The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Does Modified Footwear Improve Gait After Ankle Arthrodesis? Daniel A. Jones, MD 1, Berton R. Moed, MD 2, David E. Karges, DO 3 1
Resident Physician, Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO Professor and Chairman, Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO 3 Professor and Chief, Foot and Ankle Division, Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3
Rocker bottom shoes are commonly recommended for patients who have undergone ankle arthrodesis. Limited data are available to support this recommendation. In the present case-control study, 2 groups of participants were identified for the investigation: a study group (SG) of 9 patients who had previously undergone ankle arthrodesis and a normal group (NG) of 9 healthy volunteers. Gait data were collected using a video recorder while the participants walked barefoot and wearing rocker bottom shoes. These data were analyzed using computer-based gait analysis software. The total motion was calculated and averaged for each group for walking barefoot and wearing rocker bottom shoes. All participants completed the Short Musculoskeletal Function Assessment and the American Orthopaedic Foot and Ankle Society questionnaires. The total motion of the SG wearing rocker bottom shoes increased 4.8 (range 3.4 to 6.9 ) on mean average, an improvement compared with walking barefoot (p < .05). In the NG, the shoe wear had no effect on the total motion (p ¼ .59). Although the total motion in the SG approached the mean average of the total motion of the NG, it remained significantly less than that of the NG (p < .05). Additionally, the SG scored worse than the NG on both outcomes questionnaires (p < .05). Rocker bottom shoes had no effect on gait velocity. In conclusion, rocker bottom shoes significantly improve the total motion of ankle arthrodesis patients toward normal. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle fusion gait analysis post-traumatic arthritis rocker bottom shoes
Ankle arthrodesis is recognized as a reliable and safe procedure for the treatment of patients with ankle arthritis for whom conservative management has failed (1–6). The common indications for ankle arthrodesis are post-traumatic arthritis, followed by rheumatoid arthritis, infection, failed ankle arthroplasty, and neuromuscular conditions (1). Many other indications of ankle arthrodesis have been proposed; however, 3 general concepts of ankle arthrodesis have been consistently sought: correction of the deformity, maintenance of stability, and alleviation of pain (7,8). A common recommendation of foot and ankle surgeons for patients after ankle arthrodesis is to obtain and wear shoes with a rocker bottom sole during ambulation. Rocker bottom shoes (RBSs) have been postulated to create a more natural gait pattern in the immobilized ankle (9); however, limited gait analysis data from ankle arthrodesis patients while wearing RBSs are available. The primary purpose of the present case-control study was to determine whether the rocker bottom sole modification improves the
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Daniel A. Jones, MD, Department of Orthopaedic Surgery, Saint Louis University, 3635 Vista Avenue, 7th Floor, Desloge Tower, St. Louis, MO 63104. E-mail address: [email protected] (D.A. Jones).
gait after ankle arthrodesis. In addition, we wished to investigate whether RBSs cause changes in the gait patterns of a normal population and to evaluate the functional outcome of the ankle arthrodesis patients compared with a normal population. We undertook the present study to determine whether RBSs can improve the gait of ankle arthrodesis patients toward normal. Patients and Methods Our institutional review board approved the present case-control study, before we initiated testing. Two groups of participants were identified: a study group (SG) and a normal group (NG). The SG included patients who had previously undergone ankle arthrodesis for post-traumatic arthritis. It was determined a priori that a sample size of 8 was required for 80% power. A total of 36 patients were identified from the trauma registry at our level I trauma center and were interviewed to solicit interest in participation. To meet the inclusion criteria, the participants had to have undergone ankle arthrodesis for painful ankle arthrosis and to have radiographic evidence of united fusion. Also, ankle arthrodesis had to have been performed, at a minimum, 1 year before testing. All arthrodesis procedures were performed from July 1, 2006 to December 31, 2011. All patients were required to have been ambulating without an assistive device for a minimum of 6 months. They were required to have a leg length discrepancy of 60% incidence of ipsilateral subtalar arthritis seen in long-term studies (11,12). Therefore, we recommend a prospective, longitudinal study to investigate the long-term outcomes, specifically ipsilateral adjacent arthritis (clinically and radiographically), functional outcomes, and the pain experienced by ankle arthrodesis patients using RBSs on a daily basis. For obvious reasons, however, such a study would be extraordinarily challenging to organize and maintain compliant participation. The results of the present study suggest that RBSs allow for a more physiologic gait in patients who have undergone ankle arthrodesis. Moreover, it would be useful to identify whether the perceived increase in total motion actually results from the RBS modification or whether any shoe wear could mimic our results. Thus, we also suggest that the addition of other footwear to the previously proposed study would benefit the interpretation of the
Table 1 Paired comparisons of mean average differences within each group
Table 2 Comparisons of the mean average change in TM between groups
NG (n ¼ 9) SG (n ¼ 9)
Barefoot ( )
RBSs ( )
Difference in TM ( )
95% CI
p Value
11.3 3.9
11.0 8.7
0.3 4.8
0.83 to 1.37 3.91 to 5.71
.59 < .05
Abbreviations: CI, confidence interval; NG, normal group; RBSs, rocker bottom shoes; SG, study group; TM, total motion.
Barefoot (n ¼ 9) RBSs (n ¼ 9)
NG ( )
SG ( )
Difference in TM ( )
95% CI
p Value
11.3 11.0
3.9 8.7
7.4 2.3
5.74 to 9.12 0.96 to 3.75
< .05 < .05
Abbreviations: CI, confidence interval; NG, normal group; RBSs, rocker bottom shoes; SG, study group; TM, total motion.
4
D.A. Jones et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
outcome measures. Furthermore, an investigation could be conducted to examine the potential effect of the rocker bottom modification to shoes on decreasing the tension of the plantar fascia and/or decreasing the overload of the metatarsal flexor plates as a source of pain in this patient population. In conclusion, our results have shown that ankle arthrodesis patients gain total motion during the stance phase of gait when using the RBS modification to shoes. Additional study is indicated to determine the potential positive effect of wearing RBSs on overall patient outcomes, including secondary subtalar and midfoot arthrosis and the long-term effect of ankle fusion in degeneration of the spine. Acknowledgments We wish to acknowledge Heidi Israel, PhD, for her statistical analysis of the data used in this investigation. References 1. Canale ST, Beaty JH. Campbell’s Operative Orthopaedics, Mosby/Elsevier, Philadelphia, 2008. 2. Harris TG, Lee D. Arthroscopic ankle arthrodesis after tibial pilon open reduction internal fixation. Foot Ankle Spec 3:188–193, 2011. 3. Mann RA, Rongstad KM. Arthrodesis of the ankle: a critical analysis. Foot Ankle Int 19:3–9, 1998. 4. Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis: long-term follow-up with gait analysis. J Bone Joint Surg Am 61:964–975, 1979.
5. Piriou P, Culpan P, Mullins M, Cardon JN, Pozzi D, Judet T. Ankle replacement versus arthrodesis: a comparative gait analysis study. Foot Ankle Int 29:3–9, 2008. 6. Takakura Y, Tanaka Y, Sugimoto K, Akiyama K, Tamai S. Long-term results of arthrodesis for osteoarthritis of the ankle. Clin Orthop Relat Res 361:178–185, 1999. 7. Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am 88:526–535, 2006. 8. Wu WL, Su FC, Cheng YM, Huang PJ, Chou YL, Chou CK. Gait analysis after ankle arthrodesis. Gait Posture 11:54–61, 2000. 9. Adamczyk PG, Collins SH, Kuo AD. The advantages of a rolling foot in human walking. J Exp Biol 209(Pt 20):3953–3963, 2006. 10. Swiontkowski MF, Engelberg R, Martin DP, Agel J. Short musculoskeletal function assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint Surg Am 81:1245–1260, 1999. 11. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 83-A:219–228, 2001. 12. Fuchs S, Sandmann C, Skwara A, Chylarecki C. Quality of life 20 years after arthrodesis of the ankle: a study of adjacent joints. J Bone Joint Surg Br 85:994– 998, 2003. 13. Trouillier H, Hansel L, Schaff P, Rosenmayer B, Refior HJ. Long-term results after ankle arthrodesis: clinical, radiological, gait analytical aspects. Foot Ankle Int 23:1081–1090, 2002. 14. van Engelen SJ, Wajer QE, van der Plaat LW, Doets HC, van Dijk CN, Houdijk H. Metabolic cost and mechanical work during walking after tibiotalar arthrodesis and the influence of footwear. Clin Biomech (Bristol, Avon) 25:809–815, 2010. 15. Vanderpool MT, Collins SH, Kuo AD. Ankle fixation need not increase the energetic cost of human walking. Gait Posture 28:427–433, 2008. 16. Waters RL, Barnes G, Husserl T, Silver L, Liss R. Comparable energy expenditure after arthrodesis of the hip and ankle. J Bone Joint Surg Am 70:1032–1037, 1988. 17. Wagner FW Jr. Ankle fusion for degenerative arthritis secondary to the collagen diseases. Foot Ankle 3:24–31, 1982.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Does Modified Footwear Improve Gait After Ankle Arthrodesis? Daniel A. Jones, MD 1, Berton R. Moed, MD 2, David E. Karges, DO 3 1
Resident Physician, Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO Professor and Chairman, Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO 3 Professor and Chief, Foot and Ankle Division, Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3
Rocker bottom shoes are commonly recommended for patients who have undergone ankle arthrodesis. Limited data are available to support this recommendation. In the present case-control study, 2 groups of participants were identified for the investigation: a study group (SG) of 9 patients who had previously undergone ankle arthrodesis and a normal group (NG) of 9 healthy volunteers. Gait data were collected using a video recorder while the participants walked barefoot and wearing rocker bottom shoes. These data were analyzed using computer-based gait analysis software. The total motion was calculated and averaged for each group for walking barefoot and wearing rocker bottom shoes. All participants completed the Short Musculoskeletal Function Assessment and the American Orthopaedic Foot and Ankle Society questionnaires. The total motion of the SG wearing rocker bottom shoes increased 4.8 (range 3.4 to 6.9 ) on mean average, an improvement compared with walking barefoot (p < .05). In the NG, the shoe wear had no effect on the total motion (p ¼ .59). Although the total motion in the SG approached the mean average of the total motion of the NG, it remained significantly less than that of the NG (p < .05). Additionally, the SG scored worse than the NG on both outcomes questionnaires (p < .05). Rocker bottom shoes had no effect on gait velocity. In conclusion, rocker bottom shoes significantly improve the total motion of ankle arthrodesis patients toward normal. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle fusion gait analysis post-traumatic arthritis rocker bottom shoes
Ankle arthrodesis is recognized as a reliable and safe procedure for the treatment of patients with ankle arthritis for whom conservative management has failed (1–6). The common indications for ankle arthrodesis are post-traumatic arthritis, followed by rheumatoid arthritis, infection, failed ankle arthroplasty, and neuromuscular conditions (1). Many other indications of ankle arthrodesis have been proposed; however, 3 general concepts of ankle arthrodesis have been consistently sought: correction of the deformity, maintenance of stability, and alleviation of pain (7,8). A common recommendation of foot and ankle surgeons for patients after ankle arthrodesis is to obtain and wear shoes with a rocker bottom sole during ambulation. Rocker bottom shoes (RBSs) have been postulated to create a more natural gait pattern in the immobilized ankle (9); however, limited gait analysis data from ankle arthrodesis patients while wearing RBSs are available. The primary purpose of the present case-control study was to determine whether the rocker bottom sole modification improves the
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Daniel A. Jones, MD, Department of Orthopaedic Surgery, Saint Louis University, 3635 Vista Avenue, 7th Floor, Desloge Tower, St. Louis, MO 63104. E-mail address: [email protected] (D.A. Jones).
gait after ankle arthrodesis. In addition, we wished to investigate whether RBSs cause changes in the gait patterns of a normal population and to evaluate the functional outcome of the ankle arthrodesis patients compared with a normal population. We undertook the present study to determine whether RBSs can improve the gait of ankle arthrodesis patients toward normal. Patients and Methods Our institutional review board approved the present case-control study, before we initiated testing. Two groups of participants were identified: a study group (SG) and a normal group (NG). The SG included patients who had previously undergone ankle arthrodesis for post-traumatic arthritis. It was determined a priori that a sample size of 8 was required for 80% power. A total of 36 patients were identified from the trauma registry at our level I trauma center and were interviewed to solicit interest in participation. To meet the inclusion criteria, the participants had to have undergone ankle arthrodesis for painful ankle arthrosis and to have radiographic evidence of united fusion. Also, ankle arthrodesis had to have been performed, at a minimum, 1 year before testing. All arthrodesis procedures were performed from July 1, 2006 to December 31, 2011. All patients were required to have been ambulating without an assistive device for a minimum of 6 months. They were required to have a leg length discrepancy of 60% incidence of ipsilateral subtalar arthritis seen in long-term studies (11,12). Therefore, we recommend a prospective, longitudinal study to investigate the long-term outcomes, specifically ipsilateral adjacent arthritis (clinically and radiographically), functional outcomes, and the pain experienced by ankle arthrodesis patients using RBSs on a daily basis. For obvious reasons, however, such a study would be extraordinarily challenging to organize and maintain compliant participation. The results of the present study suggest that RBSs allow for a more physiologic gait in patients who have undergone ankle arthrodesis. Moreover, it would be useful to identify whether the perceived increase in total motion actually results from the RBS modification or whether any shoe wear could mimic our results. Thus, we also suggest that the addition of other footwear to the previously proposed study would benefit the interpretation of the
Table 1 Paired comparisons of mean average differences within each group
Table 2 Comparisons of the mean average change in TM between groups
NG (n ¼ 9) SG (n ¼ 9)
Barefoot ( )
RBSs ( )
Difference in TM ( )
95% CI
p Value
11.3 3.9
11.0 8.7
0.3 4.8
0.83 to 1.37 3.91 to 5.71
.59 < .05
Abbreviations: CI, confidence interval; NG, normal group; RBSs, rocker bottom shoes; SG, study group; TM, total motion.
Barefoot (n ¼ 9) RBSs (n ¼ 9)
NG ( )
SG ( )
Difference in TM ( )
95% CI
p Value
11.3 11.0
3.9 8.7
7.4 2.3
5.74 to 9.12 0.96 to 3.75
< .05 < .05
Abbreviations: CI, confidence interval; NG, normal group; RBSs, rocker bottom shoes; SG, study group; TM, total motion.
4
D.A. Jones et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
outcome measures. Furthermore, an investigation could be conducted to examine the potential effect of the rocker bottom modification to shoes on decreasing the tension of the plantar fascia and/or decreasing the overload of the metatarsal flexor plates as a source of pain in this patient population. In conclusion, our results have shown that ankle arthrodesis patients gain total motion during the stance phase of gait when using the RBS modification to shoes. Additional study is indicated to determine the potential positive effect of wearing RBSs on overall patient outcomes, including secondary subtalar and midfoot arthrosis and the long-term effect of ankle fusion in degeneration of the spine. Acknowledgments We wish to acknowledge Heidi Israel, PhD, for her statistical analysis of the data used in this investigation. References 1. Canale ST, Beaty JH. Campbell’s Operative Orthopaedics, Mosby/Elsevier, Philadelphia, 2008. 2. Harris TG, Lee D. Arthroscopic ankle arthrodesis after tibial pilon open reduction internal fixation. Foot Ankle Spec 3:188–193, 2011. 3. Mann RA, Rongstad KM. Arthrodesis of the ankle: a critical analysis. Foot Ankle Int 19:3–9, 1998. 4. Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis: long-term follow-up with gait analysis. J Bone Joint Surg Am 61:964–975, 1979.
5. Piriou P, Culpan P, Mullins M, Cardon JN, Pozzi D, Judet T. Ankle replacement versus arthrodesis: a comparative gait analysis study. Foot Ankle Int 29:3–9, 2008. 6. Takakura Y, Tanaka Y, Sugimoto K, Akiyama K, Tamai S. Long-term results of arthrodesis for osteoarthritis of the ankle. Clin Orthop Relat Res 361:178–185, 1999. 7. Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am 88:526–535, 2006. 8. Wu WL, Su FC, Cheng YM, Huang PJ, Chou YL, Chou CK. Gait analysis after ankle arthrodesis. Gait Posture 11:54–61, 2000. 9. Adamczyk PG, Collins SH, Kuo AD. The advantages of a rolling foot in human walking. J Exp Biol 209(Pt 20):3953–3963, 2006. 10. Swiontkowski MF, Engelberg R, Martin DP, Agel J. Short musculoskeletal function assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint Surg Am 81:1245–1260, 1999. 11. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 83-A:219–228, 2001. 12. Fuchs S, Sandmann C, Skwara A, Chylarecki C. Quality of life 20 years after arthrodesis of the ankle: a study of adjacent joints. J Bone Joint Surg Br 85:994– 998, 2003. 13. Trouillier H, Hansel L, Schaff P, Rosenmayer B, Refior HJ. Long-term results after ankle arthrodesis: clinical, radiological, gait analytical aspects. Foot Ankle Int 23:1081–1090, 2002. 14. van Engelen SJ, Wajer QE, van der Plaat LW, Doets HC, van Dijk CN, Houdijk H. Metabolic cost and mechanical work during walking after tibiotalar arthrodesis and the influence of footwear. Clin Biomech (Bristol, Avon) 25:809–815, 2010. 15. Vanderpool MT, Collins SH, Kuo AD. Ankle fixation need not increase the energetic cost of human walking. Gait Posture 28:427–433, 2008. 16. Waters RL, Barnes G, Husserl T, Silver L, Liss R. Comparable energy expenditure after arthrodesis of the hip and ankle. J Bone Joint Surg Am 70:1032–1037, 1988. 17. Wagner FW Jr. Ankle fusion for degenerative arthritis secondary to the collagen diseases. Foot Ankle 3:24–31, 1982.
