Arribart Kevin, Peryoitte Valentin, Kaniewski Anton, Bonnet Xavier, Pillet Hélène
Institut Robert Merle d'Aubigné, Valenton, France.
Arts et Métiers Sciences et Technologies, Institut de Biomécanique Humaine Georges Charpak, Paris, France.
Clin Orthop Relat Res. 2025 Mar 1;483(3):535-546. doi: 10.1097/CORR.0000000000003288. Epub 2024 Nov 5.
A hip flexion contracture (HFC) results in an inability to extend the hip by reducing the ROM of the affected hip. The condition affects one in four patients with above-knee amputations on the amputation side. While HFC in other disorders is known to decrease hip ROM and increase pelvic tilt during gait, its impact on the gait of patients with above-knee amputations remains unexplored. Typically, prosthetists design the socket with a flexion angle matching the HFC, potentially leading to compensations during the posterior stance phase of the gait cycle. To our knowledge, little is known about how or whether these compensations relate to the socket's flexion alignment.
QUESTIONS/PURPOSES: (1) Is the presence of HFC associated with modifications of spatiotemporal and kinematic parameters during gait in patients with an above-knee amputation? (2) Is there a correlation between the socket flexion angle and the spatiotemporal and kinematic parameters during gait in patients with an above-knee amputation with and without HFC?
A comparative observational study was conducted between February 2022 and June 2023. Thirty-two participants with unilateral above-knee amputations who had undergone amputation at least 1 year prior and had a minimum of 1 month of experience with their current prostheses were eligible for consideration and included in the study. After the trial, 1 of 32 participants was excluded due to other impairments affecting gait, and 9% (3 of 32) were excluded because of pain or discomfort during data acquisition on their gait, leaving 88% (28 of 32) of participants included in the analysis. The median (IQR) age of participants in the HFC group (n = 13) was 50 years (26 to 56); 85% (11) were male and 15% (2) were female. The median (IQR) age of participants in the noHFC group (n = 15) was 41 years (32 to 56), and 100% were male. Time since amputation was similar between groups (HFC median 8 years [IQR 3 to 21], noHFC median 6 years [IQR 1 to 9], difference of medians 2; p = 0.31). Thirty-two percent (9 of 28) of patients were classified according to the Medicare Functional Classification Level system as K4 (exceeding basic ambulation skills) and 68% (19 of 28) were classified as K3 (ability to walk with variable cadence and traverse most environmental barriers). Clinical and prosthetic measurements were made, which comprised measurement of the HFC using a hand-held goniometer with the patient in the modified Thomas test position, the socket flexion alignment, and the difference (δ) between the HFC and socket flexion alignment. A gait analysis was performed with an optoelectronic system equipped with six infrared cameras and two force plates to analyze the time-distance and kinematic parameters of gait. To answer our first question, we quantitively compared the gait spatiotemporal and kinematic parameters between groups, and for the second question, we evaluated the correlations between the same parameters and prosthesis alignment for both groups.
During gait, the HFC group exhibited reduced mean ± SD residual hip ROM in comparison with the noHFC group (35° ± 6° versus 44° ± 6°, mean difference -9° [95% CI -13° to -6°]; p < 0.001), increased pelvic tilt (11° ± 6° versus 7° ± 3°, mean difference 4° [95% CI 1° to 8°]; p = 0.02), increased pelvic rotation (12° ± 3° versus 9° ± 2°, mean difference 3° [95% CI 2° to 6°]; p < 0.001), and increased trunk rotation (15° ± 5° and 12° ± 2°, mean difference 3° [95% CI 0° to 6°]; p = 0.04). Greater δ correlated with decreased ROM in the contralateral hip (r = -0.71; p = 0.006), pelvis (r = -0.77; p = 0.002), and trunk (r = -0.58; p = 0.04) in the sagittal plane and with increased residual hip ROM (r = 0.62; p = 0.02). In terms of spatiotemporal gait parameters, in the HFC group, the δ correlated with an increase in contralateral step width (r = 0.58; p = 0.04) and a decrease in prosthetic step length (r = -0.65; p = 0.02).
Our findings further suggest that physiotherapists should consider the pelvic and trunk compensations associated with HFC in their rehabilitation because of potential long-term effects, such as low back pain or osteoarthritis. In addition, the correlation between the socket flexion angle and the parameters involved may support prosthetists in their choices of prosthetic settings. For now, we cannot consider these compensations as an impaired gait syndrome, and future studies are needed to evaluate their impact on patients' quality of life.
Level III, therapeutic study.
髋关节屈曲挛缩（HFC）会导致患侧髋关节活动范围（ROM）减小，从而无法伸展髋关节。这种情况在膝上截肢患者中，每四人就有一人受影响。虽然已知其他病症中的HFC会降低髋关节ROM并增加步态期间的骨盆倾斜度，但其对膝上截肢患者步态的影响仍未得到探索。通常，假肢师会设计与HFC屈曲角度相匹配的接受腔，这可能会在步态周期的后支撑期导致代偿。据我们所知，对于这些代偿如何或是否与接受腔的屈曲对线相关，了解甚少。
问题/目的：（1）髋关节屈曲挛缩的存在是否与膝上截肢患者步态期间的时空参数和运动学参数改变有关？（2）在有和没有髋关节屈曲挛缩的膝上截肢患者中，接受腔屈曲角度与步态期间的时空参数和运动学参数之间是否存在相关性？
在2022年2月至2023年6月期间进行了一项比较观察性研究。32名单侧膝上截肢患者符合纳入研究的条件，这些患者至少在1年前接受了截肢手术，并且使用当前假肢至少有1个月的经验。试验后，32名参与者中有1名因影响步态的其他损伤被排除，9%（32名中的第3名）因步态数据采集期间的疼痛或不适被排除，最终88%（32名中的28名）的参与者纳入分析。髋关节屈曲挛缩组（n = 13）参与者的年龄中位数（四分位间距）为50岁（26至56岁）；85%（11名）为男性，15%（2名）为女性。无髋关节屈曲挛缩组（n = 15）参与者的年龄中位数（四分位间距）为41岁（32至56岁），且均为男性。两组之间的截肢后时间相似（髋关节屈曲挛缩组中位数8年[四分位间距3至21年]，无髋关节屈曲挛缩组中位数6年[四分位间距1至9年]，中位数差异为2；p = 0.31）。根据医疗保险功能分级系统，28名患者中有32%（9名）被归类为K4（超过基本步行技能），68%（19名）被归类为K3（能够以可变步频行走并跨越大多数环境障碍）。进行了临床和假肢测量，包括使用手持量角器在改良托马斯试验位置测量患者的髋关节屈曲挛缩、接受腔屈曲对线，以及髋关节屈曲挛缩与接受腔屈曲对线之间的差异（δ）。使用配备六个红外摄像头和两个测力板的光电系统进行步态分析，以分析步态的时间-距离和运动学参数。为了回答我们的第一个问题，我们定量比较了两组之间的步态时空参数和运动学参数，对于第二个问题，则评估了两组相同参数与假肢对线之间的相关性。
在步态期间，与无髋关节屈曲挛缩组相比，髋关节屈曲挛缩组的平均±标准差残余髋关节ROM降低（35°±6°对44°±6°，平均差异-9°[95%置信区间-1°至-6°]；p < 0.001），骨盆倾斜增加（11°±6°对7°±3°，平均差异4°[95%置信区间1°至8°]；p = 0.02），骨盆旋转增加（12°±3°对9°±2°，平均差异°[95%置信区间2°至6°]；p < 0.001），以及躯干旋转增加（15°±5°和12°±2°，平均差异3°[95%置信区间0°至6°]；p = 0.04）。更大的δ与矢状面中对侧髋关节（r = -0.71；p = 0.006）、骨盆（r = -0.77；p = 0.002）和躯干（r = -0.58；p = 0.04）的ROM降低相关，并且与残余髋关节ROM增加（r = 0.62；p = 0.02）相关。在时空步态参数方面，在髋关节屈曲挛缩组中，δ与对侧步宽增加（r = 0.58；p = 0.04）和假肢步长减小（r = -0.65；p = 0.02）相关。
我们的研究结果进一步表明，由于潜在的长期影响，如腰痛或骨关节炎，物理治疗师在康复过程中应考虑与髋关节屈曲挛缩相关的骨盆和躯干代偿。此外，接受腔屈曲角度与所涉及参数之间的相关性可能有助于假肢师选择假肢设置。目前，我们不能将这些代偿视为一种受损的步态综合征，未来需要进行研究以评估它们对患者生活质量的影响。
III级，治疗性研究。
