Quantifying clinical misinterpretations associated to one-segment kinetic foot modelling in both a healthy and patient population

doi:10.1016/j.clinbiomech.2019.05.005

Clinical Biomechanics

Volume 67, July 2019, Pages 160-165

https://doi.org/10.1016/j.clinbiomech.2019.05.005 Get rights and content

Highlights

•
One-segment foot models overestimate ankle joint kinetics in pathological gait.
•
Overestimating ankle joint kinetics leads to clinically relevant misinterpretations.
•
Clinical motion analysis requires multi-segment foot modelling.

Abstract

Background

Rigid foot modelling approaches are still widely used to assess ankle joint kinetics in clinical biomechanical research. Yet, studies on healthy subjects using multi-segment kinetic foot models indicated that one-segment kinetic foot models tend to overestimate ankle joint kinetic data. Our aim was to compare ankle joint kinetics computed with a one-segment versus a multi-segment kinetic foot model in both asymptomatic and pathological gait. We also assessed whether differences between models can lead to different interpretations in clinical decision-making.

Methods

A two-factor repeated measure analysis of variance was performed to investigate differences in ankle joint kinetics, with the first factor being group effect (control vs. patients) and second factor being foot model effect (one-segment vs. multi-segment). Minimal detectable change was calculated to assess the clinical relevance of the observed differences in ankle joint kinetics.

Findings

Ankle joint peak kinematic, angular velocity and kinetic variables were all significantly overestimated (P < 0.05) when computed with the one-segment kinetic foot model. Kinetic differences in peak plantarflexion angular velocity and peak power generation were higher than their MDC-values.

Interpretation

Ankle joint kinetics are significantly overestimated when computed with a rigid foot modelling approach in both asymptomatic and pathological gait. This overestimation leads to clinical misinterpretations as MDC-values were less than the observed overestimation. In future studies, it is of clinical relevance to assess ankle joint kinetics with a multi-segment foot modelling approach.

Introduction

Multi-segment foot modelling gained increasing interest in clinical motion analysis since it has the potential to better describe the complex movements in the foot and ankle (Deschamps et al., 2011), in comparison to the earlier rigid or one-segment foot model (Kadaba et al., 1990). This also led to the development of multi-segment kinetic foot models that have the ability to further explore the complex functioning of foot and ankle (Bruening et al., 2012; Deschamps et al., 2017; Saraswat et al., 2014). The importance of multi-segment foot modelling is established in kinematic and kinetic studies by demonstrating the shortcomings of the one-segment foot model. For example, a study revealed that one-and multi-segment kinematic foot models lead to opposite results on ankle joint kinematics (Pothrat et al., 2015). In terms of kinetics, the one-segment foot model tends to overestimate the ankle joint power generation in the push-off phase of stance in comparison to multi-segment kinetic foot models (Bruening et al., 2012; MacWilliams et al., 2003; Zelik and Honert, 2018). The latter is attributed to the differences in ankle joint angular velocity, but these differences were only established in healthy subjects (Bruening et al., 2012; Dixon et al., 2012; MacWilliams et al., 2003). Hence, this phenomenon has yet to be thoroughly investigated and quantified, especially in a pathological group gait. Despite this knowledge, clinical motion analysis studies still implement a rigid foot modelling approach (Holmes et al., 2018; Lobet et al., 2012; Valderrabano et al., 2007; Wang and Brown, 2017). Though, currently it is not known whether this overestimation phenomenon has the same characteristics (e.g. magnitude) in persons with ankle and foot pathology and whether this leads to different clinical interpretations.

The aim of this study was to investigate differences in ankle joint kinetics assessed with a one-segment and multi-segment kinetic foot model. We compared these differences between persons with a structurally damaged ankle joint due to haemophilia (patient group) and asymptomatic subjects (control group). We also assessed the effect of the foot model used, the groups investigated and clinical relevance of the observed differences. We hypothesized that the peak angular velocity and peak power generation of the ankle joint is overestimated in the one-segment kinetic foot model for both groups. Furthermore, we hypothesized to find the same overestimation characteristics in both the control and patient group.

Section snippets

Participants

A convenient sample of ten symptomatic and ten asymptomatic subjects participated in this study (Table 1). All patients suffered from secondary ankle (tibiotalar) arthritis due to haemophilia. Severity of joint damage was scored using the International Prophylaxis Study Group-MRI score (IPSG-MRI), where a score of 0 signifies no damage and a score of 17 means most severely damaged tibiotalar joint (Lundin et al., 2012). IPSG-MRI scores ranged from 1 to 14 with an average score of 9 (SD 5).

Results

A large (partial η² = 0.77) and significant (P < 0.001) ‘foot model’ effect for peak ankle plantarflexion angle was found where control subjects experienced a peak of 17.4° (SD 5.5°) according to the PiG-model and a peak of 13.5° (SD 6.2°) according to the IOR-model. In the patient group, PiG-model showed a peak plantarflexion of 12.9° (SD 6.5°), while the IOR-model found a peak of 8.7° (SD 5.3°). A large (partial η² = 0.36) and near to significant (P = 0.052) difference was found between

Discussion

The aim of this study was to compare kinetic data of the ankle joint computed with a one-segment and multi-segment kinetic foot model in both a control and patient group. Our first hypothesis was confirmed by the results as both peak power generation and peak plantarflexion velocity were significantly lower in the multi-segment foot model compared to the rigid foot model. This was in accordance with earlier studies for the control data (Bruening et al., 2012; MacWilliams et al., 2003; Zelik and

Conclusion

This paper provides a first quantification of the amount of ankle joint power overestimation, in a patient group suffering from blood-induced ankle joint damage, measured with a one-segment kinetic foot model. Furthermore, we found that this amount of overestimation leads to clinically relevant misinterpretations of ankle joint power in pathological gait. The findings in our study therefore emphasize the importance of multi-segment kinetic foot modelling in clinical motion analysis.

Acknowledgements

This study was supported by the ASPIRE 2015 (Pfizer) research grant and the Novo Nordisk Clinical Research Grant (KD). Sponsors had no involvement in this article.

Declaration of competing interest

None.

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A convenience sample of twenty-nine subjects with end-stage post-traumatic ankle osteoarthritis (Takakura stage 3–4 (4 being complete obliteration of the joint space)) and fifteen asymptomatic subjects (CTRL) participated in this study (Table 1). This convenience sample size was based on similar clinical biomechanical research [9,10,12]. All patients suffered from post-traumatic ankle osteoarthritis secondary to ankle-related fracture (PF OA; n = 15 subjects; 9 males and 6 females) or to chronic ankle instability (PS OA; n = 14 subjects; 9 males and 5 females).
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The outcome of this study showed that the ‘foot model’ had a significant effect on RoM and power generation estimates. This is in accordance with earlier studies highlighting overestimation of ankle joint angles and peak power generation by the one-segment foot model compared to the multi-segment foot model [12,13,15]. The problem of modeling the foot as a single segment is that motion occurring in the intrinsic foot joints may add an extra rotation of the foot segment relative to the shank.
Kinematic and kinetic foot models showed that computing ankle joint angles, moments and power with a one-segment foot modeling approach alters kinematics and tends to overestimate ankle joint power. Nevertheless, gait studies continue to implement one-segment foot models to assess the effect of total ankle replacement.
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Quantifying clinical misinterpretations associated to one-segment kinetic foot modelling in both a healthy and patient population

Highlights

Abstract

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Participants

Results

Discussion

Conclusion

Acknowledgements

Declaration of competing interest

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