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Introduction: Fracture reduction and fixation of distal femur fractures are technically demanding. Postoperative malalignment is still commonly reported after minimally invasive plate osteosynthesis (MIPO). We evaluated the postoperative alignment after MIPO using a traction table with a dedicated femoral support. Methods: The study included 32 patients aged 65 years or older with distal femur fractures of all AO/OTA types 32 (c) and 33 (except 33 B3 and C3) and peri-implant fractures with stable implants. Internal fixation was achieved with MIPO using a bridge-plating construct. Bilateral computed tomography (CT) scans of the entire femur were performed postoperatively, and measurements of the uninjured contralateral side defined anatomical alignment. Due to incomplete CT scans or excessively distorted femoral anatomy, seven patients were excluded from analyses. Results: Fracture reduction and fixation on the traction table provided excellent postoperative alignment. Only one of the 25 patients had a rotational malalignment of more than 15° (18°). Conclusions: The surgical setup for MIPO of distal femur fractures on a traction table with a dedicated femoral support facilitated reduction and fixation, resulting in a low rate of postoperative malalignment, despite a high rate of peri-implant fractures, and could be recommended for surgical treatment of distal femur fractures.

Background: Digital solutions in healthcare can facilitate and improve care. However, the experiences and usefulness of using either digital foot examinations or traditional foot examinations need to be evaluated. The aims of the study were to evaluate: 1) the differences in patient experiences, having their foot examined supported by the Clinical Decision Support System (CDSS) as compared with having their foot examined in traditional practice, 2) how healthcare professionals (HCP), by using the CDSS, experienced the routine compared with performing the foot examination as in traditional practice. Methods Of a total of 141 patients, 100 patients with diabetes were single-blind digitally randomised to one of two parallel arms: having their foot examined by an HCP using a CDSS (n=47) or having their foot examined as in traditional practice (n=53) at the Department of Prosthetics and Orthotics at Sahlgrenska University Hospital, Gothenburg, Sweden. Patients filled in a modified version of the National Patient Survey (NPS) and the Orthotics and Prosthetics Users’ Survey (OPUS) at study end. Two HCPs, working at a Department of Prosthetics and Orthotics, answered surveys regarding the interaction between the patient and the CPO. Results: Patients, aged 65±14 years, perceived a high level of satisfaction with the service at the department, regardless of the method used. No significant differences between groups were found when evaluated by 27 questions in the NPS or the OPUS, with scores of 67.17±12.18 vs. 66.35±16.52 (p=0.78) for the intervention and control group respectively. One hundred per cent of the patients were risk classified in the intervention group compared with 2% in the control group. Conclusions: Patients perceived a high level of satisfaction with the services at the DPO, regardless of the method used for the foot examination. All the patients were risk classified in the intervention group. The HCPs found that, by using the CDSS, the foot examination was structured and followed clinical guidelines. Furthermore, the documentation in the electronic health record was thorough, even though further improvements, such as integration with co-existing health record systems, were requested. Trial registration: Clinical Trials NCT03088566, Registered 23 March 2017, https://clinicaltrials.gov/ct2/show/NCT03088566?cond=d-foot&draw=2&rank=3

Patients with diabetes are often prescribed insoles with metatarsal pads intended to prevent and offload forefoot ulcers. However, to our knowledge, the plantar pressures specifically at the metatarsal pad had not previously been researched. The aim of this study was therefore to explore plantar pressures at the metatarsal pad position by comparing three toe deformity groups, claw toe (CT)/hammer toe (HT) and hallux valgus (HV), with a control group (NONE). In-shoe plantar pressures were measured using F-ScanTM and a polygon region of interest at the metatarsal pad position was created. Mean peak pressure (MPP), pressure-time integral (PTI) and percentage foot-insole contact area at the metatarsal pad position (%CA) were analysed from 24 patients (48 feet) in the metatarsal pad area. No significant difference was found between the groups regarding MPP, PTI or contact area. For MPP, the highest value was found in CT/HT (140kPa ± 61) and the lowest in HV (112kPa ± 33). In PTI, the highest value was for CT/HT (2.0 Ns/cm2 ± 1.0) and the lowest for HV (1.3 Ns/cm2 ± 0.4). The %CA was highest in CT/HT/HV (95%) and lowest in NONE (70%). A new quantitative approach was presented, assessing the metatarsal pad pressure effect on its corresponding plantar area of the foot. Further studies are needed to identify the conditions in which a metatarsal pad affects different foot statuses with regard to plantar pressure.

Background: The uncemented collum femoris-preserving (CFP) stem offers preservation of the femoral neck and a more conservative soft tissue resection, which may facilitate a more normal walking pattern. We used gait analysis to evaluate if patients operated with a CFP stem showed more favourable hip kinematics and kinetics when compared with a group of patients operated with a conventional uncemented stem. Methods: 44 patients randomised to receive either a CFP or a Corail stem were studied and were operated using a direct lateral incision. Gait analysis was performed 2 years after the operation with a 12-camera motion capture system and 2 force plates. Hip kinematics and kinetics were analysed and 66 subjects served as controls. Results: None of the variables: speed, stride, cadence and stance showed any statistical significant difference between the 2 study groups. Neither did the hip kinematics and kinetics. Compared to controls, patients operated with the CFP stem showed an increased stance (62.5% vs. 61.1%, p < 0.006) and decreased hip abduction (−2.1° vs. −6.5°). Patients operated with the Corail stem showed decreased speed (1.18 vs. 1.23 m/second), and stride length (1.26 vs. 1.33 m), decreased hip extension (−7.5° vs. −12.8°) and range of hip flexion/extension (38° vs. 40.9°), as well as their hip adduction that was increased (6.3° vs. 4°), whereas their hip abduction was reduced (−2.8° vs. −6.5°), ( p < 0.004) compared to the controls. Conclusions: Use of a CFP stem did not significantly influence any of the gait parameters studied when compared to a standard stem, but still both stems studied were associated with gait deviations when compared to controls. Whether these differences could be attributed to the stem used, the underlying hip disease, or both is still unknown.

Bone-anchored attachment of amputation limb prostheses is increasingly becoming a clinically accepted alternative to conventional socket suspension. The direct transfer of loads demands that the percutaneous implant system and the residual bone withstand all forces and moments transferred from the prosthesis. This study presents load measurements recorded at the bone-anchored attachment in 20 individuals with unilateral transfemoral amputation performing the everyday ambulatory activities: level ground walking, stairs ascent/descent and slope ascent/descent. Mean peak values for the sample populations across activities ranged from 498–684 N for the resultant force, 26.5–39.8 Nm for the bending moment, and 3.1–5.5 Nm for the longitudinal moment. Significant differences with respect to level walking were found for the resultant force during stairs ascent, (higher, p = 0.002), and stairs descent, (lower, p = 0.005). Using a crutch reduced the peak resultant forces and the peak bending moments with averages ranging from 5.5–12.6 % and 13.2–15.6 %, respectively. Large inter-participant variations were observed and no single activity resulted in consistently higher loading of the bone-anchored attachment across the participants. Results from this study can guide future development of percutaneous osseointegrated implant systems for limb prostheses and their rehabilitation protocols.

Aims People at increased risk of developing diabetic foot ulcers often wear therapeutic footwear less frequently than is desirable. The aims were to identify patient groups prone to nonadherence to wearing therapeutic footwear and modifiable factors associated with adherence. Materials and methods A questionnaire was mailed to 1230 people with diabetes who had been fitted with therapeutic footwear. Independent variables were categorized into five domains. For each domain, variables that were associated with adherence in a univariate regression analysis were entered into a multiple regression analysis. Results A total of 429 (34.9%) questionnaires were analyzed. Multiple regression analyses showed significant associations (p Conclusions Patients without paid employment or without foot ulcer experience are more prone to nonadherence. To improve adherence, clinicians should advise patients to store therapeutic footwear in a visible place at home and put conventional footwear away and encourage patients’ self-efficacy and habitual use of therapeutic footwear. Future studies should investigate this topic further and explore ways to promote changes in habits. A study limitation was that all variables were self-reported.

Background: Achilles tendon rupture is common among physically active individuals, yet a high percentage fail to return to their former activity after the injury. Quantifiable factors such as type of treatment, hours of rehabilitation, and age have not been associated with return-to-play rates. A factor that influences recovery is the participant’s experience before and throughout the rehabilitation process, which can be explored using a qualitative content analysis. Purpose: To explore and describe what influences the participant to return to physical activity after an Achilles tendon rupture. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Twenty participants (14 men; mean age, 46 years) were interviewed as part of this study. All participants had ruptured their Achilles tendon 4 to 6 years before the interviews. From the interviews, codes were extracted that evolved into 19 subcategories, 6 categories, and 1 theme. Results: The overarching theme that emerged was “Help me and then I can fix this.” The 6 categories were (1) one’s own drive to succeed, (2) having a supportive social network, (3) trusting the support from the health and social systems, (4) receiving and adapting information from others drives persistence in returning to activity, (5) impact of the injury on psychological factors; and (6) influence of physiological aspects. Conclusion: To be able to recover properly from an Achilles tendon rupture and return to activity, the study participants described the importance of obtaining the support needed to be able to gain optimal rehabilitation. In the participants’ opinion, for a greater chance of successful treatment and rehabilitation, it was vital to be provided with good support.

Introduction Tibial plateau fractures involve the knee joint, one of the most weight-bearing joints in the body. Studies have shown that gait asymmetries exist several years after injury. Instrumental gait analysis, generating both kinematic and kinetic data from patients with tibial plateau fractures, is uncommon. Aim To examine walking ability and knee range of motion in patients suffering intra-articular tibial plateau fractures. Method Twenty participants, eight males and 12 females, aged 44 years (range 26–60), with unilateral isolated tibial plateau fractures, were examined 12 weeks (range 7–20) after injury. The investigation consisted of passive range of motion (ROM) using a goniometer, six-minute walking test (6 MW), pain estimation using the visual analogue scale (VAS), the “Knee injury and Osteoarthritis Outcome Score” (KOOS) self-assessment questionnaire and instrumental 3-dimensional gait analysis (3DGA). 3DGA included spatiotemporal variables (speed, relative stance time, step length), kinematic variables (knee flexion, knee extension, ankle dorsiflexion) and kinetic variables (generating knee power (extension) and ankle power (plantarflexion)). A skin marker model with twenty reflective markers was used. Non-parametric tests were used for comparisons of the injured leg, the uninjured leg and a reference group. Result The participants walked more slowly compared with healthy references (p p p = 0.001). The maximum knee extension in the single stance phase was worse in the injured side compared with the uninjured side and the reference group (p p p p p p p Conclusion Patients who have sustained tibial plateau fractures generally display a limitation in their walking pattern 3 months after injury. These limitations are mainly related to the inability to extend the knee.

Police working in active duty have a high prevalence of musculoskeletal pain, with lower back pain being the most frequently reported. As a part of uniform regulations, Swedish police are mandated to wear body armour and duty belts at all times during work. This study aimed to investigate the effect of different load carriage designs on in-vehicle sitting pressure and self-rated discomfort among police. Results showed less discomfort when wearing the alternate load carriage system incorporating a load-bearing vest and thigh holster compared to the standard load carriage system consisting of a duty belt. Pressures in the lower back were reduced when wearing the load-bearing vest whereas pressures in the upper back region increased. Relocating appointments away from the waist has the potential to improve sitting positions and the ergonomic situation for police when driving fleet vehicles. Included in thesis in manuscript form.

Objectives: In this single-subject experimental design study, we investigated the effect of late-phase stroke rehabilitation on gait pattern. Methods: A subgroup from a previous clinical study, four men in the chronic phase after stroke, received 3 weeks of enriched and task-specific therapy (ETT) consisting of task-specific exercise, socialization, sensory and cognitive stimulation in a Mediterranean climate. Spatiotemporal gait variables, kinematics and symmetry were measured before and after the intervention in an advanced gait laboratory. Statistical significance was determined with the two-standard deviation band method. Results: Subject 1 had kinematic improvements (increased knee flexion during swing and dorsiflexion during stance) and spatiotemporal gains (increased speed, double-limb support, stride length and cadence) after ETT. Subject 2 had improved swing time symmetry ratio but no spatiotemporal or kinematic improvements. Subject 3 had gains in speed, stride width and length, and knee flexion during swing. Subject 4 had a change in cadence but no gain in kinematics, nor symmetry. Conclusions: Two of the four participants had significant improvements in gait kinematics, symmetry, and spatiotemporal variables after the intervention. Future research should consider the potential effects of ETT with the aim of validating the conclusions that can be drawn from this study.

Purpose Musculoskeletal disorders are considered as a major issue affecting the health and well-being of active duty police. Discomfort from wearing mandatory equipment and sitting for long periods of time in fleet vehicles are workload factors linked to musculoskeletal disorders in police. This study aims to determine the prevalence of multi-site musculoskeletal pain among Swedish police and to explore the possible association to discomfort experience when wearing mandatory equipment and sitting for long periods in fleet vehicles. Methods In this cross-sectional study responses from 4185 police were collected through a self-administered online survey including questions about physical work environment, mandatory equipment and musculoskeletal pain. Multi-site pain was determined through summing pain sites from four body regions. Binomial logistic regression was performed to explore the association between multi-site musculoskeletal pain: (1) discomfort from wearing mandatory equipment and (2) sitting for long periods in fleet vehicles. Results The prevalence of multi-site musculoskeletal pain at least 1 day per week within the previous 3 months was 41.3%. A statistically significant association between discomfort from wearing mandatory equipment and multi-site musculoskeletal pain was found; duty belt [OR 5.42 (95% CI 4.56–6.43)] as well as body armour [OR 2.69 (95% CI 2.11–3.42)]. Sitting for long periods in fleet vehicles was not significantly associated to multi-site musculoskeletal pain. Conclusion Multi-site musculoskeletal pain is a considerable problem among Swedish police and modifying mandatory equipment to decrease discomfort is suggested as a potential means of decreasing the musculoskeletal pain experienced by many police officers.

Study Design Cross-sectional laboratory study. Background Asymmetrical knee loading during jogging and hopping has been reported in individuals who have ruptured their Achilles tendon. No studies have examined knee loads in individuals post Achilles tendon rupture during high-demand tasks, such as single-limb landings. Objectives We sought to determine whether individuals post Achilles tendon rupture demonstrated asymmetrical knee loads and impact forces during drop countermovement jumps (CMJs). Methods Achilles tendon length and the single-leg heel-rise test for endurance were assessed in 34 individuals (31 male) 6.1 ± 2.0 years post Achilles tendon rupture. Movement patterns were assessed during a drop CMJ. Data were analyzed via repeated-measures analyses of variance, with comparisons between limbs and prior treatment history (surgery versus nonsurgery). Results An 8.6% longer Achilles tendon (P.001) was found in the involved limb. During the single-leg heel-rise test, the involved limb demonstrated 22.4% less endurance and 14.6% lower heel-rise height (all, P.001). During the landing phase of the drop CMJ, the involved limb exhibited 39.6% greater loading rate (P.001), 16.8% greater eccentric knee power (P = .048), but 21.6% lower eccentric ankle power (P.001). During the take-off phase, the involved limb exhibited 12.1% lower jump height and 19.9% lower concentric ankle power (both, P.001). Conclusion Elevated eccentric knee joint power and higher loading rates during a drop CMJ in individuals who experienced Achilles tendon rupture several years earlier may be a compensation pattern for reduced plantar flexor function. This movement pattern may place individuals who have had an Achilles tendon rupture at greater risk for knee injuries. J Orthop Sports Phys Ther 2018;48(1):34-43. Epub 26 Oct 2017. doi:10.2519/jospt.2018.7684.

Following a transfemoral amputation (TFA), numerous changes in movement patterns during gait can occur. Frontal plane hip and pelvis compensatory strategies are recognized among individuals with a TFA, some thought to aid in safe foot clearance during the swing phase of gait. The aim of this case study was to evaluate the effect of an active ankle dorsiflexion provided by a microprocessor-controlled prosthetic foot, as well as the effect of individualized training on these parameters. In this case study, a 42-year-old male underwent 3 D gait analysis. Data were captured for two conditions; with a microprocessor-controlled prosthetic foot with active/inactive ankle dorsiflexion, during two sessions; before and after 6 weeks of individualized training. The main outcomes analyzed were frontal plane pelvis and hip kinematics. Prior to training, pelvic lift decreased slightly, coupled with an increase in hip abduction, during gait with the active ankle dorsiflexion of a prosthetic foot, compared to inactive dorsiflexion. After the training period, the pelvic lift was further decreased and an increase in hip adduction was concurrently seen. The results of this case study indicate a positive effect of the active dorsiflexion of the prosthetic foot but highlight the need for specific training after prescription of a microprocessor prosthetic foot.Implications for rehabilitationDecreased compensatory changes seen in this case study indicate a positive effect of the active dorsiflexion of the prosthetic foot, especially after a 6-week training period.Individualized training should be aimed at helping the user utilizing the benefits of the active dorsiflexion of the microprocessor prosthetic foot, implementing exercises that improve gait quality, technical training for this specific foot, strength training and balance exercises. Decreased compensatory changes seen in this case study indicate a positive effect of the active dorsiflexion of the prosthetic foot, especially after a 6-week training period. Individualized training should be aimed at helping the user utilizing the benefits of the active dorsiflexion of the microprocessor prosthetic foot, implementing exercises that improve gait quality, technical training for this specific foot, strength training and balance exercises.

Background: It is unknown whether the height of a heel-rise performed in the single-leg standing heel-rise test 1 year after an Achilles tendon rupture (ATR) correlates with ankle biomechanics during walking, jogging, and jumping in the long-term. Purpose: To explore the differences in ankle biomechanics, tendon length, calf muscle recovery, and patient-reported outcomes at a mean of 6 years after ATR between 2 groups that, at 1-year follow-up, had less than 15% versus greater than 30% differences in heel-rise height. Study Design: Cohort study; Level of evidence, 3. Methods: Seventeen patients with less than 15% (30% group) side-to-side difference in heel-rise height at 1 year after ATR were evaluated at a mean (SD) 6.1 (2.0) years after their ATR. Ankle kinematics and kinetics were sampled via standard motion capture procedures during walking, jogging, and jumping. Patient-reported outcome was evaluated with Achilles tendon Total Rupture Score (ATRS), Physical Activity Scale (PAS), and Foot and Ankle Outcome Score (FAOS). Tendon length was evaluated by ultrasonography. The Limb Symmetry Index (LSI = [Injured Side ÷ Healthy Side] × 100) was calculated for side differences. Results: The >30% group had significantly more deficits in ankle kinetics during all activities compared with patients in the 30% group, compared with the Conclusion: Height obtained during the single-leg standing heel-rise test performed 1 year after ATR related to the long-term ability to regain normal ankle biomechanics. Minimizing tendon elongation and regaining heel-rise height may be important for the long-term recovery of ankle biomechanics, particularly during more demanding activities such as jumping.

The gait pattern in children with cerebral palsy (CP) often differs from normal, with slow velocity, problem with foot clearance and increased stress on joints. Several factors, such as muscle tone, impaired motor control, muscle contractures, skeletal deformities and leg length discrepancy affect gait. Leg length discrepancy can be treated surgically or with elevation of the shoe on the short leg. The purpose of this study was to examine whether compensating for leg length discrepancy, with elevation of the sole, leads to a change in movement pattern during walking in children with spastic CP. Results: Ten children with spastic CP, able to walk without aids, and 10 typically developing (TD) children aged between seven and 14 years were assessed with 3D gait analysis: 1) barefoot, 2) with shoes and 3) with an extra sole beneath the shoe for the shorter leg. All children with CP had a leg length discrepancy of more than or equal to 1.0 cm. In the barefoot condition, the velocity was slower and the stride length was shorter, in children with CP compared with TD. The stride length and gait velocity increased in children with CP with shoes and shoe + sole and the stance time became more symmetrical. Among children with CP, there was more flexion in the longer leg relative to the short leg during barefoot walking. Differences in the kinematic pattern between the long and the short leg decreased with the extra sole.

Background: Deficits in plantarflexor function are common after an Achilles tendon rupture. These deficits may result in an altered distribution of joint loads during lower extremity tasks. Hypothesis: We hypothesized that, regardless of treatment, the Achilles tendon–ruptured limb would exhibit deficits in ankle kinematics and joint power while exhibiting elevated knee joint power and patellofemoral joint loads during walking, jogging, and hopping. We further hypothesized that this loading pattern would be most evident during jogging and hopping. Study Design: Controlled laboratory study. Methods: Thirty-four participants (17 participants treated surgically, 17 treated nonsurgically) were tested at a mean 6.1 ± 2.0 years after an Achilles tendon rupture. Lower extremity kinematics and kinetics were assessed while participants completed walking, jogging, and single-legged hopping trials. Patellofemoral joint stress was calculated via a musculoskeletal model. Data were analyzed via mixed-model repeated analyses of variance (α = .05) and the limb symmetry index (LSI). Results: No differences ( P ≥ .05) were found between the surgical and nonsurgical groups. In both groups, large side-to-side deficits in the plantarflexion angle at toeoff (LSI: 53.5%-73.9%) were noted during walking, jogging, and hopping in the involved limb. Side-to-side deficits in the angular velocity were only present during jogging (LSI: 93.5%) and hopping (LSI: 92.5%). This pattern was accompanied by large deficits in eccentric (LSI: 80.8%-94.7%) and concentric (LSI: 82.2%-84.7%) ankle joint powers in the involved limb during all tasks. Interestingly, only jogging and hopping demonstrated greater knee joint loads when compared with the uninvolved limb. Concentric knee power was greater during jogging (LSI: 117.2%) and hopping (LSI: 115.9%) compared with the uninvolved limb. Similarly, peak patellofemoral joint stress was greater in the involved limb during jogging (LSI: 107.5%) and hopping (LSI: 107.1%), while only hopping had a greater loading rate of patellofemoral joint stress (LSI: 110.9%). Conclusion: Considerable side-to-side deficits in plantarflexor function were observed during walking, jogging, and hopping in patients after an Achilles tendon rupture. As a possible compensation, increased knee joint loads were present but only during jogging and hopping. Clinical Relevance: These data suggest that after an Achilles tendon rupture, patients may be susceptible to greater mechanical loading of the knee during sporting tasks, regardless of surgical or nonsurgical treatment.

There is an increasing demand to quantify the footprints, ecological, economic and social, in terms of the effect of different interventions in healthcare. The aim of this study was to compare two systems providing patients with diabetes with insoles in terms of their ecological, economic and social footprints. Prefabricated insoles (PRI) were compared with custom-made insoles (CMI). Using a welfare-economic monetary approach, costs were estimated for (1) treatment, (2) travelling to and from the hospital in terms of both fuel and time consumed by the patients and (3) society through emissions contributing to climate change. The proportion of patients/year that could be supplied within the same budget, for each individual treatment, was calculated. The cost of the insoles was 825 SEK (PRI) and 1450 SEK (CMI), respectively. The cost, mean value/patient due to the consumption of patients’ time at the department, was 754 SEK (PRI) and 1508 SEK (CMI), respectively. Emissions, in terms of CO2 equivalent, were 13.7 (PRI) and 27.4 (CMI), respectively. Using PRI, a total of 928 patients could be provided/year compared with 500 patients if CMI are used. By using PRI, the cost/treatment was reduced by 46%. The cost of treatment dominated and the cost of time consumed by patients were also substantial. The societal cost of contributing to climate change was of low importance. By using PRI, the needs of 86% more patients could be met within the same budget. Using these methods, the contribution of healthcare systems to the 17 Sustainable Development Goals approved by the UN can be quantified.

BACKGROUND: When comparing neuromuscular activity between different individuals or different conditions by use of surface electromyography (sEMG) it is necessary to apply standardized assessment protocol. Most frequently used method is the maximum voluntary isometric contraction (MVIC). However, the influence of body posture on sEMG activity during MVIC testing remains largely unknown.AIM: To evaluate the MVIC method for sEMG normalization in supine versus standing positions for selected muscles of the lower extremity and trunk.METHODS: Twelve healthy individuals participated; five females and seven males (age 22-51 yrs). sEMG signals were recorded bilaterally from mm tibialis anterior, gluteus medius, adductor longus, rectus abdominus, external oblique and internal oblique/transversus abdominus according to standardized test protocol. Two different body positions were used: supine and standing position.RESULTS: MVIC peak sEMG signal amplitudes did not differ systematically between supine and standing test positions. Pronounced inter-subject variability in MVIC reference sEMG activity were observed between participants, during both supine and standing test positions.CONCLUSION: Present data demonstrate that MVIC EMG normalization is a biomechanically stable procedure that can be performed in a reproducible manner for the major leg and trunk muscles when comparing supine vs. standing test positions.

Background Therapeutic shoes can prevent diabetic foot reulcerations but their use is complicated by the fact that shoes have psychological and social meanings, which is believed to put a larger burden on women than men. The aim was to compare attitudes and attributes of women and men using therapeutic shoes for diabetic foot complications. Methods A questionnaire was posted to 1230 people with diabetes who had been fitted with therapeutic shoes. Women’s and men’s answers were compared using t-tests, Mann–Whitney U tests and chi-square tests with Fischer’s exact tests. P-values

We simultaneously examined 14 patients with OTS and dynamic radiostereometric analysis (RSA) to evaluate the accuracy of both skin- and a cluster-marker models. The mean differences between the OTS and RSA system in hip flexion, abduction, and rotation varied up to 9.5° for the skin-marker and up to 11.3° for the cluster-marker models, respectively. Both models tended to underestimate the amount of flexion and abduction, but a significant systematic difference between the marker and RSA evaluations could only be established for recordings of hip abduction using cluster markers (p = 0.04). The intra-class correlation coefficient (ICC) was 0.7 or higher during flexion for both models and during abduction using skin markers, but decreased to 0.5-0.6 when abduction motion was studied with cluster markers. During active hip rotation, the two marker models tended to deviate from the RSA recordings in different ways with poor correlations at the end of the motion (ICC ≤0.4). During active hip motions soft tissue displacements occasionally induced considerable differences when compared to skeletal motions. The best correlation between RSA recordings and the skin- and cluster-marker model was found for studies of hip flexion and abduction with the skin-marker model. Studies of hip abduction with use of cluster markers were associated with a constant underestimation of the motion. Recordings of skeletal motions with use of skin or cluster markers during hip rotation were associated with high mean errors amounting up to about 10° at certain positions. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1515-1522, 2017.

Background: Body armour, duty belts and belt mounted holsters are standard equipment used by the Swedish police and have been shown to affect performance of police specific tasks, to decrease mobility and to potentially influence back pain. This study aimed to investigate the effects on gait kinematics and kinetics associated with use of an alternate load carriage system incorporating a thigh holster. Methods: Kinematic, kinetic and temporospatial data were collected using three dimensional gait analysis. Walking tests were conducted with nineteen active duty police officers under three different load carriage conditions: a) body armour and duty belt, b) load bearing vest, body armour and thigh holster and c) no equipment (control). Findings: No significant differences between testing conditions were found for temporospatial parameters. Range of trunk rotation was reduced for both load carriage conditions compared to the control condition (p

Background: According to previous gait analyses, insertion of a total hip arthroplasty (THA) will improve the range of hip flexion-extension but not to normal. Use of short stems could have a potential to improve the motion by preservation of more bone and muscular attachments. We evaluated whether a short femoral stem resulted in improved hip motion compared to a conventional stem in patients who underwent 1-stage bilateral THA. The most painful hip was randomised to either design and the 2nd hip was operated with the design not used on the 1st side. Methods: Gait analysis was performed with an optical tracking system in 22 patients. The follow-up was performed 1 and 2 years after the operation. The mean age was 59 (SD 7.7) years and body mass index was 27.7 (SD 4.3). 66 subjects without hip pathology served as controls. Results: Minimal differences were observed, between or within the 2 different stem designs during gait at the 2 follow-up occasions. Comparison between each of the 2 stem designs and controls at 2 years revealed reduced stride length (p = 0.009), cadence, hip extension (pConclusions: We found no difference in gait parameters between the short and the conventional stem after 1-stage bilateral THA. Although both hip joints were operated at the same time motions and moments did not normalise after bilateral 1-stage operations.

Objectives To examine whether different vertical drop jump (VDJ) landing depth (small versus deep) and stance width (wide versus narrow) may alter movement biomechanics in female recreational athletes. The purpose was also to identify whether leg muscle strength is a predictive factor for knee control during a VDJ. Design Cross-sectional. Setting Biomechanics laboratory. Participants: Eighteen women aged between 18 and 30 years. Main outcome measures Three VDJ tests were used for biomechanical analysis: 1) small “bounce” jump (BJ), 2) deep “countermovement” jump with wide (CMJW) and 3) narrow foot position (CMJN). Subjects also performed an isometric knee-extension strength test, dichotomized to ‘weak’ versus ‘strong’ subjects according to median and quartiles. Results There were greater knee valgus angles during landing for both the CMJW and CMJN test compared to the BJ test (p ≤ 0.05). Differences in knee valgus between weak and strong subjects were significant for the BJ test (p = 0.044) but not for any of the other tests. Conclusions VDJ landing depth influences knee kinematics in women. Landing depth may therefore be considered when screening athletes using the VDJ test. Also, muscle strength seems to influence the amount of knee valgus angles, but the difference was not statistically significant (except for the BJ test) in this small cohort.

Background Musculoskeletal disorders are a common problem among uniformed police with lower back pain being most frequently reported (Gyi and Porter, 1998). Wearing mandatory equipment (duty belt and body armour) and sitting for long periods of time in fleet vehicles are characteristic workload factors linked to musculoskeletal disorders in police (Filtness et al., 2014, Holmes et al., 2013). Aim The aim of this study was to determine the prevalence of multi-site musculoskeletal pain among Swedish police and to explore the possible association to physical workload factors with a special focus on mandatory equipment. Method A cross-sectional study was carried out with responses from 4185 uniformed police. Data was collected through a self-administered online survey including questions about work environment, physical workload factors, mandatory equipment and musculoskeletal pain. Multi-site musculoskeletal pain was determined by summing pain sites from four body regions. Binomial logistic regression was performed to explore the association between multi-site musculoskeletal pain and 1) use of mandatory equipment and 2) sitting for long periods in fleet vehicles. Result The prevalence of multi-site musculoskeletal pain at least one day per week within the previous three months was 41.3%. A statistically significant association was found between multi-site musculoskeletal pain and mandatory equipment whereas sitting for long periods of time in fleet vehicles was not found to be significantly associated to multi-site musculoskeletal pain. Conclusion Multi-site musculoskeletal pain is a considerable problem among Swedish police and the association to mandatory equipment should therefore be further investigated including psychosocial factors.

Background The gait pattern varies within the population and between patient groups with different musculoskeletal diseases. It also varies over time due to various reasons. Three-dimensional gait analysis (3DGA) is frequently used to measure these changes, but the precision of this methodology may vary. Methods We primarily aimed to study the repeatability of hip motion measurements in patients with unilateral osteoarthritis (OA), patients with unilateral total hip arthroplasty (THA) and healthy controls. A secondary aim was to delineate any differences in hip motion during walking between these groups. Ten males and 10 females in each group were recruited. All patients underwent gait assessments using 3DGA recorded by 2 examiners. Data was analysed with comparison of variance and linear regression. Results The variability of the extension-flexion recordings was smallest in healthy controls (SD

Background: Non-removable knee-high devices are the gold standard to treat diabetic foot ulcers located on the plantar forefoot, but they immobilize the ankle, which restricts daily life activities and has negative effects on joint functioning. Objective: To investigate the feasibility of sealing a therapeutic shoe to off-load and heal diabetic forefoot ulcers. Design: A case series of seven men with type 2 diabetes and a metatarsal head ulcer were prescribed therapeutic shoes and custom-made insoles. The shoe was sealed with a plastic band. Off-loading was assessed with the F-scan pressure measurement system. Adherence to wearing the shoe was assessed with a temperature sensor and by documenting the status of the seal. Results: The off-loading was effective and all ulcers healed. Median time to healing was 56 days (range 8-160). Complications were secondary ulcer (n = 1) and plantar hematoma (n = 1). Five of seven participants did not disturb the seal. Conclusions: Sealing a therapeutic shoe is a feasible way to off-load and heal forefoot ulcers. A controlled trial is needed to compare the effectiveness and safety of a sealed shoe to other non-removable devices., Funding Agencies:Region Örebro County Promobilia Foundation OLL-459501

Background: Special insoles and shoes designed to prevent foot ulcers caused by repetitive high pressures are recommended for patients with diabetes who have any of the following risk factors: neuropathy; peripheral vascular disease; foot deformities; previous ulcers; amputation; and skin pathologies. However, there is a need for increased knowledge regarding: a) differences in the peak pressure (PP) and pressure time integral (PTI) for different types of insoles; and b) the properties of the pressure distribution for insoles used over a period of several months. We present the results of a randomized trial to compare the plantar pressures of three commonly used insoles. Objectives: The primary objective was to compare the PP and PTI between three types of insoles. The secondary objective was to explore the long-term pattern of peak plantar pressure distribution and variations in specific regions of interest (ROI). The tertiary objective was to investigate the impacts of insole adjustments, how much the insoles were used, and the levels of patient satisfaction. Methods: In a 2-year trial, 114 patients with type 1 (N = 31) or type 2 (N = 83) diabetes (62 men and 52 women; mean age, 57.7 ± 15.4 years; duration of diabetes, 12.3 ± 11.2 years; neuropathy, 38%), were randomized to be supplied with one of three different insoles. The ethylene vinyl acetate (EVA) insoles were used in outdoor walking shoes. The 35 EVA group (N = 39) received soft custom-made insoles composed of EVA of 35 shore A hardness, the 55 EVA group (N = 37) received custom-made insoles composed of EVA of 55 shore hardness, and the control group (N = 38) received prefabricated insoles composed of a hard core with a top layer of soft 12 shore hardness microfiber. Using F-Scan®, the in-shoe plantar pressures were measured at seven ROI (hallux, metatarsal head 1, metatarsal head 2, metatarsal head 4, metatarsal head 5, lateral aspect of the mid-foot, heel) on five occasions during the study period. The plantar-pressure variables used were PP (main outcome) and PTI. The plantar patterns of load were explored, satisfaction and usage of the insoles were rated by the participants, and insole adjustments were recorded. Results: A mixed model analysis estimated lower PP values in the heel regions for the 35 EVA and 55 EVA insoles (171 ± 13 and 161 ± 13 kPa, respectively) than for the prefabricated insoles (234 ± 10 kPa) (p

Early designs of uncemented hip implants turned out to be failures mainly because the prerequisites for durable implant fixation were unknown. One exception was the chrome–cobalt stem of the Madreporic Lord prosthesis. We prospectively studied this prosthetic design in 107 hips that underwent surgery in 1979–1986. At the last follow-up, five stems and 54 cups had been revised, corresponding to stem and cup survival rates of 92% ± 3% and 45% ± 5% at 26 years. In all, 66 hips with remaining Lord stems were available for clinical follow-up 26 years (24–29) after the index operation. The mean total Harris hip and pain scores were 81 (SD 14) and 41 (SD 5).

We simultaneously examined 14 patients with OTS and dynamic radiostereometric analysis (RSA) to evaluate the accuracy of both skin- and a cluster-marker models. The mean differences between the OTS and RSA system in hip flexion, abduction, and rotation varied up to 9.5° for the skin-marker and up to 11.3° for the cluster-marker models, respectively. Both models tended to underestimate the amount of flexion and abduction, but a significant systematic difference between the marker and RSA evaluations could only be established for recordings of hip abduction using cluster markers (p = 0.04). The intra-class correlation coefficient (ICC) was 0.7 or higher during flexion for both models and during abduction using skin markers, but decreased to 0.5-0.6 when abduction motion was studied with cluster markers. During active hip rotation, the two marker models tended to deviate from the RSA recordings in different ways with poor correlations at the end of the motion (ICC ≤0.4). During active hip motions soft tissue displacements occasionally induced considerable differences when compared to skeletal motions. The best correlation between RSA recordings and the skin- and cluster-marker model was found for studies of hip flexion and abduction with the skin-marker model. Studies of hip abduction with use of cluster markers were associated with a constant underestimation of the motion. Recordings of skeletal motions with use of skin or cluster markers during hip rotation were associated with high mean errors amounting up to about 10° at certain positions. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1515-1522, 2017.

Cerebral palsy is often associated with an abnormal gait pattern. This study put focus on relation between muscle strength and kinetic gait pattern in children with bilateral spastic cerebral palsy and compares them with a reference group. In total 20 children with CP and 20 typically developing children participated. They were all assessed with measurement of muscle strength in eight muscle groups in the legs and a 3-dimensional gait analysis including force data. It was found that children with CP were not only significantly weaker in all muscle groups but also walked with slower velocity and shorter stride length when compared with the reference group. Gait moments differed at the ankle level with significantly lower moments in children with CP. Gait moments were closer to the maximal muscle strength in the group of children with CP. Furthermore a correlation between plantarflexing gait moment and muscle strength was observed in six of the eight muscle groups in children with CP, a relation not found in the reference group. A similar pattern was seen between muscle strength and generating ankle power with a rho=0.582-0.766. The results of this study state the importance of the relationship of the overall muscle strength pattern in the lower extremity, not only the plantarflexors.

This study describes the changes in hip and pelvic kinematics in 19 trans-femoral amputees, who were treated with an osseointegrated trans-femoral prosthesis. Patients were studied with 3-dimensional gait analysis, walking with socket prosthesis within two days before the osseointergration procedure. The post-operative gait analysis was carried out at the 2 year follow-up visit. Fifty-seven; age-, side- and gender-matched healthy subjects served as controls. Post-operative data showed that patients who had an osseointegrated transfemoral prosthesis increased their hip extension by 7.3° (p=0.007), changing from -2.6° (range -13.4° to 10.7°) to -9.9° (range -29.4° to 5°). Moreover, the pre-operative anterior pelvic tilt was reduced by 4.0° (p=0.016), changing from 21.7° (range 11.9-34.8°) to 17.7° (range 5.5-25.7°). Values for hip extension and pelvic tilt changed toward those of controls. These results confirm that patients treated with osseointegrated trans-femoral prosthesis encounter significant changes of their kinematic pattern in terms of hip extension and anterior pelvic tilt. Even though the changes were moderate they may, in the long-term have a positive influence on low-back biomechanics and could contribute to reducing the risk of further problems with low back pain.

Background and Purpose. The physiological cost index (PCI) is a clinical measurement used to estimate the energy cost of walking. The reproducibility of the PCI has been questioned and no study has investigated the measurement error among individuals with a lower-limb amputation. The aim was to investigate the test–retest reproducibility of the PCI in individuals with a lower-limb amputation and healthy adults. Methods. The study comprised 28 individuals (20 males, eight females, mean age 49 years) with a unilateral amputation due to reasons other than vascular disease and 31 healthy volunteers (20 males, 11 females, mean age 47 years). PCI values were obtained by registering heart rate at rest and during level indoor walking for 5 minutes at a comfortable speed. A within-day test–retest assessment was performed. Reproducibility analyses included intra-class correlation, analyses of systematic differences between measurements, calculation of the smallest detectable change (SDC) and coefficient of variation (CV), and the results were finally visualized using Bland–Altman plots. Results. The reliability in terms of intra-class correlation was excellent for both groups (0.966 and 0.948). In the amputee group, the PCI revealed a mean difference of 0.026 (p = 0.016) between tests (PCI = 0.555, standard deviation [SD] = 0.214 and PCI = 0.581, SD = 0.236, respectively). In the healthy group, there was no systematic difference between tests (PCI = 0.329, SD = 0.114 and PCI = 0.331, SD = 0.110, respectively). The SDC was 0.116 in the amputee group and 0.070 in the healthy group, giving a CV of 20.4% and 21.0%,respectively. Conclusions. The within-day test–retest reproducibility of the PCI was excellent among individuals with lower-limb amputations and healthy adults in terms of intra-class correlation and acceptable in terms of agreement. The SDC, which was calculated for each group, should be considered when demonstrating an individual difference after an intervention. Copyright © 2010 John Wiley & Sons, Ltd.