Three-dimensional evaluation of lower extremity alignment during gait and standing in healthy elderly individuals: A comparative study using fluoroscopy and 3D to 2D image matching
Restricted accessResearch articleFirst published online July, 2025
Three-dimensional evaluation of lower extremity alignment during gait and standing in healthy elderly individuals: A comparative study using fluoroscopy and 3D to 2D image matching
The differences in bony alignment of the lower extremities during gait compared to standing remain unclear.
Objective
This study aimed to evaluate three-dimentional (3D) lower extremity alignment in healthy elderly individuals during the stance phase of gait and compare it with static standing alignment.
Methods
Thirty-four knees (9 females, 8 males; mean age 73.2 years) were assessed using single-plane X-ray fluoroscopy and a 3D to two-dimensional (2D) image matching technique. Alignment during stance phase and standing was evaluated in a world coordinate system, using the direction of gravity and frontal X-ray (aligned with the gait direction) as references.
Results
Compared to standing, the femur (3.5°), tibia (3.2°) and tibial joint line relative to the floor (3.3°) exhibited increased lateral inclination during stance phase (p < 0.01). In the transverse plane, the femur showed a significant increase in external rotation during stance phase (5.0°, p < 0.01) compared to standing, with no significant difference in tibial rotation.
Conclusion
Lower extremity alignment significantly differs between static standing and gait, making it challenging to accurately infer the alignment during gait from standing assessments. This approach offers a practical means for assessing functional lower extremity alignment, potentially improving clinical outcomes in realignment surgeries.
FelsonDT. The epidemiology of knee osteoarthritis: results from the framingham osteoarthritis study. Semin Arthritis Rheum1990; 20: 42–50.
2.
ShiozakiHKogaYOmoriG, et al.Epidemiology of osteoarthritis of the knee in a rural Japanese population. Knee1999; 6: 183–188.
3.
HiganoYHayamiTOmoriG, et al.The varus alignment and morphologic alterations of proximal tibia affect the onset of medial knee osteoarthritis in rural Japanese women: case control study from the longitudinal evaluation of Matsudai Knee Osteoarthritis Survey. J Orthop Sci2016; 21: 166–171.
4.
SchippleinODAndriacchiTP. Interaction between active and passive knee stabilizers during level walking. J Orthop Res1991; 9: 113–119.
5.
AaliSRezazadehFBadicuG,et al.Effect of heel-first strike gait on knee and ankle mechanics. Medicina (B Aires)2021; 57: 57.
6.
MoonJLeeDJungH, et al.Machine learning strategies for low-cost insole-based prediction of center of gravity during gait in healthy males. Sensors (Basel)2022; 22. https://doi.org/10.3390/S22093499
7.
VictorJMKBassensDBellemansJ, et al.Constitutional varus does not affect joint line orientation in the coronal plane knee. Clin Orthop Relat Res2014; 472: 98–104.
8.
OgataKYoshiiIKawamuraH, et al.Standing radiographs cannot determine the correction in high tibial osteotomy. J Bone Joint Surg - Series B1991; 73: 927–931.
9.
AkamatsuYKumagaiKKobayashiH, et al.Effect of increased coronal inclination of the tibial plateau after opening-wedge high tibial osteotomy. Arthrosc - J Arthrosc Relat Surg2018; 34: 2158–2169.
10.
MatsushitaTWatanabeSArakiD, et al.Differences in preoperative planning for high-tibial osteotomy between the standing and supine positions. Knee Surg Relat Res2021; 33: 1–11.
11.
MatsumotoTHashimuraMTakayamaK, et al.A radiographic analysis of alignment of the lower extremities - initiation and progression of varus-type knee osteoarthritis. Osteoarthritis Cartilage2015; 23: 217–223.
12.
OtaniKSatoTKobayashiK, et al.Effects of three-dimensional femur and tibia postures on the parameters of standing long-leg radiographs for osteoarthritic knees in elderly female subjects. Clin Biomech2024; 117: 106297.
13.
FujiiTSatoTAriumiA. A comparative study of weight-bearing and non-weight-bearing 3-dimensional lower extremity alignment in knee osteoarthritis. J Orthop Sci2020; 25: 874–879.
14.
DuffellLDMushtaqJMasjediM,et al.The knee adduction angle of the osteo-arthritic knee: a comparison of 3D supine, static and dynamic alignment. Knee2014; 21: 1096–1100.
15.
BenoitDLRamseyDKLamontagneM, et al.Effect of skin movement artifact on knee kinematics during gait and cutting motions measured in vivo. Gait Posture2006; 24: 152–164.
16.
WangWLiXZhangT, et al.Effects of soft tissue artifacts on the calculated kinematics of the knee during walking and running. J Biomech2023; 150: 111474.
17.
GrayHAGuanSPandyMG. Accuracy of mobile biplane X-ray imaging in measuring 6-degree-of-freedom patellofemoral kinematics during overground gait. J Biomech2017; 57: 152–156.
18.
LiJSTsaiTYFelsonDT, et al.Six degree-of-freedom knee joint kinematics in obese individuals with knee pain during gait. PLoS One2017; 12: 1–11.
19.
SatoTKogaYOmoriG. Three-dimensional lower extremity alignment assessment system: application to evaluation of component position after total knee arthroplasty. J Arthroplasty2004; 19: 620–628.
20.
KobayashiKSakamotoMTanabeY, et al.Automated image registration for assessing three-dimensional alignment of entire lower extremity and implant position using bi-plane radiography. J Biomech2009; 42: 2818–2822.
21.
KobayashiKSakamotoMSoenoT,et al.Accuracy of an image matching technique for assessing knee alignment during the stance phase of gait using single-plane anteroposterior radiography. Biomed Mater Eng2024Preprint. https://doi.org/10.3233/BME-240059.
22.
PerryJBurnfieldMJ. Gait Analysis: Normal and Pathological Function. NJ: Slack Inc, 2010.
23.
LiuJSantucciVEicholtzS,et al.Comparison of the effects of real-time propulsive force versus limb angle gait biofeedback on gait biomechanics. Gait Posture2021; 83: 107–113.
24.
SatoTMochizukiT. Three-dimensional morphology of the distal femur based on surgical epicondylar axis in the normal elderly population. Knee2021; 30: 125–133.
25.
ClémentJBlakeneyWHagemeisterN, et al.Hip-Knee-Ankle (HKA)angle modification during gait in healthy subjects. Gait Posture2019; 72: 62–68.
26.
KimHYKimKJYangDS, et al.Screw-home movement of the tibiofemoral joint during normal gait: three-dimensional analysis. CiOS Clin Orthop Surg2015; 7: 303–309.
27.
ThomeerLGuanSGrayH, et al.Six-Degree-of-Freedom tibiofemoral and patellofemoral joint motion during activities of daily living. Ann Biomed Eng2021; 49: 1183–1198.
28.
LuHLLuTWLinHC,et al.Comparison of body’s center of mass motion relative to center of pressure between treadmill and over-ground walking. Gait Posture2017; 53: 248–253.
29.
KünzlerMHergerSDe PieriE, et al.Effect of load carriage on joint kinematics, vertical ground reaction force and muscle activity: Treadmill versus overground walking. Gait Posture2023; 104: –8.
30.
Vickery-HoweDMBonannoDRDascombeBJ, et al.Physiological, perceptual, and biomechanical differences between treadmill and overground walking in healthy adults: a systematic review and meta-analysis. J Sports Sci2023; 41: 2088–2120.
31.
ClémentJToliopoulosPHagemeisterN, et al.Healthy 3D knee kinematics during gait: differences between women and men, and correlation with x-ray alignment. Gait Posture2018; 64: 198–204.
