Results of opening-wedge osteotomy for the treatment of a post-traumatic varus deformity of the ankle

Correction of Posttraumatic Medial Growth Arrest of the Distal Tibia in Adolescents

BACKGROUND

Partial growth arrest of the medial part of the distal tibial physis following fractures that penetrated the epiphysis is relatively common. We present the results of treatment, based on a protocol of supramalleolar tibial and fibular osteotomy for ankle alignment correction, and contralateral epiphysiodesis of distal tibia and fibula to balance leg length discrepancy (LLD).

METHODS

This case series study describes the results of 7 patients with a median age of 14 years (range = 10-15 years) who were operated in our institution. All were treated by closed or open reduction and internal fixation after Salter-Harris (SH) types 3 and 4 fractures of the distal tibia. All patients had a partial medial growth arrest, distal tibial varus, relative overlengthening of the distal fibula, and slight leg shortening.

TREATMENT PROTOCOL

Contralateral distal tibial and fibular epiphysiodesis to prevent significant LLD, completion of closure of the ipsilateral epiphysis, supramalleolar osteotomy of the distal tibia and fibula, and insertion of a triangular wedge cortical allograft into the tibial osteotomy creating a normal ankle joint orientation. The osteotomy was supported by a medial anatomically contoured locking plate. The fibula was fixed with an intramedullary wire.

RESULTS

All patients had uneventful healing of the osteotomy after 6 weeks. At the latest follow-up (mean 3 years, range 1.5-5 years), 6 out of 7 patients reached maturity, and the lateral distal tibial angle was within normal limits. The LLD in all patients was less than 8 mm.

CONCLUSIONS

Our protocol provides anatomic correction with the restoration of the ankle joint and prevents the progression of LLD.

LEVELS OF EVIDENCE

Level IV.

Biomechanical Effect of Distal Tibial Oblique Osteotomy: A Preliminary Finite-Element Analysis

BACKGROUND

The biomechanical effect of distal tibial oblique osteotomy (DTOO) on osteoarthritic ankles has not been investigated. Using finite element (FE) models, we aimed to elucidate the effect of DTOO on the ankle contact pressure (CP) distribution.

METHODS

This study included two patients with ankle osteoarthritis who underwent DTOO and one asymptomatic control. Patient-specific FE models were reconstructed by matching standing radiographs with supine computed tomography scans. The joint contact area (CA) and maximum CP on the articular surface of the talus were calculated before and after DTOO and compared with those of the control.

RESULTS

In the control, the CA was 584 mm2 and the maximum CP was 2.6 MPa. In case 1, the CA increased by 125% from 166 mm2 preoperatively to 375 mm2 postoperatively, accompanied by a 36% decrease in the maximum CP from 9.8 MPa to 6.3 MPa. Similarly, in case 2, the CA increased by 46% from 301 mm2 to 439 mm2, accompanied by a 27% decrease in the maximum CP from 6.7 MPa to 4.9 MPa.

CONCLUSIONS

This study suggests DTOO improves the biomechanics of the ankle, but not sufficiently compared to the control. This analytical approach may enhance understanding of ankle pathophysiology and assist in the design of the ideal corrective osteotomy.

Simultaneous hybrid closed-wedge supramalleolar osteotomy and ankle arthrodesis for post-traumatic varus ankle arthritis with periarticular deformity: A case report

The treatment of end-stage ankle arthritis associated with extra-articular tibial deformity, especially for ankles deformed by previous traumatic injuries and/or surgical treatment, is extremely challenging but rewarding. Only one previous report describes simultaneous tibial deformity correction and ankle arthrodesis for tibial malalignment and ipsilateral ankle arthritis. Here, we describe a unique case of post-traumatic ankle osteoarthritis concomitant with extra-articular varus deformity in a 77-year-old female. We have combined medial opening-wedge supramalleolar osteotomy (SMO) and lateral closed-wedge SMO in this case, which we termed 'hybrid' closed-wedge SMO, to overcome the limitations of traditional closed-wedge SMO. The patient was successfully treated with simultaneous hybrid closed-wedge SMO and ankle arthrodesis using a single lateral locking plate. To our knowledge, this is the first report describing the successful introduction of a hybrid closed-wedge osteotomy procedure in the distal tibia. Three years after surgery, the patient could walk without assistance and swim normally. The patient experienced no discomfort or pain in the operated ankle and was satisfied with the results. Radiographs confirmed that the pre-existing ankle joint line was parallel to the ground and almost invisible. The hind foot alignment was slightly valgus. No progression of the subtalar joint arthritis was detected. The simultaneous hybrid closed-wedge SMO and ankle arthrodesis was technically difficult but effective. This technique preserves leg length and subtalar joint motion. Additionally, a single lateral incision minimises the risk of impaired blood supply. The one-stage surgical treatment reduces the recovery time, duration of hospitalisation, and surgical costs. Rigid locking fixation with careful postoperative weight-bearing is required for uneventful bone healing.

The Role of Supramalleolar Osteotomies in Ankle Arthritis

The supramalleolar osteotomy (SMO) is a joint-preserving surgical procedure that allows realignment of the ankle joint in severe deformity secondary to arthritis. This osteotomy realigns the mechanical axis to provide better weight distribution through the ankle joint. With an aligned mechanical axis, the overloaded asymmetric ankle joint will shift toward the preserved joint area in a valgus or varus ankle joint. The SMO also can be used via a staged approach to correct severe deformity in an end-stage arthritic ankle before total ankle arthroplasty to optimize the implant's longevity and improve overall functional outcomes.

Supramalleolar osteotomies for ankle arthritis: a systematic review

INTRODUCTION

We investigated the mid-term outcomes of supramalleolar osteotomies regarding "survivorship" [before ankle arthrodesis (AA) or total ankle replacement (TAR)], complication rate and adjuvant procedures required.

MATERIAL AND METHODS

PubMed, Cochrane and Trip Medical Database were searched from January 01, 2000. Studies reporting on SMOs for ankle arthritis, in minimum of 20 patients aged 17 or older, followed for a minimum of two years, were included. Quality assessment was performed with the Modified Coleman Methodology Score (MCMS). A subgroup analysis of varus/valgus ankles was performed.

RESULTS

Sixteen studies met the inclusion criteria, with 866 SMOs in 851 patients. Mean age of patients was 53.6 (range 17-79) years, and mean follow-up was 49.1 (range 8-168) months. Of the arthritic ankles (646 ankles), 11.1% were classified as Takakura stage I, 24.0% as stage II, 59.9% as stage III and 5.0% as stage IV. The overall MCMS was 55.2 ± 9.6 (fair). Eleven studies (657 SMOs) reported on "survivorship" of SMO, before arthrodesis (2.7%), or total ankle replacement (TAR) (5.8%) was required. Patients required AA after an average of 44.6 (range 7-156) months, and TAR after 36.71 (range 7-152) months. Hardware removal was required in 1.9% and revision in 4.4% of 777 SMOs. Mean AOFAS score was 51.8 preoperatively, improving to 79.1 postoperatively. Mean VAS was 6.5 preoperatively and improved to 2.1 postoperatively. Complications were reported in 5.7% (44 out of 777 SMOs). Soft tissue procedures were performed in 41.0% (310 out of 756 SMOs), whereas concomitant osseous procedures were performed in 59.0% (446 out of 756 SMOs). SMOs performed for valgus ankles failed in 11.1% of patients, vs 5.6% in varus ankles (p < 0.05), with disparity between the different studies.

CONCLUSIONS

SMOs combined with adjuvant, osseous and soft tissue, procedures, were performed mostly for arthritic ankles of stage II and III, according to the Takakura classification and offered functional improvement with low complication rate. Approximately, 10% of SMOs failed and patients required AA or TAR, after an average of just over 4 years (50.5 months) after the index surgery. It is debatable whether varus and valgus ankles treated with SMO reveal different success rates.

[Mid- and long-term effectiveness analysis of distraction arthroplasty in treatment of moderate to severe ankle arthritis]

OBJECTIVE

To investigate the mid- and long-term effectiveness of external fixator distraction arthroplasty in the treatment of moderate to severe ankle arthritis.

METHODS

The clinical data of 23 patients with moderate to severe ankle arthritis treated with external fixation distraction arthroplasty who met the selection criteria between January 2007 and November 2019 were retrospectively analyzed. There were 20 males and 3 females; the age ranged from 21 to 65 years, with an average age of 43.7 years. Etiology included 8 cases of primary ankle arthritis, in which 5 cases combined with varus deformity; 15 cases of traumatic ankle arthritis, the cause of injury was 5 cases after ankle fracture surgery, 3 cases after Pilon fracture surgery, 5 cases of chronic ankle instability and repeated sprain, and 2 cases of other causes. According to Takakura staging system, there were 4 cases of stage ⅢA, 12 cases of stage ⅢB, and 7 cases of stage Ⅳ; according to Giannini staging system, there were 5 cases of stage Ⅱ and 18 cases of stage Ⅲ; according to Cheng staging system, 16 cases were in stage Ⅲ, and 7 cases stage Ⅳ. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analogue scale (VAS) score were used to evaluate the improvement of ankle pain and function before operation and at last follow-up, and the data were analyzed according to different etiological groups. At last follow-up, the surgical results were evaluated subjectively and objectively. The changes of ankle joint space before operation and at last follow-up were compared. The patients were divided into two groups according to their age: ≤45 years old group [young group, 10 cases, aged (35.62±7.41) years old] and >45 years old group [middle-aged and elderly group, 13 cases, aged (54.20±6.20) years old]. The AOFAS ankle-hindfoot score and VAS score were compared before and after operation between the two groups, and the influence of age on distraction arthroplasty was analyzed.

RESULTS

The external fixator was removed after 3 months of continuous distraction,12 patients got infection around the wire tunnels. All the 23 patients were followed up 13-143 months, with an average of 56.9 months; the follow-up time was (43.46±32.77) months and (69.80±37.79) months in the young group and middle-aged and elderly group, respectively. At last follow-up, the AOFAS ankle-hindfoot score and VAS score significantly improved when compared with those before operation ( P<0.05). According to etiological analysis, there was no significant difference in AOFAS ankle-hindfoot score and VAS score before and after operation ( P>0.05) in Pilon fracture patients, while the significant difference was found in remaining patients ( P<0.05). There was significant difference in AOFAS ankle-hindfoot score before operation between the young group and the middle-aged and elderly group ( t=2.110, P=0.040), but no significant difference in preoperative VAS score and the differences in VAS score and AOFAS ankle-hindfoot score before and after operation between the two groups ( P>0.05). The subjective and objective results of pain evaluation at last follow-up showed that 4 patients had no pain, 12 patients had moderate pain relief, 5 patients had mild pain relief, and 2 patients had no significant pain relief; among the 10 patients who were followed up more than 5 years, there were 2, 5, 2, and 1 patient, respectively; 2 patients who were followed up more than 10 years had moderate pain relief. At last follow-up, the ankle joint space was (3.7±0.4) mm, which significantly increased when compared with before operation [(1.5±0.2) mm] ( t=1.791, P=0.002). The ankle joint space was (2.9±0.5) mm in 10 patients who were followed up more than 5 years, and 3.3 mm and 3.0 mm in 2 patients who were followed up more than 10 years.

CONCLUSION

Distraction arthroplasty of the ankle joint can achieve satisfactory results in patients with moderate to severe ankle arthritis (except for arthritis caused by Pilon fracture), and age has no significant effect on distraction arthroplasty.

Outcomes of intermediate stage varus ankle arthritis treated by supramalleolar osteotomy

OBJECTIVE

To evaluate the outcomes of intermediate stage varus ankle arthritis treated by supramalleolar osteotomy.

METHODS

Clinical data of 57 patients with varus arthritis who underwent supramalleolar osteotomy at our hospital between March 2018 and December 2019 were retrospectively analyzed. The patients were grouped according to the Takakura classification, and assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and the Visual Analogue Score (VAS). Tibial anterior surface (TAS) angle and talar tilt (TT) angle were measured at the weight-bearing anteroposterior view. Tibial lateral surface (TLS) angle was measured at the weight-bearing lateral view. The differences in the above indicators of patients with different stages of varus ankle arthritis before and after treatment were analyzed.

RESULTS

The patients were followed up for an average of 31.9 ± 5.8 months. Upon the last follow-up, the AOFAS score was 84.1 ± 9.7, the VAS score 2.2 ± 1.3, the TAS angle 92.4 ± 5.5°, the TLS angle 79.3 ± 5.3°, and the TT angle 3.7±3.4°, which were significantly different from the preoperative levels (64.2 ± 14.6, 4.5 ± 1.8, 80.5 ± 6.7°, 74.9 ± 4.6°, and 5.2 ± 64.1°, respectively) (p < .05). There were significant differences in AOFAS and VAS scores before surgery and upon the last follow-up in each group (p < .05). The postoperative TT angle was significantly different from the preoperative level in stage IIIb patients (p = .003).

CONCLUSIONS

Supramalleolar osteotomy achieved good short-to mid-term clinical outcomes for intermediate stage varus ankle arthritis. This procedure could significantly improve the TAS and TLS angles of the patients at any stage and the TT angle of stage IIIb patients.

Reconstructive Surgery and Joint-Sparing Surgery in Valgus and Varus Ankle Deformities: A Comprehensive Review

Osteoarthritis (OA) of the ankle affects about 1% of the world’s adult population, causing an important impact on patient lives and health systems. Most patients with ankle OA can show an asymmetrical wear pattern with a predominant degeneration of the medial or the lateral portion of the joint. To avoid more invasive ankle joint sacrificing procedures, joint realignment surgery has been developed to restore the anatomy of the joints with asymmetric early OA and to improve the joint biomechanics and symptoms of the patients. This narrative, comprehensive, all-embracing review of the literature has the aim to describe the current concepts of joint preserving and reconstructive surgery in the treatment of the valgus and varus ankle early OA, through an original iconography and clear indications and technical notes.

Plain Radiographs Underestimate Varus Deformity of the Tibial Plafond

Understanding plain radiograph in association with 3-dimensional (3D) morphology of the ankle is essential for treatment about varus ankle osteoarthritis (OA). The aims of this study were to investigate whether the alignment of the tibial plafond as determined on plain radiograph reflected the alignment of the tibial plafond on computed tomography (CT) in varus ankle OA and whether the alignment of the tibial plafond changed as the OA progressed. The 3D CT and plain radiographs from 101 ankles with varus ankle OA were analyzed and compared with 40 ankles in control group. The tibial plafond was assessed in the coronal and sagittal planes using 3D CT. The medial angle between the vertical line and the tibial plafond was measured on 3 different coronal plane CT images which was anterior, middle and posterior area of the tibial plafond. The medial distal tibial angle on plain radiograph reflected the posterior area of the tibial plafond on CT. The amount of varus angulation on CT was larger in anterior and middle area of the tibial plafond than the posterior area. There was a difference in the degree of varus of the tibial plafond between control group and OA patients; however, there was no difference among patients in different stages of varus ankle OA. Weightbearing plain radiographs underestimate the varus deformity in anterior and middle area of the tibial plafond and there is no significant difference in deformity of the tibial plafond among patients in different stages of varus ankle OA.

Relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis

PurposeThis study aimed to evaluate the relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis. Methods: Incongruent varus ankle osteoarthritis was defined as a talar tilt of more than 4° on standard ankle anteroposterior radiographs. We retrospectively reviewed 30 patients with unilateral incongruent varus ankle osteoarthritis with normal alignment of the contralateral ankle. All patients underwent bilateral weightbearing computed tomography and standing plain radiographs. The talar tilt and the distance between the talar lateral process and lateral malleolar tip were measured from a standing ankle anteroposterior radiograph of both sides. Talar and fibular spurs were assessed on the coronal and axial views of weightbearing computed tomography. After simulating the correction of the talar tilt in varus ankle osteoarthritis, talofibular bony impingement was reassessed. Results: On the varus side, the distance between the talar lateral process and the lateral malleolar tip was significantly shorter than that on the contralateral side (p < .001). Talar spur was present in the varus side of all 30 patients on the axial view of weightbearing computed tomography and in the control side of 10 patients. After the simulation of talar tilt correction, talofibular impingement (overlap) occurred in all 30 patients with a larger extent in the severe talar tilt subgroup (p < .001). Conclusion: Talofibular impingement by lateral gutter osteophytes is closely related to increased talar tilt in patients with incongruent varus ankle osteoarthritis. Therefore, lateral gutter osteophytes should be resected to stabilize mortise and improve clinical outcomes.

Joint Preserving Surgery for Valgus Ankle Osteoarthritis

Valgus ankle OA is a complex problem with multiple etiologies that can either be isolated or superimposed on top of other medical or musculoskeletal disorders. Proper medical history, physical, and preoperative radiological examinations are crucial in deciding on surgery and planning the surgical approach. JPS, especially the varisating medial closing-wedge SMOT with solid plate fixation, has been consistently associated with good outcomes for patients with valgus ankle OA. To further improve JPS for valgus ankle OA, further clinical and biomechanical studies are required to address the long-term clinical and functional outcomes and complications.

Joint Preservation Strategies for Managing Varus Ankle Deformities

Joint preserving strategies have evolved to a successful treatment option in early and midstage medial ankle OA caused by varus deformity. Though talar tilt can often not be fully corrected, it provides substantial postoperative pain relief, functional improvement, and slowing of the degenerative process. Osseous balancing with osteotomies is the main step for restoration of ankle mechanics and normalization of joint load. Overall, the key for success is to understand the underlying causes that have contributed to the varus OA in each case, and to use all treatment modalities necessary to restore appropriate alignment of the hindfoot complex.

Radiological assessments and clinical results of intra-articular osteotomy for traumatic osteoarthritis of the ankle

INTRODUCTION

Traumatic osteoarthritis of the ankle joint caused after malleolar fractures of the ankle and tibial plafond fractures are frequently observed in comparatively young and highly active patients. Since the ankle movement in these patients is in general, comparatively favorable, orthopedists may sometimes have difficulty in deciding on a treatment policy. In our department, when treating traumatic osteoarthritis patients having a movable range within their ankle joints, we proactively applied distal tibial oblique osteotomy (DTOO) developed by Dr. Teramoto in 1994 or intra-articular osteotomy developed based on DTOO concepts such as distal tibial intra-articular osteotomy (DTIO) and distal fibular oblique osteotomy (DFOO).The objectives of the current study are to radiologically assess the ankle joint after intra-articular osteotomy for traumatic ankle osteoarthritis and evaluate the change in configuration of the ankle joint. This study summarizes the clinical results of intra-articular osteotomy obtained through the above-mentioned study.

PATIENTS AND METHODS

The subjects of this study were 20 patients diagnosed with traumatic osteoarthritis who were surgically treated for a total of 20 ankles. All patients underwent treatment with intra-articular osteotomy and were evaluated retrospectively for the following parameters: surgical procedure, fixation devices, clinical results based on the Japanese Society for Surgery of the Foot ankle/hindfoot scale (hereafter, JSSF scale) and post-operative adverse events. They were also assessed radiologically with pre- and post-operative anterior-posterior (AP) and lateral weight-bearing ankle radiographs.

RESULTS

The 20 patients consisted of 12 males and 8 females. The median age at surgery was 49 years old (range 14 - 87 years old) and the average follow-up period was 42 months (range 19 to 121 months). DTOO was applied to 10 cases, DFOO to 2 cases, DTOO and DFOO to 2 cases, medial-distal tibial intra-articular osteotomy (M-DTIO) and DFOO to 1 case, lateral-distal tibial intra-articular osteotomy (L-DTIO) and DFOO to 3 cases, M-DTIO followed by DTOO and DFOO to 1 case, and DTOO followed by low tibial osteotomy (LTO) to 1 case. Fixation devices utilized included circular external fixator for 15 cases, locking compression plate (LCP) to 3 cases, LCP and Kirschner-wire (K-wire) to 1 case, and screw and K-wire to 1 case. Radiological assessment revealed significant changes in the following parameters after surgery: tibial ankle surface angle (TAS, P= 0.0203), tibiotalar surface angle (TTS, P= 0.0021), medial malleolar angle (MMA, P= 0.0217), empirical axis (EA, P= 0.0019), fibular angle (FA, P= 0.0002), talar tilt angle (TTA, P= 0.0374), and tibial lateral surface angle (TLS, P= 0.0279). The JSSF scale also improved significantly after surgery (pre-operative JSSF scale: 51.1±11.0, post-operative JSSF scale: 89.2±8.2), p=0.0001.

CONCLUSION

Intra-articular osteotomy may change the radiological configuration of the ankle in a weight-bearing state. The present study showed very good short-term clinical results. Intra-articular osteotomy can prove a viable surgical option applicable for treatment of patients with traumatic ankle osteoarthritis having a reasonable range of motion within their ankle joints.

Distal tibial oblique osteotomy for reconstruction of ankle joint congruity and stability

Teramoto distal tibial oblique osteotomy (DTOO) is a joint-preserving surgery for ankle osteoarthritis (AOA). However, there are few articles on the radiological assessment of DTOO. The purpose of this study was to report the clinical outcomes and radiological evaluations of weight-bearing radiographs before and after DTOO. We retrospectively reviewed 52 patients who underwent DTOO between 2007 and 2018. We recorded the Tanaka-Takakura classification, fixation methods, Japanese Society for Surgery of the Foot Ankle/Hindfoot Scale (JSSF scale), and complications. The tibial articular surface angle (TAS), medial malleolar angle (MMA), tibial lateral surface angle (TLS), talar tilt angle (TTA), and tibiotalar surface angle (TTS) were evaluated using weight-bearing ankle radiographs. The median patient age was 66 years, and the mean follow-up duration was 46 ± 23 months. Two stage 2, 9 stage 3a, 30 stage 3b, and 11 stage 4 according to the Tanaka-Takakura classification were performed using DTOO. The JSSF scale improved significantly from 39.9 ± 13.8 before surgery to 87.2 ± 7.5 after surgery. Seven cases were fixed using a locking plate, and 45 cases were fixed using a circular external fixator. The TAS, MMA, TLS, TTA, and TTS significantly changed before and after DTOO. Radiological evaluation indicated that DTOO influences talar behavior during weight-bearing, and improves the clinical outcomes of AOA.

Intra-articular opening osteotomy combined with lateral ligament reconstruction for varus ankle arthritis

Background

Takakura 3B ankle arthritis is featured as obliteration of ankle space with subchondral bone contact. Among these patients, some have medial distal tibial platform erosion. It is hard to treat this kind of patients. The purpose of this study was to evaluate the therapeutic outcomes of intra-articular opening osteotomy combined with lateral ligament reconstruction for Takakura 3B ankle arthritis with medial distal tibial platform erosion.

Methods

From September 2009 to May 2016, 17 patients with Takakura 3B ankle arthritis were reviewed, including 3 male and 14 female patients. All underwent the operation of intra-articular opening osteotomy combined with lateral ligament reconstruction. All patients were available for analysis. The main outcome measurements included TT angle, AOFAS score, VAS score, SF-36 scale, and AOS scale.

Results

All patients were followed for a mean follow-up of 87.2 months (range, 49 to 129 months). The VAS scale improved from 5.5 ± 1.6 to 2.3 ± 1.9. The mean AOFAS score improved from 47.7 ± 15.7 to 75.8 ± 12.0. The SF-36 scale improved from 41.6 ± 14.0 to 67.7 ± 14.6. The AOS improved from 60.9 ± 13.9 to 28.2 ± 17.7. The TT angle improved from 14.3 ± 5.0° to 5.3 ± 4.0°. The TAS and TLS changed from 83.4 ± 2.6° and 77.5 ± 2.3° to 90.7 ± 2.3° and 78.6 ± 2.2°. However, the LTAS was not corrected significantly.

Conclusion

Intra-articular opening osteotomy combined with lateral ligament reconstruction is an effective method to treat varus ankle arthritis with medial distal tibial platform erosion.

Functional and radiological medium term outcome following supramalleolar osteotomy for asymmetric ankle arthritis- A case series of 33 patients

Introduction

Ankle arthritis is one of the most disabling and painful conditions. Up to 37.5% of ankle arthritis presents as asymmetric arthritis with ankle malalignment. Supramalleolar osteotomy is a joint sparing operation, which aims to realign the ankle joint that will prevent progression of arthritis and relieve patient's symptoms.

Aim

The aim of this study is to analyse the medium term functional and radiographic outcomes of patients who underwent supramalleolar osteotomy for asymmetric ankle arthritis.

Materials and methods

This is a retrospective outcome study of medium term outcome for 33 patients who underwent Supramalleolar osteotomy for asymmetric ankle arthritis by a single surgeon. We assessed the functional outcome of the patients with AOFAS and VAS score. The radiological parameters measured were Tibial articular surface ankle (TAS), Hind foot alignment angle (HFA) and Talar tilt angle (TT). We used the paired Student's t-test to compare the preoperative and postoperative radiographic measurements, AOFAS and VAS scores. We set the significance level at P < 0.05.

Results

We had 21 patients who underwent lateral closing wedge osteotomy for varus deformity and 12 patients who underwent medial closing wedge osteotomy for valgus deformity. The mean followup was 72 months [29-73]. The mean AOFAS score significantly improved by 44.82 ± 7.97 (p < 0.0001). The VAS score significantly improved by 5.06 ± 1.41 (p < 0.0001). All the radiological parameters showed statistically significant improvement. All osteotomy united by 8-10 weeks. We had one case of late deep wound infection, which settled down with by metalwork removal. The arthritis progressed in three cases, two patients had fusion and one patient had ankle replacement. We had 90.9% survival rate for our osteotomy at 6 years.

Conclusion

Supramalleolar osteotomy is an excellent option for patients with asymmetric ankle arthritis with good functional and radiological outcome and good medium term survival rate.

Supramalleolar Distal Tibiofibular Osteotomy for Medial Ankle Osteoarthritis: Current Concepts

The supramalleolar osteotomy is a joint-preserving surgical procedure. It is a very good treatment option for the asymmetric varus ankle and medial compartment osteoarthritis. The primary objective of the procedure is to shift medial concentration of stress toward the lateral intact articular cartilage to redistribute the joint loads during ambulation. Several studies have shown that deformities of the ankle result in uneven load distribution in the ankle joint, which eventually leads to articular cartilage degeneration. Since the lateral articular cartilage is intact, joint-sacrificing procedures such as total ankle replacement or ankle arthrodesis are not the most appropriate treatment choices for medial compartment arthritis. Results of supramalleolar osteotomies are very promising in terms of functional outcome and pain relief. In younger patients with medial compartment varus ankle osteoarthritis or even with a normal tibial anterior surface angle, supramalleolar osteotomies can be performed to realign the ankle to promote regeneration of the asymmetrically damaged cartilage. In this review article, we will discuss the indications, complications, surgical techniques, and outcomes of the supramalleolar osteotomy reported in the current literature.

The preliminary report about the modified supramalleolar tibial osteotomy for asymmetric ankle osteoarthritis

OBJECTIVE

Supramalleolar tibial osteotomy (SMO) for asymmetric ankle osteoarthritis (OA) is known to lead to satisfactory. Here, authors present a preliminary report on SMO surgical treatment in patients with asymmetric ankle arthritis.

MATERIALS AND METHODS

We reviewed cases of asymmetric ankle OA treated by modified SMO between January 2011 and October 2015. Clinical assessment was performed with the use of the ankle and hindfoot score of the American Orthopedic Foot and Ankle Society (AOFAS), foot function index, and visual analogue scale (VAS). Patient satisfaction with surgery and postoperative subjective symptoms were examined. Radiographic evaluation included preoperative and postoperative tibial anterior surface angle (TAS angle), talar tilt angle (TT angle), and tibial lateral surface angle (TLS angle). Takakura stage was measured.

RESULTS

The average follow-up period was 46.3 months. The AOFAS score was 55.7 ± 6.03 preoperatively and 76.0 ± 4.73 postoperatively. Foot function index was 60.7 ± 8.78 preoperatively and 30.8 ± 7.59 postoperatively. VAS was 7.2 ± 0.53 before surgery and 1.9 ± 0.85 after surgery. Clinical evaluations showed statistically significant improvement. The majority of patients reported satisfactory results in the subjective satisfaction evaluation. TAS angle was 84.6 ± 1.82 preoperatively and 94.0 ± 2.79 postoperatively. TLS angle was 78.8 ± 2.11 preoperatively and 81.8 ± 1.80 postoperatively. TT angle was 3.6 ± 1.26 before surgery and 2.1 ± 0.79 after surgery. Thirteen cases showed radiographic improvement of Takakura stage. Complications were not observed.

CONCLUSION

Modified SMO is a useful procedure that provides for the union and stability of osteotomy with the advantages of the existing SMO and can be performed without bone graft.

Extraarticular Supramalleolar Osteotomy in Asymmetric Varus Ankle Osteoarthritis

BACKGROUND

In recent years, supramalleolar osteotomy has become a valuable alternative for treatment of ankle osteoarthritis. The aim of this study was to investigate whether the preoperative stage of ankle osteoarthritis or tilt of the talus in the ankle mortise impacts radiologic and clinical outcomes following a supramalleolar osteotomy.

METHODS

Forty-four patients who underwent a supramalleolar osteotomy for posttraumatic asymmetric varus ankle osteoarthritis were included. Subgroups were formed according to the preoperative stage of ankle osteoarthritis and the tilt of the talus in the ankle mortise. The radiographic and clinical outcomes of each subgroup were compared, and survival rates calculated.

RESULTS

Ankles with a preoperative Takakura stage of 2 and 3a showed a significant higher survival rate at 5 years (88% [95% CI, 67-100] and 93% [95% CI, 80-100]) compared with ankles with a preoperative Takakura stage of 3b (47% [95% CI, 26-86]; P = .044). The 5-year survival rate for patients with a preoperative tilt of the talus in the ankle mortise of 4-10 degrees was 85% (95% CI, 68-100), while patients with a preoperative tilt of >10 degrees showed a 5-year survival rate of 65% (95% CI, 46-93; P = .117).

CONCLUSION

Supramalleolar osteotomy was a valuable treatment option for early to mid-stage posttraumatic asymmetric varus ankle osteoarthritis.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Ankle Arthritis

Ankle arthritis is a major source of morbidity impacting a younger working age population than hip and knee arthritis. Unlike the hip and knee, more than 70% of ankle arthritis cases are post-traumatic, with the remainder being inflammatory or primary arthritis. Nonoperative treatment begins with lifestyle and shoe-wear modifications and progresses to bracing, physical therapy, anti-inflammatory medications, and intra-articular injections. Ankle arthrodesis and total ankle arthroplasty are the 2 main surgical options for end-stage ankle arthritis, with debridement, realignment osteotomy, and distraction arthroplasty being appropriate for limited indications.

Joint-Preserving Procedures in Patients with Varus Deformity: Role of Supramalleolar Osteotomies

The most common cause for end-stage ankle osteoarthritis is posttraumatic, sometimes resulting from concomitant supramalleolar deformity. Aims of the supramalleolar osteotomy include restoring the lower-leg axis to improve intraarticular load distribution and retarding degeneration of the tibiotalar joint. Preoperative planning is based on conventional weight-bearing radiographs. Often advanced imaging, including computed tomography and/or MRI, is needed for a better understanding of the underlying problem. Postoperative complications are not uncommon, including progression of tibiotalar osteoarthritis in up to 25% within 5 years of all patients who have supramalleolar osteotomies.

Prognostic Factors Affecting Correction Angle Changes After Supramalleolar Osteotomy Using an Opening Wedge Plate for Varus Ankle Osteoarthritis

Supramalleolar osteotomy (SMO) has been suggested as an effective salvage treatment for varus ankle osteoarthritis. To identify the prognostic factors affecting the correction angle changes after SMO, a total of 53 consecutive patients (58 ankles) were evaluated retrospectively. Clinical and radiologic outcomes were evaluated, and statistical analyses were performed to identify the prognostic factors associated with the clinical and radiologic outcomes. The mean visual analogue scale scores and the American Orthopaedic Foot and Ankle Society scores improved significantly at the final follow-up (both p <.001). The mean tibial-ankle surface (TAS), talar tilt (TT), and tibial-lateral surface angles improved significantly after surgery, compared with the preoperative assessments (all, p <.001). However, at the final follow-up, these angles had changed significantly, compared with their immediate postoperative values (all p <.001), and the changes in the TAS and TT angles significantly influenced the clinical outcomes at the final follow-up (both p <.05). Male sex, high body mass index (≥26.4 kg/m²), and the existence of the lateral cortex breakages were significantly associated with the changes in the TAS and TT angle (all p <.05). Therefore, surgeons should consider these prognostic factors before performing SMO.

Supramalleolar Osteotomy Combined With an Intra-articular Osteotomy for the Reconstruction of Malunited Medial Impacted Ankle Fractures

BACKGROUND:

Malunion of a medial impacted ankle fracture may cause varus ankle deformity. This retrospective study examined the use of supramalleolar osteotomy combined with an intra-articular osteotomy in patients with malunited medial impacted ankle fractures.

METHODS:

Twenty-four patients with malunited medial impacted ankle fracture were treated between January 2011 and December 2014. Using Weber's classification, 10 had type A fractures and 14 had type B, and with the AO classification, 20 had 44A2 and 4 had 44B3. All of these patients had varus ankle deformity. Supramalleolar osteotomy combined with an intra-articular osteotomy was performed. The visual analog scale (VAS) for pain during daily activities, the Olerud and Molander Scale and the modified Takakura classification stage were used to determine the clinical outcomes and a radiographic analysis was performed.

RESULTS:

The radiographic parameters, including the tibial ankle surface (TAS) angle and talar tilt angle (TTA), showed significant differences between the preoperative and follow-up assessments. The mean tibial lateral surface (TLS) did not show a significant change. The average Olerud and Molander Scale score improved significantly from 56.4 ± 6.21 preoperatively to 77.0 ± 6.11 at the latest follow-up ( P < .01). The mean VAS decreased significantly from 6.7 ± 0.8 preoperatively to 3.1 ± 0.6 at the latest follow-up ( P < .01). No significant difference in the modified Takakura classification stage was observed between the preoperative assessment and the last follow-up.

CONCLUSIONS:

The use of a supramalleolar osteotomy combined with an intra-articular osteotomy was an effective option for the treatment of malunited medial impacted ankle fractures associated with varus ankle deformity.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

Stability of supramalleolar osteotomies using different implants in a sawbone model

BACKGROUND

With ankle arthritis often affecting young patients, joint-sparing treatments instead of total joint replacement should be considered. Only a few implants were specially developed for supramalleolar osteotomies (SMOT). This study was performed to analyse the stability of different implants and their appropriateness for SMOT.

METHODS

Twenty-five bone models (Sawbone Europe, Malmö, Sweden) were used for biomechanical testing. SMOT were performed as a uniplanar osteotomy, leaving 5 mm of lateral bone intact with a standardized gap of 8 mm. Five different plates commonly used for SMOT were assessed. For axial stability, the constructs were tested during 100 cycles for each load (150N and 800N) at a rate of 0.5 Hz. For rotational stability, each construct was subject to 100 cycles of 5 Nm torque at a rate of 0.25 Hz, performing three runs with an axial preload of 0N, 150N, or 800N. Ultimate axial load was performed for one-half and ultimate rotational load was performed for the other half of the constructs. In addition, the stiffness of the different constructs after failure was tested.

RESULTS

All constructs showed high stability and could be tested until maximum cyclic load. There was no significant difference between the five plates, neither for stiffness (axial or rotational) nor for failure load (axial or rotational). One plate indicated superiority in axial failure testing without any significant difference.

CONCLUSION

All implants could be tested until maximum load. The intact hinge apparently provides enough support to compensate for lower moment of inertia of some plates.

LEVEL OF EVIDENCE

Not applicable.

3D Printed Total Talar Replacement: A Promising Treatment Option for Advanced Arthritis, Avascular Osteonecrosis, and Osteomyelitis of the Ankle

Advanced ankle arthritis, avascular osteonecrosis, and osteomyelitis of the ankle remain a surgical challenge in the foot and ankle arena with limited treatment options. Multiple medical comorbidities contribute to total loss of the talus. Collapse of the talar body as a complication of total ankle arthroplasty, talectomy in infection, and septic talus necrosis or severe bone defects caused by tumor resection may result in need for total talar replacement. Ankle arthrodesis and tibiocalcaneal fusion after talectomy can produce severe disability of the ankle and foot. Total ankle replacement is a viable option for treatment of end-stage ankle arthritis in appropriate patient populations.

The utility of the ankle SPECT/CT scan to predict functional and clinical outcomes in supramalleolar osteotomy patients

Combined single-photon emission computed tomography and conventional computed tomography (SPECT/CT) is a hybrid imaging modality that shows a combination of metabolic and structural information about the ankle, including arthritis. We hypothesize that uptake in specific locations within the ankle joint can be associated with both clinical outcomes and may help predict which patients will have a successful SMO. Eighty-five pre-operative SMO patients with varus (37), valgus (41), or neutral (7) alignment of the hindfoot were assessed using SPECT/CT. The level of activation on SPECT/CT scans was measured. Pre and Post-operative functional scores were recorded. Patients with medial gutter activation had significantly worse (p < 0.05) AOFAS alignment (AOFAS-A) scores pre-operatively. Patients with varus or valgus alignment did not have any difference in VAS pain scores, but those in valgus did have worse AOFAS-P (pain) scores. Those with cystic lesions had a worse FAOS score pre-operatively. Ten patients (12.5%) had a treatment failure. Pre or post-operative alignment did not correlate to a treatment failure. The only statistically significant (p = 0.036) poor prognostic indicator was a bipolar lesion. Pre-operative SPECT/CT evaluation of an ankle before a SMO can be used to clinically correlate patient-specific factors such as pain and function in the pre and post-operative period. We caution against performing a SMO in patients with bipolar activation on a pre-operative SPECT-CT scan. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2015-2021, 2018.

Second-Look Arthroscopic Evaluation and Clinical Outcome After Supramalleolar Osteotomy for Medial Compartment Ankle Osteoarthritis

BACKGROUND

The aim of this study was to evaluate the clinical and radiologic outcomes of medial compartment ankle osteoarthritis after supramalleolar osteotomy (SMO) without the bone marrow stimulation procedure and confirm cartilage recovery by second-look arthroscopy.

METHODS

Twenty-two ankles that were followed for more than 1 year after SMO were retrospectively reviewed. Visual analog scale pain scores and American Orthopaedic Foot & Ankle Society ankle-hindfoot scores were used for functional evaluations. The tibial anterior surface angle and tibial lateral surface angle were measured on radiographs, and ankle osteoarthritis was classified by Takakura stage. Among the 22 patients, 21 underwent ankle arthroscopy prior to SMO, and second-look arthroscopy was performed in 16 patients 1 year postoperatively. Tibiotalar cartilage regeneration was evaluated according to the modified Outerbridge classification for the 14 patients who had undergone SMO without the bone marrow stimulation procedure.

RESULTS

The mean visual analog scale and American Orthopaedic Foot & Ankle Society scores significantly improved from 6.5 preoperatively to 1.1 postoperatively and from 60.7 preoperatively to 87.1 postoperatively, respectively ( P < .05). The mean tibial anterior surface and tibial lateral surface angles significantly improved from 83.5° and 76.9° preoperatively to 93.8° and 80.2° postoperatively, respectively ( P < .05). All preoperative Takakura stage IIIa cases and IIIb case improved to postoperative stage II. On second-look arthroscopy, cartilage regeneration of the medial compartment of the tibiotalar joint was observed in 12 of 14 patients (85%), whereas cartilage deterioration was not observed in any patient.

CONCLUSIONS

SMO without the bone marrow stimulation procedure for medial ankle osteoarthritis demonstrated cartilage regeneration in the medial tibiotalar joint in most patients by second-look arthroscopy, as well as satisfactory clinical and radiologic outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Novel Double Osteotomy Technique of Distal Tibia for Correction of Asymmetric Varus Osteoarthritic Ankle

BACKGROUND

A most challenging condition for balancing a varus arthritic ankle is the presence of a defect in the medial tibial plafond. After our initial results with a medial tibial plafondplasty did not fulfill our expectations of success, we hypothesized that adding a correcting supramalleolar osteotomy of the distal tibia would move the loading force to the tibiotalar joint more medially and move the center of rotation of the talus more laterally. In this study, we analyzed midterm clinical and radiographic outcomes in patients with double tibial osteotomy.

METHODS

Between January 2005 and February 2010, 20 patients were treated with a medial tibial plafondplasty and a medial supramalleolar osteotomy of the distal tibia. The mean age of the patients was 44 ± 12 years (range, 17-60 years). Follow-up averaged 5.9 ± 2.1 years (range, 4-11.2 years). Weight-bearing radiographs were used to assess osteotomy union and hindfoot alignment.

RESULTS

There were no intraoperative or perioperative complications. The average VAS pain score decreased significantly from 7.9 ± 1.3 (range, 6-10) to 1.3 ± 1.6 (range, 0-7). The average AOFAS hindfoot score increased significantly from 49 ± 15 points (range, 36-68) preoperatively to 86 ± 12 points (range, 66-96) postoperatively. The varus tilt improved significantly from 19.4° ± 8.2° (range, 6°-32°) to 6.9° ± 3.9° (range, 1°-12°).

CONCLUSION

The novel double osteotomy was found to be an efficient and successful method to restore tibiotalar joint congruency and to normalize hindfoot alignment.

LEVEL OF EVIDENCE

Level IV, prospective cohort study.

Interposition Ankle Arthroplasty Using Acellular Dermal Matrix: A Small Series

Although ankle arthrodesis is the reference standard for end-stage ankle arthritis, loss of mobility and adjacent joint arthritis are consequences that alternatives to arthrodesis attempt to avoid. The purpose of the present study was to report the clinical results of interpositional arthroplasty using acellular dermal matrix in 4 patients (age 32 to 42 years) for the treatment of advanced ankle osteoarthritis. The primary findings included relief of pain, with improvement in tibiotalar joint range of motion from a mean of 16.5° (range 0° to 24°) preoperatively to a mean of 31° (range 25° to 40°) postoperatively. All 4 patients underwent open arthrotomy of the anterior and posterior tibiotalar capsule with plafond exostectomy and debridement of all deleterious tissue within the ankle capsule. The articular surface of the talar dome was denuded down to smooth subchondral bone, and microfracture was performed. Autologous calcaneal bone marrow aspirate was applied, and talar resurfacing was achieved using an acellular dermal matrix. Knotless anchors placed medially and laterally within the anterior and posterior dome were used to affix the dermal matrix. The follow-up period ranged from 12 to 18 (mean 14) months. The mean pre- and 12-month postoperative Association of Orthopaedic Foot and Ankle Society hindfoot-ankle scale scores were 35 and 88.5, respectively. These outcomes suggest that interpositional tibiotalar arthroplasty using an acellular dermal matrix is successful in improving function and range of motion and decreasing pain. As an alternative to tibiotalar arthrodesis, interpositional tibiotalar arthroplasty might be the procedure of choice for young patients with end-stage ankle arthritis. Longer follow-up periods, histologic testing, and arthroscopic evaluations would be advantageous to further assess the durability of this procedure.

Hallux valgus, ankle osteoarthrosis and adult acquired flatfoot deformity: a review of three common foot and ankle pathologies and their treatments

The pathogenesis of hallux valgus deformity is multifactorial. Conservative treatment can alleviate pain but is unable to correct the deformity. Surgical treatment must be adapted to the type and severity of the deformity. Success of surgical treatment ranges from 80% to 95%, and complication rates range from 10% to 30%.Ankle osteoarthrosis most commonly occurs as a consequence of trauma. Ankle arthrodesis and total ankle replacement are the most common surgical treatments of end stage ankle osteoarthrosis. Both types of surgery result in similar clinical improvement at midterm; however, gait analysis has demonstrated the superiority of total ankle replacement over arthrodesis. More recently, conservative surgery (extraarticular alignment osteotomies) around the ankle has gained popularity in treating early- to mid-stage ankle osteoarthrosis.Adult acquired flatfoot deformity is a consequence of posterior tibial tendon dysfunction in 80% of cases. Classification is based upon the function of the tibialis posterior tendon, the reducibility of the deformity, and the condition of the ankle joint. Conservative treatment includes orthotics and eccentric muscle training. Functional surgery is indicated for treatment in the early stages. In case of fixed deformity, corrective and stabilising surgery is performed. Cite this article: Crevoisier X, Assal M, Stanekova K. Hallux valgus, ankle osteoarthrosis and adult acquired flatfoot deformity: a review of three common foot and ankle pathologies and their treatments. EFORT Open Rev 2016;1:58-64. DOI: 10.1302/2058-5241.1.000015.

Osteochondral autograft transplantation with biplanar distal tibial osteotomy for patients with concomitant large osteochondral lesion of the talus and varus ankle malalignment

Background

Osteochondral lesions of the talus (OLTs) are amongst the most common foot and ankle disorders. Varus ankle malalignment causes stress concentration on medial side of the joint, resulting in OLTs and osteoarthritis. For large symptomatic OLTs (>10 mm), Osteochondral autograft transplantation is usually recommended. This article highlights biplanar distal tibial osteotomy as an approach and management for patients with concomitant large OLTs and varus ankle malalignment.

Methods

From January 2012 to July 2014, 13 patients (6 male and 7 female) underwent surgery in our faculty and their average age was 55.4 (ranging from 34 to 69) years old. Oblique medial malleolar osteotomy was performed to expose the talar lesion, followed by an osteochondral autograft transplantation and distal tibial opening-wedge osteotomy. Weight-bearing X-rays were conducted and used for the measurement of radiographic parameters such as the tibial articular surface (TAS) and tibial lateral surface (TLS) angles. Ankle function of the subjects was evaluated according to the American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot score (AOFAS-AH) questionnaires and Visual Analog Scale (VAS).

Results

11 patients completed the follow-up over a mean period of 21.2 months. The average area of talar lesion was 135.9 mm² while the average depth was 11.4 mm. The mean time for osseous union was 8.5 weeks. Donor site morbidity was not recorded in any of the cases. The mean AOFAS-AH and VAS improved from 53 to 90 points (p < 0.05) and 6.7 to 1.9 points (p < 0.05) respectively. The mean TAS angle improved from 83.1 to 90.3° (p < 0.05).

Conclusions

Biplanar distal tibial osteotomy with the combination of osteochondral autograft transplantation could be used to address patients with concomitant large OLTs and varus ankle malalignment as this technique provides excellent visualization of the talar defect, favorable biomechanical environment for the ankle joint with high rate of good and excellent results.

Varus Deformity of the Distal Tibia From Physeal Growth Arrest Treated Using a Titanium Metal Porous Wedge

During a cheerleading event, a 14-year-old female sustained a right ankle physeal fracture that was treated nonoperatively with casting. She developed a distal medial tibial physeal arrest, and as the onset of menses was at age 16, she subsequently developed a varus distal tibial deformity. At the age of 19, she was no longer able to participate in collegiate cheerleading due to lateral ankle pain, ankle instability, and peroneal subluxation. After failing conservative treatment, she underwent an ankle arthroscopy, Broström-Gould procedure, peroneal retinacular repair with peroneal tenolysis, and a distal tibial medial opening wedge osteotomy using a porous titanium metal wedge and a one-third tubular plate. At 6-month follow-up, her osteotomy site showed abundant callus formation, and her lateral ankle pain had almost completely resolved. At 22-month follow-up, there were no residual ankle instability or pain complaints, and she had returned to collegiate cheerleading. This case report highlights a very useful, previously not described, application of porous titanium metal wedges for medial supramalleolar opening wedge osteotomies of the tibia. Such wedges are familiar to many foot and ankle orthopaedic surgeons and continue to have expanding indications.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case report.

Arthroscopic evaluation of persistent pain following supramalleolar osteotomy for varus ankle osteoarthritis

PURPOSE

The purposes of this study were to investigate pain experienced by patients after supramalleolar osteotomy for varus ankle osteoarthritis and to analyse correlations between this pain and arthroscopic findings.

METHODS

Twenty-nine patients (31 ankles) who underwent arthroscopic evaluation after supramalleolar osteotomy were reviewed retrospectively. The visual analog scale (VAS) was used to assess pain, and the patients were instructed to record the time point, location, and character of the pain. The tibial-ankle surface angle, talar tilt, and tibial-lateral surface angle were measured on radiographs.

RESULTS

The location, time point, and character of the pain experienced by the patients changed after supramalleolar osteotomy. The mean VAS score was significantly improved after supramalleolar osteotomy at the time of the arthroscopic evaluation (P < 0.001) and improved further after the arthroscopic procedures (P = 0.026). During arthroscopy, pathologic lesions such as adhesions, synovitis, and soft-tissue impingement were identified. A significant correlation was found between adhesions and dull pain and pain at rest (P = 0.016 and P = 0.005, respectively). In addition, soft-tissue impingement in the lateral gutter was significantly correlated with dull pain, pain at rest, and clicking pain (P = 0.001, P = 0.035, and P = 0.042, respectively). No significant correlations were found between post-operative radiographic measurements and development of pathologic lesions.

CONCLUSIONS

With the use of arthroscopy, persistent pain experienced after supramalleolar osteotomy was found to be associated with adhesions, synovitis, and soft-tissue impingement in medial and lateral gutters of the ankle. Arthroscopy can be helpful in identifying and treating painful lesions commonly seen after supramalleolar osteotomy. An understanding of these painful lesions will help patients have more realistic expectations regarding the supramalleolar osteotomy.

LEVEL OF EVIDENCE

Case series study, Level IV.

Extraarticular Supramalleolar Osteotomy for Managing Varus Ankle Osteoarthritis, Alternatives for Osteotomy: How and Why?

The supramalleolar osteotomy has been reported to be a joint preserving surgery with good clinical outcome for asymmetric ankle osteoarthritis, especially varus ankle osteoarthritis. Conventional supramalleolar osteotomy of the tibia and fibula creates angulation and translation of the ankle joint without changing the width of the ankle mortise. Distal tibial oblique osteotomy improved the preoperative clinical and radiological parameters; however, mean talar tilt angle did not decrease. Assessment of the ankle arthritis in sagittal, axial, and coronal planes may be helpful to achieve a decrease of the talar tilt in ankle osteoarthritis.

The Use of Tibial Osteotomy (Ankle Plafondplasty) for Joint Preservation of Ankle Deformity and Early Arthritis

Asymmetric ankle osteoarthritis (OA) is an increasingly recognized condition. It is imperative to differentiate between extraarticular and intraarticular deformity and to address these appropriately. Any associated instability and multilevel deformity must be recognized and addressed. Patients with intraarticular varus or valgus asymmetric OA have poorer outcomes and higher rates of recurrence when treated with standard techniques targeted at correction with traditional supramalleolar or inframalleolar techniques. Plafondplasty aims to correct the deformity at its center of rotation and angulation and is associated with low rates of recurrence, substantial postoperative pain relief, functional improvement, and a possible slowing of the degenerative process.

Supramalleolar Osteotomies for Posttraumatic Malalignment of the Distal Tibia

Supramalleolar osteotomies of the tibia (SMOT) for posttraumatic distal tibial malalignment has shown to reduce pain, improve function and radiographic signs of osteoarthritis, and delay ankle arthrodesis or total joint replacement. The procedure also protects the articular cartilage from further degenerative processes by shifting and redistributing loads in the ankle joint. It is technically demanding and requires extensive preoperative planning. The type of osteotomy (opening vs closing wedge) does not influence the final outcome. However, based on the limited evidence, a grade I treatment recommendation has been given for supramalleolar osteotomies of the tibia to treat mild to moderate ankle arthritis in the presence of distal tibial malalignment.

Treatment of Varus Ankle Osteoarthritis and Instability With a Novel Mortise-Plasty Osteotomy Procedure

Although joint-preserving surgery for intermediate ankle osteoarthritis has been reported to be effective, failures of supramalleolar osteotomy and plafond-plasty can occur because of persistent malalignment of the distal tibia and incongruent ankle mortise. We introduce a novel opening wedge distal tibial osteotomy procedure (mortise-plasty) with rigid plate fixation combined with synthetic bone wedges. We performed 27 mortise-plasties in 25 patients with varus ankle osteoarthritis and instability. Six males (24%) and 19 females (76%), with a mean age of 63 (range 28 to 79) years, were followed up for a mean of 27.3 (range 14 to 45) months. The mean preoperative visual analog scale score, American Orthopaedic Foot and Ankle Society score, and Takakura ankle scale score were 7.4 (range 5.4 to 10), 58.7 (range 18 to 84), and 55.9 (range 29 to 88), respectively. These scores improved significantly to 2.1 (range 0 to 6.5), 89.3 (range 67 to 100), and 84.7 (range 55 to 100) postoperatively (p < .001). The mean preoperative tibial-anterior surface angle and talar tilt angle were 84.9° (range 78° to 90°) and 8.3° (range 3° to 21°), respectively. At the most recent follow-up visit, the corresponding values were 95.0° (range 82° to 99°) and 1.8° (range 0° to 8°), respectively (p < .001). Computed tomography scans indicated that the ankle mortise narrowed by approximately 1.8 mm and the tibial plafond was lowered after osteotomy. No patients underwent lateral ligament reconstruction, ankle joint replacement, or arthrodesis. Mortise-plasty osteotomy corrects the intra-articular and extra-articular deformities simultaneously and provides good clinical and radiographic outcomes for patients with varus ankle osteoarthritis and instability.

Supramalleolar Osteotomy: Indications and Surgical Techniques

Supramalleolar osteotomies are a surgical treatment option for asymmetric varus or valgus ankle arthritis where at least 50% of the joint surface is spared. Procedure selection requires significant preoperative planning for appropriate execution. Thus, the surgeon must be familiar with the principles of deformity correction. With appropriate patient selection and proper preoperative planning, the procedure has been shown to yield excellent results, redistributing forces more evenly across the ankle joint by restoring the mechanical axis of the lower leg with minimal complications.

Intermediate-term follow-up after ankle distraction for treatment of end-stage osteoarthritis

BACKGROUND

Treatment of end-stage ankle osteoarthritis remains challenging, especially in young patients. Initial reports have shown early benefits of joint distraction for the treatment of ankle osteoarthritis. We report the five to ten-year results of a previously described patient cohort following ankle distraction surgery.

METHODS

All thirty-six patients who had undergone ankle distraction surgery between December 2002 and October 2006 were contacted. Patients were evaluated by a clinical investigator and completed the Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) surveys. Radiographs as well as computed tomography and magnetic resonance imaging scans of the ankles were obtained at the follow-up visits.

RESULTS

Twenty-nine patients (81%) were followed for a minimum of five years (mean and standard deviation, 8.3 ± 2.2 years). Sixteen (55%) of the twenty-nine patients still had the native ankle joint whereas thirteen patients (45%) had undergone either ankle arthrodesis or total ankle arthroplasty. Positive predictors of ankle survival included a better AOS score at two years (hazard ratio [HR] = 0.048, 95% confidence interval [CI] = 0.0028 to 0.84, p = 0.04), older age at surgery (HR = 0.91, 95% CI = 0.83 to 0.99, p = 0.04), and fixed distraction (HR = 0.094, 95% CI = 0.017 to 0.525, p < 0.01). Radiographs and advanced imaging revealed progression of ankle osteoarthritis at the time of final follow-up.

CONCLUSIONS

Ankle function following joint distraction declines over time. Patients should be well informed of the commitment that they must make during the treatment period as well as the long-term results after surgery.

Single-stage supramalleolar osteotomy for coronal plane deformity

A variety of surgical procedures are utilized for management of ankle osteoarthritis. The most common etiology in patients with ankle osteoarthritis is post-traumatic often resulting in asymmetric ankle osteoarthritis with concomitant valgus or varus deformity. A substantial part of tibiotalar joint is often preserved, therefore, in appropriate patients, joint-preserving surgery holds the potential to be a superior treatment option than joint-sacrificing procedures including total ankle replacement or ankle arthrodesis. This review is designed to describe indications and contraindications for single-stage supramalleolar realignment surgery. Complications associated with this type of surgery and postoperative outcome are highlighted using recent literature.

Changes of density distribution of the subchondral bone plate after supramalleolar osteotomy for valgus ankle osteoarthritis

CT-osteoabsorptiometry (CT-OAM) has been used to visualize subchondral bone plate density distribution regarding to its mineralization. The purpose of this study was to display and analyze the density distribution of the subchondral bone plate before and after supramalleolar realignment osteotomies. We retrospectively analysed pre- and postoperative CT images of nine consecutive patients with post-traumatic unilateral valgus ankle OA. The distribution charts of CT-OAM scans were quantitatively analyzed for subchondral bone plate density distribution. VAS for pain and the Tegner activity scale were used to assess clinical outcome. At a mean follow-up of 20 ± 5.6 months (range 13-27), we observed a significant pre- to postoperative decrease of the mean high-density area ratio in tibia (lateral and posterior area) (p ≤ 0.05) and the talus (lateral area) (p ≤ 0.05). Pairwise comparison between the pre- and postoperative mineralization at the articular surface showed a significant decrease of the high-density area ratio for the tibia and the talus. The VAS decreased from 6.2 ± 0.9 pre- to 2.8 ± 0.9 postoperatively (p = 0.027), and the Tegner score inclined from 4.5 ± 1.1 preoperatively to 5.3 ± 0.7 after surgery (p = 0.082). The tibial and talar subchondral bone plate density, regarding to its mineralization, decreased after supramalleolar medial closing wedge osteotomy in patients with valgus ankle OA. The results of this study suggest that realignment surgery may decrease peak bone density areas corresponding to the alignment correction and contribute to a homogenization of the subchondral bone plate mineralization.

Supramalleolar Osteotomy With Bone Marrow Stimulation for Varus Ankle Osteoarthritis: Clinical Results and Second-Look Arthroscopic Evaluation

BACKGROUND

Supramalleolar osteotomy (SMO), which redistributes the load line within the ankle joint, has been reported as an effective treatment for varus ankle osteoarthritis. However, no study has examined cartilage regeneration in the medial compartment of the ankle after SMO.

HYPOTHESIS/PURPOSE

This study aimed to investigate the clinical and radiological outcomes of SMO and to identify the association between the outcomes of SMO and cartilage regeneration evaluated by second-look arthroscopy. The hypothesis was that cartilage regeneration would be an important predictor of the outcomes of SMO and that arthroscopic marrow stimulation would aid in cartilage regeneration.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 31 ankles were retrospectively evaluated after arthroscopic marrow stimulation with SMO for varus ankle osteoarthritis; second-look arthroscopy was conducted for all these ankles. Clinical outcome measures included a visual analog scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiological outcome variables included the tibial-ankle surface angle (TAS), talar tilt (TT), and tibial-lateral surface angle (TLS), and progression of degenerative arthritis of the ankle was assessed. In the second-look arthroscopy, cartilage regeneration was evaluated using the International Cartilage Repair Society (ICRS) grade.

RESULTS

The mean ± standard deviation VAS and AOFAS scores were 7.1 ± 0.8 and 62.9 ± 4.0 preoperatively, and they significantly improved to 3.4 ± 1.3 and 83.1 ± 7.5, respectively (P < .001, for both) at the time of the second-look arthroscopy (mean, 13.2 months postoperatively). However, at final follow-up (mean, 27.4 months postoperatively), they were significantly decreased to 4.1 ± 1.6 and 79.9 ± 8.0, respectively, compared with the values at second-look arthroscopy (P < .001, for both). The mean TAS, TT, and TLS improved significantly after SMO but showed no significant correlation with the clinical outcomes and ICRS grade (P > .05 for all three). At second-look arthroscopy, the ICRS overall repair grades were normal in 1 (3%), nearly normal in 7 (23%), abnormal in 13 (42%), and severely abnormal in 10 (32%). Progressive degenerative arthritis was observed in 13 cases (42%). The ICRS grade was significantly associated with the clinical outcomes (P < .0001) and development of degenerative arthritis of the ankle joint (P = .002).

CONCLUSION

This study showed improved clinical outcomes after SMO for varus ankle osteoarthritis in comparison to the preoperative assessments. Furthermore, the ICRS grade was significantly associated with the clinical outcomes of SMO at final follow-up and significantly associated with the development of degenerative arthritis of the ankle joint. Therefore, arthroscopic marrow stimulation should be considered with SMO to ensure adequate cartilage regeneration. However, given the ICRS grades observed at the time of the second-look arthroscopies and the progression of degenerative arthritis in 42%, the long-term prognosis in this group of patients is uncertain.

Supramalleolar osteotomy: techniques, indications and outcomes in a series of 83 cases

INTRODUCTION

Supramalleolar osteotomy is an alternative surgical procedure for the management of asymmetric early arthritis of the ankle. The main goal of this retrospective study was to evaluate the clinical and radiological benefits of supramalleolar osteotomy. The secondary goal was to identify prognostic factors to help decide upon this therapeutic indication.

MATERIALS AND METHODS

Eighty-three patients, mean age 45 years old (17-79), presenting with post-traumatic asymmetric early arthritis of the ankle were followed up for a mean 3.5 years (1-14 years). Sixty-two patients presented with a varus deformity (mean: 13°), and 21 with a valgus deformity (mean: 17.5°). The presence of a preoperative clinical 'sidewalk sign' was looked for and it was considered positive if pain improved when the patient walked on a surface slope that was tilted in the opposite direction of their deformity. A functional preoperative evaluation and at the final follow-up were performed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot scale. The frontal deformity was measured by the Meary angle on a weight-bearing X-ray. Varus deformities were treated by a lateral closing wedge supramalleolar osteotomy or a medial opening wedge supramalleolar osteotomy. Valgus deformities were treated by a lateral opening wedge or a medial closing wedge supramalleolar osteotomy.

RESULTS

At last follow-up, the mechanical axis in the varus group was 1.3° and 7.5° in the valgus group. The AOFAS score significantly improved (P<0.001) by 15 points in patients with a varus deformity and 13 points in patients with a valgus deformity. A positive sidewalk sign (disappearance of pain) was correlated with a good outcome and had a positive predictive value of 0.88 (CI: 0.77-0.95) (P<0.001).

DISCUSSION

The supramalleolar osteotomy is a conservative therapeutic surgical option for the management of arthritis of the ankle associated with varus or valgus deformities. The results are satisfactory for indications of arthritis with varus and valgus deformities and a positive 'sidewalk' sign (pain relief on a slope surface tilted in the opposite direction of the deformity).

LEVEL OF EVIDENCE

Level IV: retrospective case series.

Effect of supramalleolar osteotomy and total ankle replacement on talar position in the varus osteoarthritic ankle: a comparative study

BACKGROUND

In varus osteoarthritic ankles, joint congruency is usually lost leading to progressive wear of the medial tibiotalar joint. Recent studies have shown that balancing the hindfoot with the aid of supramalleolar osteotomy (SMOT) is an effective method to decrease symptoms and to delay progression of osteoarthritis of the ankle joint. Resurfacing the articular surfaces with total ankle replacement (TAR), in contrast, may compensate for the lost joint congruency and lost stability of the talus at the peritalar joint. However, no literature exists with regard to the overall correction of talar position in all 3 planes when using these 2 treatment modalities. The purpose of this study was to determine the effect of SMOT and TAR on talar position in all 3 planes, and to compare the efficiency of both procedures in restoring overall hindfoot geometry.

METHODS

Out of 104 ankles with a varus-tilted ankle, 52 patients were treated with SMOT and 52 with TAR. Weight-bearing radiographs were analyzed to measure the talar position in all 3 planes, including the talar tilt angle (TT), the sagittal talocalcaneal inclination angle (TCI), and the talometatarsal 1 angle (TMT1) pre- and postoperatively.

RESULTS

Although after TAR the talar position was corrected in all the 3 planes, SMOT on the other hand did not fully correct the TT, and furthermore TMT1 remained unchanged.

CONCLUSIONS

Resurfacing of the worn-out articular surface and tensioning of ligaments, as is the case in TAR, radiographically restores the hindfoot geometry in the neutral position better than SMOT does.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Supramalleolar osteotomies for degenerative joint disease of the ankle joint: indication, technique and results

Patients with varus or valgus hindfoot deformities usually present with asymmetric ankle osteoarthritis. In-vitro biomechanical studies have shown that varus or valgus hindfoot deformity may lead to altered load distribution in the tibiotalar joint which may result in medial (varus) or lateral (valgus) tibiotalar joint degeneration in the short or medium term. The treatment of asymmetric ankle osteoarthritis remains challenging, because more than half of the tibiotalar joint surface is usually preserved. Therefore, joint-sacrificing procedures like total ankle replacement or ankle arthrodesis may not be the most appropriate treatment options. The shortand midterm results following realignment surgery, are very promising with substantial pain relief and functional improvement observed post-operatively. In this review article we describe the indications, surgical techniques, and results from of realignment surgery of the ankle joint in the current literature.

Effects of supramalleolar osteotomies for ankle osteoarthritis on foot kinematics and lower leg muscle activation during walking

BACKGROUND

Early stages of asymmetric ankle osteoarthritis can be treated by joint preserving supramalleolar osteotomies that surgically realign the ankle and unload degenerated cartilage. While studies have already shown pain relief and functional improvements, the effects on gait biomechanics are largely unknown. This study investigated patients' gait pattern after supramalleolar osteotomies by focusing on foot kinematics and lower leg muscle activation.

METHODS

An instrumented three-dimensional gait analysis with simultaneous electromyography of gastrocnemius medialis and lateralis, soleus, peroneus longus, and tibialis anterior muscles was performed on 12 patients with ankle osteoarthritis, seven of which were followed up 12-18months postoperatively. Additionally, seven different long-term follow-up patients (8-9years postoperatively) and 15 healthy control subjects were measured. The waveforms of the foot kinematics and muscle activation were analyzed using principal component analysis.

FINDINGS

Compared to healthy controls, principal component scores that affected the sagittal range of motion of the hindfoot and hallux were lower in all patient groups, while scores that affected the timing of the peaks in the sagittal forefoot motion were mainly altered in short-term follow-up patients. Lower principal component scores in patients with ankle osteoarthritis and short-term follow-up patients resulted in a less pronounced peak activation of gastrocnemius medialis and soleus.

INTERPRETATION

Both postoperative patient groups showed similar adaptations in their gait pattern as those observed in patients with ankle osteoarthritis. These changes are probably related to the lower ankle mobility. However, the reduced mobility seems to affect the patients' well-being less than a painful joint.

Realignment surgery for severe talar tilt secondary to paralytic cavovarus

BACKGROUND

Realignment surgeries for mild to moderate ankle osteoarthritis with minimal talar tilt have been reported to be effective. However, there has been no report on joint-sparing surgery of ankle osteoarthritis in patients with paralytic disorders who have severe talar tilt. We therefore investigated whether ankle osteoarthritis with severe talar tilt caused by paralytic disorders can be improved after operative treatment.

METHODS

This study included 12 ankles (11 patients) with varus ankle osteoarthritis from paralytic disorders with cavovarus deformity of the foot. Mean follow-up period was 3.0 years (range, 2-4.5 years). Causes of paralysis were residual polio in 7 ankles (6 patients), cerebral palsy in 2 ankles, and idiopathic in 3 ankles. Preoperative and postoperative clinical assessments were performed using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score and a visual analogue scale (VAS). The Ankle Osteoarthritis Scale (AOS) was used for postoperative assessment. Pre- and postoperative radiographic parameters were compared.

RESULTS

Mean AOFAS score improved from 39.1 (range, 32-57) preoperatively to 77.9 (range, 72-85) postoperatively. Mean talar tilt improved from 17.4 degrees (range, 9.5-33.5 degrees) to 1.4 degrees (range, 0-4 degrees). Degree of osteoarthritis according to Takakura classification improved in all ankles except two. Mean heel alignment angle was reduced from 40.4 degrees (range, 2-65 degrees) of varus preoperatively to 11.2 degrees (range, -3 to 25.5 degrees) of varus postoperatively.

CONCLUSION

Medial varus ankle osteoarthritis from paralytic cavovarus may be improved even in cases of severe talar tilt.

LEVEL OF EVIDENCE

Level IV, retrospective case series.