained from all participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Yiming Wang, Han Yu and Jianfeng Yang contributed equally to this work.
Contributor Information
Yan Wang, Email: yanwang_plagh@163.com.
Chao Xue, Email: xuechao8971@126.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.