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 signicant 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 and
ankle. 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 nowrecognisedthat it is inappropriate toconsider the foot as
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 withinthefoot andanklecomplex[35]. Anymodel
will however remain an over-simplication 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
markers indicating 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 relative to the tibia inthree dimensions
and are producing more accurate modelling of foot and ankle
kinematics. Such techniques have the benet 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 inuence of the each joint cannot not be
dened. 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, andanyinaccuracies inmarker
placement or marker movement relative to the underlying bony
structures will inuence 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 2010
Accepted 13 January 2011
Keywords:
Biomechanics
Kinematics
Kinetics
Ankle arthrodesis
Ankle replacement
* Corresponding author. Tel.: +44 7970 470533.
E-mail address: tristan_barton@hotmail.com (T. Barton).
Contents lists available at ScienceDirect
Foot and Ankle Surgery
j our nal homepage: www. el sevi er . com/ l ocat e/ f as
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
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
benet of enabling assessment of movement both of the
articulations 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 uoroscopic 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 joints to be quantied. 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 ankle
biomechanics 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 xation 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 lengthto be reduced, withpatients spending less
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. foundcadencetobesignicantly
increasedinpatients witharthriticankles comparedwithunaffected
controls, but this increase was not sufcient to normalise walking
speed due to the reduced stride length [27].
Following ankle arthrodesis, there is a signicant improvement
in walking speed [2832]. This however does remain signicantly
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 signicant 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 ndings
with an increase in cadence in the arthrodesed patient group
compared with controls, although this was not found to be
statistically signicant. The authors of this paper also noted a
signicantly increased 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
gait following ankle replacement showeddisappointing results with
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 using
second generation prosthetic designs are encouraging. Such studies
report the majority of spatialtemporal variables to be signicantly
improved following ankle replacement. As following arthrodesis
however, these remain signicantly 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
signicantly reduced in treated patients with osteoarthritis [36].
A proposed benet of performing an ankle replacement as
opposed 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 the expense of the symmetrical 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
large variations in the kinematics of the foot and ankle [4,38,39].
This individuality of biomechanics therefore creates problems
when trying to 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 dening the effect of
these changes. Early work on ankle biomechanics by Stauffer et al.
reported a reduction in sagittal plane ankle joint motion in patients
with a diseased ankle [24]. During gait, there was a reduction in
dorsiexion with the majority of ankle motion occurring in a
plantarexed 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 in
motion 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
uoroscopic imaging techniques, Kozenak et al. furthered this work
andreportedonthekinematics of thetibiotalar andsubtalar joints in
patients with ankle arthrosis. The authors reported that in patients
witha degenerative ankle joint, inadditiontoa reductioninsubtalar
rotation, the directionof rotationwas reversedwhencomparedwith
normal individuals [14]. As aconsequenceof this, motioncouplingof
the tibiotalar and subtalar joints is lost in patients with ankle
arthosis, with both joints externally rotating during stance. The
authors conrmed the ndings of Khazzam et al. in reporting a
reduction in hindfoot internal rotation, which reached statistical
signicance in the subtalar joint from midstance to toe-off.
As would be expected, ankle arthrodesis signicantly 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 signicantly
reduced in all planes following arthrodesis and these ndings 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 dened by Perry is characterised by
forward 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 the tibia is enabled by an
early heel lift in order to increase the tilt of the tibia relative to the
oor although not to the hindfoot [28,45,46]. If the ankle is
arthrodesed in slight plantarexion, knee hyperextension is
required to enable a foot at to the ground [29,42].
One of the principle 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 withinthe 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 rst 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 plantarexion (Agility, Hintegra) and
inversion/eversion (Hintegra, STAR) when compared with normal
specimens [9]. The rst 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
signicantly 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 signicant improvement in ankle range of
movement, which remained signicantly 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 dorsiexion compared to
controls but a similar degree of plantarexion. 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 motion
following 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 signicance of differing readings is less
clear. Valderrabano et 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 conicting

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

T. Barton et al. / Foot and Ankle Surgery 17 (2011) 5257 54
results with no change in range of motion in this plane post-
operatively [37]. With regards to mid-tarsal movement, no
signicant 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) prole 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 of the shear forces is seeninanaft 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 signicantly differ from unaffected patients, but
the magnitude of the vertical peaks is reduced. This change is most
signicant 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 signicant 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 conrmed by hindfoot kinematics, early heel
lift is evident with an early drop in the rst 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 not reach normal levels [25,36]. One cause of this reduction in
the 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 plantarexion 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 signicantly improve following joint
replacement. Dyrby found a signicant improvement in ankle
dorsiexion external moments following arthroplasty to levels
comparable with unaffected controls. Ankle inversion moments
did not improve signicantly 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 signicant
improvement in any of the measured kinetic parameters. The
authors do however report a normalisation of the internal
plantarexion 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 that accurately represent a
true consequence of the ankle replacement and not a result of
variations in walking velocity. The authors found the vertical centre
of mass displacement to be signicantly improved following ankle
replacement, resulting in a less at footed walking pattern and
decreased energy expenditure during gait [35].
5. Summary
The diseased ankle joint results in signicant biomechanical
changes within the foot and ankle complex. Gait is asymmetric,
and walking velocity is reduced as a consequence of reduced
cadence and stride 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].

T. Barton et al. / Foot and Ankle Surgery 17 (2011) 5257 55
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 conrmthe early heel lift and reveal 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
signicantly 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 still
limited. 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.
Conict of interest statement
There are no conicts of interest.
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