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Gait Analysis and Functional Outcomes Following Ankle Arthrodesis for Isolated Ankle Arthritis
Rhys Thomas, FRCS(Orth)1; Tim R. Daniels, MD, FRCSC1; Kim Parker, PEng1
1 Suite 800, 55 Queen Street East, Toronto, ON M5C 1R6, Canada. E-mail address for T.R. Daniels: danielst@smh.toronto.on.ca
View Disclosures and Other Information
Note: The authors thank Dr. John Rooney and Christie MacDonald for their contributions to this study.
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at St. Michael's Hospital and Bloorview MacMillan Children's Centre Gait Laboratory, Toronto, Ontario, Canada

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Mar 01;88(3):526-535. doi: 10.2106/JBJS.E.00521
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Abstract

Background: The functional outcomes following ankle arthrodesis are not known. The purpose of the present study was to compare the intermediate-term clinical results for a group of patients in whom an ankle arthrodesis had been performed with use of modern surgical techniques with the findings for a group of healthy gender and age-matched controls on the basis of validated outcome measures and gait analysis.

Methods: Twenty-six patients who had undergone ankle arthrodesis for the treatment of isolated unilateral ankle arthritis were identified and retrospectively assessed clinically and radiographically. The mean age at the time of surgery was fifty-four years, and the mean interval between surgery and assessment was forty-four months. A gender and age-matched control group of twenty-seven individuals was recruited for comparison. All subjects were evaluated with gait analysis, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale, the Musculoskeletal Outcomes Data Evaluation and Management Systems (MODEMS) questionnaire, and the Ankle Osteoarthritis Scale (AOS).

Results: On preliminary review, twenty of the twenty-six patients were completely satisfied or satisfied with their surgical outcome. All patients but one stated that they would undergo the surgery again. Five patients stated that they did not notice a gait abnormality. Twelve patients wore orthotics, and all believed that the use of the orthotics improved their gait. When the functional outcome scores in the arthrodesis group were compared with those in the control group, specific scores assessing hindfoot pain and satisfaction were similar. However, scores focusing on ankle-hindfoot function and disability revealed significant differences. Gait analysis also identified significant differences between the two groups with regard to cadence and stride length. In addition, there was significantly decreased sagittal, coronal, and transverse range of motion of the hindfoot and midfoot during the stance and swing phases of gait in the arthrodesis group. Radiographic review demonstrated that four of the twenty-six patients had development of moderate to severe arthritis of the subtalar joint.

Conclusions: In the intermediate term following an arthrodesis for the treatment of end-stage ankle arthritis, pain is reliably relieved and there is good patient satisfaction. However, there are substantial differences between patients and the normal population with regard to hindfoot function and gait. On the basis of these results, patients should be counseled that an ankle fusion will help to relieve pain and to improve overall function; however, it is a salvage procedure that will cause persistent alterations in gait with a potential for deterioration due to the development of ipsilateral hindfoot arthritis.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Tim R. Daniels, M.D., FRCSC
    Posted on March 19, 2006
    Dr. Daniels responds to Dr. Jones
    Associate Professor, University of Toronto, CANADA

    I thanks Dr. Jones for his letter. Please note that the conclusion of our paper was that ankle fusion neither normalizes function nor does it create disability. However, all the patients in our study felt that they were better off after the ankle fusion.

    Comparing one handicapped group to another does not help determine the short-comings of a treatment intervention. As orthopaedic surgeons our ultimate goal should be to normalize function; it is my personal belief that this can only be achieved by preserving motion.

    The reason for our strict inclusion criteria was to make the two groups as comparable as possible. Those patients that had substantial ipsilateral arthritis requiring surgical fusion were excluded. Please note that our radiographic follow-up focused on progression of ipsilateral hindfoot arthritis. I agree with Dr. Jones that the natural history of the ipsilateral hindfoot joints in the presence of ankle arthritis is unknown - this area requires further study. However, I would caution against advising patients that ‘the progression of ipsilateral hindfoot arthritis is due to the pre-existing disease’ – to date this conclusion is based on anecdotal information.

    Gary S. Jones, M.D.
    Posted on March 11, 2006
    Does ankle fusion cause foot arthritis?
    Concord Orthopaedics, P.A., Concord, NH

    To The Editor:

    I disagree with the conclusion of the authors that ankle fusion “creates disability with regard to foot and ankle function.” This is a statement oft repeated in the orthopaedic literature that sounds reasonable but must be challenged.

    Comparing patients with ankle arthritis to a normal patient with regard to the development of mid and hindfoot arthritis or gait analysis is not a fair comparison. Patients with even “isolated” ankle arthritis due to trauma or primary arthritis when viewed retrospectively, cannot be said to have normal subtalar or midfoot joints. This is true for the present study as well as the retrospective study of Said, et.al.(1) These patients have often had internal or external fixation and/or had prolonged casting. In addition, after trauma, though the radiological injury may be limited to the ankle, there are often unrecognized subtalar or midfoot injuries. In my twenty-seven years of othopaedic practice, it is rare to see a patient with debilitating ankle arthritis who has normal subtalar motion.

    A proper study of this question would require the comparison of patients with ankle arthritis who were not treated with fusion with those who were. Or perhaps it would be helpful to do a prospective study of patients with ankle fusion compared to patients with total ankle with regard to development of arthritis in the hindfoot and midfoot.

    I have no quarrel with the concept that patients with ankle fusion have more impairment than normal. However, we don’t operate on normal ankles. The cogent point for our patients is that well done fusions reduce disability. While I do tell my patients that they may later be troubled with arthritis in the foot, even to the point of requiring further surgery (rare), I believe this is most often due to preexisting disease. I choose to emphasize that we are making a bad situation much better.

    References:

    1. Said E, Hunka L, Siller TN. Where ankle fusion stands today. J Bone Joint Surg Br. 1978;60:211-4.

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