Gait & Posture 34 (2011) 4954

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Gait & Posture

journal homepage: www.elsevier.com/locate/gaitpost

Relevance of orthostatic posturography for clinical evaluation of hip and knee

joint arthroplasty patients
Livio Quagliarella a,*, Nicola Sasanelli a, V. Monaco b, G. Belgiovine a, A. Spinarelli c, A. Notarnicola c,
L. Moretti c, B. Moretti c
a
b
c

Sezione di Ingegneria Biomedica, Dip. di Metodologia Clinica e Tecnologie Medico-Chirurgiche, Universita` degli Studi di Bari, Policlinico- P.zza G. Cesare 11, I-70124 Bari, Italy
ARTS Lab, Scuola Superiore SantAnna, V.le Rinaldo Piaggio 34, I-56025 Pontedera, Italy
U.O. Ortopedia e Traumatologia, Dip. di Metodologia Clinica e Tecnologie Medico-Chirurgiche, Universita` degli Studi di Bari, Policlinico- P.zza G. Cesare 11, I-70124 Bari, Italy

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 18 March 2010
Received in revised form 6 March 2011
Accepted 9 March 2011

In order to verify whether orthostatic posturography (OP) can support clinical assessment of total hip
(THA) and knee arthroplasty (TKA), 81 subjects with THA and 100 with TKA were recruited and
compared with 59 healthy volunteers. All patients were tested one or two days prior to surgery; 42
subjects (20 THA and 22 TKA) were tested again after six months, and 34 (14 THA and 20 TKA) yet again
after 12 months. OP was performed using a Kistler 9286A piezoelectric force plate and the following
postural parameters (PPs) were adopted on account of their functional meaning: mean velocity and the
root mean square of the distance of the centre of pressure (CoP), sway area, and 95% of the CoP power
frequency. Eye condition and fatigue related to the test duration were also examined. The three most
meaningful PPs were identied and a logarithmic transformation was then applied to these, as well as
standardization. Almost all the PP values were higher preoperatively in the patients as compared with
the healthy subjects and it was possible to detect many statistically signicant differences between
patients and healthy subjects. However, when examining the 181 subjects at the preoperative stage, the
PPs did not show congruence with the clinical scores as well as they did during follow-up. Therefore, the
use of the OP is not recommended to monitor patients undergoing THA or TKA.
2011 Elsevier B.V. All rights reserved.

Keywords:
Postural control
Clinical evaluation
Hip
Knee
Prostheses

1. Introduction
Objective outcomes are needed to support an evidence-based
approach, as well as for medico-legal purposes [1]. Total hip (THA)
and knee arthroplasty (TKA) procedures are widely adopted. THA is
the second most commonly performed surgical procedure, with an
estimated number of more than one million operations each year
worldwide [2]. It is estimated that in the Unites States alone, by
2030 the demand for THA and TKA will have grown by 174% and
673%, respectively [3]. Orthostatic posturography (OP) is used to
evaluate the trajectory of the centre of pressure (CoP) with the
patient in upright stance [4]. Accepting the hypothesis that the CoP
planar migration is stationary, about 40 posturographic parameters (PPs) are commonly adopted to describe the statistical
properties of the CoP, in the time and frequency domains [58]. The
robustness of PPs has been clearly assessed [911], but there are
contrasting conclusions in literature about the sensitivity and
clinical signicance of PPs in subjects affected by osteoarthritis
(OA), THA or TKA [1219].

For Arokoski and colleagues, OP assessment of healthy subjects

and patients with hip OA provided comparable results [12], but in
other cases the performance of the impaired subjects did not reach
the standard of the healthy subjects [13,1619]. No studies using
OP have been carried out to assess balance control in TKA patients,
and the available literature concerning subjects affected by knee
OA shows an impaired balance control [1415].
This study was aimed at verifying whether OP could support
the clinical assessment of THA or TKA. Therefore, only PPs with a
functional meaning were adopted and a particular effort was
made to decrease their number and to make the test shorter and
simpler.
Firstly, the inuence of visual feedback and fatigue and the
possibility of discriminating between healthy subjects and
patients before and after surgery were analysed. Then, the clinical
use of OP was investigated in terms of its ability to pinpoint
relationships between PPs and patients clinical conditions.
2. Subjects and methods
2.1. Study groups

* Corresponding author. Tel.: +39 080 5478617; fax: +39 080 5565425.
E-mail address: l.quagliarella@bioingegneria.uniba.it (L. Quagliarella).
0966-6362/$ see front matter 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.gaitpost.2011.03.010

A total of 240 subjects, 98 males and 142 females, took part in the study (Table 1).
One hundred and eighty-one subjects (81 THA and 100 TKA) belonged to the two
experimental groups (EGs) and 59 to the control group (CG); 42 patients (20 THA

50

Table 1
Anthropometric and posturographic parameters in the total hip arthroplasty, total knee arthroplasty and control groups.
AP

Age (yr)

Height (cm)

PP

MV (mm/s)

RMSDRD (mm)

RMSDAP (mm)

RMSDML (mm)

SA (mm2/s)

PF95AP (Hz)

PF95ML (Hz)

THA

Session

Mean  SD

Range

TKA
Mean  SD

Range

CG

Pre-op.
6m
1y
Pre-op.
6m
1y
Pre-op.
6m
1y

64.1  11.3
62.9  11.7
66.6  10.9
160.8  9.3
159.8  7.5
159.9  9.1
75.7  13.2
79.0  11.4
79.2  14.8

4080
4080
4280
143185
146180
146185
48106
63109
51112

68.8  6.8
67.7  8.0
68.7  7.3
154.6  8.1
155.2  7.9
152.9  7.0
77.7  12.3
79.6  12.5
75.9  10.4

4880
4880
4879
133178
142175
142165
37103
55105
62104

TKA

Mean  SD

Group

THA

Test cond.

Eyes open

Session

Q1

Med.

Q3

Q1

Med.

Q3

Q1

Med.

Q3

Q1

Med.

Q3

Q1

Pre-op.
6m
1y
Pre-op.
6m
1y
Pre-op.
6m
1y
Pre-op.
6m
1y
Pre-op.
6m
1y
Pre-op.
6m
1y
Pre-op.
6m
1y

8.84
9.23
8.06
4.50
4.81
3.81
3.24
3.11
2.70
2.73
3.12
2.31
12.50
12.25
9.52
0.65
0.68
0.74
0.58
0.56
0.65

12.20
12.40
12.47
5.52
5.62
5.90
3.95
3.97
3.32
3.27
3.99
3.76
17.62
19.48
14.83
0.83
0.99
0.92
0.81
0.72
0.83

14.81
17.60
17.67
6.92
6.89
6.82
5.55
4.84
5.47
4.62
4.89
4.87
28.33
34.17
32.81
1.02
1.18
1.03
1.01
0.79
1.04

13.00
12.88
11.65
5.25
5.10
4.41
4.02
3.88
3.03
3.08
3.27
2.73
17.98
19.50
14.41
0.86
0.75
0.87
0.76
0.75
0.81

16.00
15.43
16.22
6.55
5.94
5.12
4.95
4.37
4.20
3.93
3.96
3.23
29.26
25.57
22.24
1.05
1.24
1.16
0.98
0.88
0.96

22.38
18.92
20.63
8.23
7.29
7.34
6.40
5.88
6.03
5.48
4.46
3.97
53.73
35.32
34.32
1.31
1.43
1.26
1.24
1.07
1.13

8.94
9.12
9.59
4.15
4.43
4.47
3.03
3.42
3.17
2.53
2.70
2.71
11.06
12.31
12.42
0.67
0.59
0.67
0.51
0.44
0.49

11.27
10.88
10.79
5.04
6.01
5.64
3.53
3.82
4.16
3.34
4.07
3.54
16.63
21.25
19.45
0.85
0.80
0.86
0.73
0.72
0.58

14.21
14.54
15.32
6.13
7.19
6.61
4.32
5.51
5.27
4.14
5.10
4.20
22.88
27.00
24.31
1.11
0.99
0.95
0.94
0.90
0.85

11.68
12.82
10.91
4.81
4.60
4.67
3.36
3.65
3.14
2.65
2.77
2.74
16.37
17.38
17.58
0.87
0.75
0.87
0.64
0.62
0.58

14.49
14.98
14.65
5.54
6.39
5.94
4.21
4.79
4.87
3.74
3.55
3.45
22.51
24.30
21.07
1.06
0.90
1.05
0.90
0.78
0.70

19.67
16.79
20.02
6.77
7.12
7.11
5.01
5.52
5.61
4.61
4.57
3.91
34.50
32.58
31.66
1.39
1.21
1.28
1.13
0.96
1.00

7.56

Eyes closed

Range

67.4  5.9

4876

162.3  10.5

142184

75.8  12.4

46100

CG

Eyes open

Eyes closed

Eyes open

Eyes closed

Med.

Q3

Q1

Med.

Q3

9.09

10.11

8.99

11.19

13.02

3.61

5.05

6.07

4.02

4.79

5.98

2.86

3.99

5.43

3.17

4.12

4.88

1.89

2.39

3.19

1.74

2.47

3.33

9.18

11.36

14.91

9.67

12.53

17.80

0.44

0.61

0.78

0.73

0.87

1.03

0.59

0.79

0.98

0.64

0.91

1.14

AP, anthropometric parameters; PP, posturographic parameters. THA, total hip arthroplasty; TKA, total knee arthroplasty, CG, control group. For the THA and TKA patients, the data are referred to the three trial sessions: preoperative
(pre-op.), six months (6 m), one year (1 y), whereas for the CG they refer to a single session. Since the PP data were not normally distributed they are reported as rst quartile (Q1), median and third quartile (Q3).

L. Quagliarella et al. / Gait & Posture 34 (2011) 4954

Body mass (kg)

Group

L. Quagliarella et al. / Gait & Posture 34 (2011) 4954

and 22 TKA) were tested again after six months, and 34 (14 THA and 20 TKA) again
after 12 months.
More than 90% of the patients were affected by OA, with level 4 Kellgren
Lawrence scores [20] at the time of the surgical procedure. The surgical procedures
were all performed by the same team between 2002 and 2007. Inclusion criteria for
the study were the ability to stand without support for at least 120 s and to
understand the test instructions correctly. Exclusion criteria were concomitant
cardiovascular, neurological or psychiatric disease or severe visual/auditory
impairments, functional limitations exceeding 30% of the physiological range of
joint motion, so as to exclude possible effects of xed deformities of the joint on the
postural assessments. The clinical ratings for THA patients, as described by Harris
[21], presented a maximum of 100 points and were determined pre-operatively
(average: 69.0  5.6; range: 3877), at six months (average: 87.6  8.2; range: 6298)
and at 12 months (average: 87.4  9.4; range: 6598). The TKA clinical score, according
to the Knee Society system [22], presented a maximum of 200 points. Preoperatively,
the mean score was 79.8  24.5 (range: 28109), after six months it was 108.7  28.9
(range: 35148), and after 12 months it was 153.8  34.0 (range: 64198).
The age-matched CG consisted of 35 male and 24 female healthy volunteers,
recruited among the staff working at the local Faculty of Medicine. The exclusion
criteria for the CG were the same as for the OA patients.
The procedures were approved by the local Ethics Committee and conducted in
conformity with the Declaration of Helsinki. Each participant was informed of the
study procedures and gave written informed consent before taking part in the
experimental sessions.
2.2. Data acquisition
OP was performed using a Kistler 9286A piezoelectric force plate (Kistler
Instrumente AG Winterthur, Switzerland), a Digivec system and a charge amplier
(BTS S.p.A., Milan, Italy).
After conditioning, signals were ltered by means of an analogue anti-aliasing
lter with a cut-off frequency of 49 Hz and acquired using a 12 bit analogue-todigital acquisition board. Data were collected for 120 s at a sampling rate of 100 Hz.
2.3. Procedures
Height, weight and shoe size of each subject were recorded prior to the test.
Participants were asked to stand barefoot on the force platform facing in the
anterio-posterior (AP) direction, in a comfortable self-chosen stance, with their
arms hanging down beside the body. They were instructed to stand as still as
possible during the tests and to breathe normally. Room lighting and noise were
controlled.
Before the rst test, the outline of each participants feet was traced on a paper
sheet attached to the surface of the force plate, to ensure a constant foot position
between trials [23].
Each subject carried out one test with eyes open and one with eyes closed, to
evaluate the Romberg ratio. During the eyes open trial, subjects were asked to look
straight ahead at a visual reference point (a red dot 3 cm in diameter, located 2 m
away on the wall, at eyes height). Between trials, subjects could rest in a chair for
approximately 2 min.
2.4. Postural parameters
The following PPs, as calculated by Prieto et al. [6], were adopted on account of
their clinical meaning and the need to adequately characterize balance control [8]:
1. the mean velocity (MV) of the CoP, indicating the amount of energy spent [24];
2. the root mean square of CoP time series, which is related to the amplitude of the
corrective activities [7,25], was calculated with respect to both the AP and
medio-lateral (ML) components of the CoP trajectory (RMSDAP and RMSDML
respectively), and to the vector of distances from the mean CoP to each of its
points (RMSDRD);
3. the sway area (SA) quanties the relationship between the postural control
system activities and the level of stability achieved;
4. the 95% power frequency (PF95) estimates the frequency extent of the CoP time
series, and is related to the periodicity exhibited by the postural control strategy
[26]; PF95 was calculated in the AP (PF95AP) and ML directions (PF95ML); with
the acquisition parameters used, the frequency resolution was 0.02 Hz.

Before data analysis, normalization of the PPs was done by quadratic detrending
[8,27], to eliminate any inuence of the main anthropometric features of each
subject, namely body mass and height, when the correlation coefcients were
signicantly (p < 0.05) higher than 0.1 with either body mass or height. The
normalization process produced data uncorrelated with body size, and magnitudes
and units comparable with the original ones.
Each subject was assumed to share body weight on the legs asymmetrically
when the averaged ML component of the CoP was outside an uncertainty range
(assumed as equal to the standard deviation of the distances between the middle
point of the segment joining the medial malleoli projection and the AP platform

51

axis). Other methods reported in literature [19] cannot highlight an asymmetric

position of the subject with respect to the median axis of the platform.
Data processing was carried out by custom written scripts in Matlab14 (The
Mathworks Inc., Natick, MA, USA). The CoP oscillations in both AP and ML directions
were ltered using a digital low-pass FIR lter with a cut-off frequency of 10 Hz [9].
In the calculation of the PPs, the rst 10 s of each data acquisition were discarded
[28]. The whole data series was subdivided into two consecutive intervals: T1 (from
10 s to 60 s) to allow comparison with data in literature [6,23,28] and T2 (from 60 s
to 120 s) to assess signs of fatigue [9,29].
2.5. Statistical analysis
Statistical analysis was carried out with Minitab14 Inc. (State College, PA, United
States), after performing KolmogorovSmirnov normality tests. According to the
result of the normality test, non parametric analysis of the variance (see Section 3)
was performed to compare data belonging to different groups. Results were
considered signicant when p < 0.01.

3. Results
3.1. Statistical signicance
The PPs were analysed by non parametric statistics since they
did not show a normal distribution. RMSDRD was normalized for
the subjects body mass, and RMSDAP and PF95AP were normalized
for height.
The angle of misalignment between the subjects AP axis and
the platform-related AP axis was 3  28 (mean  standard deviation) and the coefcient of variation of the distances between the
medial malleoli was less than 10%. Therefore, it could be assumed that
all subjects were similarly orientated and located with respect to the
platform.
After normalization, no statistically signicant differences
(SSD) due to age were found in the PPs after subdividing the CG
and the EGs (for each trial session) into two subgroups (under/over
60 years), but SSD due to gender were found for MV in TKA
(p = 0.001) and for PF95AP both in THA (p = 0.01) and in TKA
(p = 0.007). For these parameters comparisons were carried out
separately for males and females. The PP values in the EGs and CG
are reported in Table 1.
Comparing the PPs calculated in the interval T1 with those
obtained in T2 no SSD (MannWhitney) were found in either the
EGs or the CG.
Table 2
Statistically signicant differences in the posturographic parameters (PP) between
the total hip arthroplasty (THA) and total knee arthroplasty (TKA) groups as
compared to the controls (CG).
Groups

PP

Trial sessions

Pre-op.

6m

Gender

EO

EC

EO

EC

CG vs THA

MV
RMSDRD
RMSDAP
RMSDML
SA
PF95AP

M+F
M+F
M+F
M+F
M+F
M
F
M+F
M
F
M+F
M+F
M+F
M+F
M
F
M+F

z
y

z
z

CG vs TKA

PF95ML
MV
RMSDRD
RMSDAP
RMSDML
SA
PF95AP
PF95ML

z
z

z
z

y
z

1y
EO

EC

Trial sessions: preoperative (pre-op), after six months (6 m) and after one year (1 y)
from surgery. EO, eyes open; EC, eyes closed. p-Values: y, 0.01  p < 0.005; z,
0.005  p < 0.0005; , p < 0.0005. When SSD were present between males (M) and
females (F), the comparisons were made separately by gender.

L. Quagliarella et al. / Gait & Posture 34 (2011) 4954

52

As to the symmetry of the body weight load, no SSD was

found between eyes open and eyes closed tests or between THA
and TKA patients. The eyes closed condition was more sensitive
as a means of differentiating the postural behaviour of the
patients, because most of the SSD between the CG and the two
EGs were found during the eyes closed sessions. Therefore, in
view of the clinical application of OP to THA and TKA, it would
be possible to perform only eyes closed tests. The analysis of the
results was continued taking into account only this test
condition.
Almost all the PP values were higher preoperatively in the EGs
as compared with the CG, and many SSD were present. In
particular, SA presented the highest increase in THA (133%) and

Group: THA; PP: MV

TKA (88%) patients. Also MV, RMSD (as resultant and in the AP and
ML directions) and PF95AP were higher in THA (43% for MV, 36% for
RMSDRD, and 21% for PF95AP) and in TKA (30% for MV, 18% for
RMSDRD, and 22% for PF95AP) than in the CG.
During the follow-up, the number and signicance of SSD
declined markedly (Table 2). Only in the THA group was there a
steady reduction toward normal values in RMSDRD, RMSDAP and
SA, whereas the variations between sessions of the other PPs did
not present a clear trend. There were no SSD among sessions for
either THA or TKA patients.
When comparing THA and TKA, at the same follow-up session,
only in the preoperative session did a single SSD emerge for
RMSDAP (p = 0.004), which presented higher values in THA.

1,0

1,0

0,8

0,8

0,6

0,6

0,4

0,4

0,2

0,2

0,0

21

41

61

81

Group: THA; PP: RMSDRD

1,0

0,0

0,8

0,6

0,6

0,4

0,4

0,2

0,2

21

41

61

81

Group: THA; PP: R

1,0

0,0

0,8

0,6

0,6

0,4

0,4

0,2

0,2

21

41

21

61

81

0,0

41

61

81

Group: TKA; PP: RMSD RD

21

41

61

81

Group: TKA; PP: R

1,0

0,8

0,0

1,0

0,8

0,0

Group: TKA; PP: MV

21

41

61

81

Fig. 1. Comparison of the clinical scores (white square) with the posturographic parameters (PP black dot) for the pre-operative session, THA (left side) and TKA (right side).
The posturographic parameters reported are MV (top), RMSDRD (centre) and R (bottom). The values of the clinical scores (Harris Hip Score for THA and the Knee Society Score
for TKA) are related to the maximum possible value (100 for the Harris Hip Score and 200 for the Knee Society Score). The posturographic parameters are related to the
maximum values obtained in the patients group (THA or TKA) in the preoperative session. Higher scores indicate a better clinical condition, while higher values of MV indicate
a higher cost of maintaining the balance control, higher values of RMSDRD indicate greater oscillation widths and higher values of R indicate a higher frequency of intervention
of the control system.

L. Quagliarella et al. / Gait & Posture 34 (2011) 4954

2,0

1,5

1,0

0,5

0,0

6 12
0 6 12
THA
TKA
MV*

6 12
0 6 12
THA
TKA
RMSD*

6 12
THA

6 12
TKA

R*

Fig. 2. Mean values, with upper and lower bounds of the 95% condence interval for
the mean, of the standardized variables (MV*, RMSD* and R*), in patients subjected
to total hip arthroplasty (THA) and total knee arthroplasty (TKA), over the three
sessions (preoperative: 0; six months: 6; one year: 12). The difference from zero
indicates variations with respect to the mean values of the control group. During
follow-up the parameters did not show a clear trend toward a return to normal
conditions in both the experimental groups.

3.2. Selection of the most meaningful parameters for clinical

utilization
After the evaluation described above, the seven PPs were
reduced to three using only those which presented a correlation
coefcient with other PPs lower than 0.7 and the highest number of
SSD between the EGs and the CG, both in the preoperative and in
the follow-up sessions. On this basis, MV and RMSDRD were
preferred to SA, and PF95AP was adopted to account for the spectral
features. It was also possible to replace PF95AP with the MV to
RMSDRD ratio (R) in view of the high correlation coefcient
between R and PF95AP (0.89). Unfortunately, none of the clinical
parameters at each follow-up session were found to be correlated
with MV, RMSDRD or R (Fig. 1).
In order to identify the range of normality using a unique
threshold value, a logarithmic transformation was applied to MV,
RMSDRD and R, as well as standardization to the corresponding
mean and standard deviation (SD) values in the CG. The resultant
standardized parameters (MV*, RMSD* and R*, respectively) had a
Gaussian distribution and could be represented on the same scale
(Fig. 2).
For each parameter the normality range was assumed to be
equal to twice the SD of the CG, in order to identify those patients
with a worse balance performance in comparison to the healthy

53

subjects. Both in the preoperative and in the follow-up sessions,

92% of the CG and nearly two thirds of the THA and three quarters
of TKA were inside this range. Unfortunately, no relationships were
found between the patients classication, based on the normality range (Table 3) and the clinical parameters.
Moreover, to verify whether the OP evolution and the clinical
assessment of each subject could be correlated during the followup, a summary index for each follow-up session (K6 and K12) was
derived from the three standardized PPs. For each patient, K6 and
K12 were obtained as the sum of the differences of MV*, RMSD*, and
R* of the referred session, from the corresponding preoperative
value. According to this procedure, six months after surgery the
performance was worse in 11 THA out of 20 and in eight TKA out of
22, and at one year it was worse in seven THA out of 14 and nine
TKA out of 22. None of the clinical parameters at each follow-up
session were found to be correlated with the K indexes.
4. Discussion
The OP with closed eyes evidenced more SSD among the two
EGs and the CG than the test with open eyes; therefore, for this
kind of patients the OP protocol may be simplied by performing
only the eyes closed test.
As to fatigue, comparison between the PPs at T1 and T2 did not
demonstrate any effects due to the test duration even in patients
with very severe pain; consequently, each test may be limited to
60 s [17,19], discarding the rst 10 s during off-line processing.
Preoperatively, the values of MV and RMSDRD were in
agreement with reports in the literature [1315] and indicate
that balance control was worse than the control group. Most of all,
the higher values of SA in the two EGs highlight the increased effort
and the lower efciency of their balance control system.
The highest differences between the CG and THA groups can be
explained by the fundamental role exerted by the hips in postural
control, especially in the ML direction [4]. In particular, RMSDAP
was greater than RMSDML in the CG, indicating that postural sway
was larger in the AP direction, whereas signicantly greater
amplitude was observed in the ML direction in the THA group.
Moreover, the increased PF95AP values may indicate a greater
frequency of corrective movements made at ankle level [10].
A summary evaluation of the postural performance of each
subject can be obtained by adopting only MV, RMSDRD and the
ratio of MV to RMSDRD called R, avoiding the need to analyze the
frequency spectrum.
These three parameters were standardized (MV*, RMSD* and
R*) and used to classify results as normal or impaired.
Preoperatively, the clinical parameters of each patient did not
show congruent results with the postural performance, in fact, 63%

Table 3
Classication of the subjects with respect to the normality region.
Classication

Parameter

Trial session
Pre-operative

Severe impairment

RMSD*

R*

CG

THA

THA

TKA

x
x
x

x
x

0
0
0
0
2
1
1
55

1
11
4
0
12
3
0
50

0
4
6
0
12
4
4
70

0
1
1
0
4
1
0
13

0
1
0
0
1
1
0
19

0
2
0
0
2
0
1
9

0
1
1
0
3
0
1
14

59

81

100

20

22

14

20

x
x

x
x
x

Normal
Total

TKA

1y

MV*

x
Mild impairment

6m

THA

TKA

Groups: CG, control; THA, total hip arthroplasty; TKA, total knee arthroplasty. Parameters: MV*, standardized mean CoP velocity; RMSD*, standardized root mean square of
CoP distances, R* = standardized MV to RMSD ratio. Classication: severe impairment when at least two parameter values were above the threshold; mild impairment
when only one was higher; and normal when no parameter exceeded the threshold. For each parameter, the threshold is equal to twice the standard deviation of the CG.

54

L. Quagliarella et al. / Gait & Posture 34 (2011) 4954

of the THA group and 71% of the TKA group examined were within
the normality range. This means that pain and limited walking
endurance did not cause anomalous control of the standing
posture in most of the patients.
At follow-up evaluations, after six and twelve months from
surgery, the PP values did not show a clear trend toward
improvement in either of the EGs (Fig. 2), whereas a general
and signicant reduction in pain and functional improvements was
observed during the follow-up.
The OP evolution of each patient in the follow-up was then
examined. The summary index K showed that at both six months
and one year there was an evident impairment of the standing
balance of some patients, although this was not related with the
clinical parameters. This disagreement may be due to the lack of
items of the clinical evaluation related to balance control and/or to
the evolution of the contralateral limb conditions. Orthostatic
posture is the effect of a synergy of different sensorial afferences
whose efciency depends on various factors (age, co-morbidities,
psychological aspects) [30], and also depends on the action of both
limbs, that are often affected by the same disease. The tendency to
unload the impaired limb did not occur systematically during the
preoperative session, whereas six months after surgery it was
present in THA subjects, as also reported in a recent study [19].
Pain relief and better walking capacities are the essential goals
of hip and knee joint prostheses, therefore the congruence of PPs
with these parameters is the rst condition that needs to be
satised in order to adopt OP for clinical assessment of THA or TKA.
Examining the 181 subjects in the preoperative stage, the PPs did
not show congruence with pain and walking capacities. Neither
was this apparent during follow-up. After surgery there were
several cases of worsening in the standing performance and
improvement in the clinical condition or vice versa.
Therefore, while the use of OP was able to detect differences
among groups of patients and healthy subjects, it seems to be unable
to monitor patients who must undergo THA or TKA. This conclusion
is due not only to the lack of congruence with the clinical parameters
but also to the inclusion inside the normality range of more than 60%
of the patients evaluated before surgery. In addition, it was found
that, for THA and TKA patients, OP can be conducted in a simplied
mode both by reducing the time to 60 s and by avoiding the OE trial.
The presence of SSD in the postural control between THA and TKA
patients and the CG is still an open question.
Acknowledgement
This study has been supported by grants from Universita` degli
Studi di Bari (Finanziamento progetti di ricerca, Ateneo). The study
sponsors had no involvement in the study design, collection, nor
the decision to submit this manuscript for publication. The authors
wish to thank all the participants in the study.
Conict of interest statement
None of the authors have any nancial and personal relationships with other people or organizations that could inappropriately inuence (bias) their work.
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