Biomechanical Changes Associated With the Osteoarthritic, Arthrodesed,

8/12/2019 Biomechanical Changes Associated With the Osteoarthritic, Arthrodesed,

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Review

Biomechanical changes associated with the osteoarthritic, arthrodesed,

and prosthetic ankle joint

Tristan Barton *, Francois Lintz, Ian Winson

Department of Trauma and Orthopaedics, Avon Orthopaedic Centre, Southmead Hospital, Bristol, United Kingdom

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

2. Spatialtemporal factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

3. Ankle joint kinematics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

4. Ankle joint kinetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

5. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

6. Future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

1. Introduction

Degenerative joint disease of the ankle can result in loss of

function as a consequence of pain, stiffness and deformity[1]. This

disease process can result in significant alterations not only to the

biomechanics of the ankle joint, but to the foot and ankle complex

as a whole. Analysis of the kinematics and kinetics of gait helps to

improve our understanding of the biomechanics of the foot andankle. As the technology and accuracy of gait analysis continues to

develop, the importance of addressing the foot and ankle complex

as a functional unit becomes increasingly apparent in order to

successfully treat foot and ankle pathology [2].

It is now recognised thatit is inappropriate toconsiderthefootas

a simple lever at the distal end of the tibia. Multi-segment models

have been designed in an attempt to isolate the kinematics of the

individual joints within thefoot andanklecomplex [35].Anymodel

will however remain an over-simplification due to the vast number

of articulations within the foot and ankle. Current motion analysis

aims to group such articulating units into segments, with skin

markersindicating the boundaries of each segment (Fig.1). The four

segment models enable the movements of the hind-foot, mid-foot

and forefoot to be measured relativeto thetibia in three dimensions

and are producing more accurate modelling of foot and anklekinematics. Such techniques have the benefit of being non-invasive,

but do have a number of limitations. Firstly, as mentioned above,

each foot segment is a composed of a number of articulations and

therefore the individual influence of the each joint cannot not be

defined. This is of particular relevance in the hindfoot, with respect

to ankle and subtalar joint kinematics. A further problem is that

utilising skin markers. Such markers are placed over the bony

landmarks they represent during motion analysis. Relative move-

ments of thefour segments aresmall,and anyinaccuracies in marker

placement or marker movement relative to the underlying bony

structures will influence the overall analysis.

Foot and Ankle Surgery 17 (2011) 5257

A R T I C L E I N F O

Article history:

Received 26 October 2010

Received in revised form 23 December 2010Accepted 13 January 2011

Keywords:

Biomechanics

Kinematics

Kinetics

Ankle arthrodesis

Ankle replacement

* Corresponding author. Tel.: +44 7970 470533.

E-mail address: [email protected](T. Barton).

Contents lists available at ScienceDirect

Foot and Ankle Surgery

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / f a s

1268-7731/$ see front matter. Crown Copyright 2011 Eurpoean Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.fas.2011.01.010
http://dx.doi.org/10.1016/j.fas.2011.01.010mailto:[email protected]://www.sciencedirect.com/science/journal/12687731http://dx.doi.org/10.1016/j.fas.2011.01.010http://dx.doi.org/10.1016/j.fas.2011.01.010http://www.sciencedirect.com/science/journal/12687731mailto:[email protected]://dx.doi.org/10.1016/j.fas.2011.01.010


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More accurate modelling is achieved utilising methods such as

invasive in vivo techniques and dynamic testing of cadaveric

specimens. Invasive testing using intra-cortical pins certainly

provides more accurate data than utilising skin markers and also

allows assessment of talar motion[6]. This technique is limited by

surgical access to certain aspects of the foot, and the question

remains as to whether the foot behaves normally when gait is

analysed with pins in situ. Studies do suggest that such methods

are valid, and pre- and post-pin insertion pressure studies do show

relative normality of gait despite the presence of intra-cortical

pins[7]. Dynamic assessment of cadaveric specimens does allow

access to all aspects of the foot and ankle complex and has the

benefit of enabling assessment of movement both of thearticulations and the soft tissues [811]. In vitro loading of the

foot and ankle complex is unlikely however to accurately re-create

in vivo gait and loading patterns.

Further tools for the assessment of foot and ankle kinematics

utilise fluoroscopic and magnetic resonance imaging [12,14].

These techniques produce three-dimensional images of the foot

and ankle complex in weight-bearing subjects and enables motion

at individual jointsto be quantified. Using this technique, magnetic

resonance images produces more accurate data, however the

stages of gait can only be reproduced in a static form. Fluoroscopic

imaging allows dynamic analysis of the gait cycle, but the data

obtained is less accurate than that obtained utilising magnetic

resonance imaging.

These developments in the assessment of foot and anklebiomechanics are enabling an improved understanding of the

kinematic and kinetic changes that occur in the diseased ankle

joint. In addition, the effect of surgical treatments of foot and ankle

pathology can now be studied from a biomechanical perspective

and help guide future developments [15]. This is of increasing

relevance in the treatment of degenerative changes within the

ankle joint where traditionally ankle arthrodesis has provided the

most reliable outcome in the operative treatment of symptomatic

ankle arthritis. With continuing improvements in both the

understanding of the biomechanics and the technology of the

implants, the number of ankle replacements performed is steadily

increasing. The outcome following ankle replacement is improving

with respect to both revision rates and functional scores [1619],

but the key to the continuing improvement in implant longevity is

likely to be in the stable fixation of the prosthesis within a well

balanced foot and ankle complex. Recent biomechanical studies

suggest that if the prosthesis is misaligned, polyethylene wear and

implant survival is likely to be compromised[2022].

2. Spatialtemporal factors

A painful ankle joint results in changes to both the pattern and

velocity of gait. The majority of studies report both cadence (steps/

minute) and stride length to be reduced,with patients spendingless

time on the affected limb in stance[2325]. The overall effect of

these changes is a reduction in walking speed with an asymmetric

gait and resultant limp. This is likely to represent a protective

mechanism in order to reduce the load passing across the diseased

joint[26]. Interestingly,Dyrbyet al.foundcadenceto be significantly

increased in patients witharthriticankles compared withunaffected

controls, but this increase was not sufficient to normalise walking

speed due to the reduced stride length[27].

Following ankle arthrodesis, there is a significant improvement

in walking speed[2832]. This however does remain significantly

reduced when compared with controls. Thomas et al. found the

reduction in walking speed to be a consequence of a reduction in

both cadence and stride length[31]. Mazur et al. and Beyaert et al.

however found cadence to be comparable with controls post-arthrodesis, and the reduced walking speed to be a consequence of

a significant reduction in stride length[28,29]. These studies both

showed a normalisation in the proportion of gait spent in stance

phase on the affected side. Wu et al. reported differing findings

with an increase in cadence in the arthrodesed patient group

compared with controls, although this was not found to be

statistically significant. The authors of this paper also noted a

significantlyincreased proportion of time spent in the swing phase

of gait on the affected limb in the arthrodesed group [32].

The early studies looking at the spatialtemporal parameters of

gaitfollowing ankle replacementshoweddisappointing resultswith

minimal if any improvement in cadence, stride length and walking

speed[24,33]. As a consequence of improvements in both implant

and surgical technology, the results of more recent studies usingsecond generation prosthetic designs are encouraging. Such studies

report the majority of spatialtemporal variables to be significantly

improved following ankle replacement. As following arthrodesis

however, these remain significantly reduced when compared with

controls [27,3437]. Valderrabano et al. reported in 2007 that all

spatialtemporal factors were comparable with controls in 15

patients at 12 months following ankle replacement using the

Hintegra prosthesis [25]. Further gait studies have shown the

improvement in post-operative walking velocity to be a result of an

increase in cadence rather than stride length[35,37]. Interestingly,

Doets et al. found walking velocity to be comparable with controls

following ankle replacement in rheumatoid patients, but to remain

significantly reduced in treated patients with osteoarthritis[36].

A proposed benefit of performing an ankle replacement asopposed to an arthrodesis is that of reproducing a more normal

gait pattern. Interestingly, when comparing the two modalities,

Piriou et al. noted walking speed to be closer to normal following

arthrodesis than ankle replacement. This improved speed follow-

ing ankle arthrodesis was at theexpense of thesymmetrical timing

of gait and therefore patients walked with a more apparent limp.

Ankle replacement was found to produce a gait pattern that more

closely replicated that of controls, but with a slower velocity[30].

3. Ankle joint kinematics

Kinematics is the study of movement of the body in space

without consideration of the forces that cause that movement. Gait

analysis performed on normal individuals reveals that there are

[

Fig. 1. Placement of skin markers for gait analysis [56].

T. Barton et al. / Foot and Ankle Surgery 17 (2011) 5257 53


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large variations in the kinematics of the foot and ankle [4,38,39].

This individuality of biomechanics therefore creates problems

when tryingto surgically recreate what is considered to be normal

biomechanics in patients with foot and ankle pathology. The

painful degenerate ankle joint has major implications on joint

kinematics, and much work has focused on defining the effect of

these changes. Early work on ankle biomechanics by Stauffer et al.

reported a reductionin sagittal plane ankle joint motion in patients

with a diseased ankle[24]. During gait, there was a reduction in

dorsiflexion with the majority of ankle motion occurring in a

plantarflexed positon through both the stance and swing phases.

Valderrabano et al. recorded hindfoot kinematics in patients with

ankle arthrosis and found a reduction in motion in all planes. The

most noticeable reduction when compared to normal subjects

again occurred, as would be expected, in the sagittal plane[25].

Khazzam et al. utilised the Milwaukee four segment foot model to

analyse the kinematics of both the hindfoot and the forefoot in

patients with ankle arthrosis compared with unaffected controls

[23]. The authors reported affected patients to have a global

decrease in the dynamic range of motion throughout all foot and

ankle segments as compared to normal. In the hindfoot, affected

patients demonstrated excessive external rotation throughout

gait, and were noted to have reduced hindfoot eversion from load

response through to terminal stance. In the forefoot, a decrease inmotion in all planes was noted, and in particular, there was an

absence of varus rotation at toe-off which was present in the

unaffected patients.

Leardini et al. [13] and De Asla et al. [12] have described a

coupling between the ankle and subtalar joints during hindfoot

motion [12,13]. Using combined magnetic resonance and dual

fluoroscopic imaging techniques, Kozenak et al. furthered this work

andreported on thekinematicsof thetibiotalar andsubtalar joints in

patients with ankle arthrosis. The authors reported that in patients

witha degenerative ankle joint, in addition to a reduction in subtalar

rotation,the direction of rotation wasreversed whencomparedwith

normalindividuals [14]. As a consequenceof this, motioncoupling of

the tibiotalar and subtalar joints is lost in patients with ankle

arthosis, with both joints externally rotating during stance. Theauthors confirmed the findings of Khazzam et al. in reporting a

reduction in hindfoot internal rotation, which reached statistical

significance in the subtalar joint from midstance to toe-off.

As would be expected, ankle arthrodesis significantly reduces

hindfoot movements in the sagittal plane [29,31,32,4042]. A

degree of hindfoot motion in this plane is preserved secondary to a

mobile subtalar joint [2932]. Cadaveric work performed by

Valderrabano et al. found hindfoot motion to be significantly

reduced in all planes following arthrodesis and these findings have

been reproduced during gait analysis [911]. This reduction in

hindfoot motion in the coronal and transverse planes is likely a

consequence of either pre-existing or progression of degenerative

changes within the subtalar joint[31,40,42,43].

The second rocker of gait as defined by Perry is characterised byforward progression of the tibia relative to the hindfoot through

the stance phase of gait (Fig. 2) [44]. This motion is reduced

following ankle arthrodesis, resulting in knee hyper-extension

during late stance [28,29,32,42]. In addition to knee hyper-

extension, relative forward progression of thetibiais enabled by an

early heel lift in order to increase the tilt of the tibia relative to the

floor although not to the hindfoot [28,45,46]. If the ankle is

arthrodesed in slight plantarflexion, knee hyperextension is

required to enable a foot flat to the ground[29,42].

Oneof theprinciple concerns following ankle arthrodesis is that

of the adverse effect on the neighbouring joints of the foot and

ankle complex. Clinical studies support the theory of secondary

midfoot degenerative changes as a consequence of compensatory

hyper-extension through the mid-foot. Gait analysis however

shows motion through the midfoot following ankle arthrodesis to

be unpredictable with studies reporting both increases[29,32,46

48] and decreases [31,49,50] in forefoot motion relative to the

hindfoot. In reality, midfoot motion following ankle arthrodesis is

likely to be dependent on a number of factors. These include the

presence of pre-existing arthritic changes within the midfoot joints

[43], the progression of degenerative changes as a result of

increased stresses, and the position of the arthrodesis itself. The

employment of a variety of motion segment models and the

inherent inaccuracies of assessing the relative small movements of

the forefoot may provide additional explanations for these

discrepancies.Gait analysis following the first generation of ankle replace-

ments showed ankle movement to be preserved, although failure

rates with the early constrained designs were found to be

unacceptable [24,33]. Cadaveric testing of the newer implant

designs showed recovery of plantarflexion (Agility, Hintegra) and

inversion/eversion (Hintegra, STAR) when compared with normal

specimens [9]. The first reports of gait analysis following ankle

replacement with second generation designs were published in

2004. Brodsky et al. reported on eleven patients who underwent

ankle replacement with the STAR prosthesis and found a

significantly improved range of ankle motion in the sagittal plane

[34]. In the same year Dyrby et al. reported on pre- and post-

operative gait analysis in nine patients, again with the STAR

prosthesis, but found no significant improvement in ankle range ofmovement, which remained significantly reduced when compared

with controls[27].

Doets et al. reviewed the gait analysis in ten patients following

an ankle replacement with the BuechelPappas prosthesis and

found them to have a reduced range of dorsiflexion compared to

controls but a similar degree of plantarflexion. During normal gait

however, the extremes of movement in the sagittal plane were not

required and the range of motion was found to be comparable

between the two groups[36]. More recent studies show motion in

the sagittal plane to be improved post-operatively but to remain

reduced when compared with controls. More importantly, they

report a more physiological pattern of gait in this plane,

particularly during the second rocker [25,37]. Coetzee et al.

reported on radiographic assessment of ankle range of motionfollowing ankle replacement and found this to be improved

following ankle replacement but to a lesser extent than clinical

assessment would suggest [51]. The authors concluded that

clinical assessment of hindfoot motion is likely to include both

hindfoot and midfoot movements, and that accurate assessment of

tibiotalar motion requires radiographic measurements.

The assessment of hindfoot motion in the coronal plane

produce varying results, however the magnitude of readings in

this plane are an order of magnitude lower that at the tibio-talar

joint and therefore the significance of differing readings is less

clear. Valderrabanoet al. and Doets et al. reported an improvement

in the total range of motion of the hindfoot in the coronal plane

following ankle arthroplasty to levels comparable with unaffected

individuals [25,36]. Ingrosso et al. however found conflicting

[

Fig. 2. Perrys rockers of gait[57].

T. Barton et al. / Foot and Ankle Surgery 17 (2011) 525754


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results with no change in range of motion in this plane post-

operatively [37]. With regards to mid-tarsal movement, no

significant differences were noted between controls and patients

either pre- or post-arthroplasty [25,36]. The progression of

degenerative changes in the neighbouring joints of the foot and

ankle has been reported following ankle replacement as well as

ankle fusion, but to a lesser extent. Knecht et al. found that at a

mean of 7.2 years following total ankle replacement with the

Agility prosthesis, the grade of arthritis within the subtalar and

talonavicular subtalar increased by 19% and 15% respectively[52].

4. Ankle joint kinetics

Kinetics is the study of movement and the forces that cause that

movement. The vertical ground reaction force (GRF) profile of the

normal foot has the characteristic appearance of two peaks

representing heel strike and toe-off and a trough between these

peaks representing mid-stance (Fig. 3). The vertical peaks are at

approximately 115% of total body weight with the trough at 80%.

Fore-aft shear force in early stance is approximately 15% of body

weight and represents a braking force with the centre of gravity

falling behind the heel. As the centre of gravity moves forward over

the anklejoint,a reversal ofthe shearforces isseenin anaft direction

of a similar magnitude. In a medial to lateral direction, the shear

force is initially medially before moving laterally for the remainder

of stance with a maximal magnitude of 5% of body weight.

The pattern of ground reaction forces in patients with ankle

arthritis does not significantly differ from unaffected patients, but

the magnitude of the vertical peaks is reduced. This change is most

significant at the second vertical peak representing a reduction in

the forces at toe-off. The shear forces have been shown to be

similar between controls and affected patients [53]. There is a

global reduction in moment forces in the arthritic ankle, with the

most significant reduction the transverse plain (adduction

moment). The reduction in forces working across the arthritic

ankle have been hypothesised to be a result of muscle weakness

secondary to disuse atrophy [25] A further theory is that the

reduced forces have a protective effect by reducing joint loading

and shear forces[26,54].

Ankle arthrodesis results in a global reduction in the vertical

ground reaction forces due to a combination of joint stiffness and

muscle weakness. As confirmed by hindfoot kinematics, early heel

lift is evident with an early drop in the first vertical GRF. Beyaert

et al. analysed the location of the vertical GRF with respect to the

ankle joint. The authors found that patients with an arthrodesed

ankle demonstrated a forward shift of the GRF during the stance

phase of gait compared with controls. In addition, the GRF during

the third rocker was directed posterior to rather than through the

line of the metatarsal heads. This change in orientation of the

vertical GRF may provide a further biomechanical explanation for

the increase in mid-tarsal symptoms in patients following an ankle

arthrodesis[28].

Ankle replacement has been shown to improve the vertical

ground reaction force magnitude [55], but the second vertical peak

does notreach normal levels [25,36]. One cause of this reduction inthe vertical forces is likely to be a result of longstanding weakness

of the triceps surae that is not fully recoverable post-arthroplasty.

This theory has been re-enforced by EMG studies[37]. There is a

reduction in the plantarflexion and adduction external moment

measurements in patients post ankle replacement relative to

normal subjects. These values were found to be reduced pre-

operatively and did not significantly improve following joint

replacement. Dyrby found a significant improvement in ankle

dorsiflexion external moments following arthroplasty to levels

comparable with unaffected controls. Ankle inversion moments

did not improve significantly in this study and remained reduced

compared to normal subjects [27]. The global reductions in joint

moments are again likely a result of both protective mechanisms

and long-standing muscle weakness.Ingrosso et al. performed kinetic studies pre- and post-ankle

arthroplasty using the B0X prosthesis and found no significant

improvement in any of the measured kinetic parameters. The

authors do however report a normalisation of the internal

plantarflexion moment at mid-stance at the single support phase.

This study also performed EMG analysis and found that the co-

contacture of tibialis anterior and gastrocnemius in mid-stance

which was absent in the arthritic ankle was fully restored following

ankle arthroplasty[37]. A study published in 2009 by Detrembleur

et al. stressed the importance of performing comparative gait

analyses at similar speeds. This enables comparisons of gait to be

made before and after ankle arthroplasty thataccuratelyrepresent a

true consequence of the ankle replacement and not a result of

variations in walking velocity. The authors found the vertical centreof mass displacement to be significantly improved following ankle

replacement, resulting in a less flat footed walking pattern and

decreased energy expenditure during gait[35].

5. Summary

The diseased ankle joint results in significant biomechanical

changes within the foot and ankle complex. Gait is asymmetric,

and walking velocity is reduced as a consequence of reduced

cadence andstride length. Hindfoot motion is reduced in all planes,

and this reduction is mirrored in the forefoot. The coupling of

motion within the ankle and subtalar joints seen in normal

subjects is lost, and kinetic studies show a reduced magnitude of

the vertical ground reaction force peaks. Ankle arthrodesis

[

Fig. 3. Graphs demonstrating ground reaction forces during ambulation [58].



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improves walking speed although the asymmetry of gait remains.

Hindfoot motion is reduced in all planes, and forward progression

of the tibia through stance is aided by knee hyper-extension and

early heel lift. Kinetic studies confirmthe early heel lift andreveal a

posterior displacement of the ground reaction force through late

stance increasing the forces through the midfoot region. Ankle

replacement produces a more symmetrical walking pattern, as

well as an improvement in overall velocity. Kinematics is

significantly improved but remain reduced when compared with

unaffected subjects. The pattern of hindfoot motion more closely

resembles unaffected controls when compared with ankle arthro-

sis or arthrodesis. A similar improvement is seen in kinetic analysis

following ankle replacement, however external moments do not

reach normal levels as a consequence of long standing muscle

weakness.

6. Future directions

There is an increasing understanding of the biomechanics of the

foot and ankle complex, in particular following ankle arthrodesis

and ankle replacement. The ultimate aim of such research is to

guide improvements in the non-surgical and surgical treatment of

foot and ankle pathology and to this end our understanding is stilllimited. Gait analysis remains an overall summary of foot and

ankle biomechanics, without providing accurate information as to

the kinematics and kinetics across individual joints during gait. A

further issue is that of the changing direction and magnitude of

forces across joints through the stages of gait, and this remains of

particular relevance for the ankle replacement. Improving the

longevity of such implants is essential if they are to remain a valid

option in the treatment of the diseased ankle joint. When

performing an ankle replacement, consideration must be given

to the balance of the foot as a whole, and in particular with

reference to the forefoot. Further studies are required with respect

to the kinetics following ankle replacement in order to ascertain

whether we are accurately able to balance the forces across the

prosthesis which is essential to improve outcome and implant

survival. This is of increasing importance as such procedures are

being performed on patients with increasing degrees of hindfoot

and forefoot deformities.

Conflict of interest statement

There are no conflicts of interest.

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