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Gait Analysis of Patients Subjected to the Atrophic Mandible Augmentation with Iliac Bone Graft

Gait Analysis of Patients Subjected to the Atrophic Mandible Augmentation with Iliac Bone Graft Hindawi Applied Bionics and Biomechanics Volume 2019, Article ID 8203597, 9 pages https://doi.org/10.1155/2019/8203597 Research Article Gait Analysis of Patients Subjected to the Atrophic Mandible Augmentation with Iliac Bone Graft 1 2 2 3 Erol Cansiz , Derya Karabulut, Suzan Cansel Dogru , Nazif Ekin Akalan, 4 2 Yener Temelli, and Yunus Ziya Arslan Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Istanbul University, Istanbul, Turkey Faculty of Engineering, Department of Mechanical Engineering, Istanbul University-Cerrahpasa, Istanbul, Turkey Faculty of Health Science, Physiotherapy and Rehabilitation Division, Istanbul Kultur University, Istanbul, Turkey Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul University, Istanbul, Turkey Correspondence should be addressed to Yunus Ziya Arslan; yzarslan@istanbul.edu.tr Received 1 November 2018; Revised 11 January 2019; Accepted 29 January 2019; Published 3 March 2019 Academic Editor: Andrea Cereatti Copyright © 2019 Erol Cansiz et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In this study, we aimed to quantitatively monitor and describe the gait functions of patients, who underwent iliac crest bone grafting in atrophic jaw augmentation operation, by taking into account the alterations of gait parameters and muscle forces in the early recovery course. To do so, temporospatial and kinematic gait parameters of ten patients during pre- and postoperative periods were recorded, and forces of the gluteus medius, gluteus maximus, and iliacus muscles were calculated. Three postoperative periods were specified as one week (post-op1), two weeks (post-op2), and three weeks (post-op3) after the surgery. Restoring process of the gait patterns was comparatively evaluated by analyzing the gait parameters and muscle forces for pre- and postoperative periods. Temporospatial and kinematic parameters of post-op3 were closer to those obtained in pre-op than those in post-op1 and post-op2 (p <0 05). Muscle forces calculated in post-op3 showed the best agreement with those in pre-op among the postoperative periods in terms of both magnitude and correlation (p <0 05). In conclusion, the patients began to regain their preoperative gait characteristics from the second week after surgery, but complete recovery in gait was observed three weeks after the surgery. 1. Introduction Althoughtheanterioriliaccrestboneisaconvenientdonor site for the atrophic mandible augmentation technique, various complications associated with the donor site like Bone grafting or bone harvesting is a procedure to augment deficient bone tissue and is widely used in a number of oral chronic pain, contour defect, ureteral injury, sensory loss, and maxillofacial procedures such as reconstructive surgical and unbalance of the sacroiliac joint have been reported [5, 6, interventions [1–4]. Functional and structurally sound bone 12, 13]. Due to the operation-caused trauma that occurred in volume is essential for the reconstruction of alveolar defects. neighboring anatomical structures especially in muscle-bone For this reason, the iliac crest, calvarium, tibia, fibula, and connection sites, gait abnormalities are observed in the posto- ribs have been used as extraoral donor sites for bone aug- perative periods [14]. mentation procedures in the field of oral and maxillofacial Restoration of severe atrophic mandible for the reha- surgery [5, 6]. However, the iliac crest is regarded as a gold bilitation of patients with dental implant-aided fixed pros- standard on this specific field among other free bone graft thodontics must be three-dimensional. The high-volume donor sites [7–9]. Due to its high bone volume, relative ease donor site is required for the restoration of the atrophic of operation, and low morbidity and complication preva- mandible. The reconstruction of severe alveolar defects or lence, the iliac crest is the most preferred and well-known hypertrophic jaw bones mostly requires tricortical structure donor site in such operations [10, 11]. of 6×5 cm average graft size for augmentation [15, 16]. 2 Applied Bionics and Biomechanics (iv) Having no cognitive deficiency which may prevent At this point, the gluteus medius (GMED), gluteus maximus (GMAX), and iliacus (ILIAC) muscles must be understanding and performing of the study protocol individually separated from the muscle-bone connection The exclusion criterion was the presence of any systematic surface to harvest sufficient bone graft, which leads to the gait disease that may affect the soft and hard tissue healing. The abnormalities. Since there are many factors affecting the study protocol followed the Declaration of Helsinki and was recovery process, it is difficult to identify the healing approved by the ethical committee of Istanbul University, process exactly. Istanbul, Turkey (approval protocol no. 2016/7). Written Many researchers reported the gait disturbance caused by informed consent was obtained from all the patients. iliac crest bone grafting operations. Matsa et al. [17] reported that 28% of their study group suffered from gait disturbance 2.2. Surgical Intervention. All of the patients were operated at in the first four weeks following surgery, and all of the the Istanbul University, Faculty of Dentistry, Department of patients returned to their normal gait characteristics after Oral and Maxillofacial Surgery. A standardized surgical pro- three months of the healing period. On the other hand, tocol to harvest approximately 6cm × 3cm × 2cm tricortical Beirne et al. [18] and Sudhakar et al. [19] reported that most free bone graft from the right anterior iliac crest was per- of their patients who had undergone iliac crest bone grafting formed by the same surgeon under general anesthesia. The regained their preoperative gait characteristics within two skin incision and dissection were performed 2 cm above the weeks following surgery. Beirne et al. [18] and Sudhakar anterior superior iliac spine along the anterior superior mar- et al. [19] stated that only 6% and 2% of the patients suffered gin of the anterior iliac crest to preserve the lateral femoral from gait disturbance more than two weeks after bone graft- cutaneous nerve. After the dissection of the skin and the ing operation, respectively. Rawashdeh [20] reported that underlying soft tissues, the superior surface of the iliac crest none of their patients had gait disturbance after two weeks. was exposed. Then the GMED, GMAX, and ILIAC muscle None of the studies in the literature investigated the postop- attachmentscoveringthemedialandlateralsurfacesoftheiliac erative gait deficiency from objective and quantitative per- crestweredissectedsubperiosteallytoexposethebonesurfaces. spectives, and no consensus has been reached on the gait After the completion of the dissection process, a tricortical pattern in the early recovery period following the iliac crest autogenous bone block was harvested by using a microsaw bone harvesting. and a chisel osteotomy. Then, the sharp and rough contours In this respect, we aimed to quantitatively evaluate the were smoothed, and mini-wac drains were placed to the donor gait functions of the patients, who underwent atrophic jaw site to control postoperative edema. Finally, the three-layered augmentation operation in which the iliac crest was used closure including the periosteum, muscles, and skin was per- as donor site for the augmentation procedure, in the early formed to obtain primer closure of the wound. 1/0 resorbable recovery period. Our purpose was also to describe the polyglactin 910 sutures (Vicryl, Ethicon, Somerville, NJ, USA) biomechanical alterations of the patients by taking into wereusedfortheclosureoftheperiosteum.Muscleattachments account temporospatial and kinematic gait parameters as and subcutaneous soft tissue layers were closed by using 3/0 well as forces of the GMED, GMAX, and ILIAC muscles. resorbablepolyglactin910sutures(Vicryl,Ethicon,Somerville, We hypothesized that the changes in the gait patterns NJ, USA), and the skin incision was sutured with 3/0 nonresor- and muscle forces would quantify the progress of the gait bablepolypropylenesutures(Prolen;DogsanMedicalSupplies recovery process. Industry, Trabzon, Turkey). Patients were hospitalized for 1 day to control early postoperative complications, and postsur- gicalmedicationsincludingantibiotics,analgesics,andcortico- 2. Materials and Methods steroids were prescribed. The patients were administered antibiotics for 7 days starting on the day of the operation 2.1. Patients. This prospective study included ten systemically (1,000 mg of amoxicillin and clavulanic acid twice daily or healthy adult patients (five males and five females, aged 43 ± 600 mg of clindamycin for the patients who have penicillin 10 4 years old, height 169 ± 10 cm, mass 71 2±19 6 kg), who allergy twice a day) and analgesics (600 mg ibuprofen every 6 underwent onlay free bone grafting with anterior iliac crest hours for thefirst day and, if needed, for other days). As a corti- for the rehabilitation of severe maxillary alveolar atrophy costeroid, dexamethasone (8 mg daily) was administered for 2 between April 2016 and April 2017 at the Istanbul University daystocontrolthepostoperativeedema.Adayafterthesurgery, Faculty of Dentistry, Department of Oral and Maxillofacial mini-wac drains were removed and the patients were dis- Surgery, Istanbul, Turkey. charged withdetailedwrittenpostoperativeinstructions.Non- The inclusion criteria for the patients were as follows: resorbablesutures used for the skin closure were removed 10 to (i) Requirement to anterior iliac crest bone grafting for 12daysafterthesurgeryandthehealingperiodwasuneventful. maxillary alveolar bone reconstruction due to severe alveolar bone atrophy 2.3. Gait Experiments. Temporospatial and kinematic (lower limb joint angles) gait data were collected from the patients at (ii) Having no tumor or trauma in the lower limbs the Istanbul University, Faculty of Medicine, Motion Analy- or ilium sis Laboratory. Each patient was asked to walk as a natural (iii) Having no any other neural or muscular disorder way at a self-selected speed during pre- and postoperative periods in the laboratory. Three postoperative periods were which may merge with gait disturbance Applied Bionics and Biomechanics 3 two curves is 1, it means that pre- and postoperative muscle specified as one week (post-op1), two weeks (post-op2), and three weeks (post-op3) after the surgery. forces show a perfect agreement. Reflective passive markers were mounted on the specific Statistical significance analysis was carried out by using SPSS software (Version 21.0; SPSS; Chicago, IL, USA). The anatomic regions of the patients as described by Davis et al. [21], and three-dimensional position data of the markers level of significance was set at 0.05. Shapiro-Wilk test was were recorded by using six optical cameras (ELITE2002; performed to test the normalization of the data. All parame- BTS, Milan, Italy) of which sampling rate was 100 Hz. A ters were statistically analyzed using the one-way repeated- second-order Butterworth low-pass filter (6 Hz) was applied measure ANOVA. Bonferroni post hoc test was implemented to determine the significant difference between paired to smooth the marker trajectories. Joint angles were calcu- lated from the marker data by means of the inverse kinematic groups, if any. The differences between paired groups were evaluated at a level of significance of 0.012 (p <0 technique. The ground reaction force was also measured 012). simultaneously using two force plates (Kistler, Switzerland). Three gait trials were collected for each patient and ave- 3. Results rages of the temporospatial, kinematic, and muscle force data were calculated. Mean (±standard deviation) values of the pre- and postope- rative temporospatial gait parameters are given in Table 1. It can be deduced from the table that stance time, step length, 2.4. Muscle Force Calculation. Forces of the GMED, GMAX, stride length, and mean velocity significantly decreased and ILIAC muscles were calculated by using OpenSim, a during post-op1 and continued to increase during post-op1 musculoskeletal modeling and simulation program allowing and post-op2 when compared to pre-op parameters. All the calculation of the human muscle forces using inverse temporospatial parameters, except double support time, dynamics and forward dynamics methods [22]. The human measured in post-op3 are closer to those in pre-op than those musculoskeletal model, which is available in OpenSim library in post-op1 and post-op2. (Gait2354 model), was used in the gait simulations. The model Mean (±standard deviation) values of the kinematic gait had 23 degree-of-freedom, 10 body segments, and 54 muscle- parameters for the pelvis and hip, knee, and ankle joints are tendon actuators. To scale the inertial properties and dimen- given in Table 2. As similar as in the temporospatial parame- sions of the generic musculoskeletal models according to the ters, kinematic parameters measured in post-op3 were closer anthropometric properties of each patient, the scaling proce- to those measured in pre-op than those in post-op1 and dure was performed in OpenSim (version 3.3). Dimensions post-op2. All kinematic parameters, except RoM of pelvic tilt, of each segment of each patient’s model were scaled such that mean pelvic tilt, mean hip abduction and adduction, mean the distances between the virtual markers, which are placed hip extension, and peak knee extension, reduced in post-op1 on the unscaled musculoskeletal model, matched the distances when compared to pre-op parameters and increased while between the experimental markers. the recovery period remains. The RoM of pelvic tilt increased Static optimization (SO) was implemented for the calcula- ° ° ° from 4.07 to 5.29 during post-op1 and decreased to 3.67 at tionofindividual muscle forces.InSO, acostfunction,which is the end of post-op3. The RoM of hip flexion dropped from subjected to some physiologically based constraints, is opti- ° ° ° 40.04 to 11.8 in post-op1 and increased to 39.82 while the mized independently for each time point of interest [23, 24]. recovery duration remains. RoM of knee flexion decreased In the present study, SO was implemented by minimizing the ° ° from 53.40 to 26.48 in post-op1, and it began to increase in sum of the squares of all muscle activations subject to the post-op2 and reached to 54.69 in post-op3. The same pattern force-length and force-velocity properties of the muscles at can beobservedin peak kneeflexion aswell. Nevertheless, peak each instant of the gait cycle [25]. knee flexion at initial contact and midstance increased during post-op1 and reduced in post-op3. RoM of ankle dorsiflexion ° ° 2.5. Data Analysis. Since the grafting operation took place in dropped from 25.91 to 9.49 in post-op1 and then increased the right iliac crest, all temporospatial, kinematic, and muscle to 24.64 in post-op3. While peak ankle dorsiflexion showed force values were analyzed only for the right side of the body. a similar trend with RoM of ankle dorsiflexion, peak ankle To be able to quantitatively assess the recovery process of the plantarflexion increased in post-op1 and reduced in post-op3. patients, temporospatial, kinematic, and muscle force values Four kinematic gait parameters were taken into account were analyzed using different metrics and statistical methods. to determine if patients had a stiff knee gait pattern [26]. For temporospatial parameters, mean and standard deviation These parameters are (i) peak knee flexion angle, (ii) range of the data were calculated. Joint angles were examined using of knee flexion in early swing measured from toe-off to peak the mean and standard deviation of the peak value and range flexion, (iii) total range of knee motion, and (iv) timing of of motion (RoM) of the corresponding joint. Muscle forces of peak knee flexion in swing. If the value was more than two the GMED, GMAX, and ILIAC calculated from SO were eva- standard deviations below the average control value from luated using the root mean square difference (RMSD) and healthy subjects in the case of parameters i-iii, or more than the Pearson correlation coefficient (PCC), which were calcu- two standard deviations above the average control value in lated between the pre- and postoperative muscle forces. If the the case of parameter iv, it can be indicative of stiff knee gait. value of RMSD is 0.01, it implies a mean error between pre- A patient is considered to show stiff knee characteristics if and postoperative muscle force of 1%. PCC is a measure of three or more of these parameters were indicative of stiff knee theresemblancebetweentwocurves, andifPCCvaluebetween gait [26, 27]. In our case, all the patients met the inclusion 4 Applied Bionics and Biomechanics Table 1: Mean (±standard deviation) values of temporospatial gait parameters obtained during pre-op, post-op1, post-op2, and post-op3 periods. Temporospatial parameters Pre-op Post-op1 Post-op2 Post-op3 Statistical significance p-p ; p -p 1 1 2 790 ± 10 567 ± 25 760 ± 21 790 ± 14 Stance time (ms) p -p 1 3 p-p ; p -p 1 1 2 Stance time (% gait cycle) 58 ± 0653±1659±1359±0 9 p -p 1 3 p-p ; p -p 1 1 2 89 ± 2 5 113 ± 4794±3889±2 9 Cadence (step/min) p -p 1 3 p-p ; p-p Double support time (ms) 120 ± 10 150 ± 15 140 ± 13 160 ± 11 1 3 9±1 14±1211±1112±0 5 p-p Double support (% gait cycle) p-p ; p -p 1 1 2 Step length (mm) 536 ± 40 349 ± 46 612 ± 45 534 ± 43 p -p 1 3 p-p ; p -p 1 1 2 p -p ; p-p Stride length (mm) 1169 ± 15 651 ± 55 1217 ± 40 1082 ± 20 1 3 2 p -p 2 3 p-p ; p -p 1 1 2 141 ± 3 211 ± 12 156 ± 9 139 ± 5 Step width (mm) p -p 1 3 p-p ; p -p 1 1 2 Mean velocity (m/s) 0 87 ± 040 60 ± 0 24 0 96 ± 040 82 ± 0 5 p -p 1 3 p-p : statistical significance between pre-op and post-op1. p-p : statistical significance between pre-op and post-op2. p-p : statistical significance between pre-op 1 2 3 and post-op3. p -p : statistical significance between post-op1 and post-op2. p -p : statistical significance between post-op1 and post-op3. p -p : statistical 1 2 1 3 2 3 significance between post-op2 and post-op3. criteria for post-op1, and their gait characteristics can be clas- fracture of the ilium and damage to the acetabular fossa and sified as the stiff gait for the first week after surgery (Table 3). surrounding muscle attachments may lead to specific compli- Muscle force changes of the GMED, GMAX, and ILIAC cations [34]. Most of the surgeons believe that reduced soft over one stride are given in Figure 1. To validate the accuracy tissue trauma and avoidance of intraoperative complications of the sequence and timing of the calculated muscle forces, would diminish donor site morbidity and gait disturbance experimental electromyography (EMG) recorded during gait [34–36]. General complications and morbidity associated tasks from healthy subjects and reported in the literature was with anterior iliac crest bone grafting are well-documented used [28, 29]. It was observed that the timings of the muscle [34] but the gait disturbance is less certain. Sudhakar et al. force simulations and experimental EMG data were in good [19] stated that early recovery of gait disturbance is directly agreement (Figure 1). According to muscle force prediction related with the protection of the neighboring muscles, iliac results, postoperative muscle forces approached to the preop- spine, and tensor fascia lata from trauma. In addition to a trau- erative characteristics while the recovery process was matic surgery, effective pain management is highly related to progressing. Forces of all three muscles calculated during gait disturbance. Although some studies do not confirm, it is post-op3 showed the best match to the preoperative muscle generally accepted that the average recovery period for gait forces among the three postoperative periods. disturbance after iliac crest bone grafting varies between two The average RMSD and PCC values calculated between and four weeks [17–19, 36]. the pre- and postoperative muscle forces are given in In this study, we aimed to evaluate the gait functions of Figures 2 and 3, respectively. Muscle forces calculated in patients, who underwent iliac crest bone grafting in atrophic post-op3 showed the best agreement with those calculated jaw augmentation operation, in the early recovery course. By in pre-op than post-op1 and post-2 in terms of both magni- comparing the pre- and postoperative gait characteristics of tude (Figure 2) and correlation (Figure 3). the patients, we found that there were significant differences in the temporospatial and kinematic gait parameters and mus- cle forces between the pre- and postoperative periods, espe- 4. Discussion cially between pre-op and post-op1 periods. We observed Various types of bone grafts have been used for the recon- that remarkable progress was made in the improvement of struction of bone defects for more than a century, and anterior the locomotor function from the second week; however, iliac crest bone grafting is considered as the best option patients were able to reach their normal walking patterns from because of its functional and structural superiorities [30, 31]. the third week. In this study, although the stance time of one gait cycle Although anterior iliac crest bone grafting is considered a safe and relatively easy operation, complications of this reduced significantly from 58% to 53% from pre-op to surgical technique have been reported by many researchers post-op1, which may be attributed to the antalgic gait, no sig- [6, 13, 32, 33]. In addition to general surgical adversities, nificant reduction was seen between pre-op and post-op2 Applied Bionics and Biomechanics 5 Table 2: Mean (±standard deviation) values of kinematic gait parameters obtained during pre-op, post-op1, post-op2, and post-op3 periods. Kinematics parameters Pre-op (Deg) Post-op1 (Deg) Post-op2 (Deg) Post-op3 (Deg) Statistical significance Pelvis p-p ; p-p 1 3 4 67 ± 024 13 ± 035 03 ± 044 03 ± 0 2 RoM pelvic obliquity p -p ; p -p 1 2 2 3 RoM pelvic tilt 4 07 ± 015 29 ± 014 13 ± 013 67 ± 0 3 p-p ; p -p ;p -p 1 1 2 1 3 p-p ; p -p ;p -p Mean pelvic tilt 10 27 ± 0312 05 ± 0313 10 ± 0110 20 ± 0 3 2 1 3 2 3 p-p ; p-p 1 2 12 16 ± 026 92 ± 037 89 ± 0112 51 ± 0 3 RoM pelvic rotation p -p ; p -p 1 3 2 3 Hip -4 47 ± 0 1 -13 15 ± 0 1 -5 57 ± 0 2 -6 63 ± 0 1 p-p ; p -p ; p -p Mean hip abd/add 1 1 2 1 3 p-p ; p -p 1 1 2 -4 95 ± 0321 46 ± 0 2 -5 78 ± 0 1 -9 04 ± 0 2 Peak hip ext p -p 1 3 p-p Peak hip flex 35 08 ± 0333 26 ± 0233 29 ± 0330 78 ± 0 1 p-p ; p -p ; p -p RoM hip flex/ext 40 04 ± 0211 8±0239 07 ± 0339 82 ± 0 1 1 1 2 1 3 p-p ; p-p 1 2 11 01 ± 019 42 ± 0113 22 ± 059 97 ± 0 2 RoM hip rotation p -p ; p -p 1 2 2 3 Knee 53 40 ± 0426 48 ± 0352 06 ± 0354 69 ± 0 4 p-p ; p -p ; p -p RoM knee flex/ext 1 1 2 1 3 p-p ; p-p 1 3 12 36 ± 0218 77 ± 0110 72 ± 026 58 ± 0 4 Peak knee flex/ext at initial contact p -p ; p -p 1 3 1 2 p-p ; p-p 1 2 7 49 ± 0121 69 ± 022 89 ± 012 95 ± 0 1 Peak knee ext at midstance p-p ; p -p ; p -p 3 1 2 1 3 60 89 ± 0348 17 ± 0454 95 ± 0457 64 ± 0 3 p-p ; p -p Peak knee flex 1 1 3 Ankle 25 91 ± 039 49 ± 0122 13 ± 0424 64 ± 0 3 p-p ; p -p ; p -p RoM ankle dorsi/plantar flex 1 1 2 1 3 10 89 ± 0210 06 ± 0310 90 ± 0213 47 ± 0 2 p-p ; p -p ; p -p Peak ankle dorsi flex 3 1 3 2 3 -15 01 ± 020 57 ± 0 1 -11 24 ± 0 2 -11 18 ± 0 2 p-p ; p -p ; p -p Peak ankle plantar flex 1 1 2 1 3 p-p : statistical significance between pre-op and post-op1. p-p : statistical significance between pre-op and post-op2. p-p : statistical significance between pre-op 1 2 3 and post-op3. p -p : statistical significance between post-op1 and post-op2. p -p : statistical significance between post-op1 and post-op3. p -p : statistical 1 2 1 3 2 3 significance between post-op2 and post-op3. RoM: range of motion; abd: abduction; add: adduction; ext: extension; flex: flexion. Table 3: Four gait parameters as measures of whether a patient had a stiff knee gait pattern. Pre-op Post-op1 Post-op2 Post-op3 Peak knee flexion angle (Deg) 60.89 48.17 54.95 57.64 Range of knee flexion in early swing measured from toe-off to peak flexion (Deg) 28.91 7.33 31.57 38.52 Total range of knee motion (Deg) 53.4 26.48 52.06 54.69 Timing of peak knee flexion in swing % 12 % 9 % 15 % 13 Standard deviations are 4.1, 5.23, 3.8, and 2.10 for (i) peak knee flexion angle, (ii) range of knee flexion in early swing measured from toe-off to peak flexion, (iii) total range of knee motion, and (iv) timing of peak knee flexion in swing, respectively. and post-op3 (59%±1 3, 59%±0 9, respectively). RoM of the did not start from the second week after surgery but from the hip, knee, and ankle joints in the sagittal plane obtained for third week (Figures 2 and 3). Furthermore, we found a statis- pre-op, post-op2, and post-op3 are so close to each other. tical difference between the mean pelvic tilt angles and RoMs Both these findings implied that preoperative gait kinematics of pelvic rotation for post-op2 and post-op3 periods, which was recovered from the second week. On the other hand, we also pointed out that pelvis kinematics returned to its preop- have found that the forces of all three muscles calculated dur- erative characteristics from the third week of the surgery. ing post-op3 showed the best match to the preoperative mus- We have noticed that patients showed stiff knee gait char- cle forces among the three postoperative periods (there was a acteristics within the first week after surgery but not in the statistical difference between the muscle forces calculated for second and third weeks following the surgery (Table 3). post-op2 and post-op3), indicating that full muscle recovery However, the observed stiff knee pattern may be the result 6 Applied Bionics and Biomechanics GMED GMAX 0 50 100 0 50 100 Stride cycle (%) Stride cycle (%) (a) (b) ILIAC 0 50 100 Stride cycle (%) (c) Figure 1: Comparison of the muscle forces computed from static optimization for pre- and postoperative periods (a) GMED, (b) GMAX, and (c) ILIAC muscles. The horizontal solid bars indicate the periods of experimental EMG activity obtained from the literature [28, 29]. Solid bold line: pre-op; solid thin line: post-op1; thin dashed line: post-op2; bold dashed line: post-op3. ⁎ + 0.05 0.05 # 0.68 0.65 0.05 0.45 0.04 0.4 0.08 0.37 0.03 0.24 0.03 0.02 0.18 0.02 0.16 0.13 Post-op1 Post-op1 Post-op1 Post-op2 Post-op3 Post-op2 Post-op3 Post-op2 Post-op3 GMED GMAX ILIAC Figure 2: Mean (±standard deviation) root mean square difference (RMSD) values between the pre- and three postoperative muscle forces. , +, # denote the statistical significance among intragroup comparisons. of reduced mean gait velocity which dropped from 0.87 m/s into account in the study were predictions that are not exper- to 0.60 m/s from pre-op to post-op1. Also, we qualitatively imentally obtained actual forces. Due to the ethical concerns, observed antalgic gait in the patients during the post-op1 gait it is nearly impossible to obtain directly measured forces tasks, which may be attributed to the occurrence of the stiff from intact muscles of the human body [39]. Computational approaches such as OpenSim or AnyBody seem to be the knee gait patterns in post-op1 [37, 38]. There are a number of limitations that should be consid- most practical and acceptable alternatives to calculate muscle ered when interpreting the results. First, muscle forces taken forces [22, 40]. Second, although we implemented the scaling Average RMSD between pre- and postoperative muscle forces Force (N) Force (N) Force (N) Applied Bionics and Biomechanics 7 ⁎ # 0.01 0.01 0.02 0.02 0.02 0.99 0.98 0.97 0.97 0.96 0.05 0.04 0.89 0.87 0.06 0.79 0.07 0.71 Post-op1 Post-op2 Post-op3 Post-op1 Post-op2 Post-op3 Post-op1 Post-op2 Post-op3 GMED GMAX ILIAC Figure 3: Mean (±standard deviation) Pearson correlation coefficient (PCC) values between the pre- and three postoperative muscle forces. , +, # denote the statistical significance among intragroup comparisons. procedure to account for the different anthropometry of the Conflicts of Interest patients in the musculoskeletal models, the scaling may not The authors declare that there are no conflicts of interest precisely reflect all of the anatomical and morphological dif- regarding the publication of this paper. ferences present. EMG is commonly used to test the validity of model-predicted muscle forces in terms of the sequence and timing of muscle activity [41]. Since the ILIAC muscle Acknowledgments is located in the deepest region of the trunk, the electrical activity of the ILIAC seems unmeasurable with surface This research was supported by the Istanbul University EMG [42]. Furthermore, since the patients were reluctant Scientific Research Projects, project number Normal 27087. to enable us to record EMG signals from the GMAX and GMED muscles due to privacy, we could not record EMG signals in our study, which can be considered as another References limitation. Therefore, predicted muscle forces should be interpreted with caution. [1] M. B. Harris, J. Davis, and S. D. Gertzbein, “Iliac crest recon- struction after tricortical graft harvesting,” Journal of Spinal Disorders, vol. 7, no. 3, pp. 216–221, 1994. 5. Conclusions [2] P. A. Robertson and A. C. 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Gait Analysis of Patients Subjected to the Atrophic Mandible Augmentation with Iliac Bone Graft

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Hindawi Publishing Corporation
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Copyright © 2019 Erol Cansiz et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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1754-2103
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10.1155/2019/8203597
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Hindawi Applied Bionics and Biomechanics Volume 2019, Article ID 8203597, 9 pages https://doi.org/10.1155/2019/8203597 Research Article Gait Analysis of Patients Subjected to the Atrophic Mandible Augmentation with Iliac Bone Graft 1 2 2 3 Erol Cansiz , Derya Karabulut, Suzan Cansel Dogru , Nazif Ekin Akalan, 4 2 Yener Temelli, and Yunus Ziya Arslan Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Istanbul University, Istanbul, Turkey Faculty of Engineering, Department of Mechanical Engineering, Istanbul University-Cerrahpasa, Istanbul, Turkey Faculty of Health Science, Physiotherapy and Rehabilitation Division, Istanbul Kultur University, Istanbul, Turkey Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul University, Istanbul, Turkey Correspondence should be addressed to Yunus Ziya Arslan; yzarslan@istanbul.edu.tr Received 1 November 2018; Revised 11 January 2019; Accepted 29 January 2019; Published 3 March 2019 Academic Editor: Andrea Cereatti Copyright © 2019 Erol Cansiz et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In this study, we aimed to quantitatively monitor and describe the gait functions of patients, who underwent iliac crest bone grafting in atrophic jaw augmentation operation, by taking into account the alterations of gait parameters and muscle forces in the early recovery course. To do so, temporospatial and kinematic gait parameters of ten patients during pre- and postoperative periods were recorded, and forces of the gluteus medius, gluteus maximus, and iliacus muscles were calculated. Three postoperative periods were specified as one week (post-op1), two weeks (post-op2), and three weeks (post-op3) after the surgery. Restoring process of the gait patterns was comparatively evaluated by analyzing the gait parameters and muscle forces for pre- and postoperative periods. Temporospatial and kinematic parameters of post-op3 were closer to those obtained in pre-op than those in post-op1 and post-op2 (p <0 05). Muscle forces calculated in post-op3 showed the best agreement with those in pre-op among the postoperative periods in terms of both magnitude and correlation (p <0 05). In conclusion, the patients began to regain their preoperative gait characteristics from the second week after surgery, but complete recovery in gait was observed three weeks after the surgery. 1. Introduction Althoughtheanterioriliaccrestboneisaconvenientdonor site for the atrophic mandible augmentation technique, various complications associated with the donor site like Bone grafting or bone harvesting is a procedure to augment deficient bone tissue and is widely used in a number of oral chronic pain, contour defect, ureteral injury, sensory loss, and maxillofacial procedures such as reconstructive surgical and unbalance of the sacroiliac joint have been reported [5, 6, interventions [1–4]. Functional and structurally sound bone 12, 13]. Due to the operation-caused trauma that occurred in volume is essential for the reconstruction of alveolar defects. neighboring anatomical structures especially in muscle-bone For this reason, the iliac crest, calvarium, tibia, fibula, and connection sites, gait abnormalities are observed in the posto- ribs have been used as extraoral donor sites for bone aug- perative periods [14]. mentation procedures in the field of oral and maxillofacial Restoration of severe atrophic mandible for the reha- surgery [5, 6]. However, the iliac crest is regarded as a gold bilitation of patients with dental implant-aided fixed pros- standard on this specific field among other free bone graft thodontics must be three-dimensional. The high-volume donor sites [7–9]. Due to its high bone volume, relative ease donor site is required for the restoration of the atrophic of operation, and low morbidity and complication preva- mandible. The reconstruction of severe alveolar defects or lence, the iliac crest is the most preferred and well-known hypertrophic jaw bones mostly requires tricortical structure donor site in such operations [10, 11]. of 6×5 cm average graft size for augmentation [15, 16]. 2 Applied Bionics and Biomechanics (iv) Having no cognitive deficiency which may prevent At this point, the gluteus medius (GMED), gluteus maximus (GMAX), and iliacus (ILIAC) muscles must be understanding and performing of the study protocol individually separated from the muscle-bone connection The exclusion criterion was the presence of any systematic surface to harvest sufficient bone graft, which leads to the gait disease that may affect the soft and hard tissue healing. The abnormalities. Since there are many factors affecting the study protocol followed the Declaration of Helsinki and was recovery process, it is difficult to identify the healing approved by the ethical committee of Istanbul University, process exactly. Istanbul, Turkey (approval protocol no. 2016/7). Written Many researchers reported the gait disturbance caused by informed consent was obtained from all the patients. iliac crest bone grafting operations. Matsa et al. [17] reported that 28% of their study group suffered from gait disturbance 2.2. Surgical Intervention. All of the patients were operated at in the first four weeks following surgery, and all of the the Istanbul University, Faculty of Dentistry, Department of patients returned to their normal gait characteristics after Oral and Maxillofacial Surgery. A standardized surgical pro- three months of the healing period. On the other hand, tocol to harvest approximately 6cm × 3cm × 2cm tricortical Beirne et al. [18] and Sudhakar et al. [19] reported that most free bone graft from the right anterior iliac crest was per- of their patients who had undergone iliac crest bone grafting formed by the same surgeon under general anesthesia. The regained their preoperative gait characteristics within two skin incision and dissection were performed 2 cm above the weeks following surgery. Beirne et al. [18] and Sudhakar anterior superior iliac spine along the anterior superior mar- et al. [19] stated that only 6% and 2% of the patients suffered gin of the anterior iliac crest to preserve the lateral femoral from gait disturbance more than two weeks after bone graft- cutaneous nerve. After the dissection of the skin and the ing operation, respectively. Rawashdeh [20] reported that underlying soft tissues, the superior surface of the iliac crest none of their patients had gait disturbance after two weeks. was exposed. Then the GMED, GMAX, and ILIAC muscle None of the studies in the literature investigated the postop- attachmentscoveringthemedialandlateralsurfacesoftheiliac erative gait deficiency from objective and quantitative per- crestweredissectedsubperiosteallytoexposethebonesurfaces. spectives, and no consensus has been reached on the gait After the completion of the dissection process, a tricortical pattern in the early recovery period following the iliac crest autogenous bone block was harvested by using a microsaw bone harvesting. and a chisel osteotomy. Then, the sharp and rough contours In this respect, we aimed to quantitatively evaluate the were smoothed, and mini-wac drains were placed to the donor gait functions of the patients, who underwent atrophic jaw site to control postoperative edema. Finally, the three-layered augmentation operation in which the iliac crest was used closure including the periosteum, muscles, and skin was per- as donor site for the augmentation procedure, in the early formed to obtain primer closure of the wound. 1/0 resorbable recovery period. Our purpose was also to describe the polyglactin 910 sutures (Vicryl, Ethicon, Somerville, NJ, USA) biomechanical alterations of the patients by taking into wereusedfortheclosureoftheperiosteum.Muscleattachments account temporospatial and kinematic gait parameters as and subcutaneous soft tissue layers were closed by using 3/0 well as forces of the GMED, GMAX, and ILIAC muscles. resorbablepolyglactin910sutures(Vicryl,Ethicon,Somerville, We hypothesized that the changes in the gait patterns NJ, USA), and the skin incision was sutured with 3/0 nonresor- and muscle forces would quantify the progress of the gait bablepolypropylenesutures(Prolen;DogsanMedicalSupplies recovery process. Industry, Trabzon, Turkey). Patients were hospitalized for 1 day to control early postoperative complications, and postsur- gicalmedicationsincludingantibiotics,analgesics,andcortico- 2. Materials and Methods steroids were prescribed. The patients were administered antibiotics for 7 days starting on the day of the operation 2.1. Patients. This prospective study included ten systemically (1,000 mg of amoxicillin and clavulanic acid twice daily or healthy adult patients (five males and five females, aged 43 ± 600 mg of clindamycin for the patients who have penicillin 10 4 years old, height 169 ± 10 cm, mass 71 2±19 6 kg), who allergy twice a day) and analgesics (600 mg ibuprofen every 6 underwent onlay free bone grafting with anterior iliac crest hours for thefirst day and, if needed, for other days). As a corti- for the rehabilitation of severe maxillary alveolar atrophy costeroid, dexamethasone (8 mg daily) was administered for 2 between April 2016 and April 2017 at the Istanbul University daystocontrolthepostoperativeedema.Adayafterthesurgery, Faculty of Dentistry, Department of Oral and Maxillofacial mini-wac drains were removed and the patients were dis- Surgery, Istanbul, Turkey. charged withdetailedwrittenpostoperativeinstructions.Non- The inclusion criteria for the patients were as follows: resorbablesutures used for the skin closure were removed 10 to (i) Requirement to anterior iliac crest bone grafting for 12daysafterthesurgeryandthehealingperiodwasuneventful. maxillary alveolar bone reconstruction due to severe alveolar bone atrophy 2.3. Gait Experiments. Temporospatial and kinematic (lower limb joint angles) gait data were collected from the patients at (ii) Having no tumor or trauma in the lower limbs the Istanbul University, Faculty of Medicine, Motion Analy- or ilium sis Laboratory. Each patient was asked to walk as a natural (iii) Having no any other neural or muscular disorder way at a self-selected speed during pre- and postoperative periods in the laboratory. Three postoperative periods were which may merge with gait disturbance Applied Bionics and Biomechanics 3 two curves is 1, it means that pre- and postoperative muscle specified as one week (post-op1), two weeks (post-op2), and three weeks (post-op3) after the surgery. forces show a perfect agreement. Reflective passive markers were mounted on the specific Statistical significance analysis was carried out by using SPSS software (Version 21.0; SPSS; Chicago, IL, USA). The anatomic regions of the patients as described by Davis et al. [21], and three-dimensional position data of the markers level of significance was set at 0.05. Shapiro-Wilk test was were recorded by using six optical cameras (ELITE2002; performed to test the normalization of the data. All parame- BTS, Milan, Italy) of which sampling rate was 100 Hz. A ters were statistically analyzed using the one-way repeated- second-order Butterworth low-pass filter (6 Hz) was applied measure ANOVA. Bonferroni post hoc test was implemented to determine the significant difference between paired to smooth the marker trajectories. Joint angles were calcu- lated from the marker data by means of the inverse kinematic groups, if any. The differences between paired groups were evaluated at a level of significance of 0.012 (p <0 technique. The ground reaction force was also measured 012). simultaneously using two force plates (Kistler, Switzerland). Three gait trials were collected for each patient and ave- 3. Results rages of the temporospatial, kinematic, and muscle force data were calculated. Mean (±standard deviation) values of the pre- and postope- rative temporospatial gait parameters are given in Table 1. It can be deduced from the table that stance time, step length, 2.4. Muscle Force Calculation. Forces of the GMED, GMAX, stride length, and mean velocity significantly decreased and ILIAC muscles were calculated by using OpenSim, a during post-op1 and continued to increase during post-op1 musculoskeletal modeling and simulation program allowing and post-op2 when compared to pre-op parameters. All the calculation of the human muscle forces using inverse temporospatial parameters, except double support time, dynamics and forward dynamics methods [22]. The human measured in post-op3 are closer to those in pre-op than those musculoskeletal model, which is available in OpenSim library in post-op1 and post-op2. (Gait2354 model), was used in the gait simulations. The model Mean (±standard deviation) values of the kinematic gait had 23 degree-of-freedom, 10 body segments, and 54 muscle- parameters for the pelvis and hip, knee, and ankle joints are tendon actuators. To scale the inertial properties and dimen- given in Table 2. As similar as in the temporospatial parame- sions of the generic musculoskeletal models according to the ters, kinematic parameters measured in post-op3 were closer anthropometric properties of each patient, the scaling proce- to those measured in pre-op than those in post-op1 and dure was performed in OpenSim (version 3.3). Dimensions post-op2. All kinematic parameters, except RoM of pelvic tilt, of each segment of each patient’s model were scaled such that mean pelvic tilt, mean hip abduction and adduction, mean the distances between the virtual markers, which are placed hip extension, and peak knee extension, reduced in post-op1 on the unscaled musculoskeletal model, matched the distances when compared to pre-op parameters and increased while between the experimental markers. the recovery period remains. The RoM of pelvic tilt increased Static optimization (SO) was implemented for the calcula- ° ° ° from 4.07 to 5.29 during post-op1 and decreased to 3.67 at tionofindividual muscle forces.InSO, acostfunction,which is the end of post-op3. The RoM of hip flexion dropped from subjected to some physiologically based constraints, is opti- ° ° ° 40.04 to 11.8 in post-op1 and increased to 39.82 while the mized independently for each time point of interest [23, 24]. recovery duration remains. RoM of knee flexion decreased In the present study, SO was implemented by minimizing the ° ° from 53.40 to 26.48 in post-op1, and it began to increase in sum of the squares of all muscle activations subject to the post-op2 and reached to 54.69 in post-op3. The same pattern force-length and force-velocity properties of the muscles at can beobservedin peak kneeflexion aswell. Nevertheless, peak each instant of the gait cycle [25]. knee flexion at initial contact and midstance increased during post-op1 and reduced in post-op3. RoM of ankle dorsiflexion ° ° 2.5. Data Analysis. Since the grafting operation took place in dropped from 25.91 to 9.49 in post-op1 and then increased the right iliac crest, all temporospatial, kinematic, and muscle to 24.64 in post-op3. While peak ankle dorsiflexion showed force values were analyzed only for the right side of the body. a similar trend with RoM of ankle dorsiflexion, peak ankle To be able to quantitatively assess the recovery process of the plantarflexion increased in post-op1 and reduced in post-op3. patients, temporospatial, kinematic, and muscle force values Four kinematic gait parameters were taken into account were analyzed using different metrics and statistical methods. to determine if patients had a stiff knee gait pattern [26]. For temporospatial parameters, mean and standard deviation These parameters are (i) peak knee flexion angle, (ii) range of the data were calculated. Joint angles were examined using of knee flexion in early swing measured from toe-off to peak the mean and standard deviation of the peak value and range flexion, (iii) total range of knee motion, and (iv) timing of of motion (RoM) of the corresponding joint. Muscle forces of peak knee flexion in swing. If the value was more than two the GMED, GMAX, and ILIAC calculated from SO were eva- standard deviations below the average control value from luated using the root mean square difference (RMSD) and healthy subjects in the case of parameters i-iii, or more than the Pearson correlation coefficient (PCC), which were calcu- two standard deviations above the average control value in lated between the pre- and postoperative muscle forces. If the the case of parameter iv, it can be indicative of stiff knee gait. value of RMSD is 0.01, it implies a mean error between pre- A patient is considered to show stiff knee characteristics if and postoperative muscle force of 1%. PCC is a measure of three or more of these parameters were indicative of stiff knee theresemblancebetweentwocurves, andifPCCvaluebetween gait [26, 27]. In our case, all the patients met the inclusion 4 Applied Bionics and Biomechanics Table 1: Mean (±standard deviation) values of temporospatial gait parameters obtained during pre-op, post-op1, post-op2, and post-op3 periods. Temporospatial parameters Pre-op Post-op1 Post-op2 Post-op3 Statistical significance p-p ; p -p 1 1 2 790 ± 10 567 ± 25 760 ± 21 790 ± 14 Stance time (ms) p -p 1 3 p-p ; p -p 1 1 2 Stance time (% gait cycle) 58 ± 0653±1659±1359±0 9 p -p 1 3 p-p ; p -p 1 1 2 89 ± 2 5 113 ± 4794±3889±2 9 Cadence (step/min) p -p 1 3 p-p ; p-p Double support time (ms) 120 ± 10 150 ± 15 140 ± 13 160 ± 11 1 3 9±1 14±1211±1112±0 5 p-p Double support (% gait cycle) p-p ; p -p 1 1 2 Step length (mm) 536 ± 40 349 ± 46 612 ± 45 534 ± 43 p -p 1 3 p-p ; p -p 1 1 2 p -p ; p-p Stride length (mm) 1169 ± 15 651 ± 55 1217 ± 40 1082 ± 20 1 3 2 p -p 2 3 p-p ; p -p 1 1 2 141 ± 3 211 ± 12 156 ± 9 139 ± 5 Step width (mm) p -p 1 3 p-p ; p -p 1 1 2 Mean velocity (m/s) 0 87 ± 040 60 ± 0 24 0 96 ± 040 82 ± 0 5 p -p 1 3 p-p : statistical significance between pre-op and post-op1. p-p : statistical significance between pre-op and post-op2. p-p : statistical significance between pre-op 1 2 3 and post-op3. p -p : statistical significance between post-op1 and post-op2. p -p : statistical significance between post-op1 and post-op3. p -p : statistical 1 2 1 3 2 3 significance between post-op2 and post-op3. criteria for post-op1, and their gait characteristics can be clas- fracture of the ilium and damage to the acetabular fossa and sified as the stiff gait for the first week after surgery (Table 3). surrounding muscle attachments may lead to specific compli- Muscle force changes of the GMED, GMAX, and ILIAC cations [34]. Most of the surgeons believe that reduced soft over one stride are given in Figure 1. To validate the accuracy tissue trauma and avoidance of intraoperative complications of the sequence and timing of the calculated muscle forces, would diminish donor site morbidity and gait disturbance experimental electromyography (EMG) recorded during gait [34–36]. General complications and morbidity associated tasks from healthy subjects and reported in the literature was with anterior iliac crest bone grafting are well-documented used [28, 29]. It was observed that the timings of the muscle [34] but the gait disturbance is less certain. Sudhakar et al. force simulations and experimental EMG data were in good [19] stated that early recovery of gait disturbance is directly agreement (Figure 1). According to muscle force prediction related with the protection of the neighboring muscles, iliac results, postoperative muscle forces approached to the preop- spine, and tensor fascia lata from trauma. In addition to a trau- erative characteristics while the recovery process was matic surgery, effective pain management is highly related to progressing. Forces of all three muscles calculated during gait disturbance. Although some studies do not confirm, it is post-op3 showed the best match to the preoperative muscle generally accepted that the average recovery period for gait forces among the three postoperative periods. disturbance after iliac crest bone grafting varies between two The average RMSD and PCC values calculated between and four weeks [17–19, 36]. the pre- and postoperative muscle forces are given in In this study, we aimed to evaluate the gait functions of Figures 2 and 3, respectively. Muscle forces calculated in patients, who underwent iliac crest bone grafting in atrophic post-op3 showed the best agreement with those calculated jaw augmentation operation, in the early recovery course. By in pre-op than post-op1 and post-2 in terms of both magni- comparing the pre- and postoperative gait characteristics of tude (Figure 2) and correlation (Figure 3). the patients, we found that there were significant differences in the temporospatial and kinematic gait parameters and mus- cle forces between the pre- and postoperative periods, espe- 4. Discussion cially between pre-op and post-op1 periods. We observed Various types of bone grafts have been used for the recon- that remarkable progress was made in the improvement of struction of bone defects for more than a century, and anterior the locomotor function from the second week; however, iliac crest bone grafting is considered as the best option patients were able to reach their normal walking patterns from because of its functional and structural superiorities [30, 31]. the third week. In this study, although the stance time of one gait cycle Although anterior iliac crest bone grafting is considered a safe and relatively easy operation, complications of this reduced significantly from 58% to 53% from pre-op to surgical technique have been reported by many researchers post-op1, which may be attributed to the antalgic gait, no sig- [6, 13, 32, 33]. In addition to general surgical adversities, nificant reduction was seen between pre-op and post-op2 Applied Bionics and Biomechanics 5 Table 2: Mean (±standard deviation) values of kinematic gait parameters obtained during pre-op, post-op1, post-op2, and post-op3 periods. Kinematics parameters Pre-op (Deg) Post-op1 (Deg) Post-op2 (Deg) Post-op3 (Deg) Statistical significance Pelvis p-p ; p-p 1 3 4 67 ± 024 13 ± 035 03 ± 044 03 ± 0 2 RoM pelvic obliquity p -p ; p -p 1 2 2 3 RoM pelvic tilt 4 07 ± 015 29 ± 014 13 ± 013 67 ± 0 3 p-p ; p -p ;p -p 1 1 2 1 3 p-p ; p -p ;p -p Mean pelvic tilt 10 27 ± 0312 05 ± 0313 10 ± 0110 20 ± 0 3 2 1 3 2 3 p-p ; p-p 1 2 12 16 ± 026 92 ± 037 89 ± 0112 51 ± 0 3 RoM pelvic rotation p -p ; p -p 1 3 2 3 Hip -4 47 ± 0 1 -13 15 ± 0 1 -5 57 ± 0 2 -6 63 ± 0 1 p-p ; p -p ; p -p Mean hip abd/add 1 1 2 1 3 p-p ; p -p 1 1 2 -4 95 ± 0321 46 ± 0 2 -5 78 ± 0 1 -9 04 ± 0 2 Peak hip ext p -p 1 3 p-p Peak hip flex 35 08 ± 0333 26 ± 0233 29 ± 0330 78 ± 0 1 p-p ; p -p ; p -p RoM hip flex/ext 40 04 ± 0211 8±0239 07 ± 0339 82 ± 0 1 1 1 2 1 3 p-p ; p-p 1 2 11 01 ± 019 42 ± 0113 22 ± 059 97 ± 0 2 RoM hip rotation p -p ; p -p 1 2 2 3 Knee 53 40 ± 0426 48 ± 0352 06 ± 0354 69 ± 0 4 p-p ; p -p ; p -p RoM knee flex/ext 1 1 2 1 3 p-p ; p-p 1 3 12 36 ± 0218 77 ± 0110 72 ± 026 58 ± 0 4 Peak knee flex/ext at initial contact p -p ; p -p 1 3 1 2 p-p ; p-p 1 2 7 49 ± 0121 69 ± 022 89 ± 012 95 ± 0 1 Peak knee ext at midstance p-p ; p -p ; p -p 3 1 2 1 3 60 89 ± 0348 17 ± 0454 95 ± 0457 64 ± 0 3 p-p ; p -p Peak knee flex 1 1 3 Ankle 25 91 ± 039 49 ± 0122 13 ± 0424 64 ± 0 3 p-p ; p -p ; p -p RoM ankle dorsi/plantar flex 1 1 2 1 3 10 89 ± 0210 06 ± 0310 90 ± 0213 47 ± 0 2 p-p ; p -p ; p -p Peak ankle dorsi flex 3 1 3 2 3 -15 01 ± 020 57 ± 0 1 -11 24 ± 0 2 -11 18 ± 0 2 p-p ; p -p ; p -p Peak ankle plantar flex 1 1 2 1 3 p-p : statistical significance between pre-op and post-op1. p-p : statistical significance between pre-op and post-op2. p-p : statistical significance between pre-op 1 2 3 and post-op3. p -p : statistical significance between post-op1 and post-op2. p -p : statistical significance between post-op1 and post-op3. p -p : statistical 1 2 1 3 2 3 significance between post-op2 and post-op3. RoM: range of motion; abd: abduction; add: adduction; ext: extension; flex: flexion. Table 3: Four gait parameters as measures of whether a patient had a stiff knee gait pattern. Pre-op Post-op1 Post-op2 Post-op3 Peak knee flexion angle (Deg) 60.89 48.17 54.95 57.64 Range of knee flexion in early swing measured from toe-off to peak flexion (Deg) 28.91 7.33 31.57 38.52 Total range of knee motion (Deg) 53.4 26.48 52.06 54.69 Timing of peak knee flexion in swing % 12 % 9 % 15 % 13 Standard deviations are 4.1, 5.23, 3.8, and 2.10 for (i) peak knee flexion angle, (ii) range of knee flexion in early swing measured from toe-off to peak flexion, (iii) total range of knee motion, and (iv) timing of peak knee flexion in swing, respectively. and post-op3 (59%±1 3, 59%±0 9, respectively). RoM of the did not start from the second week after surgery but from the hip, knee, and ankle joints in the sagittal plane obtained for third week (Figures 2 and 3). Furthermore, we found a statis- pre-op, post-op2, and post-op3 are so close to each other. tical difference between the mean pelvic tilt angles and RoMs Both these findings implied that preoperative gait kinematics of pelvic rotation for post-op2 and post-op3 periods, which was recovered from the second week. On the other hand, we also pointed out that pelvis kinematics returned to its preop- have found that the forces of all three muscles calculated dur- erative characteristics from the third week of the surgery. ing post-op3 showed the best match to the preoperative mus- We have noticed that patients showed stiff knee gait char- cle forces among the three postoperative periods (there was a acteristics within the first week after surgery but not in the statistical difference between the muscle forces calculated for second and third weeks following the surgery (Table 3). post-op2 and post-op3), indicating that full muscle recovery However, the observed stiff knee pattern may be the result 6 Applied Bionics and Biomechanics GMED GMAX 0 50 100 0 50 100 Stride cycle (%) Stride cycle (%) (a) (b) ILIAC 0 50 100 Stride cycle (%) (c) Figure 1: Comparison of the muscle forces computed from static optimization for pre- and postoperative periods (a) GMED, (b) GMAX, and (c) ILIAC muscles. The horizontal solid bars indicate the periods of experimental EMG activity obtained from the literature [28, 29]. Solid bold line: pre-op; solid thin line: post-op1; thin dashed line: post-op2; bold dashed line: post-op3. ⁎ + 0.05 0.05 # 0.68 0.65 0.05 0.45 0.04 0.4 0.08 0.37 0.03 0.24 0.03 0.02 0.18 0.02 0.16 0.13 Post-op1 Post-op1 Post-op1 Post-op2 Post-op3 Post-op2 Post-op3 Post-op2 Post-op3 GMED GMAX ILIAC Figure 2: Mean (±standard deviation) root mean square difference (RMSD) values between the pre- and three postoperative muscle forces. , +, # denote the statistical significance among intragroup comparisons. of reduced mean gait velocity which dropped from 0.87 m/s into account in the study were predictions that are not exper- to 0.60 m/s from pre-op to post-op1. Also, we qualitatively imentally obtained actual forces. Due to the ethical concerns, observed antalgic gait in the patients during the post-op1 gait it is nearly impossible to obtain directly measured forces tasks, which may be attributed to the occurrence of the stiff from intact muscles of the human body [39]. Computational approaches such as OpenSim or AnyBody seem to be the knee gait patterns in post-op1 [37, 38]. There are a number of limitations that should be consid- most practical and acceptable alternatives to calculate muscle ered when interpreting the results. First, muscle forces taken forces [22, 40]. Second, although we implemented the scaling Average RMSD between pre- and postoperative muscle forces Force (N) Force (N) Force (N) Applied Bionics and Biomechanics 7 ⁎ # 0.01 0.01 0.02 0.02 0.02 0.99 0.98 0.97 0.97 0.96 0.05 0.04 0.89 0.87 0.06 0.79 0.07 0.71 Post-op1 Post-op2 Post-op3 Post-op1 Post-op2 Post-op3 Post-op1 Post-op2 Post-op3 GMED GMAX ILIAC Figure 3: Mean (±standard deviation) Pearson correlation coefficient (PCC) values between the pre- and three postoperative muscle forces. , +, # denote the statistical significance among intragroup comparisons. procedure to account for the different anthropometry of the Conflicts of Interest patients in the musculoskeletal models, the scaling may not The authors declare that there are no conflicts of interest precisely reflect all of the anatomical and morphological dif- regarding the publication of this paper. ferences present. 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