Évaluation biomécanique de la marche pour le développement d’orthèses plantaires imprimées en 3D : application à une population ayant les pieds plats

Le pied plat flexible affecte 20-25% de la population adulte. Il est caractérisé par un affaissement anormal de l’arche longitudinale médiale en charge ainsi qu’une pronation excessive du pied. Les orthèses plantaires (OPs) représentent la prise en charge conservatrice la plus fréquemment utilisée au regard de cette pathologie. Toutefois, il existe un manque de consensus quant à leur effet bénéfique, notamment à cause de la variété d’OPs (géométrie et matériaux) utilisée. Ces dernières années, le développement des techniques d’impression 3D a permis d’innover et de faciliter la production d’OPs sur-mesure. Les réalisations actuelles ne se sont cependant limitées qu’à des formes monolithiques reposant sur la forme du pied. L’objectif de cette thèse est d'approfondir les connaissances relatives à l’impact des OPs sur la biomécanique du pied plat, afin d’aider au développement et à l’évaluation d’une OP originale imprimée en 3D. À cet égard, trois objectifs spécifiques ont été définis : (1) investiguer l’effet de la forme géométrique des orthèses plantaires chez des personnes ayant des pieds plats flexibles ; (2) quantifier l’effet de la rigidité d’OPs imprimées en 3D et celle de l’addition d’éléments anti-pronateurs novateurs sur la cinématique du pied ainsi que les pressions plantaires ; (3) évaluer l’impact d’OPs sur-mesure imprimées en 3D sur la biomécanique des membres inférieurs chez des personnes ayant des pieds plats. Par la réalisation d’une revue systématique avec méta-analyse, l’effet de la forme géométrique des OPs sur la cinématique et la cinétique du membre inférieur lors de la marche chez des personnes ayant les pieds plats a pu être déterminé. Seules les études ayant clairement décrit les modifications géométriques des OPs utilisées ont été incluses. Elles ont ensuite été divisées en cinq groupes en fonction de leur forme géométrique : avec stabilisateur d’arrière-pied médial, avec stabilisateur d’avant-pied médial, avec combinaison d’un stabilisateur d’arrière-pied et d’avant-pied médial, avec stabilisateur neutre, et avec support d’arche. La revue a ainsi mis en évidence que l’utilisation de stabilisateur médiaux était la modification géométrique la plus efficace pour réduire l’éversion de l’arrière-pied et ainsi contrôler la pronation excessive. Cependant, l'hétérogénéité dans les protocoles expérimentaux contribue à la faible évidence au regard des effets des OPs sur la biomécanique de la marche chez des personnes ayant les pieds plats. Sur la base des observations tirées de notre revue de la littérature, des stabilisateurs d’arrière-pied innovants (neutre avec extension sous l’arche) ont été développés pour être utilisés avec une OP originale imprimée en 3D. Par conséquent, l’objectif de notre deuxième étude était de quantifier l’effet de ces stabilisateurs mais aussi de déterminer l’impact de la rigidité de notre OP sur la cinématique du pied et les pressions plantaires. Pour se faire, 15 hommes en bonne santé et ayant les pieds neutres (pointure 9.5-10 US) ont été recrutés afin de s’affranchir de l’interaction possible avec une pathologie. Ainsi, il a été mis en évidence qu’une augmentation de la rigidité était associée à une réduction plus importante de l’éversion à l’arrière-pied (Différence Moyenne (DM) = -0.83°). Cette dernière a d’autant plus été réduite par l’ajout de stabilisateurs (DM = -1.15° et -2.43°). Au niveau des pressions plantaires, outre le transfert de la charge vers le médio-pied induit par le port des OPs, l’augmentation de la rigidité a contribué à accentuer les pics de pression sous l’arche et l’arrière-pied (DM de +21.6% à +31.7%). Enfin, notre troisième étude avait pour but d’évaluer l’impact d’OPs personnalisées et imprimées en 3D sur la biomécanique des membres inférieurs chez des personnes ayant des pieds plats. Pour ce faire, 19 patients recrutés par l’intermédiaire de podiatres ont reçu deux paires d’OPs sur-mesure, respectivement flexible et rigide, et ont participé à une évaluation biomécanique (cinématique, cinétique, pressions plantaires). L’augmentation de la rigidité n’a eu que peu d’effets sur la cinématique et les efforts articulaires. Elle a cependant été associée à une augmentation des pressions sous l’arche (DM = +34.4% pour la pression moyenne). L’effet de notre stabilisateur a également été quantifié. Il a été associé à une réduction significative de l'éversion à l’arrière-pied (DM = -2.0°), une réduction du moment interne d'inversion à cheville (DM = -0.03 Nm/kg), et à une légère augmentation du moment interne d’abduction au genou (DM ≈ +0.04 Nm/kg). Dans l’ensemble, le présent travail de thèse a permis de mieux saisir les mécanismes d’action des OPs sur la biomécanique des personnes ayant les pieds plats, de guider le développement d’une OP imprimée en 3D et de stabilisateurs d’arrière-pied innovants, et de confirmer que l’ajout d’éléments anti-pronateurs est essentiel afin d’observer un impact bénéfique des OPs sur le contrôle de la pronation excessive.Flatfoot has been reported to affect around 20–25% of the adult population. It is defined by an abnormally low medial longitudinal arch upon weight bearing and an excessive foot pronation. Foot orthoses (FOs) have commonly been used as a conservative treatment to manage this deformity. However, due to the variety of FOs (geometrical designs and materials) that have been used, there is still low evidence of their beneficial effect. In recent years, the advent of 3D printing techniques has facilitated the production of innovative and customized FOs. Yet, current achievements are limited to monolithic form based on the foot shape. The objective of this thesis was to deepen the knowledge relative to FOs’ impact on flatfoot biomechanics, in order to help the development and the assessment of an original 3D printed FO. Three specific objectives were defined for this purpose: (1) investigate the effect of FOs, based on their geometrical design, in individuals with flexible flatfeet; (2) asses the effect of 3D printed FOs stiffness and newly designed anti-pronator components on foot kinematics and plantar pressures; and (3) evaluate the impact of custom 3D printed FOs on lower extremity biomechanics in individuals with flatfeet. Though a systematic and meta-analysis review, the effects FOs geometrical design on lower limb kinematics and kinetics during walking in people with flatfeet has been determined. Only studies that clearly described FOs geometrical design were included. They were then categorized into five groups based on the geometrical design of FOs: with medial rearfoot posting, with medial forefoot posting, with a combination of forefoot and rearfoot posting, with neutral rearfoot posting, and with arch support. The review highlighted that medial postings are the most effective FO feature to reduce the rearfoot eversion and therefore control excessive foot pronation. However, heterogeneity between study protocols contributes to low evidence of beneficial effects of FOs on flatfeet biomechanics during walking. Based on our literature review, innovative rearfoot postings (neutral with an extension under the medial arch) have been developed for an original 3D printed FO. Hence, our second study aimed to determine the effect of these postings as well as the stiffness of our FO on foot kinematics and plantar pressures. To do so, a study involving 15 healthy men with neutral feet (shoe size 9.5-10 US) was carried out. Healthy people were recruited to avoid any interaction with a pathology. The study showed that increasing FOs stiffness was associated to a greater reduction in rearfoot eversion (Mean Difference (MD) = -0.83°). Rearfoot eversion was further decreased when adding the rearfoot postings (MD = -1.15° and -2.43°). Looking at plantar pressures, besides a shift of the loads to the midfoot region while wearing FOs, higher peak pressures under the rearfoot and the medial arch (MD from +21.6% to +31.7%) were observed when increasing the FOs stiffness. Finally, the third study aimed at evaluating the impact of custom 3D printed FOs on lower extremity biomechanics in individuals with flatfeet. Nineteen patients, recruited by experienced podiatrists, were given two pairs of custom 3D printed FOs and participated in a biomechanical analysis (kinematics, kinetics, plantar pressures). Increasing FOs stiffness had little effects on kinematics and joint moments. However, it resulted in higher plantar pressures under the arch (MD = +34.4% for mean pressures). The addition of our rearfoot posting was associated with notable effects; it significantly reduced the eversion angle (MD = -2.0°) and inversion moment at the ankle (DM = -0.03 Nm/kg), and increased slightly the knee abduction moment (MD ≈ +0.04 Nm/kg). Overall, the present thesis has provided a better understanding on how FOs impact the biomechanics of individuals with flatfeet, helped the development of a 3D printed FO as well as innovative rearfoot postings, and confirmed that anti-pronator components are essential to observe a beneficial impact of FOs on the control of excessive foot pronation

Effect of 3D printed foot orthoses stiffness and design on foot kinematics and plantar pressures in healthy people

Background Foot orthoses (FOs) have been widely prescribed to alter various lower limb disorders. FOs’ geometrical design and material properties have been shown to influence their impact on foot biomechanics. New technologies such as 3D printing provide the potential to produce custom shapes and add functionalities to FOs by adding extra-components. Research question The purpose of this study was to determine the effect of 3D printed FOs stiffness and newly design postings on foot kinematics and plantar pressures in healthy people. Methods Two pairs of ¾ length prefabricated 3D printed FOs were administered to 15 healthy participants with normal foot posture. FOs were of different stiffness and were designed so that extra-components, innovative flat postings, could be inserted at the rearfoot. In-shoe multi-segment foot kinematics as well as plantar pressures were recorded while participants walked on a treadmill. One-way ANOVAs using statistical non-parametric mapping were performed to estimate the effect of FOs stiffness and then the addition of postings during the stance phase of walking. Results Increasing FOs stiffness altered frontal and transverse plane foot kinematics, especially by further reducing rearfoot eversion and increasing the rearfoot abduction. Postings had notable effect on rearfoot frontal plane kinematics, by enhancing FOs effect. Looking at plantar pressures, wearing FOs was associated with a shift of the loads from the rearfoot to the midfoot region. Higher peak pressures under the rearfoot and midfoot (up to +31.7 %) were also observed when increasing the stiffness of the FOs. Significance 3D printing techniques offer a wide range of possibilities in terms of material properties and design, providing clinicians the opportunity to administer FOs that could be modulated according to pathologies as well as during the treatment by adding extra-components. Further studies including people presenting musculoskeletal disorders are required

Predicting foot orthosis deformation based on its contour kinematics during walking.

BACKGROUND:Customized foot orthoses (FOs) are designed based on foot posture and function, while the interaction between these metrics and FO deformation remains unknown due to technical problems. Our aim was to predict FO deformation under dynamic loading using an artificial intelligence (AI) approach, and to report the deformation of two FOs of different stiffness during walking. METHODS:Each FO was fixed on a plate, and six triad reflective markers were fitted on its contour, and 55 markers on its plantar surface. Manual loadings with known magnitude and application point were applied to deform "sport" and "regular" (stiffer) FOs in all regions (training session). Then, 13 healthy male subjects walked with the same FOs inside shoes, where the triad markers were visible by means of shoe holes (walking session). The marker trajectories were recorded using optoelectronic system. A neural network was trained to find the dependency between the orientation of triads on FO contour and the position of markers on its plantar surface. After tuning hyperparameters and evaluating the performance of the model, marker positions on FOs surfaces were predicted during walking for each subject. Statistical parametric mapping was used to compare the pattern of deformation between two FOs. RESULTS:Overall, the model showed an average error of <0.6 mm for predicting the marker positions on both FOs. The training setup was appropriate to simulate the range of triads' displacement and the peak loading on FOs during walking. Sport FO showed different pattern and significantly higher range of deformation during walking compared to regular FO. CONCLUSION:Our technique enables an indirect and accurate estimation of FO surface deformation during walking. The AI model was capable to make a distinction between two FOs with different stiffness and between subjects. This innovative approach can help to optimally customize the FO design