The journal of neuroscience : the official journal of the Society for Neuroscience.

At self-selected walking speeds, elderly compared with young adults generate decreased joint torques and powers in the lower extremity. These differences may be actual gait-limiting factors and neuromuscular adaptations with age or simply a consciously selected motor pattern to produce a slower gait. The purpose of the study was to compare joint torques and powers of young and elderly adults walking at the same speed. Twelve elderly and fourteen young adults (ages 69 and 21 yr) walked at 1.48 m/s over a force platform while being videotaped. Hip, knee, and ankle torques and powers were calculated from the reaction force and kinematic data. A support torque was calculated as the sum of the three joint torques. Extensor angular impulse during stance and positive work at each joint were derived from the torques and powers. Step length was 4% shorter and cadence was 4% higher in elderly adults (both P < 0.05) compared with young adults. Support angular impulse was nearly identical between groups, but elderly adults had 58% greater angular impulse and 279% more work at the hip, 50% less angular impulse and 39% less work at the knee, and 23% less angular impulse and 29% less work at the ankle compared with young adults (t-test, all P < 0.05). Age caused a redistribution of joint torques and powers, with the elderly using their hip extensors more and their knee extensors and ankle plantar flexors less than young adults when walking at the same speed. Along with a reduction in motor and sensory functions, the natural history of aging causes a shift in the locus of function in motor performance.

https://www.physiology.org/doi/pdf/10.1152/jappl.2000.88.5.1804

Age causes a redistribution of joint torques and powers during gait

Treatment of congenital club foot.

Background: Although long-term follow-up studies have shown favorable results, in terms of foot function, after treatment of idiopathic clubfoot with serial manipulations and casts, we know of no long-term follow-up studies of patients in whom clubfoot was treated with an extensive surgical soft-tissue release.

Methods: Forty-five patients (seventy-three feet) in whom idiopathic clubfoot was treated with either a posterior release and plantar fasciotomy (eight patients) or an extensive combined posterior, medial, and lateral release (thirty-seven patients) were followed for a mean of thirty years. Patients were evaluated with detailed examination of the lower extremities, a radiographic evaluation that included grading of osteoarthritis, and three independent quality-of-life questionnaires, including the Short Form-36 Medical Outcomes Study.

Results: At the time of follow-up, the majority of patients in both treatment groups had significant limitation of foot function, which was consistent across the three independent quality-of-life questionnaires. No significant difference between groups was noted with regard to the results of the quality-of-life measures, the range of motion of the ankle or the position of the heel, or the radiographic findings. Six patients who had been treated with only one surgical procedure had better ranges of motion of the ankle and subtalar joints (p < 0.004) than those who had had multiple surgical procedures.

Conclusions: Many patients with clubfoot treated with an extensive soft-tissue release have poor long-term foot function. We found a correlation between the extent of the soft-tissue release and the degree of functional impairment. Repeated soft-tissue releases can result in a stiff, painful, and arthritic foot and significantly impaired quality of life.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

/pdf/long-term-follow-up-of-patients-with-clubfeet-treated-with-15cxxbw29a.pdf

Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release.

Background: Long-term follow-up studies of adults who had been treated for congenital clubfoot as infants are rare. The purpose of this study was to review and compare the long-term results in two groups of patients with congenital clubfoot treated with two different techniques. In both groups, treatment was started within the first three weeks of life by manipulation and application of toe-to-groin plaster casts, with a different technique in each group. At the end of the manipulative treatment, a posteromedial release was performed when the patient was between eight and twelve months of age in the first group and a limited posterior release was performed when the patient was between two and four months of age in the second group.

Methods: At the follow-up evaluations, all patients were interviewed and examined, and standing anteroposterior and lateral radiographs and computed tomography scans of the foot were made. The results of treatment were graded according to the system of Laaveg and Ponseti. Numerous angular measurements were made on the radiographs, and the measurements in the two groups were compared.

Results: The first group, which included thirty-two patients (forty-seven clubfeet), was followed until an average age of twenty-five years. The second group, with thirty-two patients (forty-nine clubfeet), was followed until an average age of nineteen years. In the first group, there were two excellent, eighteen good, eleven fair, and sixteen poor results. In the second group, there were eighteen excellent, twenty good, six fair, and five poor results. According to the system of Laaveg and Ponseti, the mean rating in the first group was 74.7 points and that in the second group was 85.4 points.

Conclusions: In the second group, use of Ponseti's manipulation technique and cast immobilization followed by an open heel-cord lengthening and a limited posterior ankle release gave much better long-term results than those obtained in the first group, treated with our manipulation technique and cast immobilization followed by an extensive posteromedial release of the foot. In our hands, this operation did not prevent relapse, and neither cavovarus nor forefoot adduction was completely corrected.

Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Long-term comparative results in patients with congenital clubfoot treated with two different protocols.

The influence of walking speed on mechanical joint power during gait

Forty-two cases of coxa vara were retrospectively reviewed. All 42 cases were classified based on their history and roentgenographic appearance. Twenty-two cases of true congenital coxa vara were identified and are the primary focus of this review. In this study we have introduced the Hilgenreiner epiphyseal (HE) angle as measured on standard AP roentgenograms of the hip. Retrospectively, this angle was measured to aid in deciding candidacy for surgery, as well as a means of determining the amount of surgical correction necessary to prevent a recurrence of the deformity. The indication for surgery should be an HE angle of greater than 60 degrees. HE angles of less than 60 degrees and greater than 45 degrees represent a "gray zone" and should be observed. HE angles of less than 45 degrees will generally correct spontaneously without surgery.

Congenital coxa vara. A retrospective review.

Residual forefoot adduction and supination deformities with functional problems and difficulty with shoe wear may occur during the course of management of the congenital clubfoot. Between 1975 and 1988, 55 patients with 71 feet who had residual dynamic clubfoot deformity underwent anterior tibial tendon transfer. There were 42 full anterior tibial tendon transfers (FTs) and 29 split anterior tibial tendon transfers (STs). The average age of the patient at the time of the procedure was 6 years. The age at surgery for FT was 5.3 years compared with 7.1 years in ST. The clinical appearance of the feet improved in both groups, according to Garceau's criteria. The range-of-motion improvement was noted in dorsiflexion and eversion. There was an increase of eversion strength of both groups by 1.5 grades. The radiographic improvement was noted in both forefoot adduction and supination. Although the FT group had a little better statistical data than did the ST group, the ST group had better preservation of inversion function.

Anterior tibial tendon transfer in residual dynamic clubfoot deformity.

The purpose of this study was to evaluate the long-term results of rectus femoris transfer in cerebral palsy children with stiff-knee gait. Thirty-eight affected limbs in 24 children were evaluated preoperatively and 1 year postoperatively by gait analysis, with 26 limbs in 18 patients having final study, averaging 4.6 years postoperatively. Functional ambulatory status was evaluated based on Hoffer's criteria on ambulation. There were statistically significant improvements of 9.8 degrees in maximum swing-phase knee flexion and 7.0 degrees in total range of knee motion at 1 year, with a small loss of knee extension in stance. At final gait analysis, the improvement in the swing-phase knee flexion was maintained, but improvement in total range of knee motion was decreased. There were no significant changes in temporal parameters. Improvement in swing-phase knee flexion and foot clearance after rectus femoris transfer was associated with loss of knee extension at long-term follow-up. Hamstring lengthening in patients who develop excessive stance-phase knee flexion may be necessary.

Rectus femoris transfer for children with cerebral palsy: long-term outcome.

Background The aim of this study was to evaluate the long-term outcome of a comprehensive surgical release for congenital talipes equinovarus (CTEV). Methods Gait, strength, segmental foot motion, and outcomes questionnaire data were collected on 24 adults (21.8+/-2.3 y) who were surgically treated for CTEV as infants. These data were statistically compared with of 48-age group matched controls (23.2+/-2.4 y). Results The clubfoot group was functional in activities of daily living, although most patients did experience foot pain after a day of typical activities, such as walking, standing, using stairs and doing exercise. Lower extremity gait kinematics was similar to the control group. There were differences in segmental foot motion with the hindfoot in a more plantarflexed position relative to the tibia and the forefoot dorsiflexed, and adducted relative to the hindfoot. Ankle plantarflexion and inversion strength and range of motion was reduced in the clubfoot group in association with an increase in hip power generation during the preswing and initial swing phases of the gait cycle. Conclusions Surgical correction of CTEV was successful in providing a functional plantigrade foot as the patients reached adulthood. However, limitations included foot pain, limited foot range of motion, and weakness. Level of evidence Level III.

Ken N. Kuo

Papers

The influence of walking speed on mechanical joint power during gait

Congenital coxa vara. A retrospective review.

Anterior tibial tendon transfer in residual dynamic clubfoot deformity.

Rectus femoris transfer for children with cerebral palsy: long-term outcome.

Long-term outcome evaluation in young adults following clubfoot surgical release.