SLR - January 2015 - Brett J. Waverly
Improvement in Gait Following Combined Ankle and Subtalar Arthrodesis
Reference: Tenenbaum S, Coleman SC, Brodsky JW. Improvement in Gait Following Combined Ankle and Subtalar Arthrodesis. J Bone Joint Surg Am. 2014 Nov 19;96(22):1863-9.
Scientific Literature Review
Reviewed By: Brett J. Waverly, DPM
Residency Program: HealthPartners Institute for Education and Research/Regions Hospital
Podiatric Relevance: Evaluation of function in regards to gait following arthrodesis of the ankle and subtalar joints in advanced arthritis. Ankle and subtalar joint arthrodesis remains the standard of care in those with end stage arthritis. This article compares gait performance in those prior to ankle and subtalar joint fusion with advanced arthritis to one year postoperative. They hypothesized that arthrodesis of the ankle and subtalar joint will improve function as demonstrated with gait analysis compared to preoperative gait function.
Methods: Prospectively studied 21 (14 male and seven female) patients with severe hindfoot and ankle arthritis underwent unilateral tibiotalocalcaneal arthrodesis with retrograde intramedullary nail. Mean age was 59 years old. Mean follow-up was 17 months. All patients went on to fusion. 3D gait analysis was performed preoperative within two weeks prior to surgery and at a minimum of one year postoperative. Patients were able to walk barefoot at a desired speed for roughly 10 meters. Twenty gait cycles were used for gait analysis. Temporospatial measurements of cadence, step length, walking velocity, and total support time were obtained. Kinematic parameters were sagittal plane motion including mean peak plantarflexion and dorsiflexion of the ankle. Kinetic parameters were sagittal plane ankle power and moment and hip power. Symmetry of gait was analyzed by comparing the step lengths of the affected and unaffected limbs. Pared t test were used to compare the preoperative and postoperative values for each perimeter for each patient with 95 percent confidence intervals significance was set up that p < 0.05.
Results: Data shows significant improvement when looking at multiple parameters of postoperative gait compared to the preoperative function with ankle and subtalar arthrodesis. Temporospatial data showed significant increases in cadence with 106 steps a minute to 110 steps a minute and walking speeds from 1.0 to 1.1 m/s (p = 0.03 and 0.001, respectively) and decreases in total support time or both limbs (p = 0.02). Kinematic results were significant with sagittal plane ankle motion decreased 13.2° preoperatively to 10.2° postoperatively in the operative limb and increased from 22.2° to 24.1° (p= 0.01) in the contralateral limb. Hip motion on the affected side increased from 39° to 43° (p= 0.007) and knee motion increased from 56° to 60°. Kinetic data was significant for increase in ankle moment from 1.0 to 1.3 Nm/kg (p < 0.0001) and hip power from 0.7 to 0.9 Nm/Kg (p = 0.005) on the affected limb. There is no change in ankle power on the affected limb, but significant change in ankle power on the unaffected limb. Overall there is significant improvement in gait symmetry, p= 0.01, with preoperative asymmetry of gait measured at 5.02 cm and no significant difference in asymmetry postoperatively.
Conclusions: Arthrodesis of the tibiotalar calcaneal joints has been a successful treatment in severe arthritis and deformity of the ankle and hindfoot. This study demonstrates significant improvement in multiple measured parameters in gait analysis. The results of the study were similar to those found in other studies concerning gait evidence and walking speeds after ankle and hindfoot arthrodesis with range of 106 to 112 steps a minute and 0.99 to 1.2 m/s, respectively. Step length of the affected limb did not increase in our study though step length with the unaffected limb had a significant increase. This can be attributed to increased stability of the patient and push off on the affected limb postoperatively, decrease in pain, or stability of arthrodesis. Sagittal plane motion in the affected limb postoperatively was a small decrease compared to unaffected limb. This likely relates to the preoperative limitations within the ankle joint. Postoperatively gait symmetry significantly improved. Gait symmetry is usually expressed as the difference in gait parameters between the affected and unaffected limbs. The improved gait symmetry is also seen in Piriou, et al. when evaluating pre- and postoperative gait analysis with total ankle arthroplasty. Gait symmetry is an important measure as it corresponds to perception of limping, which may affect patient’s satisfaction and self-image. This study had numerous strengths including objective measures within the gait analysis. The study was limited as it only applied to those with severe arthritis of ankle and hindfoot undergoing arthrodesis with intramedullary nail. The study was not able to measure the difference in gait from a pain versus mechanical stability perspective. Overall, there is an objective improvement in ambulatory function with arthrodesis of the ankle and subtalar joint.